I'm Anne Stroink and I'm a neurosurgeon here in Illinois. I do actually work on both sides of the fence. The talk you will hear will kind of want to convince you maybe to go to private practice. But on the other hand, I also have a corporate job with Advocate Healthcare System here in Illinois, which is one of our largest healthcare systems. So it kind of gives me a little bit of perspective of what corporate America would like in physicians and neurosurgeons in particular. So my background is I've been in neurosurgery and private practice now for 29 years. I was a founding, actually the first founding partner in this group, and it's varied anywhere from three to eight neurosurgeons depending on what year. And we've had ancillary services all along with in-house MRI, CT, used to do biography. We don't do that anymore. Ownership of stereotactic radio system in the past. And we've also had an opportunity to get involved in residency training program and continuing medical education through a private not-for-profit organization. And we've been involved in pre-clinical and clinical research. And now I'm doing a medical directorship, and several of my partners are doing various directorships in the hospital that are paid stipends, as well as trauma stipend. So can private practice be the right answer for you? You know, I always felt that I was on the losing side of this argument, because as Dr. Bean pointed out, young people automatically think about working for an entity. Why? Because they think of themselves as, it's a huge risk. I understand you guys are graduating with huge debts when you finish medical school. I mean, I did too. And huge debts when you maybe have a family, and you just don't make enough money as a resident to really pay off those previous education loans. So I understand that. But also realize that people can jump back into private practice after they've been in academics. I've had several friends that have done that. I've also had friends that are young neurosurgeons that started out in hospital employment, used it to pay back their bills, their education bills, and then jumped back into private practice. So we have to understand that there has to be some facility, you know, you have to be facile in the way you think about this, and it's not maybe just for that decision tomorrow. So what's the value of private practice? Well, just like we saw Dr. Bean's choice, we can show you a way out of the exit, I'd like you to just think about the exit called freedom. There's nothing better than autonomy. There's nothing better than full ownership and being responsible for what you're doing. And finally, deciding your own compensation, and I'll go into the details in a more granular level. Well, what is autonomy? Well, it's a high level of independence. You're making the choices. You get to determine your own staff, and I'm telling you, that is very important. If I hear complaints from the doctors and the surgeons' lounges when they didn't get a choice in their staff, your staff can make or break you, and I've always had a good team work with me, and I've made sure of that and made adjustments when I didn't. So having your own staff, determining your facility and resources is an important matter to some neurosurgeons. Making your own schedule is also important. It's sometimes difficult to ask for time off from an entity when it's a little bit easier to ask yourself if you can take some time off. Freedom to change and adapt your practice, oh, I hear a lot of complaints about that on both sides of the fence. We have a lot of neurosurgeons, for example, that really felt that 85% of their practice is spine, and yet they come to the emergency room and they get a little edgy when they see a subarachnoid hemorrhage that they think might be an ACOM aneurysm, and suddenly they don't feel they're quite up to date on aneurysms. And so then a hospital, when you're employed, might come back, why don't you know how to do aneurysms? Why can't you learn that? Why can't you completely support all of the emergencies that show up in our emergency room? So that can kind of be iffy for some people that are hospital-employed and don't feel that they have that full capability to provide all the things that the hospital thinks that they should provide. The other thing about autonomy that I like is the fact that in my community, which many of you will find the same, I get to choose which hospitals I work in being private practice. So I have a full-blown practice at both hospitals and have been able to maintain that independence throughout the years, which requires some good political moves but can be done. So I'm just not locked into one hospital system with one boss. And the other thing I also like about it is I get to choose a specialist for my patients. So if I was entity-employed and I hadn't used an endocrinologist that I didn't trust 100 percent to help me with my patient who, let's say, had a null cell tumor and needs some pituitary support, I like to have the choice that I get to pick the best endocrinologist, whether it's in my town or outside my town or perhaps out of my state. So that's one of the aspects of independence I enjoy. The other is ownership. It's great to own your own business. It provides a lot of value to you. And one of the concerns about business is, come on, I'll be hospital-employed. I don't want to learn business. I just want to be a neurosurgeon. Let someone else do the business for me. But I would argue that if you do learn business, you can teach business to a neurosurgeon. But you can't have a businessman become a doctor. So learning how to run a business, you learn how to run the finances, and when you know how to run the finances, then you also know how to deal