Negotiating employment contracts from a place of strength [PODCAST]

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“The most important lesson when negotiating contracts is picking your battles and coming at them with optimism and positivity. Yes, you can and should be excited about this new opportunity, but you need to receive what’s fair and reasonable in the market. Don’t be afraid to push back on things that matter, and be smart enough to let the smaller things go.”

Amanda Hill is a health care attorney.

She shares her story and discusses her KevinMD article, “Know your worth: Negotiating employment contracts from a place of strength.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Amanda Hill. She’s a health care attorney, and her KevinMD article is titled “Know your worth: Negotiating employment contracts from a place of strength.” Amanda, welcome to the show.

Amanda Hill: Thank you so much. Happy to be here.

Kevin Pho: We’ll get into the article in a little bit. First off, briefly share your story and journey to where you are today.

Amanda Hill: I’m a health care lawyer, right in Austin, Texas, but I’m not the typical lawyer. I don’t love sitting in a law office drafting articles all day and doing legal research. My passion is really just to help doctors. So all I do is represent doctors. I take phone calls from doctors. I talk to doctors day and night. Basically, when I started years ago at the Department of Veterans Affairs, I realized that I wasn’t a government lawyer, and I have journeyed forward to now, where I own my own firm and only represent doctors, medical groups, and doctor-related entities.

But one of my first jobs as a lawyer was actually trailing doctors through their day and figuring out why they had low satisfaction scores, and that was really interesting. I don’t think a lot of lawyers understand the world of a physician: the 15 minutes, that you don’t have time for lunch, that you’re squeezing things in, that you’re calling people between patients. Forget it if your kid has a crisis; you can’t just drop your day. And so I think that really spurred me to be a resource for doctors, the red phone they call if there’s a crisis. They have to have someone they feel understands their time, their day, and their crisis. What is a 99214? I know it. I know what it is.

So it’s really been a good journey, from being in the weeds with doctors to being the health lawyer that they can call and feel comfortable asking their legal questions. It’s been a journey. I didn’t expect that I would be in this place when I started, but here I am, 20-something years later.

Kevin Pho: Now, from all your experience representing physicians, what are some of the most common questions that they ask you?

Amanda Hill: Probably negotiating contracts, which is the reason I wrote the article. I get a lot of doctors, and they sound so confused: “I got this long, 25-page contract for my hospital or health system. I don’t understand parts of it. I’m very overwhelmed. I don’t think there’s any negotiating room. I’m told that I just have to sign it.” That feels very debilitating when you’re a professional and you’ve gotten to our level, and you really earn a good salary, and you feel you just have to sign what’s put in front of you. There are sections they don’t understand. They don’t know whether it’s negotiable. They don’t know whether it’s market value.

And so what I do a lot of times is demystify things for physicians, to say, “Let me tell you what this means. Let me tell you if this contract is generally good or bad,” and also give them tips and empower them to go out and do it themselves. I don’t want doctors calling me every day because they have no strength. I want to empower doctors to do this, so they can go forth and know their leverage, negotiate from a position of power, and understand what the market value is.

But the common question is usually some sort of contract issue, or if they want to buy and sell their practice. Then other times, it’s something that pops up at 6 a.m., and they go, “Oh, I need your help. I just got this medical board complaint,” or “This patient is blasting me all over Yelp, and I have no idea.” I take those calls. I answer those questions. A lot of times, I try to just give doctors patience, to say, “It’s going to be OK. We can get through this together. Take a breath. Let’s take it one step at a time.” And there’s usually a solution.

Kevin Pho: All right, let’s talk more about negotiating contracts, and that’s the crux of your KevinMD article. It’s titled “Know your worth: Negotiating employment contracts from a place of strength.” Now, for those who didn’t get a chance to read your article, just walk my audience through it. Share the story of why you decided to write it.

Amanda Hill: So again, a lot of physicians feel powerless when it comes to negotiating. They feel, “I guess I can maybe push back on the non-compete. Maybe? I don’t know. Is there anything else I should be worried about? I don’t even know what’s standard.” And I really want to empower doctors to say, first of all, you need to know what your worth is in this region. Go look at the MGMA data. Go figure out what the market is, so when you’re negotiating, you don’t say things like, “My buddy is a dermatologist, and he got this amount.” It doesn’t matter what your friends get; it’s what is in the market in this area.

