One of the advantages of using my services is that I try to collect as much information upfront about an opportunity as possible. Because all I do is physiatry recruitment , I know the “lingo” of physiatry. A simple example is that I know and take the time to ask how many inpatients the hiring entity expects the new doctor to see when a position involves inpatient. And, if you want more information, I will gladly ask the practice/hospital. I will do so without revealing your name. This enables you to get information that you would may not feel comfortable asking directly.
The same applies for the sometimes uncomfortable subject of compensation. I try to get as much information about this upfront. Sometimes the hiring entity says that the compensation is based on experience. If you want to know a salary figure, I will ask you about your years in practice, whether you’re Board Certified and in what fields, so that I can get a reasonable income figure from the hiring entity.
I suggest that you don’t reveal your current income during the interview process. I’d say something like “I am open to a compensation that is fair and reasonable for the area and my experience.” You should review your answer to the compensation question and rehearse it in advance so that it sounds confident and natural.
What follows is the presentation that I gave at the October, 2015 Annual AAPM&R meeting about The Strategy For Selecting The Best Practice Opportunity:
When you’re talking with a practice or a hospital and asking questions, be wary if the entity talks around the question but doesn’t give you an answer. Don’t think it’s yourself that isn’t understand. Go with your gut to acknowledge in your own mind that the group isn’t forthcoming. If they’re that way at the start, your relationship with them is probably headed only in 1 direction – down. Now on some subjects, the practice is justifiably close-mouthed. Such a subject is partnership. A practice is justifiably quiet about this subject. It’s like discussing marriage on your first date. Until they get to know you after a year or two of working together, do they feel comfortable talking about partnership.
The best opportunity will also be a practice or hospital that is good at planning for the future. How do you tell this absent seeing or hearing about their plans or even after hearing their plans? See how well-positioned the practice is presently and that is an indication of their future status. If it’s a solo practice doing things the way they’ve always been done, that might be a red flag.
Affiliate with a group/hospital that is on the cutting edge of technology and information management. This entities are well-prepared to address what payors want. What will differentiate the successful physician of the next 20 years will not be their prowess in medicine, but rather decisions made outside the practice of medicine. If you’re not an expert in planning, surround yourself by a hospital or practice associates that have this skill. Also, just because a practice has plans for the future, doesn’t mean that they may be implemented. How well organized and team-oriented is the practice? What past plans for the future are being realized now?
Community relations are a key to current and future successes. Community relations should encompass relations with referrals doctors, payors, hospitals, etc. It doesn’t mean that every doctor has to have marketing skills but some members of the practice should.
Geographics plays a part is selecting the best practice opportunity. You just can’t go anywhere and be successful as was true more so in the past. Suburban and rural locations sometimes pay more than a big city. Residents often want to stay near their residency which results in an oversupply of physiatrists in these cities. Some good states to practice from the standpoint of less physiatry supply are states without physiatry residencies such as OR, WY and MS. Residents often have favored states such as FL, CA and CO. The number of job applicants will be double for opportunities in these states. For example, I might find 5 physiatrists interested in Des Moines, IA versus 30+ physiatrists interested in NYC. The opportunity to find a good position in a major city is much less possible than it was in the past. The ability to be successful long-term is less too because your employer has a pool of available physiatrists and may discontinue a relations with you in favor of a doctor who is less costly. It’s the law of supply and demand so where there is greater supply of physiatrists, the compensations are often times less as are the benefits. Practice in a rural location is often less stressful because there’s less competition and often less regulations and oversight and a lower cost of living. You don’t have to go to Timbuktu for good pay; a recent placement of a recent I made in IA is getting paid $250,000 plus incentive.
Some physicians give strong consideration to the states with no or low income taxes such as AK, FL, AZ, DE, MS, GA, LA, SC, NV and WY. Geographics also sometimes determines practice patterns. For example, a NYC physiatrist sees less referrals because the internists have joined groups and don’t refer out anymore. On the other hand, a rural female physiatrist is doing more primary care as a result of the primary care doctors retiring because of the demands and costs of EMR. Demographics also have a role in the best practice opportunities. States with older populations like FL and TN tend to have drug-seeking patients.
The economic health of an area is also critical to a practice’s success. For example, AL has the lowest jobless rate in the Southeast. WY is a high tech hot spot.
The contract terms are another factor in finding the best practice opportunity. Most of the contract terms are fairly standard but items such as the bookkeeping of the incentive, terms to leave a practice, the restrictive covenant, partnership terms vary and you can select the contract with the most favorable terms. For example, a contract that doesn’t charge you to get out of it early is more advantageous. Sometimes this can cost $150,000 or more.
You should strongly consider practices that offer a broad range of services such as inpatient and outpatient physician services, MRI, PT, etc. By offering a broad range of services you can keep patients happy with one-stop shopping. Also, by offering a broad range of services, you’re not subject to a major financial impact on the practice if one of the services suffers a financial cutback. The same theories apply to having a variety of payors. It used to be that EMG’s were economically advantageous and then they were cut back. Another way of looking at this is what services you can offer. If you choose to only provide interventional services, you are limiting your income. Also, the large amount of physiatrists who provide these services means that you will have more competition when finding a job. Particular service types fare better in certain areas. If you like workers comp than it’s better in AZ for example than in the neighboring state of CA because of the laws there.
