Bottom line of my upcoming talk is that we value you immensely. You're an integral part of our practices as APPs and GI and hepatology. We can't meet our mission without you. As a result of that, I think it's very, very important to understand how great your value is, but to be able to define that in a quantitative way. That leads you to being in a strong position when you go into your contract negotiations, which is the other part of this talk. And before I start, I want to underscore also that when we talk about contract negotiations, we're not just talking about your remuneration, what you're paid overall for the great and important work that you do, but also making sure that you find the right practice to fit into to be happy. Because at the end of the day, you're going to serve patients best if you're happy doing what you're doing, where you spend the majority of your waking hours through the weekdays, sometimes in the weekend, and also covering holidays and so forth. So it's important to be happy, to find the right fit, but also to value yourself properly and value yourself enough that you make sure that you are remunerated for what you are truly worth. So here we go. I have no disclosure. So the objectives of my talk are to learn why it's important and valuable to negotiate, to define the elements that constitute your value, to describe the process of negotiation as well as the elements that constitute a negotiation, to determine what to ask for when negotiating, to learn what is and what isn't negotiable and why, to discuss successful techniques of negotiation, and to discuss what's important to do after a successful negotiation. Let's start with some polling questions. Your total compensation, is it, one, your total salary, your hourly pay? Or two, does it also include all incentive and bonus pay? Or is it three, does it also include your total salary, your hourly pay, all incentive and bonus pay, and also the dollar value of your perks, your benefits? Or is it all of that minus the taxes that you pay on all of this remuneration? One answer is correct. And the majority of you are correct. It doesn't actually include the taxes that you pay, but it includes all components of your pay, including your benefits. And we'll talk about why that distinction is important farther into the talk. Next polling question. The majority of ABPs are compensated solely based on salary or hourly pay models. Is that statement correct or is it incorrect? True or false? In a sense, I'm glad you answered true, because actually, you will find some interesting data that's demonstrating that while that was true, times are changing. And you're being compensated more and more the way the other group of providers called physicians are being compensated. So we'll have some interesting things to discuss. Great, so why negotiate? Well, because you want to make sure you're paid what you're worth, pure and simple. We just got done explaining you are immensely valued. Let's make sure you get paid what you're worth. And because you respect yourself enough to negotiate. You are important. You are invaluable. Therefore, respect how valuable you are enough to negotiate. A negotiation is a conversation. You should have the conversation. Always ask. The worst that can happen is no, and that still doesn't mean you can't talk some more. And the other reason to negotiate is that you are diligent enough to do the due diligence required to determine what your value is. Your value doesn't come out of thin air. There's plenty of evidence. You practice evidence-based medicine. Let's be evidence-based about what your true value is. As you can see in these pictures, you're well-educated, and then you're well-trained. And you have a license. So you have specialized knowledge and capabilities, but you also have a license that others don't have. So you are a scarce resource. Let's negotiate and get what you're worth. So you deserve to negotiate because you earn the opportunity by going through the education, training, and experiences that we just talked about. It's a prize to be in the position to negotiate. So don't just give that prize up. You don't get what you deserve. You get what you negotiate. This is something that Chester Karras, who was a brilliant negotiator and a business professor, said. And that quote has stuck around, and it rings ever so true. Remember, it's your job, not theirs, to make sure that you get what you deserve. Because it's actually their job to get what they need from you at the lowest cost for which they can get it. So you need to negotiate for you because you know they're going to negotiate for them. Success in negotiation, which is a conversation, is based on knowing the data so that you can be evidence-based about the negotiation. And that requires understanding that this is all about supply and demand. Understanding, marketing, and leveraging your unique value is what you need to do to support yourself in the negotiation. Do you have some special qualifications, such as a fellowship after your general APP training that's extremely valuable to the practice or practices that you're looking at, but is a hard qualification to find? Do you have unique prior experiences that are difficult to locate and hard to find? Those things are all important for you to leverage with respect to your unique value to the practice that you're visiting. Know how badly you're needed and how tight APP supply is. There's tons of data out there from the various publications that end up in your email box every day. Professional organizations, marketing firms, and so forth supply you and digest for you all sorts of data with respect to the tight supply of APPs in the market, nationally, locally, and within the specialty of your interest. How much you want or need that particular job has to do with how tough you're going to be as a negotiator, too. If you really want that job because it's the right fit, you might need to compromise a little bit to make that happen, particularly if there are a number of other candidates who are equally qualified. How