Leave contract to hang a shingle?

[Action Potential]

Hi Everyone,

clinic isn't giving me enough pts and I'm not making money.

Background: first job after residency, joined psych private practice single owner MD established in area for years, with a few mid levels.
Good payer mix in MCOL/HCOL, good size metro pop. 300K +.
got a SLOW start last summer / fall, delayed by credentialing with insurance (managements fault?) and pandemic.
Didnt See a patient until OCT '20!? panel is now up to ~250 pts, seeing 2-3 new evals daily, and few F/U trickling in now. What chaps my A** is that a mid level was hired at the same time I was, hence taking new pts that would have gone to me... no idea why this was done. The mid levels all take off on Fridays , lots of vacations, and clearly are cut from a different cloth than me. I digress.

spoke with owner, communicated that I need to see more. He said absolutely, Ill have staff get on it. later I circled back because there was a slight uptick and then returned to prior pace. Again, said I'm not seeing enough, he said we'll get you more. Oh and suggested I do shifts at a clinic in town in the meantime because they have a ton of pts and no psych help, suggested I might be able to help them.

Contract is 60 / 40 split. No sign on bonus, No production bonus, No health insurance, No retirement match, and no access to 401K option until several months in. They paid for relocation and malpractice.

making ~8-9K / month. At this pace, I MIGHT make 100 this contract year, if it picks up MAYBE 150, but 200 is impossible.
Ive been working 1099 on side at a hospital to mitigate, even taking off weekdays at clinic in favor of hospital shifts.
Im working every single weekend at hospital and working M-F at clinic. Have 500K of debt...yes, 500K all school loans, no new cars or credit cards, and don't want to lose another 1 year of building pt base if I leave now. Plus "I don't have the time" to research real estate, billing & coding contract, hire staff, blah blah.

Why arent there other physician partners? Why did I sign with 60/40 split and no guaranteed minimum? What options do I have? Leave now (pay the few thousand fee for leaving early) and lose all my pts? (maybe take them with me?)
Am I out of touch?
Thank you so much everyone for your time.

[ENT Doc]

I would start a new job search. At worst it leads to leverage with your current employer.

[jfoxcpacfp]

Just curious as to what caused you to sign a contact with these terms - there must be more to this story.

[hebel]

Hi Everyone,

clinic isn't giving me enough pts and I'm not making money.

Background: first job after residency, joined psych private practice single owner MD established in area for years, with a few mid levels.
Good payer mix in MCOL/HCOL, good size metro pop. 300K +.
got a SLOW start last summer / fall, delayed by credentialing with insurance (managements fault?) and pandemic.
Didnt See a patient until OCT '20!? panel is now up to ~250 pts, seeing 2-3 new evals daily, and few F/U trickling in now. What chaps my A** is that a mid level was hired at the same time I was, hence taking new pts that would have gone to me... no idea why this was done. The mid levels all take off on Fridays , lots of vacations, and clearly are cut from a different cloth than me. I digress.

spoke with owner, communicated that I need to see more. He said absolutely, Ill have staff get on it. later I circled back because there was a slight uptick and then returned to prior pace. Again, said I'm not seeing enough, he said we'll get you more. Oh and suggested I do shifts at a clinic in town in the meantime because they have a ton of pts and no psych help, suggested I might be able to help them.

Contract is 60 / 40 split. No sign on bonus, No production bonus, No health insurance, No retirement match, and no access to 401K option until several months in. They paid for relocation and malpractice.

making ~8-9K / month. At this pace, I MIGHT make 100 this contract year, if it picks up MAYBE 150, but 200 is impossible.
Ive been working 1099 on side at a hospital to mitigate, even taking off weekdays at clinic in favor of hospital shifts.
Im working every single weekend at hospital and working M-F at clinic. Have 500K of debt...yes, 500K all school loans, no new cars or credit cards, and don't want to lose another 1 year of building pt base if I leave now. Plus "I don't have the time" to research real estate, billing & coding contract, hire staff, blah blah.

Why arent there other physician partners? Why did I sign with 60/40 split and no guaranteed minimum? What options do I have? Leave now (pay the few thousand fee for leaving early) and lose all my pts? (maybe take them with me?)
Am I out of touch?
Thank you so much everyone for your time.

Am I reading this right? You have a 250 patient panel which you started building in late 2020 and currently only have a few follow-ups "trickling in?"

Also, who does your coding and billing?

[Action Potential]

Just curious as to what caused you to sign a contact with these terms - there must be more to this story.

Well, I signed on during a pandemic. I was in talks with several recruiters, all the psychiatry jobs were frozen / gone. Nobody was hiring, not even the Locums for 400K in Alaska. 60/40 seemed reasonable at time, of course now I realize its BS, considering psychiatrists need a couch and a desk lamp.

Was told there’s a surplus of pts and huge need in area. Other docs/ clinics are shocked when I say “yes Im taking new pts”. Pts say “wow I cant believe I got an appt with you in one week...everywhere has a 3 month wait or not seeing new pts”.

I think its bc they hired a couple mid levels just as I was hired...instead of seeing 6 new evals, Im seeing 2. Otherwise, Im board certified md, no charges/ legal history, personally or professionally. No personality clashes or conflicts... I like everyone there actually.

[CordMcNally]

I would look for pretty much any job besides the one you’re in. You could go work on an off shore drilling rig right now and make more money.

