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Episode 05: Asking The Right Questions In Anesthesia Contract Reviews w. Jon Appino

Feb 1, 2019

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

This Episode

Interview w/ Jon Appino

You Will Learn

  • Tips for negotiating an anesthesiologist’s contract
  • Strategies for dealing with non-compete clauses
  • Trends in anesthesiologist contracts, including how they vary by geography

Resources & Links

Show Notes

In this episode we speak with Jon Appino, founder of Contract Diagnostics, about things to watch out for in prospective employment agreements for anesthesiologists.  Jon’s firm has reviewed thousands of contracts for all specialties and he gives some important tips for any anesthesiologist looking at a new job offer.

Show Transcript

Transcript:
Justin: 00:00 Hey, this is Justin Harvey, your host of the Anesthesia Success podcast. My wife is an anesthesia resident and I’m a financial planner and I work with anesthesia and pain doctors as my clients. This podcast is designed to help the anesthesia community be informed about their careers, their finances, and more by taking important questions straight to the experts. Thanks for tuning in. Our guest for this episode is John Pino, founder of contract diagnostics. Contract Diagnostics is a company whose exclusive purpose is to provide physicians of all specialties with a detailed overview of a contract which they receive for prospective employment and to help those physicians understand the pros and cons of that contract and how competitive this offer may be for them. I first found John on the white coat investor blog a while back where he’s been a longtime advertiser and has been recommended by Dr. Jim Dahle, who runs white coat investor. John, thanks a lot for joining us today.

Jon Appino: Thank you for having us. We appreciate it.

Justin: Yeah, so our audience of anesthesia pain physicians are really going to benefit. I know from your insights about contract specific considerations as they’re looking for that first or maybe that second job opportunity. So to start us off, why don’t you just give us a little bit of background about your firm and the work that you do for physicians?

Jon Appino: 01:08 So if one of those things where I hate to say simple, not easy, uh, we, we review physician contracts, period. We don’t do anything else. We don’t outsource anything. We don’t operate as a recruiting firm on the side. We don’t try to sell disability or life insurance or manage investments. We just look at contracts and we love working with the physicians that we work with that, you know, we get to tell them here’s what they say and then we can guide them and coach them on how to ask for things because it’s not something that they’re typically trained in. And so we, uh, we, we love working with everybody and we look at contracts all day long. So this is what we do and we’ve done it for maybe eight years or nine years now. We’ve done thousands and thousands of contracts of course, and we really have a good time working here.

Justin: 01:50 That’s awesome. So why don’t you take us through that process of how it, how it usually works when a physician contacts you and they’re looking for help, how do you work with your clients?

Jon Appino: 01:57 So it’s very, I mean everything’s set up online and they basically send us with the agreement and they say, you know, I, here’s my questions and we go through them and we go through the agreement and whole and we have multiple different ways that we go through it. We then hop on the phone with them and we send them documentation depending on which package they select and we go over those documents, we answer all of their questions, we tell them what the contract says and maybe what it doesn’t say or what it should say. And then we can Kinda, depending on their frame, we can guide them on what the next step is. Sometimes their frame is, I grew up in this town. I want to be here forever. Sometimes it’s my spouse is in training and I’m only gonna be here for another year or two or you know, I’m single and I’m going to try this location out and if it doesn’t work out I’m going to move so everyone’s got their own unique individual story and to look at a contract is a contract, but that story is what we kind of incorporate it into our feedback to them as far as maybe based on that, here are some of the questions that you could ask or that you know some of the due diligence that you could do in the process.

Justin: 02:59 Yeah, that makes a lot of sense. And obviously you do contract reviews for a lot of. I mean all the different specialties. So you have a robust database from which to compare these contracts. Is that right?

Jon Appino: 03:09 Absolutely, yeah. One of the things that differentiate us, I mean we’re not a law firm so we don’t give that kind of advice, but we do have lots of financial data and so we can go through and we can not only talk about with the contract says and all the contracts are reviewed by an attorney of course, but we can use that internal database to say, based on this, this is what the offer should look like or what it would look like, or some of the questions that you could ask or some of the things that we’ve seen in the area or what the trends have been in the last few years, so there are certain specialties that have very interesting trends and we can talk to that depending on who the physicians.

