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AHLA's Speaking of Health Law
Regulations vs. Recruitment: Crafting Compliant, Competitive Provider Offers
Kate Taylor, Associate Principal, ECG Management Consultants, speaks with Bruce Toppin, Chief Legal Officer, North Mississippi Health Services, about how to recruit providers in a very competitive market while following strict guidelines that are frequently changing. They discuss the market backdrop; issues related to fair market value, commercial reasonableness, and recruitment incentives; and strategies for bridging the gap between competitive offers and compliance. Sponsored by ECG Management Consultants.
Watch this episode: https://www.youtube.com/watch?v=r4Ac7Qp2m9M
Learn more about ECG Management Consultants: https://www.ecgmc.com/
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SPEAKER_03:Hello, everyone, and welcome to Regulations versus Recruitment, Crafting Compliant Competitive Offers. I'm Kate Taylor, and I'm an associate principal at ECG Management Consultants. I spend a significant amount of time working on physician compensation arrangements and get, I couldn't even tell you how many phone calls from clients about working through physician arrangements and dealing with compensation matters. So I'm excited to talk to you about this topic today. Bruce?
SPEAKER_01:Yes, my name is Bruce Toppin. I'm the chief legal officer at North Mississippi Health services, a rural health care system based in Tupelo, Mississippi. I'm the chief, besides chief legal officer, I'm the corporate secretary and privacy officer. And I look at things in many different ways, but particularly when it gets to physician contracts, the regulatory side and making sure that our contracts, besides being good contracts, comply with legal issues and keep us safe from compliance risk. I've been here about 30 years and you see behind me, I collected a lot of information and books and binders over 30 years of being here.
SPEAKER_03:And I've asked him this question before, but he has read everything in that bookshelf behind him. Maybe not recently, but you have read it. At
SPEAKER_02:least once. At least once.
SPEAKER_03:All right. Well, so today, like we said, we're exploring a pretty challenging topic, one that almost every health system or hospital faces at one point or another. How to recruit physicians, and not just physicians, I should say providers, APPs are being hotly recruited as well, in a very competitive, tough market, while also following strict guidelines that seem to be changing day in and day out.
SPEAKER_01:Yeah, it's a tricky process. I mean, we want to attract really outstanding physicians to our organization. But at the same time, even for us, we're a rural area, so perhaps it's even a little trickier in our recruitment. But the number of perks and what's generous or what's creative, it seems to be escalating almost every year right now. And you have to look at the red flags to make sure that you're not going to step off into the abyss.
SPEAKER_03:Yeah, I'm glad you said that too, Bruce. I think we're going to talk about it a little bit later, but you mentioned rural markets. Every market is so different. You can't just take every market and put them in one bucket and hope that it's a one-size-fits-all. It's just not anymore. And especially with physician shortages, rising compensation, we see the benchmark data every year. I think it's more of an anomaly if compensation I don't know that I've seen that recently at all. So there's lots more pressure to put out compelling offers to get these providers in the door.
SPEAKER_01:Yeah, you're absolutely right. We have a team of folks that are involved. We have recruiters who are involved. We have administrators. We have a chief medical officer. So we have a lot of people involved. And they all have their own opinion about what is exactly needed to recruit. And we meet about that and try to get standardization but we have to review it from time to time. And I will say, I have a son who's finishing up a fellowship and I have the opportunity to help negotiate his contract from the other side. And he's in an urban area and it's slightly different. And I've also, as a courtesy, helped some of his colleagues and the residency look at it. And most of those are urban areas and they vary from urban area to urban area.
SPEAKER_03:That is really nice that you do that for your son. That's super helpful. I never I never
SPEAKER_01:get paid for it. Maybe I have to stop picking up the tab that means all to you.
