What goes into your compensation figure?

Your compensation will vary according to personal and situational factors and nationwide trends. Here’s what you need to know and expect.

By Scott Files | Fall 2016 | Vital Stats

 

In today’s competitive market, physician compensation can vary based on a variety of factors. The Affordable Care Act has created an increased need for physicians in all specialties, but knowing what to expect when it comes to compensation can be difficult. Of course experience affects what you’re worth to an employer, but there are other factors, too, including location and demand. And you have factors to consider beyond salary—signing and performance bonuses will also affect your overall compensation.

Physician compensation in high-demand specialties

Based on a national sample of physician and advanced practitioner searches, Merritt Hawkins’ 2015 Review of Physician and Advanced Practitioner Recruiting Incentives provides an indication of the types of physicians currently in greatest demand, along with the types of medical settings in which they are recruited.

The chart below shows the average compensation package for physicians for that survey’s top four most in-demand physician specialties, not including production bonuses or benefits.

As you can see, compensation ranges vary widely, even within specialties. For example, a family practice physician can expect an annual salary range between $130,000 and $330,000, with an average of $198,000 per year. The upper and lower limits of this model differ by more than 250 percent, further demonstrating that other factors are in play when determining overall compensation.

Other factors that affect compensation

What are those other factors? To varying degrees, all of the following developments have had an impact on the recruiting incentives offered to physicians:

  • Continued expansion of the Affordable Care Act
  • The accelerating closure of rural hospitals
  • The implementation of population health management through integrated organizations, such as accountable care organizations
  • The expansion of telemedicine, with one third of physicians now using some form
  • Increased scope of practice and demand for advanced practitioners, such as PAs and NPs (NPs can now practice independently in more than 20 states.)

The health care system continues to evolve, but whether care is delivered in small, independent and unconnected silos, orin vast, integrated health systems, and regardless of whether volume or value is rewarded, physicians will be the paramount providers of care and drivers of health care economics.

According to the Boston University School of Public Health, physicians receive or direct 87 percent of all personal spending on health care in the current volume-driven system through hospital admissions, test orders, prescriptions, procedures, treatment plans and related activities. The total combined economic output of patient care physicians in the U.S. is $1.6 trillion, and each physician generates a per capita economic output of $2.2 million while supporting approximately 14 jobs, according to the American Medical Association’s 2014 Economic Impact Study.

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Final thoughts

As a practicing physician, you have lots of options regarding your career. Keep in mind that your skills are in high need, and compensation will vary. The key takeaway is to make sure that you are informed on the recruiting incentives that are being offered in the area where you would like to practice.

There is always room for negotiation, and benefits—including longer vacation time and performance bonuses—can also be factors in determining which type of positions are more in line with not only your career aspirations, but also your specific lifestyle.

 

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Signing a letter of intent

How does a letter of intent differ from an employment contract? We break down what you need to know.

By Kyle Claussen, J.D., LLM | Fall 2016 | Legal Matters

 

A letter of intent (LOI) or “offer letter” outlines the terms of employment in a much simpler format than what will be presented in a contract. The LOI is a preliminary document based on the mutual interest and good faith of both parties. It acts almost as an informal promise between you and your future employer and can be an important mental step toward solidifying an employment agreement. As helpful as an LOI can be in giving you a sense of the terms of your full contract, you do need to scrutinize the components of the LOI before signing. Here are some of the potential pitfalls of signing an LOI without proper review.

Know: What you’re signing

Generally, an LOI will not be legally binding. It references a future employment agreement that will effectuate employment. There are instances, however, in which certain provisions within the LOI can, in fact, be legally binding. These provisions may include that you will negotiate exclusively with this employer for some period of time or that the negotiations will remain confidential. It’s easy to assume that, because the LOI is less formal than the contract, you can just sign it and look at the contract terms more closely later. This can be a critical mistake, however, because it may cost you leverage when you negotiate some of those major employment terms down the road. Do not sign an LOI unless you are certain that key outlined components such as compensation will meet your needs.

Here is an example of an explicit statement included in an LOI that ensures it is not binding:

“The proposed terms of this letter of intent are non-binding and for discussion purposes only. It is the intent of the parties that these terms and conditions may be modified or changed, in whole or in part, pending a binding agreement to be negotiated and executed by the parties. Furthermore, nothing in this section shall be interpreted as obliging any of the parties to enter into any agreement.”

Check: Is your LOI tailored to you?

An LOI or contract may work for one physician and be totally incompatible for another. When looking at an LOI, it may be difficult to determine whether it’s based on a one-size-fits-all contract. Look out for provisions that don’t reflect the actual position or match your scope of practice. Reusing contract and LOI templates is a much more common practice than you may think. You will typically be able to discern how individualized your LOI is by how well the key terms in the letter seem to match your specific situation.

Understand: What’s not included

Remember that an LOI is not a comprehensive list of the terms of your employment. LOIs are typically composed of the highlights of an employment agreement, such as pay, benefits and length of contract. That means terms with a more negative connotation, such as termination provisions, will be saved for the contract.

One of the important terms that may be missing from your LOI is a noncompete agreement. Noncompete clauses, or restrictive covenants, prohibit a physician from practicing within a certain geographic area after leaving a practice. For example, being restricted from practicing within a 60-mile radius for two years may be more reasonable for a neurosurgeon than a family physician.

Another value point that may not be addressed in the LOI is malpractice tail coverage. Malpractice tail coverage is an extended reporting period endorsement, offered by a physician’s current malpractice insurance carrier, allowing you to extend coverage after you leave a practice. If you have a less expensive “claims-made” policy, then either you or your employer must purchase tail coverage upon termination of employment. If you have the more comprehensive “occurrence-based” policy, then you have malpractice coverage for any claim brought against you as long as you had that insurance carrier during the alleged event.

Know: You can still negotiate

As mentioned previously, an LOI generally won’t be binding on major terms. However, some employers will still see the agreement as a promise, and therefore it can be hard to go back and change or negotiate certain provisions later. Some employers feel as though signing an LOI means making a deal, but remember that signing does not obligate you to fulfill any LOI provisions that are not legally binding. Contract negotiation is not just a mere formality after you sign the letter of intent—it is a legitimate chance for you to adjust any part of the contract that doesn’t meet your needs.

The letter of intent is an important step in moving closer to employment. After you have taken a critical look at the LOI, considered potential pitfalls and signed it, try to begin the formal contract review and negotiation process as soon as possible. The LOI plays a central role in building momentum in the hiring process, and you don’t want the process to slow down or take up any more time than necessary.

Kyle Claussen, J.D., LLM is vice president at Resolve Physician Agency, Inc.

 

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Navigating the rapid growth of telemedicine

Telemedicine is a useful way to practice medicine, but physicians need to be aware of legal and regulatory issues regarding licensure, credentialing and malpractice liability.

By Jeff Atkinson | Fall 2016 | Reform Recap

 

Telemedicine is on the rise. From 2013 to 2015, the number of people using telemedicine increased from 10 million per year to 15 million, according to the American Telemedicine Association. More than half of U.S. hospitals use some form of telemedicine, and insurers are adding telemedicine coverage too.

There are multiple definitions of telemedicine (sometimes referred to as telehealth). The Centers for Medicare & Medicaid Services in its Medicaid regulations states:

Telemedicine seeks to improve a patient’s health by permitting two-way, real-time interactive communication between the patient and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.

Cost-effective visits

Telemedicine is viewed as a cost-effective alternative to face-to-face meetings. It can be particularly important for providing care in rural areas and for patients who have mobility problems. Telemedicine may also encompass remote diagnostic services such as interpretation of imaging studies. Telemedicine is not a distinct specialty, but a method of delivering service.

Telemedicine has been found to be useful in many settings and situations, for instance:

  • For geriatric patients, a televisit may eliminate the need for hospitalization or a trip to the emergency room. This is particularly useful for patients in assisted-care facilities or nursing homes.
  • For patients who have access only to small community hospitals and need expertise beyond what those hospitals offer. In some cases, live consultations with physicians in larger hospitals could prevent these patients from needing to be transported to larger hospitals.
  • For patients who prefer the conveniences of being at home—or want access to medical help at late hours and on weekends—telemedicine provides an opportunity for them to consult with health care providers. In some cases, they can even attach medical equipment to their computers or telephones to transmit information to the providers. University of Iowa Health Care offers such a service to residents of the state via computer, tablet or smartphone, and patients pay a flat fee of $50 by credit card.

