PA/NP Supervision Compensation

[stayinalive]

Hi, it has been many years since I posted on here. Looking from some thoughts. I work in a multispecialty medium size group 100+ in an employed physician model. I am an outpatient subspecialist. The department consists of me, another physician, and a NP. The other physician previously supervised the NP fulltime, but he went on indefinite medical leave in December 2020 (good guy, unfortunate circumstances). Over the past year, I have been supervising the NP full-time (discuss patients, go into the room sometimes, and sign off on everything) and even retrained the NP. I was foolish and did not push for compensation the moment I started supervision and thought they would factor it in during my annual bonus....and of course leadership did not. I got a vague answer this year "look into it" "get back to you" and so I informed the CMO that I will stop supervision effective this coming monday. His repeated response was simply "don't do that" with I'll look into to it (I expect no action). I think leadership/he expects I'll just keep chugging along. Any recommendations on how best to proceed? Experiences with such situations? I figure they may just move the NP to another department...

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[anonperson]

Hi, it has been many years since I posted on here. Looking from some thoughts. I work in a multispecialty medium size group 100+ in an employed physician model. I am an outpatient subspecialist. The department consists of me, another physician, and a NP. The other physician previously supervised the NP fulltime, but he went on indefinite medical leave in December 2020 (good guy, unfortunate circumstances). Over the past year, I have been supervising the NP full-time (discuss patients, go into the room sometimes, and sign off on everything) and even retrained the NP. I was foolish and did not push for compensation the moment I started supervision and thought they would factor it in during my annual bonus....and of course leadership did not. I got a vague answer this year "look into it" "get back to you" and so I informed the CMO that I will stop supervision effective this coming monday. His repeated response was simply "don't do that" with I'll look into to it (I expect no action). I think leadership/he expects I'll just keep chugging along. Any recommendations on how best to proceed? Experiences with such situations? I figure they may just move the NP to another department...

Well, they got you to take extra liability and work on the house.

Never underestimate administrations desire to squeeze every last bit of work out of you. It is ridiculous but not surprising and I see it time and time again.

Your ability to negotiate depends on how in demand your specialty is (basically how much revenue do you bring in).

It seems like you are the only physician in this specific department.

What do you want? To not have any mid level or to be responsible for one and capture some type of revenue?

If the latter, how is your compensation structured? If its wRVU, then you should be capturing at least some of the RVUs the NP is generating.

Other option is a flat stipend.

You have to decide what you want and tell them and go from there.

To any new attendings reading this, if in an employed model, do not do any work for free. You set a bad precedent. The CFO/CMO/CEO are sitting fat and happy off your sweat, make every penny you can.

Take a page from lawyers. They bill by the 6 minute increment. Everything they do is worth something.

 

[stayinalive]

Yes, those reading should take this as a cautionary tale. Negotiate. Do not do work for free and expect admin to make it whole at the end of year/bonus time. I would also suggest asking for an explicit clause (whether or not there is already a NP/PA already in your dept) in the contract outlining a compensation model for current or future NP/PA supervision.

I think they will do nothing and then once I stop supervising, I think the organization will just move the NP over to a different department. That will be fine the NP's presence did not boost my own productivity. I have made the ask of a fixed stipend to continue supervising going forward, but am not holding my breath. I don't trust a wRVU model or the admin to deliver on an equitable one or pull something else going forward. I do have some market power based off location and their needs, but never want overestimate my hand.

 

[chessknt]

Yea it went on a bit too long I think to be able to get anything useful now. I agree just cutting it off immediately by pointing out that it isn't part of your contract and if they would like to add it in there to continue your supervision you would be happy to discuss and leave it at that. I think you would need to word the communication in a way so it isnt a question or a suggestion but a stated fact.

If they get upset and fire you over this then it is a malignant group and you might be dodging a bullet in the long run.

 

[NotAProgDirector]

I agree it's totally reasonable to ask for something - whether a fixed amount, or something based upon RVUs is your choice. Personally, I'd give them more time to come up with a plan - 2 weeks especially given the holidays and if this is the first time you've asked. If they do pull the NP and move them somewhere else, there's some chance all of their work will be dumped upon you. Who is going to see all of the patients they were seeing? Those patients will need follow up, and if they all get pushed out because your schedule is full any bad outcomes might be directed at you.

 

[stayinalive]

Will update everyone on how this ends up playing out. Its been messy to say the least.

 

[The kitchen sink]

Will update everyone on how this ends up playing out. Its been messy to say the least.

What was the agreement between the other physician and the NP in terms of money?

 

[stayinalive]

As promised, I am providing an update on this experience. I ended up stopping my supervision of the NP. I gave advanced notice that I would stop supervising on a specific date (one week later). Nothing happened in the interim. So on that specified stated date, I stopped supervising, informed the NP as such, and then declined everything sent my way by the NP. This unfortunately created a lot of stress for the NP. Eventually whoever she spoke to sent it up the chain to the CMO. The CMO threatened to fire me and I simply stated it was not in the scope of my contract. We both started to go down the contractual dispute pathway in our conversations. This would have involved arbitration. Within a 48 hour span, after much handwringing and some conversations, we settled on a one-time lump sum payment for the past and an agreement that supervising the NP was within my scope without additional compensation. At this point, I knew I would leave regardless and figured without getting lawyers involved, I may miss out on a few months of comp for NP supervision but this provided me something.

I resigned and left a few months later (in the spring) after finding a new job. During this process, I found it fascinating (and very disappointing) the number of physicians supervising NPs/PAs at other employed positions with no compensation or RVU credit. At most of these places, I was simply told by the future colleague docs and hiring doc/manager "if you do no want to supervise, you do not have to." Eventually, I found a position where I am NOT supervising a NP/PA and had it explicitly written into the contract that it is NOT part of the scope of my employment and that any future supervision would require both parties to agree on a compensation model for doing so.

Overall, I think because physicians are poor negotiators & some lack any spine, management would like to treat us as uber drivers if they could, and NPs/PAs expansion has exploded, supervision of NPs/PAs in employed positions (both academic and other health systems) will not be compensated anywhere 5-10 years from now.

