Career ladders, focal reviews and retention bonuses: How practice leaders can rethink staff pay

More than half of medical practices (56%) said hiring medical assistants became more difficult over the past year, according to a May 19 Stat poll by the Medical Group Management Association (MGMA). A separate MGMA Stat poll a week later found that practices reporting lower staff turnover in 2026 described investments in pay adjustments, onboarding and training, more predictable scheduling and clearer career paths.

Rachel Brace and Nicole Hart, co-founders of BackPocket Talent, a Massachusetts-based on-demand human resources (HR) firm for private medical practices and small businesses, will present "Beyond the Typical Bonus: Innovative Compensation Strategies for Private Medical Practices" on Sept. 29 at the 2026 MGMA Annual Conference in San Antonio.

Brace, the company's chief operating officer, spent more than 15 years as a medical practice administrator in dermatology, orthopedic and multisite practices, where she handled HR, billing, compliance and credentialing. Hart, its CEO, has more than 20 years of HR and operations leadership, including six years at Cigna Healthcare, and specializes in compensation architecture and compliance-aligned HR systems.

The session covers job families with real progression, skills-based pay, retention bonuses and performance-based profit sharing, and it asks attendees to calculate the financial impact of turnover compared with strategic compensation improvements.

Ahead of the conference, Brace and Hart explained how practice leaders can build career paths for front-desk staff and medical assistants, pay for skills only when staff use them, and structure retention bonuses and profit sharing. Each also named one change a practice administrator can make as soon as they return from San Antonio.

Our conversation, lightly edited for length and clarity, follows.

Could you each introduce yourselves and tell us a little about BackPocket Talent?

Rachel Brace: I'm Rachel Brace, and I am co-founder and COO of BackPocket Talent. I actually started my career at the Ritz-Carlton, Naples, in Florida, and I did that for several years, working in group reservations, handling conferences and things like that. I moved back to the Northeast, where I'm from, and started in recruiting. From there, I moved into operations, handling everything for a small business. I managed a biotech practice. I managed a buy-side brokerage practice, and from there, I went into practice management, and that's where I stayed for about 16 years.

So I've done everything a practice manager can think of, including HR. Practice management is really where I honed my HR skills, and I honed those skills with the help of my business partner, because she has been in HR for 30 years. She was my on-demand HR when I needed her, and that is what BackPocket Talent is built on. We started BackPocket Talent to help practice administrators, office managers and owners who are doing HR in addition to all the other things in their jobs. I'll let Nicole give her side.

Nicole Hart: My name is Nicole Hart. As Rachel said, I am a serial HR person. I've been around for a long time. I actually started out doing sales. Funny story: I got pushed out. I worked for a company called MCI Telecommunications. Now I'm dating myself. They used to come visit and take young people out to dinner, and they always wanted me to come. I wasn't doing well at sales, and they learned I was getting fired. I got a phone call late at night at the end of the quarter, around 10 o'clock, from the head of HR, and she said, "Do you know what's going to happen?" I said, "You're going to fire me." And she said, "Or you can move into human resources. You've got a really good personality, and the executive team thinks you've got someplace to go." That was how I landed in HR.

What's really unique about me personally is I started my career working at really big companies. The company that grounded me the most, which is kind of ironic, was Cigna Healthcare. It was the insurance industry. I worked there for six years, but they had really good best practices in place for how businesses should run. They looked at HR through a different lens. It was always, how can human resources help the business grow? They put everything in a strategic lens from that place. A lot of the things [BackPocket Talent] is built on today stem from when I worked at Cigna Healthcare.

A lot of large companies do these practices, and some smaller private equity companies also do these types of things. When I went to work at startups, I realized I was taking the foundations I learned and implementing them, because it really is a best practice, and I think it helps any business go.

When I look at medical practices, I always look at things from a different lens, and Rachel will say that too, because I always say it's a business. It's about profitability, and the human resources side falls in the back side of it. If you do things right, then your medical practice, your business, is going to run efficiently, but you have to set it up the correct way.

That's a little bit about me, and then we decided to form BackPocket Talent a little over a year and a half ago.

Your session says small practices often lose good front-line staff not because of culture, but because they can't see a path forward. What does that look like in practice?

Rachel Brace: From the outside, the practice looks fine, and that's what our session is about. We're going to take a fictional practice that we put together that looks great on paper. It's making a lot of money, everyone's getting paid well and no one's complaining. Then your best medical assistant gives notice, and you're struck with: Why? What happened?

