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Join Dennis Hursh, a health care attorney. Dennis sheds light on the often misunderstood world of physician contract negotiations, emphasizing the importance of understanding one’s true value. He shares insights from his practice, where he helps physicians navigate the intricacies of contract agreements. From advocating for fair compensation to the delicate balance of partnership requests, Dennis provides practical advice to empower physicians in their negotiation endeavors.

Dennis Hursh is a veteran attorney with over 40 years of experience in health law. He is founder, Physician Agreements Health Law, which offers a fixed fee review of physician employment agreements to protect physicians in one of the biggest transactions of their careers. He can also be reached on Facebook and LinkedIn.

He discusses the KevinMD article, “Very rarely, a physician can ask for too much.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Dennis Hursh. He’s a health care attorney, he’s the founder of Physician Agreements Health Law, regular guest on KevinMD to talk about all things contract. Today his KevinMD article is “Very rarely, a physician can ask for too much.” Dennis, welcome back to the show.

Dennis Hursh: Oh, thanks, it’s good to be here again.

Kevin Pho: So tell us what your latest article is about.

Dennis Hursh: Well, I’ve been doing this for 40 years, and for 40 years I’ve been harping on physicians to ask for what’s appropriate. The way that I do a review is, I write a letter on law firm stationery and send it to the physician, with the idea the physician will send it to the employer.

For 40 years I’ve been getting push back. I don’t want to ask for that, I don’t want to ask for that, well, I think we’re going too far, that’s too many requests, are you sure they’re not going to withdraw it? And I’ve always told them no, they never withdraw the offer. Which isn’t completely true. Once I had an offer withdrawn, but it was for credentialing reasons, it wasn’t because we were asking too much.

And then just a couple months ago I actually had an offer withdrawn, and I’m pretty sure I know why. It was a very experienced physician who was being recruited by a practice, and he insisted on a few things which generally I don’t think would have been a problem. It was a radiology practice, they had a monstrous amount of PTO but he wanted a couple weeks more. But the biggest thing was that he wanted to be made a partner immediately and not pay anything for it. And I really believe that was the bridge too far.

I think you generally get 0 percent of what you don’t ask for, so I encourage you to ask for everything, particularly when I’m doing it. If they’re concerned, you can always shrug and say, well, you know, attorneys, and just blame me, and it’s not you really asking. But I think we hit a sore spot with that.

And I don’t blame the physicians. If you think about it, you’ve been building a practice your whole professional life. It’s a very valuable practice, and you know it, hospitals will come in and give you hundreds of thousands of dollars, or maybe millions of dollars, for it. I think for somebody to come in that you’ve interviewed a couple times and has good clinical credentials, for that person to expect to become your partner, it’s just too much to ask for. And like I said, I didn’t blame him.

Kevin Pho: So before talking about that specific case, one of the things that you mentioned caught my ear. You said that a lot of physicians, they’re a little bit hesitant in terms of asking, for a variety of reasons. What do you think are some of those reasons why physicians are a little hesitant to ask for requests in a contract?

Dennis Hursh: I think you want to prove that you’re a team player, that hey, I like you, I’m interested in this position, I don’t want you to think that I’m greedy. And I think there’s a lot of that going on.

And some people are actually hesitant to even use an attorney, like somehow that shows a lack of trust. I can guarantee you there aren’t too many physician employment agreements out there that have been drafted by physicians, so they got their attorney to protect them.

I used to represent a fair number of private practices, and we were never concerned when an attorney reviewed it. We’re actually happy, because you invested in an attorney, I know you’re not juggling 12 offers and seeing what you can get from us, you’re obviously interested in this position. But I think a lot of it is, they want to show I’m really interested in this, and I don’t want to look like I’m greedy, is the impression I get.

Kevin Pho: So if you’re talking to a physician and that physician is a little tentative, what do you say to them to make them feel at ease?

