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  • Family Physician Compensation

    I am asking for advise on an employment offer.  Background information is that I am a solo physician in a rural area (county is about 18000.) But I am within 60 miles of a large metro area.  I have been self employed for 14 years and make MUCH less than most docs.  I have no nurse or MA.  I do everything in the back from vitals to lab draws, to spinning labs, to seeing the patients, etc, etc, etc.  I also do the payroll (when there is one.)  Basically I do everything.  A family member has been graciously working for me in the front office for minimum wage.  I see on average eight patients per day on a typical day.  In flu season I see up to 15 or so.  A typical day includes lots of Medicare wellness and BP and diabetes check ups.  I know that I can see more patients daily if I have trained staff to do the scut work, call patients, etc.

    I can't do this anymore.  I have had an offer from a small local hospital as follows:  156,000 yearly based on 5200 RVU, and 30 dollar per RVU.  If I do not see the 5200 RVU, I have to reimburse my employer.  If I see more than 5200 RVU, I get 30 dollar per additional RVU generated.  If I oversee mid level I get 12,000 per year.  This is based on 5 full days a week with NO admin time.  I will have to practice out of two different offices.  They also want me to be lab director at one of the offices I will work out of that is an Urgent care office.  They are not offering any additional money for this.  25 days PTO. 5 days CME with 3500 allowance.

    My thinking is that the 5200 RVU requirement is too high and the per RVU compensation is too low.  I would also like to see compensation for lab director status and 1/2 day admin.  It is a one year contract.  I would appreciate feedback.

  • #2
    Your income is low because your volume is low.

    We'll pay you $225 to work in our small city sixty miles from an urban areas. No admin or scut work. Plenty of support staff. But you'll see twice as many patients as you see now.

    Comment


    • #3
      I am the worst one to give you advice. That said, RVU volumes and rates are best answered by actual data because of the variability in the clinics where you will be working. One option would be to use one of the contract review firsts that have access to MGMA data for your location. You might be the best source! Your offer is basically $30 per RVU on a one year deal.

      How many RVU's can you produce in 46 weeks (you have six weeks off)? Is $30 per RVU agreeable to you? I would suggest having the contract reviewed by a service that has MGMA data and suggesting area's of flexibility in wording that may make a huge difference.  For example, no mention of a non-compete but renewable at your option for 5 years would help from a stability standpoint.

      A one year deal is basically selling your customer base to them for 30 per RVU for one year. Is that really what you want to do?

      Comment


      • #4
        How many RVUs are you currently averaging per year in your practice? It sounds like the new position would be a step up in terms of compensation. Are you just trying to negotiate a better deal, or would you decline the offer and stay where you are? It seems like you’re fed up with your current career track.

        Comment


        • #5
          This is a case where I would open up a broader net, get 4-5 job offers (or job looks) and start to understand what your value is.. obviously all dependent on where you are willing to live and how much you want to work
          . I guess if you can’t move and this is your only local option than it’s a simple take it or leave it with some minor negotiating -

          I’m sure some rural FP are making 400k plus working maybe harder than u want, but I also bet u can get 250k with better lifestyle in a desperate location

          Comment


          • #6




            I am asking for advise on an employment offer.  Background information is that I am a solo physician in a rural area (county is about 18000.) But I am within 60 miles of a large metro area.  I have been self employed for 14 years and make MUCH less than most docs.  I have no nurse or MA.  I do everything in the back from vitals to lab draws, to spinning labs, to seeing the patients, etc, etc, etc.  I also do the payroll (when there is one.)  Basically I do everything.  A family member has been graciously working for me in the front office for minimum wage.  I see on average eight patients per day on a typical day.  In flu season I see up to 15 or so.  A typical day includes lots of Medicare wellness and BP and diabetes check ups.  I know that I can see more patients daily if I have trained staff to do the scut work, call patients, etc.

