employment Archives - NonClinical Physicians

Now Every Doctor Can Win As a Micro-Corporation

John Jurica — Tue, 15 Oct 2024 11:51:13 +0000

Interview with Dr. Tod Stillson – Part 1 – 374

In this podcast episode, Dr. Tod Stillson describes how to win as a micro-corporation. For the past 10 years, Tod has been working under a professional services contract, rather than as a direct employee, providing him with greater autonomy and income.

Dr. Stillson shares his journey from a traditionally employed physician to an independent contractor. In this revealing interview, Tod introduces the concept of employment light and explains how doctors can negotiate better contracts with their current employers.

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The Rise of Corporate Medicine and Its Impact on Physicians

Corporate control of healthcare has led to decreased autonomy and increased burnout among physicians. Tod describes how arbitrary compensation caps and a lack of understanding from administrators have contributed to this problem.

He emphasizes the need for doctors to stand up for themselves and take control of their professional lives. And he describes the simple change he made to accomplish that goal.

Understanding the Employment Light Model

Tod explains the concept that allows physicians to work as independent contractors while maintaining a relationship with their current employer. This model offers increased professional autonomy, significant tax benefits, and an easier way to create multiple income streams. Some of the topics we cover in Part 1 of our conversation are:

Preparing to become an independent contractor,
Negotiating a professional services agreement,
Creating the opportunity for multiple income sources, and,
How to approach your employer about transitioning to this model.

Empowering Physicians to Win as a Micro-Corporation

Recognizing the lack of business education in medical training, Dr. Stillson created SimpliMD, a resource for doctors to improve their business acumen. He emphasizes the importance of understanding:

The true value doctors bring to healthcare systems, including downstream revenue,
How to negotiate fair compensation based on productivity, and,
The power of business knowledge in preserving professional and personal autonomy.

Summary

In Part 1 of this two-part episode, Dr. Tod Stillson offers valuable insights for physicians looking to regain control of their careers and achieve a better work-life balance. Dr. Stillson's experience and resources provide a roadmap for doctors to navigate the complex world of healthcare employment and find success on their own terms.

Part 2 of this conversation follows in the next episode of the Physician Nonclinical Careers Podcast.

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Today's PNC Podcast Transcript

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Transcription PNC Podcast Episode 374

Now Every Doctor Can Win As a Micro-Corporation

- Interview with Dr. Tod Stillson

John: All right, NonClinical nation. I think today's interview might potentially change your lives. Our guest today is going to explain how he was able to work in a fulfilling medical practice as a pseudo-employee while maintaining his professional autonomy and earning a much higher income. That seems like nirvana to me. So let's welcome Dr. Tod Stillson to the podcast. Hi, Tod.

Dr. Tod Stillson: Hey, John. It's great to be with you and I'm excited to share my journey with your listeners.

John: Yeah, I'm excited to hear this story from the horse's mouth, so to say. I mean, I've read about you and looked at some of the things you've done online, and this just sounds like an exciting option for some of the people out there that are unhappy in their practices.

Dr. Tod Stillson: It is one of many options that exist, and I tell you the beautiful thing about the marketplace today is although corporations strongly control it, there are lots of new developments happening for doctors to regain their autonomy and not feel like they have to end up as a corporate employee, or really what I call a high-paid factory worker, okay?

John: Yeah, that's definitely what it feels like. I mean, that's what I hear constantly. In lack of autonomy and overwork, they don't understand what a physician does.

Dr. Tod Stillson: Oh, yeah, 100%.

John: It's going to lead to the demise of the profession unless we do something.

Dr. Tod Stillson: John, you and I trained at similar times and have similar experiences as family doctors, and you're exactly right. It's the undermining of the professionalization of our great work as doctors that all doctors across the country do, but it has been eroded. I'm a fan for doctors standing up and saying, that's enough. Let's take control of this ourselves.

John: Awesome. Yeah. Well, tell us a little bit about your background and the mission that you have to educate physicians on how you have found a way to make things better, even if you're, "employed by a hospital system."

Dr. Tod Stillson: Yeah, and I'll tell you the short story, and then we can get into more details later if you want, but I grew up in the Midwest and did my training in Indiana and went out to Virginia to do my residency in family medicine as well as surgical obstetrics. Came back to Indiana and worked here basically in a primary care clinic in rural Indiana for nearly 30 years. And when I came back to this area to begin working, there was the opportunity to work as an employee of a hospital and really just receive a paycheck for it.

And this is way back in the day when it felt like everybody was in a win-win relationship, right? Where you were given a fair compensation. They still gave you a lot of autonomy in the practice. And as long as you know your downstream was good and everybody's working well, everybody wins. And it was very somewhat simple, but really great. Over time, though, as you know, the corporization of America really came into play. And even our little rural hospital began to lose its autonomy to a larger health system that began to take more control and try and crank out more money and in the process remove more and more.

It's the same script that we've heard from doctors all over the country, right? This just happens and happens and happens. And over time, for me, what happened was because I was a full-service family doctor, meaning I did inpatient care, newborn care, OB care, surgical OB, I really did everything in the hospital, okay? We were busy. I mean, in a rural place, any of those doctors out there that work in rural places you know back in the day, especially, you could be very, very busy. Consequently, I earned a lot of RVUs.

And I mean, I really cranked out a lot of money, if you will, and was paid fairly for it at the time for the hospital myself. They really still came out ahead because of the downstream, okay? But nonetheless, the hospital system that owned them came in and began looking at some of our rural family doctors' pay compared to the city people that were working. And they're like you guys are making a lot more money, and that just doesn't seem right. We're going to kind of level the playing field and we're going to put a ceiling on how much you can earn. Arbitrarily.

John: It sounds like my CFO when I was CMO of the hospital, you know?

Dr. Tod Stillson: Okay. Yeah, makes sense to them, right? Put a ceiling on this. How could a family doctor make that much money, right? And so, I'm like, all of us are like, "Wait a second, what are you talking about? We work hard for our community and for the sake of our hospital, and you want to just give us a pay cut and expect us to go, 'Oh, thank you very much. That's okay.'" So, the long and short of it is, as all these things kind of get dragged out, as they often do, our group of about eight doctors, we saw five of them leave, basically, over a year's time. They're like, "I'm not staying around for this." This left about three of us holding the balls up in the air, meaning we were working harder and doing more work, but still the ceiling loomed.

And eventually, we were just like, what are we going to do? Do we want to go out into private practice together here? Because none of us wanted to move. Do we want to just say, okay, thank you very much. I'll accept this contract or something else. I was wise enough to know, like most doctors are, I was business illiterate and also relatively financially illiterate. So one of the greatest moves I've made in my life was I reached out to some business consultants in healthcare and said, "Hey, this is the situation. What would you recommend to me to do?" And in the process, they unfolded this employment light concept to me that was newer and just coming out and people were using it in the marketplace.

And they proposed that model to me to take back to the institution I was working for. And lo and behold, because I was in a bit of a position of power, because I had a lot of patients, but number two, fortunately, my contract did not have a non-compete in it. And so, they knew that I had some power to take my 5,000 plus patients to any healthcare company that wanted a contract with me. And so, they were somewhat incentivized in that moment in time to say, "That's a good thought to make you an independent contractor that looks like you're an employee still, but really you're an independent contractor." And that's what employment light is.

And they agreed to that while I was in it and while the moment was in my favor, my business consultants also recommended you might consider purchasing a medical office building and having them lease it from you, wisely said and wisely done, they agreed to that. And so, and then really beyond that, I then negotiated an employment light agreement that is basically productivity-based, so compensation-based. If you remember, they wanted to have a ceiling for that productivity. But that was, here's the seat, that was for their traditional employees, their traditional employees they control, right?

Independent contractors, they have the freedom and liberty to form individual contracts. And so, I could then say, this is what the MGMA data is for what a family doctor in a rural area is doing. This is what I should be paid as work RVUs for that. And they agreed to it because they weren't forced to comply with the corporate employee model. Now, I have an individual one-on-one contract that quite honestly, John, I wasn't asking to be paid more than I was worth. I was just being asked, I was asking to be paid for what I was worth.

And they agreed to all that. And so, the long and short of that was the rest is history. That was over a decade ago. I've loved every minute of that decision. And that's led me to SimpliMD because that experience and my wonderful experience of seeing how that revitalized my professional autonomy is the message I have to doctors all over the country. This is possible. You can do this. It's not visible. It's not seen. Employers are not telling people about it, but it's possible. And that's the story I have.

John: That's awesome. Let me ask you a couple of questions that pop into my mind. And as I said as a CMO, I was sometimes, actually, I was doing a lot of the negotiating for contracts. And that was the thing, the contracts need to be somewhat consistent.

Dr. Tod Stillson: Sure they do.

John: But I think I've heard you speak in other settings about sometimes even given that if you're really producing a lot of RVUs because you're doing certain things that maybe the other doctors aren't, they want to put that cap on what you mentioned earlier.

Dr. Tod Stillson: That's correct.

John: So I guess my two questions, did you still somehow have any kind of a cap that affected you once you had made this change number one? And how do you avoid burnout? Because there's still the incentive, I think, is to work your tail off in a way. Maybe that's two questions.

Dr. Tod Stillson: That's a fair question. Spoken like a true doctor about the burnout side. So number one, I had no ceiling in it. And so I negotiated that in the contract, no ceiling. And in fact, I normally, and it's called the professional services agreement. You know that from being a CMO. By the way, for your listeners, professional service agreements are traditionally where locums are seated. Okay. If you want to think of it in a simple way, that's often what locums do, that's contracted labor, and that's often called the professional services agreement.

Employment light that I'm talking about, in my experience, is also a services agreement. So that's the big box that it goes into. And in my professional services agreement, it's a three-year agreement that renews. But we renegotiate at the end of every three years. And I had an elevator for my work RVUs in it as well. So I didn't just get paid a dollar value per work RVU per year. Each year that went up. Okay. And so because, right, because we have issues like we're all experiencing right now, inflation, right? So numbers tend to rise. And if you keep it static, you're going to end up on the backside of that. And a lot of physicians don't understand how that works.

So anyhow, I had that built into mine and there was no ceiling, and it was just fair compensation for the work that I was doing. Now, I will tell you this much, the moment that I turned that on and began doing the same number of work RVUs I'd been doing the prior year, I made a couple hundred thousand dollars more. I mean, literally apples, apples, not doing more work, not doing anything more, literally just being paid fairly, it led to a couple hundred thousand dollars difference in pay annually.

Now, to answer your second question though is, is there some challenges with that that you get into when it comes to, do you sometimes incentivize yourself to work harder than you need to, right? And I think any self-employed doctor, especially if you've ever been in private practice or ran your own practice in any way will ask themselves that question. And you have to guard yourself from going into that rabbit hole.

All right. Do the work you enjoy, do it at a pace you enjoy, do to the rhythm you enjoy, meet the expected requirements that that pseudo employer has for you, if you will, at least be a mid-level performer, if you will. And let it fall from there. I took five weeks of vacation every year. Okay. And by the way, in the model that I worked in, today's where people always talk about pay time off, right? PTO, all that business. Nope. In my model, when I was working, I got paid.

If I wasn't working, I didn't get paid. And I know what that opportunity cost was for me. If I took a week off, it was going to cost me about $14,000 of income. Just that's what it was. But you know what, for my own sense of well-being and my own sense of sustainability in it, it was very important to take that time off because indeed, I was a high-performing doctor, did a lot of obstetrics and was available a lot. But that was a rhythm and pace that I enjoyed. So your listeners, if you do get engaged in a contract like this, you definitely want to guard yourself from overworking because you're sort of incentivized by that carrot. Find that sweet spot, so to speak.

John: I'm going to have a series of questions here now to put you on the spot. But because I'm going to do that, I want to early in this game here, remind our listeners that you do teach other people how to do this in a variety of ways. And so tell us about, before I get into my laundry list, SimpliMD and everything you're doing to help physicians learn more about this.

Dr. Tod Stillson: Yeah, I'm glad to do that, John. One of the fundamental problems in my story that you heard was I had business illiteracy. Most of us go through our medical training and unfortunately, there's not a lot of financial or business literacy that exists, right? Now, we have a lot of organizations that have been populated out there for doctors to become financially literate, and it's for doctors, things like White Coat Investor, et cetera, that are really nice resources that are filling some gaps that exist in helping physicians. And I love that that's happening.

The reality, though, is there's not a lot of business or micro-business resources like that for doctors. And so I chose to develop SimpliMD as a micro-business competency website that would help doctors flourish and thrive by understanding their business powers and really understanding that doctors are a business individually. And so I have a whole bunch of resources and assets from courses, to consultations, to coaching, to free eBooks that can be found at simplimd.com, and that's spelled S-I-M-P-L-I-M-D.com. And so your listeners are more than welcome to go to that, take a look at the various products that exist.

They can look at the header and find everything. I love helping doctors. I just love helping them learn from what I've discovered and learning how to thrive through the preservation of their professional and personal autonomy. So it's a really powerful idea. And I can tell you at SimpliMD, I don't want to go too far around this rabbit hole, but pretty much the system is rigged against doctors. Yeah, I don't know if you know this yet or not, okay?

John: Yeah, it is, pretty much.

Dr. Tod Stillson: Systems rigged against doctors, okay? And it's because the corporatization of medicine has really stolen that autonomy we have. And then they funnel us all into W-2 workers, right? And then the federal government, who's the other force at play here, they love hiring doctors, hiring taxpayers like doctors who are W-2 employees, because they got no place to turn, right? And that we literally are the targets that they are looking at and saying, oh, you guys are the ones that make a lot of money. We're going to be happy to take all that from you as a W-2 earner.

And so there's not a doctor I don't talk to that doesn't say taxes are killing me. They're horrible. So whether it be burnout or taxes, doctors are having all of this erode that deep sense of when you and I became doctors. We're like, you know what? I don't need to be a gazillionaire, but I certainly look forward to the good life of a doctor, where I have some professional autonomy, where I have some personal autonomy, where I can make a good living and not feel like I'm being picked apart day by day. That's what doctors are looking for.

