NALTO Benchmarking Initiative Fiscal Year Overview Report for Survey Participants

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1 NALTO Benchmarking Initiative Fiscal Year 2008 Overview Report for Survey Participants April, 2009 PROPRIETARY DATA, DO NOT DISTRIBUTE OUTSIDE YOUR ORGANIZATION. Your company s license to use this data precludes distribution to nonparticipating companies or individuals in any form electronic, written or verbally without the express written permission of Staffing Industry Analysts.

2 The NALTO 2008 Benchmarking Study All NALTO members invited to participate Data collection in April 2009 Data provided from Fiscal year 2007, 2008 and Q Data collection focused on revenue, physician comp and days billed by specialty Received completed surveys from 13 companies Total 2008 revenue represented by the NALTO participants: $740M Detailed results shared with survey participants

3 Terms Used Data Element Definitions Revenue Locum tenens only does not include travel expenses, conversion or perm fees Physician comp Does not include medical malpractice or client reimbursed travel expenses paid to or on behalf of physicians Gross margin Revenue minus physician comp. Days billed One day equals eight hours Statistical Terms Aggregate The total sum of all values for a selected variable, as in aggregate revenue, meaning the sum of all revenue reported by participants in a selected specialty or group. 75th and 25th Percentile These are referred to throughout the report. The 75th percentile is the value at which 75% of all firms reporting for that data item fall below it. The 25th percentile is defined similarly. Median is the 50th percentile.

4 Executive Summary Although some deceleration of growth was seen in 1Q09, 2008 was a great year for locum tenens 2008/07 aggregate revenue growth of 17.7% compared with 16.4% 2007/06 growth in last year s survey Strong growth driven by increases in both days billed and bill rate Performance varied heavily by specialty 2008/07 aggregate revenue growth for hospitalists and family med over 35%, anesthesiology only 2.8%, radiology contracted GM% and Conversion Fees grew in 2008 Aggregate and median were higher in 2008 than 2007 for both GM% and conversion fees 2008/07 aggregate growth in both conversions (18.2%) and revenue from conversion fees (19.7%) exceeded total revenue growth (17.7%)

5 Executive Summary (continued) More companies increasing the percent of their revenue with the government, though larger companies might be seeing declines here Median percent of revenue with the government grew from 0.7% in 2007 to 7.8% in 2008 Aggregate percent of revenue declined from 18.9% in 2007 to 16.7% in 2008 More business means more recruiters Aggregate 2008/07 growth in recruiters/sales reps was 17.4%, roughly inline with revenue growth of 17.7% More business means more malpractice expense As a % of revenue, aggregate malpractice expense was 5.6% in both 2008 and 2007 (growth in malpractice in-line with rev growth) Median malpractice costs as a percent of revenue rose from 2.8% to 3.0% Physician compensation garnered a slightly lower share of revenue in 2008 (64%) compared with 2007 (67%), driven by a smaller mix of anesthesiology and radiology

6 The Survey Included a Spectrum of Specialties Aggregate 2008 sample revenue = $740M 2008 Locum Tenens Revenue by Specialty Other locum tenens 42% Psychiatry 5% Hospitalists 10% Radiology 17% Family Med/IM/Pediatrics 13% Anesthesiology 13%

7 Total Locum Tenens Revenue Growth 2008/07 70% 60% 61.8% 50% 40% 30% 20% 17.7% 24.7% 10% 8.2% 0% Aggregate 25th Median 75th

8 Strong Growth for Hospitalists and Family Med 2008/07 Aggregate Revenue Growth by Specialty -10% -5% 0% 5% 10% 15% 20% 25% 30% 35% 40% Psychiatry 17.7% Hospitalists 36.3% Radiology -3.0% Anesthesiology 2.8% Family Med/IM/Pediatrics 37.9% Other locum tenens 24.7%

9 Strong Growth for Hospitalists and Family Med 2008/07 Median Revenue Growth by Specialty 0% 10% 20% 30% 40% 50% 60% 70% 80% Psychiatry 24.3% Hospitalists 75.1% Radiology 12.5% Anesthesiology 3.4% Family Med/IM/Pediatrics 58.3% Other locum tenens 37.7%

