This talk will focus on contracts and negotiations, practical tips. At some point in your career, you will find the initial job. You will renegotiate a contract. You may look for another job at another institution requiring an evaluation of the contract. At some point, this will likely happen to you. I will try to cover some practical tips in this talk. No disclosures for this section. I do not have any polling questions. In my mind, this is a completely new language for almost everyone in the audience. The first time I heard a talk on this topic, I was completely confused. If you are confused at the end of this talk, that is okay. Hopefully, we will have some supplementary information for you in the June issue of IGIE. Along with two APP colleagues, a physician colleague and an attorney colleague, we submitted an article to IGIE. Best practice recommendations for APPs on contract terms and negotiations. Hopefully, that will be available for you in June to always have access to. Before we get into the contract and talk about some specific terms, in my mind, the whole contract process starts with your pre-interview work and your interview. Then, we have the formal contract. As you start to think about a new job or negotiating your first job, understand what you want. In your mind, what does the perfect practice look like? Make a list of your priorities, leaving the most important ones at the top of the list. For example, what type of practice do you want? Are you thinking about independent practice? Maybe an academic practice? Are you looking to stay at the same location you are at? Perhaps you are an endoscopy nurse or a clinic nurse and are obtaining your NP degree. Would you like to stay at that location or would you like to go to another city and look at other opportunities? Would you like a small practice or a larger practice? Look at the scope of practice. Are you looking to be a general GIAVP or do you want something more specific, perhaps looking at the hospital or a subspecialty? And income, again, something we always need to keep in our mind, that the income potential is something we want to discuss and make sure we address in the contract. It's an important part of the contract and our happiness, making sure we are compensated appropriately. Understand what's out there. Currently, it is a buyer's market. There are lots of jobs and lots of different types of jobs. Academic jobs have general APP opportunities and subspecialty APPs. The private practice is really quite wide open. You have traditional independent models. You have private equity groups. You have multispecialty groups. You have single specialty groups. So lots of different models. So find something that really fits your needs. Before the interview, before the contract, get a few things taken care of. And I think I may have gone for a run and had too much espresso when I do a lot of interviews as the opener. I would say do a couple interviews if you can. You'll learn about different types of practices. I think by looking at different practices and different practice models, you'll really get the ideal fit for you. Figure out what you want. And if there's a family involved, figure out what your family needs. Again, listing those things that are most important to you. Certainly try to list those things that are most important to you to get what you want, but always knowing you can't get everything. So make that list, starting with the most important things. As you go through this, narrow your field of options. And just before the visit, again, confirm the type of practice you would like to join. If you have any contacts at these practices, learn about the leadership. Learn about the culture before you go into that interview so you can develop a list of important questions. On the practice visit, remember, again, it's a buyer's market. And I always think this is an important point that is frequently overlooked. Yes, you are being interviewed. But remember, you are interviewing them as well. You have much more leverage than you think because it's a buyer's market. So make sure you get the job you want. And don't be afraid to walk away from an interview saying, this job isn't for me. I'm going to keep looking. So yes, you're interviewed, but you are also interviewing the group. When you're there, listen, observe, observe the behaviors of the physician, of the staff. Listen to how they talk to each other, their body language to each other, how they answer your questions and their body language towards you. Talk to as many people as you can. APPs within the practice, physicians within the practice, non-physicians, front desk people, administrators, nurses. Ask your questions and look for consistent answers. And if this is your first job you're looking for, a new job, I would say get there a little ahead of time. Sit in the waiting room and talk to patients. See how the front desk interacts with patients. No one will have any clue. No one in the waiting room will have any clue who you are and why you're there. So use that as an opportunity to learn. And through these techniques, you'll be able to learn about the practice culture. So some questions to explore as you're ready to sign that contract. You found the practice you want. Some final questions. As you think about getting into that contract discussion, don't make compensation the first discussion point. It's very important to you. It's very important to all of us. Put that a little low on your list. Don't make it all about the money, as we talked about in the talk earlier this morning. Think about the whole practice experience and the culture. Ask yourself, why is the practice hiring? Are they growing and need more help, which is a very good sign? Or has there been a lot of turnover within the practice? And there's turnover with APPs because the APPs aren't happy and they've not been treated well. And we'll cover this a little bit more in your duties. Make sure you understand what is expected of you as you go through the contract. So as you're ready to make a commitment to a practice, I highly recommend consulting an attorney. I think it is not in your best interest to proceed with signing a contract without legal review. They will clearly outline for you in terms you can understand the practice bylaws, the practice rules, and other forms of regulation and governance within the practice. Make sure you obtain a draft employment agreement before you sign you, before you get the final version. This will allow you and your attorney to review the contract and begin a strategy