Variation in state laws

State laws vary considerably when it comes to telemedicine. A 2015 survey by the American Telemedicine Association reports that, regarding licensure and standards, “22 states averaged the highest ‘composite grade,’ suggesting a supportive landscape that accommodates telemedicine adoption and usage.” Twenty-six states and the District of Columbia were rated “in the middle with room for improvement,” and two states were described as having “many barriers for telemedicine and advancement.”

Texas and Alabama are the two states with the highest barriers. Texas’s barriers include a regulation by the state medical board that requires an in-person physical exam before telemedicine can be utilized. This regulation is being challenged under federal antitrust laws. A trial court enjoined enforcement of the regulations, and the state is appealing the decision (Teladoc, Inc. v. Texas Medical Board, 5th Circuit Court of Appeals, appeal docketed Jan. 8, 2016). Critics of the Texas regulation say the regulation stifles competition and interferes with access to care, particularly in remote areas of the state.

States with laws or regulations that are friendlier to telemedicine do not require in-person visits as a precondition to telemedicine services. Laws in some states require insurance companies to pay for telemedicine on the same basis as face-to-face diagnosis and treatment (when telemedicine services are an appropriate standard of care for the issue at hand). Such laws are sometimes referred to as “telemedicine parity laws.”

Medicare and Medicaid will pay for telemedicine services, although in the case of Medicare, payment is often limited to services provided to rural Health Professional Shortage Areas. There are proposals before Congress and regulators to expand the telemedicine services for which government programs will pay.

Information on state laws pertaining to telemedicine can be obtained from the American Telemedicine Association State Policy Resource Center.

Malpractice issues

An aspect of parity relates to medical malpractice issues. A physician who engages in telemedicine in a state outside the state of the physician’s office will be deemed to have submitted him- or herself to the laws of the state in which the service is rendered, according to the American Health Lawyers Association.

Physicians practicing telemedicine out-of-state (or perhaps in a different area within their state) should consult with their malpractice insurance carriers regarding scope of coverage. Insurance rates may be different when practicing in more than one state.

In addition, informed consent from a patient should include discussion, when applicable, of the limitation of telemedicine compared to in-person visits.

Licensing and credentialing

Physicians considering using telemedicine to deliver care also need to be aware of licensing and credentialing issues. Many states require that, in addition to being licensed in the state where his or her office or hospital is located, the physician who delivers diagnosis or treatment via telemedicine must also be licensed in the state where the patient is located. The license may need to be a full license to practice medicine (such as in California), or it may be a limited license for telemedicine only (such as in Louisiana and Minnesota).

A related issue is credentialing. The Joint Commission on Accreditation of Health Care Organizations (JCAHO) allows, in some circumstances, an institution to rely on the accrediting process of the telemedicine provider if the provider’s institution is accredited by the JCAHO.

Communications technology has enhanced many aspects of life—health care included. In the decades to come, we can expect to see a continuation in the rapid growth of telemedicine.

Jeff Atkinson teaches health care law at DePaul University College of Law in Chicago.

 

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PracticeLink is a physician’s career resource

Wondering how PracticeLink can help you? Our physician relations manager explains what PracticeLink offers to job-seeking physicians.

By Brian Brown | Fall 2016 | PracticeLink Tips | Uncategorized

 

For more than 15 years, PracticeLink’s physician relations team has worked closely with physicians as they search for their first or next practice. Our physician-centered team is trained to help you navigate the job-search process and be a trusted lifelong career resource. More than 5,000 facilities representing more than 28,000 opportunities nationwide post their jobs on PracticeLink.com. We are proud to be the most widely used physician recruitment resource in the industry!

The in-house recruiters who post jobs on PracticeLink pay to post their opportunities, so PracticeLink is always free for physicians to use and enables you to connect directly with the employer. We are not third-party recruiters; we put you in direct contact with the employer or hiring organization.

What does PracticeLink do?

PracticeLink.com lets you easily search for a new practice by specialty, profession, geography, keyword and more. It is an easy, fast and free way to search and apply for jobs that interest you.

More than 80,000 residents, fellows and practicing physicians also receive PracticeLink Magazine, which features quarterly themed content that coincides with your job-search needs: Contracts & Compensation, Quality of Life, Job Search and Interview.

PracticeLink also hosts physician job fairs. At each event, we provide an educational seminar based on our 10-step timeline, “When to Do What in Your Job Search.” Find our upcoming job fairs at PracticeLink.com/JobFair.

Connect with us!

Start browsing jobs confidentially on PracticeLink.com, or create a free account for additional benefits, such as applying to jobs with one click; easily creating, saving and sending your CV to recruiters; and receiving alerts when new or updated jobs are posted in your specialty. We look forward to being able to help you manage your job search and find your dream practice!

Contact the team for free job-search help at (800) 776-8383 ext. 2, PhysicianRelations@PracticeLink.com, or PracticeLink.com/Physicians.

 

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The anatomy of a physician contract

Your employment contract can make or break your practice experience. This guide demystifies its terms—teaching you what to consider, what to negotiate and when to get a lawyer.

By Karen Edwards | Fall 2016 | Feature Articles

 

The contract looked good. Great, in fact. Compensation, vacation, even health insurance—all good packages—but before the physician signed on the dotted line, he consulted an attorney, Gary Sastow, J.D., with the New York-based law firm Brown, Gruttadaro, Gaujean & Prato.

Good thing he did.

If the contract had been left as it was, the physician would have been burdened with $160,000 of tail coverage upon leaving the practice. And he would have been responsible for paying all of it.

The biggest problem plaguing physicians when it comes to contracts, according to Sastow, is that they’re concerned primarily with only one part of a contract. “They want to know how much they’ll be paid,” he says. Though compensation is a significant part of any contract, it’s not the only part, and let the physician beware if he or she doesn’t keep the other sections in mind as well.

A rise in physician employment

Vaagn Andikyan, M.D.

Determining what aspects of a job are the most important to you will help you know where to spend the most time and energy in your contract review. For Vaagn Andikyan, M.D., a New York gynecologic oncologist, a non-negotiable restrictive covenant became a deal breaker. · Photo by Shaina Diaz

Let’s face it: These days, most physicians are looking at employment contracts. A recent report from the consulting company Accenture states that only one in three physicians will be in independent practice by the end of 2016. The report also states that the number of physicians in private practice declined from 57 percent in 2000 to 49 percent in 2005, with most of the physicians who left private practice seeking hospital employment instead.

For some time, physicians drove this trend as they sought to escape long hours, risky revenue streams and increasing regulations, but the 2010 health care reform legislation that gave rise to accountable care organizations also gave hospitals and physicians new incentives to work together. That means today’s physician is likely to be an employed physician, and that, in turn, has greatly increased your need to have at least a rudimentary understanding of employment contracts.

Today the average hospital employment contract is between 20 and 30 pages long and has been prepared by the hospital’s attorney, says Sastow. In other words, there’s a lot of confusing legal jargon that could trip you up, and, Sastow adds, the hospital’s attorney will have written the document to the employer’s advantage.

Gregg Bertram, founder of Pacific ADR Consulting, which handles mediation and arbitration disputes for clients, echoes Sastow. “The contract is not a neutral document,” he says. “Don’t assume it’s harmless.”

Evaluating your contract

So when you’re handed an employment contract, how do you proceed?

“Start any contract review by asking yourself first what you want from the contract and from the job. What’s important to you: Is it your schedule? Your track for advancement? Focus on your career goals, the lifestyle you want to create, and then you can better decide what things you want to negotiate,” says Mathew Parker, J.D., of the management-side labor and employment law firm Fisher Phillips.

Hospitalist Vanessa Frost, D.O., says she prepared a top-three list of things she wanted from a job, and that included pro-rating her sign-on bonus over a two-year contract—advice she received from a mentor. “That way, at the end of the second year, you only owe half of the bonus if you decide to leave. You’ve worked off the other half.”

Once you determine your top priorities, your next step is to look over the contract.

“Some people never read the contract they’ve been handed,” says Sastow.

It’s true many hospital contracts are more or less boilerplate documents, especially for new physicians, says Derrick Handwerk, managing partner of Handwerk Multi Family Office, a Philadelphia wealth management consulting company. Still, he says, “it’s a good idea to know what’s in them before you sign on the dotted line.”