Justin: 03:41 Yeah. Can you give an example of maybe one of those specialty trends that has informed one of your analysis and conversations?

Jon Appino: 03:47 Absolutely. Recently, so I mean there’s a lot of examples. Rheumatology being one of them. If we talk with employers across the country, they give us. There’s two. There’s always two needs that always pop up. One is rheumatology, the other is neurology, and so those specialties are in high demand. A lot of lot of work in the ICU is another thing that we’re seeing. Because of that, we’re seeing salaries being very robust and packages be very, very generous in those two specialties. We’re also seeing a lot of negotiating capital by those positions if they have multiple offers, you know, just because I mean everybody needs those folks. We’re also seeing really good friends right now and urology, if you look at urology as a specialty overall, the specialty is aging. A lot of physicians are older who are practicing urology and so because of that, a lot of folks are having five year plans in place to replace their urologist and so we’re seeing a lot of negotiating capital urologist as well, and then obviously with with your listenership, I mean anesthesia, we’re seeing a lot of different deals in anesthesia, whether it’s out in the field, or in a pain practice, whether it’s a hospital employed, a setup, whether it’s a group with the hospital contract, it’s with everything in healthcare.
Jon Appino: 04:54 We’re seeing consolidation and so there’s lots of considerations that should be taken into depending on what the individual physicians frame is and what you’re looking at.
Justin: 05:02 Yeah. Interesting. So as far as the, you know, the dynamics of supply and demand, you know, you mentioned some of those specialties are more in demand and maybe a rheumatologist is kind of in the driver’s seat with regards to having negotiating leverage potentially where. Where do you see an anesthesiologist or a pain physician fall in that spectrum of very in demand you’re in the power seat a little bit or the other end of the spectrum where you kind of got to take what you’re given. Where do you see them fall or does it depend on region?
Jon Appino: 05:27 All physicians are in high demand right now. I think everybody listening has probably seen the supply and demand curve for physicians. If you look at retirement patterns of, you know, new new physicians versus, you know, the older age physicians don’t want to work until they’re 80 years old anymore. You know, people don’t want to do 100 hour weeks. You look at med school enrollments and graduating and fellowship and residency programs have how many they’re graduating that are females and it’s over 50 percent now that you’ll have more time off, more part time work because that’s just what their frame tends be a lot of times and so because of those things, the supply and demand curves are dramatically shifting for every physician out there. I just saw last night a a blurb on the, I think, I don’t know if it was the local news or if it was the national news on physician burnout and how physicians are burning out and that’s causing more, more slowing down earlier in career or early retirement.
Jon Appino: 06:18 So because of that, all physicians I feel are in a good spot now. Like you said, does it matter if you’re going to San Diego or if you’re coming to rural Iowa? Of course it does. Does it matter if they’ve got, you know, one anesthesia doc or more than one anesthesia doc, or if it’s a very powerful private anesthesia group in the city and the anesthesia group basically runs the region and they do very well when their partner, they take a lot of time off when their partner, but the new folks, they don’t get that good at deals and it’s okay if you stick around for a little while, but if your frame again is a couple years and moving on or if they don’t offer partnership or if something changes with that opportunity, it just varies. So we see anesthesia deals from over 600,000 guaranteed income to 25 to 50 on the low end. Sometimes it’s because a physician has better training or they’re a better negotiator, but sometimes it’s just reliant on the opportunity and what the physician wants out of that career.
Justin: 07:14 Yeah. So if you’re talking to 25 to 50, what kinds of cases do you see where that low end is manifest?
Jon Appino: 07:19 We’ll see, you know, sometimes academic practices, but we’re seeing a lot of hybrid academics where they may appear as their academics because you know, it’s with an academic institution but you’re still a producer if you will. You’re still doing 95 percent clinical and you have rv bonuses and so we don’t really, even though a physician will tell us that it’s academic and that’s the reason for the lower compensation, I don’t always buy that. And we also see those high flute and private groups where they know that they’ve got a good thing going and they take, they make good money when their partners and they take a lot of time off and they feel relatively, you know, they’ve kind of built their, their moat, if you will, and they feel kind of, you know, you know, impervious to any outside influence. And so a lot of times they say, look, we’ll maybe it’s not an a in a major metro. It’s in a mid major, you know, a town of 200,000 to a million or a million five. And they’ve got good power, good strangle on the community, if you will. In a respectful way of course meeting as far as providing services and you know, they’ve got 10 applicants for the one role and the role because some guys retiring after working there for 20 years. So we sometimes see less financial offer, less financial viability and those markets at least for the first couple of years until they become partner.
