SCCMPod-554: Navigating APP Contracts and Salary Negotiations

Dr. McLaughlin: Hello and welcome to the Society of Critical Care Medicine podcast. I'm your host, Diane McLaughlin. Today, I'm joined by John Appino and Ryan Hakimi to discuss salary negotiations specific to healthcare professionals, including consideration of compensation, benefits, and salary.

As you know, APPs are a large part of the critical care workforce, but many do not feel that they have the skillset to negotiate a salary. John Appino is the founder and CEO of Contract Diagnostics and has been working in contract negotiations specific to healthcare providers for over 13 years. Ryan Hakimi is former founding medical director of two academic neuro ICUs where he introduced the concept of critical care APPs to his health systems.

Currently serves as the director of transcranial Doppler ultrasound services while also working full-time as a neurointensivist at Prisma Health in Greenville, South Carolina. He also serves as a professor at the University of South Carolina Greenville School of Medicine and is an active member of the APP Resource Committee at SCCM and helps APPs advocate for compensation. So with all of that, before we get started, do either of you have any disclosures to report?

Mr. Appino: I do not.

Dr. Hakimi: I do not.

Dr. McLaughlin: So I have to start by asking probably the most obvious question is, neither of you are APPs. So can you talk about how it came to be that we're going to be talking about APP contracts today? Maybe we'll start with Ryan because I know you have a personal connection with this.

Dr. Hakimi: Sure. So my mom was one of the founding APPs from the 1960s. She was a CRNA and I'm very proud to say that I was also trained by APPs at Duke when I was a fellow there in neurocritical care and stroke.

So I've maintained the connection with the APP community on multiple areas and in particular also with the American Academy of Neurology where I'm the co-chair of the APP educational sessions during their fall conference.

Dr. McLaughlin: Yeah, you've always been a huge supporter of us, so we definitely appreciate you. And it seems like maybe you identified John as somebody that could help us out. John, you're a true businessman designed to help people get good contracts, right?

Mr. Appino: That's funny. Now, I'll tell you, Ryan and I, although our crafts are very different from each other in terms of our training and our professional focus, my mother was a nurse practitioner in South Dakota. I believe her state license number was four.

So I've always had a passion around nurse practitioners and PAs because my mother was one. In our small community, I had so many people say, your mom is my doctor. And it was fun to grow up in that environment.

Since then, lots has changed. I decided not to go into medical school, which was my major in college as a microbiology and chemistry major, but I instead went into a science-based field. I went into pharmaceuticals and biotech for years and I got to know many, many different types of systems around healthcare.

And one of them was physicians. And I grew a passion for helping and educating people around their contracts because I saw a large gap in a physician going from training to a new position and not understanding the contract, from one position to the next, from quitting one to partnerships and everything in between. And that comes along with that is, of course, not just physicians, but PAs and MPs and CRNAs.

And the roles are very similar in many aspects to the physician. And when they get contract, which is not everybody, but when they get contracts, they deserve and they require the same guidance and help as a physician when it comes to understanding their contracts and understanding their compensation structure and what's fair and what you can and can't negotiate in an agreement. And so I have a passion for helping all types of providers understand their contracts and their compensation structures and make sure they're getting paid fairly.

And that can be defined in many different ways, which I'm looking forward to discussing with today.

Dr. McLaughlin: All right. Well, thank you guys for being here and extra thanks to your mothers for working in the field and getting you to be so supportive of us. I think we have to start at the beginning and we can take this from two different approaches, one of a new graduate versus an experienced APP.

But what should we even be looking at when we're getting these job offers?

Dr. Hakimi: That's a great question. So there's a sort of a more modern way that some APPs are doing fellowships now in specific arenas. So outside of those individuals, which represent a very, very small percentage of practicing APPs, most APPs, the first thing they should look at is does the program have a detailed and regimented onboarding and training session, a time period of at least weeks or months, depending on the scenario and the person's expertise or experience level.

And I always jokingly say that if you interview for a job as an APP and you say, well, what about onboarding? And they say, OK, well, we'll get you started and we'll see how it goes. And that's a job you should probably walk away from because nobody who's an APP has had specialty based training.

Nobody was a neurologist. They never did a neurology residency or neurocritical care fellowship or critical care or whatever. And so I think one of the first things that you should look at is what is the training that the program is going to provide you?