            I can’t do this anymore.  I have had an offer from a small local hospital as follows:  156,000 yearly based on 5200 RVU, and 30 dollar per RVU.  If I do not see the 5200 RVU, I have to reimburse my employer.  If I see more than 5200 RVU, I get 30 dollar per additional RVU generated.  If I oversee mid level I get 12,000 per year.  This is based on 5 full days a week with NO admin time.  I will have to practice out of two different offices.  They also want me to be lab director at one of the offices I will work out of that is an Urgent care office.  They are not offering any additional money for this.  25 days PTO. 5 days CME with 3500 allowance.

            My thinking is that the 5200 RVU requirement is too high and the per RVU compensation is too low.  I would also like to see compensation for lab director status and 1/2 day admin.  It is a one year contract.  I would appreciate feedback.
            Click to expand...


            You are correct on both, the 5200 RVU requirement is too high, and the 30 per/RVU is too low. You also need to be paid to be the lab director, but asking for 1/2 day of admin. time may be tough, as (unfortunately) most FM groups are eliminating this. Just be forewarned though that you'll most likely be expected to see 15 patients on a VERY slow day. The PTO/CME time and allowance seems fair. Also, does the one year contract have an opt out for either party without cause, such as 90 or 120 days?

            Just curious, why did you go without an RN or MA? Was it by choice or were there just none available because of your rural location? You should never be expected to do work in a new practice that a MA or RN would and can do. Not to sound snotty or elitist, but if it doesn't require a DO degree to do a job, I don't do it, otherwise it's not an efficient use of my time.

            Comment


            • #7
              I know a lot depends on the area but that sounds like an awful deal.  The average family doc does about 5000 RVU a year.  The average family doc makes 220K a year.  I can understand them paying you less if you are seeing less but if they expect you to see more then average then they need to pay up.  Everyone is looking for family docs.  you are in demand.  If you are willing to move you can get a job in any town or city you want.

              Comment


              • #8
                Keep looking as you can do a lot better than that. Also, your time is much more valuable seeing actual patients instead of taking vitals and doing lab draws.  I would suggest working on your efficiency because regardless of what job you take next, unless you remain self-employed, you are going to be expected to see a lot more patients than what you are used to.

                Comment


                • #9


                  can’t do this anymore.
                  Click to expand...


                  All the work?

                  The low pay?

                  Feel pressured to see more patients?

                  Not be able to get more patients in the door?

                   


                  but I also bet u can get 250k with better lifestyle in a desperate location
                  Click to expand...


                  not even desperate locations... or nearly that at Kaiser in.... your pick of places.


                  Not to sound snotty or elitist, but if it doesn’t require a DO degree to do a job, I don’t do it, otherwise it’s not an efficient use of my time.
                  Click to expand...


                  It isn't, this is called working at the top of your license - you should, as should everyone on the care team, from custodians, to MAs, to ... you.

                  This webinar has some thought proking slides (13, 21 pop for me, but read them all). It might help think through how to better work with others (or what a new job would look like if you work with a team, and not solo.

                  http://www.pcpci.org/sites/default/files/webinar-related/Top%20of%20License_FINAL.pdf


                  Your income is low because your volume is low.
                  Click to expand...






                   I would suggest working on your efficiency because regardless of what job you take next, unless you remain self-employed, you are going to be expected to see a lot more patients than what you are used to.
                  Click to expand...


                  ... are there more patients for you to see? How many other docs take care of the 18,000 patients?

                  Comment


                  • #10
                    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... you can do better than what they are offering. But your potential employer wants you to work to cover their costs in employing you. You need to focus on what you do- see patients (provide excellent care), document that care and bill for that care- as employed physician that is what they are paying you for- nothing else. I am impressed that you were doing everything in your office but that has come at a price.

                    My personal example should be used as a reference in negotiating with the hospital.

                    They need to pay you more per wRVU at the least. What is the benefit package?

                    The NP pay is probably low but watch their wRVU’s and if they exceed the $12,000 you should be paid more.

                    You should ask for a medical directorship for the lab work $110/hour and plan on 10-20 hours per month(based on my personal experience as a medical director) or however much time you are currently spending in your lab per month.