SPEAKER_03:Yeah. So, you know, Bruce alluded to it as well. It's not just, you know, Bruce and I are talking right now and we're actually working on a couple of projects together. It's not just the legal team and the consultant and the provider that involved. It can be the F&B team, the different members of the C-suite, the CFO, compliance. Everyone has a voice. And so there's lots of people you have to cater or two in the room. So just to set the stage a little bit before we start this podcast, let's just talk about the market backdrop just a little bit. So as we alluded to, there's the shortages across a number of specialties. Obviously, surgical-based specialties are always top of the list. Primary care, psychiatry, behavioral health, those types of things. And I know we've said this already, but competition really is intense across all of these specialties. I did want to read a quick statistic I saw that I thought was interesting. Some specialties have seen increases in compensation by up to 10 to 12% in the last two years alone, which is wild.
SPEAKER_01:Wow, that is. And although we don't employ radiologists, we're asked for recruitment assistance. And apparently, we found out that radiologists, there apparently are, for every radiologist, there are five opportunities right now. And that is driven in part by technology because a lot of residents are like, I don't want to go to radiology if AI is going to go ahead and kind of supplant it or reduce it. So a lot of radiology residents coming out and it's causing a real shortage in radiology plus they can work elsewhere. So technology is also having an impact on some of these specialties.
SPEAKER_03:Yeah. The other thing that I'll say too is since you mentioned radiology, that is actually one of the top specialties we've seen You know, we are traditionally asked to look at things when things get a little more challenging, where the compensation is a little higher than the run of the mill. So we see those, we always kind of step back and see which specialties are we taking note of the most. And radiology has been top of that list this year. In fact, we've also seen because of reimbursement pressures, which is a whole nother podcast, the increase in the number of radiology groups that are asking for stipends. hospitals and health systems.
SPEAKER_01:Yes. And, you know, while we're talking about all these other changes, the regulations really haven't changed greatly over the past, say, 20 years. I mean, you have the START regulations, you have the anti-kickback statute. And for us, which I think a lot of people forget, we also have the, as a not-for-profit organization, you have to also look at excess compensation issues and making sure, and I recall, again, that's how long I've been doing this. A long time ago, Herman Hospital, as it used to be called, had an arrangement, the Herman Hospital agreement, relative to the IRS looking at what they paid physicians who they recruited. It's an old arrangement or a letter, and if one can find it, it's interesting to look at.
SPEAKER_03:Yeah, I'm glad you brought that up again, Bruce, because I feel like so much focus is always on fair market value, or sorry, the Stark Law, anti-capex sometimes those IRS regulations kind of get stuck under the rug and maybe aren't the main point of focus, but they're equally as important if you're a nonprofit organization. I know we've talked about reimbursement shortages and all that, but I'd be remiss if I didn't miss COVID. I know that was a while ago now, but we're still feeling the, you know, the remnants of it, whether it's through physicians that are wanting to retire early or others that are moving to more locum tenens work or part-time work. So that's also added to the number of, the decrease in the number of physicians that are available to provide services for health systems.
SPEAKER_01:Yeah, Kate, you may have seen, we've seen that some physicians will state to us, well, you know, I can go work local tenants and make more money and work less hours. Now there are trade-offs doing that, but that's one of the tactics that we've heard from, I'm not sure if you've heard that from your client.
SPEAKER_03:Yeah, and one thing to think about with that too is, especially when we hear that argument from physicians, we always want to make sure that we see the locum tenens competitive offer because otherwise it's just hearsay. We need to have documentation of what else has been offered on the table before we can take that to the bank, so to speak. And the other thing I'll say is that locum tenens organizations also stack a lot of other expenses on top of that rate. And we just want to make sure the physician is interpreting correctly the actual rate that they're going to take home and not the piece
SPEAKER_01:that they're
SPEAKER_03:looking for. Exactly.
SPEAKER_01:Absolutely. Absolutely. And one of the, you know, one of the issues that keeps being brought up to me as well, a physician we're recruiting says that they can get, they can get, I'm just throwing a number out there. It's not necessarily what they, they get a hundred, 150,$200,000 signing bonus and these relocation packages and other perks that I always take the position that you have to take those monies and you You have to add them to the compensation to determine the fair market value of what will you're compensating. They're not separate items that don't get included in the compensation analysis of fair market value and reasonableness.
