Section: Residency Education Category: Life Skills

Practice Options: Private, Group, HMO, Government, Military - Pros and Cons

Aksone Nouvong, DPM

**** This lecture is not available for CME ****

  • Author
  • Aksone Nouvong, DPM

    Associate Clinical Professor
    David Geffen School of Medicine UCLA
    Chief of Podiatric Medicine and Surgery
    DVA Greater Los Angeles, CA

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    Aksone Nouvong has nothing to disclose.

  • Lecture Transcript
  • Male Speaker: Okay, here's a good friend of mine, Aksone Nouvong who comes from California and another life skills talk based on practice options that she would like to discuss and share with you. Please welcome Dr. Aksone Nouvong.

    Aksone Nouvong: Thank you. Thank you for having me up here again. This is a topic that’s actually very interesting to me because I get ask this question very often by our students and residents as to what are some of my practice option. What should I do? Should I do private practice? Should I go into an HMO? Should I work for someone else? I want to go over with you some different practice options and some of the pros and cons and the benefits that come with each one of them. These are some of the things you need to consider when thinking about what practice choices you should be making. Number one, you need to consider what type of practice you want to go into. Do you want to own a practice or do you want to work with someone else? What type of income are you expecting? We all can't make the same money as Dr. Frykberg and Dr. Schoenhaus, but you want to know what kind of income you should be expecting to have with each of the practice. Additionally, you want to look at the benefits. What type of benefits are provided in each of these type of practices? And then what are the pros and cons of going into either private practice or being an employed practitioner and do these practice provide you the goals that you would want in terms of your interest. If you have a business savvy attitude, you may not want to be employed. You may want to open up your own practice. And then where do you want to work? Do you want to work in a more rural area or in suburbia or do you want to work in a city? And then what kind of lifestyle do you want? Do you want to be on call, on a regular basis or do you want to work more of a nine to five job? And then if you have any interest in academia, there are certain practices that would allow for you to have that and other practices may not be as conducive. And then if you have a family life, certain practices are more conducive than others. We'll go over in some detail, each of these practice types. The two main practice type that you have is one, you can be an owner of a practice or you can be employed by a practice or a hospital. If you choose to be an owner of a practice, you can choose to own your own practice by yourself or you can own a practice with a group. Within each of those groups, you can either chose to own a practice with podiatric clinicians only or in a multi-specialty group. If you don’t want to own your own practice and you want to work for someone else, you can choose to also work in a group practice. If you choose to be employed by group practice, you can be in a group of podiatric clinicians only or multi-specialty group. You can also choose to be employed by an HMO, a hospital, work in the military or government institution or work in an academic institution. I go over these as list of separate entities, however, you can choose to work in a combination of all of these. You can have your own private practice and also work in a group setting also. Some of the benefits that you do need to consider when choosing between these options are you need to know if are health insurance covered or do you have to cover your own health insurance. Same thing with life insurance and malpractice insurance. Also, it's important for you to consider in terms of your retirement plans, if you own your own private practice, you would have to put aside money for your own retirement. But if you work for a hospital, if you work for an HMO or if you work for a government setting, there is retirement that they put aside for you in addition to your own contribution. There are other expenses that you need to consider. You need to consider whether they pay for car expenses, mileage reimbursement. Also do they cover your professional fees and your membership dues? Other things you also need to consider because CMEs obviously are required for all of practitioners. When you work for yourself, will you be covering for your own CME expenses? If you're working for a group or if you're working for a hospital, will they be covering CME cuts for you? Then minor details like your office. Simple things as cellphones and computers. Then in terms of demographics, some practice allow for you to work in a more city area and others will require for you to work in a more suburbia area. Again, we'll go through some of this. Fortunately, APMA put out a survey in 2012 regarding all these decisions that you would have. They sent out an online study between April and May of 2012. They sent out e-mails to about 10,500 known practitioners with e-mail addresses. They actually received approximately 728 responses. Keep in mind these surveys that were returned, almost half of the surveys were returned by solo practitioners. Some of the numbers may be slightly skewed. But they're actually very important numbers for us to consider.