                    Also is the hospital a critical access hospital? If so I would recommend reviewing what this is and how they get paid more to stay open.

                    https://www.ruralhealthinfo.org/topics/critical-access-hospitals

                    Good Luck

                    Greg

                     

                    Comment


                    • #11
                      It made me look at my statements when I started.  internal medicine- pcp here.  I am in a semi-rural area in the east coast.  when I started with my job, I had a 2 year contract.  my initial concern was I did not have enough patient base to begin with.  I was afraid at the end of my 2 year guarantee and I will make less.  eventually, I got moved to a busier location, my guarantee extended and eventually got enough patients within my first year at the new location.  I would suggest looking at the locations they are proposing and what is the volume so you can gauge whether you can generate 5000wrvu.

                      my starting salary was 180k, 36 patient hours.  I looked back at the emails with the admin from years ago when I was asking how much I will get paid with 5000 wrvu- it will generate an income of over 240k.

                      2017-2018, we were paid $52/rvu.  you have to look at mgma data to see what is the average for your area.

                      we have similar system as acMD that we have a base draw and we get quarterly bonus whatever we generate in excess.

                      I also supervise NP.  stipend is only 10k (divided among the 3 supervising mds).  O well, I guess this is low and I cannot have them all.

                      Next year, we will have value based approach.  The projections they present seem promising but I will never know until we are in it.  Basically, we will generate what we made this year as long as we meet the "metrics"  If generate excess, we will be paid only $26 per RVU.

                      I am employed, I follow the rules they set but I believe I have enough support not to do "scut work". I do not worry about their salary or their insurance. another advantage is I get to see grandrounds remotely and generate cme and moc points.  downside, I can get fired anytime. I attend meetings they require us to attend.

                      With your current practice, I wonder if direct primary care may be an option.  I have only heard good things about it.  I do not have first hand experience.

                       

                       

                       

                       

                       

                       

                      Comment


                      • #12
                        You’ve gotten some excellent advice and specifics - this is why we need to be transparent in our finances, so we can help each other out.

                        You should expect a steep learning curve your first year in a different practice model: more patients per day, oversight of tasks you were previously doing solo, change in how you code, maybe an EMR change. For that reason you should have a guaranteed salary for the first 1-2 years with no penalty for falling below any particular productivity goal. 5200 RVU for the year is not impossible but you won’t be there right off the bat.

                        Five days a week is unreasonable, no admin time is unreasonable, added responsibility on top of patient care without additional time and pay is unreasonable. You are not a resident or even a new graduate - you are a seasoned attending. You are worth more than this. If you can’t or don’t want to move at least research what other positions offer so you have some data.

                        Best of luck, feel free to get in touch if you would like (I’m Peds so not as much FP specific info, but I practice in a rural/underserved area).

                        Comment


                        • #13
                          Thanks for your reply.  From what I have gathered off the internet I feel the RVU requirement of 5200 is too high.  I have seen reliable source that says about 4950. I also suspected the 30 dollar per RVU is too low.  Because of my atypical practice and style, I can understand that the employer wants to see if I am going to be able to up my volume.  I just don't want to get taken advantage of too much.  It was by choice for the most part that I have done without MA or nurse.  I will have one in the new job.

                          I have found a lawyer to review the contract who has lots of physician employment experience so I think that will help.  I will just have to decide if I am willing to be taken advantage of by the employer and to what degree.  The salary they are offering is much higher than what I make now, but it is also much lower than what people are getting straight out of residency.

                          Comment


                          • #14


                            The salary they are offering is much higher than what I make now
                            Click to expand...


                            You made your choices over 16 years. Now you have another one to make.


                            but it is also much lower than what people are getting straight out of residency.
                            Click to expand...


                            equal pay per rvu and equal targets. Unless there is some reason for a discount.

                            Comment


                            • #15
                              Don't most private practices clean up when they get bought into a health system?  Isn't it like they are buying you out of the practice and then continue you on as an employee?  Seems that was the case for the private docs our health system gobbled up.

                              Comment

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