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First Attending Job Questions

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  •  doctorhubby 
    Participant
    Status: Spouse
    Posts: 7
    Joined: 10/20/2018

    My wife finishes training in 2020.  We want to move back to her mid-size hometown, short of something drastic happening we’re firm on this and plan on being there for the long haul.  She had casually started reaching out to doctors in the area, seeing what the market is like and there has been solid interest already.  The main options are private practice, which are mostly the older docs, and 4 hospital-based employed setups.  She’s talked to docs across this entire spectrum.  She’s leary of PP and likely not the best fit for her, at least for now.  Of the hospital options, only 1 really stands out as a good fit for her in terms of structure, culture, etc. and practicing how she wants.  Not ideal, but this may be her only good option.  They made her a tentative offer that sounds pretty good: 3yr contract, 2yr 400k followed by 100% rvu, 20k signing, malpractice+tail, no non-compete, 4-5wks vacation, cme money, 401k w/ match, 457b.  Overall seems pretty solid, above average starting salary based on everyone we’ve talked to.  100% rvu certainly gives pause, but attendings there say it’s not an issue and plenty busy.  Wife doesn’t think she’ll mind rvu-based pay vs salary.  By all accounts, the hospital is solid and on the rise.  We’re solid financially, no debt and low-mid 6-figure portfolio by the time she starts.

    1. Any potential issues or problems of signing a contract so far out? We’d like to lock it in, I think they’d like to also.  We don’t plan on anything changing between now and then.  I also can’t imagine the job market or hospitals changing that much between now and then, but I could be wrong.

    2. Any concerns with 100% rvu?  Those with experience in that setup care to share?

    3.  Any harm in not negotiating?  We’re pretty happy with most things, maybe more vacation.  But also it seems outside of salary and signing bonus, everything else is standard for all docs.  They provided a standard-looking hospital document that details everything.  If we decide not to negotiate, is a contract review lawyer necessary?

    4.  They seem to provide the full range of benefits(in addition to above: life insurance, disability), anything we might’ve missed that is commonly missed with new docs?

    5.  Certainly plan on renting the first few years, but is it even more prudent with the 100% rvu salary on the horizon? Better to wait until that settles in before buying?

    6.  They sent her a one-page summary of their interest and salary/benefits, I don’t think it’s a contract, but is this what we have the lawyer go over, if negotiating or ironing out details/language, or do we wait for the contract to go over it with fine tooth comb?

    7.  What typically happens when contracts expire?  Sign another contract?  Go on a year-to-year basis?  Is this something that should be addressed in the current contract?  Presumably, they could also not offer her a new contract after 3yrs and she’d have to find another job?  How common is this?

    8.  Any other tips, advice, things we should be looking out for, either the contract, job, organization, etc.?

    Certainly is an exciting and daunting time, but any input is appreciated..

    #171646 Reply
     Peds 
    Participant
    Status: Physician
    Posts: 2110
    Joined: 01/08/2016
    1. Any potential issues or problems of signing a contract so far out?

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    yes you find something better

    2. Any concerns with 100% rvu?

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    not necessarily. should find out what that equates to roughly based on practice volume

    3.  Any harm in not negotiating?

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    always. assume shes being underpaid.

    5.  Certainly plan on renting the first few years

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    yup

    do we wait for the contract

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    yes but that also means you told them youd like to move forward for the most part

    7.  What typically happens when contracts expire?  Is this something that should be addressed in the current contract?

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    that

     

    #171688 Reply
     childay 
    Participant
    Status: Physician
    Posts: 691
    Joined: 01/09/2016
    2. Any concerns with 100% rvu?  Those with experience in that setup care to share?

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    As I mentioned in another recent thread, you want to know exactly what “100% RVU” means.  You will want to negotiate the “conversion factor” which is the amount she will be paid per wRVU.  You should have access to current employee’s productivity numbers ie: total yearly wRVUs.

    Also if you’re signing a contract that long out, have them pay you a stipend or at least a bigger signing bonus.  $20k is pretty low I would think.

    #171695 Reply
     aCMD 
    Participant
    Status: Physician
    Posts: 8
    Joined: 10/05/2018

    What field of medicine?

    Given you are financially stable why the rush to sign a contract 2 years out? If you like them now and they like you that should still be the case in 2 years.

