Before you sign any physician employment contract, you want to be confident that you’ve identified a practice opportunity that meets your professional and financial goals while satisfying your personal style and needs. Truth is, there are any number of factors to consider, especially if you’re weighing multiple options.
But you want to make sure that you make the right choice—even if an offer sounds like a lucrative gem. “You shouldn’t be seduced into accepting a job that may be be financially better than another job, but in the big picture is not going to get you where you want to be,” says Franco Fazzalari, M.D., cardiothoracic surgeon at Beaumont Hospital in Royal Oak, Michigan.
“It may be a good solution for two years, but in the long run it’s not going to work out and you’ll have to find another job and move on. You really want to avoid that.”
Whether you’re destined for a staff job in a major health system or a partnership track in a private independent practice, it’s critical that you uncover as many particulars as possible not only about the compensation package, but also any other terms that might affect your tenure. And since decoding is all about getting into the business weeds, let’s begin with those financial and other basics that are paramount to understanding offers—and making choices.
Evaluating the financials
As a new hire, your initial physician employment contract likely will include a flat or straight base salary tied to your specialty with a possible bonus topper tied to your productivity. Since various payment structures can drive an offer, you need to focus not only on the dollar amounts, but also how they’re derived, especially if they’re anchored in your performance.
If, for instance, there’s an annual bonus, you want to know more than just what you’ll earn and when you’ll see it. How is the amount set and might those metrics change? Your new employer is likely to use one of two production formulations: Relative value units (RVUs), the Medicare measure of value for individual physician services, or net revenue, the profits calculated from actual dollars coming into the practice.
But what expectations are tied to the numbers? How many patients must you see per day? What level of RVUs will you need to generate? And what might be asked of you beyond clinical care? You may not get all of the details in your contract or an addendum, even though having everything in writing is certainly preferable. At a minimum, you want to hear a clear explanation as to what might unfold.
Although practices generally make incentives achievable, it’s up to you to find out if they’re really doable.
For instance, if the organization has built in a potential bonus based on the success of the department or larger entity, how often do physicians actually receive one? Likewise, if it’s based on your own productivity, how difficult is that to achieve? (And is there any punitive action for failing to meet goals?) If there’s a 15 percent quality bonus, for instance, is the average capture rate 14.5 percent—or 3 percent?
Keep in mind that the shape of your compensation package may very well depend on where you land. For instance, if you’re soon-to-be employed as a staff physician of a major group or medical system, you’ll likely enjoy an initial benefits package that a small independent private practice usually can’t match.
What you probably won’t enjoy is the long-term profit-sharing advantages of being a future partner in that independent group. If you’re looking at options in both camps, you clearly want to study the risks versus rewards, particularly of taking a financial step back initially for a potential ownership stake later. “It may or may not be worth it,” says Jon Appino, principal of Contract Diagnostics. “You need to consider all of those things when you’re doing your due diligence.”
When decoding any opportunity, you want to make sure that you target those aspects of the offer that might affect your ability to build your patient base and make or save money as well as pay off debt. How will the practice market your position? Can you work extra to earn extra income? And will you still be able to develop other interests, not to mention a healthy work-life balance?
Alicia Arnold, M.D., and her husband, both radiologists, considered various practice types and parts of the country before making Eau Claire, Wisconsin, home because of the excellent practice environment and reasonable cost of living. The two settled on Medical X-Ray Consultants, a small radiology private practice where her husband is now a partner and she’s been both a full-time and per diem provider.
Besides meeting their professional requirements to provide personalized, high quality care, the choice gave her flexibility not only to care for a growing family, but also to convert her interest in public speaking and community health education into a part-time role as a local medical correspondent. Arnold’s advice to others: “Most of us were called to medicine as a lifelong career, not merely a job. In assessing a position, consider the opportunity it affords for building a successful career to achieve your goals.”
Weighing benefits and future plans
When it comes to benefits, you’ll likely see a standard mix including health insurance, vacation time, personal days, a retirement plan, annual raises with cost-of-living adjustments and possibly even parental leave. Even though the package may be cut and dried, make sure that you review the provisions.
For instance, depending on how professional liability coverage is structured, you may or may not like the ramifications should you leave the place. So if it’s the one item holding you back from taking the job, see if it’s grist for discussion.
“Be prepared to negotiate for what you think is fair and appropriate for your long-term career success,” Arnold says, noting that it may be difficult to renegotiate in the future. “You’re not being a bad team player by asking for a more advantageous contract.”
