2004 Market Analysis and Executive Summary. Temporary Healthcare Staffing

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1 2004 Market Analysis and Executive Summary Temporary Healthcare Staffing

2 AN ANALYSIS OF THE LOCUM TENENS / TRAVELERS HEALTHCARE STAFFING MARKET Summary Following years of double-digit growth, many healthcare staffing firms suffered setbacks in Demand for temporary coverage in nursing, nurse anesthetists, and imaging technologists either decreased or remained flat. Demand for locum tenens coverage, however, remained strong. Despite the slowdown, evidence of physician and provider shortages forced AMA and COGME to recommend measures to attract students into healthcare fields. Temporary staffing gained efficiency in 2003, filling a majority of all demand. However, healthcare facilities seek coverage for only a small portion of actual vacant days. Estimates of physician vacancies and absences due to vacation or continuing medical education provide insight into the actual need for temporary coverage. The 18,746 cardiologists practicing in the United States would accumulate approximately 562,380 vacation days, for example. Assuming 301,275 additional vacancies due to ongoing searches for staff physicians, there were approximately 3,755 cardiology absences, every single practice day in Scant attention is paid to cost/benefit analysis when it comes to temporary staffing, in part due to the difficulty in obtaining real data. Instead, the emphasis on crisis staffing hinders a more rational approach to interim coverage. Extensive use of overtime 38 percent of traveling imaging technologists worked additional hours while on assignment in 2003 suggests that alternative coverage methods simply masked a continuing shortage of providers. In the long term, the mid-level imaging market is moving toward equilibrium. Expect demand for locum tenens physicians, particularly in surgical specialties, to grow at a moderate rate. Medical malpractice continues to drive sudden increases in demand and expenditure in crisis states. Otherwise, temporary staffing has become mainstream.

3 Changing Times For several years the healthcare staffing industry benefited from a unique combination of events that boosted demand for clinical professionals and transformed temporary practice into an attractive career option. Demographic shifts, technical advances, government policy, failed business models, misleading analysis of physician supply, an economic boom, and other factors joined to create an unprecedented boom. Locum tenens realized an astonishing growth rate of over 400 percent between 1997 and 2003 and revenue flowing to individual staffing firms often expanded by 30 to 50 percent annually during that span. By 2002, the entire clinical healthcare staffing industry topped the $13 billion mark. Last year, however, that figure tumbled to $10.4 billion. Spending on traveling imaging technologists and therapists dropped from $1.4 billion in 2002 to $1 billion last year. The temporary nurse staffing industry also plummeted. Twelve of the 20 largest healthcare staffing providers in the United States suffered losses compared to Only the locum tenens market remained strong in Close to half of all healthcare facilities required the services of a temporary physician at any given moment last year, and 62 percent used at least one temporary physician in a typical month. TABLE 1 Locum Tenens Usage: Total Spending On Locum Tenens Services (estimate) $2.6 bill $2.08 bill $1.93 bill $1.25 bill $899 mill $684 mill Source, 2004 Review of Temporary Healthcare Staffing Trends and Incentives Yet even the apparent 25 percent growth rate is deceptive. Rising malpractice costs forced staffing firms to either adjust their rates and risk losing business or slash margins. In 2000, staffing firms attracted 60 percent of the $1.25 billion spent on locum tenens services. Last year, the firms share fell below 50 percent. TABLE 2 Slowdown: Estimated Staffing Firm Revenue Growth, 2002 to 2003 Per Diem Nursing -13.4% Travel Nursing -8.5% Allied/Other -4.5% Locum Tenens 16.5% Total Temp Staffing -8.5%