10 Detailed Revenue Growth by Specialty 2008/2007 Revenue Growth by Specialty Aggregate 25th Percentile Median 75th Percentile Psychiatry 17.7% -9.3% 24.3% 100.0% Hospitalists 36.3% 28.2% 75.1% 90.5% Radiology -3.0% -5.6% 12.5% 18.3% Anesthesiology 2.8% -7.6% 3.4% 81.5% Family 37.9% 6.1% 58.3% 89.7% Other locum tenens 24.7% 13.5% 37.7% 73.4% Total Locums 17.7% 8.2% 24.7% 61.8%

11 Gross Margin $ Growth 2008/07 60% 54.3% 50% 40% 32.9% 30% 20% 25.5% 18.9% 10% 0% Aggregate 25th Median 75th

12 Detailed GM$ Growth by Specialty 2008/07 GM$ Change by Specialty Aggregate 25th Percentile Median 75th Percentile Psychiatry 19.0% 17.9% 64.2% 104.9% Hospitalists 35.8% 14.8% 66.1% 96.3% Radiology 0.0% 9.0% 19.0% 39.1% Anesthesiology 11.0% 0.6% 6.5% 64.7% Family 41.6% 7.3% 42.3% 78.5% Other locum tenens 29.9% 22.8% 31.9% 48.2% Total Locums 25.5% 18.9% 32.9% 54.3%

13 Median Growth: Days Billed by Specialty 2008/07 Total Locums 12.2% Other locum tenens 19.2% Family Med/IM/Pediatrics 50.6% Anesthesiology -2.6% Radiology 8.5% Hospitalists 45.5% Psychiatry 18.5% -10% 0% 10% 20% 30% 40% 50% 60%

14 Detailed Days Billed Growth by Specialty Days Billed Growth % by Specialty 2008/07 Aggregate 25th Percentile Median 75th Percentile Psychiatry 9.1% -20.2% 18.5% 86.1% Hospitalists 20.5% 8.4% 45.5% 64.6% Radiology -4.4% -6.3% 8.5% 18.5% Anesthesiology -1.9% -8.3% -2.6% 49.4% Family Med 28.2% -4.4% 50.6% 84.6% Other locums 5.1% 2.1% 19.2% 34.5% Total Locums 8.9% 6.2% 12.2% 41.0%

15 Growth in Revenue, GM$ and Days Billed 70% 60% 61.8% 54.3% 50% 40% 32.9% 41.0% 30% 25.5% 24.7% 20% 17.7% 18.9% 10% 8.9% 8.2% 6.2% 12.2% 0% Aggregate 25th Median 75th Revenue Gross Margin $ Days Billed

16 Gross Margin % 40% 35% 30% 34.8% 32.6% 31.3% 28.0% 29.4% 27.2% 35.4% 36.1% 25% 20% 15% 10% 5% 0% Aggregate 25th Median 75th

17 Median 2008 Gross Margin % by Specialty 0% 5% 10% 15% 20% 25% 30% 35% 40% Psychiatry 35.4% Hospitalists 33.4% Radiology 24.4% Anesthesiology 30.5% Family Med/IM/Pediatrics 36.5% Other locum tenens 34.8%

18 Detailed 2008 GM% by Specialty 2008 GM% by Specialty Aggregate 25th Percentile Median 75th Percentile Psychiatry 35.4% 33.6% 35.4% 36.1% Hospitalists 33.2% 31.2% 33.4% 35.7% Radiology 22.6% 23.3% 24.4% 30.5% Anesthesiology 28.4% 28.2% 30.5% 32.2% Family Med 38.7% 30.2% 36.5% 39.5% Other Locums 40.0% 30.0% 34.8% 40.6% Total Locums 34.8% 28.0% 31.3% 35.4%

19 Median 2008/07 Change in GM% by Specialty Total Locums 0.5% Other locum tenens 0.0% Family Med/IM/Pediatrics 0.6% Anesthesiology 1.9% Radiology 0.7% Hospitalists 0.0% -1.6% Psychiatry -2.0% -1.5% -1.0% -0.5% 0.0% 0.5% 1.0% 1.5% 2.0% 2.5%

20 Detailed 2008/07 Change in GM% by Specialty 2008/07 Change in GM% by Specialty Aggregate 25th Percentile Median 75th Percentile Psychiatry 0.4% -1.8% -1.6% -0.2% Hospitalists 0.6% -0.7% 0.0% 0.8% Radiology 1.3% -1.4% 0.7% 3.4% Anesthesiology 2.6% 0.5% 1.9% 4.2% Family Med 1.0% -1.3% 0.6% 0.8% Other Locums 1.6% -2.5% 0.0% 0.3% Total Locums 2.2% 0.1% 0.5% 2.2%