to make some changes and ultimately negotiate. So again, I want to make this point clear. Have a lawyer with expertise in health care and employment law review your contract. You don't want to be in this position where you have these two wolves, alligators, whatever you would like to call them, ready to pounce on you. You want to turn the tables on the group and make it an even view that you're both on the same plane. And an attorney with expertise in health care and employment law and in negotiation will make this an even playing field. So typical terms and sections you'll see within the contract. So this is a new terminology, a new list of words. We'll review the word term. I know you're familiar with compensation and benefits. We'll discuss duties. Look at company's responsibilities. Review the term restrictive covenant and non-solicitation. Even though you're looking for a new job or signing at your first job or renegotiating an old contract, we always have to understand the termination aspect and termination criteria and understand gap and tail insurance. Before we get into that, I want to start with a slide on negotiations and we'll end with a slide on negotiations. Remember, from the practice perspective, they want to standardize and simplify the contracts. They want to have very little negotiated. They want to have everything pretty much straight lined and simple because it maximizes options for the patient, for the practice. And I understand that. However, you have a completely different view. You want to maximize your options. So you want to individualize as much as you can, insert specific requests when you can, and maximize the benefits to you within the contract. As we go through this talk, we'll talk about negotiating the compensation, schedule, vacation. These are common things that can be negotiated and may require negotiation, and also whether you want to work full-time versus part-time. And remember, you should completely understand that it is well within your right to negotiate. You should be aware of that right to negotiate, and you should not feel like you're asking anything that's inappropriate. Look out for your best interest and understand that you can't have everything, but many times you can get a number of things that are important to you. So let's go over some definitions. Term identifies the start and end date of the contract. Typically, contracts in medicine are one year. Sometimes we see multi-year, but whatever that timeframe is, make sure you understand the start and end date of the contract. Many contracts are automatically renewable, and you should understand if it is, because if it is automatically renewable, you don't want to miss an opportunity to negotiate something new within your contract by having that deadline passed. So make sure you understand if it's automatically renewable or if there's a specific renewal process giving you the opportunity to have a work review and making choices perhaps to change your contract specifically related to some of your duties. As you start to go through this process, before you actually get the contract, if you could get something in writing about the term ahead of time, even if it's only in an email, that could be helpful to your attorney. Termination. Termination for cause and termination without cause. Those are two of the big points we'll cover. Termination for cause is typically unilateral from the organization. You want to get this as narrowly defined as possible. These should really be big, almost egregious violations. You've lost a medical license. There's been a felony conviction. There's been use of illegal drugs, disability that doesn't allow you to work in any manner. So these are big, big topics that should be very narrowly defined. You want to make sure there's a timeline. Immediate should be something that should be reserved for only something quite egregious. Otherwise, there should be a longer period notification. And I'd like to think we should have a provision in our contracts that for many of these issues where they're thinking about termination for cause, there should be some written notice of the complaint and an option for remediation. So I'd like to think that in medicine, we have a kinder nature and can remedy many of the problems that come up. Termination without cause can occur by either party. You may decide to leave and find new employment. There once again is a specified period of advance written notice, typically 90 to 180 days, but it could be shorter, rarely longer. And there's typically a provision for severance pay under some circumstances if termination without cause occurs on behalf of the organization. Gap and tail insurance, we're all familiar with medical malpractice. That's part of our benefits package. Most of us have a claims made malpractice insurance that covers us during our time of employment. It typically ends when the provider leaves the practice and the provider can be a physician or APP. You might see provider or specific language for the APP. So that's claims made keeps the type of insurance. The tail covers us after we leave for some period of time. Tail insurance provides courage after termination for events that may have occurred during the period of employment. So you've left and perhaps something comes up from a year ago or two years ago. And tail insurance lasts quite a long time, especially in retirement. There's a period of time that covers you throughout your length of retirement when that time comes. Restrictive covenant and non-solicitation. This prohibits APPs from practicing medicine for a specified period of time in a specific geographic area. So if there is a restrictive covenant from the practice's objective, they want to prevent departing APP from taking patients with them when they leave. And so they're looking out to protect their best interests. However, the group cannot stop patients from following you. If a patient on their own wishes to follow you to your new practice, they certainly can do that. You might see a companion clause, non-solicitation. This is a clause that prohibits proactive solicitation of practice patients, employees, or health plan contracts to your new practice. Once again, if a patient or an employee wants to follow you to another practice, they can. You just can't proactively solicit them. Your attorney will try to limit this time and geography as much as possible. Typically, it's one to two years. Most of the time, it's one and generally not beyond the 10-mile radius. And it's important to understand it's a 10-mile radius