Continuing Medical Education
Do they value continuing medical education enough that they encourage such pursuits and even include the specifics in your contract? Do they pay for and give you separate time off to pursue it? And what about other efforts that could put a cherry atop your competence—for instance, are there regular patient case conferences?
“If there isn’t that kind of teaming and learning going on,” says Brigitta Glick, founder and CEO of San Antonio-based Provenir HealthCare, “then it’s going to be a far less attractive model than others if that’s important to you.”
Whether you’re employed by a health system or independent practice, your position isn’t guaranteed forever. Besides sporting a typical shelf life of two to five years, initial employment contracts have a standard out clause that says usually within 30, 60 or 90 days either side can call it quits. (In some cases, 180 days, if you’re terminating the relationship.)
Your focus, however, should be on the restrictive covenant or non-compete clause. You’ll want to drill down on any parameters—time, distance or other conditions—that might cramp your ability to practice and live should you decide or have to move on.
Assume that the practice intends to impose it, especially if administrators don’t want to lose a high-producer to a local entity. “So many folks think, ‘There’s no way they can keep me from practicing in the area,’” says Patrick D. Souter, JD, of Gray Reed Attorneys & Counselors. “Well yes, there is. The employer can be protected just as much as the employee.”
In addition to understanding the clause, you want your own attorney to take a look. He or she may be able to restructure it so that you can practice in the area, perhaps in another direction. “It’s a big consideration if you’re looking at a practice and the restrictive covenant says 50 miles and five years,” says Wanda Parker, physician recruiter at The HealthField Alliance. “That basically means that you’ll be out of business.”
After completing his interventional pain management fellowship in 2017, Travis Bailey, D.O., had two goals in mind. First, unlike many colleagues in his specialty who gravitate toward hospital settings, he wanted to be in private practice. Second, it had to be in or near his hometown of Valdosta, Georgia.
When his solo practice merged with another group to form VOA: Spine and Musculoskeletal Institute, Bailey insisted on removing the non-compete clause from an agreement that was otherwise very fair in its salary, bonus potential and benefits that would help him stay ahead of the professional curve. Today, he’s not only on a path to partnership, but he’s carved out a career that fits him to a “T,” combining clinic hours and pain procedures with general anesthesia stints at two hospital locations.
His advice to other physicians? Be assertive. “There are always going to be some changes,” Bailey says. “That’s to be expected. But you shouldn’t be nervous or even scared about asking for them.”
The next phase
Even before signing your employment contracts, you want to make sure that the transition from this package to the next phase is clear.
For instance, if you’re getting a base salary with a productivity bonus, does it automatically renew, or will you transition into a different structure? And what does that look like? You need assurances in writing that at a given point, you and your bosses will have a heart-to-heart as to how your compensation and working relationship will change.
As to partnership, although there are far fewer opportunities than in years past, ownerships still exist. If that’s in your future, it merits the same kind of due diligence you’d undertake in buying into any business. Granted, your future employer may not let you review the books or pick apart the financials this early in the game.
“That’s a very touchy discussion,” says Parker. Nor will you likely see what Appino calls “granular specifics”—“on this day for this dollar you will be a partner”—in your employment contract. But you have a right to ask for information that will help you (and your accountant or attorney) learn if the practice is financially solid and both capable and serious about offering you a stake.
Also, make sure that they’re willing to commit in writing what you’ve both agreed to verbally. At the very least, you should have a framework as to the formula and track—what will the process look like and what will the buy-in actually entail? Will your participation involve a direct payment, sweat equity, or a lower paycheck over time? Moreover, will you have access to all, some or none of the practice’s long-term investments?
In any case, you don’t want to be blindsided down the road by the price or how it might work. As Fred Horton, president of AMGA Consulting, notes: “Somebody should be able to sit down with you, and say, ‘Here’s an example of how it’s worked in the past.’”
When Jose W. Avitia, M.D., joined Albuquerque-based New Mexico Cancer Center in 2012, he liked what he saw in his initial employment contract. It not only included a reasonable base salary and bonus potential for a beginning oncologist/hematologist, but also a very specific two-year track to partnership.
Besides meeting a minimum productivity standard, he’d have to demonstrate that he was a good citizen of the group, treating patients well and fostering strong relationships with referring physicians and the staff. As to the numbers, the buy-in wasn’t a lump sum dollar payment upfront. Instead, his share would be built with time and “sweat equity.”