Also, man, I roll up my sleeves, and I ask for sign-on bonuses and relocation packages. It’s like, why not? And it doesn’t have to be negative. I think a lot of physicians think that negotiating is going to make their employer mad. That happens all the time: “I don’t want to push. I don’t push too hard. I don’t want to piss them off. I want to seem very friendly and likable.” And you can absolutely be likable and negotiate for what you’re worth. Those are not mutually exclusive.

So I want to make sure that doctors realize that they can be excited about a job, they can go in with a really good attitude, and they can pick their battles. That’s one of the things I talk about a lot, right? Don’t argue everything and the kitchen sink. Pick the things that are really going to matter to you, and make sure that whatever contract you sign, you can get out of it. It needs to have an exit clause that’s pretty understandable. And if you go into a negotiation with that attitude, you’re going to get changes. You’re going to get something that’s helpful for you that you didn’t realize before.

Kevin Pho: So tell us a story of one of your clients, a case study that has come to you, because you’re right, a lot of hospital employers, they’ll say there’s a little negotiating room, sign this, and then they come to you. So tell us a story where you negotiated some benefits for that physician.

Amanda Hill: Let me use non-competes as an example. Now, of course, non-competes are different all over the country; every state has its own rules on them. But here in Texas, non-competes are a thing, and they’re very enforceable. So a physician will come to me and say, “I understand that I have to have a non-compete, and I’m sure it’s reasonable.” And I’ll look at it, and I’ll say, “This is not reasonable, because it’s saying that you have to refrain from working, let’s say, 25 miles around every single practice location that the company owns.” Now, they’ve just merged, so now they’re a part of a bigger system, and they have locations all over the region and all over the state. So what you’re signing is that you’re promising not to work 25 miles from every single location that this place has.

So oftentimes, I’ve negotiated to say, no, it’s going to be 20 miles around the place where you spend 75 percent of your time. And then I’ve had doctors call me and go, “I’m so glad you said that, because I was actually asked to round at another facility. That would actually be 50-50, and I realized that would pull in my non-compete if I did that.” So a lot of times, I negotiate those types of non-competes, where doctors didn’t realize before that they were so heavily bound by this agreement, and then by negotiating in their favor, they drastically reduced the circle to just around the place that they work.

And again, hospitals, systems, and groups constantly tell doctors, “There’s nothing you can do. This is non-negotiable.” And I always try to say to the physician, “What is your leverage?” You know, are you the only interventional cardiologist in this region? Are you desperately needed in this rural area? Know your strengths. And you can’t go in saying, “I guess that this rural hospital is just going to offer me X, and that’s all I can do.” You have to own yourself and say, “I’ve gone through so much training. I’ve gone through fellowship. I’ve gone through hell, never gotten paid a dime for years on end, barely scraping by, and now is the time where I get to put my professionalism and my worth on the table.” And I take that really seriously.

Kevin Pho: So one of the things you mentioned earlier is that you want to teach doctors how to negotiate for themselves and not necessarily hire an attorney. So what are some tips? What are some phrases physicians can say to help them become better negotiators at the table?

Amanda Hill: First of all, I always tell doctors to slow it down. I hate it when groups just DocuSign something, shoot it to you, and say, “No, here we go. There’s a contract. Please sign.” Whoa, slow that down. Get a Word version. Tell them that you need to ask your lawyer to review it. You know, slow it down. Give yourself some time to process it. First of all, even if you don’t make changes, do you even know what you’re signing? No, I don’t think a lot of physicians do. They just sign it, and they go, “What? I have to give six months’ notice when I leave this job. I didn’t know.” Or, “I have to pay a tail policy when I leave.” And I’m saying, “Do you know how much those cost? It can be $15,000.” So slow it down. Take a look at it. Make sure, even if you don’t change it, you understand what you’re signing.

And then second, I will always tell doctors, pick your battles. You do not need to return a redlined agreement that looks like you bled all over it to the other side. That’s useless, changing words, and “I don’t like how they said this. Let’s add the word ‘reasonable’ here and there.” You really need to focus on the big-picture ticket items. How do I get out? What am I going to be bound to if I do get out? Is the salary and bonus structure understandable and reasonable? And you don’t have to go to bat for every single thing.

Now, there are some things that doctors are surprised that I want to go to bat for. For example, if you’re paid on production and there’s a provision in the contract saying, “We’re going to sweep all of it. If you owe us money, we have an offset provision. We’re just going to take it all at the end and take it out of your last paycheck.” Right? That’s fine, right? Well, I’m like, “We need to have an accounting of those disclosures. What exactly do you believe that my physician owes you? You need to inform them of that.” I make certain changes that doctors don’t even think of.