21 Average 2008 Daily Bill Rate Revenue per Day Billed in ,000 1,800 $1,836 1,600 1,400 $1,463 $1,500 1,200 1,000 $ Aggregate 25th Percentile Median 75th Percentile

22 Median Bill Rate Per Day by Specialty $- $500 $1,000 $1,500 $2,000 $2,500 $3,000 Psychiatry $1,150 Hospitalists $1,281 Radiology $2,491 Anesthesiology $2,042 Family Med/IM/Pediatrics $951 Other locum tenens $1,701 Total Locums $1,500

23 Daily Bill Rate Detail by Specialty 2008 Average Revenue Per Day All figures in $'s Aggregate 25th Percentile Median 75th Percentile Psychiatry 1,176 1,035 1,150 1,256 Hospitalists 1,326 1,201 1,281 1,721 Radiology 2,423 2,385 2,491 2,675 Anesthesiology 1,508 1,947 2,042 2,228 Family Med 1, ,175 Other Locums 1, ,701 2,183 Total Locums 1, ,500 1,836

24 Median 2008/07 Change: Daily Bill Rates Other locum tenens 8.6% Family Med/IM/Pediatrics 9.8% Anesthesiology 3.1% Radiology -0.5% Hospitalists 9.5% Psychiatry 13.6% -2% 0% 2% 4% 6% 8% 10% 12% 14% 16%

25 Detailed Daily Bill Rate Change: 2008/ /07 Change in Average Revenue Per Day Aggregate 25th Percentile Median 75th Percentile Psychiatry 7.9% 9.2% 13.6% 19.6% Hospitalists 10.7% 6.7% 9.5% 16.5% Radiology -1.4% -2.2% -0.5% 0.7% Anesthesiology 2.9% 0.5% 3.1% 6.8% Family Med 7.9% 6.6% 9.8% 11.8% Other Locums 10.9% 0.3% 8.6% 22.1% Total Locums 5.0% -1.0% 9.1% 13.9%

26 2008 Median Physician Comp per Day Compensation ($) ,000 1,200 1,400 1,600 1,800 2,000 Psychiatry $742 Hospitalists $885 Radiology $1,820 Anesthesiology $1,436 Family Med/IM/Pediatrics $618 Other locum tenens $981

27 Detailed Physician Comp per Day Billed Average Physician Comp Per Day All figures in $'s Aggregate 25th Percentile Median 75th Percentile Psychiatry Hospitalists ,128 Radiology 1,875 1,715 1,820 1,892 Anesthesiology 1,080 1,349 1,436 1,564 Family Med Other Locums ,368 Total Locums ,179

28 Physician Comp Per Day as Share of Daily Revenue Aggregate Physician Compensation as % of Aggregate Revenue 2008 $ per day 2008% 2007 $ per day 2007% Psychiatry % % Hospitalists % % Radiology 1,875 77% 1,934 79% Anesthesiology 1,080 72% 1,088 74% Family Med % % Other Locums % %

29 2008 Average Conversion Fee 30,000 25,000 20,000 $21,105 $20,843 $20,092 $17,670 $23,886 $22,195 $21,370 $20,502 15,000 10,000 5,000 - Aggregate 25th Median 75th

30 2008/07 Growth in Conversions and Conv. Fee Rev. 60% 50% 49.7% 40% 35.3% 30% 20% 10% 0% -10% 19.7% 18.2% 6.5% 0.0% Aggregate 25th Median 75th -5.4% -20% -20.0% -30% Conversion Fee Revenue Number of Conversions

31 Medical Malpractice Expense as % of Revenue 7% 6% 5.6% 5.6% 5.9% 5% 4.4% 4% 3% 3.0% 2.8% 2% 2.2% 2.0% 1% 0% Aggregate 25th Median 75th

32 2008/07 Growth in Medical Malpractice Expense 60% 50% 48.5% 40% 30% 20% 18.6% 17.8% 10% 0% -10% -9.7% Aggregate 25th Median 75th -20%

