Obviously, you want a nice financial payoff for your skills. After all, they’re worth top dollar by every professional measure. But there are big picture realities to consider, too.
Specialty, practice type and geography have already shaped your final offer in ways that you might or might not have suspected. How do they move the dial up or down?
Words like value and supply versus demand come immediately to mind. They’re the underlying drivers that make these three factors so important in what you’re able to earn. They’re also key to many of the compensation surveys administrators use as one critical tool in designing how much you’re going to make.
“It’s not just a random executive pulling a number out of a hat and offering it to a physician in hopes that he or she will take it,” says Jon Appino, principal of Kansas City, Missouri-based consulting firm Contract Diagnostics. “It tends to be very purposeful and calculated from the employer’s perspective on what administrators are offering most of the time.”
As to the specific roles of specialty, practice type and geography, let’s take a closer look.
The specialty you’ve chosen will be the biggest determinant of your compensation by far. Even though primary care physicians and their non-surgical specialty colleagues are well-paid professionals, providers in procedure-rich specialties tend to rise to the top of medicine’s financial hierarchy.
Why? They experience the highest reimbursement rates for the complex tasks they perform, which ultimately is reflected in their pay.
Simply put, if you’re in orthopedics, anesthesiology, cardiac and other surgeries, what you do will likely put you in the cat bird seat in commanding a top salary.
Of course, other forces, such as supply and demand, can help shape any package. At its core, however, compensation is often less about the number of patients that you see and more about the nature of your services and the value assigned to them.
There are many physician compensation models in effect today, each having their own risks and rewards. As a new physician, however, you’ll likely encounter payment methods that blend security and risk in one way or other.
Straight salary/minimum-income guarantee plus bonus or incentive
The most prevalent model in place today for physicians just starting out, it’s a frequent standard in large corporate or physician-owned practices as well as academia and major HMOs.
The structure is basically worry-free since you’ll have a set salary and monthly income for starters. If there is a bonus, it behooves you to inquire as to how it’s formulated and under what conditions and time frame it’s paid.
Production- or productivity-based compensation
This model pays you a percentage of billings, collections or RVUs assigned to procedures or patient visits. You’ll be paid via the same relative value units whether or not the person has Medicare, Medicaid, private insurance or pays cash.
If production involves a fee-for-service form of collections minus expenses, it behooves you to not only determine the percentage of billings the group typically collects and the time frame, but also the patient mix.
Capitation or productivity plus capitation
A concept with roots in the late 1980s and early 1990s as a way to reward providers for delivering cost-effective, efficient care, it still exists in some HMO-intensive markets such as California, Minnesota and the Northeast.
Compensation involves an equal or formula distribution of prepaid health care premiums allocated to the groups for services rendered. In a similar vein, you may see an equality/equal shares type of structure if you’re headed for a single-specialty group.
Although this model allocates revenues equally after expenses, it also presumes that the physicians will be equally skilled, motivated and productive.
RVUs lead the way
Wherever you are in your medical career, you can’t underestimate the role of two acronyms — RBRVS and RVU —in how much you’re ultimately paid for your work.
Shorthand for resource-based relative value scale and relative value unit, both terms have been integral to most physician practices since 1992, when the Centers for Medicare & Medicaid Services (CMS) launched RBRVS to bring consistency to the way that it pays physicians and health facilities for their services.
By assigning specific values—the RVU part of the system—to every CPT (current procedural terminology) code, Medicare, Medicaid, and some private insurers alike have a standard methodology by which to issue reimbursements.
But how do those values eventually turn into compensation?
Hiring entities have their own formulas for parlaying work product into salaries and productivity bonuses. Many still use volume-related metrics such as number of patients or the amount of fee-for-service collections to craft a plan.
As more payers rely on RVUs in calculating reimbursement, however, those values become increasingly critical compensation measuring sticks. If your package depends on RVUs, you want to make sure you understand the particular schema, given the plethora of complicated methodologies using them today.
In determining production and incentive bonuses, employers are primarily interested in physician work or wRVUs because they account for the time, training, technical skills and judgment a physician employs in diagnosing and delivering care.
Other components—practice expense or peRVUs and malpractice RVU or mRVUs—are baked into the reimbursement pie to account for the higher direct, indirect and liability costs of providing the service.
“This is all about the effort expended in order to provide a service,” says Fred Horton, president of AMGA (American Medical Group Association) Consulting. “We’re not going to pay you based on some other type of overhead or malpractice methodology. We’re going to pay you based on your work.”
Adds Travis Singleton, senior vice president of Dallas-based physician recruiting firm Merritt Hawkins: “The net outcome is to equate difficulty and value to what the physician does.”
Winds at selective backs
Even within a specialty, your ability to command top dollar is still a mixed bag depending on other forces.
