Is this a good contract? 277k outpatient

[W19]

i would say 50-60 average

45-50 in clinic weeks

Hospital stretches can be light; but I've had one or two episodes of 90 hours over 7 days over the past few years time. I usually do 3 - 4 day stretches at this point to keep from working weekends

Thanks for sharing! I really can't decide b/t IM and FM... I like IM, but there seems to be better opportunity out there with loan repayment for FM...

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[USCguy]

Thanks for sharing! I really can't decide b/t IM and FM... I like IM, but there seems to be better opportunity out there with loan repayment for FM...

I would decide if you want to see kids and adults or just adults. That's what made the decision for me. Also, your hospital based training will be more thorough in IM vs FP. I will say I was behind in clinic skills such as joint injections, cryo, abscess I&D compared to my FP partners. Also, managing Urgent care type patients was a learning curve as well since most patients I had in residency were chronic disease followup and you never really saw them when they were sick because I wasn't in clinic then, etc etc. The gap closes quickly though. IM will be heavier in the sub specialties; in such I manage a broader scope of problems compared to them; by which i mean they refer more than I do for certain conditions (or refer earlier in the process).

Obviously, This is based on my own experience and doesn't encompass everyone else's experiences that may be contrary to mine

 

[Successor12]

This is a good traditional IM model which is more outpatient heavy. Seems like you have good flexibility and found a schedule that works for you

 

[bronx43]

Thanks for sharing! I really can't decide b/t IM and FM... I like IM, but there seems to be better opportunity out there with loan repayment for FM...

I say go with IM just because of the fellowship potential. Otherwise, if you're 100% sure you want to do rural primary care, go FM all the way.

 

[W19]

I say go with IM just because of the fellowship potential. Otherwise, if you're 100% sure you want to do rural primary care, go FM all the way.

Rural primary care! No way Jose!

I think I am doing IM...

 

[USCguy]

I say go with IM just because of the fellowship potential. Otherwise, if you're 100% sure you want to do rural primary care, go FM all the way.

I would say IM as well just because if you change your mind or interest over the 3.5 years between submitting match list and finishing residency; you have a lot of options

Would also encourage you to consider an IM program that has a "Primary Care Track". this will give you a little better prep for office type stuff my traditional counterparts weren't exposed to (coding, billing, etc). You can easily match in fellowship from PC Track if you decide to do so. About half of the PC residents from my program did fellowship each year and the other half took PCP jobs. We had 100% match rate for fellowship for the ~5 years I was tracking that data, so don't let anyone try to tell you it will negatively affect you doing PC track at a good IM program

 

[Brahnold Bloodaxe]

That nationwide average is probably weighted more towards more rural or smaller cities since that's where the majority of the jobs are. I was taking into account his proximity to a relatively large metro area. Also, with the 10% potential bonus, it can easily bump his take home up to 300k which is well within reasonable range for 6000-6500 RVU for a GIM.

Something like 80% of the US population lives in or near large urban areas and so does the vast majority of physicians, otherwise the cities would be underserved and we know that is not the case. As such, the national salary medians and averages almost certainly reflect large urban centers far more than they do rural areas.

Maybe you meant rural areas are overrepresented in job vacancies?

 

[bronx43]

Something like 80% of the US population lives in or near large urban areas and so does the vast majority of physicians, otherwise the cities would be underserved and we know that is not the case. As such, the national salary medians and averages almost certainly reflect large urban centers far more than they do rural areas.

Maybe you meant rural areas are overrepresented in job vacancies?

That statistic is only true because of the definition of the word "urban" which can mean anything from NYC to a "city" of 5k people. If you take only the large tier 1 or even 2 cities to be "large urban" then the vast majority of the US population is not actually in urban regions. The majority of physicians in the US practice outside of the largest metros.

U.S. Urban Population Is Up ... But What Does 'Urban' Really Mean?

 

[Brahnold Bloodaxe]

That statistic is only true because of the definition of the word "urban" which can mean anything from NYC to a "city" of 5k people. If you take only the large tier 1 or even 2 cities to be "large urban" then the vast majority of the US population is not actually in urban regions. The majority of physicians in the US practice outside of the largest metros.

U.S. Urban Population Is Up ... But What Does 'Urban' Really Mean?

Fair enough. According to that article "the top 48 urbanized areas account for more than half of the entire urban population" and the urban population accounts for 80% of the entire population. "More than half" can mean anything from 50% to 100% but I guess a reasonable assumption is that the author was implying a number between 50-60%. This would place the percentage of the overall population that resides outside of the largest 48 metro areas at anywhere from 60% to 70%.

However, cities that are smaller than the largest 48 include places like New Orleans, St. Louis, Pittsburgh, Cleveland etc, none of which are places that people would consider "rural." Green Bay is all the way at # 286 and again, most people would consider that a bona fide "city."