Justin: 08:32 Yeah. And in that context, I think it might be helpful for our listeners to sort of break down a couple of the sort of prototypical prospective employers and understand how is the contract, how is the negotiating process going to differ between say an academic center versus a big, uh, you know, anesthesia management company versus maybe a smaller group.
Jon Appino: 08:51 Great question. So again, depending on their frame, they say this is our contract period. Whether that’s the anesthesia group with a good thing going that they know they don’t have to negotiate or modify anything. And everyone, the other 20 or 40 physicians have signed the same thing. Or the academic group where it’s more like a ladder or you know, four pages. It’s not really formal. It’s a lot of links to policies and those things. All those things. Of course you’re still get reviewed by somebody. Are they more of a here’s what you should negotiate. Maybe not. Maybe it’s more of a here’s what’s not said. Here’s what you should clarify. Here are the policies that I would want to read. Here are some questions that we have because if you want to leave, maybe there is no provision for termination. Maybe references, bonuses, but we don’t know how they’re paid or when they’re paid or what the metrics are.
Jon Appino: 09:38 Maybe it references, you know, future compensation, but we don’t know what those are. If it’s partnership. We have a q and a that we send out here where it lists. Here are some really good questions you could ask around partnership. Again, maybe it’s not a negotiation, it’s more of a clarification and those can be very different things which are things that we do all the time here. You know, we just, because maybe a contract is not negotiable, doesn’t mean that it shouldn’t be looked at and it doesn’t mean that you still don’t have good due diligence to do when it comes to finding out if that’s the right opportunity for you. Now in a, in the setting where it’s more of a highly compensated by salary, more of a hospital setting and they need you more than you need them. Don’t become very open for negotiation. So do we want to negotiate what the bonus looks like? Do we want to negotiate a salary or a signing bonuses or relocation amounts of student loans or retention bonuses or CME amounts or flexibility as far as your schedule goes. Noncompetes. Obviously there’s lots and lots of different ways that contracts in general can be negotiated, but you know, sometimes it’s more of a clarification. Sometimes it’s a straight up negotiation. It just depends. All of this on the situation in the frame.
Justin: 10:42 So I was at the asa conference a few weeks ago in October and I went to this session where there were a handful of physicians from some of the big private practice groups and one of the physicians said essentially intimated if you come in here and you’re, you’re making demands about salary or bonus, you know, there’s a bunch of people all in line right behind you and we don’t need to flex because there’s, there’s demand for this role and your ability to move us on this key factor is you don’t have any leverage. He was very blunt about that. Would you. Would you say that that’s your experience and those larger group sometime?
Jon Appino: 11:17 Again does it mean that if it says you get a base salary and a bonus, does it mean that we wanted to go create those things or does it mean that we just want clarification so you know, is that kind of group with that type of physician likely to change? No, absolutely not. Does that mean that the contract has all the details in it that we. That you would want to know if for some reason things didn’t work out or if for some reason you’re trying to plan financially, so there was no details around the bonus. Maybe there’s some questions that we can ask around what has been historically and what paid out and how it’s taxed and how it’s paid if you don’t work there anymore due to a termination or disability or death and so just because it may be there’s no wiggle room in it doesn’t mean that we can’t provide or somebody else can provide some really good clarifying questions to ask in a situation like that.
Jon Appino: 12:03 Sometimes we’ll have physicians, that will call back and they’ll say, you know, hey, we asked a lot of those questions and you know, I was told the answer is no, no, no, that’s fine. Right. Asking the question sometimes makes us where it makes us competent that other people don’t have other situations. Right. And sometimes if we don’t ask and if they don’t tell us, look, everyone gets paid the same here. We don’t change it for new people. Okay, wonderful. Now we know that there no discrimination as far as new starts, whether you’re know, whether it’s a male or a female or whether it’s a foreign trained or, uh, uh, an American trait or whether it’s a established physician with years of experience or a new grad out of training. Sometimes they pay for, for pain fellowships or cardiac fellowship, sometimes they don’t. And so by having, even if they don’t negotiate by having the right questions to ask, at least we can feel confident that other people have a similar offer and there’s no differences between you and the colleague. You work next to it.