In today's world, there's so many forces that push back against them. And what SimpliMD is about, and some of the work you're doing I know as well, John, is all about re-empowering doctors in the marketplace to say you don't have to give into those two things. And there is a different path and a different space you can go into. That's what I talk about at SimpliMD.

John: A couple of things I wanted to say. First of all, reflecting again back to the day when I was working at the hospital as an executive the CMO, well, not CMO, the CFO, the CEO, the COO, they're going to want to get out as much as they can from their physicians. They want them to be productive. They want a bottom line. They're driven by that. And they actually, they really do not understand a physician's life. I mean, I actually had to do a lecture for the team explaining to them that when we go home at five o'clock, if we go home at 5:00, that's not the end of our day.

Dr. Tod Stillson: That's correct.

John: We could be busy doing records and answering phone calls, being on call, coming back, going to the nursing home, so many other things. And they just, they don't get it.

Dr. Tod Stillson: No, they don't.

John: So when you were talking about that, it really rang true for me.

Dr. Tod Stillson: Yeah. So there's two things to keep in mind and you understand this as a CMO. Number one, what the work you do in the clinic or face-to-face with patients, your professional services, so to speak, that's just a little, that's a small part of the bucket of what that hospital system is really looking at. They're really looking at the downstream revenue of what your work produces and it's the churn. In business world, we call that the churn, right? The churn of what you produce for them and every doctor who's in an employee situation, you need to know what your churn is. That is exactly what the real value is to your health system to them. And that is that downstream revenue.

Spoiler alert, that's usually worth anywhere from $2 to $5 million, depending on your specialty per doctor. Now translate that $2 to $5 million churn that you're creating for them, not just seeing patients in the clinic, but the whole churn and they're micromanaging every click of the mouse that you have in that clinic space and all the while are making a whole bunch of money on that churn that exists for you downstream. That's what burns out doctors. And that's where you begin to feel undervalued, uncared for, and misunderstood.

So understanding that you do have a downstream revenue beyond what you're doing in the clinic is an important part of the business model that when you become an employee, you're engaged in. And you're exactly right. The administrators don't fully respect and understand what it's like to live under that microscope that you are churning out for them and the difficulties and challenges of it, because they're really looking at you as a number on the spreadsheet.

You're an impersonal number on the spreadsheet. And here's how it looks. Physician labor, expense, period. Okay. That's your salary plus your benefits and anything else that you're doing to create money, to make the system pay for you. Okay? And then the, what you're doing in the clinic plus the downstream revenue. And that's the equation. And you need to understand the dynamics of how those things interplay and the power you have as a doctor to stand up for yourself and say, wait a second, you're undervaluing me and you're underpaying me.

John: Yeah. Now, the other thing I wanted to mention before we move on to my next question is that I did look thoroughly at your website and I felt like I was in a YouTube thing because, not because there's all videos, really, it's a lot of blogs, but the titles and the questions you're answering there are so damn interesting. You know, it's like, damn, I wish I knew that 10 years ago. Damn, I wish I knew that when I was in practice. So I mean, there's a ton of free information and it really gets to all these issues and it addresses maybe some of the questions I'm going to continue to ask you here in a minute, but I really recommend people go and check that out.

Dr. Tod Stillson: And I appreciate that, John. And I will say, I'm so thankful you said that, because to be honest, I created that website and that business with just that in mind. What would my younger self like to know and what can I communicate and share with the rest of my physician tribe that the younger version of myself, now I'm 30 years into practice and so forth, that I wish I would have known.

And part of that, John, and I really write about this in my book, Doctor Incorporated: Stop the Insanity of Traditional Employment and Preserve Your Professional Autonomy. That book was written, a little bit of my website was written with my son in mind. He's currently a third year family medicine resident in Dallas, Fort Worth with John Paul Smith Residency Program. I just was thinking, and it's really what inspired all of those, what's the best advice I can give my son to thrive in the marketplace? And all of that really somewhat began to inspire the whole work that I did with the book, SimpliMD. So intentionally, you're right. That's exactly for the viewpoint that I write those, getting those resources that can make their life better, if I would have known that 10 years ago or earlier.

John: All right. I'm glad you did it.

Dr. Tod Stillson: Yeah, thanks.

John: That's very interesting. And even though I'm never going to be practicing again, once I fully retire. Okay, here's a question. You're in the setting as a physician of being employed, you're subject to all these issues, you're burned out or what have you. I can imagine that it's not necessarily an easy conversation to say, okay, guys, I don't want you to get worried that I want to leave. I don't want to leave, but I don't want to be employed by you anymore. And I don't want to go into private practice. So I have this idea. So you help people work through that I think.

Dr. Tod Stillson: I have.

John: How do you approach that?

Dr. Tod Stillson: So there's a couple of things about it. This is important for your listeners to know. Number one, a professional services agreement and employment light, virtually every hospital knows about it. And here's why they know about it. That's because this is the pathway and the bridge they use to bring private practice doctors into their safe harbor. This is the same pathway they use. They use it virtually every year, all the time. And it's that bridge, but they want to make it a one-way bridge. They kind of want to go, well, this is what we do to engage private practice doctors to come in and become employed doctors. And this is the pathway for it.

But if you're already employed with them, it's like they've got this big kind of bar in front of them and go, you can't go the other direction with this. The reality is that they know about his existence, but it's in what I call the hidden drawer. Let me just use a real Midwestern analogy with you. I like going to the dairy queen. We've got a great dairy queen in our little community. And the day went that my wife and I went to the dairy queen and we both are going to order peanut buster parfaits. And so I order peanut buster buffet with the fudge and all that stuff was really good.

And my wife got up and she said, "I want the peanut buster parfait, but I want peanut sauce substituted for the chocolate." Okay. And I looked at her, I'm like, "Well, that's not on the menu." And she's like, "Oh, but it's on the secret menu. You have to ask for it. And as soon as she said it, they just like, "Okay, we can do it." Well, secret menus exist in all restaurants just as an FYI. Okay. But number two, secret menus exist for all employment contracts.

And the first drawer that they're going to pull out for you is the boiler plate traditional employment contract for every doctor. That's what they're going to go first. And they're going to make you think that is your option. And you have to have enough savvy to say, number one, you know there's some other contracts in your drawer there that we could also talk about. And my preference is to be considered an independent contractor, not an employee. So you have to have the business awareness and your own self-awareness to say that.

Now, if you're a doctor who's been traditionally employed and then your contract's coming up for renewal, or you want to have a conversation with your CMO, again, you got to have the awareness that this is one of the contracts that you would potentially talk about transitioning to. You're like, and here's how I coach doctors to say it. And this is exactly how I said it to my CMO.

I said, "Look, I like wearing our team jersey. I'm all for wearing our team jersey. I want to see our organization succeed, but I want to do it in a little bit different way than what we've been doing it before as a traditional employee. And I think we can do this in a win-win relationship where I'm an independent contractor that still does all the same work, still produces all the same downstream, still gets all the fair compensation from you. But what I gain from that, Mr. CMO, is A, a little more professional autonomy, and then B, an amazing amount of tax efficiency. I have now added a whole bunch of tax tools to my kit that I no longer am targeted as a just a sole W-2 employee. Now I can save 10% to 15% of my income, which for a doctor is a lot of income annually, in that model.

So guess what, Mr. CMO? I want to see you guys win. I want to see me win, and we can do this in a cost-neutral way so that everybody wins. How about it? Let's have a conversation, talk about this, and let's pull that secret menu contract out of your drawer, and let's talk through this." And honestly, it's that simple. Now, there's a couple of caveats here I want to bring forth to your listeners, John.

Number one, to be considered an independent contractor, you can't have that hospital work that you're doing as your sole contract, okay? Because the IRS is going to look at the hospital as like, hey, you're just trying to avoid FICA tax by employing this person as a contractor rather than as an employee, and they get a lot of penalties, and that's where hospitals get really uptight about these things, right? So they're like, wWell, we can't do that because we could get in trouble from the feds," and dah, dah, dah, dah, dah.

So it's very simple, right? How many doctors do you know that don't do some side hustle of some type? I mean, gosh, the studies show 40% to 50% of doctors do. I mean, it's very common. But to be considered an independent contractor, you'd want to have that primary contract and then a job stack, a secondary work that you do as an independent contractor. It could be nursing home assistant director.

It could be taking call. It could be doing telehealth. It could be, in today's world where there's physician jobs that are location independent, like gobs of them, there's all sorts of things you can do. And it's really not so much about the amount of money that you're making in those independent positions. It's that you're doing it. So in other words, you can demonstrate to the IRS and to the employer that you indeed are doing more than one job, okay?

That's the definition of an independent contractor, all right, you're doing more than one job. So that's an important caveat, but it all begins with you going to your superior and saying, "I'm interested in a win-win conversation, okay? This is not me against you. This is not me getting away from you. This is about us doing this together.

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Avoid These Mistakes When Seeking a New Practice

John Jurica — Tue, 30 Jul 2024 05:26:48 +0000

Interview with Dr. Lara Hochman – 363

In today's episode, Dr. Lara Hochman returns to the podcast to share her insights on finding joy when seeking a new practice.

Through Dr. Hochman's company, Happy Day Health, she matches physicians with private practices that prioritize their well-being and financial stability.

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The UT PEMBA is the longest-running, and most highly respected physician-only MBA in the country. It has over 700 graduates. And, the program only takes one year to complete.

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Your Guide to a Stress-Free Medical Career

Dr. Lara Hochman introduces the Stress-Free Physician Career Guide, a free email course designed to help physicians navigate the job market with confidence. This resource covers essential topics such as vetting potential practices based on personal values, choosing the right employer, and negotiating salaries. By providing this guide, Lara aims to equip physicians with the knowledge they need to make informed career decisions and find positions that align with their aspirations and values.

Avoiding Common Pitfalls in Job Selection

One of the most common mistakes physicians make when choosing an employer is focusing solely on salary. Dr. Lara Hochman warns against this approach, advising physicians to consider factors like work-life balance, practice culture, and support systems. She emphasizes the importance of thoroughly vetting potential practices by speaking with current physicians and staff. By understanding what truly matters to them and asking the right questions, physicians can avoid pitfalls and find fulfilling positions that offer more than just a paycheck.

Dr. Lara Hochman's Advice on The Importance of Knowing What You Want

Knowing what you're looking for first, and then just going out and finding that… It's very cool to see when I work with physicians who know exactly what they want, and I find them that and they land the job and they're happy.

Summary

By thoroughly vetting practices and asking the right questions, physicians can find fulfilling positions that enhance their work-life balance and overall happiness. For more resources and information, visit Happy Day Health and connect with Dr. Hochman on LinkedIn or Instagram.

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Today's PNC Podcast Transcript

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Transcription PNC Podcast Episode 363

Avoid These Mistakes When Seeking a New Practice

- Interview with Dr. Lara Hochman

John: As I've mentioned in previous episodes of the show, I'm becoming more and more convinced that we as physicians can find happiness in medical practice. I focus a lot on nonclinical careers, but I'm seeing more and more about practices that are really fun to be a part of. My guest today was here a couple of years ago, and she was talking about those situations because she matches physicians with practices. And so, I thought I'd have her come back to kind of complete that conversation. With that, I want to just say that I'm happy to have Dr. Lara Hochman here on the podcast again. Hi, Lara.

Dr. Lara Hochman: Hi, thank you so much for having me back. I'm so excited.

John: Well, good. You've been continuing to do what you were doing back then, in terms of connecting physicians with practices. I've talked to a lot of people, but I don't actually do the connecting and I never have a chance to really follow up with people necessarily if they've been on the podcast. I'm really looking for some of your advice and wisdom on this. But tell us a little bit about where things have gone, let's say in the last year and a half or two years since we spoke in terms of Happy Day Health and what you're doing, and remind our listeners as to what exactly we're talking about.

Dr. Lara Hochman: Sure. As the medical matchmaker, I created Happy Day Health as a company that really helps to match physicians with physician owned private practices. And these are practices that I have vetted, that I believe treat their physicians well, that are financially viable, and that are great places to work.

And I do this because I think it's important for us before deciding to make that leap into nonclinical medicine or to make that leap into all the dire things that we as physicians, look at what the other options are out there because there's some awesome places to work. And that's by having more physicians in private practice, this is how we really regain our voice as a physician community.

John: I agree a hundred percent. And so, I think it's going to be very useful for us to learn from you what we should really be looking at to optimize that situation. I have my ideas, but I'm not even going to get into that. And one of the things I noticed when I was looking at your website again, and reviewing some of your videos and that is that you created a new resource that I hadn't seen before called the Stress-Free Physician Career Guide. So why don't you tell us about that? Because I think our listeners, many will be interested in accessing that.

Dr. Lara Hochman: Yeah, this is an email course, it's completely free. And it runs through a little bit about vetting those practices for yourself. If you're looking for a job and trying to figure out what does that job even look like? Or how do you vet a practice according to your values? Because what's an ideal practice for me is not going to be the ideal practice for you. So using what you know about your values and what your dream job looks like, how do you use that to vet the practice and see if it's correct for you? And then how do you select your ideal employer? How do you negotiate your salary? So, it's just a very nice, easy, free resource for physicians to help answer a lot of the questions that I get repeatedly. And that are so important to know how to do.

John: Yeah, I talked to a lot of coaches by virtue of doing the podcast. And for many of them, the first step is always about identifying what your passion is, or what your goals are, or what your principles are, or vision, those kinds of things, you're starting a new business. And so it sounds like you start there, and then you just go even beyond that is to dig into exactly what you might be looking for.

One of the things that I used to advise people that were looking for a job in the hospital setting was the same thing was, make a list of everything you do, let's say in a day or a week, and separate them by what you love doing and what you hate doing, and then try and find a career that will optimize what you love and get rid of all of what you hate. So where do we find the career guide? I don't want to forget about sending people to the right place.

Dr. Lara Hochman: If you head to my website, which is www.happydayhealth.co, there's a tab at the top, the stress-free physician career guide, go ahead, and it'll be right there.