Contract anatomy

Most physician employment contracts follow a similar structure, and though you’ll want to pay attention to the whole contract, the following sections are ones that may deserve special scrutiny:

Job Location and Job Description. “Every contract should have in it a list of your job responsibilities and duties,” says Sastow. And the contract should be as specific as possible—not only in your job description, but also in where you will work and what hours you’ll work.

Sastow says he will put in the specific address of the facility or facilities where his client will work—office locations, hospital locations, clinic locations, whatever might apply. That’s because an employer may close an office location, for example, and want to transfer its staff to a satellite clinic in a nearby town—or, if it’s a multiple-state entity, to a location in a different state entirely.

“There is a lot of consolidation going around,” says Bertram. A move, whether it’s 45 minutes away or several hours away, can have a significant impact on not only the physician’s lifestyle but also his or her wallet. “Be alert to these sections,” says Bertram. “If you are signing with a hospital that has multiple locations, it’s important to nail down the locations where you’re expected to work and ask for notice if they do plan to move you.”

Vaagn Andikyan, M.D., a New York gynecologic oncologist, says he looks for work locations in contracts. “It’s important to look at them before you sign, because you could find yourself spread too thin if the hospital or practice has more than one location and expects you to work at all of them,” he says.

The employer still has the option of making that request or transferring physicians, but if the contract lists specific addresses, such moves are likely to trigger new negotiations regarding call hours or commuting expenses, says Sastow.

Besides job location, Parker also suggests paying close attention to the job description itself. “Responsibilities should reflect those within your field of specialty,” he says. If the contract has a broader statement, such as “tasks as assigned,” that’s worth negotiating, he says. Otherwise, you might find yourself performing tasks that may be above—or beneath—your level of training.

These sections may seem boilerplate, but it’s still a good idea to read them and make sure they reflect what you want from the job.

Compensation. Most compensation guidelines these days are set by corporate boards and groups like the Medical Group Management Association, says Handwerk. “The larger the hospital or group, the more likely it is the compensation rate will be standard,” he says.

And, frankly, there isn’t much room for a new physician to negotiate larger increases. “Young physicians don’t have much in the way of negotiating power unless they are in a specialty that’s needed by the employer,” says Sastow—or they are needed in a specific location.

If salaries are set in stone, Handwerk suggests negotiating other benefits. An inflation rider, for example, is a way to keep your salary from deflating as you work. “…Without a regular increase for inflation, doctors can find themselves working for less and less money each year,” he says.

Also remember that compensation isn’t just about salary. It covers benefits such as paid time off, CME reimbursement, health and disability insurance, forgivable loans, 401(k) contributions and maternity/paternity leave.

“Typically, these benefits are part of a hospital’s policies and procedures manual,” says Parker. “It’s important to understand what those policies are, so if there is something you need or want, like paternity leave, and it’s not in the manual, you may be able to negotiate it into the contract.”

Negotiations are more likely to take place if the employer is a smaller hospital or group, says Sastow. “For larger hospitals, these are usually standard policy and not negotiable.”But, as Bertram says, you never know until you try.

Bertram says it’s perfectly legitimate to ask questions of your own. “Ask employers about the financial strength of the institution,” he says.“If a hospital or group has shrinking revenues, that’s something you should know before you sign up.”

Elizabeth Clark Libert DrPareshMane ElizabethClarkPhotography 36

Thoracic surgeon Paresh Mane, M.D., consulted with an attorney on his employment contract, but ultimately handled negotiations with his employer himself.  · Photo by Elizabeth Clark

“Also, ask the hospital about its volume and growth potential,” suggests Paresh Mane, M.D., a Boston thoracic surgeon.

Call Hours. Next to compensation, call hours may be the most important section for physicians. “On-call hours will affect a physician’s career path and lifestyle,” says Parker. As the new hire in the organization, you can usually expect to work the worst hours, but if they are worse than other new hires, Parker suggests opening a dialogue with employers for a better schedule. “Most employers want to be fair,” he says.

But here again, you might want to ask your own questions, says Mane. For example, “Ask what the hospital will do if you work more than a certain number of hours. What will they do if your cases are above that limit?” He also suggests negotiating administrative time into your schedule so you can carve a day out each week for paperwork. As a surgeon, he has also negotiated block time in the operating room.

In other words, propose the hours you want for the lifestyle you want—but be prepared to negotiate. As long as call hours are kept reasonable and fair, that may be the best you can expect.

Termination and Tails. Employers typically provide malpractice insurance while you’re working at their facilities, but what happens when you leave and a patient files a malpractice suit over something you allegedly did? That’s covered by tail insurance, and that part can be tricky, as the example at the beginning of this article shows.

“Who pays the tail coverage and how much they pay may be negotiable,” says Sastow. But that negotiation is likely to depend on why you’re leaving.

If the contract is up—usually after a year—and you’re moving on to another workplace or if you’ve been terminated with cause, you can expect to pay a fair share or all of the tail coverage. However, you might want to negotiate language in your contract that makes the employer responsible for paying some or all of the tail if you’re terminated without cause. “Who pays for tail coverage depends on the reason the relationship is ending,” says Sastow. He adds: “If you’re dismissed without cause, you should negotiate language that says the employer will pay for tail coverage.”

That’s why it’s also important to pay attention to the termination section of contracts.

“The length of a contract can be misleading,” says Bertram. “Generally, contracts are for a one-year renewable term, but it’s not an absolute. You may be terminated without cause with a 30-, 60- or 90-day notice.”

“All contracts have an out clause,” says Cindy Fiorito, director of physician recruitment for Eagle Hospital Physicians in Atlanta. “Our contracts include without-cause language with a 120-day notice,” she says, adding that they will consider other notice lengths.

Generally, termination-without-cause sections are not negotiable, though most attorneys will try to eliminate the language. If left in place, they are what they are, and you need to be aware that they’re there.

Mane says he was able to negotiate the without-cause, 90-day notice termination clause in his contract to a longer term. “If you’ve moved to the area and just started practicing, three months is not enough time to let you find another job and move again,” he says. His negotiated language called for a 180-day notice period. Six months is long enough to find a new job, he says, adding, “It works both ways. If you don’t care for the environment, you don’t want to lock yourself into place either.”

In addition to negotiating a longer notice, you may also negotiate language that says the employer will pay you a certain amount if you’re dismissed without cause. “Or you may want to negotiate the restrictive covenants part of the contract if you plan to stay in the area,” says Jay Levy, J.D., a Florida attorney.

Just be sure, in any termination-with-cause section, that the cause is defined in the contract, says Levy. “There should be a clear understanding of what constitutes cause.” There should also be a “notice of default” in the contract, he continues. That means the employer will allow you a certain length of time to fix the problem. “That could range from 10 days to 30 days,” Levy says. Unless the offense is so egregious that no repair is possible, a notice of default will give you a chance to fix whatever problem you have or may be creating.

Restrictive Covenants. Of all the terms in a contract, this one may be the most contentious. A non-competition restrictive covenant says that, if you leave a practice (with or without cause), you may not work within a given distance from that hospital or place of employment for a set period of time. A non-solicitation restrictive covenant prevents you from soliciting your former patients for a set period of time.

Restrictive covenants should be taken seriously, says Levy. “Some people think they’re not enforceable. They are.”

If you can look at them from the employer’s side, they make sense, Levy continues. “The employer has gone to the trouble of bringing you in, marketing its practice and building its patient base. They don’t want to lose those patients if you leave. A restrictive covenant protects their business.”

But what if the patient has a good relationship with the doctor and wants it to continue? “A non-competition restrictive covenant doesn’t mean that the patient can’t see you,” says Levy. Of course, it may make their visit geographically inconvenient, but that’s their choice.

“I was ready to sign with an employer until I saw the restrictive covenant clause,” says Andikyan. The employer refused to eliminate the clause, “so I walked out. I wouldn’t sign a contract with a restrictive covenant clause included,” he says.

“If they’re in a contract,” says Mane, “you need to know what the language says. Any hospital facility, including an office that’s 150 miles away, may be included in the restrictive covenant language.” That, he adds, can be crippling if you intend to stay in the area.

Fiorito points out, however, that restrictive covenants may be just as limiting for employers. “If you’re a hospitalist who came to us from another job and you’re working under a restrictive covenant, it can send up a red flag,” she says. “We need to know all of the places you aren’t able to practice, because we may unknowingly assign you to facilities where you won’t be able to go.”