4 Source: Staffing Industry Analysts, Inc. All of this occurred during a year in which California established nursing staff to patient ratios, the media routinely discussed the nurse recruitment difficulties, and in which organizations such as the American Medical Association and the Council on Graduate Medical Education finally accepted the reality of a massive physician shortage. COGME had long resisted evidence from the staffing industry of a discrepancy between physician supply and demand for services. Indeed, while use of temporary providers increased from the late 1990s on, COGME insisted a dangerous surplus of physicians loomed around the corner. Now they predict a future shortage of 85,000 full time equivalents and recommend a sizeable increase in annual medical school enrollment. Locum tenens physicians filled over 1.7 million days over the course of the year, but 42 percent of the 8,326 vacancies for which coverage was requested every single day went unfilled. In addition, almost half of all hospitals reported that recruitment of imaging technologists was more difficult in 2003 compared to the previous year, according to the American Hospital Association. TABLE 3 Hospitals Reporting Recruitment More Difficult In 2003 Imaging Technologists 47% Registered Nurses 44% Source: AHA Estimates of physician vacancies and absences due to vacation or continuing medical education provide insight into the actual need for temporary coverage. The 18,746 cardiologists practicing in the United States would accumulate approximately 562,380 vacation days, for example. A review of Internet job postings by Physicianwork found 6,695 advertised opportunities, for an additional 301,275 search days. That amounts to 3,755 cardiology absences, every single practice day. Facilities erase some of this through overtime or by rescheduling patients. In this scenario, however, a mere 4.6 percent of the estimated vacant days are filled by locum tenens cardiologists. TABLE 4 Estimated Vacancies Per Day, Selected Specialties Specialty Vacancies/Day % Locums %Locums (total) Requested Filled Anesthesiology 3, Cardiology 3, Family Practice 6, Internal Medicine 6, Neurosurgery Psychiatry 2, Orthopedic Surgery 2,

5 Estimates based upon average vacation time and average days required to fill an advertised vacancy. Why, then, in the midst of an acknowledged shortage, did the demand for temporary coverage falter? Medical malpractice costs, along with supply and demand issues, drove rapid increases in daily rates paid to temporary physicians and providers. For example, rates paid to CRNAs almost doubled between 1998 and Unfortunately, cost or rather, perceived cost creates a noticeable amount of friction in the market, particularly in a struggling economy. A striking majority of administrators surveyed (80 percent) cite cost as the most significant drawback to interim physician coverage, for example. This frustration affects the perception of the temporary workforce. Staff and management often associate travel and per diem nurses with unprofessional work or burdensome habits, even though no studies prove any diminishment in quality of care when employing temporary nursing. Frustration is evident in the discussion of workplace acceptance, as well. When physicians measure the response of colleagues and patients to the presence of temporary practitioners, at least 95 percent claim to be accepted. Administrators, however, reach a different conclusion, with 79 percent recognizing acceptance by staff physicians and 85 percent by patients. The temporary healthcare staffing market suffers from a frustrating lack of clear information regarding cost and benefits. As a result, management at healthcare facilities often fail to understand the concept of using supplemental staffing strategically to achieve objectives. At $1,110 per day, a facility determines that a locum tenens general surgeon simply costs too much. Yet general surgeons generate an average of $800 in contribution income per patient day and $7,300 in inpatient/outpatient net revenue per day. Orthopedic surgeons produce $786 in contribution income per patient day and $7,400 in net revenue, according to data derived from studies by the Healthcare Advisory Board and Merritt Hawkins & Associates, versus a locum tenens cost of $1,250. Each day in 2003, 1,748 psychiatry vacancies slowed the provision of care. A 2003 survey of obstetricians/gynecologists in malpractice crisis states reveals that one-third were actively taking steps to relocate. The affect of such an exodus would be dramatic: 15 million patient visits absorbed by remaining physicians, 765,000 deliveries handled by remaining physicians. And 39 percent of the survey group indicated efforts underway to curtail services, including discontinuing deliveries. The services provided by nurses and mid-level providers are more difficult to quantify, particularly in terms of revenue. At the University of Pennsylvania hospital, however, travel nurses cost $40 per hour while full time staff nurses earn $45, benefits included. There is a growing perception amongst temporary CRNAs that healthcare facilities use their services in order to generate or at least maintain revenue. When asked in 2002 to assess their value to a hiring facility, 60 percent of CRNAs listed the continuation of patient care as a benefit, while 34 percent stressed the financial impact. In 2003, a mere 46 percent mentioned patient care, while 48 percent considered revenue as a primary contribution. Administrators, on the other hand, view the value of traveling CRNAs differently. A reasonable trove of data and experiential evidence exists for decision-makers with time and resources to compare the costs and benefits of temporary staffing, particularly in the locum tenens realm.