SPEAKER_03:Yep, totally agree. And buyout provisions is in the same boat. We've got a lot of clients who are physicians who are in private practice or are also in a competitive health system and they have a buyout clause. that that is dollars that the new hospital is paying to the old hospital to get the physician over here. And whether or not the physician ever sees those dollars, they would have had to pay it otherwise. So all of that has to be considered. Yeah, so there's constant tension here with all these factors. And so to win the physician's signature, you really have to make sure that you're keeping an eye out on regulatory updates as they come in, and also these new creative recruitment you're talking about, you really need to think through those and make sure you're assessing those correctly before you just put them on the table to the physician.
SPEAKER_01:Kate, we have a minute since this is really something I try to explain internally to what I call my internal clients, which would be part of our CEO or COO and others. But a lot of folks say, well, that's fair market value. But what really is fair market value and what is it relative to other physicians make in similar markets. Could you explain how you look at that from your standpoint?
SPEAKER_03:Yeah, there's a lot of different ways we look at fair market value, and it's both a qualitative and a quantitative assessment. I always say no, neither of those is more or less important than the other. Both are needed to tell the story there. We're going to look at benchmark data, of course. No valuation firm is not going to look at benchmark data, and it's often a sorry point for health systems as well when they're starting negotiations. But we also want to get a general understanding of what's going on in that specific market. Those market dynamics is one of the most important pieces that we can understand as evaluators. What is recruitment and retention like for your organization? How many other providers in the specialty do you have in this market? How far would a patient have to drive if this provider wasn't here? Are you sacrificing quality if you go with someone else, or is it more expensive for We could ask all those questions, but we look at really the full package of everything that we can get before we settle on a rate. And to me, broadly speaking, that's how I look at fair market value.
SPEAKER_01:So fair market value, occasionally I've run into a candidate who says, well, I can receive an offer and it's$700,000. Forget the specialty, I'm just making up a number. But it's in Los Angeles, California. In Tupelo, Mississippi, the cost of living is extremely less, although we are a rural area and we have to sometimes dig hard to get candidates who want to live in a rural area. Tupelo is great, by the way. But do you look and see, do geographic locations play any role in this?
SPEAKER_03:Absolutely. When we serve clients out in California, there are specific locations where we do apply geographic adjustments based on our evaluation not regional benchmark data. I want to clarify that. We look at specific market dynamics such as cost of living and cost of salary information. We have other benchmark data sets that we look at that help us figure out what the variance is and that compensation differential for that market. So we'll look at all of those pieces. We try and, you know, regional benchmark data is good to look at. You know, we're always going to take it into consideration. But obviously, the number of ends is much lower than for national data. And because there's a smaller amount of ends, there's more potential for that data set to be skewed. And then you've also got, for example, an area like Clinton, Tennessee, where I grew up, population 10,000, in the same benchmark data as Miami, Florida. So it can be a little bit more nuanced, and those types of things can't get covered up just because of the small data set.
SPEAKER_01:Thank you. you ever come across when you're dealing with clients who say, for instance, well, we want to recruit this orthopedic surgeon. If we recruit him, yeah, it's going to cost a lot of money, but he's going to generate this amount in fees for all the surgeries he performs. And how do you respond to that?
