Perspectives on Private Practice

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Perspectives on Private Practice

• Paul E. Wallner, DO, FACR, FAOCR, FASTRO,
  FACROSenior Vice President for Medical
  Affairs21st Century Oncology, LLCAssociate
  Executive Director for Radiation OncologyThe
  American Board of Radiology

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Practice Experience

• Academic
• Private practice
• Federal government
• Corporate employee

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Life After ResidencyWelcome to the Real World

• Initiating the Job Search
• Fellowship Training
• Post-training Opportunities
• Location selection
• Business Relationships
• Contracts
• Financial considerations_________________
• Surviving the Boards____________________
• Economics of Radiation Oncology 101
• The Healthcare Environment

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Rule 1

• Relax and try to enjoy the experience!

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Rule 2

• If the perfect job did exist, I would be an
  applicant!

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Rule 6

• Make no assumptions!

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Rule 7

• Bay-area ethnocentrism works if you live in the
  Bay-area and are ready to retire!

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Initiating the Job Search

• Timing its never too soon!
• Look in a mirror consider your goals and needs
• Cast a wide net
• Get the word out Chair, Program Director,
  faculty, friends, contacts
• Muster your resources update your resume
• Avoid cold call recruiters
• Sign nothing!
• Role of rotations?

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Post-training Opportunities

• Academic
• Government (Federal and State)
• Private Practice
• Solo, Group, Partnership, Corporate

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Location

• Consider your nuclear and extended family
• Consider non-work opportunities
• Consider your fit into a community
• Consider cost of living
• Consider schools
• Consider opportunities for spending
• Fantasy might be better than reality

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Business Relationships

• Employee - without partnership opportunity
• Large corporation model
• Ideal for part-time employment
• Employee with partnership opportunity (?)
• Dont expect guarantees and be aware of past
  history
• Partner
• Understand the risk versus benefit ratio
• Understand the legal implications
• Partnership is not (necessarily) the Holy Grail
• Owner/operator

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Contracts (general considerations)

• Get local legal advice YOUR OWN!
• Make no assumptions!
• Everything is not necessarily negotiable
• Oral commitments are not necessarily binding

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Contracts (specific considerations)

• Term (length)
• Financial Terms
• Benefits
• Termination
• Non-compete/ restrictive covenant
• Coverage
• Future relationship
• Residency requirements
• Board certification requirements
• Dispute resolution

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Term (length)

• Initial contract is typically for one year
• Beware of long contract terms
• Review roll-over language carefully
• Salary increases
• Bonus increases
• Vacation increases
• Expense reimbursement increases

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Financial Terms

• Salary
• Incentives
• Are goals measurable and attainable
• Who controls attainability
• Payment schedule
• Non-clinical activities
• Total package value
• Payment schedule
• Increase at roll-over

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Benefits(Employee versus sub-contractor)

• Pension/ 401(k) contribution(s), vesting
• Profit-sharing - vesting
• Insurance health, life, ADD, general
  liability, umbrella
• Automobile
• Meetings
• Journals
• Memberships
• Medical/other licenses
• Medical liability insurance

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Termination

• Notice period
• Cause
• Specify
• Remediation details and period
• Multi-site group issue
• Not for cause (employee at will)
• Restrictive covenant waiver
• Payment of money owed

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Restrictive Covenant(non-competition)

• Types non-competition, non-solicitation
• Review local laws and decisions- AL, CA, CO, DE,
  MA, ND, TN, TX
• Rule of reasonableness physician/patient harm
• Specific practice prohibitions
• Hospital privileges co-terminus?
• Distance
• Specific mileage
• County
• Proximity to practice
• Medicare region
• Term
• Typically 18-24 months - LA, SD

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Coverage/Call

• Frequency
• Distance especially for multi-site practices
• Back-up for unfamiliar issues

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Future Relationship

• Length of subsequent contracts
• Partnership potential
• Precise nature of partnership
• Partnership valuation
• Buy-in
• Buy-out (departure versus death)
• Asset potential

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Partnership Issues

• Consider both cultural and financial aspects
• Review existing partnership documents
• Get everything in writing
• Consider the issues as you would any financial
  transaction
• Consider risks and benefits

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Partnership The Holy (or holey?) Grail?

• Understand exactly what you are getting into!
• Understand all details of this particular
  partnership
• Types of Partnerships
• General
• Limited

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Partnership Considerations

• Long-term implications to you and your family
• Buy-in periods and amounts
• Partnership culture
• How are differences handled
• How are decisions made entrenched leadership

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Financial Issues of Partnership

• Average income
• Accounts receivable
• History, patient base, payer base, procedure mix,
  90-day aging
• Overhead and debt load
• Look for shadow employees and costs
• Goodwill
• Real Estate and equipment optional or required

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Board Certification Requirements

• Typically three years from anniversary of
  eligibility or hire
• Current meaning of Board Eligibility
• Hospital rules/regulations
• Managed care relationships/contracts

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Dispute Resolution

• Method
• Litigation versus arbitration
• Specify details
• Costs
• Venue

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Transition Considerations

• Relocation expenses fixed, total, timed
• Rent versus buy
• Health care coverage COBRA payment
• Revenue stream issues household budgets
• State licensure issues
• Hospital privileges

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• Questions?