au bon pain

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I was hoping to post this on the...forum that doesn't exist...but still awaiting access. If you don't feel comfortable posting a reply on the general forum I'd really appreciate a DM. Thanks in advance...

So I have an offer to work with an ortho group and wonder if I can get some insight from all you wise folks on how to fairly counter what I think is a pretty poor offer...

The good: Practice is in a part of town with an excellent payor mix. It's 3 orthos who have broken off from a larger group and are still figuring out the logistics of that separation. They will likely be adding more orthos and more space later next year. They own their own PT, one-room ASC on site (where all my procedures would be done), and a few other small ancillaries. They're nice docs and practice conservatively which I like. They don't expect me to take over med prescribing for their patients and told me I can practice however I'd like. They say that I could gain ownership/become a partner in 1-2 years.

The bad: they estimate they refer ~15 pain referrals/month to pain and I'd have to go out and knock on other docs doors for referrals and bring in much of my own business. They told me it could take +2 years to be running full steam (appreciate their honesty on this). They've never had a pain doctor so I'd have to assist with working out all the quirks of this in the practice and in terms of setting up the ASC for pain procedures, billing, etc. One of their MAs does their fluoro now and needs more training to become proficient/efficient.

The offer: W2 spot with benefits+40% of collections. No base salary but they say I can work in my primary specialty to have steady income when starting out (ha, lucky me). I'm still unclear why they won't offer a base but I assume it's because they don't want to shoulder the risk. They also say they won't go above 40% of initial collections as they were burned once by a primary care sports doc who only saw 5 pts/day and they lost money. To try to make up for this, they want to give me 50% of the ASC fees I generate (not sure how to legally do this). Once I hit my "overhead" (still not sure what this is) I can renegotiate for higher % collection.

From interviewing at other jobs and learning about how other ortho groups pay pain docs when starting this seems like a super low ball offer....am I right? Or am I wrong and this is actually decent? On a scale of 1 (worst) - 10 (best) what rating would you give their offer?

***What do you think is a reasonable counter offer? I'm in a position where other than medmal insurance I don't need any other benefits and they're open to bringing me on as a 1099 -- and they asked for me to make them an IC offer. What would you pitch them?

Lastly, anybody know of legal ways to benefit fairly from ASC work without having direct ownership? I've heard one way and am interested in learning if there are more.

I do have alternative options that pay solidly out of the gait but this practice seems like an ideal long-term fit given my interests and hoping to find some way to come to a fair agreement. Thanks again
 
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gdub25

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There’s a lot of details to this job opportunity that would make me lean one way or the other. This is definitely not a lowball offer, 40% of collections sounds solid to me but that is assuming their overhead is pretty typical of most practices. It is not legal for them to give you any part of the ASC profits unless you are part owner, they would have to set you up on a PSA and pay you an RVU for you to receive any part of the ASC profits and even then you technically wouldn’t be receiving the profits, it would just be disguised through the RVU.

having to go out and get your own patients in the private world is just part of it. Sounds like to me they are offering you every opportunity to go out and eat what you kill from the get-go which is the exact same kind of job offer I took and I went out and made the most of it. If you want someone to hand your patients go work for a guaranteed salary over at the hospital and be like every other schmuck who feels like they’re working for the man and underpaid. I love this job opportunity you have here because skies the limit. You go out and bring home the bacon and you’re going to be well fed. If you don’t go out and perform it’s going to be all on you and you don’t have anyone else to blame for it.

Details of this job that I think you need to clarify. What is the overhead for you? It is fair for you to have to earn the money and pay your share of the overhead but you want to define what that is coming into it. Second thing is ASC ownership. Whenever you get busy enough to justify buying in what would that by and be based onDetails of this job that I think you need to clarify. What is the overhead for you? It is fair for you to have to earn the money and pay your share of the overhead but you want to define what that is coming into it. Second thing is ASC ownership. Whenever you get busy enough to justify buying in what would that by and be based on? If you spend two years hustling and getting that place busy doing pain procedures you don’t want to have to buy in based on the increased EBIDTA that you yourself generated. If that were the case and they tell you that upfront you just simply have to point out it disincentivizes you to do a bunch of cases at the surgery center, it only hurts you in the future. The second thing regarding ASC buy-in; you may not want to buy in and do all of your procedures there. They need to understand that. Unless you own a significant portion of the ASC then you will actually make less money doing the cases there. Your professional fee is cut by 60% and the technical fee will be eaten up with the exorbitant overhead that most ASCs have. Might have that conversation now versus later. If they only have one OR and there are three orthopedic doctors with plans to bring more in they would probably be excepting of this. Getting in-office fluoro going and only doing higher reimbursement cases in the ASC like stimulator trials and implants plus their orthopedic cases they will have a more profit per hour center than they would if they have you in there doing your injections. You’ll be happy and making more for yourself and they will have a very efficiently profitable ASC.

A good friend of mine has recently gone through this exact same transition. They opted to do in-office fluoro.
 
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BobBarker

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There are more than 15 patients/month. You guys just haven’t thought of them yet.

you can do genicular rfa on every Tka two weeks prior to surgery. There is 15 already.

there are at least 10 hip pains that are really SI pain per month as well. They will probably offload the hip injections too but those don’t pay very much. Of course you could have a few patients that would pay cash for prp, amnion, gel one for the hip pain

I think it looks like a nice offer
 
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BobBarker

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If you are an anesthesiologist and you are going to provide anesthesia at the ASC at first then your income will be pretty good. There are lots of interesting business possibilities that might lead to as well.
 
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Agast

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W2 with no base salary? They would have to at least pay you minimum wage to keep it legal...good luck trying to buy a house or borrow money from the bank with that on your record, your debt to income ratio would look ridiculous.
 
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wavygravy99

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A bit low with no base, would ask for 50%. This is essentially a eat what you kill model. The up front cost is your malpractice, credentialing, EMR and support staff for you.

The 50% of ASC fee are they talking about the facility fee or your professional fees? Because you are not making a lot if you are only taking 50% of the professional fees you generate.

I will use myself as example. I joined a small Ortho group myself replacing a non-interventional PMR doc, so situation was a little different as I had existing pt base that I took over and the Ortho group was somewhat stable. I started off with 10k per month of salary as w2, I kept 50% of my collection minus my monthly salary. So If I collected 50k a month. I take home 25k ( 10k of which was already paid). My group doesn't own an ASC, so I could take my pts anywhere. I focused on one ASC bringing all my injection cases there, I kept 50% of collection there just like my regular clinic still but I was able to buy into the shares of ASC 5 months into doing cases there. 1.5 years later I became an equal partner with the other 2 general Ortho. Now I just split overhead, which pre covid was about 40%.

Your argument with them is that you are not taking any base, so the % collection should be higher, other than the upfront costs, there is not much risk. You have incentive to work hard and be productive, otherwise you won't take home anything yourself. The challenge will be the first few months when the reimbursement is slowly coming in, yes you and the practice may not take home much in the beginning
 
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