Contract change

[ninasimone37]

Maybe someone can help me out here. So I’ve been at my job for 4.5 years. I work at a small hospital in a small rural town in Iowa. This is my first job out of residency, so still wet behind the ears when it comes to contracts and compensation.

So during CoVid our competitor bought the hospital where I work and combined the two campuses to form a “Sole Hospital“ in doing so they switched to a completely different compensation model than when I started. We are going from a base salary plus bonus model to 100% productivity starting July 1st.
This makes me nervous because I’m averaging only 12-14 patients a day, and that’s if no one no-shows. In addition to that, I don’t do many procedures. I Just do straight forward primary care stuff which doesn’t degenerate that many RVUs. I recently discussed my concerns with the administration and they suggested that I see more patients a day which I agreed to but the patient flow has been low especially during the winter months.

I reviewed my numbers with HR and they themselves admitted that my pay will be cut in half if I continue at the current numbers. They are implementing the exact contract for everyone across the board regardless of speciality. I’ve expressed that I don’t think this contract works for specialties like mine that are not procedure heavy and that don’t reimburse as high as Derm or surgery for example but they refuse to budge.

Any suggestions on how I should approach this situation?

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[cj_cregg]

Are you willing/able to leave the health system? That's a huge negotiating chip for you if so, especially in a rural area.

Other relevant questions if you can't leave: Why is your volume so low? Are there procedures you can add to your practice, hospital/nursing home rounding, etc? What level office visits are you typically billing? Basically are there underlying issues that are leading to you making much less under a production only model that can be fixed...it's not that uncommon for primary care to be production based only, but is this an issue of the $/RVU not being enough or are you just really generating that few RVUs.

Also, I have to imagine the health system has an interesting in retaining/recruiting PCPs. If you can show them figures from competitors, MGMA, etc. that show this contract will get you nowhere near average compensation for PCPs in your area that might motivate them to change it.

 

[VA Hopeful Dr]

Maybe someone can help me out here. So I’ve been at my job for 4.5 years. I work at a small hospital in a small rural town in Iowa. This is my first job out of residency, so still wet behind the ears when it comes to contracts and compensation.

So during CoVid our competitor bought the hospital where I work and combined the two campuses to form a “Sole Hospital“ in doing so they switched to a completely different compensation model than when I started. We are going from a base salary plus bonus model to 100% productivity starting July 1st.
This makes me nervous because I’m averaging only 12-14 patients a day, and that’s if no one no-shows. In addition to that, I don’t do many procedures. I Just do straight forward primary care stuff which doesn’t degenerate that many RVUs. I recently discussed my concerns with the administration and they suggested that I see more patients a day which I agreed to but the patient flow has been low especially during the winter months.

I reviewed my numbers with HR and they themselves admitted that my pay will be cut in half if I continue at the current numbers. They are implementing the exact contract for everyone across the board regardless of speciality. I’ve expressed that I don’t think this contract works for specialties like mine that are not procedure heavy and that don’t reimburse as high as Derm or surgery for example but they refuse to budge.

Any suggestions on how I should approach this situation?

Procedures are not all that lucrative in primary care compared to seeing patients.

Why are you seeing so few patients after 4.5 years?

 

[Moose A Moose]

Health systems are an absolute joke.
Welcome to the future they want for you.

Peace out. Leave. Go do urgent care and get compensated better, or find a private practice. I doubt they’re going to budge. They’ll fill your vacancy with some sorry rube fresh out of residency and pile on 20-30 patients a day.

Sorry you’re dealing with this nonsense, OP

 

[VA Hopeful Dr]

Health systems are an absolute joke.
Welcome to the future they want for you.

Peace out. Leave. Go do urgent care and get compensated better, or find a private practice. I doubt they’re going to budge. They’ll fill your vacancy with some sorry rube fresh out of residency and pile on 20-30 patients a day.

Sorry you’re dealing with this nonsense, OP

If you're not seeing at least 20 patients per day then what on Earth are you doing with your time?

I see patients from 8-11:45, 90 minute lunch, then patients from 1:30-4. I typically see between 22-27 patients per day.

I have an FP uncle who takes a 2 hour lunch break, 30 minute new patients and physicals and he still manages between 20-25 patients per day.

I work for a hospital system and have complete control of my schedule and make more money than I ever though I would as an FP. That's certainly not universal, but the nice thing about family medicine is you always have options.