More importantly, Avitia had a good sense that if he’d meet the benchmarks, senior physicians would follow through on their promises. The group had a structured evaluation process to let him know well in advance that he was on track and, if not, what he needed to do to get there. He also had a sense, from potential colleagues, how the process and ownership track actually worked.
“They weren’t going to find some obscure thing that would keep me from being a partner,” he says. “They were very transparent and that was very helpful.”
Assessing your chance of success
Before you accept any offer, you want a sign that the owners or administrators actually have backup to show that you’re a necessary cog in their wheel, whatever your specialty, and that you have a reasonable chance for success.
For starters, what’s the basis for the position? Has the organization included it in the business plan or done a recent proforma to calculate the needs and financial benefits of adding someone with your skills?
You have a vested interest in learning if the community is saturated with too many stellar providers or ripe with a real opportunity for you to make a dent by marketing your services and developing referral relationships. Jesse Hackell, M.D., vice president and chief operating officer of Pomona (NY) Pediatrics, notes: “You should be asking, ‘Is there enough business here to support me?’”
Indeed, besides learning if the environment is conducive to your brand of medicine, you want a sense that it will be a good incubator for your business. Whether you want a long lifespan or see this as a steppingstone, it’s critical to find out if this is a dynamic workplace or a revolving door.
Pay close attention if you’re filling a vacancy created by an exit that’s seemingly part of a trend. You not only want to know how your future colleagues have done in meeting expectations, but that the numbers are attainable for you. “You want to make sure that you’re not stepping into a practice where they recruited five physicians,” says Horton, “and they’re all gone because they didn’t build a practice in time.”
Avitia was confident that he was dealing with a solidly established practice that not only included potential mentors who had been there for 10 or 20 years, but also younger physicians who were experiencing what he hoped to experience. As a partner since 2014, he’s been more than satisfied with his choice.
“A contract is only as good as the people behind it,” Avitia says. “If they treat their patients with respect and dignity, then they’re going to treat their employees, partnerships and other relationships in the same manner.”
In decoding any offer, make sure to keep a perspective. Just because you’re looking at a lot of money doesn’t mean it’s a good job any more than it’s a bad job just because it’s not a lot of money. Likewise, a perfectly written physician employment contract with little risk to you still might mask what could be a nightmare working situation. You may have to walk away even after negotiating everything you wanted.
Conversely, if the first draft of the agreement puts all of the risk in your court, that doesn’t mean the employer is unwilling to work out the kinks. Maybe an otherwise great practice just hasn’t been in the business of hiring recently and needs a friendly reminder as to what’s fair.
Whatever the case, when in doubt, tap your common sense. For most physicians, it’s a pretty solid GPS. Whether your antenna is telling you that this a great place with honest physicians just like you or you’re feeling an entirely different vibe, listen to your heart and act with your head. “Physicians have good gut instincts,” Appino says. “They should trust them.”
Focus on the culture
Although you’ll likely be focused on the financial terms, there are broader issues to consider in decoding any job offer. If the organization’s culture is a terrible fit, money and benefits may not matter over time. So, the more details you have about the job and the practice—especially its mission, core values and philosophy of medicine—the better prepared you’ll be to make the right choice.
For starters, you want to know if the patient care model aligns with your vision of and approach to medicine. Is the focus on quality over quantity or vice versa? And what are the guidelines for either?
Pay attention to any factors that might support or impede your ability to provide medicine the way you want to provide. If, for instance, you’re not comfortable with the pace of patient visits—you’ll be seeing too many people per hour—this might not be the place for you.
Hackell makes a point of discussing his approach to pediatric conditions with every candidate. He wants anyone coming on board to look at disease and wellness in the same way that he does.
“I think it’s only fair to offer a potential new hire a sense of what the culture is in terms of medical practice and care,” he says, noting that by raising his expectations during the interview, he not only raises the likelihood of finding someone on his practice wavelength, but also sets the parameters for later reviews.
Second, what does the position actually entail, and how will you be supported in it? You may not get a listing of specific job-related tasks and responsibilities in your contract. But you clearly want a mutual understanding as to the services you’ll be providing and what you’ll need to provide them.
