Compensation and Practice Matters Question Title * 1. Age 25-34 old 35-44 old 45-54 old 55-64 old 65-74 old 75 years or older Question Title * 2. Which of the following best describes your practice model? Solo private practice Single specialty group practice (how many partners?) Multi-specialty group practice (how many partners?) Academic faculty practice plan Hospital employee If you selected the 2nd or 3rd choice, type how many partners here Question Title * 3. How many years have you been in practice since completing residency or fellowship? 0-1 year 1-5 years 5-10 years 10-20 years >20 years Question Title * 4. How many years practicing bariatric surgery? Type years in text box. Question Title * 5. What is your employment status? Full time Part time Question Title * 6. What percentage of your time is dedicated to bariatric surgery? <20% 21-50% 50-80% >80% Question Title * 7. What is your career volume for bariatric surgery? Question Title * 8. In what state are you employed? State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Question Title * 9. Did you complete a Fellowship? Yes No Question Title * 10. If yes to the above question, what type? (MIS, MIS with bariatrics/bariatric only) Other (Surgical oncology, vascular, GI, Hepato-Billary) Question Title * 11. Select the method that most accurately reflects your current compensation model? Straight/ guaranteed salary (100% of the provider’s salary is via a fixed salary) Base salary plus incentive (payment of guaranteed base salary plus an incentive component that must be earned. May be based on one or more criteria including individual production, department/organization performance, patient satisfaction, quality measures, or other factors defined by the employer.) Production model (Compensation solely on productivity such as WRVUs, % of Professional Collections, %Gross Charges, %Adjusted Charges Other (please specify) Question Title * 12. What is the amount of your total compensation, including salary, bonus and/or incentive payments, research stipends, honoraria and medical directorship fees? (state the amount reported as direct compensation on Form W-2 and Form 1099) 2010 2011 2012 Question Title * 13. What is your estimate annual retirement contribution? (Report all contributions to retirement plans including defined benefit and defined contribution plans.) 2010 2011 2012 Question Title * 14. What of the following benefits are provided to you and paid by your employer? Malpractice insurance CME allowance Medical insurance: Employee only Medical insurance: Employee plus dependents Disability insurance Life insurance Dental insurance Vision insurance Question Title * 15. Do you receive a bonus or incentive? Yes No If you answered yes to the above question, how much is the bonus? Question Title * 16. If you receive a bonus or incentive, is it based upon RVU target? Yes No If yes, what is the RVU target? Question Title * 17. If you receive a bonus or incentive, is the bonus based upon Medical Directorship? Yes No If yes, how much is the Directorship compensated? Question Title * 18. If you receive a bonus or incentive through a Quality Metric? (select all that apply) Participation in quality improvement project Patient satisfaction Use of electronic medical record Clinical outcomes Access Peer review N/A Other (please specify) Question Title * 19. If your compensation is based on WRVU production, provide the amount per WRVU. Question Title * 20. If your incentive is based upon WRVU production, provide the threshold amount at which the incentive begins and the compensation amount per WRVU that you receive. (For example, you must produce 10,000 WRVU’s before incentive compensation begins. Once you reach 10,000 WRVU’s, you are compensated (X) amount for each WRVU above that threshold.) Threshold WRVU compensation Question Title * 21. How many work RVUs did you produce? 2010 2011 2012 Question Title * 22. How many days a month do you take call? Bariatric call General surgery call Trauma call Question Title * 23. Are you paid for taking call? Yes No If yes, how much per night/shift? Question Title * 24. How many TOTAL operative procedures did you perform in 2012 (include ALL procedures including non-bariatric procedures)? How many BARIATRIC procedures were primary (%) How many BARIATRIC procedures were revisional (%) How many total clinic (office) visits How many total clinic (office) visits were new patient visits Upper GI Endoscopy, any Lower GI Endoscopy Laparoscopy: Gastric Bypass with Roux enY (150 cm or less, short limb) Laparotomy: Gastric Bypass with Roux enY (150 cm or less, short limb) Laparoscopy: Gastric Bypass with Roux enY (150 cm or more, long limb) Laparotomy: Gastric Bypass with Roux enY (150 cm or more, long limb) Laparoscopy: Place Adj. Gastric Device Gastric Band & Port Component Laparotomy: Place Adj. Gastric Device Gastric Band & Port Component Laparoscopy: Sleeve Gastrectomy Laparotomy: Sleeve Gastrectomy Laparoscopy: Vertical Banded Band Gastroplasty (VBG) Laparotomy: Vertical Banded Gastroplasty Laparoscopy: Billopancreatic Diversion with Duodenal Switch (BPD/DS) Laparotomy: Billopancreatic Diversion with Duodenal Switch Laparoscopy: Revision/Conversion of Band Laparotomy: Revision/Conversion of Band Laparoscopy: Revision/Conversion of Gastric Bypass Laparotomy: Revision/Conversion of Gastric Bypass Laparoscopy: Revision/Conversion of Sleeve Gastrectomy Laparotomy: Revision/Conversion of Sleeve Gastrectomy Laparoscopy: Revision/Conversion of VBG Laparotomy: Revision/Conversion of VBG Laparoscopy: Revision/Conversion of BPD/DS Laparotomy: Revision/Conversion of BPD/DS Done