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Locum hospitalists: lifesavers, or a serious threat?
Is hospital medicine's relationship with locums becoming unhealthy?

Keywords: Locums in hospitals: lifesavers or threat?


by Deborah Gesensway



Published in the May 2013 issue of Today's Hospitalist


THE LOCUM DOCTOR strides through the door, and the stressed-out permanent hospitalists let out a collective sigh of relief. With help arriving to take on some of the patient load, everyone thinks, the group finally has some breathing room.

But often that situation quickly turns sour, and the grumbling begins: "He is making more money than we do. He gets to leave early because he doesn't have to go to committee meetings." As resentment swells, morale shrinks.


Related article: Moonlighting physicians in demand: is this right for you?
"Locums opportunities are draining the workforce supply for practices."

—Kimberly Bell, MD
EmCare Hospital Medicine

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It's a situation that Adam Fall, MD, regional medical director for the Eastern division of TeamHealth, a national hospitalist company, has seen more than once. "If we don't replace locum physicians soon," he says, "or if they don't have a great personality or there are problems with their medical care," the once-grateful permanent staffers "get bitter."

These days, individual group members aren't the only ones wringing their hands about locum hospitalists. While locums have been a godsend for short-staffed groups, some in the field are concerned about the number of hospitalist programs that now depend on locums as a steady diet, not an occasional splurge. Instead of viewing locums as a strategy to weather some rough patches, many groups have come to rely permanently on a constant cadre of temporary physicians.

That trend has some in the specialty worrying aloud about the downside of locum tenens for programs and hospital medicine in general. Because locum doctors can cost twice as much as permanent hires, practices can dig themselves into a deep financial hole.

But other concerns go beyond costs. Questions abound about quality, with many claiming locum doctors are less likely to pay attention to length of stay, readmission rates, patient satisfaction, communication and quality measures than hospitalists building a long-term career in a hospital and community.

Some also worry that the lure of easy money is only making the specialty's supply-demand woes worse. Some hospitalists are choosing locum careers over permanent jobs, while others with permanent jobs spend their off-hours working locum for other practices instead of picking up extra shifts—and building a stronger sense of ownership—within their own programs.

An attractive option
The idea that hospital medicine's relationship with locums may be unhealthy is relatively new. Until recently, locum hospitalists have been viewed as necessary and even beneficial.

Having a pool of temporary doctors willing to spend weeks or months in hard-to-staff facilities and remote areas has helped fuel the rapid spread of hospital medicine. Without that pool, it would be much tougher to staff start-up groups or quickly add new service lines to existing programs.

"There are times when locum hospitalists are lifesavers," says Rachel Lovins, MD, hospital medicine section chief at Middlesex Hospital in Middletown, Conn. A locum, Dr. Lovins points out, can "buy you time to really hire good fits, not just warm bodies, and that's really important." Money spent on a locum company to help you find a better hire may be "worth your while financially."

Too, the broad availability of lucrative, flexible positions has arguably helped lure quality doctors to hospital medicine. There is, after all, a group of young physicians fresh out of training who like the idea of trying out different practices or different parts of the country without committing to any one group or community—and hospital medicine has proved a perfect fit.

And even among doctors who make that commitment, the extra income they earn picking up locum work on the off days of a block schedule has been a boon to many, and another big draw to the field.

A dark side?
But some worry there's a growing dark side to the specialty's overuse of a strategy that is supposed to be temporary.

The obvious concern is cost. "It is a big bleed," maintains Kimberly Bell, MD, the Seattle-based regional medical director for the west division of EmCare Hospital Medicine, a national organization. She currently oversees the operations of five practices, all of which have used locum hospitalists while trying to find fulltime staff.

Edward Ma, MD, medical director of hospitalist services at Brandywine Hospital in Coatesville, Pa., agrees. While a full-time hospitalist may cost his group about $100 an hour including benefits, he has to pay a locums company $200 an hour per physician.

But according to Dr. Ma, cost is only part of the problem. There's also the bad public relations that comes with transience. "There is already a lot of instability with most hospitalist groups," he notes. "When you factor in locums, it ratchets that instability up another notch, which further erodes the image and reputation of hospitalists." With so many temporary doctors churning through so many programs, he says, hospitalists now are being seen as "replaceable and interchangeable."

Since he took over the hospitalist group at Brandywine last summer, one of Dr. Ma's top priorities has been to break the group's reliance on locums.

"It is disruptive to the rest of the medical staff, who have to deal with strangers," Dr. Ma explains. "Our image has been marred by a large number of people who came through this practice on a temporary basis."
Draining the labor supply

Then there's this concern: Are the enticements of liberal pay and lack of long-term commitment making the supply-demand imbalance in the permanent hospitalist market even worse?

