Who's Actually Keeping Your Money?

Two physicians can generate the exact same revenue and take home very different pay. When I asked Jeff Williams why, he didn't hesitate, because in his view it comes down to structure, and almost nobody asks about it.

"Residents and fellows need to understand the capital structure of the practice," he told me. "It's the thing they never think to raise." Then he laid out the categories like someone who's watched people sign without knowing which one they were in. "Am I joining a private-equity-backed practice? A vertically integrated health system run by a payer, Optum, United? Is this physician-owned and operated? Is there equity? Is there equity I'm buying into?" Each answer, he said, quietly rewrites your compensation, your autonomy, and your whole trajectory, and he's the first to let residents off the hook for not knowing. "No fault of their own. I was there. You don't even know what to ask."

Then he made it concrete, in dollars. "Every Vanderbilt doctor knows they're tithing the mothership," he said, meaning a cut flows up the chain and everyone understands the deal going in. "But if you're joining a big multispecialty group, you might not understand that you're getting only 75% of your collections, and then you have overhead, and then you're paying three-and-a-half to four percent of your profit to the parent company." Nobody lies to you, and nobody draws you the org chart either. "That's usually where things start breaking down."

So he wants candidates asking the money questions out loud, starting with whether there's equity and what it costs to buy in. "We wouldn't necessarily want to tell you how much it costs to buy in," he admitted of his own practice, "but we'd say, you can have an ownership stake in the outpatient imaging, you can buy into our billing company." The point isn't that every group hands you equity, it's that, in his words, "they have to understand where the money is going." A practice that's proud of its structure will walk you through it, and one that won't has told you something too.

He reads the pay structures the way a cardiologist reads a rhythm strip. "Is it a guaranteed salary for two years and then I'm paid on a percentage of collections? Am I paid on an RVU basis? By CPTs?" The same headline number, he warned, can mean a radically different paycheck once the guarantee quietly expires, which is exactly why the structure matters more than the figure designed to catch your eye.

He offered two tells to watch on the way in. The first is the offer that glitters too hard. "If it looks too good to be true, it is," he said. "They're probably paying you 1.5x to live somewhere remote, and you're going to be taking call every other week. There's usually a reason." The second is turnover, and he described the pattern precisely. "A lot of practices, as they start to go into it, have massive rapid turnover, and salaries start going up." A rising number isn't always generosity, and sometimes it's the sound of a back door that won't stay shut.

What surprised me most was Williams insisting the misalignment is expensive for the employer too, which is exactly why your hard questions shouldn't scare a good one. "They'll prop up a new rockstar doctor," he said, "and then within six months there are problems, and they quietly shuffle them out the door. You've lost a million and a half, two million dollars in lost revenue and recruiting." And yet plenty of groups stay in denial about it. "They'll tell you, we don't have a hiring problem, we pick who we want. And I know they're struggling to keep people. Where's the disconnect?"

His answer is the one number most practices won't volunteer. "You want to ask: when was the last person you hired? How many have left in the last year, and why?" If they won't answer, in his words, "that's immediately a trust bond you're never forming." He's convinced the honest practices would happily hand this over, because the disclosure itself is a selling point, and his own move was to volunteer it. "People come to us and they stay. We've had three people leave in the last two years, and these are the reasons why." The tell, then, isn't a high turnover number so much as a refusal to give you one at all.

Williams's bottom line is the kind of thing you'd expect from someone who's signed the checks and read the fine print for two decades. You wouldn't prescribe a drug without understanding how it works, so don't sign a contract without understanding where the money goes, and who's keeping the part that isn't reaching you.