Private equity has spent the last decade buying up gastroenterology practices, but according to one physician who has worked on both sides of that trade, the real risk isn’t the deal itself, it’s who ends up holding the wallet.
Rajiv Sharma, MD, president of Phoenix-based Mirage Health and a gastroenterologist, told Becker’s too many junior physicians sign partnership deals without ever meeting the person who actually controls their pay. By the time they realize it, the debt and the downside have already been pushed onto them.
According to Dr. Sharma, many private equity-backed GI deals function less like partnerships and more like a pyramid scheme, with debt and risk pushed down onto the newest, least-empowered physicians in the group.
Dr. Sharma said he coined a simple diagnostic question physicians should ask before signing on with any group: “Who is in your wallet?”
In practice, that breaks down into four questions, he said: How long is the time to partnership? Who controls your salary? How much access do you have to the decision-makers? And are those decision-makers actually available to you, or hidden “behind the veil of administration?”
“For me, the biggest red flag is when the founding physician does not talk to me, does not see me, doesn’t answer my questions,” he said. “If a prospective partner can only reach administrators, not the lead physician, that’s a big red flag.”
He said compensation at the top of a group should be an open book.
“The leaders should be able to tell the physicians: This is how much I make, this is how much I make from my bonuses from the surgery center and this is how much I make from my payout from ancillary services,” he said.
Additionally, he said, senior partners protecting that information from junior physicians amounts to a breach of “a moral obligation of senior physicians to protect the younger ones.”
Of all the contract terms physicians should scrutinize, Dr. Sharma singled out the clawback clause as the most dangerous. A signing bonus that can be pulled back after the fact, he said, is “the most dangerous clause we have in contracts”
His baseline terms for any physician unsure how long they’ll stay with a group is a higher guaranteed base salary, a signing bonus, a base salary guaranteed for at least three years, and a signing bonus that’s either fully forgiven over three years or prorated if the physician leaves early, with no clawback attached.
A Feb. 3, 2026 MGMA Stat poll found that 80% of medical groups use clawback or repayment provisions on signing/starting bonuses if a physician or advanced practice provider leaves early. Only 16% said they didn’t use one, and 4% were unsure.
Dr. Sharma was also critical of RVU-based compensation, which he said varies far more than physicians realize.
“I’ve seen RVU rates range from $36 to $95 per RVU,” he said. “Typically, anybody who puts you on RVUs is stealing from you, because if they know they can pay you $87 per RVU, but they’re paying you $36 per RVU, the difference is their profit.”
According to Dr. Sharma, physicians should push for an RVU rate of $65 or more, locked in for three to five years, with full visibility into monthly RVU totals and contractual audit rights.
He was similarly skeptical of “quality bonus” structures tied to metrics like patient-satisfaction scores, which he said are frequently set at thresholds that are effectively unreachable. This structure, he said, is rigged by design, since it lets a group withhold compensation while pointing to a metric no physician could realistically hit.
Left unaddressed, Dr. Sharma said the pattern of senior physicians profiting from deals structured against their junior colleagues has consequences including more lawsuits, an eroding profession and rising physician burnout.
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