"Part of the problem is that locums opportunities are draining the workforce supply for practices," Dr. Bell says. She notes that it took more than a year to finally convince one group's long-term locum nocturnist to join the practice as an employee. That commitment came only after some arm-twisting and an ultimatum.

"It took us saying we are eliminating locums from this practice," she recalls. "If you want to work for us, you have to come on full time or you won't get any more shifts."

Dr. Bell has also dealt with the inevitable burnout that results when doctors convince themselves that they can essentially hold down two full-time jobs, one as a locum. She had to let one locum go who worked as a nocturnist while also working days on his regular job.

"When he was on at night," she says, "he didn't want to answer calls or see patients. He wanted to sleep."

In Connecticut, Dr. Lovins points out, "I would be quite disappointed if my docs were picking up shifts at another hospital through a locums agency when I have empty shifts."

And she's concerned about the trend of local doctors deciding to do all their moonlighting through a locums company. One excellent locum physician who Dr. Lovins' program uses regularly could easily become part of the group's pool of local part-timers. Instead, the practice pays at least 50% more to a locums company for that doctor's services.

And to hire such physicians on a per diem basis, Dr. Lovins adds, would cost many thousands of dollars to buy them out of their locums contract—a stipulation that she says many locum doctors may not be aware of. That kind of financial bind, she points out, is a big disincentive for hospitals to bring good doctors on as part of their permanent team.

Different motivators
As demand for hospitalists continues to outstrip supply, hospitalists who might have trouble holding down a permanent position can easily find temporary assignments.

Robert Bessler, MD, president and CEO of Tacoma, Wash.-based Sound Physicians, a national hospitalist organization, thinks there are three types of locum hospitalists. The first, he says, are "career-noncommittal people who like the flexibility of when they want to work and when they don't want to work." Hospitalists in this group could easily secure a permanent job, he says, but don't particularly want one.

Another group includes those who work in an area and want to pick up extra shifts. "This pool is generally high quality yet hard to book for a block of shifts," Dr. Bessler notes.

But a third, less desirable group includes physicians who, he says, choose temp work "because they never last anywhere. The challenge of the recruiter is to figure out who is who in that pool." That was, he adds, a big part of the rationale behind Sound Physicians starting its own locums staffing company nearly two years ago, Echo Locum Tenens.

"Most of our locums usage is early on in a new hospital contract or to deal with rapid same-site growth before backfilling with full-timers," says Dr. Bessler. "A key benefit of Echo Locum Tenens has been our ability to rapidly take over other programs that have been in disarray, due to being short-staffed."

But even the most diligent locum may not have the same commitment or deliver the same level of care as a permanent staffer. Locum doctors may have great clinical skills, says TeamHealth's Dr. Fall, but "they don't know
which primary care doctors you discharge to are going to follow up in a week, which helps reduce readmissions, and which ones won't." And because they often don't know a community or its resources, "they don't know there's a Coumadin clinic in the community that they can refer a patient to so he doesn't come back in three weeks with a major nose bleed."

Quality indicators
Consultants, meanwhile, are less likely to trust a locum they don't know, which can affect patient care. Dr. Ma says he has been told by subspecialists that they don't know how to interpret calls they get in the middle of the night from locum hospitalists, compared to those from physicians they know and trust. "Is he credible or a worrywart?" Dr. Ma says they wonder.

Moreover, adds Roberta Himebaugh, the California-based executive vice president for TeamHeath's Western Region, locum hospitalists can be lax about quality measures and resource utilization.

"Our permanent physicians have quality incentives and at-risk pools, and we can always tell if there is a locum in a program because we don't hit the targets," Ms. Himebaugh explains. "We can drill back down through the data to individual physicians, and nine times out of 10, it's the locum who did not hit the quality indicator. There is a lack of ownership." In one program, she notes, two-thirds of the core-measure indicators that were missed were traced back to locum physicians—who provided only 7% of that group's coverage.

Burned by bad programs
Robert W. Harrington Jr., MD, is chief medical officer of LocumLeaders, a five-year-old locum tenens staffing agency based in Alpharetta, Ga., that last year placed physicians in 43 states.

Before coming to LocumLeaders, Dr. Harrington worked in a practice that used locum hospitalists "a fair amount." Because many were of less-than-optimal quality, he says that his "biggest concern" about working for a locums company "was the potential for me to be saddled with managing the unmanageable." Instead, he reports being "pleasantly surprised" with the number of quality physicians looking for locum work.