“I learned noncompete clauses are common in contracts where the employer is in a large urban area,” says Frost. In her experience, they are not negotiable, but she says she was able to add language to a contract that allowed her to come back to the restrictive area if she changed her position or if she wanted to return for a fellowship. “I didn’t want to be penalized for either of those,” she says.

Review and negotiation time frame

Once you have your contract, the employer will give you time to consider the offer. In some cases, the amount of time is set in the contract. Frost’s contract, for example, stated she had 14 days to respond to the offer.

That should give you time to consult an attorney with a strong understanding of health care law. If you do choose to use an attorney, most will understand you need a prompt review. “Unless they’re in court or very busy, I would imagine most attorneys will turn around a review in a few days,” says Levy.

Sastow says a week to 10 days is average, and Parker says the review process may take up to two weeks, depending on the size and complexity of the contract.

No matter what the time frame is, however, consulting an attorney may prove to be a wise investment. (See the sidebar “Why Hire an Attorney?”)

Whether you decide to use an attorney or not, physicians should keep one thing in mind, says Parker.

“The contract is the beginning of a relationship, one which has the potential to be long-term and worth millions of dollars,” he says. “It’s easier to dialogue about the parts that are important to you, so decide on those first. When it comes to any negotiations, however, it’s good to take a step back and consider it from the other side. A contract should be beneficial to both sides. You want to build a relationship that goes beyond the document. Keep that in mind when you negotiate, and it will pay dividends down the road.”

Karen Edwards is a frequent contributor to PracticeLink Magazine.

 

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Breaking the chains

Looking for more from your compensation? Develop a strategy for your student loans, and you may free up more income sooner than you think.

By James M. Dahle, M.D., FACEP, WhiteCoatInvestor.com | Fall 2016 | Feature Articles

 

“The rich ruleth over the poor, and the borrower is servant to the lender.” –Proverbs 22:7

There is no greater financial frustration for a resident or young attending physician than a large student loan burden, and the lack of financial training in the medical education system compounds the problem. As Vlad Kononchuk, M.D., an attending psychiatrist in Dix Hills, New York, says, “Frankly I did not have much of a strategy for anything when in residency, at least not for financial matters. It is hard to make those plans when you have so many other things on your plate!”

The costs of attending college and medical school have skyrocketed over the past two to three decades. When I started medical school in 1999, in-state tuition at the relatively inexpensive University of Utah School of Medicine was just $10,000 per year. In 2015, a mere 16 years later, that number had nearly quadrupled to $36,000 per year. Out-of-state tuition was nearly twice as high.

That trend has affected essentially every M.D. and D.O. school in the country. Out-of-state tuition can be particularly problematic, as displayed by the price tag at Michigan State University’s College of Human Medicine, which averages $73,000 per year just for tuition and fees. The Columbia University College of Physicians and Surgeons topped the private school list in 2015, at about $56,000. New York City is also an expensive place to live, so the total cost of attendance (COA) there is estimated to be as high as $94,000 per year for MS3s.

On average, D.O. schools are more expensive than M.D. schools. According to the Association of American Medical Colleges (AAMC), in-state M.D. students average $34,000 per year in tuition, fees and mandatory health insurance. Private M.D. schools average $56,000 per year, and out-of-state M.D. schools average $58,000. The D.O. averages do not include health insurance, but clock in at $44,000 for in-state and $49,000 for out-of-state, according to the American Association of Colleges of Osteopathic Medicine. The average debt upon graduation of those who took out school loans, $183,000 for M.D.s and $229,000 for D.O.s in 2015—as reported by the AAMC and the AACOM, respectively—is actually pretty amazing considering the cost of tuition.

Ethan Handler, M.D.

Refinancing his student loans was like “kicking off the training wheels,” says Ethan Handler, M.D. Doing so, however, also helped him refocus on attacking the debt. · Photo by Kat Schleicher

However, those averages obscure the fact that, according to the AAMC, 32 percent of M.D. students graduate with more than $200,000 in debt, and 8 percent graduate with more than $300,000. In addition, since most residents do not even pay enough on their debt to cover the interest, many of those who start residency owing $200,000 finish owing $300,000 or more. So if you feel you are in a deep hole with your student loans, know that you are not alone. There is little you can do at this point about the depth of the hole, but there is a lot you can do to get out of it as fast as possible if you practice lifestyle control and proper debt management.

Although some physicians will have their debt paid off by their employers or forgiven by the federal government, the vast majority will eventually have to pay off their student loans themselves. The secret to doing this is to live a lifestyle similar to your resident lifestyle for a period of two to five years. For example, if you owe $200,000 and have an attending salary of $200,000, you can live on $50,000, pay $50,000 in taxes and put that other $100,000 toward your student loans, eliminating them completely within two years. In order to do this, however, you will need to resist the siren call you hear from peers, friends and family to grow into (or beyond) your income as soon as you can. With proper lifestyle control, most physicians can be out of debt within two to five years of residency graduation. It isn’t complicated, but it does require discipline.

Unfortunately, the other key to getting rid of your debt—proper student loan management—is far more complicated. In fact, it can be ridiculously complicated to determine the proper path during residency because a multitude of options are available to minimize interest accumulation, minimize payments and remain eligible for government forgiveness programs. Proper student loan management can even affect the best way to file your taxes and the type of retirement account to use as a resident. Much of this information I learned the hard way. As a resident who got sick of financial professionals ripping me off, I decided to educate myself on the basics of personal finance and investing. Since then, I’ve been sharing what I learned with other physicians—both in my book, The White Coat Investor, and on my blog of the same name. In this article, I’ll share some of that same information with you. Due to the complicated nature of the in-residency loan management process, this article will provide only brief general rules for residents while encouraging them to learn more about this complicated topic from other sources or to obtain professional advice. Prior to listing these rules, I’ll define the commonly used federal government programs residents need to know about.

The federal programs you need to know

Public Service Loan Forgiveness (PSLF) is a program that allows for complete tax-free forgiveness of your remaining federal Direct Loans after making 120 qualifying monthly payments, no matter how much debt you have left. The programs whose payments qualify include the standard 10-year repayment plan and the three income-driven repayment plans: Income Based Repayment (IBR), Pay As You Earn (PAYE) and Revised Pay As You Earn (REPAYE.)

Income-driven repayment plans have several common features, but the main one is that the payments are dependent only on your income (and family size) and not on the amount of debt you have or the debt’s interest rate. You can determine what your payment amount would be by taking your income and subtracting 150 percent of the federal poverty line for the size of your family. The remaining amount of money is called your “discretionary income.” IBR requires you to pay 15 percent of your discretionary income toward your student loans, while PAYE and REPAYE require 10 percent. For most residents, those payments don’t even cover the interest on the loans. The discretionary programs have a forgiveness feature too, but physicians rarely take advantage of it because it doesn’t apply until 20 to 25 years have passed, and even then, the amount forgiven is considered taxable income. REPAYE has an additional interesting feature in that half of the interest not covered by the monthly payments is subsidized by the government, effectively lowering your interest rate.

Rules for residents

With that brief introduction to the government programs, let us consider three general rules for residents trying to navigate through these complex decisions.

Rule 1 for Residents: If you hope to obtain PSLF by working for a 501(c)3 nonprofit after completing residency, then you want to stay in a government income-driven repayment program during residency.

Rule 2 for Residents: Minimizing payments, minimizing interest accumulation and maximizing loan forgiveness may be mutually exclusive. For example, the best way to minimize payments is to defer your loans until residency completion, but you’d better expect them to be a lot bigger at the end than they were at the beginning! The best way to maximize loan forgiveness is to make payments that are as small as possible during residency through one of the government programs. Which program will allow you to do that best, however, varies according to your marital status, spouse’s income and the type of student loans.

Refinancing your loans can help you to minimize interest accumulation, but it also turns the loans into private loans, which are no longer eligible for Public Service Loan Forgiveness. The private lenders who refinance loans for residents do, however, allow for very small payments ($0 to $100 per month) during residency. To make things even more complicated, the latest government income-driven repayment program, REPAYE, may partially subsidize the interest on your loans, effectively lowering the interest rate to a level below that which you would get from a private lender. This is because residents don’t typically qualify for the lowest rates from private lenders. Instead of the 2 to 4 percent an attending might be able to get, a resident will probably only be offered a rate of 5 percent.