Justin: 12:57 Yeah, absolutely. And I think I really liked this idea that you’re presenting a kind of just getting clarity on things that aren’t obvious and especially when it comes to comp, you know, physician comp is very complex potentially and you bringing clarity to what does this contract actually mean as far as the bottom line as far as the number that’s going to be in your checking account every month or every year. That can be a really valuable service in itself. Can you talk a little bit about what it looks like for you to work with a physician to maybe interpret or untangle what does it mean if we have RVU or a percent of reimbursement collections or, or something like that. And how does that translate into you empowering a physician to be able to make an informed decision? So again, they’re all different, you know, so I’m having, like you said, some have our views, some have collections, some have salaries. Now let’s take maybe an RVU example. If, if you, if we have a physician looking at our values and trying to benchmark, oh they, they’re going to pay me 3:50 k and they, they’re setting a 7,500 a RVU target, you know, how do I know if that’s a good or bad deal?
Jon Appino: 13:54 Yeah. So I love being able to have the right clarifying questions. So if you’re not the only person there, what are the others do in terms of numbers? I love to ask what expectations are. So what are the employers expectations of you in the first and the second and the third year? If 7,000 is the goal, if that’s the goal, would be hitting 7,000 that meet your expectations or would that be the minimum expectation or what? I be exceeding? I love to get report and asked what kind of monthly reports are provided. So I use. So the physician knows how he or she is trending towards hitting that particular number. We always tell you guys to find out how they set their metrics. So do they just come up with it internally? Do they peg it to a certain standard? MGMA, AMG, etc.
Jon Appino: 14:41 What they’ve done in the past. We were negotiating with the neonatology group a while back and we were told that all physicians are paid the same structure. We asked where the last time they hired was they nine years ago. Right. So, so sometimes you know, having those questions to be asked to see, okay, you paid everyone the same but you have to change it. This might be a really good time to do so. You know, I think in that can play as well. But you know, if it’s an RVU model, we’d love to see what the expectations are. We love to know what the other people are doing. We love to know what kind of reports that they’ll be getting up. We love to know if it’s prorated for termination. So if you, if you work a half of a year, but you see the half of the production bonus, is it, is it binary if you cross that 7,000 threshold or not, or is it, hey, if you only work a half a year, we, we prorate the 3,500 females who’ve taken maternity leave. What happens if you take maternity leave and you’re out for three months and not producing our views? Then what happens to the structure? Those are all questions to understand when you’re working on under an incentive compensation model that has to do with our views.
Justin: 15:40 YeahAnd then, you know, there’s obviously, aside from sort of the big numbers of what, what’s the company look like, there’s all the ancillary benefits that are an important part of the total picture. Um, can you maybe touch on a couple of the important, uh, you know, perks of a physician contract and how you help benchmark those versus other contracts and see if there’s ways to improve potentially those options.
Jon Appino: 16:00 So absolutely something benefits can be a big part of it. We’ll see some independent contractor deals with anesthesia. You know, obviously there was no benefits. So if there was no benefits and your out of pocket 30,000 a year or more or less depending on what you come up with, with, with extra taxes that the employer’s not paying or a couple of your own health insurance or liability insurance, a cme dollars, etc. Understanding how that might be a really good benefit to you and maybe how that’s not a good thing. If you’re an employed physician, then that what’s the vacation, what are the policies? And of course all the details that someone who listens to your podcast. Of course we’ll be very astute to, to make sure that they managed with, you know, if they have life insurance or disability insurance and what those amounts are.