with federal regulations. And suddenly you start developing the skill sets that you need to be a leader. So leadership skills and control, direct control over your overhead and costs is also an incredible value because the hospital-employed neurosurgeon suddenly gets told, we're going to cut what we're going to pay you because your indirect costs have gone up. They may not be so terribly transparent about what those indirect costs are. It depends on how you're employed and how much you trust the people you work with. But also don't forget you're liable for understanding health care regulations, which again is another skill set that you could acquire. So these are some interesting opportunities. Startup practice, that's going to be tough for someone right out of residency training. I remember when I took my first loan out, which I think was $40,000, I thought I'd never get that paid back. But it really doesn't take too long, but I know that that would be a struggle for many of you. But just so you know, you have to establish a business entity, you have loans and startup costs. You may not, and you will not see receipts for six months because that's how long it takes. That's why hospitals sometimes dread the first year or two they have hired you because they have to wait forever to get those receipts in. But I can tell you, your employees want to be paid that first two weeks. So you have to consider about your payrolls, the EHR that you might choose, accounting, office, face coding. It can be done, but it's clearly challenging. Malpractice is probably going to be your biggest cost those first three to six months. You have to balance that, what you're going to use for property, casualty insurance, various insurances, worker compensation insurances, and credentialing, insurance contracts. All of that's going to fall on your shoulders, and I know that that's quite daunting, at least in the beginning. So why not consider established practice? There's a lot of value to that. When you join a practice, consider what positions there that you're joining have invested in. Do they own their own building? Are you going to be an owner of it someday? What are their assets? What are their ancillary services? So that becomes important because private positions have the opportunity to get into those ancillary services where you won't if you're an entity-employed position. There's various buy-in models, and we've talked about that, so I'm going to go on to the next point about the strength of negotiating. When you join a practice where there's a lot of well-seasoned neurosurgeons, they've already done a lot of negotiations for you before you've shown up. They may have already landed a very good trauma stipend for you that you just walk into. They may have already agreed to a service agreement with their hospitals so that you just have to get involved with it and figure out what they want from that service agreement. Those are additional benefits besides just what you make alone as a neurosurgeon. And also there's joint ventures. So compensation is generally based on your performance and your profitability. The income is distributed between the partners, and you have to discuss with your partners how that will be distributed in the future. The additional income, however, is compensation you should not ignore, joint ventures that we'll talk about here in just a minute, and just the value of being independent, knowing that you're responsible for what you make. So let's talk a little bit about opportunities now for some additional income, ancillary income. I think one of the biggest interests that a lot of neurosurgeons have, they share with their orthopedic colleagues and some other subspecialty surgeons, and that's the ancillary surgery center. You can't, you know, you're probably going to be very much discouraged to join one of these if you're going to be entity employed. And then if you're in private practice, you do have the opportunity to join these, although it does cost something up front, you have to do your business model value to see if that's really worth it to you. But I can tell you in our community, it's been highly, highly, highly successful. So other things you consider is physical therapy, imaging. You have to recognize imaging has taken a huge drop in reimbursement, and I think that's why a lot of doctors have left private practice, because they were relying on that imaging. But it is still a possibility. It allows you to have a physician practice that's patient-centered, and it's enormous convenience when you're practicing. So if a patient comes into your office, it's a follow-up CT head scan for subdural, we've just done before. It's kind of nice to get the image, take a quick look at it, and take care of the patient rather than going back and forth to where your radiology department might be. Then sometimes you can get into what we call durable medical materials, such as bracing, bone stimulators. Those are also opportunities in private practice, and also the trauma stipend, as well as hospital directorships. And just to kind of, again, compare this to hospital employment, which already Dr. Vee and I have covered. There's a base compensation there, but it's based on fair market value, and as others have said, that fair market value can be argued depending on which survey and how you look at it. Activities or incentives, that means working beyond what you're already making, your base RVUs and minimum thresholds, they're already decided for you, and you don't have much say on how, you know, they'll say your bonuses are based on how we do it with other doctors, and it's hard to negotiate past that in the contract. Don't forget about the restricted covenants. You work for one hospital