Rule 3 for Residents: The best government program for most residents is the REPAYE program. There are two caveats to this, however. The first is that, depending on how much their spouses earn, married residents may be better off in the IBR or PAYE programs and filing their taxes as Married Filing Separately. The second caveat is that if you decide to go for PSLF after residency, you will likely want to switch from REPAYE into IBR or PAYE upon residency completion in order to maximize forgiveness. IBR and PAYE payments are capped at the 10-year Standard Repayment Plan payment, whereas REPAYE payments may rise above that level, depending on your income.

Decisions after residency

As an attending, the decisions become much easier. If you are directly employed by a 501(c)3 nonprofit or government employer, you should pick the income-driven repayment plan that gives you the lowest payment, pay the minimum on your loans, and obtain PSLF after 120 total payments. If you are not eligible for PSLF, you should probably refinance your loans with a private lender. Various terms and rates are available from at least 20 lenders, and what you qualify for will depend on your credit and debt-to-income ratios. You may be able to lower the interest rate on your loans from 6 to 8 percent in the federal programs to 2 to 5 percent, saving thousands in interest each year. Of course, just because you refinance doesn’t mean you want to forget about those loans and go on the minimum payment plan. You don’t get out of debt by taking on more debt; you get out of debt by living like a resident for two to five years and throwing a huge chunk of money at those loans every month—whether the interest rate is 7 percent or 3 percent.

Ethan Handler, M.D., an otolaryngologist and cosmetic surgeon practicing in Oakland, California, worried a little bit about refinancing his loans. He knew that he would “lose the government-provided safety blanket” to go into forbearance or have income-based payments in case something happened to his income. He ended up refinancing his loans at 3.5 percent and found that it was like “kicking off the training wheels. Once I refinanced and no longer had the safety net of hardship or forbearance, I took more responsibility for my debt. What had previously looked like a funny and absurdly high number ($240,000 upon residency graduation) on paper became something I’m working hard to erase.”

There is also some risk that the government could change the PSLF program. The Obama administration has made budget proposals that, if passed by Congress, would limit the amount of forgiveness to just $57,000.

Amanda Weinmann, M.D.

Amanda Weinmann, M.D., opted to live frugally while paying off her student loans—a choice that allowed her to pay toward her debt while in residency. · Photo by Tim and Madie Photography LLC

Amanda Weinmann, M.D., an attending family physician in St. Paul, Minnesota, didn’t like that the program seemed so politically uncertain—not to mention the fact that no person has yet received forgiveness through the program. (The program requires 120 monthly payments after 2007, and there have not yet been 120 months since 2007.) The idea of dragging out payments on the $162,000 she graduated medical school with was very unappealing. “I was psychologically uneasy with making payments that didn’t even cover the unsubsidized interest, and I felt that, since I borrowed the money and had the means to pay it back, I should.” By living frugally, she paid off a car, avoided credit card debt, funded a Roth IRA and paid off $64,000 of her student loans while in residency.

Another alternative for those concerned about the political viability of the program (aside from avoiding it altogether as Weinmann did) is to save up the equivalent of the debt on the side in an investing account. If the program disappears or becomes severely limited, the funds in the side account can be applied to the debt. If forgiveness materializes as expected, the side account will provide a boost to your retirement nest egg.

Owen Vincent, D.O., a family physician practicing in Prairie du Chien, Wisconsin, uses this approach. He works for a 501(c)3 and is going for PSLF for his $315,000 in student loans. He states, however, “I’m also saving as much as I pay each month in taxable accounts [above and beyond my retirement savings]; so if [PSLF] doesn’t work out, I’ll throw a lot of money at those loans quickly and get rid of them, and if it does work out, I’m that much closer to financial independence eight years from now.”

Employer loan assistance

In interviewing physicians for this article, I was surprised by just how many of them had received loan assistance from their employers. This is an increasing trend among physicians and non-physicians alike. The classic example is the military with its various programs including the Health Professions Scholarship Program, which pays for tuition, books, fees and a stipend for medical students, and the Financial Assistance Program, which pays an annual grant (currently $45,000) plus a monthly stipend to residents in exchange for a service obligation.

The National Health Service Corps (NHSC) offers similar programs. The NHSC loan repayment program offers up to $50,000 toward your student loans in exchange for a two-year commitment to an NHSC-approved site. The NHSC also offers a scholarship program similar to the military HPSP program in that the student receives tuition, fees, other educational costs and a living stipend in exchange for a commitment to serve in an NHSC-approved job. Each year of support in medical school requires a one-year commitment, with a minimum of two years. The scholarship is generally considered the better deal, but the loan repayment program has its advantages as well. This program, however, is generally available only for primary care providers, mental health providers and dentists.

Vincent, who expects Public Service Loan Forgiveness, found that he also qualified for a state-specific, rural provider, tax-exempt loan repayment of $50,000. Kononchuk, too, was surprised to discover that he qualified for a New York loan repayment program designed for physicians treating underserved patients. He says, “I see way too many people not even consider such programs, as they assume that if they don’t live in a rural area, they won’t qualify. Guess what? I work in NYC and I still met criteria!” If he stays in the same job for five years, the program will have paid his entire $150,000 student loan burden.

The bottom line is that more and more employers, states and communities are offering student loan repayment programs and the qualifications are highly variable. You may be surprised what you can find. Vincent says: “My locale may not be for everyone—as some would never dream of living more than an hour from a Target—but I’ve found the slower pace allows for more meaningful time with family, friends, patients and hobbies. Plus, the much lower cost of living has done wonders for my financial situation.” If you, like Vincent, are willing to work in a geographic locale where few physicians are interested in working, you may find you have significant negotiating power. Even if you cannot get a higher salary, consider asking for assistance with student loan repayment.

Whatever your strategy for your student loans, the keys are lifestyle control and educating yourself about proper loan management. As Weinmann says, “It’s literally worth tens of thousands of dollars to spend a little time educating yourself about loan options. If you compare that to your hourly rate as a resident, you’ll find this to be a great use of your limited free time.”

James M. Dahle, M.D., FACEP is the author of The White Coat Investor: A Doctor’s Guide to Personal Finance and Investing and blogs at whitecoatinvestor.com. He is not a licensed financial adviser, accountant or attorney and recommends you consult with your own advisers prior to acting on any information you read here.

 

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Apples and oranges: how to compare job offers

Compensation is important, but comparing your offers when making a job change means more than just looking at the bottom line. Are you evaluating every facet of the opportunities?

By Bruce Armon | Fall 2016 | Feature Articles

 

During the course of your career, you will make many changes: finishing training and taking that first job, advancing within an organization, switching jobs, moving to a different town or, eventually, retiring.

You may initiate many of these changes. Family situations may cause some. Your employer may precipitate others. Still others may result from mergers, acquisitions, affiliations or consolidation as health care continues to evolve. Regardless of the cause of a change, when it is about to occur, you will need to evaluate and compare multiple opportunities.

Comparing opportunities by weighing the costs and benefits of various options is critically important. And crucial to a proper cost/benefit analysis is the understanding of what is most important and viable to you in both the short- and long-term. Which job will protect your future and provide you the flexibility you need for the next opportunity you’ll pursue down the road?

Weigh it: Familiarity

The road through residency and fellowship can be long and winding with an uncertain future. After finishing training, you might weigh the option of staying at the same academic medical center.

There are benefits to staying in the same environment: continuity, familiarity, and the opportunity to teach junior residents whose strengths and weaknesses are known. There are also potential costs to staying at the institution where you trained. You may struggle to be seen as a peer rather than a trainee. You may find upward advancement difficult in a crowded division or department. And you may be more accepting of less compensation in exchange for the comfort of staying at a familiar institution.

To help you evaluate

If you’re considering whether to stay in your current program or not, ask yourself:

  • What is my relationship like with my mentors here? How long will they practice here?
  • What are the growth opportunities?
  • Will I always be viewed as a resident or fellow, or will I be able to be viewed as a colleague?
  • Would I be better off in a different environment that would broaden my professional experiences?
Caren Kirschner, M.D.

Geographic location, quality of life and benefits were most important to Caren Kirschner, M.D., as she evaluated opportunities. · Photo by Colin Lenton

Caren Kirschner, M.D., had three primary considerations when comparing opportunities after completing residency at St. Christopher’s Hospital for Children in Philadelphia: geographic location, quality of life and benefits. Each was of equal priority, and more important to her than other criteria such as starting salary or advancement opportunities.