6 TABLE 5 Cost/week Gross charges/week Orthopedic surgery $6,350 $23,247 Urology $6,100 $20,331 Cardiology $6,100 $21,455 Gastroenterology $5,100 $22,025 Source: Staff Care, MGMA. Based on 2002 data TABLE 6 Cost per week (excluding overhead, malpractice) Perm Locums Orthopedic surgery $6,562 $6,350 Urology $5,771 $6,100 Cardiology $5,833 $6,100 Gastroenterology $5,000 $5,100 Source: MGMA, Staff Care. Based on 2002 data Median total patient visits/week Orthopedic surgery 108 Urology 92 Cardiology 85 Gastroenterology 83 Source: MGMA TABLE 7 An unfilled vacancy increases patient wait times, the number of cancelled procedures, and eventually patient migration. Wait times are a measure of the interaction of demand for services and physician shortages. Beginning in the middle of the last decade, staffing industry observers began reporting a sharp increase in searches for medical specialists. Several factors created the upswing: an aging population, demographic shifts, changing patient treatment preferences, expanding diagnostic and surgical options, and the rise of payment plans allowing greater direct patient access to specialists, amongst others. At the same time, the shifting patterns of medical education, physician retirement, evolving practice patterns, and physician demographics altered physician supply. The result is that patient access to specialists has become increasingly problematic. As a guideline, in evaluating physician practices, a physician is generally considered busy if his or her practice is booked for new patient appointments two to three weeks in advance. At that point, the use of locum tenens or the recruitment of a new physician becomes warranted. Current average wait times at urban practices suggest a majority of physician offices in selected specialties have reached this level, according to a

7 recent survey by Merritt, Hawkins & Associates. In cardiology, average patient wait times reached or exceeded 14 days in 11 of the 15 urban markets surveyed. In 40 percent of the markets, cardiology wait times surpassed 21 days. Dermatology wait times exceeded 14 days in 80 percent of the markets studied. Vacancies amongst the nursing and mid-level staff may undermine physician retention programs. Few administrators, however, have the ready tools to compare the cost of an extended vacancy to the cost of a locum tenens physician or traveling provider. TABLE 8 Patient Wait Times At Or Exceeding 14 Day Wait Time Per Specialty Source: Merritt, Hawkins & Associates Those ultimately responsible for the recruitment of interim coverage responded to perceived cost by finding alternative methods to fill vacancies. This trend was evident in mid-level staffing during Facing an average increase in cost per filled day for imaging technologists of $23, the number of shifts coverage by travelers each day fell from 4,925 in 2002 to 3,459 last year. The portion of facilities searching for temporary coverage on any given day dropped from 49 percent to 41 percent. Consumer demand for imaging never slacked, however, and hospitals reported a vacancy rate of close to seven percent, according to the AHA. In order to balance concerns over the cost of temporary coverage and patient flow, administrators resorted to extensive use of overtime. In 2003, healthcare facilities kept temporary providers in place for partial or complete overtime shifts during 38.5 percent of all assignments. Presumably, full time staff absorbed an equal share of overtime shifts, as both traveling imaging technologists and facility administrators cite preventing staff burnout as on of the more significant contributions of traveler staffing 42 percent and 43 percent, respectively. Hospitals responded to the nurse shortage and persistent cost increases in travel nurse coverage through extensive use of overtime, too. The availability of part-time nursing staff 40 percent of nurses are considered part-time allowed facilities to increase overtime without unduly stressing the workforce. In addition, many travel nurses accepted full or part-time positions as temporary opportunities slacked. Other coverage strategies came into play, as well, including facilities establishing a pool of semi-retired physicians and providers to step in and assist. And more facilities sought

