So, it was interesting listening to what happened in Denver about having ice cream. So my guys, when I was in Boulder, we found a marijuana shop, and my guys always had Hershey bars with marijuana at night before they went to bed, so it was a whole different experience. It was definitely fun, yeah, it's what you make it. So this is kind of a difficult topic to talk about, and I wrote this article, Pros and Cons of Hospital Employment, about eight years ago, and then Nick Scaglione, Louie McIntyre, who's here, Dave Glazer, who's the healthcare attorney for the Mayo Clinic, and I give this instructional course lecture. We're in our third year of it because last year got canceled. For those of you who are really concerned about contracting, we call it the good, the bad, and the ugly, and I can tell you, it's a real issue today for you guys, because when I signed a contract back in the early 80s, it was two pages, double space, and I just looked at one for one of the fellows, it was 40 pages, single space. So I'm going to go through this with you. I've looked at 23 contracts, I do it for fellows. So my email is bcoletrush.com. Just send it there. No, it's b-e-r-t-x-0-0-1 at gmail.com, and you can get it from the ANA office, but I'm happy to look at your contracts for you. I'm not an attorney, but I've looked at so many of them now, I have a pretty good feel if they're trying to screw you or not. So I'm going to move forward with this, if it works, and it's not working. I'm sorry. What should I use? Go ahead. One or two. No, that's good. Oh, I'm sorry. Well, that's what I did do, didn't I? Okay. I'm sorry. I'll go back. Can we go back one? I apologize. So let me start with a series of comments. Do not have your divorce or family law attorney review your contract. You got to use somebody who does contract law, and I'll explain that in a minute. It's familiar with issues regarding health care, review it for you. These contracts are not very difficult to understand beyond the legalese language. They're very, very difficult to change, however. So I put this up. It's not something I want you to read in the slide, and any of you can have this. It should be on our ANA website. But if you Google Becker's and Medscape, going back to 1-1-21, there's several really good articles. Just put in there Google contracts, and you'll see all these articles written by people a lot brighter than I am about what you should and what you shouldn't look for. I do want to point out one thing in this slide, though. The average amount you're going to make for a hospital is about $3.3 million net. So when they're offering you, you know, $450,000 or $500,000, they're going to tell you that they're going to reach the MGMA guideline, which they want to be at the 50th percentile. So what I say to people when I've represented some people talking to administrators, so if we're at the 50th percentile, does that mean you're the best of the worst or you're the worst of the best? And because that's really what they're saying, and so I don't think you should approach it that way or let them use that argument. So I'm going to discuss some basic concepts of contracting issues that I've reviewed and responded to on some employment concerns, whether you're beginning a private practice or your hospital or large system employed. So first of all, what is considered a full-time? How many work days are required? How many days are required to be on call, and are you compensated for call? And does outside work product belong to the employer? It shouldn't be an issue as long as it does not materially impair the performance by the employee of his or her duty. So in other words, if you're doing depositions or independent medical exams at 5 o'clock at night, you're done with your workday, they shouldn't want you to afford that money back to them. And the other thing that's full-time, I just saw a contract where it said that you have to allow an extra 10 hours a week for other activities as recommended by the hospital, which is absolute nonsense. So I'll show you that in just a second here. So you want to define outside activities referred to in these contracts and exclude them from hospital ownership. Independent medical examinations, depositions, medical record reviews, paid quality assurance rolls with insurers, any paid agreements with implant companies, clinical advisor fees, consultant fees, speaking fees, royalties, et cetera. Most of the employed positions, even in private practice, will try to include those in their contracts. So if you start doing independent medical exams on a weekend, which are maybe a huge demand in your community, you shouldn't have to have that count as part of your salary because it's outside the scope of your employment agreement. So this is a typical example of contract language. Professional fees. Employers shall have the exclusive right and authority to set, collect, and retain all fees. Well, that's fine if it's pro fees that you're earning from charging patients, the practice, all professional fees generated by surgery, et cetera. But look what else they put in here, including without limitation, professional retainer fees, honoraria, medical director fees, professional consulting, teaching fees, on-call fees, incentive payments from the government. So when I saw this in the contract, I had the fellow redactal just cross everything out and I told him to send this back to the attorney. Employers shall have the right to adopt the physician's first born at employer's discretion. And the reason I put that in is to point out that it was also ludicrous that why don't we add this to the contract? And of course the attorney then literally redacted all of that, which was great. So he recognized how ludicrous the commentary was. The other thing is the enforceable no-competes. Now it's really interesting over the last 48 hours, I don't know if you folks know this, but Biden is trying to sign this by executive order that you can't have no-competes, which would be awesome for you guys. So we'll see what happens with that. The other thing is these contracts are usually about three years and they have a 90-day outclose clause for either one of you. So in essence, you're signing a 90-day contract. So keep that in mind when you look at these out clauses. Potential inability to ever graduate from a rigid call schedule. So a buddy of mine who's a little, well, he's my age and he retired a few years ago from Kaiser, but he had to take call every fourth night until he was 65. Couldn't get out of it. Those retirement ages are very, very common in