Jon Appino: 16:49 And of course they’re not portable, so if it’s not portable, you know, and you leave, now you’ve got to go buy a new policy. Well now you’re older maybe with some other health issues. So maybe those policies are more expensive when you go to bio for your next position, knowing all of those, those ancillary things. And then, um, one of the things that we always tell physicians that they really need to know is not only that they have the benefits and what they are and clarifying on what they are, but also knowing when they start. So if you’re 401k doesn’t start for a year, that’s important that you know, so you can plan around that. If your medical insurance doesn’t start for 60 days after your first day of employment, that’s important because you may have Cobra Insurance to buy from your prior employment and that could cost you a thousand or $2,000 a month. So planning financially for those transition costs could be one of the really important things around the benefits. Then of course, you’ll receive very robust benefit plans that can add up to hundreds of thousands of dollars with student loans and moving expenses, you know, in the medical and all the other types of. You can see very, very robust plans if that’s what the employers offer.
Justin: 17:54 I want to talk for a minute about a noncompetition noncompete clause and because that’s something that a physician is gonna want to know. If I go somewhere, it doesn’t work out what are the terms of termination and then where can I work or what is the acceptable radius within which I can practice and does it mean to have to move two states away in order to be able to continue doing what I’m doing. Uh, what, what are you seeing out there as far as what’s an acceptable maybe standard English, and again, I understand there’s some variability here, but as far as a fair noncompete radius in the anesthesia world, what should our listeners be looking at?
Jon Appino: 18:26 It depends so much on I think the type of practice you are, a lot of times, again, if we take that very highly successful private practice in a setting that they have, they kind of own the market, if you will. Maybe having a noncompete in that situation is maybe not have as big of a deal because maybe there’s no chance that you can’t compete with them. You know, it’s not like a radius, you know, maybe it just that we have. We have exclusive contracts to provide anesthesia services at these two hospitals are five hospitals and you cannot take those contracts. Which makes sense. It doesn’t mean that you can’t open up your own practice, but would you want to knowing that they own all the ones that provide the service? Sometimes it’s again, all that stuff is important that you understand, but sometimes it’s almost a nonissue because if it doesn’t work out it was have to move because there is nowhere else that you could work.
Jon Appino: 19:16 Right. Depending on the exclusive nature of the anesthesia contracts, you know, again, if it’s like a pain practice, maybe it’s like, you know, you have a mile radius for a defined amount of time, one year, 10 miles from the practice locations. Sometimes it’s from one location, sometimes it’s from every location, so it’s important that the physician knows how that’s structured because if it’s from every location and they’ve got five locations, it might be more catastrophic than if it’s just from the one location that the physicians work and as the employer maybe ads accounts or ads, locations that could grow. That’s of course outside the physician’s control. If they sign a contract and there’s one location, so let’s say 10 miles from, from the clinic that they work on, and then over the next five years, which they are, they work, they’re. The employer expands to 10 more offices now.
Jon Appino: 20:01 If you didn’t know how it was structured when you started, now it’s from every single office. Again. There’s all those kind of nuances where we’ll see like in a rural setting we’ll see 50 miles, you know, one year for 50 miles you can’t work. Which is fine, you’re going to move away and other times we’ll see you. You can work wherever you want to. You just can’t compete with the accounts that we have contracts with, which makes sense. The exclusive contracts. So if and when those contracts comes up, you can’t file a proposal with the hospital, you have to steer clear otherwise maybe they can work wherever they want to. Sometimes we’ll see damages in there. If the physician Bruxism, sometimes we’ll see. You know there they’re more like a, it’s a mile radius. Sometimes it will say like more non interferences. So it doesn’t say you can’t work, it says you can’t interfere with us, but maybe interfering means taking their accounts and maybe taking their accounts means working because there’s no other places to work if you provide inpatient anesthesia services.
Jon Appino: 20:50 So you know everything’s different and unique and. But what we definitely see them sometimes that’s one of those negotiating points like you mentioned earlier and sometimes it’s like, look this is what we have here. We don’t change it. Sometimes with the larger groups, they don’t budge on that noncompetes, but maybe they don’t budge on the radius or or having it in there or not, but maybe they would budge on how it’s forgiven or primary location versus every location or other nuance to the noncompete that maybe it’s not. It’s not a, you know, as a binary because there is it not maybe it is going to be there period. They don’t negotiate it, but maybe there’s other factors on it that the physician could clarify and potentially negotiate as far as changing and maybe providing a little bit more freedom for himself or herself if and when the relationship doesn’t work out long term.