So in other words, over 40% of the population lives in the 48 cities larger than New Orleans, and probably at least another 40% of the population lives in the 238 cities that are smaller than Arlington but larger than Green Bay. I think it's safe to say that nationwide salary averages are more reflective of what you can make in a city larger than Green Bay than what you'd make in an actual rural community.

 

[bronx43]

Fair enough. According to that article "the top 48 urbanized areas account for more than half of the entire urban population" and the urban population accounts for 80% of the entire population. "More than half" can mean anything from 50% to 100% but I guess a reasonable assumption is that the author was implying a number between 50-60%. This would place the percentage of the overall population that resides outside of the largest 48 metro areas at anywhere from 60% to 70%.

However, cities that are smaller than the largest 48 include places like New Orleans, St. Louis, Pittsburgh, Cleveland etc, none of which are places that people would consider "rural." Green Bay is all the way at # 286 and again, most people would consider that a bona fide "city."

So in other words, over 40% of the population lives in the 48 cities larger than New Orleans, and probably at least another 40% of the population lives in the 238 cities that are smaller than Arlington but larger than Green Bay. I think it's safe to say that nationwide salary averages are more reflective of what you can make in a city larger than Green Bay than what you'd make in an actual rural community.

Where did you get the numbers that show Pittsburgh, St Louis, Cleveland, New Orleans are outside of the top 48 largest metros or "urbanized areas?"

List of Metropolitan Statistical Areas - Wikipedia

List of United States urban areas - Wikipedia

The bigger point I'm trying to make is that even if you live within the confines of a metropolitan area, it doesn't mean you actually live in an area which provides all the benefits of living "in the city." For instance, I live in a top 30-40 metropolitan area by population, however, the job offers INSIDE The actual city are quite different from job offers 40 minutes out, despite the fact that the farther job is still within the metropolitan area. The lifestyle you're living there is vastly different from the one you would enjoy if you were 10 minutes away from where all the action is. So, perhaps my terminology was off, but what I meant to convey is that the majority of the physicians in the country do not live within the truly urbanized areas where the saturation of physicians easily pushes down the compensation packages.

 

[Brahnold Bloodaxe]

I used this link
List of United States cities by population - Wikipedia

which now that you point it out appears to be a mistake, since it is a list of cities whereas the article was probably referring to "urban areas" as an official census category. At any rate, I see what you're saying, no point to further split hairs here.

 

[psychMDhopefully]

My advice? Go rural, and find a gig that pays you for productivity. Get the highest pay per wRVU you can find, and make sure they have the volume to support your productivity. The ideal situation is that you can hit the ground running. Then put your head down and be ready to see 25+ patients a day. Live frugally, and you'll have your debt paid off in a few years.

Should you really be worried about paying you loans off in a couple of years at the expense of quality of life? I'll be at about 320k when I start practicing, hopefully salary~debt when I start.

 

[sangria1986]

You can make that much pretty easily as a hospitalist too. With more flexibility in your schedule. Though the negative is nights/weekends/holidays.

That was my reasoning for outpatient. I've assumed as an outpatient I will have a drop in income but thats ok. I want my nights and weekends. Also this gig is offering me 6 weeks vacation which I feel is enough for me.

 

[bronx43]

Should you really be worried about paying you loans off in a couple of years at the expense of quality of life? I'll be at about 320k when I start practicing, hopefully salary~debt when I start.

Quality of life? I mean, do you really feel like your quality of life is somehow deficient if you use 50k a year? As a resident, you live on less than that.

 

[sangria1986]

One of my arguments is that IM offers far greater sources of employment. This statement is a lot like what others said-but in my survey of outpatient salaries IM is higher than fam. You could argue this is because of greater complexity but I would counter that FM can simply counter with more volume.

I think IM pays more even with this accounted for because the shortage is more acute (even for primary care). Why? Because people have the choice to work in hospitals or apply for fellowships. I know many attendings who used to be internists but then went onto fellowships or hospitalist track.

 

[sangria1986]

In terms of lifestyle I think if you live within 30-40 minutes you can definitely enjoy the city lifestyle.

Our goal is to live downtown and I will commute. I dont mind the extra driving because once I get home all I have to do is take the elevator down the condo and then walk- thats right - walk - not drive to wherever i want to go- to eat out, to shop, to enjoy theater or arts or music or sports.

I definitely think city life is the way to go- especially with the cuts coming up we will be more and more dependent on employed patients (instead of rural patients on medicaid) who have adequate insurance to think that seeing their pcp is worth their money.

 

[Captain DO]

If this is for general internal medicine, then that's a reasonable job in terms of the money. If you're billing mostly level 4s with some level 3s, then 20 patients per day with 6 weeks of vacation nets you around 6000-6500 wRVUs. The national average for dollars per RVU is around 40-45 for IM, and you're getting around that. Considering that you're within 30 minutes of a big city, it's pretty generous.