SPEAKER_03:Well, I first want to make sure I would immediately call Bruce on the phone and tell him that one of his colleagues put that in an email and it needs to be deleted immediately. I listened to a webinar a long time ago that I just loved and I've repeated it constantly. But one of the presenters said, you know, I want my clients to hope and pray that they get referrals all day long, but just don't write it down or repeat it or say it to anyone out loud. So, yeah, that needs to be out of the picture. But that also kind of brings in the commercial reasonableness aspect of this discussion. You know, you need to make sure that it makes sense outside of the fact that it's going to generate referrals for your organization. Do you actually need to pay, whether it's a neurosurgeon, an orthopedic surgeon, that amount of money? Is the demand there? And maybe the demand's not there, but you need to be able to tell the story, well, we want the demand to be there, right? We anticipate creating a better quality of care, an easier location for patients to get to. So the demand's not there now, but we feel like it's going to grow and be there if we bring this physician in. So just be able to tell those types of stories, I think, will help that that referral argument go away just a little bit.
SPEAKER_01:So from a commercial, reasonable standpoint, it is part of the story, though, to tell, and again, it varies from location to location, but from ours, it's really commercial and reasonable where you have shortages, and we're a healthcare professional shortage area to say, hey, look, we have documented information that says we have, you know, we're short 10 orthopedic surgeons, and there's a wait time to get to see an orthopedic surgeon. that doesn't even take into account what referrals they may or may not generate but it's dealing with is that part of your mission and are you fulfilling your mission by going ahead and providing the service to the community
SPEAKER_03:yep exactly and you can find all that usually as you know in the sort of a community health needs assessment or sometimes organizations get a physician health a physician needs assessment which helps them figure out you know is there a shortage of different specialties in their market all of that information is going to be great to have on file and document for sure.
SPEAKER_01:You may see a lot of different mistakes that some organizations make. I hope they don't. But one that we don't, I believe we don't, and if I find somebody doing it, I tried to squash them like a bug, is trying to make a promise to a physician that is outside of our contract. And I remind everyone, no, everything has to be reduced to writing not only their salary and their benefits but the signing bonuses in particular and other perks have to all be included in that writing and and one of the demands now and i think we mentioned signing bonuses before though physicians being recruited want want money you know i want my money when i sign my contract right and we take perhaps a conservative approach it's like okay we'll pay you half the money of your signing bonus the other half you get when you show up to work in so many days. But the half we give you, it's secured by a promissory note that we'll execute on. I mean, do you recommend that to your clients or not?
SPEAKER_03:Absolutely. A callback provision, similar as the promissory note, just making sure that there's something in place that can protect the hospital should the physician decide to go a different route, even midway through the contract. It really, it helps kind of seal the deal. I am interested though, Bruce, what other types of mistakes have you seen over your career in these contracts with providers?
SPEAKER_01:Well, you know, it gets into a little bit of the perk side as far as time off. I think one of the things now we're seeing is how much time off a lot of physicians, younger physicians, you know, maybe I'm old school and I'm the guy saying, you know, off my lawn wagging my finger. But they're looking at lifestyle in part as much as financial aspects. And so I've found a couple of times where some administrators said, well, yeah, we're only going to give you four weeks of vacation when you show up, but don't worry about it. If you want to take any time off you want. And it's trying to go around or we'll give you a, it's not in the contract, but we'll give you a medical directorship physician. And so we're going to add$50,000 to a medical directorship. It's not in the contract. It's nowhere promised. And the physician shows up and says, I was promised a medical directorship.
SPEAKER_02:And
SPEAKER_01:so those are a couple of it. I try to, as best I can, to prevent that by educating our administrators about it. And for instance, medical directorship, unless it's required by regulation, it's hard for me to justify it. So
SPEAKER_03:yeah, I totally agree. And as part of my practice in this area, over the years, I learned from others above me to read those contracts. I'm not a lawyer, but I learn a lot from reading those contracts based on the things that people like you, Bruce, pay attention to and have seen people made mistakes on before. So it really helps me read those and make sure that I advise other clients in a similar fashion. One
SPEAKER_01:more point on loans. This is just my thought process. So as there's been changes in the Trump administration, they're capping the amount of money, and it includes medical students, that can occur relative to loans.
UNKNOWN:Right.
SPEAKER_01:I think you're going to have students perhaps coming in with more debt. And it may result in some of them truly having a need for monies as quick as they can. And that may mean things more stipend payments as they're going through their residency because they incurred such a large amount of debt in medical school.