So in that vein, it’s helpful to have a lawyer. But if you don’t have access to a lawyer, and that’s where the counselor part of “attorney and counselor” comes in, I want you to succeed. I don’t want you to just sign contracts. So slow down, pick the big-ticket items, and do some research on what you think you’re worth.

And then always find a back door. That’s really huge. Find a back door out of this contract. I’ve had so many physicians over my 20-year career say, “This is my dream job. We’re settling in this town. My kids are going to go to school here. This is it for me. I’m not ever going to have to leave.” And then two years later, I get a crying phone call saying, “I have to move closer to my mother,” or “My husband got another job,” whatever, “and I have to leave.” And so where’s the back door? How do you get out? Is it an easy 90-day out, “See you later”? Or is it liquidated damages in six months, and you have to go through all these hoops? So always find a way out of a contract.

Kevin Pho: So these are all scenarios that occur before you sign on the dotted line. Now, I’m sure there are common scenarios that happen in the midst of a contract. So what kind of questions do you get from physicians if they’re not happy with the current contract that they’re employed under?

Amanda Hill: I get a lot of those questions too. A lot of it is, “Yeah, I wish I’d known you before I just signed this thing. I had no clue what I was doing, and all of a sudden, I have these partners that are difficult to deal with. It’s a work-life balance that is not OK with me. I need to find a way out.” And I think that is a more strategic discussion. You really have to say, OK, what are the reasons you want to get out? Are you being harassed? Is it a discrimination issue? Are all the partners golfing, and you’re the one that’s on call? Or is it just not a good fit?

And sometimes, if it’s just not a good fit, it requires a conversation. We all have to be adults. Sometimes you have to go to your employers and say, “Look, I want to give this another six months of my time so I don’t leave you in the lurch. I want to make sure I cover call and I’m a good team player, but it’s not working out. I really am not meant to be in this setting.” Maybe I’m a hospitalist, and I don’t love it, and I want to go into outpatient practice, or something completely different, where it’s not a threat to your employer. You’re not saying, “Y’all are jerks, and I’m out of here.” You can really have that collegial conversation. I always try that, but it’s always good to try to leave a job amicably if you can.

And if that doesn’t work, there are other strategies where you can set yourself up for success. You wouldn’t want to quit a job and then later argue, “They were absolutely sexually harassing me,” without pointing it out before you leave, right, to give yourself some protections. So if you’re in a bad contract, not all hope is lost, but you do need to strategically think, before you put in your termination notice, about how you protect yourself. Maybe if there’s a fraud and abuse issue going on in your practice, you might want to point that out, make a compliance complaint, make it known, and establish yourself as pointing out the problem right before you leave. And then you might have some leverage.

All I do is games of leverage with physicians. Know your leverage. If you have no leverage, you’re not going to get anywhere talking to any other side that’s adversarial to you. So anytime you can build leverage while you’re employed, while you’re in a bad contract, then that helps you.

Kevin Pho: So what about something like if you want a pay bump even after you sign a contract? Is there any recourse for physicians if they want to renegotiate their pay or adjust their compensation?

Amanda Hill: Usually not, if you go about it the right way. What I would not advise is a physician saying, “This is unfair. I get paid nothing, and I’m bringing home $450,000 a year,” right? No one has a lot of sympathy for that. But if you go to your group and say, “Look, I’m paid on a flat-rate salary, right? You pay me $250,000 a year,” for example, “Look at my billings. I’ve pulled in so many millions for this practice. I want to feel that I’m making your practice valuable, but I also want to feel fairly compensated for that work, and I don’t feel like the structure right now is really valid, given the fact that you’re making four times off my back.”

And if you present that in a way that’s factual and evidence-based, and you’re looking at numbers, it’s not because of emotion. Keep emotion out of it. It’s not because “I feel it’s unfair,” or “All my buddies are getting paid more,” or “I can’t afford the Europe vacation.” It’s about, “Look how much you’re bringing in, and look how much I’m getting of that. For example, you’re only paying me 25 percent of my production. That’s not enough. That’s not market value. The MGMA numbers say that 60 percent of MGMA is X, and I’m getting paid woefully under that.” Using numbers and logic gets you a lot further.

