Perspectives on Private Practice

Paul E. Wallner, DO, FACR, FAOCR, FASTRO, FACRO

Senior Vice President for Medical Affairs21st Century Oncology, LLC

Associate Executive Director for Radiation OncologyThe American Board of Radiology

Practice Experience

• Academic

• Private practice

• Federal government

• Corporate employee

Life After Residency:Welcome 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

Rule #1

Relax and try to enjoy the experience!

Rule #2

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

Rule #6

Make no assumptions!

Rule #7

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

Initiating the Job Search

• Timing – it’s 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?

Post-training Opportunities

• Academic

• Government (Federal and State)

• Private Practice– Solo, Group, Partnership, “Corporate”

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

Business Relationships

• Employee - without partnership opportunity– Large corporation model– Ideal for part-time employment

• Employee – with partnership opportunity (?)– Don’t 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

Contracts (general considerations)

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

binding

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

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

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

Benefits(Employee versus sub-contractor)

• Pension/ 401(k) – contribution(s), vesting• Profit-sharing - vesting• Insurance – health, life, AD&D, general

liability, umbrella• Automobile• Meetings• Journals• Memberships• Medical/other licenses• Medical liability insurance

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

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

Coverage/Call

• Frequency

• Distance – especially for multi-site practices

• Back-up – for unfamiliar issues

Future Relationship

• Length of subsequent contracts

• Partnership potential

• Precise nature of partnership

• Partnership valuation

• Buy-in

• Buy-out (departure versus death)

• Asset potential

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

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

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”

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

Board Certification Requirements

• Typically three years from anniversary of eligibility or hire

• Current meaning of “Board Eligibility”

• Hospital rules/regulations

• Managed care relationships/contracts

Dispute Resolution

• Method– Litigation versus arbitration– Specify details

• Costs

• Venue

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

Questions?