And of course, during that time period, the expectation should be that you get paid.

Dr. McLaughlin: John, anything to add?

Mr. Appino: No, I think Ryan did a great job on, you know, looking at the position, a couple of things to analyze in the due diligence phase. Right. And when it comes to the job in general, I think, you know, we always coach people to, you know, look at the like what Ryan said, look at the position and the expectations and the requirements, not just when you start, but then in the future.

We love questions around schedule. And if there's a contract, which, you know, I don't know what percent of APPs have contracts, let alone this particular specialty. But, you know, we think a full discussion, if there's a contract, of course, should ensue.

And even if there's no contract, a full discussion around the job and the requirements on your time. And of course, everyone's time is valuable. So how do you trade that time?

Well, for money and benefits. And those things should be very clear and very detailed. If it's a salary position, great.

How does it change over time? What's the range in the department? If there's bonuses, we want to know the details and the nuances with those structures.

So many, many questions beyond just the job description when it comes to what's important as they're looking at a job and analyzing if it's the best next step for their career.

Dr. McLaughlin: Should there be a contract? Or I don't feel like I know a lot of APPs that do have contracts. And if there's not, how do you ensure what you're promised is what you actually get?

Mr. Appino: So I have a couple of thoughts. I'd love to hear Ryan's take on this as well. So I don't know what percent of nurse practitioners, PAs, and CRNAs receive contracts.

The vast majority of CRNAs have them. From what we see, we do a lot of CRNA contracts as we have a relationship with the American Association of Nurse Anesthetists. But as far as PAs and MPs, I don't know what percent of them have contracts.

But there's lots of things that typically would go into them. One, of course, is your schedule and what the expectations are for your hours. And if you're working 1.0 full time, what does that mean?

If there are shifts, if you're Monday through Friday, 8 to 5, if there's a call obligation, those things could be documented in a formal agreement. Obviously, compensation could be documented. If there's bonus structures or signing bonuses or quality bonuses or any other types of differential pay, those things could be documented in a contract.

Things like malpractice insurance are generally more simplistic when it comes to PAs and nurse practitioners, but it depends on the setup of the organization. And, of course, if there's restrictive covenants, depending on the state and where you are, that's usually included in a contract, as well as termination and how you should get out. If it's just given a normal one-week or two-week notice, or there's a formal 90-day or 120-day notice before you have to terminate your position and move on, all of those things are items that we typically see in contracts, whether they're physicians or PAs, whether it's dermatology or critical care, and we see more and more of these folks get contracts.

But I'd love to hear Ryan's take on how his programs have done it and how they structure these types of relationships.

Dr. Hakimi: Yeah, I think a lot of these things depend on the practice setting that you're in. So, in general, academic medical centers, even for physicians, don't have a detailed contract. That is changing a lot over the last several years.

But let's say 15 years ago or so, people had what's called an offer letter. And the offer letter was one to two pages. It basically said what your position is by title.

It said, for example, you're an assistant professor or a director of the ICU or whatever it said. And it said your FTE, which was not defined in those offer letters. It had your compensation.

And it had a few sort of, depending on the scenario, it had a few do's and don'ts. For example, something along the lines of the physician agrees to follow all of the standards of the university employee handbook. Failure to do so will result in termination or something like that.

Now, that has continued in a lot of settings where those academic medical centers hire APPs, which, again, they're sort of like the one pager or one to two pager and such. Now, as health systems are merging and they're becoming this word that I don't care for, prividemic, where they're acquired by health systems, academic centers and such. Ours is an example of that.

Then those places, because they are rooted in a history of private medicine, they're the ones that have much more detailed contracts. So, for example, when I came to this institution, even though we're an academic medical center with a medical school on our physical campus, the items that you would normally find in an employee handbook were actually part of your contract. So the contract was about 55 pages, which was very shocking for me because I'd never seen a contract like that.

But you went through things such as, you know, as detailed as sexual harassment and IT policy with PHI, which normally is not included in a contract. So I think going back to John's point, I think the key salient points are what is your compensation? What is your FTE status?

And ideally, what is a definition of the FTE status? And in critical care, very often it's termed in terms of shifts or weeks. It's very rarely termed in terms of hours.