I recommend that you seek out medium to large-size groups or large organizations. The days of the solo practice or 2-person physiatry practice are dwindling. It’s just too hard as the group doesn’t have the ability to volume discount their expenses nor the capacity to reach out nor serve a large population which is what healthcare payors are now seeking.
A practice or facility that can offer a rehab continuum from acute rehab to SNF care is ideal. That way, no matter what type provider may be impacted by a Medicare cutback, the practice has other revenue sources. This provider will also be favored by healthcare payors for the range of services managed.
Whether partnership is offered or not can’t be solely considered as good or not good. It depends on the group. If it’s a physiatry group, then partnership should be offered. However, if the compensation adequately addresses the missed income by not being a partner, then all things are equal. Sometimes, multispecialty groups won’t offer partnership because of the different income that say orthopods or neurologists bring to the table compared with a physiatrist.
In regards to physician attrition, find out if the position you’re applying for is new or a replacement. Sometimes, new instead might mean that the position has been vacant for awhile. Why is their physician turnover? Sometimes this is difficult to find out. A physician recruiter should be able to find this out.
When considering the best practice opportunity, which of the following type of providers is the best? (SLIDE) Each has their plus’s and minus’s. A national rehab company has rehab as its #1 priority and has a pulse on what is going on in government and even an influence with government. On the flip side, it is corporate medicine with set ways of doing things. However, if it’s managing a rehab unit then there’s less chance for established ways of doing things. A rehab unit allows you to be a big fish in a little pond however rehab may not be the priority of the hospital. It also depends if it’s a community or for-profit hospital. If it’s a for-profit hospital, its mentality may be more like the national companies. Freestanding rehab hospitals are typically owned by a national companies and have the corporate mentality. The rewards are great both professionally and financially but you should be willing to be part of the corporate team. SNF’s can be part of a large chain or individually-owned and hence have the pro’s and con’s of what I’ve just described. Private practices allow for more individuality however if they’re in a metro area have the potential to be bought by the local hospital system and then individuality is lost. Academics offers the ability for collegiality and research although compensation is often less.
Selecting the best practice opportunity requires you to know the language of the field. What is an independent contractor? An independent contractor is someone who signs a contract, typically with a rehab hospital to provide rehab services. It is tantamount to being a private practice physician. You are responsible for the personal expenses such as health and malpractice insurances and whatever practice expenses there are. The advantage is that there is no middle man so what you kill is what you eat.
The restrictive covenant is language in a contract that restricts you from practicing in a certain area for a certain time should you leave the practice. These haven’t been upheld in courts but it can be costly to still have to go through the process of trying to get out of one.
A stipend is the compensation for providing a service such as being the Medical Director, Rehab. It is on top of whatever compensation you receive for services rendered.
An income guarantee is income but I think the word guarantee is misleading because it’s not usually given without strings. It usually means that whatever income is provided has to be paid back in a certain amount of time. Scrutinize the bookkeeping of an income guarantee. One doctor told me he didn’t get his January or February payments until March.
An incentive also called a performance bonus is monies you will receive if you meet usually certain productivity requirements. This is different from a bonus which is a one-time payment, oftentimes at sign-on.
NOW THAT I’VE TALKED ABOUT THE CHARACTERISTICS OF THE BEST PRACTICE OPPORTUNITY, I’d like to talk about the hiring trends. Everyone is looking for a physiatrist! This holds true for most areas except your urban areas, particularly where there are residency programs. Rural areas have more opportunity, more pay and less stress.
Employers want productive doctors. Attention to time management is paramount. Practice want doctors who can see 2-4 patients per hour, not 12 patients/day.
The supply of inpatient physiatrists is less and the demand is therefore greater. I’d say ¾ of graduating residents are going into pain management fellowships. Therefore the pool of graduating residents seeking a job is small. You can be among a few candidates for an inpatient/outpatient job versus among 10’s of interventional candidates for one job. There is more demand for BI doctors or even just inpatient than interventional doctors. There is a demand for peds rehab although the compensation is usually less.
There are more options available now to be an employee.
Practices want doctor who will go out and market in order to build the practice.
They want a corporate/practice ombudsman.
I just covered the need for efficiency and attention to time management.
Employers are looking for team players regardless of their practice preference.
Rehab residencies are growing with new programs in TN, NE and PA.
Some practices are hiring PA and NP’s because it’s hard to find a physiatrist and the PA/NP is less expensive.
NOW THAT I’VE TALKED ABOUT THE CHARACTERISTICS OF THE BEST PRACTICE OPPORTUNITIES AND THE CURRENT HIRING TRENDS, I’D LIKE TO TALK ABOUT THE PITFALLS.
Some states like TX are cracking down on prescriptions for opiates and physiatrists’ licenses are being censured. Some states have a high percentage of drug seekers so certain practices in these states like FL and TN are places to avoid.
A practice opportunity is more than about lifestyle. Don’t go to a city just because of the lifestyle it affords. Usually these are cities that as a result have an unusually high concentration of doctors so it’s more competitive there and offers less compensation and benefits.