A lot of times, they've been doing the same job, they have the same title and they're not making any more money. Maybe along the way, they've picked up a few tasks and they haven't been recognized for that. No one's ever sat down with them and said, "Hey, this is where we'd like you to go."

Usually in a practice, the only promotion people see is to the manager, and we're not really talking about promotions. We're talking about the path forward and growth. So we talk a lot about career paths. People leave because they can't see where the job is going to go, and that's really what it looks like in a practice. You're stuck.

What does a real career path look like for someone who starts at the front desk or as a medical assistant, and how could a small practice build that path?

Rachel Brace: I'm going to be fully honest here. We did not do this when I was at a practice, and it's something I think my practice would have benefited from. A lot of people weren't talking about it at the time, and I think it's a big deal right now in medical practices.

You don't need to have some huge org chart or anything like that. You just need to ask the questions. You need to sit down with the staff and define what those levels look like. If it's a front-desk person, maybe it's receptionist one, receptionist two, receptionist three, whatever you want to label it, but each piece has to have a pay step attached to it. So you come up with your pay scale. We recommend that they overlap.

If you have somebody who's been in the practice for five years and they're front-desk receptionist one, maybe they're happy there. Not everybody has to climb the ladder. You just have to have the ladder. So you're going to branch out. You're going to have those three layers. They may add some cross-training to that. They may add authorizations, whatever. And you tie your key performance indicators to that, so the person in those roles understands what they need to do to get to that next level.

That's the big thing in medical practices: There's one job description, and everybody has the same one. That's the reason we think career paths are the way to go.

Nicole Hart: Just to add to that about the differentials, they could also be tied to your setting. You might only have one person at your front desk today, but you might know that you're going to open up another branch, or you're trying to grow and you're going to be hiring more doctors, and you have a three- to five-year plan. With that, you might be hiring more people, so where does the person who's currently at your front desk go? They might feel a little bit of resentment.

So you start to think, OK, if we hired somebody more junior, what tasks would that person take? There are milestones as you go through it, and it helps you delineate the different types of roles. Even though you might not have it today, you know where you're trying to go. It's just a best practice in general, and it keeps things fair and consistent, specifically when you have key performance indicators, because there's no unconscious bias.

Could you explain what skills-based pay is and how it works in a practice with only a handful of employees?

Nicole Hart: In the fictitious practice we created and talk about, there is an office outside of Boston, Massachusetts, where there's a high Portuguese population. In that situation, we might have somebody who's floating between offices, and we have an employee who speaks Portuguese. When they're in that office, they're using that skill set, so they should get paid for that skill set. But when they're not using that skill set, they should not be getting compensated for it.

You could also set it up for somebody who's working a shift differential. Maybe you have a practice that's open later at night, and you want them to stay later, so you might pay them $1 [more] an hour, but four days a week they don't [stay late]. So you decide what your criteria are going to be for a shift differential.

The difference is, and I think Rachel owned up to this in her practice, they just paid people more money when they wanted them to do something. Well, when they're not doing it anymore, you can't take it away. I mean, you can, but you're going to have employees go rogue.

If you have it set up and you're tracking it in your HR system and your payroll system, when they put their time in, they can say, "Oh, I worked in the office where I need to speak Portuguese for four hours that day." And automatically, when you process payroll, it's going to know whatever that dollar rate is. You're only paying for when they're using those extra skill sets.

How should a practice use retention bonuses so they actually keep people around, instead of becoming an expected part of the paycheck?

Nicole Hart: I look at retention bonuses as a very unique thing. It shouldn't be a fire drill because you don't want somebody to leave. It should be that you have critical jobs, and those critical jobs are hard to fill.

For example, and we do talk about this, take medical assistants. Most people are in a gap year. They're going to go to school to become a doctor, so you know they're not going to stay around that long. So maybe you want to get creative. There are some certifications they could get, and you would put it in their offer letter: "If you get certified in X, we're going to pay you a one-time bonus of this." Or, "If you do this and you work for six months and you prove you're taking the skills you learned, your base salary goes to here." You make sure you clearly outline what they need to accomplish so you can retain them.

And if, say, you have a four-year trajectory in mind where you don't want to have turnover in this high-turnover role, you would think about the milestones that would trigger those different types of retention bonuses, depending on the role and what's important to your medical practice.

Profit sharing can sound complicated or risky for a small practice. Could you explain a simple, compliant way to share the practice's success with staff?

Nicole Hart: I'll start with a theory, and then Rachel can take it, because this was my little brainstorm. Again, it goes back to employee retention. I look at things from a business perspective, and a medical practice is a business. People want to make money. They know what their growth strategy is.

