Brave New World – What Do You Look for in a Private Practice Anesthesia Group?

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Let’s start with the big picture. What do you want from a job? Most of us want the same things: income, job security, professional satisfaction from delivering good patient care, and satisfying professional work environment. Other obvious factors such as cost of living, lifestyle, proximity to family, and weather all play important roles, but I think the aforementioned four are the big ones when it comes to evaluating a potential job. Let’s parse each issue and see what questions surface when it comes to evaluating a potential group to join.

1) Income

What’s the compensation structure? Does the compensation structure fall on the individualistic or group-oriented end of the spectrum? I wrote about this topic of compensation structure in a previous article, “Show Me the Money.” As I said in that article, the best structure, in my opinion, is one that lies somewhere in the middle of the spectrum with pooled unit value and possibly some revenue sharing. Not only does this kind of scheme shift the payer risk from the individual to the group, but it also promotes collegial and equitable work environment without sacrificing the incentive to work.

Has there been a decrease in the pooled unit value in recent years? A successful group should always be on the lookout for opportunities to maintain – if not increase – the pooled unit value. What do I mean? In “Show Me the Money,” I pointed out how your reimbursements can differ for similar cases depending on the payer (higher for private insurance and much lower for Medicare and Medicaid). If a group has a contract with only one hospital whose payer mix has been deteriorating, the group’s pooled unit value has to decrease as well because that’s its only source of revenue. In the current environment of decreasing reimbursement, a successful anesthesia group has to negotiate continuously to gain access to facilities with good payer mix. For example, you might see groups competing to provide services for GI endoscopy centers in the hopes of boosting reimbursement. In sum, you want to join a group that’s actively working to maintain, or better yet, increase its pooled unit value.

Is there a buy-in period? If there is, ask them how long the buy-in period is, and how much the buy-in will cost you. During a buy-in period, you as an employee (until you’re eligible for partnership) either have a part of your income taken by the group or are paid a salary for the duration of the buy-in period. You should also find out if the group has a reputation for hiring physicians and then replacing them after a period of time. It would be terrible if you were to join a group that has a buy-in period, only to be let go before you were eligible for partnership.

How much do partners or shareholders make? This question seems obvious, but I put it on here because I am afraid that some recent graduates might feel uncomfortable posing questions that make them seem overly concerned with money. Don’t be. Physicians in the real world know how important money is, and they will not think you rude for asking them questions related to money and income. Ask them how much a partner usually makes. Ask them how much their recent pooled unit values have been. This will give you an idea of how much you can expect to make.

2) Job Security

Does the group want to be bought out? It’s a brave new world out there – more and more private practice groups are merging with one another, or they are getting bought out by larger, multi-specialty national groups. Why, you ask. The larger national groups, like Sheridan, CEP, and Somnia have contracting and management expertise that smaller groups rarely have. The most obvious benefit is that the smaller groups – in partnership with larger, national groups – have more leverage in negotiating for better reimbursement rates from payers. In addition, the national groups are better at cutting cost by their economies of scale, helping them in the age of Affordable Care Act when cost-cutting is at a premium. So as you can see, the incentives are there for the private practice groups to seek partnership with national players.

Most of us want the same things: income, job security, professional satisfaction from delivering good patient care, and satisfying professional work environment.

As someone about to finish residency looking for a job, you should ask your prospective future employers if they’re actively seeking to be bought out or merge with another group. The fact that they’re looking to partner with another entity is not a bad thing. But what does that merger mean for you? Let’s say you join a group that has a buy-in period where you’re made shareholder after a year or two. And let’s say that the group is acquired by a national group while you’re an employee. What happens to you when you’re not yet a shareholder? These are important questions to consider as more anesthesia groups are considering mergers or buyouts for better leverage. Usually anesthesia group buyouts involve a payout of cash or stock to partners, but smaller – if any – compensation for employees or non-partners. After the payout, remaining physicians usually sign new employment contracts that stipulate lower salary or decreased pooled unit value from future revenues. If a buyout happens when you are still an employee and not yet a shareholder, then you most likely won’t have anything to show for it except for a decrease in your paycheck.

Does the group have a stable contract with the hospitals and surgery centers? In California, you can’t be directly hired by a hospital (same in Texas) because of laws aimed at preventing corporate interference with the practice of medicine. That means that private practice groups are contracted by hospitals to perform certain functions within the hospital for a certain length of time. When you interview with a group, you should ask how stable this contractual relationship is. Ask whether the contract gets renewed every couple of years. Is the contract terminable without cause? If so, how many days of notification does the hospital give the group?

