little pay in FM

[DIce3]

I would demand a 100% salaried model or look elsewhere. A forced high Medicaid population on a production model sounds like the definition of pain.

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[deleted87716]

The hospital has no idea how to pay us if not based on production. Do you mind if I ask how you guys do it so I have an alternative to offer?

We "eat what we kill," so to speak. Basically, my revenue - my expenses = my paycheck.

 

[deleted87716]

I would demand a 100% salaried model or look elsewhere.

Salaries are for suckers, too. If you're salaried for more than a couple of years, you can rest assured that you're being underpaid for the revenue you're generating.

 

[DIce3]

In a standard primary care practice, production is almost always a better deal. A mostly Medicaid practice may be a different situation. As my Medicaid percentage is 1-2%, I am not the expert as to how to optimize a Medicaid heavy office. These 1-2% of my patients take 5-6% of my office staffs' time and 3-4% of my time. I would think a primary care doctor working with mostly Medicaid patients would require a heavy subsidy if working on any sort of production model.

 

[deleted87716]

I would think a primary care doctor working with mostly Medicaid patients would require a heavy subsidy if working on any sort of production model.

Indeed, which is precisely why I don't accept Medicaid.

Most Medicaid-heavy practices are (hopefully) Federally Qualified Health Centers, and are subsidized. Note that these clinics typically offer fairly low-paying (salaried), low-autonomy, high-volume jobs for physicians. People work there because they want to.

Personally, I'd rather just volunteer at free clinics (which I do).

 

[sazerac]

Medicaid is not 100% of Medicare in my state. RVUs are fine except for the insanely high no-show rate of medicaid patients. Currently if I have a fairly full day, my no-show rate is between 30-50%. Getting paid with RVUs given that is not so good.

Is it impractical or unethical to double-book patients, on the assumption that one won't show up? Kind of like the airlines?

Otherwise this high rate of no-shows is breaking the whole model of making appointments in the first place. Again, I don't know how much control you have over your environment, but it seems like the system (both patients and providers) would be better served with a walk-in model.

 

[VA Hopeful Dr]

Indeed, which is precisely why I don't accept Medicaid.

Most Medicaid-heavy practices are (hopefully) Federally Qualified Health Centers, and are subsidized. Note that these clinics typically offer fairly low-paying (salaried), low-autonomy, high-volume jobs for physicians. People work there because they want to.

Personally, I'd rather just volunteer at free clinics (which I do).

We're not a FQHC, which is good because my partner and I do have a pretty good say in how things are run. The only 2 things I've noticed that really require approval from the higher ups are large purchases (more than about 5k) and if we're going to close to office for extended periods (had to get permission to close for 4 days out of the week for Christmas). Otherwise we set the hours, appointment length. We decided we each only wanted to work 4.5 days a week and each now have a half day off. The only thing we're concerned about is salary in this practice.

The only frustrations are those inherent in this particular population and I can deal with that fairly well because most of these folks are so thankful to have found a doctor that they really are a pleasure to work with. However, like anything else, a few unpleasant ones can mar that fairly well.

 

[VA Hopeful Dr]

Is it impractical or unethical to double-book patients, on the assumption that one won't show up? Kind of like the airlines?

Otherwise this high rate of no-shows is breaking the whole model of making appointments in the first place. Again, I don't know how much control you have over your environment, but it seems like the system (both patients and providers) would be better served with a walk-in model.

We've thought about double booking, but if everyone shows up your day goes to crap pretty darn fast.

 

[MOHS_01]

In my current job, my partner and I are actively rebelling against going to RVUs when our salary runs out after year 2 (with a 50% medicaid rate, the no shows alone would cost us a fortune). The hospital has no idea how to pay us if not based on production. Do you mind if I ask how you guys do it so I have an alternative to offer?

