Job prospect

[Redmen27]

Presently doing a spine/pain fellowship and recently interviewed for a job in the midwest. Wanted to know if this is a standard and reasonable contract?? Long standing pain/spine practice, multiple spine suregeons and interventionalists, 4d a week of injections, 1d clinic, referrals fed from spine surgeons and the community, very reasonable base salary pay. Bonus is 100% of net collected over the base, minus 40% overhead. Pretty good bennies, no partnership availability. Thoughts??

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[specepic]

Presently doing a spine/pain fellowship and recently interviewed for a job in the midwest. Wanted to know if this is a standard and reasonable contract?? Long standing pain/spine practice, multiple spine suregeons and interventionalists, 4d a week of injections, 1d clinic, referrals fed from spine surgeons and the community, very reasonable base salary pay. Bonus is 100% of net collected over the base, minus 40% overhead. Pretty good bennies, no partnership availability. Thoughts??

Speaking as a 2010 grad now in my first gig:

First off, common question here and search will reveal info, that being said, I have no problem with new discussions.

Most important factors are:
-is this the way you want to practice, i.e. for this gig ?be a technician
-will this location work for you/family

As a new grad it is tempting to focus on the $$ and compare offers that way. Much more important is whether the day in/day out work is how you want to practice. This gig sounds like a shot-monkey type job. Probably pretty good $ wise--if not they are screwing you with 4 OR days/week, but if you are from a PM&R background may not be full filling (making assumptions here). Other issue here is surgeons will be deciding on what/who/where to inject and may involve schechy stuff like series of 3. Your ethics/morals may be tested (unless you have few).

I personally do not put a needle in anyone I have not first eval'd, examined, seen the MRI in detail. Don't forget its now you, not your attending whos ass is on the line. Grandma is counting on you to not take advantage of her and do whats right, not what is lucrative.

If you don't like talking to patients or contuniuty of care and just like to bend needles not reflex hammers, go for it

 

[Jcm800]

Presently doing a spine/pain fellowship and recently interviewed for a job in the midwest. Wanted to know if this is a standard and reasonable contract?? Long standing pain/spine practice, multiple spine suregeons and interventionalists, 4d a week of injections, 1d clinic, referrals fed from spine surgeons and the community, very reasonable base salary pay. Bonus is 100% of net collected over the base, minus 40% overhead. Pretty good bennies, no partnership availability. Thoughts??

take it.

 

[bedrock]

Sounds excellent from a pure fiscal standpoint. You just have to ask yourself if you're comfortable with the clinical setup.

The ratio of one clinic day to four procedure days seems a bit extreme. Would be hard to fill four procedure days from one clinic day unless that day is strictly for new evals and you never followup on anyone and you just do different procedures until they get better or return to the surgeon. I would certainly clarify how this works with the other interventionalists in the practice. I would also clarify your autonomy treating patients. It's one thing to have referrals primarily for interventional pain procedures, another to be told you must do series of 3 ESI, then 4 level RF, then stim trial on grandma who isn't that bad off.

Regarding the pay. 60% of collections is generous. Around 50% is average, and 40% is often seen in desirable locales. You should also confirm the site of service. If you're doing 4 procedure days in office and keeping 60%, then you will make a lot of money (well above average). If you're doing 4 procedure days in an ASC that the surgery group owns, then you will make decent but average money as your professional fees in an ASC are much lower (BTW, your ASC days don't actually induce overhead for the group, and if they owned the ASC they would make quite a bit from collecting the facility fees on the procedures you do in the ASC).

If it is the second option (ASC based), I would inquire if you are able to buy into the ASC which would could make your ASC time much more financially rewarding if practice partnership isn't an option.

 

[SCIronMike]

60% is incredible. I'd be all over that.

 

[lobelsteve]

Sounds too good to be true.
Downside: You have no idea who or why you are injecting.
Downside: Increased risk for claims against you.
Downside: If in ASC, you will not make nearly as much as you think.
Downside: You will not follow patients and treat them.
Upside: Some people don't like to follow patients and treat them.