    100% RVU– I have been on wRVU’s since I began. Below is a copy from a prior post on my contract/pay structure:

    I am an employed family doctor NO Ob care in practice 14 years. Multiple support staff- CMA, LPN, RN, PA and NP in our office. I believe our current family medicine contract is $180,000/ year guaranteed x 1.5 years with signing bonus. This equals 400 wRVU’s per month. After 1.5 years you are expected to cover this amount or reduce your ‘draw’- see below. Our group employs physicians in both urban and rural communities we are paid the same based on wRVU’s at $37.50. We have a monthly ‘draw’ in which I am paid a set amount ( I choose in conjunction with management) currently around $14000 per month. Every quarter we go through a reconciliation process and any amount over the ‘draw’ is paid out in the next paycheck. If by the end of the year we have not cleared the our yearly ‘draw’ we have to pay the amount we did not cover back (I have never done this). We have a productivity bonus structure based on prior year MGMA percentile data by provider type that is paid out at the end of the fiscal year.

    Looking at my reports for Fiscal Year 2017-18 for Family Medicine No OB (1 FTE)- from MGMA:

    Percentile       wRVU

    50th               4850

    75th               5947

    90th               7150

    For Fiscal Year 2017-18 I generated 7183.12 wRVU’s over the 90%ile.

    So I cleared the 75th%ile I received $1.50 per wRVU earned for the year= about $11,000

    If we clear the 90th%ile we are paid 5% of our total pay for the year. Each year that we clear the 90th%ile this increases by 1% to a max of 9%. Therefore this bonus was hit as well.

    For supervision of NP and or PA we are paid $7.50 per wRVU they generate. These providers also have a similar bonus structure to the above.

    We are paid $110 per hour (this is roughly what we make per hour in the office) for any required meetings, Medical directorships, etc.

    We also receive decent Health Insurance, 401k with Roth option, 457b non government, CME reimbursement at $2500/ year, ALL licenses- State, DEA and Board Fees are considered a practice expense paid directly by my office (not part of CME) and 4 weeks Vacation and 1 week of CME time off (not paid).”

    So places to negotiate and things to look for (random thoughts): NP/PA supervision pay/process, Bonus structures (if offered), compensation for non clinical duties (ie those that do not have a wRVU associated with them)- do not give your time away, Call schedule, how much input do you have on your daily office schedule, what EMR is the system using and is it integrated outpatient/inpatient and in the community. Do they use scribes, templates and or voice recognition software for documenting visits, how much support staff will you have. Are there opportunities for advancement into leadership, medical director positions. You did not mention if they pay for licenses- ask about this. Is the vacation – paid ie a daily stipend when you are off.

    With regard to your contract and what happens at the end of 3 years- I would anticipate this an “evergreen” contract in that it renews automatically every year on its anniversary unless there is a written request to terminate the contract. I would anticipate you being required to work 3 years under the contract or there may be a penalty/pay back process for the signing bonus and guaranteed pay portion of contract.

     

    Good luck

    Greg

     

     

    #171700 Reply
    Liked by Doc Spouse
    ENT Doc ENT Doc 
    Participant
    Status: Physician
    Posts: 2038
    Joined: 01/14/2017

    You’re 1.5 years out, so good job to your wife for being so proactive and looking into these options and talking to all those people. Has she visited the hospital and seen the operations in the clinic? Does she have specific info on patient volume, referral base, hospital financials, how consults are allocated, what the $/wRVU will be, % Medicaid (this affects no shows), who controls scheduling and patient flow, etc.

    I’d make sure there’s a termination without cause section of the contract that includes her. That way if things change or she finds another job she can terminate with proper notice and jump ship.

    My concerns re: 100% wRVU is that your info is based on word of mouth and not numbers provided. Secondly, you don’t provide the conversion rate. And also importantly, your clinic flow/volume is not just dependent on you but the support staff, scheduling and rooming operations, hospital marketing budgets, built in referral system or payer contracts, local competition, and the time it takes to do all the hospital check in crap to stay in compliance with any host of programs/protocols not designed by you. The effect of these issues is that you find that your salary is less dependent on you and more dependent on others’ capacity to help you generate wRVUs. This would be a huge concern with going to 100% wRVUs. If I was 100% in control maybe, but she certainly isn’t.