 

[anonperson]

As promised, I am providing an update on this experience. I ended up stopping my supervision of the NP. I gave advanced notice that I would stop supervising on a specific date (one week later). Nothing happened in the interim. So on that specified stated date, I stopped supervising, informed the NP as such, and then declined everything sent my way by the NP. This unfortunately created a lot of stress for the NP. Eventually whoever she spoke to sent it up the chain to the CMO. The CMO threatened to fire me and I simply stated it was not in the scope of my contract. We both started to go down the contractual dispute pathway in our conversations. This would have involved arbitration. Within a 48 hour span, after much handwringing and some conversations, we settled on a one-time lump sum payment for the past and an agreement that supervising the NP was within my scope without additional compensation. At this point, I knew I would leave regardless and figured without getting lawyers involved, I may miss out on a few months of comp for NP supervision but this provided me something.

I resigned and left a few months later (in the spring) after finding a new job. During this process, I found it fascinating (and very disappointing) the number of physicians supervising NPs/PAs at other employed positions with no compensation or RVU credit. At most of these places, I was simply told by the future colleague docs and hiring doc/manager "if you do no want to supervise, you do not have to." Eventually, I found a position where I am NOT supervising a NP/PA and had it explicitly written into the contract that it is NOT part of the scope of my employment and that any future supervision would require both parties to agree on a compensation model for doing so.

Overall, I think because physicians are poor negotiators & some lack any spine, management would like to treat us as uber drivers if they could, and NPs/PAs expansion has exploded, supervision of NPs/PAs in employed positions (both academic and other health systems) will not be compensated anywhere 5-10 years from now.

Good job.

Nice to hear that you stood up for yourself.

 

[MD46]

Good!
I mean if you are supervising there is always liability. If one accepts that and gets paid for the supervision then thats fine. I agree we are poor negotiators and complacent for the most part and end up getting used. Its our collective fault that the admin folk get away with doing this.

I was in a similar position where they wanted me to off load good well paying followup patients to NP while adding medicaid new heme patients to my schedule. So technically I am supervising the the NP who sees this patient, but she bills under her self and hospital doesnt pay me anything for it. I asked them to compensate me they said no.

I just stopped giving NP any patients, now she works as a glorified nurse taking care of inbasket messages and refills. Not ideal for her I agree, but still a little push back from my end I think. Also when you are in collection model these things hurt even more.

 

[Osteoth]

As promised, I am providing an update on this experience. I ended up stopping my supervision of the NP. I gave advanced notice that I would stop supervising on a specific date (one week later). Nothing happened in the interim. So on that specified stated date, I stopped supervising, informed the NP as such, and then declined everything sent my way by the NP. This unfortunately created a lot of stress for the NP. Eventually whoever she spoke to sent it up the chain to the CMO. The CMO threatened to fire me and I simply stated it was not in the scope of my contract. We both started to go down the contractual dispute pathway in our conversations. This would have involved arbitration. Within a 48 hour span, after much handwringing and some conversations, we settled on a one-time lump sum payment for the past and an agreement that supervising the NP was within my scope without additional compensation. At this point, I knew I would leave regardless and figured without getting lawyers involved, I may miss out on a few months of comp for NP supervision but this provided me something.

I resigned and left a few months later (in the spring) after finding a new job. During this process, I found it fascinating (and very disappointing) the number of physicians supervising NPs/PAs at other employed positions with no compensation or RVU credit. At most of these places, I was simply told by the future colleague docs and hiring doc/manager "if you do no want to supervise, you do not have to." Eventually, I found a position where I am NOT supervising a NP/PA and had it explicitly written into the contract that it is NOT part of the scope of my employment and that any future supervision would require both parties to agree on a compensation model for doing so.

Overall, I think because physicians are poor negotiators & some lack any spine, management would like to treat us as uber drivers if they could, and NPs/PAs expansion has exploded, supervision of NPs/PAs in employed positions (both academic and other health systems) will not be compensated anywhere 5-10 years from now.

I never get why docs have so little spine. We have such a great skill set and are so
Valuable to our patients our community and to society.

 

[Mehena]

If you can't win them join them.
My next side hustle is to open an online NP school and churn to flood the market. Hopefully see their house of cards fall in the process. jk

 

[NewYorkDoctors]

I employ midlevels in my private practice. they do "all the grunt work" and I just stop by for end to review the big picture. it works great.

this is especially helplful for patients who can't give a history to save their lives.

Patient: " I feel unwell"
Provider: "how so? please be more specific"
Patient: " I just feel unwell okay? tell me why?"
Provider: *sighs inside and prepares to ask the ROS questions* "okay let's take it from the top. do you have headache?
Patient: "stares blankly and does not respond."
Provider: "do you have dizziness?"
Patient: "why does my butt itch sometimes?"

The midlevels are great for buffering from this kind of (very common) patient exchange that occurs.

 

[DrMetal]

I employ midlevels in my private practice. they do "all the grunt work" and I just stop by for end to review the big picture. it works great.

this is especially helplful for patients who can't give a history to save their lives.

Patient: " I feel unwell"
Provider: "how so? please be more specific"
Patient: " I just feel unwell okay? tell me why?"
Provider: *sighs inside and prepares to ask the ROS questions* "okay let's take it from the top. do you have headache?
Patient: "stares blankly and does not respond."
Provider: "do you have dizziness?"
Patient: "why does my butt itch sometimes?"

The midlevels are great for buffering from this kind of (very common) patient exchange that occurs.

Great, hiring mid-levels instead of physicians (no doubt, to save money). It's nice to see how us doctors sh!* on ourselves. We really can't complain then.

Careful there. When the medical-industrial complex realizes how stupid and easy most of medicine is, it might replace you entirely (allowing the mid-levels to practice independently, no physician supervision necessary). Then you might wish to have back some of that 'grunt work'.