Kevin Pho: I think the studies show that female physicians get paid significantly less than male physicians, pretty much across every specialty, primary care or procedural-based. Now, are there any specific issues for female physicians when negotiating contracts?

Amanda Hill: Well, obviously, as a female, I have a special place in my heart for female physicians. I give so many speeches for free to female physicians because, strangely enough, I feel like my calling on earth is to help doctors. And I’ve always talked to them about taking the female out of it. You don’t have to act like a demure lady when you’re negotiating. This is a business conversation. And so yes, everyone needs to be professional, and everyone needs to be on board and not act emotional, but we need to go in as professionals, equal to any other specialty, which we have earned. If you’re a highly trained, board-certified plastic surgeon, then you deserve what a board-certified plastic surgeon earns, and it is not about looks. It’s not about emotion.

You go in there just like the men, because oftentimes, and this does sound sexist, but men ask for what they’re worth more. Women are always undervaluing themselves: “I don’t want to push. I don’t want to seem greedy. I might take off time for my kids.” No, everybody needs to take off time for their family. You need to be able to go in and say, “I deserve this. I deserve it because I’ve earned it.” And you smile, and you’re positive, and you go in with a good attitude, and you show them.

Again, always, when negotiating, you have to look at what the other side needs and what the other side wants. Think like the employer and say, “This is the value that I can present to you. And in fact, it’s actually a benefit that I’m a female, because you don’t have a lot of female cardiologists or radiologists, and I am presenting to you a different perspective, and that’s to your advantage.” And I think that we need to present, as a female, even our gender and the way we think as a strength, and negotiate for that.

Kevin Pho: We’re talking about Amanda Hill. She is a health care attorney. Her KevinMD article is titled “Know your worth: Negotiating employment contracts from a place of strength.” Amanda, what are some of your take-home messages that you want to leave with the KevinMD audience?

Amanda Hill: I think, first, I’d say find help. The doctors that I hear from that are at the end of their rope and are burned out have just been trying to do it all for so long. They have no margins left for anything, for their family. They have no margins for their patients. They’re burned out. They’re fried. So they come to me and say, “I’m done. Get me out of this contract. Get me out of this job. Help. I want to go hide in a jungle.” You know, it’s like, wait, don’t get to that point where you’re absolutely fried.

It’s a hard world out there, and you’re trained to be a really good physician, and I don’t think the general public understands what it’s like to have sick, frustrated people in your face all day, 25 to 35 times. That wears on a person, right? So you can’t also be a compliance guru, and a legal guru, and an expert on HR, and all the things that you’re required to do as a physician. You have to say, “I cannot do this alone. I have to bring in a village and a team that can support me.” Because once you lose the joy of medicine, the light goes out. You’re done. You’re not going to be a good physician.

And so I think having a team to support you, having a good lawyer, and a good finance person, and a good navigator, and a good billing and coding team, and all the people working with you, that’s when, years later, clients are like, “All right, well, I’m in the zone. I’m rocking and rolling. I feel supported. I feel secure.” And it’s just like with any human being. If you don’t feel safe, if you’re in a war-torn area where you’re getting guns shot in your window, you can’t settle. You can’t do well at anything.

And so doctors aren’t feeling safe. I’m hearing it, and I’m extremely busy because of all the doctors calling me, saying, “I don’t feel protected. I feel like the government is a boogeyman. They’re out to get me. Medicare regs are not my friends. I don’t want to get an audit. I’m paranoid.” And so for someone to say, “I got you. You’re going to be OK. You’re going to be safe,” it’s really important. So if you don’t have those people, it’s really imperative to go find them before it’s too late.

Kevin Pho: And how can people reach you?

Amanda Hill: I’m launching a new company, which is so exciting. It’s called Guard My Practice, so you can go to the website, guardmypractice.com. I’m launching a subscription-based service with 15-minute videos, so you can sign up, and you get CME at the end of the year for all of these hours, which is exciting. And I offer tips, just what I’m doing today, right? How to negotiate, how to deal with a difficult patient, so you want to set up a management services organization, how do you deal with your nurse practitioner.

Anyway, that’s a good way to reach me, through that website. Send me an email. I love hearing from doctors, even if you’re not my client. I take doctor calls all day. It’s like my mission on earth to help doctors through crises, and then I try to get someone to help you. So reach out anytime. I’m here, and I really care about the healers of our country.

Kevin Pho: Amanda, thank you so much for sharing your time and insight. Thanks again for being on the show.

Amanda Hill: Thank you so much.

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