Perspectives on Private Practice Paul E. Wallner, DO, FACR, FAOCR, FASTRO, FACRO Senior Vice President for Medical Affairs 21 st Century Oncology, LLC Associate Executive Director for Radiation Oncology The 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 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?