33 Government Revenue as % of Total Revenue 25% 20% 16.7% 18.9% 20.4% 17.6% 15% 10% 7.8% 5% 0% 0.7% 0.0% 0.0% Aggregate 25th Median 75th

34 2008/07 Growth in Government Revenue 250% 200% 190.9% 150% 100% 100.0% 50% 0% 4.0% 0.0% Aggregate 25th Median 75th

35 Average Number of Recruiters th Median 75th

36 Revenue per Average Number of Recruiters 1,600,000 1,400,000 1,200,000 $1,263,133 $1,339,444 1,000,000 $1,040,291 $1,001,335 $929,646 $883, , ,000 $738,917 $668, , ,000 0 Aggregate 25th Median 75th

37 GM$ per Average Number of Recruiters 450, , ,000 $360,050 $405,993 $408,278 $394, , ,000 $255,925 $222,145 $293,152 $272, , , ,000 50,000 - Aggregate 25th Median 75th

38 Compensation per Avg. Number of Recruiters 100,000 90,000 80,000 $86,647 $83,609 $76,629 $75,000 $83,106 $77,033 70,000 60,000 $60,881 $60,118 50,000 40,000 30,000 20,000 10,000 0 Aggregate 25th Median 75th

39 Recruiter/Sales Rep Metrics: 2008/07 Growth 50% 45.2% 40% 30% 23.5% 20% 17.4% 10% 0% 9.5% 7.8% 7.9% 3.9% 3.6% 4.1% 2.1% -2.1% 0.1% Aggregate 25th Median 75th -10% Revenue/Sales Rep Comp/Sales Rep Number of Sales Reps

40 Aggregate Cost Structure Aggregate % of Total Revenue by Cost Element 2008 Other Costs/Profit 28% Sales Rep/Recruiter Comp 8% Physician Comp 64%

41 Aggregate Cost Structure Aggregate % of Total Revenue by Cost Element 2007 Other Costs/Profit 25% Sales Rep/Recruiter Comp 8% Physician Comp 67%

42 Specialties in Demand (some get mixed reviews) Growing in Demand Hospitalist (8) Family Practice (5) Primary Care (4) Emergency Medicine (7) Pulmonary (2) Pediatrics (1) Surgery (1) Cardiology (1) OB/GYN (1) Psychiatry (1) Shrinking in Demand Anesthesiology (8) Radiology (6) CRNA (2) Psychiatry (2) Cardiology (1) OB/GYN (1) Numbers in () indicates number of respondents

43 Decelerating Revenue Growth in 1Q09 70% 60% 61.8% 50% 40% 30% 20% 24.7% 18.0% 10% 0% -10% 8.2% 11.0% -2.0% 25th Median 75th Q Rev Growth 2008 Rev Growth

44 Additional Results What % of commercial revenue (excluding government) is generated through VMS? 12 of 13 respondents noted 0% for 2008 and 2009 What % of revenue is split with another staffing firm? All responses noted 3% or less Have you acquired another locum tenens staffing firm between January 1, 2007 and December 31, 2008? 1 of 13 respondents answered yes

45 Implementing Improvements Using Benchmarking Choose the right metrics for your situation and strategy cost, efficiency, growth, etc. Determine your baseline performance Compare your performance to industry metrics Investigate underlying causes for performance variances - practices to consider, etc. Develop an improvement plan Implement, measure and follow up

46 2008 NALTO benchmarking survey Data For The Year Ended December 31, 2008 December 31, 2007 Item Revenue Physician Comp Days Billed Revenue Physician Comp Days Billed Locum Tenens Business Only Psychiatry Hospitalists Radiology Anesthesiology Family Medicine, Internal Medicine, Pediatrics Other locum tenens revenue Other Revenue Data Total Locums $ - $ - - $ - $ - - Conversion Fee Revenue Number of Conversions Revenue from Government (all specialites) Operating Data Data For The Year Ended December 31, 2008 December 31, 2007 Average Number of Sales Reps/Recruiters Total Compensation for Sales Reps/Recruiters Medical Malpractice Spend What % of commercial revenue (excluding government) is generated through VMS? Percent of revenue split with another staffing firm Estimated Locum Tenens revenue growth % in Q Q Open ended questions: What specialties are increasing in demand? What specialties are decreasing in demand? Have you acquired another locum tenens staffing firm between January 1, 2007 and December 31, 2008?

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