So many types of GI jobs these days...

[RUbrown]

I wanted to put this out there into the interwebs, feel free to comment. I recently started looking for jobs in the NE (5+ years out from fellowship). Things have changed a bit from when I last looked.

Far less solo practitioners, maybe they all got bought out, or closed due to covid.

Many multi specialty groups; pcp/cards/gi that make their own physical network and keep expanding by buying more practices. Interesting model, the guys at the top that started it usually get the most profit. However they seem to incentivize newer people with ASC shares at the very least.

Hospital paid groups, some inpatient work, mostly outpatient, salaried by the hospital. Have to deal with the inefficiencies of the hospital, this seems like an okay way to go. Like an easy 8-5.

Academics

And lastly, quickly becoming the most pervasive and least liked in my opinion...the private equity owned groups. PE comes in and buys parts or whole practices with promises of taking care of the "business" aspect of GI. So doctors and just be doctors. Meh, personally the thought of some business bro making financial, and consequently medical decisions for me doesn't sit well. Unfortunately, they found a cash cow in GI/Heme/cards and these guys are popping up everywhere.


I find myself looking at 3 types of practices right now. Small group private with partial ASC shares they co-own, hospital group in a well known well run hospital system, and a growing multi specialty (started by cards, but gi in the infancy). If there are any seasoned GIs on the board, I would love to chat with you and get your opinion on some of the above.

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[Scope guy]

I feel the multispecialty model works only in smaller towns with not enough GIs. getting hard to find it in cities of decent size.

 

[IM2GI]

Be very cautious about joining a post-PE group. You will give up 30% of your salary in perpetuity and you missed out on the big lump sum cash the existing guys got. PE is going to ruin independent practice. There is a lot of smoke and mirrors about how they will be more efficient, etc, etc, but good luck replacing that income. They want to flip you in 3-5 years, and the next guy wants to flip you, etc, etc.

 

[cards67]

I think its more about the specific job than practice type. Across various specialties, I've heard good and bad about all types of practice setups.

 

[RUbrown]

Yeah, it's so hard to tell just from the intro phone calls and tour of the Endo suite. Of course everything is honkey dorey during those things.

What's the current ask for new hires in PP vs hospital based in the NE with experience.

PP
400 + 65/rvu over 8000 - seem fair? First 2 yrs
Partnership in 2 years

Hosp employed
450 + 65/rvu over 7000

Thoughts?

 

[adagio]

Excellent topic.
Agree with colleagues here.
One additional point I have noticed :the more desirable the location the worse the job. Most of us in GI went into it because of endoscopy exposure. Jobs located in "undesirable" areas strike me as endoscopy heavy given lack of competition from other groups saturating the area.
I'm interventional endoscopy trained and live 90 minutes from a major metro area but my job is almost 90% interventional focused. No clinic parient gets added without my approval even if the day is not filled. I do one to two clinic days a month. This is mostly because of difficulty recruiting, poor weather in the winter. This was my own salvation because I could not stand doing ibd, liver, motility etc so I chose the job rather than location. I get paid the same as the general gi guys but don't do weekly night call. However, I end up doing q2 interventional call since there's only 2 of us.
Something gotta give :location, weather, job description or salary.
Lastly for the bonus above rvu cutoff this is an imaginary carrot as hospital inefficiencies will guarantee not being able to get over that. Based on the options you give pp seems the more financially viable option for you.
I went to hospital based employment because more than 75% of interventional volume comes from the inpatient side.

 

[indonacious]

Yeah, it's so hard to tell just from the intro phone calls and tour of the Endo suite. Of course everything is honkey dorey during those things.

What's the current ask for new hires in PP vs hospital based in the NE with experience.

PP
400 + 65/rvu over 8000 - seem fair? First 2 yrs
Partnership in 2 years

Hosp employed
450 + 65/rvu over 7000

Thoughts?

Agree that getting too much over 7000 is hard in most hospital environments.

Regarding the PP job, partnership buyin amount factors in and how things are distributed after partnership. Is that the pay structure for years 1-2? If so, that is quite good for pre partner. How much are you expected to clinically do to get that base? 4 day weeks/5 day weeks? 30 min slots? More/less? How much call? To me these are all just as important as comparison of raw salaries is not adequate given the large variability between positions.