There is little that can be done to overcome demographics and payer mix, unfortunately. You could try to get a salary based upon expected wRVU production assuming a full schedule and using MGMA median for $ per wRVU as a benchmark... but odds are the suits already know roughly what you're worth to the system overall and will not go above that $ figure. Ultimately, as payer mixes erode for everyone (increased # of Medicaid per population compounded by the demographic shift of baby boomers switching from better paying private plans to Medicare and now this ACA cluster which will accelerate the shift from better paying plans to poor paying plans and Medicaid), margins will be compressed and the suits will become more oppressive (and stingy with the $$).

I would ask for your CPT and wRVU reports over the time of your employment. Make some realistic assumptions about the demographics you serve to project your reasonable expectations for production and if that number does not pay the bills consider relocation. There is no way around demographic morass -- trust me, I live with it daily.

 

[VA Hopeful Dr]

There is little that can be done to overcome demographics and payer mix, unfortunately. You could try to get a salary based upon expected wRVU production assuming a full schedule and using MGMA median for $ per wRVU as a benchmark... but odds are the suits already know roughly what you're worth to the system overall and will not go above that $ figure. Ultimately, as payer mixes erode for everyone (increased # of Medicaid per population compounded by the demographic shift of baby boomers switching from better paying private plans to Medicare and now this ACA cluster which will accelerate the shift from better paying plans to poor paying plans and Medicaid), margins will be compressed and the suits will become more oppressive (and stingy with the $$).

I would ask for your CPT and wRVU reports over the time of your employment. Make some realistic assumptions about the demographics you serve to project your reasonable expectations for production and if that number does not pay the bills consider relocation. There is no way around demographic morass -- trust me, I live with it daily.

Job interview tomorrow in another location, wife has a contract in hand from them already.

That said, we're pushing for a salary with quality bonuses kinda like the hospitalists do. The problem is, the hospital isn't sure exactly how to do that AND outpatient quality measures tend to go badly. Its not like inpatient where you measures are "did the CVA patient leave with a statin prescription?". Mine are more "Are 70% of your diabetes controlled?" which is, especially with medicaid patients, usually outside of my control.

 

[MOHS_01]

Job interview tomorrow in another location, wife has a contract in hand from them already.

That said, we're pushing for a salary with quality bonuses kinda like the hospitalists do. The problem is, the hospital isn't sure exactly how to do that AND outpatient quality measures tend to go badly. Its not like inpatient where you measures are "did the CVA patient leave with a statin prescription?". Mine are more "Are 70% of your diabetes controlled?" which is, especially with medicaid patients, usually outside of my control.

This is a H-U-G-E problem that we are all about to have to deal with regardless of practice setting and compensation formula. "Quality" metrics and "value" based compensation models are fatally flawed; quality is, quite often, difficult to assess in healthcare... and without the "quality" portion readily defined "value" is nonsensical. You've already alluded to the second problem with this -- patient selection. Who will take care of the ignorant, belligerent, hard headed, and the sanctimonious?

 

[VA Hopeful Dr]

This is a H-U-G-E problem that we are all about to have to deal with regardless of practice setting and compensation formula. "Quality" metrics and "value" based compensation models are fatally flawed; quality is, quite often, difficult to assess in healthcare... and without the "quality" portion readily defined "value" is nonsensical. You've already alluded to the second problem with this -- patient selection. Who will take care of the ignorant, belligerent, hard headed, and the sanctimonious?

Either clinics like mine that are possible only because the hospital is doing well financially or county/residency clinics with extra funding independent of billing.

 

[altap]

BD if you "eat what you kill" (revenue-expenses=paycheck), how about the employer?
I guess my question really is what is the best option for an employed physician?

 

[deleted87716]

BD if you "eat what you kill" (revenue-expenses=paycheck), how about the employer?
I guess my question really is what is the best option for an employed physician?

Technically, I am an employed physician. However, as a partner in a physician-owned group, I'm my own employer.

 

[altap]

Technically, I am an employed physician. However, as a partner in a physician-owned group, I'm my own employer.

Thanks. Good for you