Good hospitalists are interested in locum opportunities in part because of the competitive pay, Dr. Harrington says. But he points to another factor at work, one that's a byproduct of the specialty: Many good hospitalists working locum have been "burned by a bad first or second job" and are wary about taking on a permanent post in another untried practice that they'd have to go through a lot of pain to leave. Those physicians view the locum pathway as a good alternative.

"There are a fair number of good quality physicians who for one reason or another value the flexibility of the locum lifestyle over the security of a full-time job," Dr. Harrington says.

A symptom, not the disease
Dr. Harrington admits there are real issues in the booming locum industry, particularly in hospital medicine. But he maintains that the real trouble is not with individual physicians working locum, but with poorly managed and underfunded practices. He argues that hospitalists' dependence on locum physicians is a symptom, not the disease.

"What I would say to the people who now claim that hospitalist locums are potentially hurting the specialty is, 'Why are you using locums? Is there a problem with your compensation plan, workload or culture?'" Dr. Harrington says. "Something is preventing these groups from being able to recruit and retain permanent physicians."

He points out that practices desperately looking for physicians to cover shifts often don't have the right plan in place to recruit permanent physicians and hold onto them. Such groups can't pull off the even harder task of managing uncommitted, temporary employees, and then blame locum doctors when things inevitably go wrong.

In fact, Dr. Harrington says, some practices are so dysfunctional—think unsafe patient volumes or lack of subspecialty support—that his company has been unable to provide them with locum hospitalists.

"I always say I don't want to put good doctors into bad situations," he explains. "There have been instances where we will say, 'We can't be successful in this environment. I can't put locum tenens in here for three months because after a week, they are going to call me and say they want out.'"

"Dysfunctional programs"
Despite concerns, many also think that the extreme use of locums may be a passing trend. As programs grow and mature, their ability to recruit and retain permanent hospitalists generally improves, as does their ability to cover staffing holes with part-timers. And the need to have all hospitalists meet quality measures that now have financial consequences, they say, will prompt some programs to cut back on the number of locums they use.

Some health systems are already pushing back, choosing to drop or pick up hospitalist coverage based in part on locum use. Both Dr. Bessler from Sound Physicians and TeamHealth's Ms. Himebaugh point out that hospitals are now asking staffing companies to spend more time taking over the management of a group—if that will allow them to start a program without needing locums.

And in Florida, Raj Mahadevan, MD, owner of Cape Coral Hospitalists, whose physicians work in several hospitals in the Ft. Myers-Naples area, recently secured the hospitalist contract at one hospital that had had four different hospitalist groups in four years. All those groups had relied heavily on locum hospitalists.

"One group had credentialed about 70 people in 18 months," Dr. Mahadevan says. "It was driving the medical staff crazy. Consultants never knew who was rounding, patient satisfaction scores were low and length of stay was high." During negotiations, Dr. Mahadevan told administrators that "locums are not an option." He believes that helped his group win the contract.

As hospitals and groups look for ways to trim expenses, locums are often the first on the chopping block. And to provide temporary coverage, some groups are instead putting together pools of community-based primary care physicians interested in moonlighting. Others are cross-credentialing hospitalists who work in hospitals owned by the same hospital system. That can help eliminate strict site-adherence in 12-hour days and seven-on/ seven-off block schedules that may leave some sites overstaffed and others uncovered.

And many agree with Dr. Harrington's assessment that part of the problem stems from the specialty itself. As Dr. Lovins says, "It's our job to make the permanent hospitalist positions attractive enough that people want to stay long-term."

The challenge for hospital medicine isn't that there are too many locum hospitalists filling too many vacant positions, Sound Physicians' Dr. Bessler points out.

Instead, "there are too many dysfunctional programs out there," he explains. "If you get the program right, those locum jobs will go away. If there are more good permanent roles created, there will be less demand for locums."

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.


What does working locum mean for hospitalists?

IN TERMS OF HOURLY WAGES, locum hospitalists are typically paid about $150 an hour, significantly more than the roughly $100 an hour that permanent doctors may earn. They're also reimbursed for housing and transportation.

But while locum hospitalists receive a higher hourly rate than employed colleagues, they work as independent contractors. That means they have to pay their own taxes, buy their own health insurance and fund their own retirement.

While many locum hospitalists think they would probably earn more as an employee with benefits, they say that working locum means "a significant income" with a maximum amount of independence and flexibility.

"When it's done right, we find a lot of people do very well," says Robert W. Harrington Jr., MD, chief medical officer of LocumLeaders, a five-year-old locum tenens staffing agency based in Alpharetta, Ga., that placed physicians in 43 states last year.

What does "done right" look like? "You have a good accountant, you open a SEP IRA and write off all the expenses that are allowable for 1099 income," says Dr. Harrington. "And you have a spouse with a full-time job who has benefits, so you don't need the security of benefits."
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