Justin: 21:36 With regards to landmines, things to definitely watch out for. Are there any rules of thumb as far as a nonstarter in a contract? If you. If you see this or if you don’t see this, you absolutely need to address that before proceeding?
Jon Appino: 21:50 great question. Of course. I’m going to say it depends on the physician’s situation, but a lot of times I would say if there was. If there was not clear termination provisions, that can be an issue. If a physician does not know how he or she can quit or move on, if they’re unhappy, that could be a major issue. If there’s not clear definition around compensation. So if it’s a salary, okay, if there’s a ball, how does the salary change? But if there’s a. If there’s a bonus provision, sometimes bonuses are discretionary. I don’t know that they’ll change that and that’s not a landmine, but it doesn’t. Again, it provides a lot of clarifying questions to us and again, the physician’s perspective may have unique things that I would consider a landmine versus somebody else’s. So if you’ve got a spouse working in the area, maybe the noncompete becomes more of a binary horrible idea to sign up versus not having good clarity around something.
Jon Appino: 22:42 How the malpractice insurance is paid or how tail is covered is one of those very important thing. You know how a bonus is paid on termination is one of those very important things. We’ve taken far too many calls from physicians who feel like they’ve been wronged at the end of a relationship and I think sometimes that does happen, but I think more often if they haven’t been wronged, they just didn’t understand the termination provisions and how dollars are bonuses were paid, are repaid, and so maybe it’s not that they were misled by the organization. They just didn’t understand the policies or they did ask the right questions and so we take calls more often than we would fake around people who feel that they’ve been ripped off or wronged by their former employer, which may be the case, but sometimes they just didn’t understand something.
Jon Appino: 23:28 So we’ll get. Having good granular clarity around those things I think are very important because we always tell everyone that we work with that. Contracts are for expectations. So very high level. What are you going to do for me and then what am I going to do for you? And then what happens if want to go our own way or we want to end our relationship. And so if you look at those three things, termination of course is what if we want to end our relationship, so lots of details and understanding everything in there. And then the what am I going to do for you? Well, you’re going to give them your time and your expert opinion. So we always tell the physicians there should be lots of detail on your schedule, lots of detail on your location, lots of detail on your call because that’s the expectation and I think it’s fair to have those in the contract.
Jon Appino: 24:13 And then what are they going to do for you? Of course, that’s compensation and we’ve covered that as far as having a lot of detail around base salary and bonuses and everything else and then how those things are paid if the relationship goes where I want to talk for a second about. So you mentioned MGMA and other sort of benchmarking organizations and studies. To what extent do you use those to, to evaluate how competitive a contract is or do you have a sufficient volume of your own work? So we use both. You know, I think a lot of employers say we use MGMA so it’s important that we’re aware of that data and what it looks like and how it’s changed and we’ve got lots of data so we can go back and look at trends over time and be a little predictive based on what we know about a particular market or a specialty and what the trends have been in the last few years.
Jon Appino: 24:58 But of course with any data set like that, it’s got a little bias, right? Because you know, some people take surveys, some people don’t, so you’ve got, you’ve got the people, you mean the, the cardiologist who’s earning a million five maybe isn’t in taking surveys on how much you earn, you know, but then you’ll some of the data with a. we’ve got a lot of. We’ve got more part time work right now, more independent contractor works and some of the tax laws have changed over the years. And so because of that, that skews the data a little bit. It doesn’t make the data irrelevant. I think it’s still the gold standard and one of the best out there to evaluate and when we talked to employers, a lot of the things that they tell us is that’s what they use for setting and pegging compensation. So it’s very important to understand that no, but our internal data is raw.
Jon Appino: 25:43 It’s robust, it’s blinded, but we know if you’re an anesthesia working at a certain metro area, here’s what the starting salaries look like. Here’s what the vacation time looks like, here’s what the cme dollars look like or or signing bonuses and so we can say, you know, if a physician has just one offer and he or she can’t compare five other offers that they have with a given metro area, we might be able to do so with our data because they. Here’s what other people are paying in the area so they can make an informed decision on is the equation right? The time for money equation worth it. It doesn’t make sense based on the potential future with the organization and in that context, maybe we can close with just one or two case studies where we do a lot. You can do a mini recap of one of the anesthesia or even other physicians whom you have helped analyze a contract and maybe some some helpful things that you brought to bear in that situation.