 

[Benzo4every1]

we do not get paid extra to do supervising NP , PA, or APPs.
Now with the new billing that came into place, we can bill for additional time if we did extra besides writing a cosign note with APP's initial encounter. Our hospital is pro-APP

 

[dozitgetchahi]

Yea it went on a bit too long I think to be able to get anything useful now. I agree just cutting it off immediately by pointing out that it isn't part of your contract and if they would like to add it in there to continue your supervision you would be happy to discuss and leave it at that. I think you would need to word the communication in a way so it isnt a question or a suggestion but a stated fact.

If they get upset and fire you over this then it is a malignant group and you might be dodging a bullet in the long run.

Hi, it has been many years since I posted on here. Looking from some thoughts. I work in a multispecialty medium size group 100+ in an employed physician model. I am an outpatient subspecialist. The department consists of me, another physician, and a NP. The other physician previously supervised the NP fulltime, but he went on indefinite medical leave in December 2020 (good guy, unfortunate circumstances). Over the past year, I have been supervising the NP full-time (discuss patients, go into the room sometimes, and sign off on everything) and even retrained the NP. I was foolish and did not push for compensation the moment I started supervision and thought they would factor it in during my annual bonus....and of course leadership did not. I got a vague answer this year "look into it" "get back to you" and so I informed the CMO that I will stop supervision effective this coming monday. His repeated response was simply "don't do that" with I'll look into to it (I expect no action). I think leadership/he expects I'll just keep chugging along. Any recommendations on how best to proceed? Experiences with such situations? I figure they may just move the NP to another department...

Yeah…one way or another you do need to get compensated for the time and effort that goes into supervising this NP. Usually this comes in the form of a cut of the midlevel’s RVUs, or in a stipend, or in some other sort of compensation. I agree that the best thing to do would have been to ask how you were going to be compensated for this right when you started supervising the NP.

Personally, I don’t (and won’t) work with midlevels. If this was forced on my at my current PP job, I’d leave, but fortunately they give physicians the latitude to make the decision whether or not they want to work with these providers here.

Personally, I’d do two things: 1) give them a 2-4 week period to come up with a compensation plan for this and 2) as a backup, start looking for another job. Whenever you start pushing admin types to make these kinds of decisions, you never know what will happen next - even if you seem to be secure at this job.

 

[NewYorkDoctors]

Great, hiring mid-levels instead of physicians (no doubt, to save money). It's nice to see how us doctors sh!* on ourselves. We really can't complain then.

Careful there. When the medical-industrial complex realizes how stupid and easy most of medicine is, it might replace you entirely (allowing the mid-levels to practice independently, no physician supervision necessary). Then you might wish to have back some of that 'grunt work'.

meh. i see your point. but hiring other physicians in a small private practice like mine is rife with headaches.

I want more money - but you didn't generate more revenue.

I want more time off - but you asked for more money

I'm going to stab you in the back once I get a chance - you can try.

so on so forth

the midlevels don't have such problems.

 

[DrMetal]

meh. i see your point. but hiring other physicians in a small private practice like mine is rife with headaches.

It's not just with respect to 'other physicians in a small practice', it's with respect to all physicians, in every specialty, in every type of practice. This is exactly how the medical-industrial complex see us (we want too much, we're too entitled. . .= replace with a mid-level).

Well, at least you're honest about it.

 

[NewYorkDoctors]

It's not just with respect to 'other physicians in a small practice', it's with respect to all physicians, in every specialty, in every type of practice. This is exactly how the medical-industrial complex see us (we want too much, we're too entitled. . .= replace with a mid-level).

Well, at least you're honest about it.

im glad we agree to disagree.

if it makes you feel any better, I am waiting for a friend to graduate IM residency so I can hire him to the PMD of the practice (while I transition to full time subspecialty and also can create a real PCMH). At least a friend won't be backstabbing me (I hope).


my point is, physician extenders (physician assistant or associate or whatever they want to call themselves and "doctors" of nurse practitioner) can help physicians out. look at a busy surgeon. if he/she has a lot of inpatient work and surgeries to do, who will help out to round, do wound care, follow up office results etc... the PA/NP. A surgeon cannot possibly do ALL of those things in one day.

giving them full autonomy to push doctors out is just too much of the crony capitalism of the medical industrial complex cutting corners. But at the end of the day, patients will still want to see MD/DOs. At the end of the day, a moderately complex patient who sees an exclusive NP will be getting that "referral to Internal Medicine."

 

[MD46]

meh. i see your point. but hiring other physicians in a small private practice like mine is rife with headaches.

I want more money - but you didn't generate more revenue.

I want more time off - but you asked for more money

I'm going to stab you in the back once I get a chance - you can try.

so on so forth

the midlevels don't have such problems.

No wonder things for physicians are going down the drain………..

 

[NewYorkDoctors]

No wonder things for physicians are going down the drain………..

meh not for me. things are going up and up.

I use midlevels as my extenders but do not give them any autonomy. Everything goes by me. I mean I run my office somewhat democratically and I will take my staff suggestions into consideration. I will consider anything that improves efficiency.

Escape the big hospital systems, join an IPA, create your own private practice, continue to maintain hospital affiliation for procedures (if applicable to your specialty), and enjoy your independence.

The longer doctors stay tethered to the big corporate hospital systems, the worse off one will be. "doctors going down the drain" is really more of a function of being tethered to the big hospital corporations because the physician may be unwilling or unable to branch out and go entrepreneurial. If you make yourself a cog of the medical industrial complex, then you reap what you sow. This is not a personal attack on anyone. This is just my philosophy and I have been very glad I am an independent "free agent" of sorts.

And contrary to the stereotype, I do not do 5 minute crap visits as a private physician. I try to be as "academic" as I can. Although I do not do research anymore (other than help fellows with their manuscripts ... that's not really research thats just scholarly activity), I keep up with the journals (online of course no wasted paper for me), text my academic super specialist colleagues for tough cases, review uptodate for complex cases, etc

I also try to do "the full Monty" and take no shortcuts.