    She has leverage here in that it sounds like they really want her and she’s a threat (or at least should make it apparent that she’s interested in local work otherwise). Negotiate, especially the wRVU thing.

    #171703 Reply
    jfoxcpacfp jfoxcpacfp 
    Moderator
    Status: Financial Advisor, Accountant, Small Business Owner
    Posts: 6148
    Joined: 01/09/2016
    6.  They sent her a one-page summary of their interest and salary/benefits, I don’t think it’s a contract, but is this what we have the lawyer go over, if negotiating or ironing out details/language, or do we wait for the contract to go over it with fine tooth comb?

    Click to expand…

    You need the contract before you hire an attorney unless you want the attorney/reviewer to negotiate for you (I believe Contract Diagnostics offers this service). The one-page summary means nothing at this point and can change between now and when you’re ready to negotiate.

    7.  What typically happens when contracts expire?  Sign another contract?  Go on a year-to-year basis?  Is this something that should be addressed in the current contract?  Presumably, they could also not offer her a new contract after 3yrs and she’d have to find another job?  How common is this?

    Click to expand…

    It typically depends on what, if anything, is stipulated in the original contract. Up to her, too, if she wants some specific succeeding period but, at this point, there is no way to tell what you will want when the contract runs out. Some contracts say that they will automatically renew if such and such is accomplished OR if “nothing bad happens” (just the gist, lol). Others that the contract goes on a year-to-year basis – not all stipulate, though.

    The purpose of a contract is for both sides to be represented in a way that is fair to them – not necessarily fair to both parties. You can be assured that the hospital is putting its own interests before hers. And you can be assured that everybody will be wearing their best Sunday manners. That doesn’t mean they aren’t thinking of what is fair to your wife but, if there is a question, their well-being will be first priority. The hospital is above all in business to stay in business. That means making employees happy to stay, to some CEOs. To others, it means the company’s interests will best be served by making all decisions with the bottom line in mind. Think about that before you decide there is nothing to negotiate.

    Johanna Fox Turner, CPA, CFP, Fox Wealth Mgmt & Fox CPAs ~ 270-247-0555
    https://fox-cpas.com/for-doctors-only/

    #171705 Reply
    Liked by Doc Spouse
    jsr52 jsr52 
    Participant
    Status: Physician
    Posts: 156
    Joined: 03/20/2017

    2. Any concerns with 100% rvu?  Those with experience in that setup care to share? – ask what everyone else in the group is making, I did that and was told all the docs make X amount on average, and one doc who choose to be less productive makes X (which was still a good number)

    3.  Any harm in not negotiating?  We’re pretty happy with most things, maybe more vacation.  But also it seems outside of salary and signing bonus, everything else is standard for all docs.  They provided a standard-looking hospital document that details everything.  If we decide not to negotiate, is a contract review lawyer necessary? Yes, there is harm, you come off as weak, they expect you to negotiate. You are leaving money on the table. When I negotiated I got a 30,000k increase in base + a 20K increase in signing bonus (this was huge for covering expenses like board exams prior to finishing fellowship). If you are pretty happy with most things as is you will be happier after negotiating. 

    4.  They seem to provide the full range of benefits(in addition to above: life insurance, disability), anything we might’ve missed that is commonly missed with new docs?

    5.  Certainly plan on renting the first few years, but is it even more prudent with the 100% rvu salary on the horizon? Better to wait until that settles in before buying?

    6.  They sent her a one-page summary of their interest and salary/benefits, I don’t think it’s a contract, but is this what we have the lawyer go over, if negotiating or ironing out details/language, or do we wait for the contract to go over it with fine tooth comb?

    7.  What typically happens when contracts expire?  Sign another contract?  Go on a year-to-year basis?  Is this something that should be addressed in the current contract?  Presumably, they could also not offer her a new contract after 3yrs and she’d have to find another job?  How common is this?

    8.  Any other tips, advice, things we should be looking out for, either the contract, job, organization, etc.?

    Certainly is an exciting and daunting time, but any input is appreciated..

    #171707 Reply
     doctorhubby 
    Participant
    Status: Spouse
    Posts: 7
    Joined: 10/20/2018

    Great thoughts so far.  Some of the points brought up have been mentioned in the documents provided or in person, other info will be clarified moving forward and/or have it spelled out in the contract more clearly.  Few more questions, is pay for call common for employed setups?  What about pay for going to dept/hospital meetings?