John: Just start filling it out and using it. Okay, cool. One of the ways I like to look at some things sometimes when people are thinking about their career, and it's kind of like clickbait when you look at the internet, but it's like mistakes to avoid. That's why I'm going to ask you questions about mistakes that we can avoid. So, let's start with, I'm assuming that you're dealing mostly with physicians who are coming from practice, maybe they're coming fresh out of residency or fellowship, but they're probably going to start as an employee. They may not end up that way, and I guess I'll ask you about that in a minute, but what's the biggest mistake when choosing an employer? Should we just go with the one that pays us the most? Or how do we find out for sure that we're going to like being at, working with some group, assuming mostly it's going to be a physician group?

Dr. Lara Hochman: That's funny, that would probably be the biggest mistake that I see is just going with the one that pays the most. And I totally get it. Yeah, it's not even desperate. It's the loans and I want to get paid my worth and I want to feel well compensated. And those are all very valid. But in doing that, there's a lot of other things that get overlooked a lot.

Maybe besides compensation, and I was speaking with a financial advisor once who said the best paying job is probably your red flag. That's the red flag is if it pays really well. You can think of it that way. But, yeah, it's definitely interesting how pay structure works. And especially in the insurance model and how insurance companies pay hospitals versus FQHCs versus private practice. That's all important to take into account.

But I would say the other biggest mistake, oh, gosh, it's so hard to narrow it down to one. One of the ones is interviewing too many places, which sounds silly, almost, but what I tend to see is that then you go into analysis paralysis, so you don't know what you're looking for beforehand. Then you're interviewing at multiple practices, you get multiple offers, they're all a little bit different from each other. What ends up happening is you just shut down. When you have too many tabs open in your brain, and these are big tabs. This is a big life decision. And then it often people just end up picking the highest paying one.

So, knowing what you're looking for first, and then just going out and finding that. It's very cool to see when I work with physicians who know exactly what they want, and I find them that and they land the job and they're happy, like, easy peasy versus the ones and typically those are the younger new grads or anything don't really know what they want yet. And they just look everywhere. And then sometimes they'll lose opportunities because they take too long. And that may have been this incredible opportunity that they've lost. So, that would be a big one. And one that I think would be pretty unexpected.

Another one is not vetting the practice appropriately. You hear a lot of times, even in physician owned practices of a bait and switch they promised me this, but then I got that. And it's actually pretty easy to avoid that situation just by speaking with physicians that are already in the practice saying, well, an example is a physician I recently placed in this pretty cool practice. She came from a bait and switch situation where she was a high producer. She wanted to see a lot of patients. She was promised a lot of patients and she was paid purely on production, which is great potentially, but turns out they couldn't even fill her schedule more than five patients a day. That's something that could have been avoided. So, not vetting the practice appropriately is really important. So you don't get into the bait and switch situation.

John: Yeah. I was chatting with a physician recently that I know very well and he's fresh out of residency a year or so ago. And he had that exact situation. It looked like a good practice. It was actually physician run and owned have been around a long time, but his volume was nowhere near what they said it would be. They practically guaranteed it, although not in the contract of course. And he wasn't making anywhere near because the productivity kicked in at the end of the first year and he was still in the process of building his practice. So that was rough for sure. And he's gone somewhere else now, which is very disruptive.

Dr. Lara Hochman: Yeah. It's so important to know what you're getting yourself into. And on the flip side, the practices that are hiring, it's expensive to hire doctors and you don't want to tell them the wrong thing and then have them arrive and realize it's something different and leave. Because then you've lost many tens of thousands of hundreds of thousands of dollars by hiring someone unnecessarily. So, practices need to be honest as well. It's really a two way street.

John: And I think we talked about this last time that maybe physicians don't have deep pockets. If they're a small group, three, five, 10, whatever, even a group of 20, they don't have the resources of a large hospital system. So focusing on the pay is probably, the cultures of those two situations are completely different. Again, it gets back to what you said before about focusing on the, just the pay.

Dr. Lara Hochman: Yeah. There's so much more to that. And especially with how much we want a good quality of life as we should, those are really important things to look at. What's your work-life balance going to be like, what what's the culture of the practice going to be like, will you have a voice? Will you have autonomy? Will admin listen to you? Do you have support? There's so many things that are going to be important to avoid burnout. That's really should not be overlooked. It's really important.

John: What about to switch gears a little bit, just in terms of negotiating everyone, maybe you find the ideal practice, looks like it would be ideal, but you do have to go through that process. So maybe mistakes you might see related to negotiating the contract once it gets to that point.

Dr. Lara Hochman: The big things are around transparency. I don't really see negotiating as I'm going to say what I want and you say what you want and it's buttheads until someone has to give in. Negotiating really is coming to an agreement on what works on both sides. And really working towards that together, I think is so important.

If you're just closed mind and you're like, I want X, Y, Z, and this is it, or else you're probably not going to get anywhere. You're not going to get what you want and versus using the example of tail malpractice insurance, I went tail, the practice doesn't want to provide tail. Well, maybe you can meet in the middle and see how it'll work for both. Obviously, tail is going to be less expensive for something like pediatrics than it would for OB-GYN or neurosurgery. But if I stay three years, perhaps you can pay 50%. If I stay, stay five years, you'll pay 100%, whatever it is, but trying to find something that works for both ends. Because if you're going to ask a new an OBGYN practice to pay your $100,000 tail, if you leave off to one year, that's probably not fair. Seeing it from both sides really is important, when it comes to negotiating for sure.

John: When I was CMO of a hospital, I used to do a lot of contract negotiations. And when I came away with, once I left was yeah, a small practice is not going to be able to put all that money out after one year of work and you just leave. But if you're working for a large hospital system, I put my foot down and say, look, this is the cost of doing business in that situation. But when it comes to, you got to give your physician partners a little bit of a break. If you're talking about tail for a very high cost specialty, that makes perfect sense. Anything else in the contracts that you've found maybe have been stumbling blocks that maybe unnecessarily prevented someone from accepting a relatively good or very good position?

Dr. Lara Hochman: Yeah, actually recently I had a physician, wonderful physician with an incredible practice who she had her dollar amount that she wanted to earn and just wasn't realistic. She didn't want to see a whole bunch of patients. So, unfortunately the math didn't work. But she was coming from a big hospital system that could blow money and was burnt out seeing 20 patients a day coming to a small private practice who had scribes admin support. When you're done, you're done. Awesome culture. This practice is just exemplary, really, really good practice, good morals, good ethics. But they see far more patients a day than this physician was used to.

And what it ended up coming down to was the practice said, we love this physician. We would love to have her join our team. However, she'd be seeing half the amount of patients we are and getting paid more. And we can't justify it. We can't that she's not even bringing in the revenue to be able to justify her salary.

I think knowing what it is that you're asking is so important. And that comes back down to the win-win situation that we were talking about earlier, but understanding what it is you're asking for before asking for it, and then truly actually listening to what the practice is saying back, because you may lose the job opportunity of your lifetime. And you may have been willing to take that lower salary, but because you didn't quite play ball, so to speak not take part in that two-way conversation, you may lose something that could be really cool.

John: Yeah, because every practice is totally different. And if one is very efficient, it has a lot of support like you said, they had scribes. That gets rid of a lot of work. Oh boy, that's probably based on just, again, she was fixated on one thing, and that was the most important, and she wasn't going to listen to any kind of alternatives.

Well, again, that gets back to the vetting. When I think about vetting like hospital systems, there's a lot of data out there publicly, probably not so much for physicians, but give us a few examples. Who should they talk to if they're trying to vet a practice? I can imagine there's be dozens of different approaches to trying to get information, including maybe talking to some of the patients, but what do most of your clients do to try and learn as much as they can about an opportunity?

Dr. Lara Hochman: The first step is in the interview. Really, there are almost no wrong questions. There's wrong ways to ask certain questions. But if there's something that you're afraid to ask, it probably means it's one of the most important things to ask. So, I'll have doctors who say this is really important to me, but I'm afraid to ask it. I really want to be a partner, but I don't want to scare them away, but if that's something that's really important to you, you definitely want to ask. It goes back to knowing your values and knowing what's important to you, and that's where that starts. Ask the hard questions. Definitely not just ask them, but ask them in a nice way. How would you want to be asked certain questions? Speak with other physicians that are already in the practice. If you're interviewing with a practice that only has one physician or one clinician, speak to the office manager. Speak to the medical assistants. Look at the turnover rate.

So, if the practice is turning over their office managers or billing people, that's potentially a red flag. So, look at that. If there's no one to speak to, well, that's not really very good. And then you want to ask those people about things that are important to you. You can ask around in the community. What I like to do when I'm interviewing for jobs or I actually went to a practice as a patient who now ended up being a repeat client of mine, but when I was in the waiting room, I was speaking with the receptionist and asking her what's it like working for this practice? She didn't know who I was. She didn't even know that I was evaluating if I wanted to work with them as help them find a doctor. But speaking with as many people as you can is one of the most important things. And if there are more than one physician in the practice, those are the people you want to speak to.

John: Okay. This is a question I think that my listeners will have. So, you've connected these physicians with practices. It's mostly physician run practices. Do the majority of those, are they looking for eventual partnership? Are some of them looking just to remain an employee, if it suits them? What's your experience been with that sort of goal?

Dr. Lara Hochman: It's about 50-50, I would say. The practices that are looking for partners, part of how I vet it is are they actually looking for a partner or are they just saying you're a partner so that they'll draw you in? Yeah, the practices that I work with that are looking for a partner are looking for a true partner. They want someone to bounce business ideas off of. They want someone to help them grow their practice. They want someone to be a part of the business, and typically they will start teaching you that before you become partners so that at the time of partnership, you can hit the ground running.

John: Okay. Another question that might come up, I'm thinking for my listeners. We've heard a lot about physicians going into practice that they love. And one of the options that some of the solo people have done that I've talked to have gone into a DPC. And I think I saw that one of your listings had specifically mentioned that. So, where does that fall in this? Are many of your practices that you're working with, are they DPCs? Are more going that way? What's your feedback on that whole situation?

Dr. Lara Hochman: There's definitely more DPCs opening up for sure. There's no question about that. As more people learn about it, it's such an attractive option. Some of my practices are direct primary care, direct specialty care or concierge. I wouldn't say the majority yet. I imagine that will change as more and more practices open, but it's an incredible option. It's really great.

John: Okay. All right. I'm trying to think of other questions that I've been asked personally, or that I have. Those are the top things that I was interested in learning about. And I mean, it sounds very hopeful to me. I think I'm going to have to get some more guests running DPCs and things like that. Tell us your website again, where can we find you and where can we look for the Stress-Free Physician Career Guide?

Dr. Lara Hochman: My website is www.happytohealth.co. Please check it out. That's where I have all of my jobs posted that I'm currently helping. You can sign up if there's something you don't see that you want, you can sign up and I'll let you know when something does come up for that. The Stress-Free Physician Career Guide is on there. There's a link to a course that I ran on opening your own practice. Anything is on there. I'm on social media, LinkedIn, Laura Hockman MD is where I'm the most active. I am on Instagram, Happy Day MD, I think. I don't even know.

John: I forget where my social media is. But yes, definitely. I saw the YouTube videos. So they're definitely going to be found there. You've been on another podcast, I'm sure, where you address this issue. So we can look for you there. All right. I guess I'm going to let you go in a minute here. But I'm just thinking, okay, if you're currently an employed physician, you're in a practice or working for a large corporation, you're probably doing the usual insurance company driven healthcare and you're getting miserable, any other advice you have just in general for how these people should think about the rest of their careers while they're feeling miserable?

Dr. Lara Hochman: Yeah, we got one life, we have to enjoy it. There'll be no job that's going to be good 100% of the time. But if you're miserable, why wait? What are you waiting for? If you're so unhappy, there's going to be something better, whether it's nonclinical, and that's where your podcast really can come in handy, or something clinical is out there that you enjoy, I would say, open up your mind. There's a lot of where we feel like we need to be practicing one way or we need to do it one way or another.

What have you got to lose? Take a job that sees less patients, take a job that if you want to stay clinical, think about what it is you actually don't like about your job. And most of what I hear is not clinical part, it's the admin part. So there's jobs available out there where you can still see patients and still do good in the world, and not have to deal with all the admin stuff. So you got this, it's just a matter of finding what you want, but knowing what you want first, so that you can go out and find it.

John: Yeah, so many physicians obviously want to be taking care of patients. And like you said earlier, there may be that practice not that far away that just has scribes, and you don't have to deal with the EMR as much as you do now, or whatever that issue might be. I think things are starting to turn for the better. I really appreciate you doing what you do and sharing these updates with us from time to time so that we keep the faith. Thanks again for being here today, Lara.

Dr. Lara Hochman: Yeah, thanks so much for having me. I really appreciate it.

John: You're welcome. I'll hopefully talk to you again next year or two.

Dr. Lara Hochman: Great.

John: Bye-bye.

Dr. Lara Hochman: Bye.

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The post Avoid These Mistakes When Seeking a New Practice appeared first on NonClinical Physicians.

How to Set Up Your Medical Writing Business

John Jurica — Fri, 21 Jun 2024 10:45:58 +0000

How to Start Your Own Medical Writing Business: A Practical Guide

Starting your own medical writing business can be both exciting and challenging. Whether you're an experienced medical writer or a healthcare professional looking to transition into writing, setting up your business involves several important steps. Here’s a straightforward guide to help you get started.