For example, I spend quite a bit of time talking to my bronchiectasis patients about the GERD rules, using an anatomical model to demonstrate how different sleeping positions will lead to reflux, and emphasizing some of the basics that PMDs do not even emphasize. (The reason being preventing inoculation of GI flora into the airways)

If I see upper lobe bronchiectasis with an appropriate medical history, I'll go the extra mile to screen for CF (it's a bit of a process to get an adult an appointment at the Children's Hospital for sweat testing) and then get that genetic testing.

I will take the time and effort to get the patient started on pulmonary hygiene with hypertonic saline. Many insurances do not cover this as a pharmacy benefit. so I have to often buy the devices for the patients (who refuse to spend $30 themselves) and get the saline for them.

As appropriate, I will get them a chest vest and provide in office education.

(The DME companies "rent" a compressor and charge the patient monthly coinsurance - it's a scam honestly unless they are Medi/Medi/Manager and have $0 copay - even then its a scam to the system)

I have also used the revenue generated to buy a CPET system. While many elderly patients with undifferentiated dyspnea are not going to give a good effort on CPET and there are not too many elite athletes out there in my neck of the woods, I do use it for lung resection surgery evaluation. ATS and ERS guidelines are fairly clear on its use when PPO FEV1 / PPO DLCO < 30-60%. Yet outside of the top academic centers, CPET is not used and many pulmonologists (private or academic) still use the 2L, 1.5L, 1L FEV1 rule for pneumonectomy, lobectomy, and segmentectomy. That's just not doing things by the book.

While all of this seems "standard" in an academic medical practice, I have seen other private pulmonologists just not do anything besides empiric cipro. not even an attempt for sputum culture induction in the office. Then the patients are given empiric Trelegy Ellipta for no particular reason besides "dyspnea" and cannot get an easy history (as above).

But how is this all possible? I have midlevels to help me with all this. PA to help go through some of the specific details of management (rather than my repeating myself for the fifth time to a patient who has comprehension issues whether due to presbycuisis, older age, or lower educational attainment - and yes I have my staff talk at a 6th grade level and use layterms by the book). Needless to say, a respiratory therapist is a must for me.

If I did all of this myself, I would seem like 3 patients a day and I would go bankrupt and go back to the hospital systems as cog in the wheel that can be easily disposed of.

At the end of the day, my goal is not to make the most money to buy a yacht or fancy car. I don't care about any of that. I wear the plainest clothes when not at work and get mistaken for a "slacker useless Gen Y millenial" when I am sipping a coffee at a local coffee house. I wouldn't have it any other way.

But I do want to generate the most revenue possible to expand the business and hire more people and create more jobs. Is that so wrong? Is this a worse career goal than an academic doctor in the ivory tower who wants to publish original research? No these are separate paths.

 

[anonperson]

im glad we agree to disagree.

if it makes you feel any better, I am waiting for a friend to graduate IM residency so I can hire him to the PMD of the practice (while I transition to full time subspecialty and also can create a real PCMH). At least a friend won't be backstabbing me (I hope).


my point is, physician extenders (physician assistant or associate or whatever they want to call themselves and "doctors" of nurse practitioner) can help physicians out. look at a busy surgeon. if he/she has a lot of inpatient work and surgeries to do, who will help out to round, do wound care, follow up office results etc... the PA/NP. A surgeon cannot possibly do ALL of those things in one day.

giving them full autonomy to push doctors out is just too much of the crony capitalism of the medical industrial complex cutting corners. But at the end of the day, patients will still want to see MD/DOs. At the end of the day, a moderately complex patient who sees an exclusive NP will be getting that "referral to Internal Medicine."

Maybe I'm old fashioned but it bothers me when the surgeon has the NP/PA round post op.

Yeah, it's not billable but if you cut into someone, a physician should see them post op.


Sure, the NP picks the low hanging fruit and easy reimbursement and sends the train wrecks to the physician.

That sounds like a recipe for burnout.

Sometimes it's nice to have a couple of easy patients to buffer your day.

 

[anonperson]

meh. i see your point. but hiring other physicians in a small private practice like mine is rife with headaches.

I want more money - but you didn't generate more revenue.

I want more time off - but you asked for more money

I'm going to stab you in the back once I get a chance - you can try.

so on so forth

the midlevels don't have such problems.

Got it.

You want to generate as much revenue on the backs of mid levels who won't challenge you.

You sound like an administrator of a typical health system

"These physicians are out of line and demanding too much."

 

[NewYorkDoctors]

Edit: removing from thread and taking it to DM

 

[Osteoth]

What percent of RVUs do you guys think is fair to supervise? Highest I’ve seen is 20%.

If they’re billing under you and let’s say average PCP bills about $500k, you pay the PA $150, give the clinic their 10% profit, that leaves 60% of the pie left, which we’ll never get but why can’t we get 40% if we’re doing all the work and taking all the risk?

 

[anonperson]

Edit: removing from thread and taking it to DM

Not interested in going into DMs.

I'll happily reply in public.

You said yourself, hiring a physician is a headache because of the cost and demands they have.

That's the same argument that administrators use when screwing over physicians and maximizing mid level use.

You're doing the same thing on a smaller scale.

Docs who have their own private practice are often averse to hiring other physicians in my experience.

The solution would be to use physicians but that incurs cost and headache that isn't acceptable to you.

You have your own personal fiefdom so you can run it how you want.

 

[NewYorkDoctors]

Not interested in going into DMs.

I'll happily reply in public.

You said yourself, hiring a physician is a headache because of the cost and demands they have.

That's the same argument that administrators use when screwing over physicians and maximizing mid level use.

You're doing the same thing on a smaller scale.

Docs who have their own private practice are often averse to hiring other physicians in my experience.

The solution would be to use physicians but that incurs cost and headache that isn't acceptable to you.

You have your own personal fiefdom so you can run it how you want.

I'm glad we agree to disagree.

Have a nice life and career. I wish you no ill will and I hope you find a solution that works for you and your family

 

[HemeOncHopeful19]

What percent of RVUs do you guys think is fair to supervise? Highest I’ve seen is 20%.

