David Ramos, MD, MPH, FACC Managing Physician ColumbiaDoctors of the Hudson Valley

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1 David Ramos, MD, MPH, FACC Managing Physician ColumbiaDoctors of the Hudson Valley

2 The Changing Landscape of Medicine Changing Culture Demographics Income Terms and definitions RVUs, Restricted Covenants, Incentives Employment Opportunities What/Where and How much? Things to consider

3 77.4 percent are somewhat pessimistic or very pessimistic about the future of the medical profession. Over 60 percent of physicians would retire today if they had the means. Over 52 percent of physicians have limited the access Medicare patients have to their practices or are planning to do so. Over 26 percent of physicians have closed their practices to Medicaid patients. In the next one to three years, over 50 percent of physicians plan to cut back on patients, work part-time, switch to concierge medicine, retire or take other steps that would reduce patient access to their services. Close to 92 percent of physicians are unsure where the health system will be or how they will fit into it three to five years from now. A SURVEY OF AMERICA S PHYSICIANS: PRACTICE PATTERNS AND PERSPECTIVES- 2012http:// on_2012_biennial_survey.pdf

4 In % docs were in solo or single specialty groups and this has declined to 33% in Over 50% are now employed. Solo practice is now 13% of workforce and less than 1% opportunities available are in solo practice. In 2010, the specialties with the largest numbers of active physicians were the primary care specialties of internal medicine (109,048), family medicine/general practice (106,549), and pediatrics (55,509). In 2010, less than one-third (30.4%) of the active physician workforce in the United States was female. Percentages of females in the top specialties ranged from a high of 58.1% in pediatrics to a low of 4.0% in orthopedic surgery. In 2010, four in 10 active physicians in the United States were age 55 or older.

5 Specialty National 6 yrs Practicing Average Cardiology $402, Critical Care Medicine $258, Endocrinology $214, Family Medicine $199, Gastroenterology $398, Hematology & Medical Oncology $314, Hospitalist $210, Nephrology $252, Infectious Disease $225, Internal Medicine $208, Pulmonary Disease $298, Rheumatology $220,500.00

6 Relative value unit (RVU), a comparable service measure used by hospitals to permit comparison of the amounts of resources required to perform various services within a single department or between departments. It is determined by assigning weight to such factors as personnel time, level of skill, and sophistication of equipment required to render patient services. RVUs are a common method of physician bonus plans based partially on productivity. Mosby's Medical Dictionary, 8th edition. 2009, Elsevier. The work RVUs for evaluation and management of an established patient in the office are: Level 1 visit.17 Level 2 visit.45 Level 3 visit.67 Level 4 visit 1.10 Level 5 visit 1.70 By comparison a nuclear stress test is RVU and typical R/L HC is RVU The median RVU for some specialties Internal Medicine: 4700 RVU Cardiology: 7150 RVU Gastroenterology 7947 RVU Heme-Onc 4630 RVU

7 Restricted Covenant or Non compete Clause Typically for a duration of 1-2 years, usually limited to 5 mile radius around any office or hospital in which the group practices. Should be limited to specialty, not medicine in general. Enforceable, expected but possibly negotiable.

8 Can be included in first year contract but not expected. Usually tied to productivity index: RVU, charges, or collections (gross or net). Quality metrics: Utilization rates, disease specific metrics, patient satisfaction.

9 Employment Contract Usually over a specified period of time. state how much clinical time. Geography. call coverage. compensation (Base/Incentive/Fringe). Malpractice (Claims made/occurrence/tail). Vacation. Terms of Termination. CME. Non Compete Clause. Hospital Guaranty and Relocation Agreements (STARK) Usually separate from employment, extra incentive to practice in a community. Incentive is for one year, but linked to staying for longer.

10 Independent Contractor Locum tenens (you are the corporation and pay your own taxes, no fringe but higher salary. Partnership Usually start with employment agreement with a specified term to partnership (2-4yrs average). Buy-in, buy out. Compensation model as partner (equal profit vs percentages). Assess amount of debt/liabilities the group carries including outstanding business litigation. Need to assess the financial operations/viability. Need to be clear on organizational structure.

11 The distribution of physicians by type of practice in 2012, according to the survey was: Single specialty group Multispecialty group Solo practice Other Hospital employee Faculty practice plan 45.5 percent 22.1 percent 18.4 percent 5.7 percent 5.6 percent 2.7 percent 50% physicians practice in state other than where they trained.

12 Specialty National 6 yrs Practicing Average Median Starting Range Cardiology $402, $272, Critical Care Medicine $258, $198, Endocrinology $214, $165, Family Medicine $199, $138, Gastroenterology $398, $272, Hematology & Medical Oncology $314, $222, Hospitalist $210, $165, Nephrology $252, $180, Infectious Disease $225, $158, Internal Medicine $208, $145, Pulmonary Disease $298, $191, Rheumatology $220, $163,500.00

13 CULTURE is everything. Your vision of where you want to be. Your vision of who you want to be. Spend wisely. Never forget you are a professional.

14 A SURVEY OF AMERICA S PHYSICIANS: PRACTICE PATTERNS AND PERSPECTIVES al_survey.pdf 2012 Review of Physician Recruiting Incentives An Overview of the Salaries, Bonuses, and Other Incentives Customarily Used to Recruit Physicians-Merritt Hawkins eypdf.pdf Physician Employment Contracts American College of Physicians oyment_contracts.pdf 2012 Physician Specialty Data Book Center for Workforce Studies AAMC Advance Data of Physician practices 2007 CDC The Physician s First Employment Contract A Guide to Understanding and Negotiating a Physician Employment Contract From the Employee Physician s Perspective

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