So if a medical practice says, "OK, in 2026 we're going to end the year making $20 million, and in 2027 we want to get to $22 million," you don't necessarily have to share those goals. But I firmly believe the best businesses are fully transparent, and you say what you're trying to get to. You say there's a piece of the pie that comes with it, and you define what the criteria are. Maybe you say, "We're going to take 3% of that money and set it aside for nonmedical positions," so not for the doctors, but for the employees. If you reach that goal, then they get a percentage of that in a bonus. We really go into depth in our presentation about the different ways you can deliver it.

Second, if you don't want to be fully transparent, you could set it up within your management team that it's going to happen, and at the end of the year you could say, "Hey, we did really well, so we're giving you this bonus." But I believe in transparency, because I believe it drives a high-performing culture, and it helps you separate the different levels of the organization so the core employees understand that what they do and how they do it actually helps the practice grow.

Rachel Brace: Just from being in the medical practice administrator role, I know a lot of doctors keep that stuff close to the chest. It's a different mindset. It's a different culture in a medical practice. It's a smaller environment. I think their concern is that if people see those numbers, they get upset, saying, "Well, you're making this much money. How come we're not making this much money?"

Like Nicole said, it is a part of your culture. People have to understand how their role fits into the practice, and that when the practice makes money, the doctors make money, and then you make money. Everyone has to have a common goal. So if they had a number in mind, you tie it to something the practice is doing well that employees can recognize, whether it's the number of reviews you get or however you want to tie it, so the employees can feel that they're part of that process.

How should practice owners who think they can't afford to pay staff more weigh that cost against what turnover is already costing them?

Rachel Brace: We address this in our presentation as well. The thing to realize is that the cost of turnover in the majority of these practices is more than the cost of retention, and that's what our whole presentation is about. There's a way to figure out what it costs when somebody walks out the door, but there are a lot of pieces to that puzzle: how much the employee made, how much it costs to recruit, how much you're paying the recruiter, the cost of the ad and who's filling in the gaps. All of that goes into figuring out that percentage or that cost.

The national average is between 16% and 20% of a person's salary in the medical industry for someone making under $75,000, and we use that quite a bit in our presentation. So if you're looking at something that's 18% of costs for turnover, and a retention bonus you're going to give them at six months and maybe 12 months is only going to be $2,000, you have to weigh those options. You're paying the money regardless. You just need to shift the focus: We should be paying money for retention, not to have them walk out the door. It's as simple as that.

When I was in a practice, it was, "Oh, should we give them more money? Should we do this?" And we never really looked at how much it costs when somebody walks out the door, because you're usually scrambling and you're not thinking straight.

What is one tip you would give a practice administrator that they could put into place first thing after the conference?

Rachel Brace: Like I said earlier, we didn't do this, but I am a huge proponent of career paths. I think it helps show the employee what their trajectory is at this practice. They can see that they can grow into a different role. So that's what I would pick. They could do it for one role and see how it works.

Nicole Hart: I have a different perspective, and we do talk about this in our presentation as well. Most small businesses do everything on the employee's anniversary date, their hire date, and I really am a big believer in performance management that treats people equitably. If you do a focal review, where you pick a date and time when everybody gets their review, and you've built these career paths, you're evaluating everybody fairly at the same level, and everybody understands everything, so you can actually pay for performance. You're treating people equally if everybody gets their review on the same date and time every year.

Your session is on Tuesday. What is each of you looking forward to at this year's conference?

Rachel Brace: I'm looking forward to being done with the presentation. No, I'm actually looking forward to being with my people. I haven't been to a national MGMA conference. I have been to several regional ones, but I'm looking forward to chatting with the practice administrators and the owners, seeing what's new in the industry and talking about BackPocket and how we can help them. It's been a while since I've been to a medical conference, and I'm interested to hear about some of the new things going on.

Nicole Hart: For me, this will be my first medical conference, so I'm looking forward to sitting in on some of the sessions. We're actually partnering with a company that does artificial intelligence, and one of the things we're working on is being able to go into a medical practice that's implementing AI to help with billing or to help automate certain things. You don't want to get rid of your employee, and the tech stack we're working on looks at how you change that role to fit the way you're implementing artificial intelligence.

I can't wait to hit the vendor floor, because there are a lot of vendors talking about solutions to help automate with AI, and really understanding that will help us as we hone this vertical within our business. I'm excited to see how what we're trying to do on the human side fits with the tech stack they're building on the back end to help medical practices become more efficient.