good a specific opportunity is compared to others that are or seem available to you is also important because to be in a strong position of negotiation, you probably are better off having other opportunities that you're at least looking at and considering so that you can make a comparison. Because as a valued expert but in a competitive area where there are other candidates who are very competitive, you are not going to want to put all your eggs in one basket if you're going to want to be able to negotiate hard. So to negotiate, you need to know what you're worth. And that's what defining your value is about. So how do you bring value to the practice? How are you personally valuable to the practice? Because that's important to defining your value. And I can't underscore enough, as the print in red says, it's not just what you do, it's also who you are. Let me explain. As a provider yourself, you contribute to improved access, patient volume, patient satisfaction, and capacity for the practice, the center, and or the hospital or system that you work for. You bring new skills, clinical expertise, business proficiency, and research talent and capability to the team, just like Dr. Vacari mentioned. You can expand the practice's clinical skill set and capabilities and augment efficiency as well as improve patient quality and satisfaction, also like Joe mentioned. And of course, you're an exemplary citizen who's an absolute pleasure to work with and infectiously brightens up the practice milieu. I can't tell you how important it is, because at the end of the day, we spend a lot of time with each other. And isn't it so important when you come in to have a smile on your face as you walk in the door because you're excited about working with those great people that you work with? And that's how you want them to feel about you. That makes you uniquely valuable. And that goes beyond your skills. That's who you are. And you want them to value that too, because who you are is an individual. Nobody else is exactly like you, which means nobody else is exactly as valuable as you in exactly the same way. All right, so why are you valuable? Well, first, you're frontline client-facing members of the group. You're the ones who see the patients. You make important decisions that impact their lives. You're amongst the most important, but also costly resources to the practice. You're a costly resource because you are incredibly valuable. That's why you can command that. You're amongst the most remunerative resources in the practice. You're an indispensable player on the healthcare team, and you are a scarce resource. As I said before, you're licensed. Very few people have a license to practice as an APP. You're one of a limited number of APPs educated and trained every year, and demand for healthcare is not only high, it's going higher, as Dr. Vicari pointed out with his evidence. It's unsaturated. It's never gonna be saturated, and it continues to increase as the slope gets steeper for that demand. Every medical specialty and practice must compete with other specialties and practices for licensed healthcare providers, and that is you. And you have multiple other opportunities for employment where work may be as or more satisfying, might be better compensated, have better benefits, be easier, less unpleasant, less physical, have fewer impediments, better hours, greater resources, and have nicer partners to work with. So you are incredibly valuable, and that's why. So why is defining your value important? Because you can't just pull a number out of thin air. Your value is quantitated in terms of remuneration, and it's qualitative in terms of what an awesome personality you are to work with, what impact you have on the work milieu to brighten up the environment and make everybody else who works there happy and productive. But you need to know what to ask, and it needs to be based on data, because your remuneration at least needs to be in line with objective comparators. And those comparators have to do with what others with the same qualifications make, databases out there that provide you with that quantitated evidence, and some of that is going to come to you by word of mouth. So what others make with the same qualifications, with the same portfolio of experience, education, training, pedigree, and specialization, in the same location or region, and the same specialty and type of practice. All those are inputs into what you can reasonably expect and ask for in compensation. There are many sources of data out there, some are going to be more accurate and up to date than others, so you have to be careful about comparing apples to apples. Remember what's not included in these numbers, and that's going to be something we're gonna talk about in just a moment. Because if you look at some of the today's equivalent of want ads for employment, such as indeed.com, the numbers they show you for salaries, and remember, there are some states where they're actually required to report salary, and so they actually put a number there. Those often only reflect base salary and do not reflect other components of your compensation, as was hinted at in one of the polling questions, which we're also going to cover. And there may be more accurate numbers from organizations like the MGMA, where you may have to pay to play, you may have to pay to access these numbers, which are better numbers. But remember that anything that you pay in your job search is an unreimbursed business expense, if it is unreimbursed, and you can deduct that from your taxes, so that will help. You know other APPs, ask them, word of mouth is powerful. They can tell you what their total compensation package is, if you're confidential about it, and they're your good friend, they may be willing to divulge that to your advantage. All right, so this is a late addition to my slide deck that I threw in there. After the deck was uploaded, I just read this data a couple of days ago and tabulated it for you, because I just wanted you to see the spread here. This is APP, or