If they’re billing under you and let’s say average PCP bills about $500k, you pay the PA $150, give the clinic their 10% profit, that leaves 60% of the pie left, which we’ll never get but why can’t we get 40% if we’re doing all the work and taking all the risk?

Because as OP has pointed out too many people are pushovers, don’t want to “ruffle feathers” or have a non-compete and are tied to the area

 

[bronx43]

Not interested in going into DMs.

I'll happily reply in public.

You said yourself, hiring a physician is a headache because of the cost and demands they have.

That's the same argument that administrators use when screwing over physicians and maximizing mid level use.

You're doing the same thing on a smaller scale.

Docs who have their own private practice are often averse to hiring other physicians in my experience.

The solution would be to use physicians but that incurs cost and headache that isn't acceptable to you.

You have your own personal fiefdom so you can run it how you want.

Why don't you encourage people to start their own practice, instead of trying to shame someone for hiring midlevels? You can easily hang a shingle across the street from a midlevel heavy clinic and steal all their patients. Multiple people on SDNs have done that and are thriving. It's not impossible, but it is hard work and delayed payout.

Honestly, this type of "gimme" thinking is what truly dooms physicians as a whole. We all want to be hired. And not deal with business side of medicine. And get paid above MGMA median. And live in a nice area. And not work too hard.

Absolutely nothing is stopping any physician from taking the risk and putting in the work of building a business from scratch. The only way that physicians can ever regain a position of strength in this game is by going independent or at least present a credible threat.
*I do not supervise or work with midlevels and never will, but that is not the point here.

 

[NewYorkDoctors]

Why don't you encourage people to start their own practice, instead of trying to shame someone for hiring midlevels? You can easily hang a shingle across the street from a midlevel heavy clinic and steal all their patients. Multiple people on SDNs have done that and are thriving. It's not impossible, but it is hard work and delayed payout.

Honestly, this type of "gimme" thinking is what truly dooms physicians as a whole. We all want to be hired. And not deal with business side of medicine. And get paid above MGMA median. And live in a nice area. And not work too hard.

Absolutely nothing is stopping any physician from taking the risk and putting in the work of building a business from scratch. The only way that physicians can ever regain a position of strength in this game is by going independent or at least present a credible threat.
*I do not supervise or work with midlevels and never will, but that is not the point here.

I concur wholeheartedly.

As a Generation Y millennial (who absolute detests other Gen Y and Gen Z snowflakes out there), I find it highly ironic that I am the one who encourages a "go get out there and get some mentality" while the Anonymous poster (who might be a Gen X or maybe a boomer - I am making this assumption based on the 'old fashioned' comment) is the one with the entitled Gen Z participation trophy attitude.

And I don't feel shamed. I wear a big scarlet letter everyday. That "letter" is the $ sign. Or perhaps to sound less like a mercenary, that "letter" is a signs that says "the hospital administrators got nothing on me."

Maybe I'm old fashioned but it bothers me when the surgeon has the NP/PA round post op.

 

[MD46]

Why don't you encourage people to start their own practice, instead of trying to shame someone for hiring midlevels? You can easily hang a shingle across the street from a midlevel heavy clinic and steal all their patients. Multiple people on SDNs have done that and are thriving. It's not impossible, but it is hard work and delayed payout.

Honestly, this type of "gimme" thinking is what truly dooms physicians as a whole. We all want to be hired. And not deal with business side of medicine. And get paid above MGMA median. And live in a nice area. And not work too hard.

Absolutely nothing is stopping any physician from taking the risk and putting in the work of building a business from scratch. The only way that physicians can ever regain a position of strength in this game is by going independent or at least present a credible threat.
*I do not supervise or work with midlevels and never will, but that is not the point here.

I concur wholeheartedly.

As a Generation Y millennial (who absolute detests other Gen Y and Gen Z snowflakes out there), I find it highly ironic that I am the one who encourages a "go get out there and get some mentality" while the Anonymous poster (who might be a Gen X or maybe a boomer - I am making this assumption based on the 'old fashioned' comment) is the one with the entitled Gen Z participation trophy attitude.

And I don't feel shamed. I wear a big scarlet letter everyday. That "letter" is the $ sign. Or perhaps to sound less like a mercenary, that "letter" is a signs that says "the hospital administrators got nothing on me."

I get what you both are saying and in an ideal world one should strive for a physician led all physician practice and potentially if financially viable have an NP to help, however I dont think due to reimbursements cuts vs hospital based practice; private practice will stay lucrative and above MGMA as you stated.

Taking example of what I am familiar with i.e. heme onc, private practice is going out of fashion as most groups are either being bought by hospital systems or becoming part of US Oncology.

Hospital gets paid more for chemo, there are larger profit margins but they mostly keep revenue from chemo and pay doctors only E/M visit share.

I know a few managing partners of private practices and things are getting tighter everyday. Overheads are increasing while reimbursements getting lower. If you join a US Oncology group they have their prefered drug lists which they send out monthly so they tell you which drugs are preferred to use over the others, if you dont follow u get penalized in one way or another. Autonomy not as good then.

If its pure private group that owns their own office, their building and also have their own lab and oral chemo dispensary they still might be doing a little better right now but senior partners dont share a piece of their pie and try to keep their profit margins good by hiring new grads with dream of partnership and after paying them below market for a few years, saying this is sweat equity and never make them partner.
Then try to find some one gullible again every few years. Hence physicians screwing physicians over.
(Also many such places are attractive to big PE groups and health systems and get good offers to buy them, partners join, get a good deal and screw over current employees and now no partnership)

Per my calculation in a good rvu based model vs a standard plan that most PP groups have in HOnc, 3yrs employed, 3yrs junior partner and then 7th year full partner with some buy in, one really starts to get ahead after 5-8 years as senior partner. By then if you have invested good as employed you are ahead already plus by 7th year mark things might have changed for PP anyways.

Yes, being you own boss sounds great and is amazing if it works well. Need to know pros and cons and its not everyones cup of tea..