Kirschner chose to join a private practice, but familiarity still played a role. “I grew up in the Philadelphia area and went to medical school and completed my residency in Philadelphia. I knew I wanted to stay in the immediate Philadelphia area, and I really wanted to avoid an unpleasant commute,” she says.

Weigh it: Geography

As in Kirschner’s case, geographic location is a top consideration for many physicians comparing job options. Geographic preferences are mostly personal, but there are also practical and legal issues regarding the area in which you choose to work.

Professional liability insurance costs vary among regions largely because of each region’s reputation of being provider-friendly in legal matters and because of its history of suits, judgments and settlements. If the cost of professional liability insurance is significantly more in one community than another, that may affect the salary that can be offered by an employer—and your choice to practice there.

Noncompete clauses prohibit physicians from practicing within a certain distance from their previous employer for a certain amount of time after they leave that employer. A clause’s scope may vary depending upon your specialty, employment setting and the competition in an area. If you know you want to be in a specific community for a long time, a noncompete stipulation may be the most important section of your contract. In states that prohibit noncompetes, you may find that employers include a liquidated damages clause to ensure that physician employees pay damages if they practice within a certain radius during a certain time frame after their employment ends.

Cost of living is another consideration tied to geography. How much of your salary will go toward housing, property taxes, groceries and transportation? Will you need to budget for private school tuition in one practice location and not another?

To help you evaluate

Plan to talk with realtors, local school district officials, leaders in the local hospital and others who will provide objective information. Ask about anything that’s particularly important to you: cost of housing, school options, athletics and other recreational activities, and turnover of other physicians.

Knowing the standard of living that your base salary would provide in a community is also important, particularly when you are considering relocating to an area with which you have limited familiarity. Get a clearer picture of the areas you’re considering with help from these websites:

  • CNN Money (cnnmon.ie/28PPyEd): A straightforward online calculator.
  • Sperling’s Best Places (bit.ly/1wO6KTN): A calculator that factors in food, housing, utilities, transportation and health costs.
  • Bankrate (bit.ly/1gTzoZ0): Detailed cost comparisons for a few dozen common cost-of-living items, from ibuprofen to tennis balls.
  • The U.S. Department of State (1.usa.gov/1RrNOPI): A list of helpful resources regarding salaries, cost of living and relocation, including links to various chambers of commerce as well as realtor and retirement information.

Weigh it: Compensation

Two jobs that both pay $150,000 annually may result in very different standards of living depending on where each is located. But there are also other factors to consider as you compare compensation. The salary in the contract is just the beginning.

A fundamental premise that you must understand as you compare compensation offers is that your total pay (base salary, bonus, benefits) will be based upon some variation of return on investment—the return you provide on the investment employers make in you. Employers will pay you less than what you generate in revenue because the resulting margin will help fund their other operations, which may include less profitable practices. Your responsibilities—whether clinical, administrative, research or a mix—also affect your compensation.

Employers typically pay physicians based on one of three models: straight salary (with or without bonus opportunities), productivity, or profit-centered.

Straight salary. The straight salary model guarantees you a specific amount of pay for a defined period of time. No matter how hard you work, how many patients you see or how many procedures you perform, your salary remains the same.

Productivity. Under this model, you are paid according to your personal productivity. This may be measured as cash in the door, work relative value units (wRVUs), patient encounters, number of call shifts, overnight shifts or another standard. This model often includes a lower base salary or draw, but the more productive you are, the more money you can make.

The wRVU measurement eliminates bias based on the payer mix of a physician’s patients. For instance, a physician who treats only uninsured patients likely generates far less cash in the door than a physician who treats only privately insured patients. But if they work the same number of hours and see the same number of patients, they should have the same number of wRVUs.

Profit-Centered. A profit-centered model bases your salary on both your productivity and your expenses. Your compensation depends on both the opportunities you have to generate revenue and your ability to keep expenses to a minimum.

If you’re considering an opportunity with this payment model, it is important to understand the approximate revenue you can generate and how expenses are calculated. Are expenses determined pro-rata (for example, if there are five physicians in the profit center, they are each responsible for 20 percent of the expenses), or are they based on some other formula?

For some employers, the compensation model may be negotiable. If you’re more comfortable with one model over another, it’s worth asking your potential employer if their model is flexible. The response will likely depend on the size of the practice and how developed its infrastructure is. Other employers may start you with a straight salary that shifts to a productivity model at some pre-determined point in time.

To help you evaluate
Diane Godorov, D.O.

When evaluating offers, “having an objective, unbiased resource to help you set compensation expectations is very important,” advises pediatrician Diane Godorov, D.O. · Photo by Kelly Giarrocco

Diane Godorov, D.O., is a pediatrician who has worked in several different settings including private practice and urgent care. “It is important to know what you are supposed to earn and how realistic it is that you can attain proposed bonuses,” she says. “Having an objective, unbiased resource to help you set compensation expectations is very important.”

One source of objective data is the Medical Group Management Association (MGMA), which publishes several reports compiling annual compensation data for physicians. MGMA data shows how salaries are affected by factors such as specialty, years of experience, size of practice and geographic location and can help you understand the physician marketplace.

For physicians pursuing academic medicine, the Association of American Medical Colleges (AAMC) publishes physician compensation data. AAMC reports include detailed information about how compensation is affected by faculty level, departments and specialties, and the mix of clinical work, teaching and research.

Many employers use national surveys such as the above to set salary and bonus caps at the median or 75th percentile. By creating this cap, an employer can ensure that compensation is based on fair market value and balanced among peers. Ensuring there is a salary floor, too, can ease your anxiety of switching from a job with a guaranteed salary to one that may be variable and based on factors outside your control.

Another compensation factor to be aware of is that, if your practice includes clinical or academic research, your employer may expect you to secure grant dollars to cover part of your own compensation. If the grant dollars are eliminated or reduced, your compensation may be adjusted accordingly. In many instances, receiving additional grants may not increase your compensation, but it can allow additional research to be performed by hiring additional staff.

Weigh it: Benefits

Benefits are an often-overlooked piece of the compensation package, but they can make a significant difference both in dollars and in quality of life.

For Kirschner, “maternity leave was an important consideration of any job offer.” As a pediatrician and a hopeful mother, she prioritized this benefit as part of her job search.

It’s important to understand how the benefits you’re offered compare both monetarily and toward your quality of life. What is the value of the health insurance and vacation time offered, or the funds available for CME? How about the value of the retirement program or the professional insurance coverage offered?

An opportunity with a lower base salary but excellent benefits may actually be better than one with a higher base salary and few or no benefits.

Weigh it: Family Fit

Stuart Ort, M.D., was a successful otolaryngologist in California for eight years. He practiced with one other physician and had no employment-based reason to switch jobs. But as he weighed his happy job situation with a desire to be closer to family in the New York City area, family took the higher priority.

In his search for a new practice, Ort says his “major consideration was finding a non-academic institution or group where I would be able to focus the vast majority of my time and energy on clinical work.”

Ort reached out to friends in the New York City area and ultimately identified a large single-specialty ear, nose and throat practice. Even though it is a much larger practice than his former employer, Ort reports that he is “very happy with how transparent the practice is and the fact that no one feels like they are missing out or are getting unfairly treated.” Despite moving cross-country to a very different practice environment, Ort says his new practice is a “great fit.”

To help you evaluate

To help ensure your new practice and community meet you and your family’s needs, ask these questions:

  • What is the real estate market and school district like?
  • Does the community offer access to my and my family’s religious, educational and extracurricular needs?
  • How close would I be to family and friends?
  • How is the climate and environment?
  • What community do most physicians live in? What is the commute like?
  • What do physicians in the area do when they’re not working?
  • What do other physicians and their families like best about living and working there?

Comparing your options

Some physicians compare the job-search process to a dating game: you meet a lot of different people interested in getting to know you better, and they all want to see if you are compatible with them. Once you are interested, the employer prepares a contract to make the relationship official.

Mike Srulevich, D.O., who recently changed jobs, was philosophical as he considered a new opportunity. A change in jobs “can be transformative on several levels,” he says. “You may have been doing the job for years, but all of a sudden it’s a new culture, a new schedule and a lot of different personalities.”