system, and that's who you work for. You don't get choices to work at any other hospital system, and your patients might have wanted that. The other thing that I think you have to pay attention to is intellectual property rights. Now, to me, that would be the deal breaker, to walk into a hospital and be told that anything that I think about, that I invent, any clinical trial where I might be working with a company, they own that, and I think about young people nowadays and the enormous opportunities that you folks have to develop things, new instrumentation, apps that you can write that might have a big impact on education in the future. Most entities will ask for those rights to your intellectual property because they think many of the ideas that you generated were on their property, and then they own them, and I'm seeing that with managed care contracts, too. You can join partnerships where you have a share risk sometimes, like with an ACL. Read the contract. They want your intellectual property, so that's something that you have to consider. It's a limited autonomy that we mentioned already. They're going to help you determine your vacations, your work schedule. You really can't work after 5, which some of us in solo practice are sometimes guilty running clinics until 6.30, sometimes 7, and of course paying our staff overhead, but still at least having that choice. And there is limited control about your electronic medical records, what you're going to use. And again, I mentioned the transparency in cost attribution. So hospitals as a partner. You don't have to be employed to have a hospital as a partner. I have two wonderful hospitals that I have as partners that I work with. Hospitals are hungry to build neuroscience service lines. You know, the age of cardiology is kind of maybe not as important now as the development of neurosciences, so that's something that you have to consider for your future. Your partnership is based on paper performance, quality metrics, reimbursement ACOs. Just read those contracts carefully. And working together, however, you can get medical directorships for hospitals without necessarily being employed. They need someone to head the section or the Department of Neurosurgery or the Department of the Neurosciences. They need someone to help them with understanding how strokes are run and what doctors think about the American Heart Association stroke protocols, trauma protocols. They still need that partnership too. You can also work on joint ventures. Most of the ambulatory care centers in our community are ventures with hospitals. And of course, our hospital is your partner when it comes to capital equipment and trauma stipends. So I assure you, you will still have those partnerships. Questions to ask, however, when you're thinking about being solo in a practice that's private, whether it's solo or with partners, don't feel shy toward the end. Ask for a financial statement. I don't know if Ms. Rossman is going to agree with me, but are your senior partners invested in you? I would say the number one thing, if you're going to join a private practice or even a hospital employment, are those senior partners going to come for your first craniotomy that's a microvascular decompression? Maybe you haven't done one for a couple of years because you did some other fellowship that didn't involve MEDs. Well, it's really nice when your senior partner comes up, provides some assistance, walks out and says, gosh, Dr. Smith, you just did that effortlessly, so that they can make sure the hospital understands you're a great neurosurgeon. Your senior neurosurgeon should be promoting you besides just being a mentor. And what is their succession plan? Because I am seeing a lot of practices that are starting to come down. I see a lot of more senior neurosurgeons considering employment at this time because it's just a little easier to say, I don't want to deal with the business anymore. So those are questions you need to ask, make sure there's longevity to that practice. And so questions we're going to handle later, and I will give you Dr. Denzel. I'm going to talk about the good, the bad, and the ugly of multi-specialty practices. I'm going to give you my disclosures. I am a shareholder in a multi-specialty practice from which I actually get stipends. And I'm also a partner in a consulting company. So many people think that this is tough times. You've heard some of the statistics about the change in medical practice. I view this as actually an opportunity because we have more choices for where and how we're going to practice now than most neurosurgeons have ever had. Medical practice is changing at a meteoric pace. There's lots of mergers and acquisitions between hospitals, between medical groups, and on and beyond. And there's a lot of posturing that's going on right now. And I would only echo what Judy said, which is find the practice where you like the people and most of the rest of this stuff won't really matter to you. But a lot of the traditional silos are disappearing. And so how you practice in the coming decade is probably going to change from how most of us practice. The benefit for you is that you won't have practiced the way we did. So you won't have to go through that change because you will come into this new order, whereas many of us that have gray hair came into the old order. Neurosurgeons are both very vulnerable, but also well-positioned. The care costs of providing neurosurgery are very high. And in today's value-based medical system, the cost of our care and the cost of supporting neurosurgeons is a bad thing. The good thing is that the services that we provide are essential. And therefore, they can't really leave us at the altar because we're really too