8 temporary coverage on their own in 2003, sidestepping the perceived cost and resources of staffing firms. TABLE 9 How Many Staffing Firms Do You Work With When Recruiting Temporary Physicians? None 6% 2% One 23% 3% % 63% 4 or More 16% 32% Source: 2004 Review of Temporary Healthcare Staffing Trends The healthcare industry also responded by shifting delivery of care. As a result, the number of non-physicians performing more advanced clinical services has been increasing steadily. CRNAs now personally administer about 65 percent of the 26 million anesthetics given to patients each year in the United States. They are the sole anesthesia providers in more than 65 percent of rural hospitals and 50 percent of all hospitals. Meanwhile, the American College of Radiology endorsed the formal training of radiology assistants, known colloquially as supertechs. It is expected that radiologic technologists trained for additional duties will ease the caseloads of radiologists, who now often read 60 studies per day. Yet many radiologic technologists already perform extended work, including initial image interpretation, injecting contrast, and conducting fluoroscopy. Research by the University of Arkansas for Medical Sciences discovered that unofficial image interpretation by radiologic technologists had become routine. Final Exam Approval Provided By Radiologic Technologist 71% Physician 12% Chief Technologist 6% Other 11% Source: University of Arkansas TABLE 10 It is difficult to quantify the effectiveness of such measures. Extensive overtime presumably has a negative effect on staff morale and therefore staff retention. Mid-level providers reported fewer options. Although most continued to find steady assignments, those using traveling as a platform to find a permanent placement jumped from four percent of the interim workforce to nine percent. Travelers also tended to use more firms in their quest for assignment

9 opportunities, an indication of a more restricted job market. Creative coverage strategies had little effect on the locum tenens market, however. Service Impact Of Workforce Shortage TABLE Increased wait times for surgery 17% 19% Reduced service hours 17% 17% Cancelled surgeries 11% 10% Curtailed plans for expansion 4% 7% Source: AHA Equilibrium and Efficiency In the midst of these challenges, temporary staffing firms managed to achieve a surprising level of efficiency. While unable to weaken resistance to temporary staffing based upon cost, which still ranks as the foremost drawback when administrators consider interim coverage, staffing firms noted a recognition of the quality of temporary physicians and providers. A resounding 87 percent of administrators rate traveling technologists and therapists as worth the cost. Physicians earned an 89 percent approval rating versus cost. And 91 percent considered CRNAs worth the expense. In addition, the majority of administrators see no difference in patient care when using interim services, with two-thirds ranking locum tenens equal when comparing the number of patients treated per day and almost three out of four finding no significant change in gross charges generated per day. Indeed, 72 percent consider temporary physicians equal to their permanent staff while 84 percent rank traveling CRNAs as equal to staff members. A couple of key factors account for this: an increase in fill rates and a stable and more predictable cost structure. Costs modified as staffing firms aggressively shopped medical malpractice carriers and trimmed margins in the wake of market shifts. Fill rates, a measure of assignments filled versus demand for coverage, increased in all market segments perhaps the most significant trend of In 2001, staffing firms and in-house recruiters filled a mere 39 percent of all demand for traveling imaging technologists, for example. That figure rocketed to 75 percent last year. In addition, 44 percent of all administrators report that staffing travelers proved easier in Note, too, that promptness in supplying locum tenens candidates once held the top spot when facilities evaluated staffing firms, with 71 percent citing it s importance in That figure tumbled to 53 percent last year.