Identify Your Niche
First, define the kind of medical writing you want to specialize in. The field includes technical writing for pharmaceutical companies, journalistic writing for physicians and patients, and writing continuing medical education (CME) manuscripts. Knowing your niche will help you target clients and tailor your marketing efforts.
Create a Business Plan
A business plan is your roadmap to success. Outline your goals, target audience, pricing strategy, and marketing plan. Here’s what to include:
- Mission Statement: Define why the organization exists, what its overall goal is, the kind of product or service it provides, and its primary customers or market.
- Market Analysis: Research your target market and competitors.
- Services Offered: List the types of writing you plan to provide.
- Pricing Strategy: Set your rates based on industry standards and your experience.
- Marketing Plan: Plan how you will reach potential clients, including creating a website, leveraging social media, and networking.
Choose Your Business Structure
Decide on the legal structure for your business—sole proprietorship, LLC, or corporation. Each has its own legal and tax implications. It might be worth consulting a business attorney or accountant. Also, don't forget to register your business name and get any necessary licenses or permits.
Build an Online Presence
In today's world, having a professional online presence is crucial. Create a website that showcases your services, portfolio, and contact information. Consider including:
- About: Share your background and qualifications.
- Services: Detail the writing services you offer.
- Portfolio: Provide samples of your work.
- Testimonials: Include feedback from past clients.
- Blog: Post industry insights and writing tips to demonstrate your expertise.
Network and Market Yourself
Networking is key in the medical writing industry. Join professional organizations like the American Medical Writers Association (AMWA) or the International Society for Medical Publication Professionals (ISMPP). Attend conferences, webinars, and workshops to connect with potential clients and stay updated on industry trends. Use social media, especially LinkedIn, to build your professional network and highlight your expertise.
Get Your First Clients
Getting your first clients can be tough but rewarding. Start by reaching out to your existing network and offering your services. You might consider doing some work for free or at a discount to build your portfolio and get testimonials. Freelance platforms like Upwork, Freelancer, and specialized medical writing job boards can also help you find opportunities.
Manage Your Business Operations
Effective business management is crucial for long-term success. Set up systems for tracking income and expenses, invoicing clients, and managing deadlines. Tools like QuickBooks for accounting and Trello or Asana for project management can help keep you organized.

Summary

Starting a medical writing business requires careful planning, networking, and dedication. By following these steps, you can build a successful business that leverages your expertise and meets your clients' needs. Stay adaptable and continuously look for opportunities to grow and develop professionally.

EXCLUSIVE: Get a daily dose of inspiration, information, news, training opportunities, and amusing stories by CLICKING HERE.

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Some of the links that I refer you to are affiliate links. That means that I receive a payment from the seller if you purchase the affiliate item using my link. Doing so has no effect on the price you are charged. I only promote products and services that I believe are of high quality and will be useful to you. As an Amazon Associate, I earn from qualifying purchases.

The opinions expressed here are mine alone. While the information provided on the podcast is true and accurate to the best of my knowledge, there is no express or implied guarantee that using the methods discussed here will lead to success in your career, life, or business.

The post How to Set Up Your Medical Writing Business appeared first on NonClinical Physicians.

Negotiate a Great Contract, Avoid Burnout, and Be Happy

John Jurica — Tue, 13 Feb 2024 13:34:59 +0000

Interview with Ethan Nkana – Episode 339

In today's episode, Ethan Nkana explains how to negotiate a great contract, avoid burnout, and protect yourself legally.

Ethan's advice revolves around empowering physicians to advocate for their best interests, understand the nuances of their contracts, and seek professional assistance for optimal negotiations.

Our Show Sponsor

We're proud to have the University of Tennessee Physician Executive MBA Program, offered by the Haslam College of Business, as the sponsor of this podcast.

The UT PEMBA is the longest-running, and most highly respected physician-only MBA in the country. It has over 700 graduates. And, the program only takes one year to complete.

By joining the UT Physician Executive MBA, you will develop the business and management skills you need to find a career that you love. To find out more, contact Dr. Kate Atchley’s office at (865) 974-6526 or go to nonclinicalphysicians.com/physicianmba.

Did you know that you can sponsor the Physician Nonclinical Careers Podcast? As a sponsor, you will reach thousands of physicians with each episode to sell your products and services or to build your following. For a modest fee, your message will be heard on the podcast and will continue to reach new listeners for years after it is released. The message will also appear on the website with over 8,000 monthly visits and in our email newsletter and social media posts. To learn more, contact us at john.jurica.md@gmail.com and include SPONSOR in the Subject Line.

Our Episode Sponsor

Dr. Debra Blaine is a physician like many of you, and her greatest challenge was fear. The whole concept of leaving clinical medicine was terrifying. But she is so much happier now as a professional writer and a coach. According to Debra, “It’s like someone turned the oxygen back on.”

If fear is part of your struggle, too, she would like to help you push through those emotional barriers to go after the life you really want. Click this link to schedule a free chat.

Or check out her website at allthingswriting.com/resilience-coaching.

A Crucial Step in Career Success

In this interview, Ethan Nkana, founder of the Rocky Mountain Physician Agency (RMPA), sheds light on the often-overlooked importance of negotiating your best employment contract. The conversation highlights the significant role contract negotiations play in a physician's career course. These negotiations have an enormous impact on overall job satisfaction, financial well-being, and work-life balance. Ethan's expertise, honed through years of working in hospitals, is presented as a valuable resource for physicians navigating this complex terrain.

Key Considerations in Physician Contract Negotiations

Ethan provides practical insights into the essential elements of physician contracts, guiding both new and experienced physicians. From compensation and restrictive covenants to job duties and support resources, the discussion offers a roadmap for physician employment agreements.

On this matter, we explore the top two or three critical elements that physicians should prioritize. These topics are demystified, with Ethan offering his valuable insights. Tail coverage for malpractice insurance and considerations for experienced physicians seeking contract renegotiation are also explored.

Ethan Nkana's Advice for New Graduates

It's a matter of asking, knowing how to ask, and what to ask for. For the first time attendings coming out, please do not feel as though you have to sign whatever is put in front of you… I want to encourage you, please advocate for yourselves, know what matters to you most, and ask for those things in your contract.

Summary

Ethan shared valuable insights into why you must fight for your best employment contract, and what to prioritize. He also reminds us that there are professionals like him who will serve as your agent to get you the best contract possible.

NOTE: Look below for a transcript of today's episode.

EXCLUSIVE: Get a daily dose of inspiration, information, news, training opportunities, and amusing stories by CLICKING HERE.

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Download This Episode:

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Today's PNC Podcast Transcript

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Transcription PNC Podcast Episode 339

Negotiate a Great Contract, Avoid Burnout, and Be Happy

- Interview with Ethan Nkana

John: Sometimes physicians can be their own worst enemies. We finish our training and agree to work for a large practice or a hospital system, and then two or three years later we're miserable. And we discover that our contract does not protect us from being mistreated or underpaid. My guest today is Ethan Nkana, and he's here today to help us avoid those issues. Welcome Ethan. I'm glad to have you here today.

Ethan Nkana: Thank you so much for having me, John. It is a delight to be here with you.

John: I don't know why I haven't talked to someone like you sooner. I've been doing this podcast for several years and I've always focused on nonclinical, but the reality is, for most physicians, they want to go clinical. And they may not want to do it forever, but heck, if they're going to work clinically, they shouldn't be subject to low salaries and being beat up and burned out after two years. I think some of what you're going to tell us today is going to help us avoid that. And I really do think, and I don't talk about this enough, but every physician that's going to be employed really has to have someone help them negotiate their contract. That's my opening for you. Take it from there. Tell us about your background and how you got into this.

Ethan Nkana: Yeah, spot on, John. And actually I want to touch on what you said a moment ago. So much of what I get to do in my job is education. And so, I think it's so important for doctors first to understand what is in your contract and the risks, the benefits and burdens, all of those things. During our conversation I don't want this to sound like a sales pitch for my business. I want to help doctors know how to do it for themselves so they don't need someone like me.

But I think you highlighted something that is extremely important about the relationship that doctors have with employers is often overestimated. And so, doctors have this fierce loyalty to employers, which they find out the hard way is not necessarily reciprocated. I'm glad that you and I get to talk today.

John: I'm going to say another prelude to this whole conversation for those that are listening, because I used to do negotiations on the hospital side for these physicians. I think when you're negotiating or you're having someone negotiate for you, you have to realize, the way you set this thing up and the document that you sign is going to be what you're going to live by for the next few years. And if it turns out there's big holes in it or there's things in there that just don't align with what you thought you were getting, you're going to be miserable. Again, that's just my admonition to those as we get going. Tell us how you got started and I did a little intro separate from this and I talked about how you go back to the legacy with your mom, but tell us about that and then how you got into this.

Ethan Nkana: Absolutely, and I think one of the cool things about what I get to do now is it's kind of the only thing I've ever done in my career. As you mentioned, my mom is an anesthesiologist. Coming out of college, she told me, you've got to get into healthcare, you're going to always have a job. What she didn't know is that I got laid off in 2019 and all of a sudden kind of found myself having this existential crisis.

And in the midst of that crisis, I had this question, "Why don't doctors have agents like professional athletes?" I started thinking about your training journeys as a physician, how that parallels with an athlete. Then you go pro and there's all of this money and athletes hire agents, but doctors tend to DIY it. And so, I founded RMPA - Rocky Mountain Physician Agency as an agency for physicians. And so, my job is similar to a talent agent, athletes, actors, you name it, my job is to negotiate and renegotiate physician contracts for the most money and best terms for my doctors.

John: Now that leads me to a question about that process. Do you usually get involved with their first contract or do you have a lot that are halfway through and now they're getting ready to re-up or renegotiate? Because I could figure that would be a whole different scenario.

Ethan Nkana: Yeah, we do actually quite a bit of both. We do first time attending, what we call rookie deals. Doctors who are coming out of residency and training. And we also negotiate deals for experienced doctors. As you mentioned, those are very different. The reason that for me, it's kind of like a fish in water is because the only thing I've done in my career is work in hospitals. From HR intern, which is my first job, supply chain, food and beverage, physician contracting, finance. If it's in a hospital, I've either done it or I know it.

And so, for me, it's really easy to kind of transition between, "Okay, I have a rookie doc who's going in their first contract. What are some of the things we want to prioritize?" But the cool thing about that though, John, is I get to see into the crystal ball of what attending doctors are concerned about. Then I get to say, "Hey, Dr. Jones, you might want to make sure that you lock in your call schedule, because that's the most common thing that experienced doctors call me about." It's kind of this cool dichotomy of getting to see doctors at the beginning of their career when it's all in front of you, and then I also get to work with doctors as they progress through their career, renegotiating their employment contracts.

John: And I think it's implied, but I have to ask you directly. Given your experience, even prior to doing this and then starting the agency and now doing this, would you agree that if you really pay attention and you get the right contract, life is going to go a whole lot better? Or on the other hand, maybe you walk away from something. If you can't get to that contract, it means there's something wrong. Is that your experience?

Ethan Nkana: That is spot on, John. I think that often gets overlooked because psychologically we are so averse to change. And so, when doctors think about what it takes in order for them to advocate for their best interest, there's this big barrier, this big wall of change that they have to go through, or they have to think about scaling. And so, a big part of my job is the psychological part of helping doctors understand, "Yes, there's going to be change and it's going to be worth it." You're going to be happier, you're going to have less stress, you're going to have more support in your practice, you're going to be more fulfilled with your work, and then obviously make a bunch more money to do that.

John: Awesome. All right, obviously you're not going to be able to walk through like a typical 15 page contract or something and cover all, but all the bases. But tell us in your experience what are the top two or three issues and what are some of the pitfalls and maybe the things where you really have to step in and say, "This isn't worded right, or we really have to pay attention to this?" Just take it away and we'll learn as much as we can from you.

Ethan Nkana: Yeah, great question. I have what I call the big five, which are the five provisions that if I had 15 minutes, here's where my eyes would go. First and foremost, the compensation. We're all looking for that big sexy six figure number to see what's my annual salary. But don't forget about your bonuses. Your production bonuses, volume bonuses, signing bonus.

The second thing that I'm looking at is education loan debt assistance. I can count on one hand how many doctors I've talked to who do not come out of training with some type of debt, usually in the six figure range. And so, my responsibility is also to help make sure doctors can pay that down as quick as possible. Going back to what you mentioned a moment ago, which you teed up is doctors being happier. And one way doctors are happier is when they have less student loan debt hanging over their head and then they can use that money to fund the lifestyle they've worked so hard for. And so, I always will encourage doctors to ask for education loan debt assistance. Those can be big dollars anywhere from $25,000 to $50,000, and sometimes above that a year in addition to whatever you're putting into that.

The third is non-competes. You've probably heard of those. They're also called restrictive covenants. The primary difference in this between sports and doctors is that in sports, once your contract ends, you can go play for any team who's going to hire you. But for doctors, it's so much more restrictive. And I don't think people appreciate that. When a doctor finishes their contract, that's when the restriction ends. Let's say you do five years with an employer and then they say, "Nope, you got to get out of town because you can't practice within 20 miles." So, who's going to move 20 miles away and they can change your school district for your kids and your church and social network? I don't have to go into all that, but the non-compete can be really burdensome.

I'll give you a quick cheat code. The non-compete penalty should be paid by your new employer. I often hear doctors say, "Well, I can't go anywhere because of my non-compete." Don't worry about that, negotiate that into your new contract so that way you don't have to worry about that. They'll give it to you upfront as a bonus. They're going to forgive it over the period of your contract. And that way if your employer comes knocking on your door saying, "Hey, you owe us X thousands of dollars", cool, I have a check for my new employer to pay you. So you don't have to worry about getting sued.

The other thing I want to look at is your job duties and schedule. This is huge. This is the thing I often say if doctors got the resources and support they needed from employers, I would be out of a job. But the fact of the matter is, medicine is a business and doctors are a very important cog in a very large wheel. And so, understanding what your clinical contact hours, your patient contact hours are each week, what are your call expectations. And then I just had this issue last week, what happens to call when a doctor leaves? Do they have a support pool to cover that for you? Or do other remaining doctors have to take more call and now impinge upon your lifestyle?

And then lastly, it's your resources and support. You want to make sure you have adequate administrative, clinical, financial support in your contract so that way you can perform at the highest level. It's stressful enough the work that doctors do. Make sure that the hospital provides you with the resources to play at the highest level or to care for patients at the highest level.

John: Those cover a lot of areas. Let me ask you a question or two, maybe about two or three of those. The salary. What drives it? Is it surveys? Is it, "Look, I'm just going to get as high salary as I can. If they're really hurting, then they're going to pay a lot of money." What do you find works the best? And do you usually find that you can get more dollars than the physician actually anticipated?

