I remember distinctly how one day our group met with one of the many hospital presidents that have come and gone in my time. The first thing he asked was not how are you? but rather “are you employed or in private practice? “Why is this relevant?” I asked myself, aren’t we all doctors taking care of patients? or are we? In this article we will explore the differences (and similarities) between Neurologists in private practice v those employed by a hospital or healthcare system.

According to the American Academy of Neurology (AAN) 2020 Insights Report, in 2019 49% of its US members were employed by a hospital, 22% were employed by a practice, and 13% were owners or partners. In the same report the percentage of members in solo practice fell from 18% in 2008 to 11% in 2019. In the same period Neurologists in a Neurology Group went up from 20% to 27%, you get the gist.

If the trend continues solo practices will soon relegated to a display in a museum of natural history along with other extinct species like the T-Rex, and the Dodo. I’m not saying that is a good or a bad thing, it’s just evolution. The practice of medicine in the US has become too costly and impossibly complicated for a solo practitioner to bare alone. I myself am employed by a Neurology private practice, and while we are probably in the endangered species list, we are still game in this mass extinction of private practice.

So are you employed or in private practice? Let’s face it, regardless of whether you work for a Neurology group practice or a behemoth healthcare system, most of us are already employed. As such, the autonomy train has long left the station!

So how do you define autonomy? In my mind autonomy implies the ability to decide your work hours, vacations, and taking time off for emergencies. From what I have seen the larger the group the harder it gets for one to decide his/her hours. That said, smaller practices are subject to other types of pressures (i.e. man power) that may make your 4th of July getaway as elusive! So now that the autonomy issue has been settled—meaning we ain’t got any!—we can continue with our exercise.

What is your salary? According to Doximty the estimated compensation for Neurologist in my area is $208,000, where the median home price is $496,500. Are we being compensated enough? I am afraid the answer is a resolute negativo. So what drives our salaries? you may ask. Our salaries are driven in part by CMS (Centers for Medicare and Medicaid) and by market forces, such as geographic location, years in practice, and other. So how does CMS determine your pay? It starts when you bill the appropriate code, CPT (current procedural terminology) code, followed by coding the appropriate diagnosis or ICD (International Classification of Diseases) code. Finally, a determination of payment is made based on RBVRS (resource based relative value scale) of which RVUs (relative value unit) are an important part.

So what is an RVU? An RVU is a measure of value used by CMS to calculate physician reimbursement (Baadh et al. 2016). Prior to the creation of the RVU, CMS reimbursed physicians using a “usual, customary, and reasonable” rate which led to payment variability (Uwe Reinhardt 2010). Currently for each service provided, the payment formula contains 3 RVUs, one for physician work (~52%), one for practice expense (~44%), and one for malpractice expense (~4%).

The 3 RVUs are each multiplied by a GPCI or geographic practice cost index, so called GPCI adjustment. The sum of the three RVU components adjusted by their GPCIs is then multiplied by the Medicare conversion factor (CV) for the final price or Fee for service Medicare pays for one overall RVU. The formula looks something like this:

Fee(z) = (Work RVU2 x Work GPCI + PE RVU2 x PE GPCI + PLI RVU2 x PLI GPCI) x CV

In paper CMS regularly adjusts RVUs (i.e. due to advances in technology, etc.) In reality adjustments in RVUs are made by an elite group of 29 physicians, the Seal Team 6 if you will, within the AMA known as the Specialty Society Relative Value Scale Update or RUC. The RUC has such punch that CMS follows the RUC’s recommendations 90% of the time! (Uwe Reinhardt 2010). So AMA where are you?

Other forces that determine your compensation include, you guessed it, Location, Location, Location! So if you want to work in NY, one of the states with the highest concentration of jobs according to the US Bureau of Labor statistics, well… it’s going to cost you, whether you are in private practice or employed by a healthcare system.

Other factors that may influence your compensation include, years of experience, level of training, discipline within Neurology (procedure v. non-procedure based), performance, and other. N.B many of these factors are subject to change with Obamacare.

Can someone say benefits? Benefits, are the third metric I will analyze in our exercise. What are your benefits? Typical benefits packages include, healthcare, dental, disability, and malpractice insurance, paid vacation, CME stipend, licensing fees, personal days, and 401K matching. Anything short of the above is a nonstarter! But provided you get the above said bare minimum, the quality of benefits will vary from employer to employer. Big organizations have more clout and can therefore negotiate better contracts with health insurances, while others will try to sell you their homegrown plans (whether better or worse).

Quality of Life (QOL), our last metric of the day, a metric that is hardly considered by those deciding between a life in private practice v employed. QOL is also difficult to measure. How do you measure your work related QOL? Inevitably, one of the first things that come to my mind is burnout! Yes indeed, the dreaded “B word,” subject of much lip service, especially by large conglomerates which bolster on meaningless campaigns like “the joy of medicine, or the joy in practice.” Campaigns devised by the medical industrial complex to appease our ever increasing number of charred Neurologists while accomplishing nothing. So what are some of the drivers of burnout in your practice? Administrative burden (i.e. prior-authorizations, forms), patient load, time per patient, call schedule, COVID-19? So what can be done about the burnout crisis? Well firstly, I would argue we need more time with our patients. This however, is in direct opposition with the current business model of medicine, in which doctors’ and other practitioners’ salaries are dependent on number of patients/procedures they generate. Secondly, we need smarter technology, while voice recognition and electronic medical records are improving, we are a long way from opening a chart and having AI warn us that patient so and so is at imminent risk of a stroke, or patient x has had an uptick in her seizures over the last month. I would argue at least half the time we spend with our patients we are just doing data entry! Is this what the industry calls “working at the top of our license”? Hardly; Lastly, we need to be better compensated whether it is monetarily, in time, or other.

Well there you have it, my 2 cents on private practice v employed. In the end whether your work for the largest employer in the state or are in an old fashion moms and pops solo practice, we are all working class Neurologists!

Disclaimer: The views and opinions expressed in this blog are those of the author and do not necessarily reflect the views or positions of any entities they represent.