from where you actually practice, the physical location where you practice. So if the practice has satellites, it's not the farthest satellite. It's where you practice. Also know that enforceability varies from state to state. Typically, it's 50-50 whether this restrictive covenant or non-solicitation will hold up. But don't regard this as a major advantage. If you do end up in court, the practice can outspend you in a lawsuit. So just make sure you get this covered ahead of time by your attorney. Duties, which is very important, and it's very simple. The duties outline what you will do in your job description at the practice. You will see it described something like this. The provider agrees to devote full time, and they'll define full time to the practice and to perform such services, which will be outlined, and duties, which will be outlined as from time to time to be assigned to the physician by company. Confusing, but all it means, it's going to outline your work duties. And it's built to protect them, but also to protect you if you agree with the work duties that you sign in the contract. It hopefully avoids that ping-ponging of you from practice or location to location and from the endoscopy center to the clinic. Outlining that your duties are in the clinic if you're a clinic APP, what your weekly hours are, what your expectations are for patient load. And so, again, clearly define that with the help of your attorney and get this as narrowly defined and as specific as possible. Compensation, something definitely that you want to talk about. Understand the salary. Will you have a salary only? Is it base salary plus bonus? Is it purely productivity? How is all of this determined? Are we used to determine your salary? Make sure you completely understand how you will be paid. Understand the timeline. Will your salary change over time? Are there cost of living increases built in? Are there merit raises built in? Make sure you understand how your salary changes over time, and that should be in the contract. And some of these variables vary by geography. Your attorney can help, and you can both go to Medscape, MGMA, Merit Hawkins as examples to look for benchmarking to maximize your income. As I said, look for other incentives or other productivity-based incentives. You might see performance measures such as patient satisfaction, good citizenship. That's a little harder to define, but these may impact on merit raises. Payment for non-revenue-creating activity could be in there, such as you getting involved in research activities, and maybe there's some compensation for that. And maybe you get paid for call. Make sure all of that is clearly outlined in the contract. Benefits. Malpractice insurance, as I alluded to when we talked about TAIL, that absolutely should be covered in the contract. Again, usually claims made, malpractice is the most common. Other typical benefits are health insurance. Dental is typically included with vision. You might see an HSA or an FSA. There may be a disability and likely a disability policy. Life insurance may or may not be provided. A big one, something that I highly recommend you vet thoroughly in the contract with your attorney is the retirement plan. There are many different opportunities, as I said this morning in my other talk, 401K, 403B, profit-sharing, defined benefit. Make sure you maximize your access to these retirement plans. Make sure you understand when they start. It's typically after the first year of employment, and see if there is a company contribution. You want to start now thinking about your future and planning and financially planning for your retirement, so maximize your contribution to any of these qualified plans. Paid time off should be clearly outlined in the contract, and I think is an area for negotiation if it doesn't seem like it's appropriate. Four to six weeks is the time frame we see thrown around. Again, I like five to six weeks of pure vacation. I like sick time or leave for illness and CME separate, so try to negotiate those separately. If they do want to lump them, make sure it's six weeks or more for all of this grouping. Maternal leave and family leave obviously should be covered in the contract, especially where there are companies that employ 50 or more people. Other things that are important for benefits, they may seem small, but they can add up. Professional memberships, how much do they pay? CME, not just time off, but how much they pay for time off, and these things can be negotiable. Is there a signing bonus? If you're relocating, do they help pay for relocation expenses? Are there student loan repayments? We are starting to see some student loan repayments in some practices. We'll finish up with negotiation. Remember, everything is negotiable theoretically. You just can't have everything. Negotiate what is important to you. If that's compensation, and I again urge you to view total compensation, then make it compensation. It's scheduling that you really need to have that 10-hour, four-day workday. Make that your priority. Maybe working part-time 80% is your priority. Perhaps vacation is priority. Work through these things, full-time versus part-time, weekends call. Are there opportunities for research? Are there opportunities to teach? Look to get these put in the contract if they're important to you. Always negotiate from position of strength. You do that by understanding the data. There are plenty of resources for you to understand the data, so data, data, data, and your attorney can help you negotiate from a position of strength. Even if they're not present, they can prepare you for the negotiation. Remember, when negotiating, speak slowly and speak confidently. Have a relaxed and confident body position and body language. Never demand. Always ask. Be respectful. You expect them to compromise, and sometimes you may need to compromise if it's acceptable to you. In summary, the interview process starts the contract process. Do your homework and be prepared for the contract review when it comes up. Have an attorney present. Understand the contract terms. Understand that you can negotiate and should not hesitate to negotiate if it's important to you. And I can't emphasize this enough. I know there will be an increased expense for you, but legal review, legal review, legal review. You have to look out for your best interests. With that, I have completed the talk. Thank you, and I will turn this over to John for the Q&A.

contracts

negotiations

job market

practice options

employment contracts

compensation