Being a pediatric neurologist, for instance, may increase your compensation into the medical subspecialty realm, but not into the procedural realm. As to other specialties, supply and demand is the focus.
Pathologists, for instance, have been harmed lately by a difficult market. Appino can only speculate as to the reasons—perhaps technology has improved efficiency or training has produced too many. Yet with fewer job openings now than in the past, employers have the upper hand.
On the other hand, rheumatologists and other short-supply specialists such as neurologists and urologists are definitely seeing an uptick in their financial outlook. With an aging population demanding their skills, in many cases they can write their own tickets.
And what about primary care? You’re likely still bringing up the compensation rear, even with promises since RBRVS originated in the 1990s that your field would one day be rewarded equal to that of procedural-based groups.
Citing AMGA survey comparisons of 20 specialties between 2009 and 2017, Horton notes that orthopedic surgery still holds the top place with family medicine, internal medicine and pediatrics anchoring the bottom. “Basically, they haven’t moved at all,” he says. “The wealth hasn’t really been redistributed as promised.”
That doesn’t mean, however, that there aren’t promising exceptions. As a residency program faculty member with Jacksonville, Florida’s St. Vincent’s Family Medicine Center, Robert Raspa, M.D., is in charge of 30 family medicine physicians, with 10 not only graduating each year, but also heavily recruited for their skills.
New physicians may need to be assertive about their worth even as they’re being wooed. Theresa Rohr-Kirchgraber, M.D., preaches the value of assertiveness to her residents and fellows as the executive director of the Indiana University National Center of Excellence in Women’s Health.
Rohr-Kirchgraber, who is also the Barbara Kampen Scholar in Women’s Health, doesn’t have to look further than her own experience as an example.
Board certified in both internal and adolescent medicine, she went to bat for herself after discovering that her primary clinical appointment in pediatrics was costing her thousands of income dollars.
Although she held a secondary appointment in internal medicine and saw mostly adult patients, administrators weren’t keen on upsetting the parity applecart with her pediatric colleagues by just changing her status but keeping her in the adolescent division.
It took some negotiating, but Rohr-Kirchgraber succeeded in switching the appointments. In practical terms, she now has fewer interactions with her adolescent medicine colleagues, but she’s finally on par salary-wise with other internists.
“We’re always trying to be nice and helpful because we’re just so grateful,” she says. “But we have to recognize that we bring a completely different set of skills to the group. We need to understand our worth.”
The majority of newly recruited candidates—some estimate as high as 70 percent—will join hospitals, medical groups, urgent care centers, clinics and other structures as dedicated hires, not necessarily future owners.
What does employment specifically mean for your compensation package?
For starters, you may not be bearing the brunt of the business responsibilities shouldered by your self-employed colleagues, but you’re also likely to experience a lower average income as a price for the freedom.
At least one survey, Medscape Physician Compensation Report 2017, demonstrates that while increased numbers of physicians are choosing an employed position, they’re also likely to earn less than their self-employed counterparts.
The 2017 results reflect overall differences of 28 percent between the $343,000 average earnings per year of providers willing to take on the business demands of private practice and $269,000 for their employed peers.
Whether you’re hired by a health system or perhaps even a group, your compensation will be built initially on a base salary, which provides a predictable income level for your clinical services. The package will also include an incentive bonus that rewards your productivity and, in some cases, the standard of your work.
Beyond the type and volume of your services, you may have to demonstrate your worth via quality outcomes plus other harder-to-quantify measures such as patient satisfaction and corporate citizenship.
More than likely, however, you’ll be rewarded based on some sort of volume metric. Even though there’s wide variety in the incentive models and formulations used today, there’s a better-than-average chance that your plan will revolve around RVUs.
“We can say that we want to move to quality, but fundamentally mathematics still work on volume,” Singleton says. “To me, RVUs are the bridge from volume to value. It’s the best we have at the moment.”
Granted, the interest in joining an independent private practice with a path toward ownership isn’t what it used to be. Still, there are opportunities for physicians with an entrepreneurial spirit. Solidify these offerings before taking the deal.
Finances. Whatever practice structure, if your deal includes a potential proprietorship of any sort, you should be focused from the get-go on what that really means financially. How will your deal be structured? What will your investment actually buy?
Impact. In a similar vein, how much clout will you actually have? You may be a shareholder, but if your stake is relatively small, your influence will be equally small.
Structure. Make sure that you understand the steps, timeline and payment options for securing your slice of the business. Ditto on overhead that you’ll have to split with others.
Assets. Likewise, whatever your investment, make sure the assets—e.g. the equipment, real estate and ancillary services—have real value.
