Navigating Salary and Benefit Negotiations

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Dear Director,

I’m a rising senior resident about to start the job search. What can I expect for salary and benefits and are these negotiable?

With the recent release of the MedScape physician salary survey, it’s possible to view average salary and benefits of emergency physicians around the country. Salary and benefits are just two components that should be part of your job selection equation.

The key drivers for me in every job I’ve had is whether I liked the work, my boss, my colleagues, and felt that I was treated and paid fairly. Each of those is subjective, but has been more important for me than just salary and benefits. With that said, getting a well-compensated job is definitely on the priority list for most docs. As background, several of my jobs paid a flat rate regardless of experience. As a day one attending, I was paid the same as others who had been at the site for a decade. When we got a raise a month later, I also got the same raise. Fair or not to the others, everyone was felt to be an equal. Other employers have rewarded experience (sometimes reflected in a higher hourly rate or a reduced total annual hours target for a fixed salary) and a few jobs I’ve worked factored in productivity.

Location

Just like in real estate, location ends up being one of the key drivers in job selection. There are certain sectors of the country based on supply and demand of physicians that pay higher rates while others pay lower.  I certainly admire those docs who have the freedom and desire for adventure that allows them to follow the dollar. But, as a chair, I’m generally looking for someone who has a tie to my area. It takes a couple of years to build your attending skill set to a reasonable level of productivity. When I interview people who want to spend a couple years in D.C. before they move “home,” I do worry that I’ll spend too much time and energy making them a valuable player for someone else and won’t get a good return on my investment.

Employment Status

Physicians commonly prefer an employment model compared to independent contractor status or partnership tracks. As an employee, your contract will generally guarantee you a salary and benefits in return for a fixed amount of hours. There may be rules about moonlighting. As an independent contractor, you’ll have more flexible in monthly shift commitment, generally be able to save more money for retirement and have more tax deductions (consult your accountant on these last two points).

On the other hand, you’ll pay additional tax (your portion of Social Security that generally gets covered if you’re an employee). You may get fewer benefits, but ultimately have more freedom to work multiple jobs or have the amount of down time that you want. There are still many partner-type opportunities available, however as an owner of the company, you’ll be financially responsible for all aspects of the business.

I’ve lived in all three worlds and been happy with all three models. I’ve also seen people move between IC status to employee and back and be happy with each transition (except for the headache that comes with changing benefits and tax preparation). Employee models are on the rise because most new grads want the ease that comes with it. I’ve also seen entrepreneurial people exclusively search out IC models as they thought it would be a better fit for the side jobs they wanted to do.

Self-employed physicians made about 10% more than employed physicians, according to the MedScape Emergency Physician Compensation Report. That did not take into account the value of all benefits. Despite this, more EM docs are employed than self-employed, which is consistent with national trends.

Salary

The pay for EM continues to increase. Although our pay is considered mid-range across all specialties, the average pay is nearly double what I earned when I started 20 years ago and went up 3% compared to the previous year. Most EDs will have a fixed starting salary for new grads. While there might be a little wiggle room, I’ve not found this to occur frequently. The bigger questions may have to do with how long your hourly salary might be protected if the group has a productivity pay model or how long are you at the site before you begin to share in profits. While you might be able to negotiate some time on the productivity pay, it’s unlikely you’ll get anywhere on the profit sharing. The good news is that the emergency physicians as a whole generally feel that we’re paid fairly for the work we do, according to Medscape. Also, keep in mind that most emergency physicians work 30-45 hours a week seeing patients and usually spend at least several hours a week on administrative tasks.

Men reportedly earned more than women in emergency medicine though women are more likely to work part time (17% of men and 26% of women work part-time). In essentially every group I’ve been a part of, salaries (hourly rates and/or base pay before productivity incentives) have been the same for men and women. However, disparities in salary continue to be reported. It’s been suggested to me by female leaders, that men may be more aggressive in contract negotiations than women. Regardless of whether you’re male or female, you should certainly negotiate for what you believe to be the fair starting salary. Since most of us take jobs close to where we did residency, usually with a phone call or two, you can determine the fair market rate.

Benefits

Depending on the employment model, benefits may range from only malpractice to a wide range of financially useful add-ons. While there’s likely to be little room for negotiation, benefits may include health and dental insurance, disability and life insurance, and retirement contributions. Additionally, many docs get a CME allowance, which may help pay for a conference or other subscriptions. If there’s any room for negotiation in the benefit package, it usually is in the CME allowance, though be prepared to justify how attending additional conferences is a benefit to the group.

According to the MedScape poll, the large majority of EM physicians get employer subsidized malpractice and health insurance. About 60% get a retirement plan with match. The closer I get to retirement, the more I wish I had this benefit when I first started working. Other benefits that might be offered and increase the value of your compensation package include additional insurance (vision, dental, life and disability), paid time off (for vacation and/or CME) and parental leave with pay.

Malpractice Insurance

Medical malpractice insurance and tail insurance coverage are really both industry standards. But since the devil is in the details (and the fine print of the contract), it’s important to understand the two main types of malpractice insurance. Occurrence plans cover malpractice claims when they occurred during the time period of the plan. I had an occurrence plan at my last job that meant that my malpractice was covered for any claim that might arise even after I left. You won’t get to pick what kind of policy you have and many of the larger groups self-insure, but at the end of the day, you want to make sure you are well covered during your time with the group and then if/when you leave the job.

Whereas claims made plans cover “claims” that are made and reported while your insurance is in place. A tail is required to be purchased if you leave the plan (i.e. leave the job) and this additional insurance coverage can be very expensive (1.5-2 times the annual cost of the policy, which can total $40,000 to $50,000) and may not necessarily be paid for by your employer if you leave the group – again tail insurance is an industry standard in my book. I can remember interviewing someone who wanted to leave his group, but the cost of purchasing the tail on his malpractice insurance made leaving nearly impossible given his financial situation at the time.

Signing Bonus

At the risk of irritating every employer, signing bonuses have become fairly standard across the industry. The range on these can be huge, but may also include paying back a portion (or all) of the bonus if you don’t stay at the job for a certain length of time. I’ve always thought that the higher the bonus (and pay), the more desperate the group is to fill the spot. And since there’s no free lunch, just be sure you know what you’re signing up for.

Conclusions

Everything is negotiable when it comes to a contract so it doesn’t hurt to ask. Employers likely have the most wiggle room when it comes to signing bonuses and you may be able to make an argument for additional CME support (dollars and time). But be reasonable in your ask since you don’t want to leave an impression that you’re a pain in the butt before you even start to work there. After all, the employer can always withdraw the contract offer. The good news is that most of us are pretty satisfied with our pay and benefits so make sure you like the job for the actual job.

And make sure you’re comparing apples to apples when you look at overall value of a contract.

A very high paying independent contractor job may have a great hourly rate, but the employee model job that comes with retirement and paid vacation may ultimately be more valuable to you. Perhaps the best news as you begin your career, is not only do most of us think we are fairly compensated, about 85% of us would choose EM again. Those are pretty good odds that you’re going to enjoy your career.

 

References

Physician Incomes Keep Rising, Albeit Modestly, Report Shows – Medscape – Apr 11, 2018.

Medscape Emergency Medicine Physician Compensation Report 2018 – Medscape – April 18, 2018.

 

ABOUT THE AUTHOR

EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Chief Performance Officer with Emergency Medicine Associates, a founding partner of Alteon Health. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

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