specifically APN, U.S. Average Hourly Pay Rate by State. So these are people that are paid hourly. Look at the difference between Tennessee, which is on the lowest end, and California, which is on the highest end. That's quite a spread. Some of that though has to do with demand, and some of that also has to do with cost of living, and probably other inputs to consider. My point here is that clinical medicine is a very regional business. And so you can't compare a salary in Kentucky to a salary in New York, apples to apples. You have to take into consideration what's going on regionally, and that's how you can determine where you can start to negotiate. So you need to know before you go. The practice models and compensation models vary greatly. Most APPs aren't in salary-only or hourly-only compensation models anymore, actually, as you'll see. Formulas that are used to establish your compensation do vary a lot. Many common compensation formulae include multiple components, including salary, productivity incentives, other variables, including quality metrics, volume or throughput, and so forth. Salary and clinical productivity does usually comprise the largest proportion of total compensation, and the formula for total compensation is listed there for you. In a nutshell, it's your base pay plus any incentive pay plus the dollar value of your entire benefits package. So do you know the current APP compensation models? As we said, it's not just about fixed salary or hourly pay. There are now practices where part of your pay is based on your productivity. They may use an RVU-based model like they do for most physicians' practices. There may be salary plus that productivity incentive-based pay. Partnership or profit-sharing is also starting to creep in, which may or may not be a benefit depending on what you want. And there are some emerging trends that include value-based pay, team-based care, loan repayment bonuses for meeting specific goals that the practice sets. So your compensation models are beginning to look more and more like our compensation models because at the end of the day, we're providers too. So what did a recent survey show? This was done by the MGMA, over 500 responses from medical group leaders. And that survey showed that 40% of the respondents, so not a majority, rely solely on either set salary or hourly wage. 42% said their organizations considering updating APP compensation models as utilization and staffing models evolve. And many suggest potential addition of work RVU productivity or other incentives that might be combined with a set base salary. A percentage of collections or services provided or cash receipts after overhead, quarterly or year-end bonuses based on productivity, incentives tied to quality measures, patient experience scores, no closure, citizenship, a per work RVU incentive based on average RVUs over a 12-month period that's rolling. So again, stuff that we're used to as physicians, and because you're a provider, they're treating you more and more like the physicians. So this is a graphic representation of what I just was talking about with that recent poll. And as you can see, the majority are now, the majority of APPs are now compensated with salary plus incentive compensation, and that's solely salary or hourly pay has dropped down to about 40%. All right, so how do these compensation elements sum up? The specific elements and the relative weight of each element do vary between employers and practices, but some are pretty consistent across most organizations. So base pay, salary or hourly pay is usually the substantial proportion of your compensation, but it's gonna be dependent on the practice type, specialty, location, hours, intensity, et cetera. And these are gonna vary from year to year based on multiple factors. And these may be tiered based on your level of experience, how long you've been at the practice, seniority. It might be supplemented with other types of pay, which may be benchmarked or may be adjusted based on multiple factors, such as if you have a leadership role, you may receive a separate form of compensation for undertaking that extra work and responsibility. Clinical productivity incentive pay is usually also a substantial proportion as you saw in that poll just now. It's usually measured by a standard metric of work, such as a work RVU. There is a downside to this is if you have some choice over which patient you see, then this can lead to some cherry picking of patients that lead to better work RVU generation per unit of time. And so there's pros and cons to using this type of incentive pay. So let's talk about total compensation. And I said earlier that this is your monetary compensation plus the dollar value of the benefits and other perks that you received. And some of those perks may actually be worth more dollar for dollar than your monetary compensation, because you either don't pay taxes on it. It's already, you know, it's tax, it's either pre-tax or not taxable, right? So if you're paying taxes on what you pocket, some of this you may not pocket till after you retire, at which point you'll be in a lower tax bracket. So you get to keep more of the value of it, or they may be non-taxable benefits. So the total compensation might be your salary plus your incentive pay, plus the dollar value of these benefits. And you really, when you compare practice to practice and pay package to pay package, don't forget to figure in the benefits packages. They can vary greatly from practice to practice, and you don't wanna leave money on the table or calculate wrong. These may be very generous. They can contribute a lot of monetary value, particularly if there's excellent insurance of various sorts, or there is tax deferred compensation where they match your 401 or 403, or better yet, if they also provide you with a pension, especially if that pension is fully contributed to by the employer and you don't put a nickel into it, that dollar for dollar is more valuable than the taxable income that they're paying you month by month. An accurate comparison of