    In general, this is what they actually found in these surveys. They found that podiatrists who are actually employed mainly practice in the urban area while podiatrists who own their own solo or group practice, practice more in the suburbia area. Those who are employed were more likely to be ABPS certified or qualified. Those who own their own practice were not likely to be board qualified or certified. Again, keep in mind this survey, the majority of them were sent back by solo practitioners. Nowadays, majority of you won't be ABPS qualified as you are all on three-year residency programs. Same thing with residency completion, most employed podiatrist were residency trained while those who own their own private practice were not. Then in terms of employed practitioners, they were likely to be more recent graduates, younger and majority of the people that were employed were female podiatrists versus those that were solo practitioners. Here is what you want to know. What are your expected incomes? In terms of where you can be practicing, what you can be practicing and who are you going to be working for. If you look at the top row there, this is broken down by, the top three is if you were an owner of a practice. The first one is if you were an owner of a solo practice. The second and third is if you are an owner of a group practice in a podiatric only group or a group practice with multi-specialty and the rest of it is if you were employed by either a group practice solo podiatric, group practice multi-specialty and then HMO, hospital, military and then academic. Looking at this grid, some things to consider. The majority of the people that returned the survey made between 100 to $175,000 per year so that’s about how many people that returned. Of those that made between 100 and 175,000, the majority of the people were military or government employees and then those who are employed by academic institution. So that's the average amount for that type of setting. However, if you look at this other column here, there were people who actually made less than $100,000 a year and that's the second highest group of income people that return their survey. Unfortunately, those are mainly seen in solo practitioners and employees of a practice group of podiatric clinicians only. More people who made less than $100,000 were solo and then those that actually work for a group of podiatric clinicians only. The next largest group of income earners were actually between 175,000 to 250,000. In that group, the majority of people were employed by HMO and also owners of a group practice that were multi-specialty. If you want to make between $175,000 to $250,000, maybe this is an area you might want to consider. Then the last group that I want to go over, which is a very important group is those that make over the $325,000 and that would be Dr. Schoenhaus, Dr. Frykberg and Dr. DiDomenico over there. Very few people actually make over $325,000. But for those who do make over $325,000, they were the owners of either a group practice, a podiatric or group practice of multi-specialty groups. This is a great breakdown of income based on what type of group setting you would like to work with or what type of practice setting I should say. If you want to compare, if you want to be an owner of a big practice comparing in general the median and mean income. For those who own your own practice, in general as stated, those who own their solo practice made significantly less money than those who own a group practice with a multi-specialty group as you can see here. The average is 160,000 versus about 280,000. If you are an employed practitioner that work in a group setting, important thing to realize is if you are employed by group practice with only podiatric clinician, unfortunately, they make significantly a lot less money than those who work in a group setting with the multi-specialty clinicians.


    And then if you look at the overall breakdown again, those who are employed by group practice of podiatric clinician make significantly less money than even the other employed practitioners who work for HMOs, hospital setting, military, government and also the academic. That's income-based and that's what you should expect based on what type of group setting you'd like to be in. Now in terms of benefit, as I discussed, so benefits are also going to be important for you. In terms of benefits, if you're looking at health insurance, if you are the sole carrier of benefits for your family, you may want to consider more working for someone else. Because if you are working for a multidisciplinary group or if you're working for an HMO or hospital, academic setting, they are more likely going to cover your health insurance. However, if you're a solo practitioner, the chances are you're going to have to pay for your own health insurance or if your spouse or your family already have insurance for you, that's something that you don't have to worry about as much. This is the same as for life insurance and same as retirement. Now retirement is kind of important. In terms of retirement, if you own your own practice as stated, you have to put away your own money. If you're not organized enough to put away your own money, that may not be a best option for you. You have to put away your own money for retirement. However, if you're an employee of a group or of a hospital setting, you put away your own retirement and there's contributions from the hospital or from that group in addition for your retirement. That’s something to keep in mind when looking at retirement plans. Then professional and membership dues, unfortunately, if you work for a military or an HMO, they're not likely going to pay for your membership due. Those are things that you would often have to pay for yourself. However, if you're in private practice, usually money is set aside for CMEs and professional dues. Malpractice, most people carry malpractice so you won't have to worry about that as much. As stated earlier, very similar to professional, in CME, most people who are in the private practice side will cover for CMEs. The pros and cons of all these. I want to go in detail on pros and cons of which practice group. Again, if you're an owner, you can choose to own solo or you can own in a group setting and then the terms of the group setting, you can own with just podiatric clinician or own with a multi-specialty. If you're employed, you can be employed by these groups. You can be employed by a group of podiatric clinicians only or be an employee of a group with multi-specialty or you can be an employee of an HMO, a hospital, military or government and/or an academic setting. I could have put a check mark by all the pros for each one of these areas. Holidays seems really simple, Christmas, Thanksgiving, you want to take off. Unfortunately, if you are solo practitioners, you can choose to take any of the holidays off but as you take time off and you're not seeing patients, you're not getting paid for those. When you take a holiday, you're not being paid for your holiday because you're not seeing patients, you're not being reimbursed. Depending on how you're employed with the group setting, if you're salary-based, they may pay for your holiday but some group settings may not pay for your holiday. You have to consider when you're signing that contract. If I take a day off, am I being paid for that day in terms of a holiday? But in general, if you work for an HMO, a hospital, the military government or academic setting, when you take a day off for Christmas and Thanksgiving, it's paid for you. That's the same with sick days. Now, vacation is just a little bit different. Because again, if you own your own practice and you're not seeing patients, you could take more vacations whenever you want to. You can't do that when you're employed because they set when you can take vacation. However, when you do take vacation as an owner of a private practice, you're not being paid because you're not seeing those patients. But if you work for the HMOs in hospitals, vacations are actually built-in. That is actually part of your benefit packet. That's the overhead that they cover for you. You have all the vacations paid. In terms of autonomy, if you own your own practice, obviously, you have a lot more autonomy. You can do whatever you want, go in whenever you want to, start whenever you want, end whenever you want, take time off, work holidays, work weekends. That's the autonomy you have when you're an owner of a solo practice or a group practice. Unfortunately, when you're an employee of someone else, you don't have the same autonomy. That's the con of working for a group setting or a hospital or an institution.