Ethan Nkana: Absolutely. Every time we go into negotiation, we make our doctors more money. I was asked by a physician group last week, "Well, what happens when that doesn't happen?" The way I get paid is a percentage of my doctor's pay. So, if I don't make them more money, I don't get paid. Our batting average has to be a thousand in order for us to even stay alive. So, we always make our doctors more money.

I think the important thing for doctors to understand, I'm going to bookend this. The most important things that I think would be how busy you are as a physician. Let's take your specialty out. Your specialty is going to of course drive. Like a neurosurgeon, generally speaking, is never going to make less than a nephrologist. That's just never going to happen realistically. We'll leave that out of the conversation. Let's just talk about within your specialty how salaries might change a little bit.

The doctors who generally make the most money are going to be the busiest doctors. My job when I worked in hospitals was to quantify for my CEO how much money we're going to make off of Dr. Jurica based on how busy you are, the type of procedures you do, and then the other counterbalancing expenses, how much do you cost us as a hospital? And then the balance between that is what's called the ROI or return on investment. Doctors are seen literally as line items on financial statements, and I could quantify down to the dollar how valuable doctors were to our hospital. And so, that rule sets the bar as like the busiest doctors generally tend to make the most money.

The other major consideration is where you're practicing. Even if you're looking at two high cost areas, say New York and California, you cannot compare those. Because there's just so many nuances. Now, I'm not an expert in finance, but there's just so much nuance. You must look in similar geographic regions, but then even within that, the care setting you're in matters. Some doctors are in private practice, some doctors in academics, some are in safety nets, like county hospitals.

The general rule of thumb that the data shows is that the fewer layers between the insurance carrier and the patient, the higher pay for the doctor. Private practice, highest pay. Insurance pays the doctor, who pays the practice, and then the expenses get paid for the practice from there. Then as you get to the world that I was in, which is, and I only worked in nonprofit, so I never worked for a for-profit hospital. But those hospitals are looking at "Well, how can we bring on the most doctors of a particular specialty within a geographic area?" They call them service areas.

And so, the chess game that I get to play is how can I help shift doctors among health systems in a way that they have to pay doctors the most money to either acquire or retain them. And so, my job is to help doctors maximize the value of that compensation with your employer. We're looking at "I'm going to pull your stats. I'm going to pull how busy you are." In sports, how many touchdowns did you throw? How many points did you score? How many rebounds did you grab? I want to know how many procedures did you do? How busy are you? Because those are the things that are going to impact your compensation. I can tell you from experience if you come in with the latest and greatest MGMA report, your hospital or employer will find 18 different ways to invalidate that data. "Well, this is looking at private practice. This is looking at left-handed doctors." Just save yourself the time, save yourself the money.

You should get a ballpark of what your salary should be. Doximity, Medscape, Merritt Hawkins, Physician Thrive. They all publish national and annual surveys on physician compensation. So you should have a ballpark of what you should be making. But if you think that that's going to help you in negotiation, you're just going to get laughed out of the room, unfortunately.

John: Now, one of the things that I remember that really drove physicians crazy in this process is the actual way that they're paid. And I'm sure it's changed since I was involved with this, which is more than 10 years ago. Well, they are going to be paid based on RVUs, number of patients seen, just a flat salary, some other goofy formula. Is that becoming any less complicated or do you still see all these different methods of trying to figure out how much you're going to actually take home?

Ethan Nkana: I'm convinced that the industry of law is made up so that people intentionally cannot understand it unless you go through this rigorous three year training program. Yes, it's extremely complex. Could a doctor understand it? Absolutely. But the time that it would take you, I was looking at a family medicine doctor's RVU bonus structure, and it was the wonkiest thing I'd ever seen. And I'll spare you the gore of how bad it is. But the point being, it's unlike anything else I've seen in the country. And so, this one organization has this bonus structure that's disadvantageous to the doctor and she has no recourse to change that. One, she didn't understand how it worked, which, how could you? It's so dense. And then secondarily, when I explained to her, "Hey, this is not in alignment with the industry standard and it's disadvantageous to you", how do you think she feels? It's miserable and it's unfortunate that we don't do a better job of making it plain.

I think what doctors appreciate about working with me, it's that I'm not a practicing attorney, I'm an agent. So, how I talk to you is different. How I interact with you is different. I'm not charging you when you call me. I get a bill from my attorney if I send him a text message or if I send him an email. Again, no disrespect, I have an attorney for my business, but it just seems like a really unsustainable way to add value for my doctors.

John: Well, let's take it one step further than what you described. Maybe you have someone who was in this job, they're unhappy and miserable, now you're helping them. They find out they can't understand the structure, they're never going to get a bonus because they don't really even know what to do to get the bonus. And the hospital is just not budging. To me, that's like, "I know it's tough, but maybe this is not the place you should be working. At the end of the day, we can find you a better job that's going to pay more and it's going to be more transparent." I would think physicians are in enough demand, that they would be able to within a reasonable distance, find a different job.

Ethan Nkana: Yeah. Where were you when I started this out, John? You are preaching exactly what I believe to be the reality for doctors is sometimes you need to go to grow. And I'm not saying that you should go into a contract negotiation, willing to cut ties. But the first question that I ask a doctor when we're getting ready to work together is let's say you present your employer with very reasonable requests and they say no to everything. What are you going to do? And if you say, "Well, Ethan, I'll just go back to work tomorrow and do what I got to do", cool, I'm not a good fit for you then. We work with doctors who say, "Ethan, I know that I'm worth more than that. I know that I deserve better. My patients deserve better, my family deserves better."

All right, here's what we're going to do for you. I'm not going to waste your time as a doctor or my time by talking to your employer until I have an offer for you from somewhere else for more money and better terms. And then I come back to your employer and say, "Hey, Dr. J is looking for a nice little salary bump, he needs an extra PA for his practice. We need you to make those changes for him going to this new contract." They're going to say what they always say, "Not interested. - Okay, cool. Just so you know, Dr. J has an offer across the street for more money and better support. If you're not willing to pay, he's going to walk. - Oh, hold on, hold on. We can have a conversation about this."

Because now they know the economics of Dr. J moving across the street. And what they count on is Dr. J doesn't know his economics, but I do. I know exactly what your work to this hospital and conversely I know how much it would mean at another hospital in your area if they had you working on their team.

John: Now you said something earlier about the non-compete and the fact that you know where you're going should be able to buy you out of that in some way. Now the contracts I've seen have actually never had a dollar amount attached to what that would be. They're just a threat. "We're going to take you to court. And it says here you can't work within 20 miles and you can't work for anyone under this other system." That makes me think, then your contract should always have a figure of how to buy that out. Is that kind of what you're saying?

Ethan Nkana: Exactly. Typically contracts will. I won't go off the deep end about the legality of non-competes and whether or not they're enforceable because there's lawyers who spend their entire careers researching and understanding that. And that's just not my world. For me, it's more a matter of practical implications. I want my doctors to be able to violate their non-compete with no penalty. That's my goal. I don't care about "Is this enforceable?" It doesn't matter. Well, I'm going to assume it is enforceable and get you a route around that. I think it's important for doctors to know that, exactly like you said, Dr. J, there should be a finite number in there. If there's not, it's not going to be harmful for you necessarily. But the point being, that's going to be the amount that you are going to need to cover if you violate your non-compete.

And then again, here's the cheat code. Tell your new employer, "Hey, I've got this tail that I need covered for me. Can you help?" They're going to say, "Cool, we'll pay you that bonus, but you have to work for us for three or four years" or something like that. So, you can get around it. And I've worked around non-competes with new employers. But it's just something that when I was a hospital exec, I used to scare doctors with non-competes. Well, you don't want to upset the CEO because they might come after you. You know that's in your non-compete area. And of course, it has a chilling effect and doctors won't try to. I had a general surgeon last week who didn't feel like she could make that move because of her non-compete, despite me explaining exactly how she can navigate that.

John: I could go on all day with questions about the contracts.

Ethan Nkana: Let's do it. I got all day.

John: Oh no, something else occurred to me. How hard should you push for a notice? I've seen notice from three months to six months to a year. And to me, if you're miserable and you're ready to go, I don't know, waiting a year, and maybe again that's another buyout, but where do those usually fall on your clients?

Ethan Nkana: My goal is usually 90 to 120 days. And the reason I say that is because that's your one runway to find a new job. Let's say if you want to leave, you give them 30 days or 90 days notice, there's no harm, no foul. You're able to go practice where you want. The more impactful situation for doctors or detrimental is when the employer says, "Hey Dr. J, we don't need you anymore." And then now what's my runway to making my next dollar? You don't have that stability. And God forbid, if you're a primary breadwinner for your home, that can be devastating for doctors.

So, it's super important to make sure that you have a nice little runway. Typically what you'll see is it'll say the hospital or employer will give the doctor 90 to 120 days notice, but we can tell you, you're done as of today. But they have to pay you that full runway amount. So, that's the other thing to think about is they can still let you go right away, but they still owe you that notice period amount of pay, which can be significant for you.

John: All right, one last quick one.

Ethan Nkana: Let's hear it.

John: Tail coverage was always something... I was on the other side, again, I was pushing that you have to pay as much as we could get you to pay, and then the contracts we'd shoot for, all of it or have a reducing amount based on how long you've been there. But do you get contracts where you just say, "Look, it's a cost of doing business, I can't work if I don't have insurance, I'm not going to pay it." Do some institutions accept that these days?

Ethan Nkana: What I tend to see across the country is kind of two primary approaches. The default I would say is the employer is going to pay for tail coverage in some of these large healthcare systems. The exception to that is when I see private practices, that's where I tend to see more of the doctor has to cover 100% or the large majority of the tail coverage. And by no means is that a rule or research. That's just kind of my anecdotal observations. What I shoot for, for my doctors in any setting is employer covers 100% of tail insurance. I won't get into the intricacies of occurrence based first claim space, but just know if you need tail coverage insurance, there's kind of the primary default, which is your employer should pay that.

The other approaches I see is, the other bookend is the doctor pays the whole thing. But in private practice, what I'll sometimes see is the employer will cover more tail the longer the doctor's there. So, let's say the employer will cover 50% tail, but after two years they'll cover 100% tail coverage. The sensitive, weird thing about that is you're talking about when you end the relationship, but it's super important to talk about that because it's not something you want to have to find out the hard way that is disadvantageous to you.

John: Yeah. And the thing that I remind physicians about it, particularly if they're looking at their first contract, the tail is very low when you've never seen a patient since you're training. It's only when you've been in practice for a while where it can skyrocket. Eventually if you're an ortho or OB or whatever, it's going to be enormous. We had one guy at our hospital, he just walked away. He didn't pay it and he wasn't going to pay it. And I think the hospital had to protect itself by paying it even though it wasn't in his contract. I wouldn't recommend that approach.

Ethan Nkana: Yeah, likewise, I would not tell you "Walk away and not pay." Yeah. But that is one way to take the most aggressive approach. It's like, "Man, I'm not going to do it. What are you going to do?"

John: Yeah. All right, we are going to run out of time here. I want you to spend a little time, again, talking to us about your company. It's RMPA. rmpa.co is the URL for Rocky Mountain Physician Agency. Tell us more about that.

Ethan Nkana: Yeah. I think the cool thing about what I get to do for doctors is I'm not a traditional law firm or attorney. While my background is I'm trained as a lawyer, I have an MBA, I spent my entire career working in hospitals. And so, what that's allowed me to do is create an industry where we represent doctors the same way agents negotiate talent deals like artists, musicians, movie actors, professional athletes are the common one for me. And so, the cool thing about my work is I get to see doctors at the beginning of their career and help them negotiate a really strong foundation. And at the same time, attendings come to me and say, "Hey, I don't want to get screwed on another contract. Can you help me make sure that I get the best deal in this next contract?"Or physician groups will come to me and say, "Ethan, there's four of us, 10 of us, 20 of us. We have crummy contracts, crummy conditions, but we don't know how to get the attention of our employer." And so, that's where I come in and say, "Look, you get back to doing what you do best, which is taking care of patients, and I'm going to represent your interests to make sure that we address all of your concerns."

And as you know. Dr. J, doctors are not a monolith. If you have 10 doctors in a group, it's not 10 doctors who are all prioritizing the same things. Some of you are going to be in different stages of your career, so you may value different components of your contract, your job, or your lifestyle. And my job is to help take those priorities and interpret them in a way that your employer can understand and make sure they're in your contract for you.

John: Now, you alluded to this earlier, but we didn't get into detail about it. But basically when you're engaged, your plan is to put the onus of the payment on the employer, which is most of us have not gone that route. That would tell me that maybe there's a timing issue here. We're not going to bring you in at the last minute. When would be the best time for either a new physician coming out of residency, fellowship or someone who sees their contract up for renewal in a year or six months? When would be the best time to talk to you?

Ethan Nkana: Yeah, good question. I would start by saying if you are an experienced doctor, you should renegotiate now. Unless you've negotiated in the last six months, nine months, 12 months, you should renegotiate your contract now. Because the chances are you probably haven't had a salary raise in the last 2, 3, 5 years, which means you're taking a pay cut. So, experienced attendings, I would say call me first. And I only say that because as we were talking about, I think we're recording this Dr. J, but we're not a good fit for every doctor. I'll be the first one to say, "Hey, if you are a doctor who only wants to work in this specific hospital or setting and you're not willing to consider your options", I'll be the first to tell you we are not a good fit and we're not going to meet your expectations.

The doctors who are a good fit for us are the doctors who understand that they deserve better. And they call me and they say, "Ethan, I'm frustrated. I'm frustrated with my practice, with not having enough support, with not having enough resources. My staff is not supported." Those are the conversations we can help talk you through. You just want us to give you the answers to the test. We'll be happy to do that. And in fact, we do that. We'll be with University of Michigan next week doing a workshop for them on how to go from training to your first job and make the most out of it. My view of it is call us first. Send us a note first and we'll help you help lay out the roadmap for you.