 

[ninasimone37]

Are you willing/able to leave the health system? That's a huge negotiating chip for you if so, especially in a rural area.

Other relevant questions if you can't leave: Why is your volume so low? Are there procedures you can add to your practice, hospital/nursing home rounding, etc? What level office visits are you typically billing? Basically are there underlying issues that are leading to you making much less under a production only model that can be fixed...it's not that uncommon for primary care to be production based only, but is this an issue of the $/RVU not being enough or are you just really generating that few RVUs.

Also, I have to imagine the health system has an interesting in retaining/recruiting PCPs. If you can show them figures from competitors, MGMA, etc. that show this contract will get you nowhere near average compensation for PCPs in your area that might motivate them to change it.

It appears to be both, I don’t see enough patients and I don’t generate enough RVUs. I admit that I need to educate myself on how to maximize my productivity and becoming more comfortable with office procedures would help but I’ve been complaining for a while about the low patient flow in the clinic where I am and nothing is being done about it. There were days in February where I only had 8 patients on my schedule and at least one would no show. How can I help such a situation?

 

[ninasimone37]

Procedures are not all that lucrative in primary care compared to seeing patients.

Why are you seeing so few patients after 4.5 years?

I think it’s the nature of the small town where I work. There are multiple plants in the area and sometimes they lay people off causing them to move out of town so the patient flow is always in flux. This makes my practice very unstable which is why the new payment model makes me nervous.

 

[ninasimone37]

If you're not seeing at least 20 patients per day then what on Earth are you doing with your time?

I see patients from 8-11:45, 90 minute lunch, then patients from 1:30-4. I typically see between 22-27 patients per day.

I have an FP uncle who takes a 2 hour lunch break, 30 minute new patients and physicals and he still manages between 20-25 patients per day.

I work for a hospital system and have complete control of my schedule and make more money than I ever though I would as an FP. That's certainly not universal, but the nice thing about family medicine is you always have options.

I have 22 slots per day open to see patients but there’s just not enough patients to fill them. I show up everyday ready and willing to see more patients but we really have some slow periods that make it difficult.

 

[ninasimone37]

Health systems are an absolute joke.
Welcome to the future they want for you.

Peace out. Leave. Go do urgent care and get compensated better, or find a private practice. I doubt they’re going to budge. They’ll fill your vacancy with some sorry rube fresh out of residency and pile on 20-30 patients a day.

Sorry you’re dealing with this nonsense, OP

Sad state of affairs for sure. Thank you for your compassion.

 

[anonperson]

It appears to be both, I don’t see enough patients and I don’t generate enough RVUs. I admit that I need to educate myself on how to maximize my productivity and becoming more comfortable with office procedures would help but I’ve been complaining for a while about the low patient flow in the clinic where I am and nothing is being done about it. There were days in February where I only had 8 patients on my schedule and at least one would no show. How can I help such a situation?

If this is the situation after 4.5 years, it probably isn't going to get better.

The MGMA data is here on the board. You can get a sense of fair compensation very easily.

Just to counter what one of the other posters stated. I'm pro physician but you have to be in realistic. If you're only seeing 14 patients a day, you really can't justify a higher salary. That is a pretty low number to see. Typically seeing 20 patients a day is the goal, which is reasonable.

In these situations you have a few options:
1. Find a new job in a different area/health system
2. Take the new contract and eat the pay cut
3. Try to forge out on your own with your own private practice in the same area.

Honestly, the town you are in sounds like a less than ideal place. It sounds like a dying Midwest town. I would cut your losses and find somewhere else. There are plenty of places that will pay you well for reasonable work.

Just make sure your tail coverage situation is taken care of. You shouldn't have to pay for it especially since you are with a health system.

 

[cj_cregg]

That is tough.

If you really want to stay in the system, agree with getting some education to maximize your coding/billing - making sure you know how to document correctly to get more (appropriate) level 4s, coding problems to maximize RAF scores, and is your hospital system doing any kind of value based care bonuses you could take advantage of? Can you do some chronic disease management /group visit stuff? AAFP/FPM has some good resources on this.

Procedures that are easy to learn and super quick to tack onto an existing E&M visit - joint injections (shoulder, knee, carpal tunnel), nexplanon, punch/shave biopsies. Things like toenails, excisional biopsies, etc take longer and may not get you as much bang for your buck, IUDs can go either way depending on the patient.

