PA/NP Supervision Compensation

[dozitgetchahi]

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.

Reading through this thread…there’s a lot to unpack here.

I agree completely with you regarding fair pay for the work we do, which is often very intense and very long.

I am not fond of midlevels “managing” patients on their own. I do not, under any circumstances, agree with it or think it’s a good idea. I do take a dim view of PP types who regard midlevels as a source of “ancillary income” (unfortunately you will find a lot of PP partners in my specialty who think this way), and I generally think of those folks as barely a notch above those docs who sell their souls to drug companies for cash to do “talks”. I think the practice of using midlevels this way is short circuiting our profession, endangering patient wellness, and steadily causing the public to lose respect for MD/DOs.

My feelings on this have nothing to do with whether it’s happening in PP, community practice, academia, etc. This stuff has been going on across the board for years, including in the ORs with CRNAs and such, and I think the overall effect on the medical profession (and patient care) has been strongly negative. There are plenty of ways to make money in medicine without selling out your profession and jeopardizing patient safety. Saying “I’m in private practice, so I need to use midlevels” is not an excuse. IMHO, midlevels should be used for things like “in basket” tasks and refilling scripts, and not much more.

(I also agree with questioning the idea that midlevels are easier to “control”. For starters, I have seen midlevels ask for more cash, backstab, and do everything described in the post above - and more. Furthermore, my experience has generally been that PPs who like midlevels because “they’re cheaper and easier to control” also treat their physicians like yesterday’s garbage. I have seen way too many PP senior partners take a “lord of the manor” attitude within their practices - bossing around physician associates as if they were their residents or something, underpaying them, eating their ancillaries without offering partnership, and generally acting like douchebags. Obviously I’m not there to see what’s going on in that particular practice, but I have interviewed at enough bad PPs to see that this IS often what’s going on. I have encountered way too many PPs who want to hire another physician…but also want to pay and treat that physician like a midlevel. Other physicians are still physicians; they are your colleagues, and they deserve to be treated like it too.)

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[stayinalive]

Reading the various posts here has been interesting.

As the OP, I want to share my final takeaways centered on my original post. Please note these are primarily for employed positions at healthcare systems/group/integrated delivery network:

- If you are supervising a NP/PA already, there is no going back from that.
- If you are in an employed model and not yet supervising a NP/PA, it is a matter of time before you are asked/assigned to do such supervision.
- If management/department chair is reasonable and a true partner, you may be able to decline doing so or even obtain some compensation for it. If you are able to get compensation in terms of a stipend/RVU, there is a decent chance it'll continue on that path even with a new management team, but still they may take it away or alter it in the future.
- More likely management/department will not be reasonable, will treat you like a fast food employee, and will force the NP/PA onto you. And its always a matter of time until a new management team with this sort of thinking comes along. They will not offer your compensation and if you have colleagues, most will take it without much resistance.
- Depending on your market power based off location & specialty, your options will vary. See previous discussions/posts.
- If you are starting a new job, prepare for this scenario. Put it in writing. If it is not in your contract, It might be true or it might not be true. If someone is not willing to put it in writing, then once again it may or may not be true. Some places have extremely standard contracts so they won't budge esp if you are PCP or low-demand specialty/they don't really need you even if there no plan for a PA/NP. Other places won't put it in because well they are lying to you and will force one on you in due time.

As a general note, I wish physicians were more flexible with our location. I wish family tries, spousal job, and personal affinity for a location were not always hanging over us. Employers know this. It shrinks our market power and our options. Ideally if you can live like a military family and be okay moving around every few years, you have a good shot at avoiding the struggles facing today's physician.

Also again as general principle for employed positions- if its not in writing, it may or may not be true. Get it in writing. Make no assumptions.

 

[stayinalive]

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

This is a great post and I agree with so much in here.

 

[anonperson]

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.


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

What Olympic level reaching are you even talking about?

You wrote that hiring another physician for your practice is a headache. Not me.

That's a pretty clear unambiguous statement that you prefer mid levels in your practice because physicians are too disruptive and won't bend to whatever you want.

Shocking that a physician wants reasonable time off and reasonable compensation.

Why should I view that as a positive? How am I reaching in any way?

That's the same thought process, albeit on a smaller scale, that various health systems use across the country to screw over physicians.

Please feel free to refute that...

Wait, you can't because you're doing the same thing.

 

[dozitgetchahi]

Reading the various posts here has been interesting.

As the OP, I want to share my final takeaways centered on my original post. Please note these are primarily for employed positions at healthcare systems/group/integrated delivery network:

- If you are supervising a NP/PA already, there is no going back from that.
- If you are in an employed model and not yet supervising a NP/PA, it is a matter of time before you are asked/assigned to do such supervision.
- If management/department chair is reasonable and a true partner, you may be able to decline doing so or even obtain some compensation for it. If you are able to get compensation in terms of a stipend/RVU, there is a decent chance it'll continue on that path even with a new management team, but still they may take it away or alter it in the future.
- More likely management/department will not be reasonable, will treat you like a fast food employee, and will force the NP/PA onto you. And its always a matter of time until a new management team with this sort of thinking comes along. They will not offer your compensation and if you have colleagues, most will take it without much resistance.
- Depending on your market power based off location & specialty, your options will vary. See previous discussions/posts.
- If you are starting a new job, prepare for this scenario. Put it in writing. If it is not in your contract, It might be true or it might not be true. If someone is not willing to put it in writing, then once again it may or may not be true. Some places have extremely standard contracts so they won't budge esp if you are PCP or low-demand specialty/they don't really need you even if there no plan for a PA/NP. Other places won't put it in because well they are lying to you and will force one on you in due time.