     

    #171711 Reply
    ENT Doc ENT Doc 
    Participant
    Status: Physician
    Posts: 2038
    Joined: 01/14/2017

    Call would be expected as part of your being employed. That would be incredible if you got additional pay for that. I imagine medical staff meetings may be required but ask. Same thing for Dept Meetings. If you were volunteering your time on another committee I imagine that might be more negotiable.

    #171713 Reply
    Liked by jfoxcpacfp
     Tim 
    Participant
    Status: Accountant
    Posts: 600
    Joined: 09/18/2018

    http://physiciancompensation.org/PDFs/2015RSPWB/2015Survey.pdf

    1) This was shared was shared previously. AMGA and MGMA have detailed surveys and data available.
    To determine fair, you need data. Being new, sorting through you want to hire a “guide” to make sure you understand what the market is and the potential upside as well as downside.
    2) Your interest is being paid for every hour you spend on behalf of your occupation. Oncall, administrative, etc. as well as practicing medicine. You want a “guide” to translate that into your contract.
    3) Any expenses relating to credentials, both maintaining and renewing your interest is them being paid. Some are offering student loan repayment as well.
    Some will agree to a retention bonus either on completion or a renewal (built in signing bonus).
    Almost all verbal understandings of responsibilities compensation and factors the impact you need to be in writing.
    The best way to get this is an attorney that specializes in healthcare law and employment contracts.
    Rather than seeking items to negotiate, I would suggest you focus upon which guide to “hire”.

    https://www.whitecoatinvestor.com/forums/topic/contract-review-service-contract-diagnostics-dennis-hursh-or-someone-else/

    #171728 Reply
     GoBlueMD 
    Participant
    Status: Physician
    Posts: 36
    Joined: 05/27/2017

    Sometimes, the large base for two years is to get your foot in the door. Make sure that the amount of wrvus you would have to generate to get 400k after the honeymoon phase is in line with MGMA median. I suppose the first two years will be a trial run. In addition, the signing bonus will have strings. If you leave earlier than 3 years, you may have to pay some or all of it back.

    4-5 wks vacation seems low, but this will depend on the specialty. Maybe that does not include CME time? This should be added in/clarified as that may add another 2 weeks paid time off. Also make sure that weekend call counts as a shift that would have to be balanced with an extra weekday off. If not the 4-5 wks vacation will not be accurate.

    #171730 Reply
     doctorhubby 
    Participant
    Status: Spouse
    Posts: 7
    Joined: 10/20/2018

    Sometimes, the large base for two years is to get your foot in the door. Make sure that the amount of wrvus you would have to generate to get 400k after the honeymoon phase is in line with MGMA median. I suppose the first two years will be a trial run. In addition, the signing bonus will have strings. If you leave earlier than 3 years, you may have to pay some or all of it back.

    4-5 wks vacation seems low, but this will depend on the specialty. Maybe that does not include CME time? This should be added in/clarified as that may add another 2 weeks paid time off. Also make sure that weekend call counts as a shift that would have to be balanced with an extra weekday off. If not the 4-5 wks vacation will not be accurate.

    Click to expand…

    Never heard of this, is it common?

    #171733 Reply
    SerrateAndDominate SerrateAndDominate 
    Participant
    Status: Physician
    Posts: 222
    Joined: 02/01/2018

    Great job on jumping on this. Never too early. I did the same with a hometown group, and it is working out beautifully. Never hurts to ask for a fellowship/residency stipend.

    Earn everything.

    #171736 Reply
    Liked by Tim
     doctorhubby 
    Participant
    Status: Spouse
    Posts: 7
    Joined: 10/20/2018

    Is a stipend basically signing bonus?  Right now it’s 20k, but seems like more can be asked for.

    #171737 Reply
    SerrateAndDominate SerrateAndDominate 
    Participant
    Status: Physician
    Posts: 222
    Joined: 02/01/2018

    It can be. It’s like a signing bonus distributed over your last 1-1.5 years in training. In some cases, it can be in addition to a signing bonus. All about what you ask for and their willingness to bring someone on

    Earn everything.

    #171738 Reply

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