Jon Appino: 26:33 Yeah, so I so one story that comes to mind this time every single year. And this happened, I think it was two years ago. It was anesthesia, but this would be this, I think that you could say this will be similar for anybody, but this happened to be an anesthesia physician and she was working with a smaller group, I want to say three physicians, maybe, maybe two or three or four, something like that. Smaller. We had worked with her and we said, look, you know, it just says you’ll be paid a certain salary and you’ll work as they need. There was no detail on any additional compensation for additional hours or how many hours or what call looked like. It was just kinda high level. Right. You’ll work for us and we’ll pay you some money. We told her this is really important that you have this documented because I don’t know if they’re paying you, let’s just say it was 300.
Jon Appino: 27:19 If they’re paying you $300 for a 40 hour week or an 80 hour week. So I don’t know how. I feel about 300. Might be very good. If it’s three days a week, it might be not very good if you’re working seven days a week every day. And so we never heard from her and uh, we hear from her a year or I never heard from her last two years ago. Around this time around. I’m like mid January I think it was. And I got an email from her and it said, it said, hey guys, I just came off the Christmas to New Year’s week. So seven days I worked a hundred and eight and a half hours. And she said I’m not happy. I think she used different language of course, but she said I’m not happy. And she said, they’re telling me they’re not going to pay me anymore.
Jon Appino: 28:00 Is this okay? And so we talked with her and we said, did you get the click, the schedule clarify? And she said, no, it says I’ll work wherever they want me to. And we said that you don’t know, we don’t see a whole lot of wiggle room for you to demand or request additional money. So she said everyone else was at home with their families and here I am my first Christmas out of training where I’m not a resident and here I am basically living at the hospital doing everything for the all four people by myself and I don’t paint anymore. So that’s a, that’s a situation that, you know, and she happened to be anesthesia and of course, you know, anesthesia when you’re on service your own surface so it can be. And uh, you know, and that’s just what her Christmas to new years week was like. And I think that every time that we come around this time of year
Justin: 28:49 and the pain of the situation obviously isn’t as much the fact that she had to work Christmas because it already does sometimes, but that she was shocked and appalled at the conditions. And didn’t see it coming because I didn’t get the clarity up front.
Jon Appino: 28:58 Yeah, people will say, look, I’m newly trained, they say maybe I’ve got a lot of loans and I want to work at the holidays and I want to take that extra week. But again, if there’s no extra compensation and you’re trading time for money, you know, I don’t think that she got an extra week off. I don’t think that she had a break the next week. I don’t think that the gay friend, that was just how it worked. And why could they do it? Because they were the boss and she was not so specific that we had to do with, with, uh, with, you know, we always hear a physicians, whether it’s anesthesia not wearing, they have collection based structures. And so let’s say you have a salary, they get paid a dollar based off or you get paid a percentage based on the collections that come in for your work. And you know, if you’re not getting reports and you don’t know what collections are and you stopped working there, say you know today what patients pay you or pay the insurance companies, pay them in a month, you know, you think that you’ve worked really hard and you’ll get that compensation, but you don’t.
Jon Appino: 29:53 And so we oftentimes see physicians with collection bonuses, which is, is common in anesthesia and we will see them not receive dollars that they’ve rightfully earned and worked hard for and they’ve traded their time and their expert opinion for. But they wouldn’t receive them because the contract wasn’t set up to receive the allocable dollars based on if and when they came in based on the termination.
Justin: 30:18 Yeah, no kidding. And going into those situations with eyes wide open and understanding the implications of this contract language obviously sets you way ahead of the curve as far as being able to be an informed.