As a general note, I wish physicians were more flexible with our location. I wish family tries, spousal job, and personal affinity for a location were not always hanging over us. Employers know this. It shrinks our market power and our options. Ideally if you can live like a military family and be okay moving around every few years, you have a good shot at avoiding the struggles facing today's physician.

Also again as general principle for employed positions- if its not in writing, it may or may not be true. Get it in writing. Make no assumptions.

You likely have more options wrt job searching than you think, even locally.

I thought the same way with my first job - I was divorced, and the job was near my ex, so I took a job where the pay wasn’t that competitive to begin with because I thought I had to do it to stay in the area. (I also got some slightly bad vibes at the interview.) That job was abusive and miserable, but I unfortunately stuck with it for several years (among other things, I misunderstood the contract and thought I would owe them a huge portion of the sign on if I left before 3 years - which wasn’t actually true). One of the very best things I did for myself was to leave both that job and the area - at job number 2, I got a substantial pay increase and was treated better going forward. Staying there would have frankly damaged my career and my sanity after a point. You can always travel to see family…spouses can find other jobs elsewhere too…and in terms of “personal affinity”, you may find that there are other places in America you like to live. (Your spouse and family should also care about whether or not you like your job and/or are being treated like garbage there…it’s a two way street.) There are a lot of doctors who cite these reasons for staying in crappy situations, but the real reason is often inertia.

Unless you truly live in the middle of nowhere, you likely have other job options in your neck of the woods. Hell, my job #2 was in a small southern town of not even 10k people, and there were 2 hospitals and several large multispecialty private practices there…people would just bail out of one institution when things started to suck, and head to one of the others. It kept those institutions honest. Even if you think you are tied to one location, you should start exploring other job options nearby. If this place forced an NP on you with none of your input and zero compensation for doing so, I’m guessing there are other aspects of this job that suck too.

 

[dozitgetchahi]

Reading the various posts here has been interesting.

As the OP, I want to share my final takeaways centered on my original post. Please note these are primarily for employed positions at healthcare systems/group/integrated delivery network:

- If you are supervising a NP/PA already, there is no going back from that.
- If you are in an employed model and not yet supervising a NP/PA, it is a matter of time before you are asked/assigned to do such supervision.
- If management/department chair is reasonable and a true partner, you may be able to decline doing so or even obtain some compensation for it. If you are able to get compensation in terms of a stipend/RVU, there is a decent chance it'll continue on that path even with a new management team, but still they may take it away or alter it in the future.
- More likely management/department will not be reasonable, will treat you like a fast food employee, and will force the NP/PA onto you. And its always a matter of time until a new management team with this sort of thinking comes along. They will not offer your compensation and if you have colleagues, most will take it without much resistance.
- Depending on your market power based off location & specialty, your options will vary. See previous discussions/posts.
- If you are starting a new job, prepare for this scenario. Put it in writing. If it is not in your contract, It might be true or it might not be true. If someone is not willing to put it in writing, then once again it may or may not be true. Some places have extremely standard contracts so they won't budge esp if you are PCP or low-demand specialty/they don't really need you even if there no plan for a PA/NP. Other places won't put it in because well they are lying to you and will force one on you in due time.

As a general note, I wish physicians were more flexible with our location. I wish family tries, spousal job, and personal affinity for a location were not always hanging over us. Employers know this. It shrinks our market power and our options. Ideally if you can live like a military family and be okay moving around every few years, you have a good shot at avoiding the struggles facing today's physician.

Also again as general principle for employed positions- if its not in writing, it may or may not be true. Get it in writing. Make no assumptions.

Also, wrt “getting it in writing”…my experience in this profession has been that even a “good contract” is actually only as good as the people who signed it. Bad institutions will find ways to violate good contracts, and they will often do so with relative impunity. Why? Because they know that aside from leaving, your only other recourse is generally to sue - which is a long, complicated, time consuming process with no guarantee of success. I have worked for multiple institutions at this point who willfully violated contracts (example: $160k+ unpaid bonuses, tail coverage, and loan reimbursement at job #2), and I am in the process of suing. It’s a pain in the ass, it wastes tons of time, and I may not get anything out of it in the end. I can also tell you that if, for instance, you have an NP forced on you despite having a contract that says you can’t, the courts (and your lawyer) likely won’t give much of a damn about that. It was actually very hard just to find an attorney who gave a **** about my case even though I can point to clear-cut breaches of contract with six figure damages - I talked to lots of lawyers who basically ghosted or otherwise blew me off after the initial consult call.

What is your recourse in these situations, then? Leave the job. Sometimes, these institutions rely on physician inertia when forcing stupid crap on their medical staff…BUT there are also lots of institutions where doctors have called the bluff, left their jobs, and left the institution hanging wondering how the hell it was going to make things work without physicians. Don’t be a patsy.