My 2 cents

 

[NewYorkDoctors]

I get what you both are saying and in an ideal world one should strive for a physician led all physician practice and potentially if financially viable have an NP to help, however I dont think due to reimbursements cuts vs hospital based practice; private practice will stay lucrative and above MGMA as you stated.

Taking example of what I am familiar with i.e. heme onc, private practice is going out of fashion as most groups are either being bought by hospital systems or becoming part of US Oncology.

Hospital gets paid more for chemo, there are larger profit margins but they mostly keep revenue from chemo and pay doctors only E/M visit share.

I know a few managing partners of private practices and things are getting tighter everyday. Overheads are increasing while reimbursements getting lower. If you join a US Oncology group they have their prefered drug lists which they send out monthly so they tell you which drugs are preferred to use over the others, if you dont follow u get penalized in one way or another. Autonomy not as good then.

If its pure private group that owns their own office, their building and also have their own lab and oral chemo dispensary they still might be doing a little better right now but senior partners dont share a piece of their pie and try to keep their profit margins good by hiring new grads with dream of partnership and after paying them below market for a few years, saying this is sweat equity and never make them partner.
Then try to find some one gullible again every few years. Hence physicians screwing physicians over.
(Also many such places are attractive to big PE groups and health systems and get good offers to buy them, partners join, get a good deal and screw over current employees and now no partnership)

Per my calculation in a good rvu based model vs a standard plan that most PP groups have in HOnc, 3yrs employed, 3yrs junior partner and then 7th year full partner with some buy in, one really starts to get ahead after 5-8 years as senior partner. By then if you have invested good as employed you are ahead already plus by 7th year mark things might have changed for PP anyways.

Yes, being you own boss sounds great and is amazing if it works well. Need to know pros and cons and its not everyones cup of tea..

My 2 cents

A well thought out response . I enjoyed reading this and learning from your insights .

I will admit not every doctor can make it in the private practice market due to factors behind his her control and the corporate hacks know this . The great equalizer now is increasing patient volume . But unless there are more hours of the day , a physician extender will be required to help sustain that volume or else the patient care will suffer . Again I don’t mean have the Np or PA independently see patients . I mean have them do the “dirty work “ so the doctor can then see each patient more efficiently.

But my initial point is physician “extenders” can be a valuable tool to a physician if deployed correctly . It can also be a detriment if used by administrators to save money at the expense of having a doctor

 

[MD46]

A well thought out response . I enjoyed reading this and learning from your insights .

I will admit not every doctor can make it in the private practice market due to factors behind his her control and the corporate hacks know this . The great equalizer now is increasing patient volume . But unless there are more hours of the day , a physician extender will be required to help sustain that volume or else the patient care will suffer . Again I don’t mean have the Np or PA independently see patients . I mean have them do the “dirty work “ so the doctor can then see each patient more efficiently.

But my initial point is physician “extenders” can be a valuable tool to a physician if deployed correctly . It can also be a detriment if used by administrators to save money at the expense of having a doctor

Totally agree.

 

[chessknt]

Aside from enslaving midlevels to churn profit, what else are people doing to help cover the office overhead? I live in an area with essentially no competition for patients but everyone is on ****ty government insurance. The money from pfts, lab collection, cpet and even imaging is peanuts compared to what the asc/Endo/cards guys or the infusion money that onc gets. Is it really just collecting enough scraps from the floor to make a meal unless you're in cards/gi/onc?

Even Botox and cosmetic crap if you're willing to mortgage your shoul doesn't mesh well with a regular practice environment--these cash paying patients don't want to be around sick people. There really doesn't seem to be medically sound legal ancillary income sources of income for the non procedural specialties u less you can run an infusion center.

 

[VA Hopeful Dr]

I get what you both are saying and in an ideal world one should strive for a physician led all physician practice and potentially if financially viable have an NP to help, however I dont think due to reimbursements cuts vs hospital based practice; private practice will stay lucrative and above MGMA as you stated.

Taking example of what I am familiar with i.e. heme onc, private practice is going out of fashion as most groups are either being bought by hospital systems or becoming part of US Oncology.

Hospital gets paid more for chemo, there are larger profit margins but they mostly keep revenue from chemo and pay doctors only E/M visit share.

I know a few managing partners of private practices and things are getting tighter everyday. Overheads are increasing while reimbursements getting lower. If you join a US Oncology group they have their prefered drug lists which they send out monthly so they tell you which drugs are preferred to use over the others, if you dont follow u get penalized in one way or another. Autonomy not as good then.

If its pure private group that owns their own office, their building and also have their own lab and oral chemo dispensary they still might be doing a little better right now but senior partners dont share a piece of their pie and try to keep their profit margins good by hiring new grads with dream of partnership and after paying them below market for a few years, saying this is sweat equity and never make them partner.
Then try to find some one gullible again every few years. Hence physicians screwing physicians over.
(Also many such places are attractive to big PE groups and health systems and get good offers to buy them, partners join, get a good deal and screw over current employees and now no partnership)

Per my calculation in a good rvu based model vs a standard plan that most PP groups have in HOnc, 3yrs employed, 3yrs junior partner and then 7th year full partner with some buy in, one really starts to get ahead after 5-8 years as senior partner. By then if you have invested good as employed you are ahead already plus by 7th year mark things might have changed for PP anyways.

Yes, being you own boss sounds great and is amazing if it works well. Need to know pros and cons and its not everyones cup of tea..

My 2 cents

You don't get paid directly for chemo but your RVU value is significantly higher than IM subspecialties that don't have high paying procedures or infusions.

 

[NewYorkDoctors]

a

Aside from enslaving midlevels to churn profit, what else are people doing to help cover the office overhead? I live in an area with essentially no competition for patients but everyone is on ****ty government insurance. The money from pfts, lab collection, cpet and even imaging is peanuts compared to what the asc/Endo/cards guys or the infusion money that onc gets. Is it really just collecting enough scraps from the floor to make a meal unless you're in cards/gi/onc?