contracts now. And possible termination without cause, which means you didn't do anything wrong. They just don't like you. So termination without cause, either party may terminate this agreement without cause by giving the other party hereto at least 180 days prior written notice. What I would add here is that the no-compete goes away if this occurs. If the employer terminates without cause and the conditions imposed in sections above, note this specific section will become null and void. That may go away if Biden has his way, which would be awesome. Here's some unconscionable no-competes. If the contract is terminated, the employee cannot practice medicine as an employee or independent contractor under a management contract within 25 miles of any of the hospital and practice sites. So you're imagining you're in the Minneapolis-St. Paul area and you're owned by a line and you're employed by a lineman. Well, they have 24 clinics all within 10 miles of each other. So imagine if they said you couldn't practice within 25 miles of any of the hospital and practice sites, you'd be 100 miles outside of Minneapolis or St. Paul, which would be a huge problem, especially if you had kids in school. So add language to protect yourself stating, with the exception of a private practice group, and if you know some groups you might want to be with, or as a solo practitioner or list an academic or other group practice that you could practice in. So that's one way of solving that issue. Okay, what am I doing wrong? Okay, sorry. So if you look at some of the data out there, which again, hopefully will go away, most people cannot get out of these no-competes. Only 8% of respondents were able to do them. And so it's really a problem which hopefully is going to go away. Defined professional fees, just as we talked about. You need to have this ability to award injunctive relief, and I'll explain that in a second. The term of the contract, termination without cause, medical staff duties at discretion administration. So I saw one contract last year where you had to go to four meetings a week. And they were either at 6 a.m. or 6 p.m. at the discretion administration. Compensation clause to allow clawback or termination. I was telling Mike about one of the young guys that I had looked at three years ago, and what happened was he got his first year or second year salary clawed back. They were paying him $300,000, they asked for $150,000 of it back, and they really set him up in an awful situation. They had too many orthopedists as part of the group, and it was an employed position, and they weren't allowing the other family docs to refer to him because all the other docs wanted the referrals. So he literally had no way to build up a practice. So he's doing one to two cases a week after a year. He couldn't meet his RBU production. So they got rid of him and asked for half of his salary back, which is just ridiculous. But it can happen. And this is what I was talking about. Physician will actively participate in hospital medical staff committees as assigned by the medical staff. So I had one fellow add here, if agreed to by the physician. So I mean, if they want to add four committee meetings a week, they have to compensate you for it, in my opinion. Physician is expected to have no less than 40 available clinical patient hours per week in the practice site as scheduled by employer. And then look at what they put in here. Physician acknowledges it may take 40 to 50 hours per week to complete 40 scheduled hours. Seriously? So you want to delete that italicized sentence. But this is the kind of stuff you have to look for in your contract, and you don't need an attorney to do it that's charging you $500 an hour to look at your contract. Now this is this concept of injunctive relief, which I have seen in literally every contract I've looked at. If the provisions in the above section are breached or threatened to be breached by the employed physician, the extent of actual damage sustained by the employer will be difficult to ascertain, although great and irreparable. And again, bullshit. And that compensation at law will be inadequate, and that money damages alone will not be an appropriate measure of the harm to employer from such continued breach. So here's the remedy. The parties expressly agree that the employer shall have the right to injunctive relief for breach or threatened breach, which means they can come after you with any legal or equitable remedies that may be available. So they're going to come after you for money. Because to an administrator, it's not the money, it's the money, right? So the physician shall indemnify and hold the employer harmless with respect to all employers' costs and expenses, including attorney's fees. So if they want to exert this injunctive relief, you're going to have to pay their attorneys and yours. Anyway, it's BS, so try to get rid of as much of that as you can. I'm going to next go to employment concerns. What are your work locations? Are they multiple? So are you going to have to drive 50 miles to different locations? How far away are they? How are they going to market you? And I'm using the example of that one individual, sadly enough, who got clawed back. But they have to market you. They have to give you the ability to be successful or you're screwed. What kind of support staff will you have available? Will they give you a physician, assistant, scribe, med tech, AT, and a secretary? Well, you can't be like Dr. Cole unless you have a staff at 10 or 12. But in all seriousness, if you don't have a physician, assistant, or scribe, and you've got EPIC, you're screwed. It's an extra two hours a day just doing your medical records. Even just having a med tech or an athletic trainer is helpful. And then having a secretary is extremely helpful. So you've got to ask this question. What kind of support staff are they going to give you? If the contract does not allow salary increases, how many are you going into employed positions, do you think? Yeah, so maybe a third to 40% of you. Related to your work RVU production. So if they tell you you've got to hit 7,500 RVUs and you're not going to get any ancillary revenue like we do in private practice from ASCs, from MRIs, from your PT department, from your DME. The bottom line is there's got to be some way to be equivalent to the others in the area that are getting the ancillary revenue. So what you do is you try to increase your work RVU number. So for example, there's a group in St. Paul where they do extremely well as employed physicians. They're also getting 