Jon Appino: 30:27 Yeah. And that’s what it’s all about. Some people will call and they’ll say, hey, I got this contract and you know, I mean they said everyone signs the same thing and they said don’t even try to negotiate it and don’t waste your while having it reviewed, you know, they’ll say, do I need to get it reviewed? And you know, of course you have a biased opinion, but we say yes. So we will say find someone if you don’t want to work with us, that’s okay. Find someone but just have it reviewed by somebody who you feel does a good job. And that would be. So who does more than a couple per year or somebody who you. And the other thing is, is a lot of local court law firms, you know, they’re not familiar with the Rvu models. They’re not familiar with compensation trends. They have financial disclosures to have with the employer because there may be conflicts if they’ve taken money from the employer to do, to write contracts or to shake deals or to talk about their hospital contracts with, to provide, it guides them and they way they may have a conflict with the employer.
Jon Appino: 31:16 So that’s one of those things that make, you know, a company like ours may be a little bit more advantageous, but at the end of the day we tell everybody who calls or everyone that we had on the podcast just have it reviewed by somebody even if it’s a couple hundred bucks, provide this level of information to you, even if it’s not negotiable. So there are no surprises. I think Justin, you’ve probably seen the data where it says 56 percent of physicians do not stick around after their first. The first term of their contract. You’re more than likely to leave and find a new position and that can be painful because you may have to buy a tail. You may lose out on bonus is you may have to a noncompete, maybe that partnership track that you were hoping on and the big dollars, lots of vacation time doesn’t pan out. Right. So it’s important that you have these things understood upfront and I feel the data is skewed because I think if you poll people who had their contracts reviewed by somebody, I think that the data will be much less because the expectations would hopefully be more clear so there would be less surprises and if there’s less surprises and I would assume that people would leave less often.
Justin: 32:17 Right? Absolutely. And that’s why I’m really. I love the work that you guys do and, and I feel the same about the work that I do is that it’s such a high value, you know, if you’re going to be signing a contract that is a 300,000, 400,000 or more dollar decision, does it not make sense to spend a couple hundred dollars or maybe up to a thousand dollars or whatever the price point is to have it reviewed by a professional to make sure that it’s a good deal, right thing to make sure the compensation is structured appropriately and that you’ve asked these clarifying questions up front. Does that not make sense? It absolutely does. I’m a huge proponent of services like yours, John, and I’m really grateful for the work that you’re doing that as we’re sort of side by side here in different ways, trying to equip physicians with this valuable information.
Jon Appino: 32:56 Absolutely. Well, we have, uh, you know, we’d have so much fun doing what we do here and um, I think people think that we’ve lost our minds because this is fun. Look it up. Papers and contracts and you know, and I’ll ask the up every day, all day, but we wouldn’t do it sometimes. Twenty hours a day and the busy season, if we didn’t love it, you know, we wouldn’t work almost every Saturday between what was encouraged. Anybody to call us and ask us any questions. We do consults, we don’t charge people for those. Um, if they have questions they want to run by us or you, everything’s flat price so you don’t have some hourly, right? That you’re going to not know what you pay up front. And we don’t treat them like each doctors, quote unquote, you know, so we can charge them fees and stuff. So we tell people just to have everything looked at by somebody. We have a fun time doing it here. If you want to work with us, we can hit our website or give us or contact you and you can pass them over whenever the best. But know we have a good time to do what we do here. I see a big value in working with these folks but also and you helping them and guiding with the way that you do.
Justin: 33:54 Yeah, that’s great. And you know, to be able to say that you do something that you love, that you really help and impact people and that it gets you out of bed every morning. That’s a. that’s a really awesome thing to be able to say. So I’m glad that we’re both in that boat. John.
Jon Appino: 34:05 We love those emails when they come in and they say, they said, Hey, based on your coaching or your record, I was able to talk to them and they gave me this and they you to or thank goodness I use you two years ago because you know, it’s like a physician. You see we don’t do. Of course, as intricate work as they, we don’t, people don’t rely on us for life and death decisions, but you know when someone, when you see that patient that every once in a while you have a patient that’s so grateful and it means the world to you. It’s kind of the same for what we do and I will be the same as us.
Justin: 34:39 Yep. Absolutely. Well, John Pino, thank you very much for joining us today. Really appreciate your perspectives. We appreciate you having us.

Show produced By:

Dan Gummel & Justin Harvey

Show Music:

Great Scott:  Don’t Hold Back

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