States such as RI with high Medicare/aid populations pay less.
It’s impossible to avoid time spent on administration. One doctor told me that he was told when in residency that administrative work would be about ¼ of his time and now years later, he spend 2/3 of his time doing administrative work.
Small practices maybe at a disadvantage as I mentioned earlier. Joining a 1-person practice depends on the area. If it’s rural, it’s fine. Cities with developed health systems can complicate a practice. A physiatrist in Boston told me that doctors who used to refer to him can’t now because they’re part of a different hospital system. Another physiatrist in Las Vegas told me that the small practices are being bought out by the hospitals. A NYC physiatrist told me he’s seeing less referrals because the internists have joined group and don’t refer out anymore.
On the other hand, a rural physiatrist is doing more primary care because the family doctors are retiring because of the cost of doing business. An interventional physiatrist told me that he’s staying with the safety of a hospital system because of the collapsing reimbursement and denials for cervical epidurals and sacroiliac joints.
You must prepare for the initial phone call you’re likely to receive upon providing your cv to a practice. You must also prepare for the interview and contract negotiations. You can find more information about this on my website. Please make sure your cv has dates that are consecutive and no typo’s. My website has a sample cv and the newsletters and blogs on it provide more information.
Know beforehand what points are negotiable.
Restrictive covenants are a common staple of most Employment Agreements. They restrict you from practicing in your specialty within a defined geographic area for a set period of time after your employment ends. You may have been told that “they’re not enforceable anyway”, but while some states and courts do frown upon them, in most instances they are in fact enforceable so long as the geographic and defined practice scope of the covenant is reasonably related to the legitimate business interests of the employer. Does the employer actually get patients from that reach area? Are they in that line of business? In many cases the answer is “yes”.
Regardless, even if you think it is an overreaching covenant, can you afford to spend the legal fees to fight it, particularly if you need a job right away without exposing your new employer to cease and desist threats that make them fearful they are wasting their time in hiring you or you cannot get your legal fees reimbursed after all of that hassle (even if you win)? The answer is a resounding “no” so you must only sign an agreement if you can live with the covenant.
Yes, restrictive covenants are even imposed for part-time jobs that are 3 or fewer days a week. You will still be introduced to their patient base and referral sources so you are a threat regardless. Nonetheless, I recommend balking at signing one if you are only there for 2 or fewer days per week, or seeing if they are willing to modify the length of time of the covenant or the geographic scope because of this. Perhaps the geographic scope will increase only if you leave your employment in year 2.
If you have another job at the same time, then make sure that the covenant does not interfere with the locations of your other job. Even if you work at one location on behalf of another employer, they may have more than one office and expect you to either switch or to refer across offices. If one of their offices or facility affiliations falls within the defined geographic area, then make sure that you have express permission to continue to work for them without issue.
Always ask for them to reduce this. The worst they can do is say “no”. Within an urban environment, miles might not be an appropriate border, and streets, avenues and natural boundaries (parks or rivers) may be better. In suburban or rural areas, the appropriate mile radius is largely dependent on the nature of travel and the availability of healthcare in the area. Experienced attorneys can advise you as to propriety. In any event, see if you can prevent it from falling outside of the border of a particular city, county or even the state in which you are located.
Typically they will have a broad covenant that applies to all of their locations, even if you do not work there. If it says you cannot work within a specified mile radius of any office or facility of theirs (or those with which they are affiliated), then try to have them limit it to their main site only, your primary site only, or just both their main site and the secondary primary site in which you are assigned. The manner of determining your primary site might be based on number of days on average spent there, percentage of time split, or number of patient encounters. The objective basis should be stated in the agreement. Having a covenant apply a radius surrounding every office including offices in which you may never work or only sporadically provide coverage could have the result of drastically expanding the geographic area beyond fairness.
Article contributed by Ron Lebow, More information on this subject will follow in the next newsletter
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CHECKLIST FOR PREPARING TO NEGOTIATE A PHYSIATRY CONTRACT
o Practice negotiation in daily life and for your contract negotiation
o Consider the contract terms from the employer’s perspective
o Set targets/goals for what would be the features of the best negotiation outcome (salary, benefits, etc.), the features of your
expected negotiation and the features of the least acceptable negotiation outcome
o Make a list of the strong points of you for the position
o ID how much risk you’re willing to take in the negotiation
o Do you have something special to offer, e.g. a business background, moonlighting, marketing activities?
o Is the compensation competitive?
o What is the compensation and incentive based on, e.g. productivity, quality, cost, etc.?
o How will the compensation data be collected and submitted?
o Does the sign-on bonus have pay-back requirements?
o When do the benefits (health insurance, etc.) start?
o What is the call schedule?
o Is there a basis e.g. payor for what patients you will see?
o What if any resources (PA, tech, etc.) will I be provided?
o Is the incentive attainable?
o Is there a restrictive covenant and, if so, what is its length, geographic limitation, etc.?
o What are the terms of terminating the contract?
o What type of malpractice will be provided?
o What is the contract term? Is it renewable? By whom is it renewable?