If an outpatient PCP position is salaried....how does all that RVU, billing business work? Do they make less or more than their salary depending on productivity? Or do they just track it so when the contract expires they use that to come up with a new salary?

I have no idea how the business/billing side works....

 

[bronx43]

If an outpatient PCP position is salaried....how does all that RVU, billing business work? Do they make less or more than their salary depending on productivity? Or do they just track it so when the contract expires they use that to come up with a new salary?

I have no idea how the business/billing side works....

Salaried usually still stipulates that you have to see a certain number of patients. You still have to bill, but unless you're wildly overbilling or underbilling, the health care system that is employing you may not catch it. Since you aren't really paid directly by your billing, you yourself may not care to learn billing all that well.

 

[USCguy]

If an outpatient PCP position is salaried....how does all that RVU, billing business work? Do they make less or more than their salary depending on productivity? Or do they just track it so when the contract expires they use that to come up with a new salary?

There is a subtle difference in vocabulary here that you have to clear up with any future employers; salary (guaranteed salary) vs. salaried

Most offers I entertained after residency included a guaranteed salary the first year or two, which then dropped dramatically thereafter. Your employer will expect you to produce at a certain level. Usually this is expressed as some percentile of MGMA. While you still have a base salary, you shouldn't take any job that doesn't have some sort of production bonus built in.

"Salaried" usually means you make the same amount no matter how much (or little) you do as long as you show up on time and "punch the clock". This situation could foreseeably put you at risk of financial abuse as the boss could load your plate with work and you just have to "keep the line moving". I believe Mayo uses this system, but I would have a hard time trusting anyone to the point of agreeing to something like this.

You have to take ownership of your situation and do what it takes to pick up some of the "business and billing" information. If nothing else, go and sign up for a free subscription for MEDICAL ECONOMICS magazine. Also, thehappyhospitalist blog has some good info.

Don't sell yourself short; get educated and get the best deal possible.

 

[sangria1986]

There is a subtle difference in vocabulary here that you have to clear up with any future employers; salary (guaranteed salary) vs. salaried

Most offers I entertained after residency included a guaranteed salary the first year or two, which then dropped dramatically thereafter. Your employer will expect you to produce at a certain level. Usually this is expressed as some percentile of MGMA. While you still have a base salary, you shouldn't take any job that doesn't have some sort of production bonus built in.

"Salaried" usually means you make the same amount no matter how much (or little) you do as long as you show up on time and "punch the clock". This situation could foreseeably put you at risk of financial abuse as the boss could load your plate with work and you just have to "keep the line moving". I believe Mayo uses this system, but I would have a hard time trusting anyone to the point of agreeing to something like this.

You have to take ownership of your situation and do what it takes to pick up some of the "business and billing" information. If nothing else, go and sign up for a free subscription for MEDICAL ECONOMICS magazine. Also, thehappyhospitalist blog has some good info.

Don't sell yourself short; get educated and get the best deal possible.

I agree with this 100% also aafp has blog posts on billing and employment.

I would also say that salaried can be a nuanced interpretation in that you can be salaried with benefits - 401k malpractice coverage etc but have a contract that stipulates income based on wrvu.

Generally employment in outpatient settings take a couple forms.

One is guaranteed salary w bonus and the other is straight production w or wo a low base guarantee.
in each case it is critical you understand how your bonus or productivity is paid.

The general trend is toward wrvu payments. These exclude having to worry about cost of the clinic etc (more on that). In a wrvu model your income is based on a predetermined value per wrvu say 45 dollars. This is multiplied by the rvu average value per patient. (This is entirely dependent on your patient population and coding such as 99214 v 99213 but generally for IM it is 1.4)
You multiply these two values along w number of patients per week and then how many weeks you work. This is your income.

Its very important you correlate whatever incomes they claim you can make and compare to these values. This will tell you the number of patients you need to see to make this claimed amount.

Other models within this system exist. Including graded rvu payments that increase w more work. The systems will argue this is in your favor as it rewards greater efforts on your part but I find its a hogwash. Generally they start you at such low payments that you will be underpaid and even w really hard work you will struggle to go up in the rvu values. For example they may say for the first 4000 rvus you bill you will be paid 40 per rvu and when you reach 6000 rvus you will get paid 45 per rvu etc.

Other models are more outdated in my opinion. They may say you make your gross revenu subtract your costs for practice and take whats left. I find these models are outdated platforms. They used to be great because ownership was involved in the process but the ownership opportunities with these clinics are limited today. I suspect they are run this way because they benefit the established physicians but are not viable for new physicians who begin with less ownership or control.

Finally you need to make sure that you are offered a fair market salary. The 50% mgma data is a reasonable start. Generally your pay should reflect or be better than this.