important for all the hospitals and the services. So when you have that position, in the end, you have a lot of room to negotiate. Multi-specialty practices come in all flavors. There are faculty practices, such as the Cleveland Clinic. There are HMO facilities, such as Kaiser in California. And then there are physician-owned administered, such as the one that I work for, which is Mount Kisco Medical Group. And all of these have some things in common, but they're all very different as well. Some of the key comparisons, and you've heard a lot of us talk about the pros and cons, I tend to think of them more as key comparisons because what's a pro for one person may be a con for another person. If you are in some kind of hospital employment, you probably are not going to have any kind of buy-in. With a multi-specialty practice, you will frequently have some kind of buy-in to that practice. Now, that buy-in may be indirect. It may mean that you're earning a less percentage of your income for the earlier years than later, so you may not actually have to fork over money. But in some multi-specialty practices, you may actually have to come up with a chunk of money at the beginning. With hospital employment, your initial negotiations may be fairly flexible. With a multi-specialty practice, they may have standard contracts for all their employees. So you may actually have much less flexibility in your initial contract. We have very little information about what's going to be for renegotiations of hospital employees, because there are very few neurosurgeons and even surgical subspecialists who have gone on to renegotiate their contracts. Though we are targeting this to get information on an ongoing basis through our socioeconomic organization. And renegotiations with a multi-specialty practice almost never occur. Revenue sharing is possible in a hospital employment model, but rare in a multi-specialty practice. It's usually present, but it can be very variable. Ancillary income is very likely in a multi-specialty practice, and oftentimes can account for up to 25% of your income. Insurance negotiation. Most hospitals are going to negotiate primarily for their hospital fees, and they may put the professional fees secondary on their negotiations with the insurance companies. Whereas a multi-specialty practice is very, very influential. In my community, we really command much higher rates than anybody else, because we are a multi-specialty practice. Little autonomy in the hospital, as you've heard. In a multi-specialty practice, it can be variable. It can be very much autonomy, or it can be very little. It depends on the model. And in terms of administrative responsibility, don't think you will have no administrative responsibility if you're employed by a hospital. You may not have to do your own books, but you may actually have a very high level of administrative responsibility that relate to what the hospital needs in terms of their own mandates. In a multi-specialty practice, usually your administrative responsibilities will be limited. What are the key things to consider if you are looking at a multi-specialty practice? You want to look at what their administrative structure is. You want to look what their reimbursement structure is. Who are the key competitors in the community, if there are? Is there a small private practice neurosurgery group, and you're going to be the first neurosurgeon in a multi-specialty practice? Or are you one of five neurosurgeons in a multi-specialty practice of 400 doctors, and there really is no competitor in your community? Probably the most important thing is what's the overall reputation of the group, especially if you're joining a bigger group. And that bigger group can be 5, or 20, or 50, or 500 people. It's going to be much harder for you to distinguish yourself through your own skills and your own reputation if the group itself has some kind of negative or less than optimal reputation. Ancillary income, this tends to be much more stable over time, so that's an important thing that you want to know. And what is the fiscal soundness of the organization itself? Like I said, the overall reputation is really the key factor. It's important in helping you build your practice, whether you're the first neurosurgeon in that group or one of several. Also, the appropriateness of the referrals to you depends a lot on the quality of the physicians in the group. If the physicians in the group really are very uncomfortable with all aspects of neurosurgical care and they're sending you a lot of non-operative stuff, that's going to influence your practice a lot differently than if they're sending you well-filtered patients, because then you can be more productive in what you do. In terms of the reimbursement structure, know that there are many models. And the key is to understand what's done and how your practice will do in that setting. So many people have talked about the RVU-based model. And hopefully, we'll talk specifically about what an RVU is. But actually, it's a work unit. And while this has been the standard, it's my understanding that this, as a standard, is going away as a model for reimbursement in many places, because how much RVUs you do may not reflect, actually, what the hospital, what your specialty group earns, because it's insurance-based and whatever. So RVU-based may not remain as the leading source of your reimbursement structure. Some is collection-based. And then, of course, this comes into play. You could work very hard. If you're working on Medicare patients, you're going to be earning less than if you're taking care of other kinds of insured patients. So collection-based is a different model. Sometimes, the income is very shared. And