10 TABLE 12 Cost Still A Factor, But... Cost a Worth Drawback The Cost Physicians 80% 89% Imaging Techs 88% 87% CRNAs 80% 91% Source: 2004 Review of Temporary Healthcare Staffing Trends One of the most intriguing trends is the narrowing perception gap between travelers and administrators. In previous years, providers judged themselves as accepted in the workplace while administrators doubted the level of welcome extended to travelers. The margin of difference often ranged between 15 and 30 percent. Last year this gap narrowed considerably, perhaps because technologists and therapists have become committed to traveling over a longer term, providing a steady pool of experienced, qualified candidates. Close to one-third of all travelers have spent more than three years in the interim workforce. The CRNA market experienced a similar transition. Data from 2002 revealed a surprising level of frustration in the interim CRNA market, most of it related to cost. More than 90 percent of survey respondents cited cost as a drawback when seeking temporary CRNA coverage. Such concerns reverberated through 2002, affecting perception of the acceptability of CRNAs. In 2003, however, perceptions changed dramatically. Concerns over cost dipped to 80 percent the only market segment in healthcare staffing experiencing such a shift. With frustrations eased, assessment of skill level climbed. TABLE 13 Are You Accepted By Providers Administrators Medical Staff Physicians 95% 79% Technologists 93% 79% CRNAs 93% 91% Patients Physicians 98% 91% Technologists 98% 93% CRNAs 100% 98% Administration Physicians 89% 80% Technologists n/a n/a CRNAs 94% 88%

11 Source: 2004 Review of Temporary Healthcare Staffing Trends The staffing market has already responded to shifts in demand specifics. The high-demand imaging modalities (NMT, RT, CT, and UTVE), which once accounted for 75 percent of all demand, now make up 62 percent evidence of a broadening market. Since 2001, the primary care portion of locum tenens demand remained relatively stable. Last year the industry began filling an increasing number of subspecialties while demand for psychiatrists, radiologists, and anesthesiologists settled. With the physician shortage well established, demand for surgical specialists increasing, and wait times disrupting patient care, locum tenens emerged as a mainstream solution, often serving as part of a facility s strategic staffing plan. TABLE 14 Strategic Benefits Of Locum Tenens Planned Vacation/CME Coverage 57% 50% Maintain Revenue 36% 16% Prevent Staff Burnout 27% 6% Prevent Patient Migration 3% 0% Source: 2004 Review of Temporary Healthcare Staffing Trends More than a third of all locum tenens physicians already practice in a permanent setting, using some of their vacation time to add much-needed FTEs back into the market. Other segments of temporary staffing draw stability from a supply-side influx rather than shortages which promises to calm once-frenzied demand. A study conducted by the American Society of Radiologic Technologists points toward increasing enrollment in radiography, radiation therapy, and nuclear medicine education programs. ASRT concludes from their study of student enrollment that U.S. healthcare facilities will meet projected demand for radiation therapists and nuclear medicine technologists within five years. The Bureau of Labor Statistics expects a need for 7,000 additional radiation therapists and an added 8,000 nuclear medicine technologists by 2010, based on year 2000 staffing levels. Assuming stable enrollment and attrition rates, ASRT plans for a surplus of 200 radiation therapists and 2,800 nuclear medicine technologists. Radiographers, on the other hand, will fall well short of expected demand. Already these projections are reflected in fill rate data from the travel staffing industry. Fill Rate By Modality Mammo ECC MRT NMT Rad Tech CTT Ultrasound UTVE RTSP