comparisons between employers really does require a detailed comparison of total compensation. So all those reams of PDFs that they provide for you and the website that they give you access to to look at their benefits package, you really need to go over that with a fine tooth comb because that frequently is worth at least 30% of your total compensation. And at some generous practices and institutions, it might be worth more than a third of your total compensation. But at the end of the day, remember it's not all about the money because what's most important is being in a practice where you're gonna be most happy and feel most valued. But being valued also means making sure that you're being compensated what you're worth and being treated fairly from that perspective. So where the rubber meets the road is all about what to do. Do your research, know what you're worth, develop a basic understanding of the current range of specialty specific compensation in your area or region. Talk to people, look at websites and other resources that are available to you. And if you have to pay to get on those, tax deduct those. Understand the APP positions that you're considering. Dr. Vickery talked about this. And how much compensation can you expect at your level of experience or seniority? You really need to understand what you're worth and then ask for what you're worth. And if anything isn't clear, ask questions, but ask politely and not in a demanding way. And if the pay is tiered, understand how and whether ascension from tier to tier is guaranteed year to year if you have to meet certain marks. Learn how you're expected to be promoted. Understand that while the salary part of compensation might be relatively easy to understand, the other components might be more difficult to understand. You need to know what you have to do to hit those marks so that you have a good understanding of whether you can meet those marks or not. And ultimately how that's gonna contribute to your overall pay. Ancillary measures might be complex and they might vary year to year, as I just mentioned. If you can't understand these models, you might need to engage a compensation expert or an attorney to help you understand or to help you negotiate. And those expenses are also tax deductible. Ask questions, ask lots of questions, but be polite. And the best time to ask is before you sign your contract and buy a new house and move your family to a new town. You don't wanna make a mistake. Don't be afraid to negotiate. You are valuable. You're a scarce resource. They want you, make them want you. If you plan to negotiate, consider hiring those experts that I just mentioned to you and tax deduct the costs. Remember, they always have a lawyer when they're drawing up your contract. Why shouldn't you? So to be taken seriously, you need to know what's negotiable and what's not. Not everything's negotiable. Most things pay-related, even if you're salaried, are probably negotiable. And as I mentioned, there may be other buckets from which they can pay you more, such as your leadership role that stack on top of your salary or productivity incentive. What may be negotiable is things like perks, certain ones like relocation expenses. Those sorts of things are one-time expenses. They're almost like a hiring bonus. And those sorts of things tend to be more negotiable than recurrent expenses, parking, for example, or maybe details related to work. If you have certain needs with respect to schedule or certain medical, patients with certain medical conditions that you don't wanna see or treat, who you would do or don't work with, what conditions you treat, those things might be negotiable. But what probably won't be negotiable is things related to a benefit package, which is gonna be the same for everybody in your group. You're not gonna be able to negotiate that. Your health insurance, that's a package that's offered to all the providers, and you're probably not gonna be able to negotiate that. Same thing with retirement benefits and programs and incentive pay structures. Those sorts of things tend to apply to the entire class and are not individually negotiable. How do you negotiate? I don't know how to state this more clearly. Make them want you, specifically you. Make yourself unique. Make yourself likable, desirable. Make yourself indispensable to them better than any other candidate. First, you need to put your best foot forward. You know this. It starts well before negotiation. How did you work your way into APP school? That's incredibly competitive. Make sure all your documentation is ducks in a row. That's what they see first. That's your calling card these days, your CV. Make sure it's polished and it's structured in a way that's easy to see and demonstrates your strong points. Make sure you've read up on that practice. Know all the members of the practice, who's who. Know who's interviewing you. Know what their interests are and address them by name and smile. Interview well. Be your very best and be proud that you got the interview and that opportunity to negotiate. Look professional and confident. Demonstrate that you're gonna be the ultimate team player and a model citizen who's going to improve everybody else's productivity because the whole practice is gonna be a happier place for your being in the environment. And listen, listen, listen. Talk enough, but don't talk too much. You wanna be a listener and show that you're a listener who processes what you're listening and asks insightful questions based on what you heard. Take time to think before you answer, but not too long. Be agreeable. Don't argue. Consider what the interview is asking, what they're asking for and what they're saying. And remember to be confident but also to be humble and respectful. You have to be all of those things. You don't wanna be boastful, but you wanna be confident in a humble and respectful way and be enthusiastic. Keep your high energy up in all circumstances. And no matter what you need to look at and sound confident, humble, and respectful. Speak clearly, make