SPEAKER_03:Yeah. And that's another incentive that we do see educational loan reimbursement. Candidly, I haven't seen it in the arrangements I valued very, very frequently over the last two years. I don't know if that's because valuation work, as I said, has really shifted towards organizations reaching out to us for more experience, high profile physicians, or if it's just that that trend is kind of going away and getting replaced with things like signing bonuses. But absolutely, I mean, we've seen those educational educational loan reimbursements easily into the six figures, obviously, but as high as$455,000, it can get significant.
SPEAKER_01:Okay, good. Well, I guess we'll, let's talk about reality.
SPEAKER_03:Yep. So what we're seeing actually on the ground, and this will get fun because we talked about it a little bit, some of our war stories, if you want to call it that. But one of the things, as we've said a couple of times, is that signing bonuses have grown significantly in terms of frequency, how often we're seeing them involved in the transaction, as well as the size. Like I said, loan repayment is also super, super common, especially for more junior positions. Again, I don't see that quite as often anymore. I just think there's a trend moving towards signing bonuses.
SPEAKER_01:And you probably see, because you look at more contracts across a wider spectrum, I mean, I'm just focused here on my health system other than helping out my son and his buddies. But what other perks now are trying to pop up, you know, like whack-a-mole?
SPEAKER_03:Yeah, it's, you know, we get asked that question a lot. You know, what are some more creative recruitment incentives that we've seen beyond your sign-on bonuses? And some of them are non-cash, you know, child care, reduced works schedule, that's an increasingly popular one. And then, you know, housing allowances, I know that is cash, but that's another example I've seen pop up a lot, especially in the Hawaii market. But the challenge is how do you value all of these fairly when you put them next to each other, especially when you've got these non-cash related perks?
SPEAKER_01:Yeah, I guess that's hard to value. I mean, when you hire someone full-time time, which roughly, I mean, physicians, a lot of them do work a lot of hours, and we're grateful for that here, but if you're hiring them, and particularly if they go more to an office practice as opposed to a hospital-based practice, you expect our non-physician employees, 2,080 hours as full-time employee, and they have more weeks off or vacation, and now they're truly working 1,800 hours, so So how do you value that? Do you take the salary and look at it differently when they're working 1,800 hours versus when they're working over 2,000 hours?
SPEAKER_03:Yeah, we do. We have to right-size those against what the market expectation is versus what it's going to be under this agreement. Obviously, we can't make a comparison to something that is not consistent with the market. So we do have to make some adjustments to account for those. But it is becoming increasingly common. You know, it goes without saying, too, survey data lags behind, depending on which survey you're using, anywhere from a year to a year and a half, maybe even two years. I'm not totally sure. But it's, you know, it can create a little bit of a lag. And so we often have physicians that ask about that just to make sure that the data that we're using in our assessment is the latest and greatest and fair at the end of the day, based on what's going on in the market in actuality.
SPEAKER_01:Yeah, well, you're overpaying. Not only you're overpaying, but you create a compliance risk. You underpay, you lose the candidate. Sounds a little bit like football in NIL.
SPEAKER_03:Yeah, no kidding. That's additionally a whole other podcast that we could start on that topic. But yeah, creative structures, I think, help in these discussions. I always encourage quality to be a part of the discussion, depending on the house system and where arrangements are with the provider that may or may not be something that'll work right off the bat. But I do think it offers a little bit of help on both sides of the fence if you can incorporate that quality component because you're helping that provider improve the quality of care that's being provided, but also helping the health system and the patients at the same time. But yeah, we're seeing just incredibly creative offers going to across the table. But that gets us to this point. How do we help organizations bridge that gap between these competitive, very creative offers and recruitment incentives and compliance, which gets to Bruce's cup of tea?