If taking the job depends on adding staff or updating equipment, for instance, it’s worth getting the commitment in writing. With mergers, acquisitions and even capital budget changes a real possibility during the life of your contract, don’t leave anything critical to a handshake. “You shouldn’t rely on just the trust of the organization,” says Appino. “The people who make those guarantees and approvals could change. They could get promoted, retire or even become disabled and new people may make different decisions.”
Third, what about call coverage? You need to know the particulars as to how many times a month you’ll be on deck and how those rotation obligations will take shape. Can you just triage over the phone, or must you show your face on site? And is there a back-up plan for sudden departures?
Finally, will you be surrounded by a diverse slate of physicians and other professionals who work as a supportive team or is it a competitive atmosphere in which everyone sails alone? You want a sense of how everyone interacts, especially over patient care. Does it suit you?
Whatever the case, ask your potential colleagues if they’re pleased with the administrative dynamic and feel that their wants, needs and even future aspirations have been met. Since non-economic aspects of any offer can affect your day-to-day work experience—they’ll either help you flourish or lead to burnout—they should be a priority too. In short, whatever your goals, make sure that what makes you tick, makes the place tick.
Words of wisdom
A few final tips for assessing your options and moving forward with a winning contract:
Soul search first. Although networking and research are important in weighing any offer, the real sleuthing begins by knowing who you are and what’s critical for meeting your goals and needs. Whether you’re aiming for financial freedom, job flexibility or a positive work/life balance, you want to be clear as to your priorities in determining how each offer stacks up.
“Knowing about yourself is incredibly important before you even begin,” Glick says, “so that you can weed out opportunities that don’t fit and still maximize your time in interviews.”
Tap legal eagles. Never accept a job without consulting a health care attorney and, if necessary, an accountant first. The right attorney not only can assess the package, but also help you recognize when it’s time to move on because an employer won’t budge on something key to you.
“Securing that attorney ahead of time will enable you to be very nimble and quick when you start receiving contracts,” Glick says. “This person knows which elements will have to be negotiated and which ones are OK because he or she already knows what’s important to you.”
Talk to others. Your interview may offer a promising glimpse into an opportunity, but to peel back the layers of any organization, you’ll want to speak to as many future coworkers as possible. They likely can give you a reality check like none other as to what a day in the life might be like in this work environment.
“It’s really just kind of looking under the carpet, to see what those who’ve been in that position will tell you,” Souter says. “I’ve never had a group not make physicians available. If they won’t, it’s a major red flag.”
Focus on the payer mix. If you’ll be employed by a hospital or other large health system, it may not matter that you’re seeing a substantial number of Medicare and Medicaid versus privately insured patients.
The organization will deal with the economics; you just have to deliver the care. But if you’re joining a private practice with a patient base heavily weighted toward government reimbursement, it could affect your potential income stream. Understanding your new employer’s payer mix is critical.
Not just the money. Weighing two offers for ostensibly the same position in the same market can sometimes yield wildly different compensation packages. You need to know the particulars to uncover which one just happens to be the perfect fit for your budding career, even if it’s at lower pay.
Beware of bonuses. Since sign-on bonuses and moving expenses are common in physician employment agreements, don’t be afraid to ask for them if they’re not stated outright. Keep in mind, however, that there may be a clause allowing the employer to recoup a prorated amount for the remaining years on the agreement should you decide this isn’t your dream job.
Also, you’ll have to pay taxes on your bonus in the year you receive it. So, if you don’t want to tangle with the IRS, particularly when you’re juggling a raft of other expenses, you may want to negotiate student loan forgiveness over the length of the contract. You want to check with your attorney and accountant, but asking the practice to erase a portion of your debt each year might help you financially.
“It doesn’t sound quite as exciting as getting a big sign-on bonus,” says Parker, “but the tax implications would be different because you’re not taking that big hit all at once. Instead, you’re meeting an important goal — paying down your loans.”
Work options. If you’re anxious to pursue any activities—precept, teach, research or even moonlight—beyond your patient care duties, make sure that you discuss and stipulate it upfront.
In terms of moonlighting, in particular, hiring entities may or may not welcome you entertaining other jobs, even if it’s a great way to market the practice. It could present competitive challenges too. So, you want to know the rules.
“Some contracts are very restrictive,” says Parker. “They don’t want the doctor they’ve just employed to be distracted or over tired, so they don’t allow it. Other practices are fine with it. Since you can’t negotiate after you sign the contract, anything you want, you have to get upfront. So, it never hurts to ask.”