12 TABLE 15 ON THE REBOUND It is uncertain whether evidence of approaching equilibrium results from a successful application of staffing, rescheduling, overtime, and other methods of accounting for shortages, or from short-term muting of demand due to economic forces and rising costs. Industry data suggests, however, that the downturn experienced by the temporary staffing industry in 2003 may be a momentary lull. Table 4 above indicates the estimated percentage of actual vacancies for which healthcare facilities seek locum tenens coverage is rather insignificant: only 6.6 percent of vacant days in cardiology and 1.3 percent of vacant days in neurosurgery, for example. Thus while 70 percent of cardiology demand is filled by a locum tenens physician, a mere 4.6 percent of actual vacant days are filled. Healthcare facilities requested coverage for 8,000 vacant positions each day in 2003 and the effect of broader staffing shortages appears throughout published research: 32 percent of physicians enter the locum tenens market in part to escape the burdens of permanent practice; 21 percent list preventing staff burnout as one of the benefits they bring to a hiring facility. Two opportunities exist for each interim physician. The need for psychiatrists to fill shortages and temporary gaps is astounding. Psychiatry accounted for 17 percent of all days demand last year, 15 percent of all days filled, and 11 percent of all spending. While the average family practice assignment request covers 12 days and the average radiology request 11 days, facilities searching for psychiatry coverage often request 20 or more days. This suggests a physician shortage of some concern. When asked how many times during the course of their residency they had been solicited by individuals or organizations seeking to recruit them, 68 percent of residents in specialties indicated 51 times or more. In 2001, by contrast, only 28 percent indicated that level of activity. In addition, 43 percent indicated they had received over 100 recruitment solicitations, compared to just 7 percent in 2001 The U.S. Department of Labor projected a shortage of CRNAs reaching 9,000. Nursing shortages have been widely discussed. Even without allowing for hidden demand overtime and vacancies for which facilities do not seek coverage shortages amongst mid-level staff are noticeable. TABLE 16 Known Number Of Unfilled Mid-Level Days, Per Day Modality Unfilled Days Per Day Echo Cardiographer 32.5 MRI Technologist 49.6 Nuclear Med Technologist Radiologic Technologist 86.3 CT Technologist Ultrasound Sonographer Ultrasound/Vascular Tech Rad Tech/Special Procedures 60.1 RT/CT 86.3 Physical Therapist Selected modalities Source: 2004 Review of Temporary Healthcare Staffing Trends

13 TABLE 17 Vacancy Rates For Hospital Personnel 2003 Registered Nurses 8.4% LPNs 7.0% Imaging Technologists 6.6% Source: AHA Any number of factors may boost or diminish supply and demand in the temporary market. By regulating competition and compensation structures, Stark II adds a level of difficulty to the recruitment of permanent staff that potentially makes locum tenens more attractive. Managed care and rising medical malpractice rates cause a maldistribution in supply as physicians abandon high cost/low reimbursement regions. Anecdotal evidence indeed suggests that a marginal but noticeable number of physicians enter locum tenens practice after being driven from a permanent setting by increasing malpractice costs. At the same time, the malpractice crisis in specific states drives demand for locum tenens services. The upward pressure medical malpractice concerns places on temporary staffing demand is clearly illustrated in the case of Pennsylvania. The Pennsylvania Medical Society reported a significant number of high-risk specialists abandoning their practices: 600 general surgeons in a five year period; 145 orthopedic surgeons over that period; 80 anesthesiologists in two years; 40 obstetricians over the same two year period. The state was one of the first identified by the American Medical Association as a liability crisis area. Accordingly, 43 percent of the counties in Pennsylvania are experiencing physician shortages. When asked why they use locum tenens, 74 percent of Pennsylvania-based administrators cited loss of staff. And 62 percent of those reported relocation of a physician as the reason for the loss. In the 2003 Review of Temporary Healthcare Staffing Trends and Incentives, survey respondents from northeastern states claimed a moderate amount of concern (54 percent) over malpractice coverage when recruiting for temporary coverage. Data from Pennsylvania, however, revealed that three of every four administrators worried about liability insurance. Not surprisingly, over a one-year period, spending on locum tenens services, including costs associated with physician search and medical malpractice coverage, jumped from $84 million to almost $122 million for the state.