SPEAKER_01:Yeah, and I get involved. I like to get involved early. Like I said, part of it is setting up within your organization. If you're not in-house, if you're outside, if you're involved in it, getting involved early and seeing it Now I'm very hands-on here. So I draft all the physician contracts. Other places are different. You've seen one in-house office. You've seen one. And I think it's important to get all the data you can. And that includes, you know, the market data, which you all have and various market data in the business case that we talked about. And occasionally somebody would say, well, they have an offer from so-and-so for this. And I'm like, and it doesn't make sense. I'm like, okay, well, If they're willing to share the offer with the actual document, I'll look at it. It's another piece of evidence that I'll look at and consider. You're
SPEAKER_03:absolutely right. I'm so glad you said that because just like you, we hear that all the time. I can appreciate that there's competitive offers out there, but I can't take that to court if this arrangement ever gets
SPEAKER_01:looked at. Base value that they say on an email, this is what I got. Okay, well, let me see the proof.
SPEAKER_03:Yep. And I also want to make sure that, you know, what the numbers we're throwing on the table, the detail behind those numbers aligns with the detail behind the numbers on the competitive offer. You know, maybe what I'm throwing out includes a part-time admin role and what they're throwing out is full-time clinical role. You know, maybe that's why there's a discrepancy there. So it's always good to check those numbers. And same thing here. We always prefer to get involved early. You know, it does happen and you know, through no fault of anyone that, you know, you've got to get a specialty physician in the door and things have to happen quickly. And sometimes we get engaged after the fact. That happens. Obviously, the preferred is that we can get involved earlier and see where the numbers are and help them make sure that they're compliant. But as you are experienced, too, sometimes you just have to be flexible.
SPEAKER_01:You do. You have to look and it's an ever-changing marketplace. So, you know, we talked about the non-cash benefits. But we also go ahead and make sure that we document this. Now, from our standpoint, fortunately, I think we moved a little further. So we have an electronic documentation system for contracts. And so all that has to be submitted. So we retain that in the event that we ever were to have scrutiny from our government agency, it would be easy to lay our hands on it instead of an exchange of information. And that just disappears into ether. We want all those documents to be in one place to support the fair market value, the commercial reasonableness, as well as why you actually did it.
SPEAKER_03:Yeah, totally agree. The more documentation, the better, which I recognize for some health systems is hard to acquire. It can be difficult to get all the information from all the different parties. But it really does tell that story. And at the end of the day, I know what's going to matter is that you did everything you could to get that information to tell that story. Especially you mentioned commercial reasonableness. That's really where you get the majority of the qualitative information. Especially having that documented is important and having that in your files to be able to pull up and say this is the situation at the time. This is why we felt the need to have to put this forward. We looked at everything. We looked at other potential opportunities. Nothing worked out this is our best avenue. And that's exactly what the government's going to be looking for.
SPEAKER_01:Now, we moved, you know, we talked a lot about, you know, here's a salary, here's what we're going to pay you. And another component of that, though, is not just the base salary, it's WRVU, tiered WRVU payment. And we put that in there. But I think you also were moving toward almost all of our contracts now have a quality component.
SPEAKER_02:Nice. Yeah.
SPEAKER_01:And the quality component is for some, not all of our contracts, actually part of it is a withhold that you have to meet a certain tier of the quality to earn back say 10% of your base. Or you have to meet this quality in order to qualify to get WRVUs. And then there's a bonus kicker if you have exceedingly good quality, which we hope they all do. So we don't just want physicians to have contracts that are laden with just churn WRVUs, churn WRVUs because that creates other issues and other compliance risks and quality issues too.