Taking a new job, he says, is “like buying a new house: Finding it might be the easiest part.” Once you sign the employment contract, you must “navigate the paperwork, coordinate schedules and unpack life as it formerly was [in order to] start a new and different professional life.”

Just as in house-hunting or dating, physicians who are comparing options must understand and prioritize their own short-term and long-term goals. Choosing among multiple options is never easy. As you weigh the costs and benefits of opportunities, make sure you have carefully defined your own objectives. Additionally, make sure that the language of your final contract is consistent with these objectives and matches your impression of the opportunity. Identifying what matters most to you will help you make the choice that is most professionally and personally gratifying.

Bruce Armon is chair of the health care practice group at Saul Ewing LLP and frequently speaks to physician audiences and other health care audiences. He has helped hundreds of physicians and practices over the years with contractual, compliance, reimbursement and regulatory issues.

 

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Fayetteville, Arkansas

By Liz Funk | Fall 2016 | Live & Practice

 

Fayetteville, Arkansas

The northwest Arkansas area has experienced a growth spurt in the past 10 years; the population has grown, as have cultural offerings and job opportunities. Still, one thing remains the same: a devotion to the Razorbacks, the University of Arkansas’ beloved sports program.

“I moved here in 1987 after my residency training. Since 1990, there are 24 net new people living in northwest Arkansas every day. There is no prediction that that’s going to slow down any,” says Stephen Goss, M.D., president of Mercy Clinic Northwest Arkansas.

Goss was born and raised in southeast Arkansas. Inspired by his upbringing on a farm, he initially planned to become a veterinarian. He attended Ouachita Baptist University in Arkadelphia, Arkansas, where he pivoted onto a medical science track and met his wife. “The college was in my wife’s hometown, and both of her parents were professors at the university.” Goss attended medical school at the University of Arkansas for Medical Sciences, and trained in internal medicine and pediatrics.

Old Main.jpg

Finished in 1875, Old Main is a well-known symbol of higher ed throughout Arkansas.

Goss has two adult sons, both of whom were raised in northwest Arkansas. Goss says the area was a great place to raise kids and that virtually everyone who grows up in the area is a fan of the Razorbacks. “I have season tickets to the Razorback football and basketball games. It’s hard to grow up in Arkansas and not be a Razorback fan. Win, lose or draw, we’re for Arkansas.” Goss says that the University of Arkansas is undergoing a stadium expansion, in part to accommodate the growing number of locals who want to go to games.

This population growth has been great for Mercy Clinic Northwest Arkansas. “We have robust recruitment for Mercy in NWA. We still have plans for much more over the next several years. We’re becoming a really vibrant area in the Midwest. We’re the only community where they have seen a 25 percent growth rate. The closest place to that, in terms of growth, is Austin, Texas,” says Goss. In fact, Fayetteville’s growth appears to mirror the transformation that Austin has undergone, with new housing developments, more restaurants and young professionals moving there every day.

“Our town used to have a small-town feel, but now there are lots of new restaurants, lots of biking trails and many more amenities,” says Goss.

The bike trails are hugely popular among locals, according to Kym Hughes, the executive director of Experience Fayetteville. “The city trails really inspire people to live a healthy lifestyle. Many people are avid cyclists, and they enjoy the system here.” The Experience Fayetteville office is quick to mention the many accolades that Fayetteville has earned from national media, including Best Affordable Place to Live in America and the No. 3 Best Place to Live in America according to U.S. News and World Report in 2016. The city was also ranked No. 23 on Forbes’ 2015 Best Places for Business and Careers.

Dayna Pangle, a physician recruiter for Mercy, says that northwest Arkansas is widely known for its local economic growth. This certainly applies to her organization: “We are in the process of a $250 million expansion; we’re looking at adding 100 physicians in the next five years.”

Says Pangle, “Mercy Hospital Northwest Arkansas is currently 220 beds. We have approximately 135 integrated physicians and 60 advanced practitioners.” Pangle says that her main recruiting focus is primary care, and she is actively looking for primary care physicians. Mercy also has 10 clinics within the health system.

“We offer the opportunity to be part of a larger health care system,” says Goss. “Being part of a larger system lets you be a part of more things than if you were a stand-alone. We’re truly an integrated group of physicians. It’s not a hospital employment model. We have the whole organization integrated. We work together between hospital and clinic. We’re often looking at how we can solve health care issues as a system. We get lots of good traction and more robust programming as a result of that.”

For example, Goss describes their hybrid lab, where surgeons are able to perform a new procedure for the replacement of aortic valves. “Another thing we’ve gotten started is what we call our heartburn treatment center. We’re doing a better job diagnosing and giving better treatment for people with heartburn,” says Goss.

Pangle has another powerful talking point to use when she is selling job candidates on Mercy Hospital: “The University of Arkansas in Fayetteville—and the beloved UA Razorback football team—is just 20 minutes away.”

Al Gordon, M.D., is a family physician at FirstCare Family Doctors-North, part of the Medical Associates of Northwest Arkansas (MANA), a multispecialty group that provides an umbrella for about 75 physicians in private practice to share common administration, marketing and billing offices. Gordon not only helped start MANA, but he also was on the first primary care team for the University of Arkansas athletic department.

Gordon’s relationship with the Razorbacks started in 1994; today he is the head team physician for the University’s Department of Athletics and medical director of the graduate program in athletic training.

“As far as University of Arkansas sports, it’s almost like everyone in the state supports them, no matter who you might be supporting otherwise,” Gordon says. “To be an integral part in that, there’s a lot to be said for that. …The relationships that are formed with these student-athletes, that’s also a big part of why I do it. I have student athletes who participated 20 years ago who are still in contact with me. That means more to me than anything.”

An Arkansas native who grew up in the eastern part of the state, Gordon headed north to Fayetteville for residency after completing medical school in Little Rock.

“In Northwest Arkansas, we’re rather spoiled,” he says. “There are so many things to do, whether you’re a music, art or sports enthusiast. It’s just one of those kinds of areas, and we’re fortunate to have that.”

Another employment option for physicians looking in northwest Arkansas in the Fayetteville Diagnostic Clinic, also part of MANA. The Fayetteville Diagnostic Clinic offers a wide spectrum of specialties at one location, including internal medicine, gastroenterology, rheumatology and sleep medicine.

Or, consider Washington Regional Medical Center, a nonprofit hospital in Fayetteville that’s part of the locally governed health system Washington Regional. The system also operates several specialty clinics in the northwest Arkansas area.

“This is an area where there is a lot of opportunity, and we are recruiting a lot,” says Goss. “A lot of people think, ‘Arkansas?’ But they owe it to themselves to do a little research and see all that we have to offer. It’s a very unique place. We have a nice regional airport, and we’re well-located geographically. We’re not that far if you want to take a drive to Dallas, St. Louis or Tulsa. We have a great public school system, all four seasons, and lots of outdoor activities. It’s a great community, it has good people, and it’s a good place to grow your life.”

Says Gordon: “I like to visit areas all around this great country, but I’m always glad to be going home.”

 

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Madison, Wisconsin

By Liz Funk | Fall 2016 | Live & Practice

 

Having a major university in town helps make Madison a thriving cultural center in the Midwest, with eclectic restaurants, a variety of arts and culture offerings and, of course, sports.

Brad Schmidt, M.D., would be the first to tell you about Madison’s full range of entertainment options. He lives in Madison with his family and is the Medical Director of Inpatient Specialties at SSM Health St. Mary’s Hospital – Madison. SSM Health, an integrated delivery network, operates more than 55 medical group locations and three hospitals across south central Wisconsin.

“I have always been interested in science. I enjoyed combining the biology and science of medicine with connecting with people. I had done a little bit of research, but I missed the interactions with people. Working in a hospital was a way to put it all together. I started as a hospitalist, and (back) then it was a much newer and different field than it is currently,” says Schmidt.

Brad Schmidt, M.D.

Brad Schmidt, M.D., was born and raised in Wisconsin and is happy to call Madison home. “Our experience has been great,” he says. · Photo by Ueda Photography

Schmidt has enjoyed raising a family in Madison. He and his wife have three children, and they take advantage of the full range of entertainment options in the area. “With the university here there are many sporting events and cultural events. It’s a very high quality of life with a very engaged city. We like that, even though we have so many options, it has a smaller town feel.”