So it might say you have the obligation of working 165 shifts or 180 shifts or whatever. It may be very general and say this will include a mixture of days and nights and weekends and holidays, something like that. Or it might be much more specific where it says that the nights will be divided equally amongst the current pool of APPs in that discipline.

So I think it really depends on the organization. And if you don't have that clarity listed in whatever document, whether you call it an offer letter or a contract, ideally get it by email and then keep that email because hospital leadership turns over constantly and they have a very poor institutional memory.

Dr. McLaughlin: And I will say my experience has always been the two-page offer letter and sometimes requiring some clarification.

Mr. Appino: We do see those two-pages or three-page contracts. And yeah, they oftentimes lack a lot of detail. It may split up a percentage of academic or clinical time and have a lot of things in there.

But like Ryan said, oftentimes it just references other policies. So understanding what those policies say, if there's a restrictive covenant policy or a lot of times what we're seeing now, even in these academic contracts is a salary and then a reference to a faculty compensation plan. And the faculty compensation plan oftentimes is not clear on how it changes over time or even though it's academics, we're seeing a lot of RVU structures for bonuses and production metrics in these things.

So yeah, depending on the situation, a lot of things need to be clarified in those two-page letters as well.

Dr. McLaughlin: So I think that brings us to what everybody wants to hear, which is about the money. So I think a lot of people are under the impression never accept a first offer. When is it appropriate to negotiate salary?

What type of information should you go in armed with? And how do you know what your true value is?

Dr. Hakimi: So excellent questions. So first and foremost, because more often than not, at least in academics, you're being hired by a physician. In the physician world, there's sort of this historical unwritten rule that if the person, their first questions out of their mouth relate to salary, that's a faux pas or things like that.

So I would wait to see where the conversation goes. I would certainly not have a discussion before I come to the job interview unless, unless you have a lot of experience. And so therefore you do command that authority.

So if you are a brand new graduate, I don't think you should bring up the salary in the original email communications that you have with regards to applying for the job. If you're somebody of your self stature, Diane, who has had a number of years, has accomplished quite a few things, has a multitude of academic accomplishments, publications, areas of expertise, then the way that I have done that as later in my career is I say it in a very bland way. I say, this is what I'm looking for.

And I recognize that not everybody's budget can support that. And I just want to make sure that I'm being understanding of your time and your organization's commitment to this process. And I understand that if your budget doesn't support that, I'm not here to argue and it's perfectly fine and we can still be friends, but we're not going to, this, this process is not going to move forward.

However, if you think that that range is achievable with further discussion or is reasonable in your consideration, then I would love to learn more about your organization and move forward. And potentially, you know, if you deem me appropriate, come for an onsite interview, so on and so forth. You don't have that credibility when you're a brand new graduate, whether you're a physician, an APP, it doesn't make any difference, CRNA.

So I would play that very, very differently, depending on your current position in the field and such. And then lastly, there is a lot of free resources that are out there. One of which is the American Academy of Neurology, if it pertains to neurology.

Many of us have sort of secret ways of getting MGMA data. You know, that information costs several thousand dollars, tens of thousands of dollars to get, but many people have it. And so you can get MGMA data on what is the range for APPs and things like that.

There's publications out there. There are things like Practice Link have every five years or so, they'll publish something so you can go and look up, like, what does a medical intensivist make in terms of range? And some of them have it broken down by region.

But I wouldn't bring any of those things to the initial discussion because it doesn't matter how much the job offer is, if it's a terrible job, not only are you going to be dissatisfied, your employer is going to be dissatisfied. So the first key is figuring out what is the job and are they going to provide me with training and what are their expectations? And do I think it's a fit?

Because if it's not a fit, it doesn't matter what the dollar amount is. It's not going to work. And nobody wants to have it on their resume that they're changing jobs every six months.

And the employer doesn't want to spend all the time, effort and money to get you onboarded and you get up and leave in six months.

Mr. Appino: Yeah, I would agree. I think that making sure it's the right fit, you know, depending on how you found the job opening, oftentimes they do have salary information there. So you should know, you know, that there's some, whatever range, if your needs to Ryan's point are 30, 40% higher than the job description or the posting that you see, but yeah, maybe it's not a good fit to begin with.

But we always like, you know, instead of jumping in about compensation to Ryan's point, we always like, instead of asking about your specific compensation, we like asking more broad questions at the appropriate time. And those questions can be, how do you set compensation and how does it change over time? And what's the range in the department?