 

[hyperalgesia]

Presently doing a spine/pain fellowship and recently interviewed for a job in the midwest. Wanted to know if this is a standard and reasonable contract?? Long standing pain/spine practice, multiple spine suregeons and interventionalists, 4d a week of injections, 1d clinic, referrals fed from spine surgeons and the community, very reasonable base salary pay. Bonus is 100% of net collected over the base, minus 40% overhead. Pretty good bennies, no partnership availability. Thoughts??

Is this a multispecialty group that owns the ASC where you'll be working? Like others have said, it's kind of risky to be injecting pts that haven't been evaluated (maybe by anyone). A complication will bring up all kinds of questions directed squarely at you alone. But if the referring docs/owners are flexible and receptive to you, it could be okay. I would just make sure that any contract you sign, you have a way out. You just don't want to be trapped in a bad situation.

 

[drusso]

No partnership??

 

[SCIronMike]

No partnership??

Out here in So Cal, all the jobs either have:

1) No partnership track
2) A stated 3 year partnership track, but the senior partner dumps you at 3 years and hires a new grad
3) A partnership track that ends up being full share of overhead but half dividends

 

[specepic]

Out here in So Cal, all the jobs either have:

1) No partnership track
2) A stated 3 year partnership track, but the senior partner dumps you at 3 years and hires a new grad
3) A partnership track that ends up being full share of overhead but half dividends

Would agree with drusso's concerns-I am a relative neophyte but opposed to So Cal the upper midwest and south should have a partnership track unless the annual potential income w/o it is super sweet

 

[Jcm800]

despite owning 50% of my practice, partnership isnt always such an important thing for everyone. It turns out it is for me, but would i need it if i was respected, listened to, utilized properly, had built in referrals, excellent reimbursement and with a say so in the operations that affect me, probably not.

It is annoying meeting with the accountant at 6 pm on a friday when its snowing and you want to get home, but you have to determine an "end of the year tax strategy" or the all of the endless reports, insurances, employee gripes, billing statements, etc.

its not all bad, if i want a day off, a week off, a month off, i take it...but im not paid if i dont work....

bottom line is, in my limited experience as a business owner, there will be less of us in the future, so why deal with the headache now, especially if it isnt worth it financially. just some thoughts as "a partner"

money isnt everything, as we all say, but partnership isnt everything either...
i turned away some pretty sweet offers because there was no partnership, knowing what i know now, i probably would have still turned them down, but ask me in 5 years, i may think differently. good luck

 

[PMR 4 MSK]

Everyone wants partnership, but do you really want to be tied financially to that many people for that long? In my practice, all owner's homes and retirement accounts were put up as collateral against the building of first the ASC, then the new clinic building. Then they all had to put $50K cash into an escrow account. Buy-in for new guys is very, very high - high 6 figures.

If the surgeons just want a needle-monkey, and you don't mind it, it sounds like a good practice. Get a proforma of what they anticipate you'll make and how they arrived at those numbers. The numbers sound a lot like my deal which I find favorable.

If the surgeons want injections, and the patients want injections, and you don't see a contra-indication, go for it. The proceduralist will not necessarily be held accountable for the rest of the treatment plan. I could see an injection gone bad and the plaintiff claiming you should have tried other things first, but you can also argue the other way.

I currently get referrals from a neurosurgeon who asks for specific injections. I see them the day of the injection, and if reasonable, I do it. I don't see it as my job in those cases to go over every medication and decide if they are appropriate, look at how much PT they had and what the therapists were doing, review all injecitons done to date, etc. I do, as part of informed consent, let them know of the alternatives, as well as the risks, and they sign and verbalize their understanding and wishes to go through with the injection.

Interventional rads do this for most of their career. I also do this for MRI arthrograms - Ortho in the practice orders it, I inject the dye before the MRI.

Not all injections requested by someone else require a full work-up by you. If you want to do it, go for it. It might benefit everyone involved. But there are times having procedures tee'd up for you is nice. There are times I am in clinic that I wish I wasn't. Usually it's when I have my fourth new 45 yo female of the day with 35 years of "all over pain" crying and catastrophizing, begging me to give her "something for pain."

 

[SSdoc33]

If the surgeons want injections, and the patients want injections, and you don't see a contra-indication, go for it. The proceduralist will not necessarily be held accountable for the rest of the treatment plan. I could see an injection gone bad and the plaintiff claiming you should have tried other things first, but you can also argue the other way.

