Things you wish you had known before hiring a midlevel

[rmsdudqkr]

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I will be hiring a PA at my practice given the high volume so that s/he could see routine followups and make room for more new patients + procedures.

If anyone could share any insights into considerations for hiring a midlevel, that’d be much appreciated!

 

[thecentral09]

Realize it will probably take 6 months until u get anything useful which is an expensive period, how many patients they need minimum to cover their costs(salary,vaca, CME, insurance, etc, how much additional staff (nurses, auths, front desk etc) will be needed to bring them in.

I have 3 midlevels in private practice with the third still training. My main PA helps with basic injections saving time for me to do higher level spine stuff and news. Good PAs will increase your practice revenue by hundreds of thousands per year by 2 mechanisms -them generating revenue, but more so it frees you up to do higher level work to minimize wait times. I routinely do 30 procedures per day and oversee all of them at 2 sites.

Obviously if employed how much $/wRVU are u getting of them seeing patients with taking on all the risk u are from having them see patients on your behalf. Either this model or ensure your employer is paying you ~25-50k/year to oversee them.

 

[sloh]

Realize it will probably take 6 months until u get anything useful which is an expensive period, how many patients they need minimum to cover their costs(salary,vaca, CME, insurance, etc, how much additional staff (nurses, auths, front desk etc) will be needed to bring them in.

I have 3 midlevels in private practice with the third still training. My main PA helps with basic injections saving time for me to do higher level spine stuff and news. Good PAs will increase your practice revenue by hundreds of thousands per year by 2 mechanisms -them generating revenue, but more so it frees you up to do higher level work to minimize wait times. I routinely do 30 procedures per day and oversee all of them at 2 sites.

Obviously if employed how much $/wRVU are u getting of them seeing patients with taking on all the risk u are from having them see patients on your behalf. Either this model or ensure your employer is paying you ~25-50k/year to oversee them.

Only 20-25k/yr?

 

[JFS]

Only 20-25k/yr?

Has anyone been able to negotiate this with a hospital system?

 

[thecentral09]

My prior employer was paying me zero, and since i couldnt hit my wRVU bonus threshold because of things out of my control/ iet staffing and amt of procedures i could schedule, the only thing that adding additional midlevels was additional risk on my license which was unilaterally monetized by the hospital. again, another reason for leaving.lesson leraned.

 

[Ronin1]

Everything is negotiable. I’m HOPD and get all mid level wrvus. Granted it’s all simple follow ups. I wouldn’t have a no in this model for supervision fee alone

 

[Ducttape]

you should easily be able to get a small bonus for supervising. getting all their rvus is much tricker. after all, they still have to pay the PA...

PAs and NPs are great if you establish ground rules and are willing to teach.

many docs are not, and then they develop an adversarial relationship with the PA that leads to frustration, stress and recriminations.


decide beforehand with admin whether you are going to use the advanced practice provider as a separate provider or as a physician extender. this will determine their roles and avoid situations such as overreach or the situation where you feel the PA is doing something you do not approve of.

look for a more experienced APP. the young ones right out of school want to play doctor. the more experienced ones generally just want a job that they find interesting and somewhat fulfilling. a good resume may be an APP who worked in ER for 10-15 years who isburnt out from the ER and a stable 9-4 job would be perfect.

 

[cowboydoc]

Has anyone been able to negotiate this with a hospital system?

I get half that for supervision. However, I capture a significant amount of their RVU volume (both of us see new patients.) Dumping the tedious, non-revenue generating work on them has made me much more efficient at gobbling the RVU pellets.

Overall, I think I'm doing 20% more RVUs even with 15-20% reduction in hours worked since adding a PA.

 

[Greenbayslacker]

Our system gives neither a bonus nor RVUs for supervising. Their logic is that the PA's drive up our procedures thus improving our earnings

 

[lobelsteve]

Our system gives neither a bonus nor RVUs for supervising. Their logic is that the PA's drive up our procedures thus improving our earnings

Risk and no reward.
You are getting screwed.

 

[DOctorJay]

Our system gives neither a bonus nor RVUs for supervising. Their logic is that the PA's drive up our procedures thus improving our earnings

Same here

 

[CleanUp]

Same

 

[thecentral09]

Same

U guys need to redefine your employment scenarios. All risk, no reward. The system is making $ off the risk to your license and you don’t see a thing for it. In PP ~20% of my pay is the extra funds generated by midlevels.