 

[moonlighter123]

Can someone help me a bit? I am trying to evaluate which would pay better two different offers, both hospital employed, both with guaranteed base, but different productivity bonus.
1. 425k + 65/wrvu (once threshold of 425/65 is made)
2. 425k + 85% net collections (once collections meet up to 425k)


Am I wrong to think that wRVU is superior based on

https://www.bostonscientific.com/content/dam/bostonscientific/Reimbursement/Gastroenterology/pdf/Polypectomy_Coding_and_Payment_Quick_Reference.pdf

I.e. if I did a 45385 cold snare, job 1 would only pay $258*0.85=219.3 which is way less than 4.57wRVUs*65 =297.05

Is my logic wrong?

 

[slopes23]

Can someone help me a bit? I am trying to evaluate which would pay better two different offers, both hospital employed, both with guaranteed base, but different productivity bonus.
1. 410k + 65/wrvu (once threshold of 425/65 is made)
2. 410k + 85% net collections (once collections meet up to 425k)


Am I wrong to think that wRVU is superior based on

https://www.bostonscientific.com/content/dam/bostonscientific/Reimbursement/Gastroenterology/pdf/Polypectomy_Coding_and_Payment_Quick_Reference.pdf

I.e. if I did a 45385 cold snare, job 1 would only pay $258*0.85=219.3 which is way less than 4.57wRVUs*65 =297.05

Is my logic wrong?

Presumably when they say net collections they mean only on the physician fee and it doesn’t include the facility fee. Also where are you doing the scope? As you likely know, where the scope is done effects the reimbursement. Also, geographic location can effect the reimbursement as well.

Only reason I ask is that I’d be surprised if you aren’t missing something in the equation about what goes into the net collections number, because presumably they would be compatible options and often the net collections offer can be more sparkly because the number is bigger, especially when you look at billable. The crux of this model is that you get what is collected and not what is billed so it’s riskier. You are supposed to rewarded for this increased risk however by having a higher ceiling. If it turns out to actually be a lower ceiling than I don’t see why that would be a good route to go. You should/could ask what the collection rate tends to be.

 

[moonlighter123]

Presumably when they say net collections they mean only on the physician fee and it doesn’t include the facility fee. Also where are you doing the scope? As you likely know, where the scope is done effects the reimbursement. Also, geographic location can effect the reimbursement as well.

Only reason I ask is that I’d be surprised if you aren’t missing something in the equation about what goes into the net collections number, because presumably they would be compatible options and often the net collections offer can be more sparkly because the number is bigger, especially when you look at billable. The crux of this model is that you get what is collected and not what is billed so it’s riskier. You are supposed to rewarded for this increased risk however by having a higher ceiling. If it turns out to actually be a lower ceiling than I don’t see why that would be a good route to go. You should/could ask what the collection rate tends to be.

I have to clarify, but I believe they mean the physician fees. It would be done at the hospital and not an ASC (though my understanding is that the physician fee is independent of location, it's only facility reimbursement that matters?)

But let's say hypothetically let's say that they collect everything they bill for XXX 45385 cold snare...it seems to me for a Medicare patient wRVU would always win out over physician fees? ...I think?

 

[slopes23]

I have to clarify, but I believe they mean the physician fees. It would be done at the hospital and not an ASC (though my understanding is that the physician fee is independent of location, it's only facility reimbursement that matters?)

But let's say hypothetically let's say that they collect everything they bill for XXX 45385 cold snare...it seems to me for a Medicare patient wRVU would always win out over physician fees? ...I think?

It depends, there is a code for in-office colonoscopies where the physician fee is substantially higher because there is not a facility fee, but this requires a unique private practice set up which it sounds like your situation would not fall into. So yes, it sounds like wRVU is a better deal, but I would clarify what other possible things may fall into the net collections side because it strikes me odd that they would offer it that way.

Payor mix can influence this a lot too as well as contracted reimbursement rates they may have with different payors as wRVU wouldn't change but the collection amount would so perhaps this is where the difference is. Sometimes you may be able to request a proforma of how these scenarios tend to play out in their situation. Important metrics would be getting their average net collections per physician and compare that to average wRVU. This will make things much easier to compare the two scenarios with much greater precision as you can take 0.85 of the net collections number and compare that to 65*(average total wRVU) number.

It just strikes me as very strange that the net collections option doesn't have the higher ceiling. Usually the trade-off is do you want more predictability (less variance) at the price of lower ceiling, or you OK with additional risk at the cost of more variability/less predictability. Other thing to clarify is what goes into getting you to the 425k base, meaning what is the trigger that allows you to start making the bonus. I know you mentioned it in your OP, but is it 85% of net collections all the way to 425k? Or is it 100% net collections to 425k and then 85% thereafter? It feels like something is just missing.