85 bucks per RVU once they hit 7,500. So it's not very difficult to get up to that seven figure salary, believe it or not, when you get your RVUs that high and they're feeding you cases from the family docs. But you will need support staff, patient volume to allow this to happen. So you're going to need internal referrals if you're hospital employed. And do the family docs have to refer to you internally? So that's a legal question, right? But we've discussed this many times with Dave Glaser at many of our meetings. And what has to happen is they have to say, look it, we want you to go see Dr. Tokish, for example, if he's employed. But you can go see Dr. Burt, the private guy down the street. But we really want you to see Dr. Tokish first. So that's kind of the way that should be handled. And it works out basically for most people who are hospital employed extremely well. What's included in your salary? Is it base pay, medical directorships, call pay, incentive based upon RVUs? What are the benefits? Do you get health insurance? Do you get life insurance? Do you get disability insurance, pension plan? Malpractice includes your tail. So if you leave and about 52% of orthopedists leave after one year, what you'll find is there's going to be a tail on your malpractice insurance. So if you get sued at month 13, you may not be covered. So you've got to make sure that tail is included. Are they going to pay for your medical education courses, cell phone, professional organizations? And one of the difficult questions is, has anyone left practice recently? Could I talk to that individual? If they hesitate, that should be a red flag. And is anyone retiring soon? You're hopefully going to enter a practice where there's some old guys that are retiring soon that are busy. Is the practice growing? Consider meeting with what's called the C suite, which is the CEO, CFO, anybody with a C in front of their name that's in administration. And that's a really important question, right? Because if their volumes are declining, if the salaries are declining, if their ancillary services aren't doing well, that's a red flag as well. Be careful of buyouts of senior partners that are exorbitant, that feel that they're owed a great deal of money for setting up the practice. At our group, we had an easy in, easy out. And the way we did it is that if you come into the practice, we're going to gather all your ancillary revenue for the first two to three years until you become a partner. And that's basically your buy-in. So you're not going to get credit for any of that except for your buy-in. And as you leave, we just say goodbye to you. And then you get bought out of your earnings, or the best way to do that is out of any real estate that you own. So it's not a big number. So bottom line is read contracts carefully, hire a health care attorney or contract law attorney to review the ramifications of the language in the contract if you don't understand it. Try to talk to other orthopedists in the community to see what kind of reputation the hospital or group has. And these are my final comments on beginning practice. Do not joust. So for example, if Dr. McIntyre's patient comes to me who hasn't done well, and I say, you know that Dr. McIntyre, yeah, he's kind of questionable the way he did that. I can tell you that that will come back to bite you within three to five years. And I've seen it in numerable occasions. I've done a lot of defense malpractice work, like John Richmond, he can tell you stories that would take an hour. And so much of it has started that way. So stay above it, guys. Do not joust with the other guys in your community. It will come back at you. Number two, don't operate on patients with questionable indications. We've had some horrendous cases in our area where docs build up these massive practices with basically negative MRIs, mild changes on their MRIs for arthritis, getting total hips and total knees. And it can become a huge problem, especially as insurers start to look at these cases with more peer review. And number three, be compassionate. Be compassionate with your colleagues. Be compassionate with your patients. After four to five years, when you hit your stride, it makes a huge difference. So stick your ego in your back pocket on a lot of these things. It'll really, really make a difference for you long term. Thank you very much. And if you have any questions, I'm going to, I can stick around for about another half an hour. If you have any questions, can I just take them now, Mike? Does anybody have any burning questions they want to ask? Happy to answer them because we have time. Wasn't that good, guys? I mean, come on. All right, so BERTX001 at gmail.com. If you have a practice management question, please throw it at me. If you have a contract, I'll be happy to do it. I've been doing it for about five, six years now. And it allows me to build up this repertoire of bad contracts. So I'm happy to look at them. Can I just hijack you for a second since you don't have any questions? Yes, sir. I just want you guys to know, when I finished, we got out of the mine, and Mr. Cerberi, the military, he was kind enough to take my contract, look at it, show me several places where I messed it up. So when he says he's interested in doing that for you, there's no place else except in the military. So if you have a question, that's the best person to ask. Thank you. Sorry. Thank you, sir. Thank you very much. Thank you, guys. Thanks, Jack. Thank you, Jack. That talk is so good. And I encourage you, if you have a big contract that you don't understand, get a contract attorney. You know, I'm an idiot and I read those things and I'm like, I don't know what the hell this means. And it's some of it's ego and pride. You know, you're like, oh, I can figure this out. It's gonna be fine. It's not fine. They're trying to screw you. So I also like the comment about don't joust, you know? So I'm partners with Buddy Savoie, Tulane, and when he gets these referrals in that are six time failed cuff repairs, whatever, his notes are so gracious. Because he'll be like, oh, I'm seeing this patient's referral of Dr. Smith, fantastic orthopedic surgeon, did a wonderful job, but unfortunately it all fell apart. So be gracious. So next, and I also want you to look around the room. So to show you the support that you guys have as residents of Fellows, our entire presidential line is here. So we've got Dr. Gettleman, Dr. Stone, Dr. Tokish. So we are here for you. Next.

employment contracts

medical field

contract law

work hours

compensation