I currently get referrals from a neurosurgeon who asks for specific injections. I see them the day of the injection, and if reasonable, I do it. I don't see it as my job in those cases to go over every medication and decide if they are appropriate, look at how much PT they had and what the therapists were doing, review all injecitons done to date, etc. I do, as part of informed consent, let them know of the alternatives, as well as the risks, and they sign and verbalize their understanding and wishes to go through with the injection.

Interventional rads do this for most of their career. I also do this for MRI arthrograms - Ortho in the practice orders it, I inject the dye before the MRI.

Not all injections requested by someone else require a full work-up by you. If you want to do it, go for it. It might benefit everyone involved. But there are times having procedures tee'd up for you is nice. There are times I am in clinic that I wish I wasn't. Usually it's when I have my fourth new 45 yo female of the day with 35 years of "all over pain" crying and catastrophizing, begging me to give her "something for pain."

do you also bill an E&M for these patients, or just the procedure codes?

 

[Tenesma]

partnership is a lot more than just about % ownership and money.... it also means that you have a commitment to the practice and have a say (to some extent) on what does/doesn't happen in the practice...

some people never were meant to be entrepreneurs - and love the McDonald's shuffle: show up at work, bust your ass, go home, rinse and repeat... some people want more...

whenever a practice does NOT offer partnership - it is usually because of money - they are able to hide it better and pay you less...

 

[drusso]

partnership is a lot more than just about % ownership and money.... it also means that you have a commitment to the practice and have a say (to some extent) on what does/doesn't happen in the practice...

some people never were meant to be entrepreneurs - and love the McDonald's shuffle: show up at work, bust your ass, go home, rinse and repeat... some people want more...

whenever a practice does NOT offer partnership - it is usually because of money - they are able to hide it better and pay you less...

Agreed. On a purely philosophical level--and others I'm sure will have different opinions--I think that its important for physicians to own their practices in health care. I have grave concerns about what happens (and is happening) to our profession when all the docs are owned by the hospitals, the HMO's, the very large multi-specialty clinics, the medical schools, and by the government. I see subtle but real differences in attitudes, comittment, and worth ethic between physicians who own their practices and those who are employed.

In my more cynical moments, I see the purposeful isolation of medical trainees from basic business knowledge and procedures (all in the name of "professionalism") as part of a systematic effort to "dumb-down" medical graduates. Face it: Learning to negotiate "conflicts of interest" be they financial, professional, or ethical is part of being a grown-up. If you don't know how and why you're paid for what you do, what you're really worth to organization, or what revenue you create, then you are more likely to gratefully accept whatever "the Man" is willing to pay you for your efforts.

Meeting with the accountant in the middle of a snow storm is a hassle, but it sure does keep you tuned into how the sausage gets made. Employed/owned physicians just go home and don't think twice. So, I tend to view these "no partnership" offers with some skepticism. It signals to me that the employer/owner is not looking for an equal, but looking for a subordinate. Having said that...someday I do imagine just working somewhere and punching the clock. Let some one else worry about meeting payroll!

 

[Tenesma]

you are right... i wonder why there is no business education... i remember as a resident and as a fellow, that as soon as I talked business side of medicine I would get scowls from academics stating that medicine is about helping people, not buying fancy cars...

while I agree with the noble premise - it is slavery to have us become the pawns of HMOs and corporate structures...

the interesting thing, is that most of the new grads are interested in "employment" with "no responsibilities" --- however they also want the income of a business owner...

it just doesn't work that way.

meeting your accountant is the first step - the next step is to find an accountant to audit your accountant to make sure you are being fed the right info... eventually, you will get busy enough to outsource these meetings/corporate/entrepreneurial responsibilities to decrease your time commitments to this.

I like to think of my business as a growing flower... if you don't water it, if you don't provide fertilizer, if you don't clear the brush, that flower is going to die...