 

[DOctorJay]

U guys need to redefine your employment scenarios. All risk, no reward. The system is making $ off the risk to your license and you don’t see a thing for it. In PP ~20% of my pay is the extra funds generated by midlevels.

You are absolutely correct.

However, it’s not like these big health networks are going to change for an individual doc who understands this.

The only option is to leave.

 

[Baron Samedi]

You are absolutely correct.

However, it’s not like these big health networks are going to change for an individual doc who understands this.

The only option is to leave.

Is mid-level supervision something typically put into the initial contract in these scenarios or added on later?

 

[thecentral09]

Mine (of course) was added later. I was out of fellowship and didn’t know any better, after a year they started loading PAs into my clinic ( I said no more after 2), but they just added them based on practice demand with no change/addedndum the physician employment contract regarding oversight. Classic hospital bait and switch to employed docs to extort their license for more revenue for the coorporation after the physician grows the practice for them

 

[MitchLevi]

I will be hiring a PA at my practice given the high volume so that s/he could see routine followups and make room for more new patients + procedures.

If anyone could share any insights into considerations for hiring a midlevel, that’d be much appreciated!

They’re terrible.

You’ll learn.

 

[drusso]

U guys need to redefine your employment scenarios. All risk, no reward. The system is making $ off the risk to your license and you don’t see a thing for it. In PP ~20% of my pay is the extra funds generated by midlevels.

You hit the nail on the head. #knowyourworth

 

[DOctorJay]

Is mid-level supervision something typically put into the initial contract in these scenarios or added on later?

I started without a midlevel until my schedule got busy enough to warrant one. The other more senior docs in my practice had them and it did seem like a good way to increase procedure volume and number of procedure days.

For a short time we were given an additional $5k to our salary for supervising (although interestingly even the other docs without midlevels also got the added $5k in salary).

Now there is no additional remuneration and we are also told the increase in our procedure volume is the “benefit”.

Most of our newer docs are deciding not to add on a midlevel. They have less procedure time and aren’t as productive (yet). It’ll be interesting to watch over time to see how it plays out wrvu wise.

 

[CleanUp]

You are absolutely correct.

However, it’s not like these big health networks are going to change for an individual doc who understands this.

The only option is to leave.

Yes. I left.

 

[CleanUp]

U guys need to redefine your employment scenarios. All risk, no reward. The system is making $ off the risk to your license and you don’t see a thing for it. In PP ~20% of my pay is the extra funds generated by midlevels.

I’d suggest it’s not as black and white as it seems. They argue they are feeding me patients, allowing me more procedure time, and opening up my clinic for new patients. Once I realized that I’m good enough to get patients on my own, the boost from procedures isn’t that high without a meaningful equity ownership, I’m beholden to the DON and asc staff, and I could make more money by breaking the volume model I left. Different strokes for different folks though.

 

[Ducttape]

it actually does work to our finanicial benefit to have an advanced practice provider.

and yes, it significantly increases volume and procedural access.

you dont believe me, on your own, take a look at every single orthopedic office and tell me that most orthopedists are solo practitioners.

the key is to make it work in a way you feel comfortable. some like the APP to operate independently. some use them as a physician extender.

 

[stsa84]

I get half that for supervision. However, I capture a significant amount of their RVU volume (both of us see new patients.) Dumping the tedious, non-revenue generating work on them has made me much more efficient at gobbling the RVU pellets.

Overall, I think I'm doing 20% more RVUs even with 15-20% reduction in hours worked since adding a PA.

Know this is an older thread. How exactly are you capturing some of their RVU volume? Are you having them see new patients, and then you go in and see them at the end, formulate the plan, and then bill the visit as a shared visit, getting the full wRVU from the visit?

 

[cowboydoc]

Know this is an older thread. How exactly are you capturing some of their RVU volume? Are you having them see new patients, and then you go in and see them at the end, formulate the plan, and then bill the visit as a shared visit, getting the full wRVU from the visit?

Basically treat them like a resident when we’re in clinic together. I see everyone and make plans together, they do most of the note, and I sign the final. Their absolute RVU production is trash, but the clinic bills out >$1M/year more than before I had a PA.

 

[clubdeac]

That they will end up replacing me to “work at the top of their license”

 

[clubdeac]

PA’s just want to practice at the top of their license too

When are physicians going to fight back?

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