But I say for experienced attendings, you should renegotiate now. And I know it's going to feel awkward. "Well, my contract is not up." Renegotiate now. If you wait until it's up, you're going to be too late and the hospital is going to slow play you, which they love to do. And then if you're a first time attending, I say that the appropriate time to start looking for your job is about nine to 12 months from when you're finishing training. Typically you'll finish training June, July timeframe. So, nine to 12 months before that is when you should really in earnest kind of get the job search started and then looking to sign a deal in the spring so that way you can do the onboarding, HR, drug tests, all of that. And then potentially you might relocate. So, you'll need to consider that as well.

John: The people I talk to are usually pretty miserable. And so, have you ever been involved with someone who says, "Look, I am in the middle of my contract. It may be a three year contract, or maybe I'm early, it's been a year. I need to renegotiate it now, as you said." But have you had it where they said, "I am going to invoke my need to give my notice. I'm going to give my 60, 90 whatever, 120 days notice and it's not because I want to leave, it's because I just want to talk to you about getting a better contract." The employers, do they respond okay to that?

Ethan Nkana: Yeah, that's a really interesting perspective. I haven't considered that before. I haven't seen that exact situation. I always tell my doctors, whether they work with me or not, get a safety net first. Before you go to your employer and invoke your notice or say, "Hey, I'm going to leave", get an offer first or get some interest first because that will allow you to have, one, some confidence because you can actually back up what you're saying. But secondarily, it gives you a soft landing spot. In case you need it, you really need out, you'd have a landing spot that would allow you to have an uninterrupted livelihood and an ability to make a living. So, if you do put in your notice, I would say go get an offer first.

John: Makes sense. All right, one more time, what's the website and maybe the phone number if you want to give us that too?

Ethan Nkana: Yeah. The phone number is (720) 471-0059. My email address is ethan@rmpa.co. And then we're on Instagram and LinkedIn. We're also starting our new business YouTube page, where we have given a bunch of free tips on how doctors can advocate for themselves in contract negotiations.

John: Very good. Any other last thoughts or advice for us before I let you go? I'd say let's talk about the new grads that are coming out. Just any other things you want to leave before we get out of here?

Ethan Nkana: I think one of the most common misconceptions about first time attendings is that they do not have the ability to negotiate. And I want to be the first one, hopefully, to break that myth. Every one of the doctors that we work with makes more money in their contracts. It's a matter of asking, knowing how to ask and what to ask for. For the first time attendings coming out, please do not feel as though you have to sign whatever is put in front of you. I said a thousand times as a healthcare executive, "It's a standard contract, you can't change anything." And guess what? Doctors didn't change anything. I want to encourage you, please advocate for yourselves, know what matters to you most and ask for those things in your contract.

John: Excellent advice. I really appreciate that. Well, I guess that's all we have time for today. Ethan, I'll have to have you come back someday but this has been fantastic. I've learned a lot. With that, I'll say goodbye.

Ethan Nkana: That's been a blast. Thanks Dr. J.

John: Bye-bye.

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The post Negotiate a Great Contract, Avoid Burnout, and Be Happy appeared first on NonClinical Physicians.

Follow These 8 Steps to a Career in Quality Improvement – 027

John Jurica — Tue, 13 Mar 2018 14:59:57 +0000

In this episode, I respond to a listener's question about pursuing a career in quality improvement. Her ultimate goal is to become a chief medical officer for a health system. I list the tactics I would use to achieve that career goal.

Free Career Transition Guide

Before I jump into today’s content, I need to tell you about a new “how-to-guide” I’ve written. It’s a 24-page manual, complete with checklists for 5 nonclinical careers. It outlines the steps you can take to pursue a career in utilization management, clinical documentation improvement, informatics, medical writing, and hospital management as VP for Medical Affairs.

I wrote it based on my personal experiences, and what I’ve learned doing interviews for this podcast. I was thinking of selling it on Amazon as a Kindle Book. But for now, it’s completely FREE for listeners to this podcast. To download your copy, just go to Free Career Guide.

A Listener's Question

I was on a phone call the other day, talking with a physician listener interested in exploring a new career. She was working as a gastroenterologist in a fairly large medical group and had become involved in quality initiatives at her local hospital.

Let’s call her Nina.

She didn’t have a formal leadership role in the hospital or medical group, but she really enjoyed working on quality improvement projects. And she wanted to explore a career in quality improvement.

She was thinking that she might ultimately want to work as chief quality officer at a hospital or a large group. And, she asked me how to best pursue such a career.

I thought you’d like to hear the advice I gave her, so I’m presenting that today. But first, let me give you a little more information about this relatively new senior hospital executive position.

A New Position: Chief Quality Officer

As hospitals have begun to shift from volume- to value-based care, someone must be responsible for collecting and submitting data needed to demonstrate the organization's quality. And there are multiple processes, tools, and departments that must coordinate their efforts to make that happen.

Let me point out some of the duties of the CQO:

Implementing quality improvement measurement tools that can provide risk-adjusted outcome measures;
Implementing a tool that will cull clinical data for the purpose of reporting to CMS;
Writing and implementing a quality improvement plan that addresses all QI activities, such as
• physician peer review,
• chart reviews for quality monitoring,
• implementing mandatory quality initiatives, such as those for central line infections and DVT prophylaxis,
• initiating QI projects using QI models such as PDCA (plan – do – check – act),
• performing root cause analyses for serious errors or sentinel events;
Monitoring public reporting (Hospital Compare, HealthGrades, LeapFrog, Truven Top 100 and others);
Hiring, directing and evaluating the director of QI department and often the Patient Safety Department; and,
Developing and promoting a culture of safety and quality.

I described my vision of the ideal QI program in Building a Great Hospital Quality Improvement Program.

I’ve seen tremendous growth in this field. This is primarily because CMS is penalizing hospitals financially that don’t meet quality, safety, length of stay and readmissions benchmarks. So, it now makes sense to invest 200- to 300-thousand dollars to avoid paying millions of dollars in penalties. And a CQO will promote quality of care and the hospital’s rankings and reputation.

Suffice it to say that there is a growing demand for physicians who meet the qualifications needed to lead hospital quality efforts.

My Roadmap to Chief Quality Officer

As I thought about her situation, there were several ideas that came to mind, and I shared those with her. Thinking more about the question later, here is what occurs to me:
In general, there is a pretty standard approach to shifting from a strictly clinical career to one in hospital administration, including a role as CQO. It involves these basic steps:

Overcome mindset issues
Demonstrate commitment
Utilize mentors
Obtain unpaid real-world experience
Get formal education
Acquire certifications and degrees
Obtain formal or paid experience
Actively pursue a CQO position

It’s sometimes possible to skip a step or rearrange the order. Some clinicians are thrust into a formal, paid position out of necessity and have to address multiple steps concurrently. Some physicians may obtain an advanced degree, such as an MPH, while completing medical school, not realizing it will help them in the search for a CQO job later. But most of us need to follow the steps I’ve outlined.

And there are tactics along the way that help accelerate the process, like joining appropriate associations, obtaining coaching, and networking.

1. Mindset

I’ve previously discussed the issue of mindset and self-limiting beliefs with at least two of my guests – (Episodes 10 and 18). Nina had already overcome that barrier. She was really excited about quality improvement and knew it was something she’d be good at.

2. Demonstrate Commitment

In the hospital setting, in order to be involved in formal and informal QI projects or standing committees, those in charge must understand that you have both interest and expertise. In an absurd example, the president of the medical staff is not going to recommend someone in the finance department to work on quality initiatives due to lack of both of these attributes.

Physicians already have the necessary expertise to get started. We know medicine, epidemiology, statistics, and basic infection control and quality improvement principles. But unless someone in a leadership position knows we’re interested, they won’t seek out our help.

Our interest can be demonstrated in only 2 ways: what we say and what we do.

In my conversation with Nina, I started by asking her if she had talked to the director of the Quality Improvement Department at her hospital. She had not. I told her the director would be the person who'd have the most information about the quality improvement enterprise there.

If there was a chief quality officer, she'd know who that person was, and she'd also know which physicians had been most active in the quality initiatives. If there's no chief quality officer, there might be a medical director or two that were involved in certain projects.

Photo by Dan Gold on Unsplash

And during that conversation, of course, Nina would tell the director that she was interested in working on QI projects, even if they did not involve her specialty. She’d also express this interest to the chair of her department and to the chair of the QI Committee and the president of the medical staff.

She’d also have a conversation within her medical group, to the extent there was a formal QI department or team.

Finally, she’d really demonstrate her interest by consistently attending the meetings, and contributing her input and time to the projects she was working on.

3. Mentors

I told her that based on those conversations, it should be possible for her to identify a mentor or two to begin speaking with. The Director of Quality, generally a nurse with special training, could be one of her non-physician mentors.

The best mentor would be a physician already deeply involved in quality, such as the CQO or medical director for quality. Remember, the typical mentor is generally a step or two ahead of you. I described how to identify and engage a mentor in Episode 4 of this podcast.

If there's no mentor readily available in your organization, it’s possible to identify mentors outside the organization. There are associations that physicians like Nina can join. They provide access to education and certification, but a big benefit is the networking and access to mentors.

The National Association for Healthcare Quality is probably the best known. There is also the American College of Medical Quality.

Another way to find a mentor is by using LinkedIn. Membership is free, so there's really no barrier to joining. On LinkedIn search for PEOPLE with the designation of chief quality officer or medical director for quality. You can filter the list by geographic LOCATION. If there are any reasonably close by, you can start by asking to connect on LinkedIn. Later you can speak with them directly, or even meet them face to face.

Then begin a dialogue, ultimately creating a relationship in which you can ask for advice as you pursue a career in quality improvement.

4. Informal or Unpaid Experience

I suggested to Nina that while speaking with the Director for Quality Improvement, she should inquire about ongoing quality projects that she can help with, and committee meetings she can attend.

The committee structure at a hospital is fairly formal. And each committee has assigned members. Nina was concerned that she couldn’t attend a meeting if she was not the appointed committee representative.

However, I advised her that most medical staff committees can be attended by any medical staff member. Just to avoid potential confusion, it is wise to speak with the chair of the quality committee and the department chair about attending as a nonvoting member because of your interest in quality improvement. You’ll quickly become a regular member.

Doing so demonstrates commitment, offers another opportunity for networking and mentoring, and begins the process of acquiring experience in QI. By observing the chair, you will also learn about planning and running meetings, project planning and working on an interdisciplinary team, all useful leadership skills.

Nina can also volunteer to sit on any formal quality or process improvement teams that her medical group might have. Learning about process improvement is very useful. PI projects are more common in the outpatient office and procedural settings than formal QI projects.

Lean is the term used for process improvement methods originally developed and implemented by Toyota. Lean process improvement uses techniques to reduce waste and improve quality in manufacturing. It’s now been applied to the healthcare setting.

Nina and I talked about learning Lean methods in the office setting, and possibly becoming certified in Lean process improvement. Knowing Lean concepts and procedures is very useful for those interested in quality improvement.

5. Formal Education

This brings us to the next step involving formal education. You can become a green belt or black belt in Six Sigma, another PI methodology designed to reduce variation in care. As noted a minute ago, there are courses in Lean process improvement.

The associations mentioned earlier (NAHQ and ACMQ) provide formal education in quality improvement, as do other organizations:

Institute for Healthcare Improvement
American Association for Physician Leadership (see Episode 24)
Many specialty societies

6. Certification and Advanced Degrees

The NAHQ provides a path to certification in quality improvement through the Healthcare Quality Certification Commission. After obtaining the necessary experience and education, you can take an exam leading to achieve the designation as a Certified Professional in Healthcare Quality. It's a national certificate in quality improvement that demonstrates expertise in the field.

You can take that a step further and complete a master's degree in quality improvement. There are multiple university programs. The AAPL has helped develop a program specifically for physician leaders. It’s called the Master’s in Healthcare Quality and Safety Management (MS-HQSM) offered by Thomas Jefferson University.

I did not discuss this option with Nina during our call. It might be best to wait on pursuing this degree until after working in a formal QI position. That might allow you to get your employer to contribute financially and with time off to pursue the degree.

7. Formal Paid Experience

At some point, you’ll want to get into a formal QI role. If you have enough meaningful experience in quality and safety projects and with the CPHQ certification, you may be able to transition to a full, or near full-time position as CQO or VP for Medical Affairs.

More likely, you’ll split your time between clinical work and quality activities as the Medical Director for Quality in a health plan, medical group or hospital. In the hospital setting, you’ll bridge the gap between clinical and management realms. You’ll be promoting quality initiatives, reviewing quality data, presenting quality reports to medical staff departments, and working with individual physicians to improve their metrics.

During this phase of your career transition, you’ll continue to hone your quality and management skills. You’ll need to focus on leadership skills also, since the Chief Quality Officer serves as a senior level executive.

Therefor, you will need to shift your educational efforts to focus on leadership topics. Organizations such as the AAPL, the American College of Healthcare Executives and the Advisory Board are just a few that offer leadership education that will help you.

Reminder: Think About Your Resume

As Nina pursues her career as a CQO, she should keep in mind that she will be competing with other highly qualified physicians. At some point she’ll be sending resumes to prospective employers.

Those employers will be looking primarily at what this new CQO can do for them. So, they’ll be looking on the resume, and soliciting during the interviews, evidence of what Nina has accomplished.

They won’t put much weight on what committees she’s been part of, or which projects she’s worked on. Instead they’ll be looking for the initiatives she’s led. They’ll be looking for evidence of metrics she’s improved. Did she get length of stay down significantly, or reduce mortality or complications? Has she increased compliance with core measures? Did she help reduce the occurrence of never events?

Keep this in mind as you participate in formal and informal positions. Don’t be a passive participant. Be a leader in these positions. Don’t just remain a committee member. Step up to committee chair when you can. And keep track of the measurable improvements that result when you and your team tackle each quality initiative.

Time to Pursue a Career in Quality Improvement

By following the steps I’ve outlined, you’ll find a CQO position.

It'll be easier if you’re willing to relocate, but if you live in a large metropolitan area, you might not need to.

The job is very rewarding, because you’ll be helping to improve the care of thousands of patients through your efforts. Quality Improvement was always one of my favorite departments when I was CMO.

Quick Review

Let me quickly review the steps I’ve outlined for Nina to follow as she pursues a career in quality improvement.