SPEAKER_03:100%. And I think quality can be tricky too because it does involve both parties, right? You want the physicians that are going to be working to meet these metrics involved in the decision process because they're the ones, boots on the ground, they know what needs to be corrected and and fixed and improved, et cetera, whatever it may be. And then you have to have leadership involved too, because sometimes there's cost reduction measures that you're trying to achieve as well. So it can be a difficult conversation to have to figure out what those metrics need to be, what the thresholds need to be. You know, as you said, is it a withhold? Is it an in addition to, you know, each of those have pros and cons to them from the physician side and from the hospital side, there's upside and downside risk can go a lot of different ways. But at the end of the day, I think what we hope for is that there is that quality component in there, but that those quality metrics actually have teeth. I love to see quality metrics, but what I don't love is when I ask for a data request and I get the historical performance back. And for the last year and a half, I've seen 100%. And so my question is, well, why hasn't this been changed yet after the second month or something like that? Again, it's hard administratively, though, to update that and keep track of it. So I
SPEAKER_01:can appreciate that as well. It can't just be a layup. It can't be an easy thing to get. They've got to really show that they've earned it by providing outstanding quality. And we care to make sure. It's not all or nothing because if it's too hard, you discourage the physician from even trying.
SPEAKER_03:Yep, exactly.
SPEAKER_01:You have to work through that. It's something that's extremely important From our standpoint, to continue to recruit, I mean, we end up recruiting upwards in the neighborhood about 30 different positions a year. So it's an ongoing process. And it's changed from the first year I arrived to now. And what do you really see if you were to go ahead and say, navigating today, how we go ahead and try to balance all this?
SPEAKER_03:Being flexible, I think, is number one. I think number two is making sure you're continuing to have conversations with different health systems across the board. This is from an evaluation perspective, obviously, to make sure that you're ears to the ground in terms of what's going on, how different health systems are assessing the risk that comes with some of these incentives and these pay packages. Sometimes it just takes a different health systems perspective for you to change your mind on an approach. I also think we have to have a little bit of grace sometimes with regards to regulation. There's so many changes and there's so many things to consider. You just have to sometimes step back, recognize there's gonna be some missteps, but it's also how you take corrective action when those missteps occur. There's so much to be paying attention to. I think we'd be silly to think that there aren't mistakes out there with arrangements with providers. It's just that we have to figure out how to correct them and mitigate them going forward.
SPEAKER_01:Yes. I mean, so we have shortages of physicians. We have, in some areas, Medicaid potentially in many states, payments being reduced. And then we have Medicare going ahead and really starting to push more bundle payments. So there's a lot to figure out of what you have available to compensate these physicians for.
SPEAKER_03:It's a lot. It's a lot to consider. consider and you just have to surround yourself with, make sure you're not the smartest person in the room is what I've
SPEAKER_02:heard before. I don't have to worry about that.
SPEAKER_03:Yeah, there's a lot going on. It's hard to keep up with it all. It is. So that's what I mean when you just have to kind of show a little bit of grace to it because there's just, it is so hard. It's a lot to get through and wade through for sure.
SPEAKER_01:Well, I'm glad we had this time to discuss this. I mean, we discussed it before, and it's an area that I think is just, for now, particularly as we have shortages of physicians, going to continue. And not to even mention, you know, in our area, because we're rural, we have a significant number of foreign medical grads, which also adds another complexity to it. Because the regulations with that, you know, you have to have certain pay measures that are at least equal to what the median rate would be. And usually, they have to be here three years. And the government prevents you from putting in certain provisions in the contract that you normally would put in. So there are complexities that you have to constantly look at. But with help from you and others, hopefully we'll make it through.
SPEAKER_03:Yeah, I think so, yeah. I think we will. Bruce and I are in the weeds on these issues. We're always happy to pick up the phone and talk through it. So we appreciate you listening to this discussion on this super complicated and hot topic.
SPEAKER_01:So hope you enjoy it, including my bad jokes. And I look forward to talking
SPEAKER_02:again, Kate.
SPEAKER_01:Yeah, that's right. That's right. Yeah. You have someone to look at a contract for free because they're a resident you know i'm a guy because i didn't seem to do that too much for my son and his friends but um uh it's been great and thank you uh for doing this with me i really enjoy it
SPEAKER_03:yeah absolutely thanks everyone
SPEAKER_01:thank you
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