Put It in Writing

Physician extenders, commonly referred to as mid-level providers or practitioners, often offer financial profitability for the practice as well as efficiency, improved quality of care, enhanced flexibility for physicians and greater patient satisfaction. When you hire an extender, it’s important to go beyond a handshake and clearly define the terms of the relationship in a contract. Below are some of the key issues that should be addressed in a mid-level provider’s employment agreement.

Contractor vs. Employee

Physician extenders can either be hired as independent contractors or as employees. In an employer–employee relationship, the employer generally has more control over the duties of the employee than over the duties performed by an independent contractor. While there are additional pros and cons to consider, nurse practitioners and physician assistants are more frequently hired as employees.

If the mid-level practitioner is hired as an independent contractor, you should include provisions that include the following concepts:

  • The parties agree that the agreement is not intended to create an employer–employee relationship, partnership, joint venture or any other relationship between the parties, other than that of independent contractors.
  • The extender will not be entitled to perks and other benefits that may otherwise be available to your employees (e.g., health insurance, pension, 401(k) plan).


Prior to determining the proposed salary amount, you should estimate the amount of revenue the physician extender is expected to generate for your practice, along with the associated cost of employment. Remember, the associated cost of employment is not just the individual’s salary, but also the additional perks (e.g., healthcare insurance premiums, professional liability insurance premiums, continuing education expenses, licensure fees). In my experience, physicians generally aim to net a profit of 15 to 20 percent of the mid-level provider’s services.

If you are reluctant to employ an extender at a higher salary up front, you may want to consider tiering compensation based on length of service. The nurse practitioner, for example, would receive $X/month for the first six months, $X+/month for the second six months, $X++/month for the second year, and so on. Another option is to adjust compensation based on satisfactory performance for which a mechanism or framework for review should be established.

Physicians generally aim to net a profit of 15 to 20 percent of the mid-level provider’s services.

Restrictive Covenants

When a mid-level practitioner leaves your practice, some of your patients may follow the mid-level to his or her next place of employment. This risk is substantially less likely with a mid-level than with a physician, however, and can be minimized by including restrictive covenants. A non-competition clause, for example, prohibits a physician extender from practicing within a specified geographic area for a stated period of time.

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