Even Botox and cosmetic crap if you're willing to mortgage your shoul doesn't mesh well with a regular practice environment--these cash paying patients don't want to be around sick people. There really doesn't seem to be medically sound legal ancillary income sources of income for the non procedural specialties u less you can run an infusion center.

Are you part of an ipa ? The ipa helps me negotiate the best insurance payment rates even for managed Medicaid Medicare .

Straight Medicaid pays peanuts I agree . But in my neck of the woods most lower income patients have some form of managed Medicaid and the IPA has negotiated good rates.

Doing a new consult 99203 with a pft (pleth) , 6mwt , and pocus lung in office gets me about $400 revenue for that visit

Straight Medicaid pays me like $150 for all that . So there is a steep drop off

 

[bronx43]

I get what you both are saying and in an ideal world one should strive for a physician led all physician practice and potentially if financially viable have an NP to help, however I dont think due to reimbursements cuts vs hospital based practice; private practice will stay lucrative and above MGMA as you stated.

Taking example of what I am familiar with i.e. heme onc, private practice is going out of fashion as most groups are either being bought by hospital systems or becoming part of US Oncology.

Hospital gets paid more for chemo, there are larger profit margins but they mostly keep revenue from chemo and pay doctors only E/M visit share.

I know a few managing partners of private practices and things are getting tighter everyday. Overheads are increasing while reimbursements getting lower. If you join a US Oncology group they have their prefered drug lists which they send out monthly so they tell you which drugs are preferred to use over the others, if you dont follow u get penalized in one way or another. Autonomy not as good then.

If its pure private group that owns their own office, their building and also have their own lab and oral chemo dispensary they still might be doing a little better right now but senior partners dont share a piece of their pie and try to keep their profit margins good by hiring new grads with dream of partnership and after paying them below market for a few years, saying this is sweat equity and never make them partner.
Then try to find some one gullible again every few years. Hence physicians screwing physicians over.
(Also many such places are attractive to big PE groups and health systems and get good offers to buy them, partners join, get a good deal and screw over current employees and now no partnership)

Per my calculation in a good rvu based model vs a standard plan that most PP groups have in HOnc, 3yrs employed, 3yrs junior partner and then 7th year full partner with some buy in, one really starts to get ahead after 5-8 years as senior partner. By then if you have invested good as employed you are ahead already plus by 7th year mark things might have changed for PP anyways.

Yes, being you own boss sounds great and is amazing if it works well. Need to know pros and cons and its not everyones cup of tea..

My 2 cents

I totally agree, though the hospital vs independent dynamic wasn't really the point of my post. Clearly Newyorkdoctors isn't a hospital, and he is making it work. He has no advantage that the rest of us don't have. I just find it off putting that people who didn't take the risk and put in the work are shaming someone who did and is making business decisions to optimize return on investment.
If one is against the hiring of midlevels, then he/she can build a business and hire all physicians. It's much easier to take the safe road of guaranteed salary and employment, while pointing the finger at others who took a different route.

 

[bronx43]

Aside from enslaving midlevels to churn profit, what else are people doing to help cover the office overhead? I live in an area with essentially no competition for patients but everyone is on ****ty government insurance. The money from pfts, lab collection, cpet and even imaging is peanuts compared to what the asc/Endo/cards guys or the infusion money that onc gets. Is it really just collecting enough scraps from the floor to make a meal unless you're in cards/gi/onc?

Even Botox and cosmetic crap if you're willing to mortgage your shoul doesn't mesh well with a regular practice environment--these cash paying patients don't want to be around sick people. There really doesn't seem to be medically sound legal ancillary income sources of income for the non procedural specialties u less you can run an infusion center.

Cards are mostly employed. CMS more or less decapitated independent cardiology practice 5-10 years ago when they gutted private practice reimbursement and kept it high for hospital based.
Endoscopy and outpatient surgical are somehow still sucking on the teat of CMS.

 

[chessknt]

Cards are mostly employed. CMS more or less decapitated independent cardiology practice 5-10 years ago when they gutted private practice reimbursement and kept it high for hospital based.
Endoscopy and outpatient surgical are somehow still sucking on the teat of CMS.

Cards in my area are clearing 7 figures with ease. They built a stand alone Cath lab and ep makes 6 figures on each ppm. They have the only cmri in the region and apparently do lung cancer screening and manage diabetes as well.

 

[bronx43]

Cards in my area are clearing 7 figures with ease. They built a stand alone Cath lab and ep makes 6 figures on each ppm. They have the only cmri in the region and apparently do lung cancer screening and manage diabetes as well.

What size of city are you in? I encountered this in rural areas at my old gig, but I don't see this in many metros >100k. Though there are quite a few employed cards that clear 7 figures with ease, so it's unclear that it's an employed vs independent thing.

 

[chessknt]

a

Are you part of an ipa ? The ipa helps me negotiate the best insurance payment rates even for managed Medicaid Medicare .

Straight Medicaid pays peanuts I agree . But in my neck of the woods most lower income patients have some form of managed Medicaid and the IPA has negotiated good rates.

Doing a new consult 99203 with a pft (pleth) , 6mwt , and pocus lung in office gets me about $400 revenue for that visit

Straight Medicaid pays me like $150 for all that . So there is a steep drop off

What is the medical necessity of an office lung pocus unless you are looking for an effusion? Are you actually getting paid to look at a lines?

I am assuming that PH would be hard to do correctly and that the infused drugs don't catch any more revenue to be worth the hassle.

There is a chain of primary care here but they seem to have a bunch of government contracts after bribing the local officials that netted them close to a billion for covid testing over the last year and opened up infusion centers for antibodies that double dipped. They also do their own pfts but the quality on them is horrendous (I got a referral for a fireman who failed his pfts from them only 2x to find them to be normal on our machine) and their midlevels seem to refer everything out.

 

[chessknt]

What size of city are you in? I encountered this in rural areas at my old gig, but I don't see this in many metros >100k. Though there are quite a few employed cards that clear 7 figures with ease, so it's unclear that it's an employed vs independent thing.