oftentimes, there are these things called ladders, where when you first become a partner, you may earn less than what you're going to earn two or three or five or seven years later. So you're a partner, but you're not really a full partner, in terms of sharing in the income. The administrative structure, who really runs the group? There may be a physician who's at the head of it. But if the CFO really runs the group, then it's not really a physician-run group. There may be several physicians who are leading doctors in the group that really influence what happens. But they may have a titular administrator at the head. So you really need to understand who carries the power within the group and how the decisions are being made. How much does their board and the physician input count for where the group goes? The best way to figure this out if you're at a multispecialty group is to ask some of the younger members of the multispecialty group what they feel about that. And what is the corporate and physician mentality? And this comes back to, what's their personality? Do they only work hard, and they don't know how to play? Are they staying until 10 o'clock every night? Or do they have some kind of balance in their life? What is their overall gestalt about how they're running their group? You want to know what the size, reputation, and penetration of other multispecialty groups are in the area, or what's happening with hospital practices. And in our community, we're the only big multispecialty group north of this kind of invisible line in our community. There's one south. But we don't really compete with them. And to date, none of the hospital practices have been able to compete with us. So it was very easy for me to bring in another neurosurgeon when my practice got too large for me to handle. And also understand what the subspecialty composition of those other groups are. We do have one group north of us that's almost as large as we are. But they're almost entirely private practice. They have no neurosurgeons and only two neurologists. So while in overall size, they're as big, their subspecialty distribution is very different. As I said, your ancillary income oftentimes represents up to 25% of your income. And for me, it's been much more reliable in terms of that income has been steady, while mine has varied from year to year for a number of things. And we all know what they include, imaging, LLCs. And also in multispecialty groups, you oftentimes get a significant amount of income from real estate holdings as well. The fiscal soundness of the group, this is business 101. Know what the major liabilities of the group are if they've taken out major loans and you're coming in. You may not be the benefit of some of these secondary ancillary incomes if the loan is eating up a lot of the resources of the group and what their recent large investments are, and also if there are potential lawsuits. Again, in our community, there was a large multispecialty group. There was an orthopedic surgeon who was found to be very problematic. And the group folded. It was 225 doctors, and they folded because of the lawsuits of one orthopedic surgeon. So my experience, I'll share with you. I started off in academic practice as an assistant professor in 1994. I maintained that position until 2005, though the practice structure changed considerably during that time several times. And I guess that's why Bill asked me to talk about change, which you'll hear from me tomorrow. Between 2005 and 2010, I was in a private setting with just two neurosurgeons. And then since 2010, I've been in the multispecialty group. I'll just share my personal experience throughout my career. I've worked with many wonderful colleagues. I've not always had that experience. I can tell you that now in my multispecialty group, it's probably been the best environment in terms of the colleagues and the peers that I work with. My revenues have increased since I joined the multispecialty group. I do have less autonomy in terms of making decisions about how I run my practice, though I maintain complete autonomy, obviously, over who I care for and what surgeries I offer them and how I run my interaction with my own patients and my own surgery. I do have significantly less administrative responsibility, but that translates for me into having more time to generate work units and income for myself or to spend doing other aspects of balancing my life. What's the future of multispecialty practices? We're very well positioned in the accountable care organization world. We're currently the strongest competitors to hospital practices. The growth of multispecialty practices may get ahead of the experience. And we've seen a little bit of that in our group. We went from 75 doctors to 300 doctors over just a very short interval. And we are going through some of the growing pains that are associated with that. And we expect that we're going to become even larger. And if you get to be 500 or 1,000 doctors, do you lose some of the benefits of knowing every single doctor that's in your multispecialty practice, as everybody does in our group right now? And rapidly, these groups are crossing over into carrying their own insurance products. And that's going to change the face of the practices again. It is an excellent alternative to hospital employment. There may be some financial benefits to a multispecialty practice. It is a dramatic alteration in autonomy and a cultural change. But that's not always a bad thing. And our immediate future multispecialty practices changing rapidly and long range, who knows? So make your choices and be happy with them. Thank you.

neurosurgeons

private practice

hospital employment

autonomy

ancillary services

multi-specialty practice