Dennis Hursh: First of all, I’m not going to ask for anything unreasonable. So I’m not going to say, hey, I want nine months of paid vacation, because that would be great. I’m not going to say I want more money unless I can justify it. I will point out, if your compensation’s below median, that you should be paid median compensation. But I’m not going to ask for anything unreasonable.

To say I want you to use reasonable discretion, I don’t want to be assigned to locations without my concurrence, I don’t think any of that is going to strike the other side as being totally unreasonable, this person is going to be hard to work with. I think they’re all reasonable requests.

And again, I think you ask, it’s very easy, the employer can say no, we’re not changing that. I don’t think anybody’s going to get up in arms and say, how dare you ask for the right to choose where you’re assigned.

Kevin Pho: With apparently one exception, and that’s partnership. So let’s talk about this exception. So this was a radiology private practice. The prospective physician wanted to be made partner immediately with zero buy-in. Now, did this physician run this request by you, and if he did, what did you think about it?

Dennis Hursh: I kind of blame myself for not pushing back harder. I said, I’ve never seen anybody let into a partnership day one. You put yourself in their shoes. They know you interview well, but they don’t know, day to day, are they going to be losing staff because you’re hard to work with, are you just going to have an abrasive personality? They just don’t know you well enough to be a partner.

But I didn’t push back hard enough, obviously, because the physician was convinced that they really needed him and they were going to make the offer anyway. So I kind of blame myself for not saying, don’t do this. I tried to talk him out of it, I should have said no, we shouldn’t do that, but I didn’t.

Kevin Pho: And when you presented this to the private attorney, what was the response? Did he simply just remove the offer?

Dennis Hursh: Yeah, they withdrew the offer. They didn’t give a reason, but I’m certain I know the reason. I mean, there was nothing unreasonable, there were a few things in there that were a big ask. But again, I want PTO? No, that’s what everybody gets. Nobody’s going to say forget it, we’re walking away because you want more PTO. But I’m sure it was the partnership, that they just said no, there’s no way.

Kevin Pho: And for context, what is the normal time frame before one is considered for partner, and what’s a typical buy-in for a similar situation?

Dennis Hursh: It’s all over the board. I mean, I’ve seen one year, I’ve seen seven years. So it kind of depends on the practice and kind of what they did before. The way I think it works is, somebody set up a solo practice, and when that person brought in his or her first partner, I think however long it took and whatever they did then, that’s going to just carry on and say, that’s how we do it. So there isn’t really a hard and fast rule.

I see a lot of partnerships that let the physician in for practically nothing, and I think the idea is, you understand when you come in, we’re paying you less than median and you’re going to make less than median for three years, but at the end of three years you’ll be a partner and we’re doing very well here. So I’ve seen that, I’ve seen nominal buy-in, give us a hundred bucks. And the one I don’t like is, I’ve seen buy-ins for fair market value, whatever that means.

So it’s all across the board. But virtually everybody wants, the least I’ve ever seen is a year, because in a year we’ll know, if we’re burning through MAs because nobody can work with you, we’re going to know that in the year.

Kevin Pho: So it sounds like there’s a boundary when it comes to making requests and not overstepping that boundary. And sometimes that boundary, aside from this exception, sometimes can feel a little fuzzy to physicians. So how can a physician know what is reasonable to ask for? Where does that boundary lie?

Dennis Hursh: Well, I think you just look at it like, is it unreasonable for me to say, we’re agreeing I’m working in these three locations and I don’t go any place else unless I agree? I mean, do you feel that’s an unreasonable request? I personally don’t. Do you feel that if I’m asking for moonlighting opportunities, that you won’t unreasonably withhold permission for that? Again, I don’t think it is.

I think sometimes physicians look at, like, a three or four page letter and say, there’s all these bullet points, and they say, I’m asking for many things. But I think you have to look at each one and say, is this unreasonable? And as long as what you’re asking for doesn’t make you say, oh wow, these guys are suckers if they give me this, then I think it’s reasonable.

Kevin Pho: Now, is there any specific part or aspect of a contract where a physician can perhaps push harder in one area versus another?