Exit plan. Finally, how would you unravel the deal if you’re miserable or just want new scenery? How do you liquidate the shares? Such questions not only will help you mitigate your risk, but also determine if it’s a good opportunity for your career.
As a private-academic hybrid practice, Pulmonary Associates of Corpus Christi, Texas, offers its nine pulmonary/critical care specialists “the best of both worlds,” says founder Salim Surani, M.D. They’re able to provide clinical services and ICU coverage for various hospitals while teaching residents and fellows.
Compensation is based on direct patient care with an academic stipend. There’s also a partnership opportunity in the wings for a zero dollar buy-in if a doctor likes the guarantee portion structure the group usually offers.
If that isn’t enough to draw interest, the partners sweeten the deal with other benefits such as no non-compete clause and a rotating night call schedule that has each doctor covering one week with the next nine weeks off.
“Our feeling is that if you want to attract good people then you have to give something better than anyone else,” Surani says. “Otherwise why would they want to come in?”
Although the objective is to keep providers, he agrees that if a buy-in is in your future, you want to know the amount and entry point of your investment as well as the exit clause.
“You never want to go into something when you don’t have a clear-cut exit planned,” says Surani. “Otherwise you’re going to be stuck in that practice—and there’s nothing worse than not enjoying what you’re doing.”
The nuanced ins and outs
It’s incumbent on you to understand the parameters of your specific plan, given the potential nuances.
For instance, depending on the formula, the incentive portion of your deal may involve a modest kick-in for the first and second years while you develop sea legs and a following.
After that, your salary may be gradually reduced or even eliminated, leaving you dependent solely on whatever productivity and/or earnings structure your employer has in mind.
Whatever the case, you need transparency. Too often, say experts, physicians look at the numbers and just assume what’s behind them rather than understanding where they come from or how they’re set.
“One of the things that continues to amaze me is how many physicians can’t recite how they’re being paid,” says Horton, noting his surprise at job incumbents who don’t know the ins and outs of their original compensation packages.
“They’re able to tell me how much they make but they can’t necessarily articulate the mechanics. And that’s really important.”
In medicine, like business, location is often everything—including playing a role in what you can earn, especially given supply and demand for your skills.
When considering the trifecta of factors—compensation, location and practice type—that are key to any job decision, Appino suggests prioritizing the two most important ones since you likely can’t have all three.
Why so? Popular places to live and work may not offer the best shot at the best deal.
If you’re willing to accept a smaller package, by all means hang tough for that idyllic place you’ve always associated with a great life. But if money is a priority, you might need to open your eyes to areas of the country that hadn’t been on your radar.
Mega trends at work
Regional analyses from the Merritt Hawkins 2017 Review of Physician and Advanced Practitioner Recruiting Incentives confirm that physician salaries tend to be highest in the Midwest and Southeast.
Both areas are top pay strongholds, say the authors and other experts, because of a healthy dose of fee-for-service medicine, good payer mixes with comparatively high reimbursement rates and a large number of productive, independent physicians. There’s also a lower physician-per-capita ratio.
Conversely, physician incomes tend to be a bit suppressed on the West Coast because it’s typically the highest capitated market with the most managed care, says Singleton.
Likewise, lowered physician incomes on the East Coast, particularly the Northeast, also reflect a relatively high prevalence of managed care/capitated compensation plans as well as competition.
That’s not to say there aren’t pockets that run counter to existing trends; just that you should be aware of umbrella forces driving compensation where you might want to work and live.
5 mantras for negotiating
With a hefty number of nuances with any compensation negotiation, it’s worth your while to take these tips to heart.
All in the formula. Selecting a specific compensation plan likely isn’t in the cards for any physician, let alone a new kid on the block. Your package will likely reflect what your future colleagues with similar backgrounds are earning.
A different lens. No matter who’s paying your compensation, you’ll likely see your package through a different lens than your employer. You’re focusing generally on the net amount of your monthly check; administrators may be picturing every cost associated with hiring you and ensuring that the figure fits reasonably into the business picture.
Fair is fair. Regardless of the creative ways organizations find to appropriately pay physicians, the final package must meet fair market value standards. Whatever an organization pays you has to be reasonable in light of the marketplace.
The sky is not the limit. Health systems, hospitals and independent practices have limited pools of money for compensating their providers. So, if you’re angling for a sign-in bonus, relocation stipend, loan forgiveness or other attractive goodies, the money for your singular salary bucket may have to be divvied up into several smaller buckets to accommodate your request.
Be cautious going it alone. If your goal is to become an independent contractor rather than an employee, make sure that you understand the financial pros and cons of essentially freelancing your skills.
Whatever your specialty or skills, you’ll need facts on hand to achieve a financial payoff that befits your experience and skills.
By knowing how specialty, practice type and geography move the dial on any offer, however, negotiations may no longer loom quite so large.