    Then in terms of billing, this can be actually a pro or a con for all these practice type. In terms of billing, unfortunately, I think it's a con. I'm not very good at billing but if you own your own practice, you have to have some business savvy because you have to go to bill for these patients, understand the billing aspect of it. If you work for someone else, they bill for you, so you don't have to worry about the headaches of billing and the business aspect of your profession. Again, same thing with overhead, overhead is very similar in terms of a billing. If you take time off of your private practice and you're going to be gone for two weeks, wish you take two months, two weeks or three weeks off, you still have to pay for your overhead. Your employees that work in your office you're still going to have to cover them even whey you're off and you're actually not being paid during that time. But if you work for a hospital, you take time off, you don't have to worry about the overhead cost. The next one is a flexible income. This is the biggest pro if you own your own practice because you have that opportunity to have this flexible income. You can make as much money as you want or as little money as you want, depending on how much effort you put into it. When we looked at the income earlier, you can make as little as under $100,000 but you can make as much as over $325,000 if you own your own practice, whether it's solo or in a group setting. However, it's really hard to make that much money when you're working for an HMO, a hospital, military, government or academic because the salaries are usually set for you. However, if you still wanted to work in that type of setting, you can do, like I said, a combination of both, part private practice and then part group setting. I think Dr. Schoenhaus actually discussed whether you want to do private practice startup or private practice working for someone else and that's another decision you have to make. Also in terms of calls, when you're working by yourself or especially when you're solo practitioner, all these patients are your patients so you're on call for your patients the entire time. If you work for a group setting depending on how it's worded in your contract, you may have to cover someone else's call. But if you're an employee of another group and there's multiple people, you can actually share calls. The pros of working for someone else, you actually have shared calls. The second to the last one is economic independence. I wrote that up there because if you are private practitioners and the economy decreases like it did several years ago, you may lose some of your patients. So your income is dependent on the economics of the entire nation. But if you're working for a hospital, if you're employed, it doesn't matter what the economics is around you because you are salary paid so your income is not based on what the economy is. The last thing is patient source. The pros and cons of those, like I said, if you your own your own private practice, it's your decision as to how much money you make. So you can generate and also advertise for as many patients as you want. If you're an employed person, they find patients for you so you don't have to seek as much patient load. Those are the pros and cons of each of these type of practices. In summary, basically overall, there was a significant difference between people who own a private practice versus those who are employed based on the net income in 2011. However, those who did own their own practice, the ones who owned a multi-specialty made significantly more money than those who actually were employed. You should choose these types of practice based on what you're interested in, the benefits, the lifestyle you want and whatever makes you happy. Look at the income and benefits. Thank you so much.