Dennis Hursh: Well, I think that’s one of the advantages of asking for a lot. If I send you a four-page letter, you’re in a lot better position. You go, this first bullet, we can’t do that. OK. This second bullet, we can’t do that. OK. Third, no. Fourth, no. The fifth bullet, you start saying, wait a minute, this one’s important to me. I think you’ve shown kind of you’re a team player, you’ve given up four.

So I think it’s more important, in my mind it’s easier to negotiate if you’ve got a lot of points, because you can give some of them away. The contrast would be if I came to you and said, Kevin, there’s three things that are really important to me. Well, if you give me two of those things, I mean, I think in your mind you met me more than halfway, so I’m kind of being unreasonable if I stick on that. If there were 15 bullet points and I stick on three, I just think it’s a whole different dynamic.

Kevin Pho: How about things like salary and call and PTO? Are there any specific aspects where perhaps an employer would have more flexibility versus others?

Dennis Hursh: No, it’s going to depend. A larger organization is going to be more comfortable putting a maximum call. If there’s two physicians, even saying one to two, if I get sick or I’m on CME or I’m on vacation, it’s going to be just you for a month. So some of it depends on size.

But the thing is, MGMA has data on all that. So you can go in and say, look, in a private practice the median PTO is this. So this isn’t me saying I want more, this isn’t, I’m a snowflake, I’m so special, you should give me more. This is just a statistic, that the median is this. And I don’t see how anybody can argue with a statistic like that.

Kevin Pho: Should physicians worry about negotiations becoming too contentious? For instance, if there was a particularly difficult negotiation that was eventually resolved, are there any repercussions to those physicians when they start that job?

Dennis Hursh: I don’t think so, because if I’ve decided during negotiations I don’t like you, then we’ll withdraw the offer. But the thing is, and it’s happened once in 40 years, thousands of contracts.

The thing is, it’s an important thing, it’s hundreds of thousands of dollars at stake. So I don’t think anybody says, boy, you’re really being unreasonable by working on what’s going to be your career and hundreds of thousands of dollars. I don’t think most people view that as an unreasonable thing for you to be concerned about.

Kevin Pho: So in this particular example that started off this episode, what was the reaction of that particular physician once that offer was withdrawn?

Dennis Hursh: He was, I think, disappointed, because if he’d gotten everything we asked for it would have been a fabulous thing. I believe he understood. I’m not sure, we didn’t speak much after that. But I think his sense was, well, good riddance. I felt it was reasonable. If they’re not going to be reasonable, then I don’t want to work with them either.

So I don’t think he was crushed. And again, in today’s market, it’s not like there aren’t a hundred other people that are anxious to hire you. So it’s not like, now I’m going to be without work.

Kevin Pho: And how did that change your perspective going forward? Do you simply not ask for similar requests?

Dennis Hursh: I am going to be very much more assertive when I’m talking to physicians now. If I really think it’s over the line, I want to make it really clear to them that everything I’ve asked for is reasonable, I’m not sure that this request is reasonable. And some people say, well, I don’t care, I’ve got a lot of other good job offers, that’d be great if I get it, if not, I’ll just keep looking.

Kevin Pho: We’re talking to Dennis Hursh. He’s a veteran health care attorney, he’s the founder of Physician Agreements Health Law. Today’s KevinMD article is “Very rarely, a physician can ask for too much.” Dennis, as always, let’s end with some of your take-home messages to the KevinMD audience.

Dennis Hursh: Well, this was an outlier event. I mean, I think the thing to keep in mind is, still, you get 0 percent of what you don’t ask for. There’s an amazing physician shortage in this country, you are entitled to get a reasonable contract, so you should ask to get a reasonable contract. It’s just, probably partnership is the bridge too far, and you probably should not ask to become a partner for free. Other than that, get what’s reasonable.

Kevin Pho: Dennis, as always, thank you for coming back on the show and sharing your insight and perspective.

Dennis Hursh: Thanks, Kevin.