14 TABLE Increase In Demand For Locum Tenens Services, Selected Crisis States Illinois 62% Ohio 31% Pennsylvania 45% TABLE 19 West Virginia 43% Texas 48% Mississippi 57%

15 Source: AMA; 2003 Review of Temporary Healthcare Staffing Trends addendum. TABLE 20 If You Plan To Make A Career Change, To What Extent Is Your Decision A Response To Rising Malpractice Rates? Has little or nothing to do with it 26% Is one of many factors 35% Is a significant factor 26% Is the single most significant factor 13% Source: 2004 Survey of Physicians 50 To 65 Years Old The malpractice crisis creates an obvious ripple effect. Other issues may or may not alter supply and demand in the temporary staffing market but are worth noting. The same-dayservice trend, or open access, has the potential to reduce emergency room visits. Evidence suggests that the growing number of patients entering hospital emergency departments is being driven by the privately insured. A report by the Center for Studying Health System Change indicates that privately insured patients accounted for much of the 16 percent increase in hospital emergency department visits between 1996 and Many of these patients are not truly in need of emergency care, but have found it difficult to see a private practice physician in the time-frame they are comfortable with, so they turn to emergency departments. Meanwhile, the burden of malpractice coverage for emergency physicians forced many staffing firms to limit their recruitment in that specialty. Hospitals converting to critical access status before rules change in 2006 may generate additional demand. More than 900 of them existed at the start of 2004, mostly in the Midwestern states. A survey by the Rural Health Research Center at the University of Minnesota claims 60 percent of the critical access facilities used staffing changes to improve care. TABLE 21 Top Five Staffing Changes, New Critical Access Hospitals Increased nursing staff 19.4% Added mid-level staff 19.4% Added physician staff 11.1% Added PA/NP staff 6.9% Source: Rural Health Research Center, University of Minnesota Demographic trends have the greatest potential to alter supply and demand. Orthopedic surgery emerged as the specialty area in high demand last year, driven by a more active elderly population and aging baby boomers seeking to maintain vibrant lifestyles. Multiplying sites of service and increasing income offers also push the supply and demand of orthopedic surgeons,

16 but aging Baby Boomers receive a generous amount of credit for shifting demand for specific medical services, which in turn creates demand for temporary staffing. Older people, for example, use diagnostic tests such as medical imaging at a much higher rate than younger people. A National Imaging Associates study shows that patient use of imaging triples after age 65 driving up demand for both physicians and imaging technologists. Demand for MRI systems remains strong. Procedures closed on 22 million in 2002, up 22 percent from 2001, according to IMV Medical Information Division. The report expects MRI installations to surpass 1,000 units each year for at least the next five years. Searches for traveling MRI technologists comprised only 2 percent of the mid-level market in 2001, but jumped to seven percent a year later. TABLE 22 Annual Physician Visits by Patient Age Years or older Annual Visits Source: National Ambulatory Health Care Administration New technologies and new efficiencies have the capacity to reshape temporary demand. Molecular PET scanning could both reduce and generate demand, depending upon skill set. A study by the Department of Veterans Affairs and the University of Iowa discovered that hospitalists cut a patient s length of stay by an average of one day and reduce hospital costs by ten percent. In-hospital nursing services cut costs by an even greater amount all of which could boost demand for temporary coverage. Telemedicine and augmentative surgery also promise to alter temporary staffing. New information may change services, as well. A recent report out of Columbia University claims whole body CT scans can significantly increase cancer risk. Radiation levels from the procedure equals 100 mammograms and is similar to levels received by survivors of Hiroshima and Nagasaki who stood 1.5 miles from the point of detonation. Whole body scans reached a peak of 32 million procedures in The crisis staffing habit also tips the balance of supply and demand, as healthcare facilities react to immediate needs first. Radiology and anesthesiology experienced a wave of crisis staffing during the late 1990s into 2002.

