Rewriting the rules: Achieving a million-dollar income in family medicine

You have your option today, to find out the playbook for earning a million dollars a year in primary care.

You can listen to the podcast interview about my blog post on KevinMD "the Family Medicine Playbook to Earn a Million Dollars Annually"

You can watch it on YouTube by clicking the image

Or you can read my article from KevinMD Rewriting the rules: Achieving a million-dollar income in family medicine

According to the 2024 Doximity survey, the average annual compensation for a family physician is around $300,813. For 90 percent of family doctors, this is their reality—stuck in the matrix of traditional employment. They feel unloved, undervalued, and used by the system to feed the corporate cash register. I know because that is what I did for the first 15 years of my career. However, I discovered a better option within the system and have thrived at it over the past decade. You don’t have to settle for following the herd into traditional employment; you don’t have to leave the system altogether and go into DPC or private practice. There is a third space option for you.

Recognizing the limitations of traditional employment

Traditional employment models are not designed for high-performing doctors who excel in both quality and quantity of care. The status quo often conditions primary care physicians to perform at an average level, imposing ceilings on productivity compensation through restrictive wRVU models and inefficient clinical support. Recognizing this limitation midway through my career, I made a pivotal decision to break free from traditional employment. I continued working for the same employer in the same job—but this time in a different way.

Traditional employment structures in primary care tend to prioritize cost containment and downstream revenue, often to the detriment of physicians’ potential to excel. Compensation models based on productivity via relative value units (wRVUs) can be limiting, especially when employers impose caps on earnings. This setup discourages high performers who are willing and able to take on more patients and provide a broader range of services.

Embracing the independent contractor model

A decade ago, I established my own professional corporation and transitioned to being a long-term independent contractor with my employer—a model called “employment lite.” This shift allowed me to negotiate a fair market value MGMA-based $/wRVU rate higher than that of my traditionally employed colleagues. More importantly, it removed the employee ceiling on my compensation because I was now a micro-corporation and viewed as a business, not an individual. My professional services agreement (PSA) enabled me to earn more based on my negotiated contractual productivity and performance. As a reference, I earned nearly $900,000 last year.

As an independent contractor, I gained the flexibility to structure my work in a way that aligned with my strengths and professional goals. This autonomy was crucial in allowing me to negotiate higher compensation rates. The traditional employment model often ties compensation to standardized rates that do not account for individual productivity and the quality of care provided. By stepping out of this model, I was able to set terms that reflected my true value.

Monetizing every aspect of my work

To maximize my earnings, I monetized every element of my professional work. This included:

• OB call: Managing unassigned obstetric call duties at the hospital.
• Newborn-pediatrics call: Handling calls for unassigned newborn and pediatric patients at the hospital.
• Adult medicine call: Providing care for unassigned adult patients on call for the hospital.
• Nursing home work: Providing medical services to nursing home residents.
• Sports medicine: Providing sports medicine services and athletic trainer oversight at our local high school and junior college.
• Nurse practitioner collaboration: Getting compensated for the oversight and collaborative relationship with three nurse practitioners in my clinic.
• Minor surgeries and procedures: Performing a variety of minor surgeries and the full complement of office-based procedures.
• Surgical obstetrics: Providing surgical obstetrical care at our local hospital.
• Medical education: I regularly precepted medical students and residents; however, although it would have been reasonable to do so, I chose not to monetize this space.
• Health system governance: While this was modestly monetized, I gradually withdrew from my ill-conceived belief that I could change the system from within. I chose to abandon giving my time to the hospital’s corporate interests and instead invested it in my own micro-corporation—a truly great decision in retrospect.

After assessing the scope of what I had previously been giving away for free as part of my corporate citizenship, my feelings ranged from outrage to a kick in the gut. How could I have been blind to give all this away in exchange for a predictable paycheck that was solely based on direct patient care? But when I came to my senses and became a micro-business owner who understood the value of what I brought to the system, I became empowered to monetize each element of my professional services.

Each of these activities not only diversified my income streams but also allowed me to provide comprehensive care to my patients. This holistic approach to patient care ensured that I was indispensable in my community, which in turn, strengthened my negotiation position with my employer.

Choosing a rural practice

Practicing in a rural area with a patient base of 5,000 individuals who preferred local care significantly contributed to my success. This setting allowed me to manage a large patient panel, with the judicious support of NPs, while providing comprehensive care across a broad spectrum of services.

Rural health care presents unique opportunities and challenges. While fewer resources and specialists may be available, there is also a greater demand for comprehensive primary care services. By positioning myself as a versatile provider capable of handling a wide range of medical issues, I became a cornerstone of my community’s health care system. This not only enhanced my earning potential but also my professional satisfaction. Rural health represents a growing opportunity for geographic arbitrage for doctors.

Optimizing office workflow

Efficiency in office operations is crucial for high performance. I demanded the hospital provide me with three team-care scribe nurses who organized and scribed every patient visit. This system allowed me to focus entirely on face-to-face patient care and medical decision-making while my nurses handled orders, documentation, referrals, and patient preparation for subsequent visits. This efficient workflow enhanced both patient satisfaction and my productivity.

The use of scribe nurses transformed my practice. By delegating administrative tasks, I could see more patients each day without compromising the quality of care. This team-based approach ensured that each patient received thorough and attentive care while I maintained a high level of clinical efficiency. The result was a significant increase in both patient throughput and satisfaction, directly translating to higher earnings.

Investing in real estate

In addition to my clinical earnings, I made a strategic investment by purchasing the medical office building used for my practice. The hospital leases this space from me, and over the past decade, the lease payments have paid off the building, which is now a million-dollar-plus asset. This property generates an additional $125,000 in annual income for my household. When added to my professional earnings, this pushed me over the million-dollar mark.

Investing in real estate provided a stable and substantial secondary income stream. By owning the building, I wisely used other people’s money to secure a valuable asset that appreciates over time. This strategic move further diversified my income and contributed to my financial security.

Thriving in today’s health care system

My experience demonstrates that thriving in today’s health care system is possible, but it requires a departure from the status quo. I have achieved financial success by recognizing and overcoming system inefficiencies and maximizing care delivery in my unique practice environment while providing high-quality care.

For fellow physicians aspiring to similar success, consider exploring the long-term independent contractor model, monetizing diverse aspects of your work, optimizing your practice operations, and wisely choosing your geographic location to work. The path to thriving as a high-performing doctor is available—you just need to navigate it differently.

Conclusion

The health care landscape is challenging but offers numerous opportunities for those willing to think outside the box. By breaking away from traditional employment models, optimizing workflows, and strategically diversifying income streams, physicians can significantly enhance their earnings while maintaining high standards of patient care. My journey from a traditional employee to a high-earning independent contractor demonstrates that financial and professional success is possible and attainable with the right approach.