And, you know, do you offer bonuses and what can I do to increase my pay at a higher percentage than what might be reasonable or normal or expected? And I think when asking those questions, you get answers on if you could ask for more. So for example, if your question is, how do you set pay in the department?

They may say, these are the bands we have. And then we start you in band one. If you're out of training, we start you in band two or three.

If you have experience, depending on your tenure in the role and your experience, they may say we have everyone in the department at the same level. And we look at the compensation every other year. And these are the data sets that we use.

Ryan brought up a couple of examples. And so depending on how they answer that question, how do you set compensation? If they set compensation, the same for everybody in the department to ensure pay equity, then the question of can I have more might not be a reasonable or a healthy question, but how does it change over time?

And what should my expectations be when I'm in for five years or for 10 years? So what metrics do you use when you increase the level of compensation for the department in general, if they pay everybody the same, we feel those kinds of questions are very valuable. And there's lots of great resources for data out there.

Ryan mentioned a couple. We have an internal database here at Contract Diagnostics where we have live and real data from the physicians, the nurse practitioners, the PAs, the CRNAs that we help through the process. So we can kind of gauge it to the particular market.

We do have MGMA. We do have AMGA. We have lots of the other data sets here to access as well for each individual position.

But I do think that the story matters. So even if you look at MGMA and it says the Western region compensation average or 75th percentile or 10th percentile is X for this particular role. Again, it's the Western region.

MGMA can get more specific based on minor geographic area. There is some state level, but probably not in a craft as specific as this one we're speaking of. But even if you take MGMA data, you've got this regional data.

And California is the same region as Alaska is the same region as Wyoming is the same region as Hawaii. And we all know that even if you look at California, there's a big difference between San Jose and San Mateo or San Francisco and Sacramento or even, you know, Tahoe on the California side. So we feel that the story matters, right, about the account and about how many other people they have there and how long it's taken them to fill the position, why it's open in the first place.

And coming back to what we talked about before, which is the job fit, you know, what's the position required in terms of hours, in terms of commitment or shifts like Ryan brought up. So we feel that not just the number matters, but the story matters behind it. And I think it's a really good discussion to have around all of those things when anybody's discussing pay for any particular role.

Dr. McLaughlin: Yeah, it seems like whenever somebody starts looking for a new job, the first thing they talk about is money. But at the end of the day, that's not what keeps somebody in a job. And that's not what gives people job satisfaction.

And so knowing that, or simplifying and saying, mo' money, mo' problems, something like that. How do you talk about the other things, like onboarding, like protected time, like mentorship? How do you talk about that when job offers?

Mr. Appino: When we go into a discussion around compensation, you know, people always say, whoever, John, or whomever they're working with over here, is this a good pay? Is this a good number? What should the number be?

We never say good or bad, yes or no, because I don't know. Again, I want to come back to what you need to do for that money. And if you're burning out, if you're miserable, if they don't have the technology or the resources that you need, if you have a passion around a project or research or working with a certain type of patient or in a certain setting, a certain level of care, all of those things are super valuable when it comes to your job satisfaction overall and how long you'll be there.

And I think all those things are super valuable when it comes to the role in general outside of the pay. But I'd love to hear some tips from Ryan on what he thinks about the process.

Dr. Hakimi: So, I've been part of two startups, and in both scenarios, one of the questions that our leaders have asked me is, what's going to make somebody come here and you're starting a program from scratch? What's going to do that? So, at my first job, we were at the University of Oklahoma.

So, we were the first ones to give academic titles to all APPs in the department. That was a major benefit for a large number of people who had academic interests. So, all APPs were hired in as an instructor in the department of neurology, and they had the same capabilities of moving up to assistant professor and associate professor and things like that.

It's very, very challenging, but it's possible. And we did that. So, that was something that was relatively unique, and many people value that.

In terms of other potential things, one of the lines that I always use with recruiting people was that I may not be able to give you more money, but I can make your job better. And so, the environment, what is the culture of the team, let's just say? And it may be anywhere from, well, you're just you at an APP, all the way to something much, much larger, where people see what kind of support there is and redundancy.