 

[Raryn]

Finally you need to make sure that you are offered a fair market salary. The 50% mgma data is a reasonable start. Generally your pay should reflect or be better than this.

Highly region dependent. 50th percentile nationwide would be a phenomenal job offer in NYC. Would be trash in Wyoming.

 

[sangria1986]

Another consideration is that guaranteed salaries arent really guaranteed and even if they are may not be worth it.
A guaranteed salary can be in many forms. Sometimes they will give you a low base salary each year regardless of your productivity. If its really bad they may punish you or may just reflect this by paying you that much less the following year.
Other guarantees are still based on productivity. For ecample they may claim each quarter they will amend you guarantee for the next quarter based on the preceeding performance. They can also do this on a yearly basis.

More importantly you need to ask why a base salary is important. If one contract offers you 160k base plus productivity and the other only offers productivity the question is how mch productivity?
If on straight prod you only need to see 14 pt a day to make 225k this may be reasonable since conceivably 14 pt a day is not hard at all.
at this point you may want to ask if the productivity is comparable. If the straight prod is offering more money per patient and has the lwoer threshold to make the minimum you want then its not an issue.

 

[sangria1986]

Highly region dependent. 50th percentile nationwide would be a phenomenal job offer in NYC. Would be trash in Wyoming.

I agree. So i will amend by saying many systems offer contracts based on averages or comparisons to mgma and regional data figures.

 

[sangria1986]

Furthermore if you want to breakdown straight productivity offers the concerns would include whether you can meet those productivity offers.
If you struggle to get enough patients after 2 years you may not have enough of a floor to protect your income. If 14 is all you need to make say 200 and with no shows or too many healthy 40 year olds and seeing only 12 patients a day you may struggle to meet this.

Thats not to say this will happen but you should do your research. What is the growth rate of your area. Are there enough employers. What is the mix of payors? Employers will tell you the payor mix is not important because they are rvu neutral. They will claim that with this model you are paid the fixed value per rvu so no need to worry. Really though it will affect you in the long run. With failing cities or towns and declining payor base from insured populations their income will decline in the long run. They may need to revisit the rvu value and decrease payments sell the hospital system etc.
these are things to keep in mind if you plan to stay long term have kids or are planning to or have onerus noncompetes that prevent you from leaving the practice.

 

[sangria1986]

The other thing to consider is the competition of the environment.
I find the northeast pays less because they are super saturated and because of less competition. There are fewer systems in place. In the midwest and south there are more systems in play.

If the system is too large-multistate. They may be unwilling to be competitive. They cna absorb unfilled positions vs having to bump up everyones salaries.
I find large regional players that are not super big ie a few billion in rvu or size and are only in the state to be the best match in terms of financial stability and competitive pay

 

[USCguy]

Highly region dependent. 50th percentile nationwide would be a phenomenal job offer in NYC. Would be trash in Wyoming.

That's crazy to me that you would be paid so much less in a place with such a high cost of living

 

[Raryn]

That's crazy to me that you would be paid so much less in a place with such a high cost of living

Welcome to medicine. Tons of other doctors also want to live in NYC.

 

[USCguy]

Having never lived in NYC,

Welcome to medicine. Tons of other doctors also want to live in NYC.

What is the going rate around NYC? If you have a wRVU number that would probably give the best comparison between job A and job B (but doesn't account for cost of living)

 

[sangria1986]

Having never lived in NYC,


What is the going rate around NYC? If you have a wRVU number that would probably give the best comparison between job A and job B (but doesn't account for cost of living)

Having extensively interviewed by telephone across the east coast and visited i can say that manhattan will pay about 120 for 18-20 pt a day. An 30 min to an hour out and you are looking at 180k. In boston its about 140 and 30 min out its 190.
These are starting. They will all claim that w hard work and full panel blah blah eventually you can make 300-400

 

[bronx43]

Having extensively interviewed by telephone across the east coast and visited i can say that manhattan will pay about 120 for 18-20 pt a day. An 30 min to an hour out and you are looking at 180k. In boston its about 140 and 30 min out its 190.
These are starting. They will all claim that w hard work and full panel blah blah eventually you can make 300-400

Wait... 120k for 18-20 patients a day? Lol.

Eventually make 300-400 with a full panel? If 20 patients a day isn't a full panel, what is?

 

[sangria1986]

Wait... 120k for 18-20 patients a day? Lol.

Eventually make 300-400 with a full panel? If 20 patients a day isn't a full panel, what is?

Yeah. I was told by a recruiter their more established docs who "love their job" see 25-30 a day. 10-12 hr days

 

[VA Hopeful Dr]

Yeah. I was told by a recruiter their more established docs who "love their job" see 25-30 a day. 10-12 hr days

That sounds awful