All that being said, the bottom line is that these contracts are not something you can hang your hat on because exclusive contracts can be terminated or lost to other groups. Let me give you an example of contract instability that’s currently playing out in California. According to a recent article in Modern Healthcare, Tenet – a national healthcare service company – is planning to appoint an outside staffing firm to manage physician contracts at up to 12 California hospitals for specialties like anesthesiology, emergency medicine, and radiology. Up to now, Tenet has dealt directly with physicians. Due to this new development, many physicians are worried that, “the move could result in some physicians losing their jobs if they’re not offered a contract or offered rates that are too low.” Tenet wants to save money by having the lowest bidder staff their hospitals, and this makes perfect business sense. It’s just very unsettling for physicians who want some degree of job security. In an era of consolidations, I believe that you will see more of this type of news. I also see subsidies from hospitals going away as hospitals have more options to choose from different providers.

So what can you do? You can’t really predict if the group you’re considering joining has contracts that will get renewed, nor can you foresee a buyout. Rather, you should examine if your potential group is working to provide good value to the hospital and surgery centers. What do I mean? I believe that job security for a group comes not from contracts, but making the hospital believe that it cannot function without the group because it’s providing good value – high quality service delivered expeditiously in a cost-effective manner. After you join such a group, be proactive in proving your value by getting involved in the administrative and business side of the group in addition to being a good clinician. All this increases your value to the group and subsequently, the group’s value to the hospital, making your job more secure. Also volunteer for hospital committees and Medical Staff so that you can foster a good relationship with the hospital administration, other physicians, and nursing staff.

Do most new hires make partner? This one is self-explanatory. You should be wary of groups that routinely hire physicians for a short time and let them go.

3) Professional Satisfaction

Do you do your own cases? What kind of cases would you be doing? Are there separate cardiac or pediatric subgroups? Find out the case mix and see whether your skills will be adequately challenged. It is my belief that you should do all different kinds of cases when you first get a job out of residency. This allows you to not only keep your skills up, but develop confidence early in your career. Also, many groups have cardiac or pediatric subgroups. Is this something you’re comfortable with? If you were to switch jobs down the road, would not doing any pediatric cases for a while make you less comfortable with taking care of kids? Even if you’re not a pediatric anesthesiologist, you should feel comfortable doing routine pediatric cases like T&A’s.

Does the group hire nurse anesthetists? Or does the hospital hire them? What’s the working relationship between anesthesiologists and nurse anesthetists like? I’ve never worked with nurse anesthetists in my private practice jobs, but I see the importance of finding out how you will work together with them.

4) Satisfactory Work Environment

Does everyone in the group get along? As I’ve said many times, slightly group-oriented compensation structure with pooled units is more conducive to collegial work environment because it reduces friction over room assignments. Also trust your gut instinct here. Do the people seem happy? Or do they look overworked and unhappy? Do people seem friendly and collegial? Also ask if you can shadow someone for half a day and check out the work environment in the operating room.

Is the group flexible enough to allow part-time work? In my first job, physicians got creative and devised a plan that allowed them to work part-time. For example, four anesthesiologists formed a subgroup and did the work of three physicians, allowing each member of the group to have extra days off. This kind of flexibility might be something you are looking for.

How is the group run? I’ve never been a part of group that is run by one or two people although I occasionally hear of such groups. Both groups that I’ve been a part of were run by a board of directors who were elected every couple of years. In my opinion, having a board of elected directors is a good structure to run a large group, as opposed to a more dictatorial structure.

How are vacations allotted? In a complete revenue-sharing group, where everyone makes the same amount of money, all the partners usually have the same number of weeks off. In such a group, vacations have certain monetary value and can be sold and bought. In a group with zero revenue-sharing, you theoretically can take off as much time as you want; you just don’t make any money during that time. Even in such a practice, however, there is usually some limit as to how much time you can take off.  Vacations are important; try to figure out what system you feel comfortable with.

How many hours a week do you work? Self explanatory.

As you can see, there are a lot of factors that you should evaluate before deciding on a group.  I hope that I’ve raised some issues that you might not have been aware of.  And please share with me issues that I might have overlooked in the comment section.

On a more practical note – keeping these issues in mind – what can you do?  If you can, try to talk to a couple of anesthesiologists who have left the group within the last couple of years. During the interview, ask the group if you can get contact information of people who have left the group. People have different reasons for leaving jobs, but finding out about those reasons might be very helpful for you in deciding whether to join a practice. For example, a physician might tell you that he/she left a group because of declining unit value. This might be a tip-off that the group is not expanding their business.

Also, you probably should not think that the first job you end up with is your last. Life is often unpredictable, and you might find yourself looking for another job for various reasons down the road. So don’t take out a huge mortgage and buy a house right away after you sign your contract. Don’t get an expensive car right away. For first few years at least, you should save some extra money (on top of other savings such as down payment and retirement) for the possibility of switching jobs. Having this reserve should lessens at least the financial impact of having to switch jobs, let’s say, because your group gets bought out by a national healthcare group before you are eligible for partnership.  It would be terrible to be working at a group you want to leave, but not being able to do so because you don’t have the money to relocate and find another job.

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