Appropriately, the Schmidt family members are sports fans. “We are diehard Packers fans. We also have season basketball tickets, which has been great over the past few years.” The Badgers are the University of Wisconsin’s Big Ten NCAA men’s basketball team. Schmidt says that there is strong local devotion to the team and that virtually everyone can get tickets to see them play: “In Madison, it’s generally pretty easy to get tickets.”

SSM Health physician recruiter Christopher Kashnig says that Madison’s attractiveness piques physicians’ interest, but what seals the deal is the culture at SSM Health Dean Medical Group, which has been around since 1904. “We tend to be innovative as an employer. We try new things. We try to be state-of-the-art. We pilot a lot of projects and we try to be cutting-edge,” says Kashnig.

For example, SSM Dean Medical Group was an early adopter of the patient-centered medical home. “We received a large grant from a major philanthropic organization to pilot a patient-centered medical home. We chose six of our primary care clinics for a pilot study; we looked at how to structure staffing and workflow.”

In total, SSM Health Dean Medical Group has more than 55 locations in 18 counties across Wisconsin. “We have four big clinics in the city of Madison, five clinics in suburbs of Madison, and the rest are in small towns across Madison. In Madison, we admit to St. Mary’s Hospital.” St. Mary’s is a full-service hospital with 440 beds.

“We are competitive financially with other offers around the country and around the city. We have Madison, and Madison sells itself. Madison has culture, it has sports, it has theater. When you have a big college campus and a state capital, there is a lot to do,” says Kashnig.

Judy Frankel, director of public relations and communications at the Greater Madison Convention and Visitors Bureau, moved to Madison from Long Island, in New York. She was pleasantly surprised by the extent to which Madison is a busy and bustling area. “I’ve been here for 15 years. Madison is an amazing place to raise a family. It has great public schools, and the university is world-class. The university brings in a lot of opportunities for families whether it’s lectures or performances, music and theater.”

For those interested in potential employment opportunities in Madison, another employer of physicians in the area is UnityPoint Health System, which operates a clinic in Madison, called UnityPoint Health-Meriter. UnityPoint operates a number of clinics across Wisconsin, providing family care, urgent care and emergency medical care.

The Wisconsin Office of Rural Health, which serves as a linchpin for a number of state-wide health promotion initiatives, runs a 25-year-strong physician recruitment program to place talented physicians in jobs across Wisconsin. Their nonprofit physician placement program works with clinics, hospitals and other health care providers to recruit physicians who are a match. According to the website, “Physicians placed into these sites promote and sustain a high quality of life, especially in rural, underserved areas.”

Schmidt was born and raised in Wisconsin, and feels good about his decision to stay in the state and build a life in Madison. “Madison has a state-of-the-art performing arts theater at the Overture Center. A family donated $250 million, so we have Broadway shows come through, everything from The Lion King to Stomp. We have a great farmers market with local food products; it’s fun to have those kinds of options and know where you’re getting your milk. That’s what creates the feeling that you have many choices with regard to restaurants, theater, comedy, performing arts, and still feel connected to the local community.”

This applies when it comes to sports, too. The University of Wisconsin basketball team may have the biggest fan base, but the university’s large sports program has something for everybody. “There are ways to enjoy sports beyond the high-profile teams you read about. I can take my daughter to a volleyball meet at the University of Wisconsin. I can take my son to soccer games at the University of Wisconsin.”

Says Schmidt, “Our experience has been great. We feel like our kids get a great education. There are lots of things in Madison that we can choose to have our kids experience. Overall, we love it.”

 

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Morgantown, West Virginia

By Liz Funk | Fall 2016 | Live & Practice

 

Whether you “bleed blue and gold” or you’re more of a casual sports fan, you’ll find scores of opportunities in Morgantown to enjoy the West Virginia University athletics program. For physicians, building a career with WVU Medicine offers flexibility and room for upward growth.

“I’ve always had an affinity for college towns,” says Taylor Troischt, M.D., the medical director of a pediatric clinic operated by WVU Medicine. “I like the vibe, I like the variety of culture. You get the amenities without the stress or expense of a big city. My wife’s family lives in Hagerstown, Maryland. We knew we wanted to be closer to her family. When we were looking for jobs, we started by looking at college towns within a two- to three-hour radius of where her family lives. WVU Medicine seemed to be the best situation; we could both find a job in the same field in the same area. It’s not always that easy.”

Taylor Troischt, M.D.

“I like the vibe, I like the variety of culture. You get the amenities without the stress or expense of a big city,” says Taylor Troischt, M.D., of living in a college town. · Photo by Rebecca Devono

“WVU Medicine offers a really good blend of career opportunities and a good lifestyle,” says Troischt. “We’ve had plenty of opportunities to relocate with other jobs and other areas; the fact that we’re still here says a lot.”

Troischt and his wife, who is also a pediatrician in the same office, had a fairly specific idea of what they were looking for in a community. In Morgantown, they feel they’ve hit the jackpot.

“I love college sports and college athletics. I don’t ‘bleed blue and gold’ like a lot of people who grew up here, but it’s always fun to see the teams do well,” says Troischt. “I love football. I love basketball. We love going to the games. It’s a lot of fun being part of a major athletic conference for basically every sport. It’s great that WVU is part of the Big 12.”

“The sports scene is huge,” says Katie Webster, the visitor services specialist at the Greater Morgantown Convention and Visitors Bureau. “Football season in the fall is an awesome time. Football is the pride of the school and the state. Around the whole state, you see people wearing WVU stuff. Whether or not they went to school there, everyone is supportive of the college.”

“Our academic flagship hospital sits adjacent to the WVU Football stadium and in close proximity to our baseball, soccer, swimming and basketball venues, so sports are never far away from reach and the minds of WVU Medicine employees,” says Deveran George, director of talent management and physician recruitment for WVU Medicine.
The WVU Medicine flagship academic hospital and Level I trauma center is Ruby Memorial Hospital in Morgantown. “However, we are also part of a system with more than 12,000 employees and nearly $2 billion in annual revenues, the WVU Medicine – West Virginia United Health System,” says George. WVU Medicine – West Virginia United Health System also operates eight other hospitals and numerous clinics throughout the Morgantown area as well as the state of West Virginia and surrounding region.

Ruby Memorial Hospital is currently 532 beds, but an upcoming expansion, a 10-story tower addition, will bring the count to 646. Other hospitals and associated clinics in the WVU Medicine – West Virginia United Health System include Potomac Valley Hospital, Camden Clark Medical Center, St. Joseph’s Hospital, WVU Medicine Children’s Hospital, the WVU Cancer Institute, and the WVU Eye Institute.

Says George, “It is a time of unprecedented growth at WVU Medicine, so we are expanding and growing our footprint throughout the state and region to meet the needs of our patients, state and surrounding region. … As a result of this growth and demand for our services, we are recruiting for every department—primary care and specialty. Some of the needs and focus include heart and vascular, orthopedics, pediatrics, neurology, oncology, rheumatology and digestive diseases, to name a few.”

For Troischt and his wife, building careers with WVU Medicine and raising their children in Morgantown is a choice they’re very happy with. “It’s a good community where people look after each other. My kids make cracks at me about this: When we’re out, they’ll see me saying hi to four or five families. When you’re a pediatrician in a small town, you’re going to get to know a lot of people.”

Webster says that the Morgantown population tends to be outdoorsy and takes advantage of local outdoor activities. “During the summer it’s especially great, because there is so much to do outdoors. We’re right on a lake and a river, so there’s boating, fishing and water rafting.”

For those interested in a day trip, the great outdoors is just beyond Morgantown.

“Morgantown is surrounded by forests and parks. Within a couple of hours you can get to so many parks, waterfalls and caves. People like to hike and bike on the trails, especially,” says Webster.

Troischt’s son and daughter are both athletes, which increases the family’s affection for where they live. “My kids love Morgantown,” says Troischt. “They have a great peer group. If you put time and effort in, you’ll be amazed what kind of opportunities there are here.”

Troischt says, “My daughter is in the ninth grade; she does track, and she does ballet. She has been busy with her dance career. She’s had amazing opportunities to train with professional dancers downtown at the Metropolitan Theatre. My son is a swimmer and participates in a swim league organized by WVU. His coach is going to the Olympic Trials, and he does lessons one-on-one.”

“It’s really amazing what opportunities a small town like Morgantown can have,” says Troischt. “There is opportunity, charm, safety. You’re not going to find all that in a lot of places.”

 

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