FAQtual Insights: The Contract Playbook Part 1

Contract negotiation for clinicians is often approached as a one-time administrative step. In reality, it directly shapes compensation, autonomy, workflow, and long-term career trajectory.¹ For experienced NP/PAs, the goal is not simply to secure a position, but to structure a role that aligns with clinical expertise, productivity, and sustainability.

Below are the key questions—and evidence-based considerations—that should guide negotiation, informed by insights from Joseph Gatti, DMSc, MPAS, MBA, a board certified dermatology physician assistant with over 8 years of experience consulting contract negotiations.

How should I evaluate compensation beyond base salary?

Base salary is only part of the picture. Most private dermatology offers use one of these structures:

Base + % of collections – The most common. Understand realistic production thresholds to see what the bonus is actually worth.

100% collections – High upside for experienced providers, but variable.

Straight salary/hourly – Predictable, lower ceiling; common in hospitals/academics.

wRVU-based – Rare in dermatology; usually only in large systems or specialized settings.

Always ask for historical production data, such as: average collections per provider, typical bonus payouts, and wRVU equivalents if relevant.

Example:
A PA got an offer: $120K base + 25% of collections above $825K. Excited, she imagined the bonus—but the most productive PA in the practice never hit $825K. That bonus was effectively unreachable.

Another offer: $105K base + 20% over $350K. A moderate producer generating $650K would take home $165K. Less flashy on paper, but far more realistic.

Bottom line: Don’t judge an offer by base salary or headline bonus alone. Check historical numbers, calculate achievable total compensation, and compare offers on real earning potential.^2,3

Gatti’s advice:

“The base salary is never the offer. It is the opening number of a math problem most clinicians never bother to solve.”

What is a fair productivity target in dermatology?

There’s no universal benchmark—targets vary based on practice type, patient complexity, procedural mix, scheduling, and support staff.^2,4 What’s achievable depends on the resources provided (e.g., medical assistants, scribes, clean scheduling, responsive front desk).

Guidelines from national data and real-world experience:

• Experienced PA (year 4–5+): Seeing 25–30 patients/day with strong support, annual collections of $575K–$850K+.
• First-year PA: Building a panel, learning insurance workflows, seeing 18–25 patients/day, collections typically $350K–$500K.

Important tip: If your offer includes a bonus trigger that seems high (e.g., $600K in year one), ask what the last new hire actually produced. If the practice won’t share, that’s a strong signal the bonus is likely unattainable. High targets without adequate support are often more about optics than realistic compensation.

Bottom line: Evaluate productivity targets in the context of the practice infrastructure and historical performance, not just the number on the contract.

Gatti’s advice:

“Fair is when the production target in your contract matches what providers in that practice actually produce. Not what the owner hopes for. Not what the recruiter promised over lunch. What the data says.”

How does procedural mix affect compensation?

Procedures are one of the biggest drivers of income in dermatology. Biopsies, excisions, and cosmetic services typically generate much higher revenue than standard medical visits alone.^2,5

This means 2 providers can have the same schedule and patient volume—but very different compensation.

Real-world example:

• PA #1: Medical dermatology only → lower revenue per visit
• PA #2: Mix of medical + procedures → 40–60% higher collections

Same hours, similar effort—very different paycheck.

Why this matters:
In collections-based models, your income is heavily influenced by:

• Which patients are on your schedule
• What procedures you’re allowed to perform

If you don’t have access to procedures, your earning potential is effectively capped, even if that’s never explicitly stated. In some practices, procedures are reserved for physicians or select providers—leaving others in a more limited, “medical-only” role.

What to clarify before signing:

• Are procedures included in your role?
• How are they distributed across providers?
• Will you receive training or mentorship?

Bottom line: In dermatology, access to procedures = access to higher income. If your contract (or the practice structure) limits that access, it directly limits your long-term earning potential.

Gatti’s advice:

“Procedural access in derm is not a perk. It is the primary driver of income and one of the fastest ways to build patient trust in your clinical competency. A contract that does not address this consideration is like a lease that does not mention square footage. You might love the address. You have no idea what you are actually getting.”

How should I approach negotiating autonomy?

Autonomy is shaped by state law, supervision requirements, and—most importantly—practice policy. Even in states with broader scope, your day-to-day independence is often determined internally.^6,7

It’s reasonable to clarify expectations around:

• Independent patient management
• Prescribing (including systemic therapies)
• Procedural responsibilities

Framing autonomy as improving efficiency and patient access can make these conversations more productive.

Why this matters:
Two practices can operate very differently. In one case, an experienced PA was required to have every biopsy and prescription co-signed, despite years of experience. This went far beyond legal requirements and created delays in care for every patient.

This kind of over-supervision isn’t just frustrating—it can:

• Slow down patient care
• Create workflow bottlenecks
• Limit your ability to practice at your training level

What to ask before signing:

• What does day-to-day oversight look like?
• Is chart review concurrent or retrospective?
• When and how does autonomy expand with experience?

If the answer is vague (e.g., “we’ll figure it out as we go”), assume autonomy may not meaningfully improve. In some cases, excessive oversight can even be used later to justify lower compensation or restricted responsibilities.

Bottom line: Autonomy isn’t just about independence—it directly impacts your efficiency, patient care, and earning potential. Get clear, specific answers upfront rather than relying on assumptions.

Gatti’s advice:

“Autonomy is not about ego. It is about patient access and operational efficiency. An experienced PA or NP who cannot independently manage a straightforward derm panel is being underutilized. The practice is paying for a specialist but in reality utilizing the provider like a scribe.”

Final Perspective

Negotiating a clinician contract requires a clear understanding of how compensation models, productivity expectations, and practice structure interact.^2,4 For experienced NP/PAs, the process is less about securing a position and more about defining a sustainable and appropriately valued role within a high-demand specialty.

References

1. Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections From 2021 to 2036. Washington, DC: AAMC; 2023. Accessed March 17, 2026. https://www.aamc.org/data-reports/workforce/report/complexities-physician-supply-and-demand-projections-2021-2036
2. Medical Group Management Association. Provider Compensation and Production Report. Englewood, CO: MGMA; 2023. Accessed March 17, 2026. https://www.mgma.com/data/benchmarking
3. Centers for Medicare & Medicaid Services. Medicare Physician Fee Schedule and Relative Value Units. Baltimore, MD: CMS; updated annually. Accessed March 17, 2026. https://www.cms.gov/medicare/physician-fee-schedule
4. American Academy of Physician Associates. 2023 AAPA Salary Report. Alexandria, VA: AAPA; 2023. Accessed March 17, 2026. https://www.aapa.org/research/2023-aapa-salary-report/
5. Resneck JS Jr, Kimball AB. The dermatology workforce shortage. J Am Acad Dermatol. 2004;50(1):50-54.
6. American Association of Nurse Practitioners. NP Fact Sheet and Scope of Practice Overview. Austin, TX: AANP; 2023. Accessed March 17, 2026. https://www.aanp.org/practice/practice-management/scope-of-practice
7. American Academy of Physician Associates. Scope of Practice Policy. Alexandria, VA: AAPA; 2023. Accessed March 17, 2026. https://www.aapa.org/advocacy-central/scope-of-practice/