She should:

Overcome mindset issues
Demonstrate commitment
Find and utilize mentors
Obtain unpaid/informal experience
Get formal education
Acquire certifications and degrees
Obtain formal paid experience
Actively pursue a CQO position

Along the way she’ll find appropriate associations to join, like the NAHQ and AAPL, she’ll network with colleagues, and she’ll take advantage of educational opportunities as they arise.

I hope you found this information helpful. If you have any questions, post them in the comments section below, or contact me at johnjurica@nonclinical.buzzmybrand.net.

Don't Forget to Download Your Free Guide to 5 Nonclinical Careers

As noted earlier, I’ve completed a Free Guide called 5 Nonclinical Careers You Can Pursue Today that outlines the steps for 5 more highly popular careers. It can be found at vitalpe.net/freeguide

Let’s end with this quote from John Ruskin:

See you next time on Physician NonClinical Careers.

The resources included in the podcast are all linked above.

Right click here and “Save As” to download this podcast episode to your computer.

The easiest ways to listen: vitalpe.net/itunes or vitalpe.net/stitcher

The post Follow These 8 Steps to a Career in Quality Improvement – 027 appeared first on NonClinical Physicians.

What You Need to Know About Physician Recruiting Incentives

John Jurica — Wed, 28 Jun 2017 16:33:15 +0000

If you work for a large medical group or hospital system, you may be involved with recruiting physicians or negotiating employment agreements. It’s a set of skills worth learning because so many systems are on a recruiting binge. Salary levels have consistently grown at single digit rates for years. But the type and size of physician recruiting incentives have been more variable.

With the recent release of the Merritt Hawkins 2017 Review of Physicians and Advanced Practitioner Recruiting Incentives, I thought you might like a deeper review of that topic.

When recruiting physicians and advanced practitioners (physician assistants and nurse practitioners), the primary determinant of success in attracting good candidates depends on:

Compensation offered;
Quality of life (location, hours, cultural fit, etc.); and,
Other recruiting incentives.

I addressed compensation and the use of RVUs and salary surveys in Physician Employment Agreements and More on Understanding RVUs.

But it is equally important to understand recruiting incentives that might be offered and how they have evolved in recent years.

Physician Recruiting Incentives May Determine the Outcome

Each physician candidate is generally concerned with a handful of issues when seeking a position.

It might be primarily salary, location and loan repayment. For some, it is signing bonus and salary. For others, it might be opportunity for advancement and retirement plan options.

I once spent over a year in the recruitment of a urologist. He was very meticulous and somewhat demanding, but always cordial during our conversations. He was pleased with the basic components of our offer, which included a standard set of perquisites.

Cystoscope – a urologist's best friend.

Other issues that concerned him were his involvement in setting up the office, interviewing his prospective staff, and helping to create protocols to be used in the office. As a surgeon, he was interested in rapidly building his practice. He wanted assurance that referrals would allow him to perform sufficient surgeries to maintain his skills and prepare for board certification.

We addressed all of these issues during interviews, on site visits, and numerous phone conversations. With urologists being very difficult to recruit, we included a generous signing bonus as part of our offer of employment. Our usual practice was to pay such a bonus when the physician started seeing patients.

In this case, however, we agreed to pay part of the bonus when the employment agreement was executed, many months before he was to start seeing patients. He would receive the second installment when he had successfully been credentialed by our hospital medical staff. We would make the final signing bonus payment once he started seeing patients.

It was this flexibility in structuring payment of the signing bonus that ultimately enticed him to accept our offer.

Let’s take a quick look at the current status of incentives being offered by the almost 3,300 physicians and advanced practitioners that are described in Merritt Hawkins’ review.

Current State of Physician Recruiting Incentives

In spite of efforts to encourage the use of quality or value metrics, the approach to bonus is still heavily productivity based.

Seventy-two per cent of offers included some kind of bonus in addition to a guaranteed salary. Of those offers that included potential bonus payments, 52% were based on RVUs, 28% on net collections, 14% on patient encounters, and 6% on gross billings.

Types of productivity incentives used.

Quality incentives were incorporated into 39% of offers. When used, the quality-based bonuses averaged 20% of the total potential bonus.

Other, very common incentives (over 95% of searches) include:

Relocation Allowance (averaging about $10,000)
CME Expenses (average amount $3600 per year, with a range of $500 – $30,000)
Health Insurance
Retirement Benefits

Disability insurance was also offered most (91%) of the time.

Liability Insurance

Merritt Hawkins included liability insurance as a benefit. But I consider it to be a business expense, as I wrote about in Why Demoralize Your Employed Physicians Over Tail Coverage?.

The review did not list “tail coverage” (extended reporting endorsement) as a specific type of bonus. However, it is commonly disputed in negotiations and should be addressed in future studies, in my opinion.

Signing Bonus and Loan Forgiveness

Signing bonuses were common but not universal (offered 76% of the time). When offered, the average signing bonus was $32,600. However, the range was zero to $275,000. I suspect that last figure was an outlier due to some very unique circumstances.

I was surprised to see that for the MH searches, only 25% included an offer of loan forgiveness, or what we called loan repayment. This is something that is quite common for hospitals in the midwest to offer.

When included, however, the amounts varied substantially. In this report, the amount forgiven or paid was distributed over one to three years, and ranged from $10,000 to $260,000, with an average of $81,000. It’s important to remember that most organization will cap this figure. And the need for loan forgiveness will vary greatly between candidates.

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Summarizing

So, that’s the snapshot of physician recruitment incentives based on the most recent MH survey. You can find the complete summary at Merritt Hawkins 2017 Review of Physicians and Advanced Practitioner Recruiting Incentives.

It all seems pretty consistent to what I have personally found to be true:

Salaries continue to climb for almost every specialty.
Bonuses are generally based on productivity, mostly using worked RVUs to track it.
Quality bonuses are becoming more common, but only account for about 20% of the total annual bonus offered.
Relocation expenses, CME allowance, health insurance, and retirement savings options are common and expected by most physicians.

I was surprised that loan forgiveness was offered in only one-quarter of assignments. I expect that percentage to rise as medical school loan amounts continue to increase.

Cost Considerations for Employers

Physician leaders working in hospitals and medical groups should understand these incentives, and their cumulative costs. With signing bonuses, relocation expenses and loan forgiveness, the first year total compensation costs will be 140% or more of the base salary.

For example, if a family physician or hospitalist is offered a salary of $230,000 to $260,000, he is likely to be provided:

$10,000 in relocation expense,
$32,000 in signing bonuses,
$12,000 in health and disability insurance,
$3,600 in CME expenses,
$7500 in matching 401(k) or 403(b) deposits, and
$25,000 in loan forgiveness.

This will bring the total expense to $320,000 to $350,000 for the first year.

For organizations that are heavily recruiting new physicians, those figures can quickly run into the millions of dollars in costs that will not be recouped for years.

There are some IRS issues that these incentives create. If you pay a signing bonus to a resident before she has officially started, do you report that as 1099 or W-2 income? And physicians being recruited need to understand that all of those bonuses will be treated as income by the IRS and that the amounts actually received may be smaller, due to withholding by the employer.

Next Steps

Please add you're thoughts and questions in the Comments. I will respond to them all.

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Thanks for joining me.

Until next time.

The post What You Need to Know About Physician Recruiting Incentives appeared first on NonClinical Physicians.

Inflated Physician Compensation Prompts OIG Scrutiny

John Jurica — Sat, 17 Jun 2017 17:26:34 +0000

Modern Healthcare recently reported that Mercy Hospital Springfield and its affiliate clinic settled a case with the Department of Justice for allegedly submitting false claims to Medicare (Mercy pays $34 million to settle fraud, physician compensation claims). The case involved allegations of inflated physician compensation at an infusion center.

Modern Healthcare quoted the DOJ: “When physicians are rewarded financially for referring patients to hospitals or other healthcare providers, it can affect their medical judgment, resulting in a overutilization of services that drives up healthcare costs for everyone,” said acting assistant attorney general Chad Readler.

The hospital system acquired the infusion center from a group of oncologists. It was then able to charge hospital based fees and take advantage of 340(b) pricing for its medications. This is a common tactic used by hospitals to access favorable payments from CMS for hospital based services.

Inflated Physician Compensation

The DOJ alleged that the hospital paid the oncologists inflated amounts for management services following the transfer of ownership. This led to allegations of Stark Law and False Claims Act violations, ostensibly for exceeding fair market value and potentially encouraging referrals.

According to a National Law Review article regarding this case, the complaint alleged that “the compensation amount for the physician supervision work at the infusion center was approximately 500 percent of the wRVU for in-clinic work where the physician was actively involved in patient care… was not fair market value, nor was it commercially reasonable.”

Mercy agreed to pay $34 million to settle the lawsuit.

I addressed a similar issue in a popular post in 2016 (Physician Salaries and OIG Risk). I am re-publishing the content here for new readers. The previous article addresses inflated salaries. But the tactic of paying inflated management fees in order to maintain referral patterns has the same effect.

Pitfalls Involving Salary Surveys and OIG Allegations

I have been following news reports about recent OIG (Office of Inspector General) investigations related to physician compensation. These investigations have resulted in fines for alleged Stark Law and FCA (False Claims Act) violations. There seems to be more activity recently, including investigations in response to whistle-blower lawsuits.

Here is my take: Hospitals and health systems that use survey data (such as MGMA and AMGA) to set compensation levels for newly employed physicians are under intense scrutiny. This scrutiny results because:

it appears that collections generated by the employed physicians do not support the salaries being provided, or
salaries of newly employed physicians significantly exceed compensation previously generated in their independent practices.

The Stark and FCA regulations require that physicians that care for Medicare patients not be paid for referrals. And health systems must pay employed physicians based on fair market value. In the past, it was assumed that direct evidence of payment for referrals (e.g., emails, memos, board meeting minutes, etc.) was needed in order to demonstrate such a violation.

More recent cases seem to indicate that indirect evidence can support such an allegation. If a practice is not profitable, and a hospital system continues to pay a physician in spite of losing money on the practice, the OIG will infer that such losses are only being allowed as a result of referrals.

Example

It is fairly common for a procedural specialist such as a cardiologist or orthopedist to be paid at the median salary survey level. This may hold true even as their collections and worked RVUs only reach the 25th percentile or less. This may represent a loss to the practice in excess of $100,000 per year.

I once asked a physician that was unable to build a practice to leave our medical group, in part because of his inability to generate the income needed to justify his salary (in spite of years of aggressively marketing his practice).

Such losses may be acceptable in situations where the system is the only provider of important services. But if board members or executives indicate that such losses are balanced by “downstream” services like imaging and surgical care, the OIG may interpret that as a violation of Stark and FCA regulations.

Recommendations

What can you do to reduce this risk as you hire new physicians into your medical group? Here are five suggestions:

Be aware of these issues and NEVER imply that your system can afford to pay a higher salary because of “downstream revenues.” Instead, focus on the actual patient encounters and procedures that the new physician must provide to generate collections needed to cover her salary.
Once hired, assist new physicians with marketing themselves. They need to build visits and worked RVUs as quickly as possible. Your organization can allow for a negative bottom line for a practice initially, but must strive for a financial break-even after a year or two.
Work closely with the billing office and teach new recruits about billing and coding. They must learn to appropriately capture the payments for the work that they do.
Provide employed physicians with regular (at least quarterly) reports listing the following: encounter volumes, coding distribution, billings, collections, worked RVUs and income and expenses for the practice. Teach physicians how to interpret these reports.
Require your management team to meet with their physicians regularly. During such meetings review their reports, track their performance, define goals for the practice and develop joint plans to meet those goals.

With teamwork, clear communication, and effective goal setting and execution, you should be able to:

build a practice for your new physicians that they can be proud of,
reach a financial break-even, and,
avoid allegations of Stark and FCA violations.

[Disclaimer: I am not an attorney and I do not provide legal advice. I offer advice about management and leadership topics that can assist physician executives in addressing common management issues. You should always engage a qualified attorney in negotiating and executing employment agreements with physicians and in evaluating your organization's potential risk for OIG investigations related to physician employment.]

Summary

When recruiting highly trained proceduralists, it's easy to forget that their salaries cannot be linked to downstream (e.g., imaging and facility-driven) fees. There must be a reasonable relationship between the direct patient care revenues and expenses, and their compensation.

Is this a challenge for your group practice or health system? How have you addressed it?

What other employment issues have you had to address in your organization?

Until next time.

John Jurica

The post Inflated Physician Compensation Prompts OIG Scrutiny appeared first on NonClinical Physicians.

Failure Promotes Discovery and Breeds Character

John Jurica — Sat, 15 Apr 2017 12:23:14 +0000

I was awakened at 2:30 AM by the ringing of my home telephone not two feet away. It was startling and disorienting. My “land-line” never rang at night. And my wife and I rarely answer it because only telemarketers call us on that phone.

But my wife answered. She determined that the caller wanted to speak to me. After clearing my head for a few seconds and focusing on what the caller was trying to tell me, I finally heard:

“This is Maya. I am calling to tell you that my father, Kan, died earlier this week.”

I quickly apologized for not recognizing her more quickly. She apologized for calling in the middle of the night (it was 4:30 PM in Japan where her call originated).

I thanked her profusely for informing me and expressed my condolences. I told that her father was truly a good friend and special person who would be sorely missed.

Digesting the News

Returning to bed, I was unable to sleep for several hours. I dozed for an hour or two, then got up at 5:30 A.M. and had a cup of coffee.

Shake out the cobwebs.

Kan and I met when I was working as a food chemist at Kraft Foods Research and Development in the late 1970s. I had graduated with a bachelor's degree in chemistry and started working at Kraft shortly thereafter. During my orientation, I met another newly hired food scientist, Thomas Stratton, Ph.D.

I didn’t meet Kan until some months later when Tom arranged a meeting of the three of us to discuss rooming together. I was the youngest and least educated of the three of us. Kan was also a Ph.D. chemist.

At our meeting, Kan seemed to be an aloof, highly intelligent scientist. After a short conversation, we agreed to work out an arrangement in which we would rent a house together less than a mile from Kraft R & D in Glenview, Illinois.