 

[painchas]

How do you put a dollar value on the 900,000$ loan to start the practice from 0. All of the marketing junk done to establish the name and reputation of the practice. The constant early on asking of yourself "is this practice going to make it long term?" Building the practice up one brick at a time. The constant struggle in the first several years of hiring and firing getting it right with the office team, finding the right manager....again... You have to put a margin in there for new hires above overhead to justify why you did what you did to make it go in a very competitve enviroment. Becoming the king daddy practice comes with a price. New hire MDs cant just assume fairy dust was sprinked to make success happen. Full partners.... I dont think so. Does Truett Cathy do it a Chik fil a. Did the folks at Coca Cola do it in the beginning or now? Thought

 

[Jcm800]

How do you put a dollar value on the 900,000$ loan to start the practice from 0. All of the marketing junk done to establish the name and reputation of the practice. The constant early on asking of yourself "is this practice going to make it long term?" Building the practice up one brick at a time. The constant struggle in the first several years of hiring and firing getting it right with the office team, finding the right manager....again... You have to put a margin in there for new hires above overhead to justify why you did what you did to make it go in a very competitve enviroment. Becoming the king daddy practice comes with a price. New hire MDs cant just assume fairy dust was sprinked to make success happen. Full partners.... I dont think so. Does Truett Cathy do it a Chik fil a. Did the folks at Coca Cola do it in the beginning or now? Thought

this is the truth. We talked about a third "partner" next year, but i doubt they would become truly 33% for at least three years, and then they would have to "buy in" and that buy is on all the sweat and stress and toils. If you are hiring someone, that means you have done something right. Now if you work hard and put in the time and show value, then there is merit in adding you as a "partner" but it takes years to figure that out. If you (the new hire) can do it better, then do it. Start your own practice from ground up and you will never have to worry about being partner, you will be the partner, maybe the ONLY partner if you so wish.

The viewpoint changes depending if you are the employee or the employer. Everyone wants it all, but why should someone give it to you. While it may not be "fair" for the employer to take advantage of the new grad, its business, and if you can get a lot for little, then it was good business decision. Now those decisions dont work out long term, but there are guys in my area that have been in practice for 15 years, on their 5 "partner." do the math...

 

[lobelsteve]

I think people equate owning their business with being partner as a necessary.
I like to think I'm one of the guys from the movie " Office Space ". Initech Pain Practice.

I want nothing to do with being partner or dealing with business. I accept a salary and productivity bonus and perform work as I am trained. It was clear from the beginning regarding the level of autonomy and what patients I would and would not see, what procedures I do and do not do, and my prescribing habits. I had a spreadsheet detailing how much each procedure and follow up was worth based on CMS, PPO avg and had ability to alter casemix to get approx bottom lines. We used my data to determine how much I was worth to the practice. Since ancillaries were not part of my deal (Stark) and are owned by the practice and I am an overutilizer of imaging and PT compared to the PCP, it made good sense to the practice.

I have no control over the business side of things, only the clinical side of things. I work M-F 8-4, no call. I make half of what a Pain practice owner makes. I go to 1 monthly meeting and get paid to go. I have no risk in the business. I have no worries or stress in the business. I am treated very well by my admin and by the owner docs.

I know of a pain doc an hour away who built his practice from scratch. He is not married. He worked 120 hours per week for the first 3 years and took home under $100k each of those years. He now makes $1M a year and has hired 1 doc under him. He still works 80-100 hours per week.

We make the same per hour and I can live with that, my wife, 2 kids, and a golden retriever. Someone get me a Volvo wagon and I'm a stereotype.

I would never want to be a partner or own my business. Life is too short to chase millions- I was up watching the Geminids fall from the sky and got too cold out. Only 2 hours until my first patient of the day. Ahhh. Loving it.

 

[Tenesma]

painchas... i 100% agree with you... but you need your MDs in the practice to feel like they are committed or invested - they will always perform to a higher degree and in the interests of the practice if they have "some" ownership stake... does it mean that they get full control of the practice? no...

the other beauty of sharing partnership is that it is a way to financially divest yourself of your practice when you hit retirement...

 

[PMR 4 MSK]

do you also bill an E&M for these patients, or just the procedure codes?

Just procedure codes.

you are right... i wonder why there is no business education... i remember as a resident and as a fellow, that as soon as I talked business side of medicine I would get scowls from academics stating that medicine is about helping people, not buying fancy cars...

while I agree with the noble premise - it is slavery to have us become the pawns of HMOs and corporate structures...

the interesting thing, is that most of the new grads are interested in "employment" with "no responsibilities" --- however they also want the income of a business owner...

it just doesn't work that way.

meeting your accountant is the first step - the next step is to find an accountant to audit your accountant to make sure you are being fed the right info... eventually, you will get busy enough to outsource these meetings/corporate/entrepreneurial responsibilities to decrease your time commitments to this.