One of the keys for APPs is nobody wants to be on an island. Whether you're an APP who has 15 years of experience or this is your first job, you don't want to be somewhere where you're completely by yourself. And so, staffing needs to be ensured that it's based on peak, not on average.

That's a term that I always use. So, what is the worst case scenario? And am I going to be able to handle that in the current staffing environment?

So, that's something you look for for fit, not, well, if we look at 365 days on average, we have two admissions per 24 hours. And so, clearly, you could handle two admissions on your 12-hour shift. No, we need to think about those things.

So, there's a variety of things. There's opportunities for research. For some people, it matters.

For some people, it doesn't. Now, if you're at a center where that is a job requirement, you need to be very upfront with the APP and say, hey, we require all our APPs to participate in posters, clinical trials, academic endeavors. We're not going to expect you to be the first author or the one who's originating the idea, but we just expect you to participate.

And that's going to be done outside of your work hours. Or you could be at a place like my current place where we have a multitude of opportunities. However, it is completely your choice.

And if you just simply come to work, take care of patients, and you go home, and you never participate in any research or any publications or anything like that, that's still okay, and that will not hurt your salary. So, those types of things, you'll hit various target groups because some people really care about academic involvement, some people care really about research, and some people care about the day-to-day job support. And those are three different types of candidates.

And you have to present your job, whoever is the one presenting the job to the APP, you have to present your job accurately so that the candidate then matches. So, if you're hiring somebody to be just somebody who comes to work and takes care of patients and goes home and things like that, you're probably not going to get somebody who has 15 publications as an APP under their name, because they're not going to be happy in that environment.

Dr. McLaughlin: Well, I think it gives everybody a lot to think about and really a good starting off point when negotiating either a new contract or a new job offer. We're getting to the end. Is there any last comments or last words of advice that you guys have?

Dr. Hakimi: I think to seek out help. Don't be ashamed to call a friend, call a colleague, even whether it's a physician or an APP, and say, would you be willing to talk to me about this job? I've been doing that for probably over 10 or 15 years now, that I provide private consultation and I've kept my word.

I've never told anybody who I've talked to whose contract I looked at or anything like that. And there are people like that who enjoy the mentorship and enjoy the connection and look for somebody like that to help you who has a better understanding of the market because they've been in the field for a number of years.

Dr. McLaughlin: John, any last words?

Mr. Appino: No, I couldn't agree more. I think leaning on people who have experience and advice to give in a confidential way is something that is super important. And knowing that it's an important process and finding a job, securing a job, interviewing for a job, doing due diligence on the job, and then if you sign something or if you just work there, that's a big process.

These folks earn really good money. We've seen really good trends over the years for a variety of reasons. And I think for those reasons, it's an important decision to be able to workshop these things with somebody.

Because having somebody like Ryan, who has a lot of history with this stuff, or a friend, depending on what their level of experience is with different roles, or a company like Contract Diagnostics, being able to have someone that you can trust to discuss the things and figure out what should you ask for and in what order and who do you ask. Knowing that positions are much different from an academic center to a for-profit health system, to a nonprofit health system, to a private group, all these situations are vastly different. The relationships with the employer and the facilities could be dramatically different as well.

The roles could be dramatically different. The compensation could be dramatically different. So understanding what those differences are and having a very robust conversation with anybody that would be in the process, in the mix, we would encourage wholeheartedly.

And whether things are negotiable on compensation or on schedule or on benefits or not, doing proper due diligence, we feel is in the best of everybody, from the employer to the provider themselves to the patients that everybody serves. So I couldn't agree with Ryan more when he says, seek help and lean on others who know a little bit more than you do in this situation. Or just have an ear to talk to you.

Sometimes that helps you solve problems by yourself, I feel.

Dr. McLaughlin: Well, with that, thank you both for being here today and giving some great tips to get started with contract negotiations. Don't worry to my administration, I'm not going to be knocking on your door later today, but hopefully you guys can use these tips. And so with that, this concludes another episode of the Society of Critical Care Medicine podcast.

If you're listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine, I'm Diane McLaughlin. Thank you.

Announcer: Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, is a neurocritical care nurse practitioner at University of Florida Health Jacksonville. She is active within SCCM, serving on both the APP Resource and Ultrasound committees, and is a social media ambassador for SCCM. Join or renew your membership with SCCM, the only multiprofessional society dedicated exclusively to the advancement of critical care.

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