good eye contact, be poised, sit and stand straight up, dress in a tidy fashion without extraneous ornamentation and don't wear things that might be perceived as controversial. You can do that in your own personal life, but not when you're interviewing if you want the best chance of getting that job that you really want the most. Ask rather than tell, be grateful and look and sound that way. And remember that it never hurts to ask how you ask. And congratulations, remember you succeeded. You got the interview and you nailed your interview and you wouldn't be able to negotiate if you hadn't done that. So now you're ready to negotiate from a high position from the perspective of being the person that they wanna recruit. You're wanted now. Next, they gotta have you, but you need to know what you want. What are your goals? What do you need from the practice? Ask for what you need. Make sure you understand what's realistic though before you negotiate because you can't be asking for the pie in the sky because you're evidence-based just like you are when you take care of patients. Know what others in that area, in that specialty and that kind of practice expect and receive. Be honest with yourself and your loved ones too about what you need. And I'm talking about your schedule and things like that. There's more to life than your career and there's more to your life than just you, right? Everybody has other people that are important to them and they need to be considered in this. And understand the practice, read up about them, understand what their mission is. Different practices have different missions, different desires and future projections. See where you fit into that culture. Get a feel for your power and desire to negotiate. How much do they want you? How much do they need you, right? Even more importantly, how much do you want them? Are they the practice or are there others that are equally good in your mind? But never burn bridges because until you sign, nothing's secure. So the one that might seem second best, don't get rid of it yet, okay? Tips to remember, be prompt on arrival and communicating, polite, humble. Take time to think and consider, but don't drag things out because then you seem inconsiderate. Never hurts to ask, but you gotta know when to stop asking. Don't be a pest. Be in regular contact without being a pest. Make it just right, not too much. Don't burn bridges, don't be greedy. Don't be afraid to ask for what you know to be reasonable and do that by presenting evidence. You know how to do that. So be seen as evidence-based because that'll show that that's how you see your patients too. And ask, don't tell. People like to be asked. So ask for what you need. And then a lot of negotiation, remember, gets done by email, especially if it's long distance, which can be great for many reasons. But beware of emails and what you say there because they can be forwarded to other people. So you want to be careful. Some things might be better talked about on the phone. Don't forget, there's still a thing called a telephone. Afterwards, follow up promptly and be grateful. Send a thank you communication to everyone. And you may want to do that to each individual rather than a big CC list. Kind of looks better and more personal and professional. If you like the practice and want to join them, pick up the phone, let them know as soon as possible. Tell them you are so enthusiastic. They'll love that. And you can still ask for things you need and want. Even after you've signed, you can always revise a contract, but I can't underscore enough that you probably want to do as much as you can before they finalize the contract because it's pain for them and it's additional legal expense for them to go back and revise. Be patient waiting for that contract. Like I said, keep in touch. Strongly consider having a specialized attorney review your contract, a medical contract attorney. It's going to cost you many times, a couple thousand dollars but that's going to be tax deductible and might help you to sleep at night and keep you friends with your new colleagues. Having an attorney participate in these negotiations, you can actually pay them extra to do the negotiating for you. That may be advantageous if you're negotiating, for example, with the people who taught or trained you and you might feel like it might be uncomfortable to negotiate directly with your teacher. I was in that situation once I got the attorney to do it and she did a beautiful job of it for me and she charged me an extra thousand dollars but it was worth every penny because I didn't have to go toe to toe with my teachers. Sign the legally reviewed offer and return it promptly. Get that thing inked because then you know you're good. All right, so here are the pearls. Treat any and all opportunities and people with utmost respect. Be organized, prompt, look professional, polite, confident, humble, grateful and upbeat. Understand the prevailing compensation models, be evidence-based. Know the components of total compensation. This is what to compare, not just your salary because the rest of it is over 30% of your total take and some of it is not taxed. Some of it is tax deferred to when you make less and they're in a lower tax bracket and so therefore dollar for dollar is even more valuable than your salary. Seek data to understand what compensation is reasonable in your situation and your region and negotiate in an evidence-based manner and they will respect you more and take you seriously. Understand what's negotiable, what might be and what is not negotiable. I outlined that for you earlier and consider having a medical contract attorney review or even negotiate your offer letter or contract in certain situations and don't forget to tax deduct those expenses. All right, if you have any questions or comments, I can't wait to dialogue with you and I thank you very much for your attention.

Advanced Practice Providers

GI and hepatology

contract negotiations

compensation models

job satisfaction

negotiation techniques

total compensation