Having grown up as the oldest of ten children, I had developed some independence. I had been working since I was 12 years old (sweeping floors in the Catholic grammar school I attended). I saved my money, put myself through college with a little help from my grandfather and was financially responsible for myself throughout.

But I was still living at home. So at 22 years of age, I was ready to move out. Living in a four-bedroom bungalow with my parents, two brothers and seven sisters, all sharing two bathrooms, was a strong incentive to get out.

It was one of the best decisions I ever made.

Time to Move Out

Following that initial meeting, we found a large two-story house and the three of us arranged to rent it, sharing all of the expenses equally.

A Glenview home.

Needless to say, I came to know Kan very well. At twenty-nine years old, he was a brilliant, intense, traditional Japanese gentleman. He was also inquisitive and at times eccentric.

A Unique Roommate

He taught me to appreciate Japanese cuisine, eat gohan (rice) with hashi (chopsticks), and cook Tonkatsu.

He was intensely committed to learning, and fascinated with computing. Having obtained the 8080 and earliest 8086 microprocessors, he built his own desktop computer, and began programming.

He wanted to be ambidextrous, so he stopped using his right hand and forced himself to do everything with his left hand for several months.

I learned that while in graduate school he wanted to learn piano. So he used his knowledge of music from his early school days and began playing and memorizing Beethoven's Moonlight Sonata, one measure at a time. Within 10 months, he was able to play it flawlessly.

Self taught piano.

That taught me that anyone can learn a new hobby or vocation.

He was the consummate skeptic, always asking “why?”.

I remember one day I suggested that he wash his car. It literally had several years of dust and dirt that had accumulated since he bought it. We had a frustrating conversation in which I explained that it was best for the longevity of the car that it be kept clean.

But he repeatedly asked “why?” “What was the purpose?” The finish would be unaffected by not washing it. And the time devoted to keeping it clean could be spent doing more important things like programming, cooking or playing the ancient Japanese game Go.

I learned acceptance and detachment from Kan, and to remain curious.

His courage to move to another continent and create a new life, while maintaining connections to his old life in Japan, taught me how to conquer fear.

He taught me the value of experiencing other cultures. Getting to know Kan was like spending a year partially immersed in another culture. I was only 22 years old and soaked it up.

Living Together

Our agreement was that each of us would do all chores and evening meals for a week at a time. So, every third week, Tom and I got to enjoy home cooked Japanese meals. The other weeks we would feast on Tuna Noodle Casserole (one of Tom’s favorites) or meatloaf, corn and mashed potatoes (my version of my mother’s cooking).

That same week of cooking, I would spend a little time each day, sweeping, replacing paper towels and toilet paper, stocking the refrigerator, vacuuming and picking up the 2-story house.

I learned about teamwork, responsibility and hard work.

During that time together, we shared wins and losses, good times and bad, like brothers. Together, Tom and Kan helped me by providing perspective when my first serious relationship ended, by listening and sharing stories about their break-ups.

It was an experience of a lifetime that would never be repeated or equaled.

Failure Promotes Discovery

I never would have worked at Kraft, never would have met Kan and Tom, never would have experienced the maturity and wisdom of two older surrogate “brothers,” if not for one massive failure:

Being rejected by all of the medical schools to which I had applied.

My entire high school and college career had been focused on getting into medical school. At the time, it was the thing to do if you had a high grade point average and a bent for science. But it was also my family’s dream for me, and my dream for myself.

I was placed on a waiting list, but ultimately denied admission. So, I needed to get a job, save some money, buy a car and contemplate my next career move.

That's when I saw the ad for a food chemist at Kraft, and applied.

Failure Breeds Character

I cannot fully measure the positive impact of my experiences during the two years between graduating from college and beginning medical school in the fall of 1979. When I entered medical school, I was still an immature, sheltered, lower middle class kid with a lot to learn.

But I was much better prepared as a result of my time with Kan and Tom.

We never know how life will shape and mold us. But it is the rare “failure” that doesn’t teach us an important lesson.

It is best to embrace our failures, learn from them, and overcome or transcend them.

Moving On

Kan left his food science career shortly after I left for medical school. He transitioned to his true love: computer programming. He designed arcade style coin-operated video games in the early 1980s for D. Gottlieb & Co. These were the “old school” video games that replaced pinball machines. He was the proud creator of Mad Planets.

One of Kan's creations.

He later developed computer programs used by other computer programmers, and sold and supported a suite of software tools for almost 30 years.

Losing Touch

Kan and I did not keep in close touch over the years. We moved away from each other. He married and had three children. I married, attended medical school and residency, divorced and remarried.

I visited him on occasion. He and his wife visited us a few years ago. I spoke with his daughter about her career plans on the phone.

As he became older, he developed some medical problems and moved back to his home in Japan. We followed each other via Facebook.

I was saddened by his passing. But I never got the impression that he feared or dreaded death. He was fascinated by his illness and the beneficial effects of his home oxygen. He spent his last days with his family and friends, playing Go, and posting his oxygen levels as his illness progressed.

I believe he was satisfied with his life.

I know that I was privileged to have been a part of it.

And it was all due to a massive “failure” in mine.

The post Failure Promotes Discovery and Breeds Character appeared first on NonClinical Physicians.

Does An Executive Salary Stand Up to a Clinical Salary?

John Jurica — Mon, 30 Jan 2017 14:00:23 +0000

One of the things that was nice about being on the executive team of a hospital was the possibility of making a year-end bonus. The bonus was generally tied to achieving four or five organizational goals, but we had a good team and we generally received 70 to 80% of the monies that we were eligible for each year. The bonus was usually paid in March. Including the bonus dollars, my annual executive salary was well above my previous clinical salary.

One of the questions that any physician thinking about a career as a healthcare executive will consider is: How well will I be compensated? It is probably not the most important question. But it can be a concern for a mid-career physician thinking of making the transition. A reduction in income may not be acceptable, even if it is only temporary.

Like any decision, this question can be difficult to answer, because there are so many variables. But let’s look at this question and see how the finances might play out.

Executive Salaries

First, let’s look at recent information regarding the salaries of physician executives. According to the most recent survey collected and published through a joint effort of Cejka Executive Search and the American Association for Physician Leadership, here is what we know about the current state of salaries for physicians executives.

The average salary for a physician in a leadership position was $350,000.
The highest-paid cohort of physician executives earned $499,000 and included executives with titles such as Chief Strategy Officer, Chief Innovation Officer, and Chief Integration Officer. These are obviously not the traditional CMO nor VP for Medical Affairs.
Physician CEOs had an average annual income of $437,500.
Chief Medical Officers earned $388,000 per year.
The Chief Quality or Patient Safety Officer earned $375,000.
The Chief Medical Information Officer had an average salary of $372,500.

Clinical Salaries

Now let’s look at average salaries by medical specialty for clinicians. I will present the recent Medscape Physician Compensation Report for 2016 for averages for physicians in the following specialties. There are other surveys available, and various levels of granularity in the data. But the numbers shown below are a pretty good estimate of average salaries.

These salaries will be affected by how many procedures are being done, how many days are spent in the office and how much emergency call is taken (for the pertinent specialties). Comparing the above statistics and graph, it is obvious that anyone practicing a primary care specialty, or a medicine subspecialty, may well make significantly more income by moving into an executive position.

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Work – Life Balance Considerations

Just as there are on-call and other quality of life considerations with regard to clinical medicine, such considerations affect the executive's role.

An executive position is not a 9 to 5 job by any means. I had administrative call – about once every 8 to 10 weeks, for a week at a time. The call was rather easy, helping managers and directors solve problems that came up during off-hours.

There were frequent dinner meetings and weekends spent in board retreats and strategic planning retreats. However, overall, I think the quality of life for an administrator can be much better than that of a busy physician. Most of my physician colleagues are on call every third or fourth day, or making hospital or nursing home rounds on weekends or after office hours. Most surgeons of any type work longer hours than the typical physician executive.

Educational Costs

Finally, there are some upfront costs to consider when selecting this new career path. Here are some of the likely upfront and ongoing costs.

Membership in the AAPL is $295 per year.
There is course work in the areas of finance, leadership, management, quality, etc. A three-day live course through the AAPL will run about $2,000 to $3,000. A good cross-section of leadership and management topics would consist of the equivalent of three or four such meetings. This may be subsidized by your medical group or hospital employer if you're already involved in committee work.
You may seek an advanced degree, such as an MHA, MBA or MMM. The MBA can run from $20,000 to $80,000 or more. The Executive MBA provided by the University of Illinois has a cost close to $100,000. The cost of a straight MBA at a top 20 graduate school will generally run $30,000 to $60,000. In a small private university, near my home, the cost is $24,000. The Masters in Medical Management involves similar costs. Some online MBA programs can be completed for under $20,000.
Completing the CPE (Certified Physician Executive) will cost another $3,000 after all prerequisites are met.

Conclusion

The salary considerations definitely should not be a barrier to considering a job as an executive, unless one is a very highly compensated cardiologist or orthopedist. The quality of life will probably be better than that of most clinicians.

For several primary care specialties, a shift to executive leadership may result in a sizeable increase in salary compared to the typical practitioner. However, there may be upfront costs such as the cost of acquiring an advanced degree or completing a certification, such as the CPE.

I previously listed the four steps to take before choosing a management career. Now is time to do the cost-benefit analysis. The costs to obtain the necessary background education, and possibly an advanced degree, are significant. But, besides the increase in salary I experienced, the intellectual challenges and excitement of mastering a new field more than offset the financial and time commitments required.

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The post Does An Executive Salary Stand Up to a Clinical Salary? appeared first on NonClinical Physicians.

Why Demoralize Your Employed Physicians Over Tail Coverage?

John Jurica — Sun, 01 Jan 2017 17:11:33 +0000

I was sitting across the table with a new family physician recruit for the third time. He was a particularly challenging recruit to work with, but we really needed family physicians. We had added several physician assistants and nurse practitioners and we needed qualified primary care physicians to collaborate with them. We were back to discussing tail coverage.

I had explained to the candidate that it was our practice to require tail coverage to be covered by the physician. It was one of the ways that we used to promote longevity of the relationship. We would be willing to waive the requirement in the event that we decided to terminate the agreement without cause, or if the candidate became disabled or died (to protect his or her estate). But those were the only exceptions.

He ultimately accepted the terms, after negotiating a higher sign-on bonus and student loan repayments. But I could tell he was unhappy about the tail coverage issue.

Attracting Good Candidates

Before you hire a new physician, you must first recruit viable candidates and then negotiate an acceptable employment agreement.

The recruitment process can be lengthy and costly. During the process, you will try to convince the worthwhile candidates that together you will have a long and prosperous relationship. You will attempt to project a welcoming, supportive and collaborative work environment.

But the demoralization begins during the negotiation process itself. There is one contentious legal provision that many employers continue to wage war over. It concerns the issue of placing the responsibility for payment of tail coverage (also called an extended reporting endorsement) on the new employee in the event he or she leaves the organization in the future. I gave the prospective candidates a review of this at Contract Doctor: Who Pays for Tail Coverage?

Why Do Employers Continue to Fight for This?

The cost for tail coverage can be quite high. I’ve seen rates of 50% to over 200% of the current annual premium amounts. The cost starts out very low during the first few years of practice, but quickly rises and reaches a plateau in a well established practice. It can easily reach $100,000 to $200,000 or more.

And employers would rather not pay it.

This is a cost that only occurs when the physician leaves, so there is no income to offset the cost (other than some residual accounts receivable). No more surgical procedures or consults. No more referrals for MRI or CT scans.

Because the cost is variable, it is difficult to predict. And it is not something an employer typically plans for. If several physicians leave at the same time, it can result in a huge bill to the employer.

It is also a potentially very powerful incentive to prevent physicians from leaving. Who would want to pay a $200,000 penalty for resigning? The employer is then spared the trouble and cost of recruiting a replacement.

Hospitals already lose money on physician practices (averaging over $100,000 per physician per year). It is a hard pill to swallow to shell out six figures when employed physicians that are just hitting their stride decide to move on.

It is especially annoying to pay the tail coverage when the physician is forced to leave after being dropped from Medicare or losing his or her license.

Why the Tail Coverage Conversation Is Upsetting

Let me explain to my non-physician colleagues, including the CFOs out there, why this issue is so demoralizing…

First, the majority of new hires are young physicians. While they understand the concept of medical malpractice and using insurance to mitigate its effects, most of them have never had to think about the reality of paying for it. And they certainly never needed to think about the consequences of not having tail coverage.

Then, here they are, having lived frugally for years, often with upwards of $200,000 in debt. And the new employer, a multimillion dollar organization, is trying to convince them that this future financial cost, that may be 5 times their current salary as a resident or fellow, will be their responsibility if things don't work out.

This does not create a warm, fuzzy feeling.

Also, it is literally impossible to work as a physician without liability coverage. The coverage is clearly a cost of doing business. Insurability is always a condition of employment. Appointment to most hospital medical staffs requires an agreement to purchase tail coverage when you leave.

The physicians are in the midst of the negotiation, trying to move forward with an employment agreement, being told that they're going to love working with your team. Meanwhile, you're trying to convince them that this is the way your contract works and is non-negotiable.

As a hospital executive involved in dozens of contract negotiations in the past, I can attest to the frustration and confusion this causes in candidates. I am sure we lost some good ones over this issue. And I know we started a long-term relationship off on the wrong foot.

Why Employers Should Abandon This Practice

This whole discussion is irritating and illogical. Accepting the responsibility for paying for tail coverage will, no doubt, have financial implications. But there are better ways to encourage long-term retention. And the financial consequences can be mitigated and planned for.

It is possible to actuarially predict the future costs of paying for it. You may need to adjust down loan repayment incentives or sign-on bonuses. But taking tail coverage off the table will actually be a competitive advantage when recruits compare your offer to organizations that still insist on saddling them with the uncertain cost of tail coverage.

Has your organization already abandoned this approach? Let us know in the Comments.

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The post Why Demoralize Your Employed Physicians Over Tail Coverage? appeared first on NonClinical Physicians.

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