[Action Potential]

Am I reading this right? You have a 250 patient panel which you started building in late 2020 and currently only have a few follow-ups "trickling in?"

Also, who does your coding and billing?

Yes, thats correct. Majority since hire 1-2 evals, then 4-5 follow up and maybe 2-3 evals more recently, have had 4 eval sometimes.
2 Evals x 5 days / week = 10. 10x4=40. 40 x 6 months = 240.

I *think* its done in house. Not positive.

[zlandar]

Look at your contract and see if there is a noncompete. Check who covers your tail if you leave the practice.

Network and see what jobs are out there. How are your fellow residents doing? Maybe they know a job opportunity.

[hebel]

Yes, thats correct. Majority since hire 1-2 evals, then 4-5 follow up and maybe 2-3 evals more recently, have had 4 eval sometimes.
2 Evals x 5 days / week = 10. 10x4=40. 40 x 6 months = 240.

I *think* its done in house. Not positive.

I think the glaring issue with this job is the pay. You seem frustrated at the lack of new patients, but I would say that actually you've been able to build up that 250 patient census very fast. You are actually not too far off from a "full" panel size, so I don't think your panel size/patient volume is the issue either. In fact, you've been working very hard. I saw earlier you being frustrated about only having 2 new patients per day instead of closer to 6. Six new evals in a day would be insanity. I've capped my employer at 2 per day. So this goes back to the main issue of why are you making such little money despite working pretty hard in my opinion.

What are your monthly wRVU figures?
Is the 60/40 based on the billed or collected wRVUs?
What codes are you using for new patients and what codes are you typically billing for follow-ups?
How long are your follow-up slots?
What's the approximate follow-up frequency for patients? (often it's 2 weeks after first visit, then monthly, then q 3 months once stable). I would expect you to have more daily follow-ups since this panel is made up of mostly newer patients.
Are you utilizing psychotherapy add-on codes?

I would also ask this question on the sdn psychiatry forum. There's lots of private practice psychiatrists who will be very helpful. I'm an employed psychiatrist. Ultimately, your current income seems so far apart from what you should be making for the (1099?) work you're doing that I could see this job not working out in the end. They are getting a phenomenal deal from your work so far.

[Action Potential]

Good thoughts and questions from everyone, thank you.

zlandar No non-compete in contract. Good question about tail coverage but its not an issue, I can purchase my own for <5K. so what. Other residents are doing well, they signed on with VA and Academics, but not in my state, no help.

hebel Havent asked or been given those wRVU numbers. 60% is gross receipts collected. New evals get typical 90792, most follow ups are 99214 as being an MD I tend to get more complicated pts and many* have not stabilized. Have a small % stabilized and 99213. Billing for psychotherapy very infrequently (although Im using it), so maybe thats an area that could help, but regardless, is it going to make up for not seeing 15- 20 pts daily? Follow ups are 20mins, and yes my f/u frequency is very similar, near identical (I learned something in residency!). Im not running a mill, not even close, not what I went to school for.
Sorry, to clarify, I am "employed" w-2 in clinic, Im 1099 on side hustle/ hospital.
I...think a full panel would be >500, maybe closer to 1000? 15 pts / day x 5 days x 4 weeks = 300 x Q 3 months = 900. Correct me if it doesnt work this way?
I don't feel like I'm working hard...yes, 4 evals is not nothing, 6 is a lot, but coming out of residency, its less work than I was doing there, for sure.

[eyecandy]

Wait, am I understanding that you're receiving 60% of gross receipts, but not receiving health insurance or a matching 401K? So do tell what exactly is 40% of your reimbursements going to --the front desk staff and rent alone? Sounds like you're paying for the mid-levels with your salary. Although I'm a completely different field this seems extremely high overhead you're paying for psych. Am I missing something?

If I was in your shoes I would is start interviewing, procure a reasonable job offer then go back to your boss and renegotiate. List out all the things that you need to stay and kindly ask for every last one of them. If they want to keep you they'll meet your requests. If not, move on. Good luck! let us know how it turns out

[Shant]

This seems so disproportionate to me that staying guarantees spending the next decade fighting for what you should have started with. I would strike out on my own, do an advertising blitz on availability and get on with building a proper practice.

[braindoc]

Well, I signed on during a pandemic. I was in talks with several recruiters, all the psychiatry jobs were frozen / gone. Nobody was hiring, not even the Locums for 400K in Alaska. 60/40 seemed reasonable at time, of course now I realize its BS, considering psychiatrists need a couch and a desk lamp.

Was told there’s a surplus of pts and huge need in area. Other docs/ clinics are shocked when I say “yes Im taking new pts”. Pts say “wow I cant believe I got an appt with you in one week...everywhere has a 3 month wait or not seeing new pts”.

I think its bc they hired a couple mid levels just as I was hired...instead of seeing 6 new evals, Im seeing 2. Otherwise, Im board certified md, no charges/ legal history, personally or professionally. No personality clashes or conflicts... I like everyone there actually.

stop what you're doing right now and go read dennis hursh's book the final hurdle. Then consider hiring resolve or contract diagnostics to help you figure out your outs for this contract and what you should be commanding as a new attending in your field.

[FIREshrink]

You are being abused so badly I think I need to call APS. My salary guarantee was $140k 18 years ago and i surpassed it within four months.

[Action Potential]

Ay yi yi, its worse than I thought. The overwhelming response has been that I need to figure this out ASAP. All of you just saved my life.
Will be back with an update on contract review, negotiation, moves.