It's the largest city in an otherwise rural area about 250k people but the catchment area nets another 150-200 people. They have no competition and have the e tire market monopolized. I wouldn't have any competition either from a pulm side but I also can't build a Cath lab....

 

[bronx43]

It's the largest city in an otherwise rural area about 250k people but the catchment area nets another 150-200 people. They have no competition and have the e tire market monopolized. I wouldn't have any competition either from a pulm side but I also can't build a Cath lab....

True but may not be the worst thing in the world. Building a cath lab or ASC is highly capital intensive and if CMS ever changes their minds about reimbursement (they’re already set to drop conversion rate for 2023), you may be left with huge debt load without the necessary cash flow.

 

[dozitgetchahi]

Aside from enslaving midlevels to churn profit, what else are people doing to help cover the office overhead? I live in an area with essentially no competition for patients but everyone is on ****ty government insurance. The money from pfts, lab collection, cpet and even imaging is peanuts compared to what the asc/Endo/cards guys or the infusion money that onc gets. Is it really just collecting enough scraps from the floor to make a meal unless you're in cards/gi/onc?

Even Botox and cosmetic crap if you're willing to mortgage your shoul doesn't mesh well with a regular practice environment--these cash paying patients don't want to be around sick people. There really doesn't seem to be medically sound legal ancillary income sources of income for the non procedural specialties u less you can run an infusion center.

Two points:

- If you’re PP and the payor mix sucks, you might have to move and/or consider DPC or something similar (this doesn’t work for every specialty).

- What I’ve seen some larger PPs do is to start setting up non-medical ancellaries. For instance, my current practice owns a very profitable parking garage that supplies a surprising amount of ancillary income to partners each month. You might have to get creative.

 

[NewYorkDoctors]

What is the medical necessity of an office lung pocus unless you are looking for an effusion? Are you actually getting paid to look at a lines?

I am assuming that PH would be hard to do correctly and that the infused drugs don't catch any more revenue to be worth the hassle.

There is a chain of primary care here but they seem to have a bunch of government contracts after bribing the local officials that netted them close to a billion for covid testing over the last year and opened up infusion centers for antibodies that double dipped. They also do their own pfts but the quality on them is horrendous (I got a referral for a fireman who failed his pfts from them only 2x to find them to be normal on our machine) and their midlevels seem to refer everything out.

Yes I am. It pays $40 - $50 per POCUS.

And I do it for a sensible reason that I can document. It's not for "screening." that would be wrong.

But not every patient who comes to me has a recent CXR but may have a baseline from a few years ago. If someone complains of dyspnea cough and possible LRTI, just take a look. I can defer sending to radiology sometimes as a result if physical exam, PFT, and lung US checks out.

Moreover, many overweight individuals have "diminished breath sounds" up to around T4-T5 on auscultation. While PFts are going to show restriction with low ERV values, it is helpful for me to ensure there is no pleural effusion. I have been surprised before.

I also like to use it in the office for someone I did a TBBx on or sent to radiology for transthoracic needle biopsy who complains of chest pain a few days ater.

I mean I do some tactile fremitus and chest excursion but that's all just for show for the patient.

One side of the argument is "not sure how this saves money. It's just going into your pocket."

Exactly. That's the point.

I think more money is saved going after the Medical Industrial Complex for price gouging (see insulin, COVID vaccines, medical devices...) than it is going after the little guy who is simultaneously doing more for his patients. Of course with all the lobbyists out there, the MIC is not going anywhere anytime soon.

 

[MD46]

You don't get paid directly for chemo but your RVU value is significantly higher than IM subspecialties that don't have high paying procedures or infusions.

It is because the amount of revenue we generate for the hospital with infusion is higher than most other IM subspecialities hence getting paid more per rvu makes sense.

 

[VA Hopeful Dr]

It is because the amount of revenue we generate for the hospital with infusion is higher than most other IM subspecialities hence getting paid more per rvu makes sense.

Obviously, just pointing out that your E&M codes pay better than almost anyone else IM trained.

 

[sloh]

It is because the amount of revenue we generate for the hospital with infusion is higher than most other IM subspecialities hence getting paid more per rvu makes sense.

Incentives 🙃

 

[anonperson]

Why don't you encourage people to start their own practice, instead of trying to shame someone for hiring midlevels? You can easily hang a shingle across the street from a midlevel heavy clinic and steal all their patients. Multiple people on SDNs have done that and are thriving. It's not impossible, but it is hard work and delayed payout.

Honestly, this type of "gimme" thinking is what truly dooms physicians as a whole. We all want to be hired. And not deal with business side of medicine. And get paid above MGMA median. And live in a nice area. And not work too hard.

Absolutely nothing is stopping any physician from taking the risk and putting in the work of building a business from scratch. The only way that physicians can ever regain a position of strength in this game is by going independent or at least present a credible threat.
*I do not supervise or work with midlevels and never will, but that is not the point here.

I'm not shaming anyone for opening up shop and being in private practice. I don't care either way.

But don't post about being in private practice and then state it's too much of a headache to hire another physician because mid levels are easier to control and expect me to support that.

No chance.

Each specialty and region has its own nuance where being in private may or may not be beneficial.

Being a solo OBGYN is a recipe for disaster. Sure you may be your own boss but your work life balance is terrible.

Meanwhile being a solo derm or plastics is much more feasible.

What I want for physicians is fair pay for fair work. Whether it's an employed model, private practice, solo, etc.

I've done private practice ( a poorly run one), employed for a health system ( disorganized) and now a FQHC. Surprisingly the FQHC offers the best working environment but this is not universal.

 

[NewYorkDoctors]

But don't post about being in private practice and then state it's too much of a headache to hire another physician because mid levels are easier to control and expect me to support that.

That’s some Olympic level mental gymnastics , coping and reaching there . I did not expect anything from you other than to ignore the post . But the rest of your post does shed light on why you responded the way you did.

What I want for physicians is fair pay for fair work. Whether it's an employed model, private practice, solo, etc.

You’ve gotten burned before and it sounds like it was through no fault of your own . I do have more empathy now that I read your post