Are you a DO who can do OMM and get patients to come in for additional visits for MSK complaints to fill some slots? Can you do prenatal care and keep the babies after delivery? Is there a need for MAT in your community?

Also, if the patient volume isn't there because of community factors....if they want to keep a family doc there, can you drop to like 0.5-0.7 FTE in that office and the rest in an admin role? Or have a few half days a week at another nearby location with volume to spare, urgent care/fast track ER shifts, staffing at a nearby residency clinic, etc?

 

[ninasimone37]

That is tough.

If you really want to stay in the system, agree with getting some education to maximize your coding/billing - making sure you know how to document correctly to get more (appropriate) level 4s, coding problems to maximize RAF scores, and is your hospital system doing any kind of value based care bonuses you could take advantage of? Can you do some chronic disease management /group visit stuff? AAFP/FPM has some good resources on this.

Procedures that are easy to learn and super quick to tack onto an existing E&M visit - joint injections (shoulder, knee, carpal tunnel), nexplanon, punch/shave biopsies. Things like toenails, excisional biopsies, etc take longer and may not get you as much bang for your buck, IUDs can go either way depending on the patient.

Are you a DO who can do OMM and get patients to come in for additional visits for MSK complaints to fill some slots? Can you do prenatal care and keep the babies after delivery? Is there a need for MAT in your community?

Also, if the patient volume isn't there because of community factors....if they want to keep a family doc there, can you drop to like 0.5-0.7 FTE in that office and the rest in an admin role? Or have a few half days a week at another nearby location with volume to spare, urgent care/fast track ER shifts, staffing at a nearby residency clinic, etc?

Thank you for your response. No the health system does not have any bonus program at the moment, just production pay.

Can you recommend any resources such as a course or advisor that can educate me on the RVU issue? And yes, I definitely agree with including the procedures you mentioned in my practice.

As for as all the other suggestions concerning the utilization of my time outside the clinic, I’d have to ask.

 

[cj_cregg]

Thank you for your response. No the health system does not have any bonus program at the moment, just production pay.

Can you recommend any resources such as a course or advisor that can educate me on the RVU issue? And yes, I definitely agree with including the procedures you mentioned in my practice.

As for as all the other suggestions concerning the utilization of my time outside the clinic, I’d have to ask.

AAFP's Family Practice Management has some great resources on the website to make sure your coding and billing accurately reflect the work you do, not to mention a bimonthly journal. FPM Toolbox

Website above has great articles on levels of billing and requirements for each, documenting/coding social determinants of health (VERY easy way to bump an appt to level 4), double billing for wellness/E&M same day, maximizing RAF scores, and how to do/bill for Chronic Care Management, group visits, and transitional care management CPT codes and how to do/bill for those.

 

[VenusinFurs]

Leave the system. This change is probably a really bad ****ing sign.

 

[ObsequiousAplomb]

What I find the most horrifying/amusing is that it seems the reason your census is low is that it is low across the department, not by any virtue of yours. So the administration can't successfully give you enough patients to see. When you went to HR their response was "see more patients." How is that your responsibility if the community can't support the clinic's census demands?

Maybe the real plan for switching to productivity (aside from $$$$$) is to encourage enough providers to leave that censuses will go up enough for people to be busy enough to justify their jobs. I'd strongly consider taking their hint, if at all possible.

 

[hallowmann]

So in addition to billing what you're worth (virtually everyone should be a 99214 with sprinkles of 99213s and 99215s), you should cut back your hours. If I were you, I'd cut back. You're going in 8-5, because that's your blocked off schedule and pts are being scheduled in a way not designed to maximize your productivity. You're wasting time there.

Cut back to 3-3.5 days a week so you are seeing the same number of patients per week, but doing 20 or so per day, and at least have the other days open so you can work elsewhere or just have them to yourself. If demand picks up, you can always increase. I hope you don't have a non-compete or anything, because those can be punitive in Iowa.

 

[Sushirolls]

Open your own private practice, select for better paying insurance, continue with a lighter clinical schedule and shift your work burden to the admin of running your practice. Make the same money, and never be owned by a Big Box shop again.

Exits exist.

 

[VA Hopeful Dr]

Open your own private practice, select for better paying insurance, continue with a lighter clinical schedule and shift your work burden to the admin of running your practice. Make the same money, and never be owned by a Big Box shop again.

Exits exist.

If there are hospital-owned practice, can't draw in enough patients to fill a schedule, there's almost no way he'll be able to do that well in private practice either.