Also, just for clarity sake, the presumption that you collect everything you bill is not reasonable. Reason being, the hospital May bill $1000 to medicare in physician fees alone and is only able to collect $258 of that lets say. So keeping the terms billables and collections as distinct in your head is important. Then on top of that, some payors may not reimburse for the procedure for whatever the given reason is, this may be less common (hopefully) but this would also go against the collections figure.

 

[moonlighter123]

It depends, there is a code for in-office colonoscopies where the physician fee is substantially higher because there is not a facility fee, but this requires a unique private practice set up which it sounds like your situation would not fall into. So yes, it sounds like wRVU is a better deal, but I would clarify what other possible things may fall into the net collections side because it strikes me odd that they would offer it that way.

Payor mix can influence this a lot too as well as contracted reimbursement rates they may have with different payors as wRVU wouldn't change but the collection amount would so perhaps this is where the difference is. Sometimes you may be able to request a proforma of how these scenarios tend to play out in their situation. Important metrics would be getting their average net collections per physician and compare that to average wRVU. This will make things much easier to compare the two scenarios with much greater precision as you can take 0.85 of the net collections number and compare that to 65*(average total wRVU) number.

It just strikes me as very strange that the net collections option doesn't have the higher ceiling. Usually the trade-off is do you want more predictability (less variance) at the price of lower ceiling, or you OK with additional risk at the cost of more variability/less predictability. Other thing to clarify is what goes into getting you to the 425k base, meaning what is the trigger that allows you to start making the bonus. I know you mentioned it in your OP, but is it 85% of net collections all the way to 425k? Or is it 100% net collections to 425k and then 85% thereafter? It feels like something is just missing.

Also, just for clarity sake, the presumption that you collect everything you bill is not reasonable. Reason being, the hospital May bill $1000 to medicare in physician fees alone and is only able to collect $258 of that lets say. So keeping the terms billables and collections as distinct in your head is important. Then on top of that, some payors may not reimburse for the procedure for whatever the given reason is, this may be less common (hopefully) but this would also go against the collections figure.

Payer mix is a great question. Likely 50commercial /50 just judging on the hospital stats. It's funny but it's hard to find anything online about what is a 'good' payer mix.

You bring up several good points, I will have to clarify with them first...thank you!

 

[Scope guy]

Many PP groups, especially 1 or 2 member groups do the shady thing of bringing someone on collections but schedule mostly medicare and medicaid patients to the new guy while the existing guys take bulk of share of private payors. You can work your ass off but not gonna make the 425k after collections. They will use this opportunity to fire you in 2 years saying you are not bringing enough money and replace you with a new goat and start the process all over again while keeping 100% of the practice to themselves.

If PP, try to go for a group that has 3-4 physicians, ideally someone who became partner by joining the group in the past 3-4 yrs.

Can someone help me a bit? I am trying to evaluate which would pay better two different offers, both hospital employed, both with guaranteed base, but different productivity bonus.
1. 425k + 65/wrvu (once threshold of 425/65 is made)
2. 425k + 85% net collections (once collections meet up to 425k)


Am I wrong to think that wRVU is superior based on

https://www.bostonscientific.com/content/dam/bostonscientific/Reimbursement/Gastroenterology/pdf/Polypectomy_Coding_and_Payment_Quick_Reference.pdf

I.e. if I did a 45385 cold snare, job 1 would only pay $258*0.85=219.3 which is way less than 4.57wRVUs*65 =297.05

Is my logic wrong?

 

[Scope guy]

Be very cautious about joining a post-PE group. You will give up 30% of your salary in perpetuity and you missed out on the big lump sum cash the existing guys got. PE is going to ruin independent practice. There is a lot of smoke and mirrors about how they will be more efficient, etc, etc, but good luck replacing that income. They want to flip you in 3-5 years, and the next guy wants to flip you, etc, etc.

Exactly. I have been saying this. even if you are promised a lot of things and get hired by a PE group, things can become upside down when they flip in 3-5 years. they have strict non competes and only option will be to uproot the family and move elsewhere. They have ruined jobs in TX, chicago burbs and slowly capturing other big markets. Any large GI group with >50% GI partners over the age of 50 are at risk coz the majority owners can decide to sell the practice even if the junior most guy objects.

 

[1Cor1557]

Very good points on "net collections" and PE noted above. I like getting paid by RVU because when I get a bunch of alcoholics, and foreign bodies and food boluses on call without insurance or funding I still get paid for my work, and even if you try really hard to serve the interests of the patients and their well being, subconsciously it's tough not to be resentful that you are working hard for the good of others without compensation in a net collections scheme even if you may miss out on a potential higher ceiling within a good setup which as pointed out above is not as easy to find these days being as favorable it may intially seem