I like to think of my business as a growing flower... if you don't water it, if you don't provide fertilizer, if you don't clear the brush, that flower is going to die...

My entire formal business education in training consisted of 1 day of lectures in med school and 2-3 hours in residency. I was naive enough to think that because i could balance my checkbook and am good at math that I could run a business. I sucked at it.

As above, some people are cut out to be entrepreneurs and others to be employees. What matters is what works for you. If partnership is important, don't take a job where it is not offered or "iffy." Know what it will take to become a partner from the start. Don't be the first new hire of a solo practice where he tells you you "might" be offered partnership in 2 years. It'll never happen.

I like having more free time traded for less money. I make more that 98% of Americans, and more than 99.9% of the rest of the world.

Work smarter, not harder.

 

[Tenesma]

amen... everybody should read the 4 hour work week - while a lot of it is an extreme way of doing things, it reminds you that there are ways to adjust your life and work less hard for more money.

 

[Tenesma]

and an additional thought: not only do we get little business training... but we often start relying on outside counsel (accountants, tax lawyers, finance professionals), who, in fact, do NOT really have our best interest in mind. Their focus is usually short-term profit off our hard work....

literally EVERY finance professional I have ever met, as soon as they become aware of my cash flow/assets wants to sell me on ALL kinds of products - especially cash-value life insurance plans... and they never ever have to disclose their commissions and kickbacks - in fact, in their industry kick-backs are expected and legal...

which is so different from medicine, where not only are kick-backs illegal, but we are morally/ethically/and more recently legally obligated to share our financial dealings as it relates to health care cost....

i wish there was a book written by doctors for doctors....

 

[Sandpaper]

i wish there was a book written by doctors for doctors....

...like an updated "The House of God"?

There is clearly a need for a more jaded and cynical view of medicine as oppose to the touchy-feely lovey-dovey books regurgitated by the celebrity doctors out there.

For many people the perception is that medicine is a profession, a "calling". And money, running a practice, contract disputes with payors are the hush-hush dirty aspects of modern medicine best kept out of view, kinda like when your teenage daughter gets knocked up by, say, Levi Johnston.

But I digress, being a martyr is to no one's advantage. Recently heard a talk given by Samuel Shem, writer of The House of God. He seemed chagrined by its success and now is trying to make amends for its cynical ways by publishing a more saccharin book, The Spirit of the Place. The name itself is nauseating.

 

[drusso]

How do you put a dollar value on the 900,000$ loan to start the practice from 0. All of the marketing junk done to establish the name and reputation of the practice. The constant early on asking of yourself "is this practice going to make it long term?" Building the practice up one brick at a time. The constant struggle in the first several years of hiring and firing getting it right with the office team, finding the right manager....again... You have to put a margin in there for new hires above overhead to justify why you did what you did to make it go in a very competitve enviroment. Becoming the king daddy practice comes with a price. New hire MDs cant just assume fairy dust was sprinked to make success happen. Full partners.... I dont think so. Does Truett Cathy do it a Chik fil a. Did the folks at Coca Cola do it in the beginning or now? Thought

Law firms do it all the time. Associates are hired, work their *sses off, and become named partners. If they can't meet the required production and leadership requirements, they're passed over. They can either continue to work as an associate or move along to a different practice.

 

[drpainfree]

all we have to do is to look at how successful chiros are in running business...

 

[powermd]

Just procedure codes.
My entire formal business education in training consisted of 1 day of lectures in med school and 2-3 hours in residency. I was naive enough to think that because i could balance my checkbook and am good at math that I could run a business. I sucked at it.

I have a master's degree in business (health concentration). It taught me next to nothing about the practical management of a solo or group private practice. I sure learned a lot about how to function in a corporation, assuming someone were to put me in a high level managerial position immediately. What a waste of time. 99% of it is common sense, the rest is accounting.

 

[Tenesma]

the true benefits of a master's business degree (depending on where you go) are A) Networking B) learning how to manage/delegate...

an MBA running an office practice is a waste of a degree