How much money should you get to supervise a mid level?

[Karen]

I am a derm looking at new contracts and some of the jobs want me to supervise PAs and sign off on their charts. How much is reasonable to get as compensation for the time (some are fresh out of school and some are well seasoned) and additional liability?
5%, 10%, 20%, 50%??
$25 per chart, $50 per chart???

[CM]

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[MichaelB]

I’m not sure what a fair amount would be, but you definitely need to get something for it. I would think a percentage of revenue would be more fair than a per chart amount, but would be harder to calculate.

My guess is somewhere in the 25% range. If you are looking for a per chart amount, maybe $15-$25 but no more. This definitely needs to be something you discuss in detail and have written out clearly in the contract.

[wideopenspaces]

I know it's not the same but when I supervise residents I get paid as though I was seeing patients myself. I'm employed though. So if I spend 4 hours supervising them, it counts as 4 hours of seeing my own patients. Doesn't matter if I'm supervising 1 or 6. We also have a PA and some NPs but I don't have any responsibility over them and I've never asked the doc how much he gets paid to do it.

[VagabondMD]

A NYT article you might want to read re Derm supervising midlevels and the discussion here, in case you missed it.

https://www.whitecoatinvestor.com/forums/topic/beware-the-aggressive-dermatologist/

[Jaqen Haghar MD]

Not sure about derm, but I supervise residents, PAs, NPs in EM.  Full RVUs for residents and 30-50% RVUs for the PAs and NPs.  I interview and examine all the patients seen with all of them, not just signing charts.  They do a lot of the procedures and grunt work.

I can tell you that working with a good, hand picked and well trained and mentored PA or NP is much easier and probably much safer in my experience.  The right ones, with experience and training become an extension of yourself.  You work together as a well oiled machine over time when things work out, and you invest in them properly.

In my opinion, working with residents can be much harder and more frustrating.  Some operate like they are still in school-mode (which they are of course) the quality is much more variable, as they can't be hand picked directly and you are stuck with even the poor ones, they take years to get better and faster, and if and when they do get better, they graduate and move on.

Of course things have to be set up right.  If you are just blindly signing off on a bunch of charts that a low quality and poorly paid PA is seeing, it's a recipe for disaster.

[q-school]

are you supervising them as in they see patients and you are not directly involved in the way they work, or are they extensions of you that allow you to optimize your schedule?  the derms we have use their extenders to create significant improvements in their own rvu streams.

 

[Dicast]

In my EM group we get all production of the PA/NP when their production covers the hourly rate they are contracted at. Some of that rate goes to the administration of their company. So it is variable depending on patient numbers, season and skill of the extender.

As Jaqen Haghar states, a good np/pa is much easier to manage than many residents.

[MPMD]

Dicast wrote:

In my EM group we get all production of the PA/NP when their production covers the hourly rate they are contracted at. Some of that rate goes to the administration of their company. So it is variable depending on patient numbers, season and skill of the extender.

As Jaqen Haghar states, a good np/pa is much easier to manage than many residents.

Click to expand...

Yeah to be honest I've never heard of getting paid by the patient to supervise a PA/NP. At least in EM don't most groups just pay midlevels salaries to basically bump the group production?

I think this forum skews a bit negative on midlevels relative to the general physician population at least at my hospital. It seems like we're always asking why we can't hire more?

 

[childay]

It sounds like you are just supervising, not actually seeing the patients typically.  Obviously that amount would be different than if you were billing etc.

My hospital offered me a ridiculously low amount to supervise a new employed NP.  I countered and pointed out how much work it will actually take to do safely, and liability concerns.  They eventually agreed to my demands.

[MPMD]

childay wrote:

It sounds like you are just supervising, not actually seeing the patients typically.  Obviously that amount would be different than if you were billing etc.

My hospital offered me a ridiculously low amount to supervise a new employed NP.  I countered and pointed out how much work it will actually take to do safely, and liability concerns.  They eventually agreed to my demands.

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was that aimed at me?

if so, yeah it sounds like our situations are very different.

every encounter i have with a PA/NP in my dept makes my life/job easier. that is not an exaggeration.

[childay]

MPMD wrote:

childay wrote:

It sounds like you are just supervising, not actually seeing the patients typically.  Obviously that amount would be different than if you were billing etc.

My hospital offered me a ridiculously low amount to supervise a new employed NP.  I countered and pointed out how much work it will actually take to do safely, and liability concerns.  They eventually agreed to my demands.

Click to expand…

was that aimed at me?

if so, yeah it sounds like our situations are very different.

every encounter i have with a PA/NP in my dept makes my life/job easier. that is not an exaggeration.

Click to expand...

No was referring to the OP.  Obviously a lot of different models depending on what sort of work you/they do.

In my case supervising a NP in no way improves my efficiency or increases my productivity (assuming I am not seeing pt myself).

[Panscan]

Just like there are good docs and bad docs there are good mid-level and bad mid level. Not sure the comparisons to a resident. Maybe an intern isnt as good as a decent PA but start talking pgy2 and above and the resident starts pulling away fast unless the mid-level has been working in the field for significant amounts of time

[Jaqen Haghar MD]

Panscan wrote:

Just like there are good docs and bad docs there are good mid-level and bad mid level. Not sure the comparisons to a resident. Maybe an intern isnt as good as a decent PA but start talking pgy2 and above and the resident starts pulling away fast unless the mid-level has been working in the field for significant amounts of time

Click to expand...

A new grad PA might take a year or two or three to start getting up to full speed, same as a resident, but perhaps a little faster, as their emphasis is on working, not schooling.  Where I work, our seasoned PAs have been working with us for 10 years.  They are hand picked as smart and mature, and invested in heavily.  If they don't excel in a 100% productivity based compensation system for docs, they are soon replaced.

If you look at data like patients per hour, RVUs per hour, and competence with procedures, they crush the residents mathematically speaking.  It literally takes three 2nd year residents to match some of their single $/hr productivity stats.  (Not considering that the residents work for free though)

It makes sense because the experienced ones are in the top % and have a head start in years on the job, but to be honest, I would bet that 1/2 of our residents won't be as good as them during their entire careers sadly.  They don't seem to be as motivated.

To be fair, we don't take "average" PAs or NPs, and the residents we get are pretty average and the residency match can be a random selection of great "students" with no real world experience yet and you are stuck with them.

[JK]

I definitely appreciate all the opinions here. I read the article from NY Times which is a good cautionary tale for sure, but I would have direct supervision of the midlevels. They would see their own patients (likely lots of acne, warts, etc...) but I would be available on-site for support and questions. To some of the posts already mentioned, a lot just depends on the quality of the midlevel you get. Some are unbelievable and others have a lot to be desired. My hope would be that they would be good and amenable to teaching/instruction and if not, then they could be replaced by someone different.

I was just really curious how much to ask for in a contract if I were to be supervising midlevels. Yes, they would be doing most of the work in seeing patients, but my name would be on the chart for a co-signer and if they needed me frequently (new grads moreso) then that would pull away from my own productivity. The hope would be that eventually they would be well seasoned and only rarely need attending support after a considerable amount of training.

The one contract offer listed 5% which seems incredibly low. I was thinking 15-25%. With practice overhead ~50% in many places, that leaves a profit for the owners, a profit for the midlevel doing the work, and then additional income for me.