17 TABLE 23 Demand for Locum Tenens Radiologists, % 14% 12% 10% 8% 6% 4% 2% 0% Source: 2002 Review of Temporary Healthcare Staffing Trends Recently, according to the 2004 Review of Physician Recruiting Incentives issued by Merritt, Hawkins & Associates, there was a noticeable decline in the demand for radiologists in A similar decline in demand was evident in anesthesiology. This is an example of the waning side of crisis staffing. Once the crisis abates and the gaps filled, facilities turn to other areas of need. As a result, demand for temporary radiologists and anesthesiologists flattened out in 2002 and Other factors generating or curbing supply and demand include new clinical skills assessment tests imposed on international medical graduates, an aging physician population, and the premium young physicians place on quality of life. A general shortage of physicians could be exacerbated or reduced depending upon the career decisions of older physicians those 50 years-old or older constitute 38 percent of all physicians in the United States. Expressed another way, over 225,000 physicians are at the point where retirement or a reduction in services are feasible options. The number of physicians leaving the medical field each year cannot be anticipated with precision. Most physicians maintain their medical licenses even if they are seeing few patients. The economic downturn and the decline of the stock market inhibited the retirement plans of many physicians. Survey data, however, suggests that close to 40 percent of this group plan to take steps that would either remove them from a patient care setting or reduce the number of patients they see.

18 TABLE 24 In The Next One To Three Years, Do You Plan To: Retire 8% Seek a medical job in a non-clinical setting 10% Seek a job in a non-medical field 3% Close your practice to new patients or reduce workload 17% Source: 2004 Survey of Physicians 50 to 65 Years Old Recently trained physicians typically put a higher premium on quality of life issues than senior physicians. Younger physicians today prefer and expect set hours, favorable call and coverage, and regular vacation time. A much higher percentage of young physicians today are female than was the case in the past, and female physicians work 18 percent fewer hours per week than male physicians, according to the AMA. For these reasons, it may require two younger physicians to replace one senior physician. A 2003 survey of final year medical residents also reveals that young physicians have absorbed the general climate of gloom and pessimism about the medical practice environment. Encounters with litigious patients, medical bureaucracy, crammed schedules, and continuing medical education cause one in four newly trained physicians to question their choice of a career prior to even entering that career. TABLE 25 If You Were To Begin Your Education Again, Would You Study Medicine Or Another Field? Medicine 76% 95% Another Field 24% 5% Source: 2003 Survey Of Final Year Medical Residents Continued shortages will affect price of and access to healthcare. Public concern for the cost of care, however, is a powerful mechanism against drastic changes in the cost of services. Instead, facilities must adapt to cover the shortages without publicly unacceptable price increases. Many options exist: reduce demand, open more medical school slots or rely upon foreign medical graduates, relax state licensure, and so on. The temporary staffing industry gained a level of efficiency and respect necessary to benefit from shortages, new technologies, and other trends in healthcare delivery. In many respects, temporary staffing has become mainstream, a recognized component of staff planning. Yet crisis staffing continues to generate demand for temporary coverage, and exigencies of the moment rising malpractice rates for physicians, higher income levels for travelers swing the supply of temporary providers in uncertain directions. Specific objections remain, such as the general failure to determine the need for interim coverage based upon a solid understanding of costs versus benefits. Essentially, and it is difficult to avoid this comparison, the temporary staffing industry is experiencing a transition from niche industry to accepted partner, much in the manner of Clevon Little s Sheriff Bart character in the 1974 film Blazing Saddles: rapidly becoming an underground success.

19 ADDENDUM Cost/Benefit, selected specialties 2002 Data Orthopedic Surgery Median total patient visits/week 108 Median gross charges/week $23,247 Weekly loss without physician (revenue overhead) $22,589 Locum tenens cost per week $ 6,350 Gastroenterology Median total patient visits/week 83 Median gross charges/week $22,025 Weekly loss without physician (revenue overhead) $16,925 Locum tenens cost per week $ 5,100 Urology Median total patient visits/week 92 Median gross charges/week $20,331 Weekly loss without physician (revenue overhead) $19,558 Locum tenens cost per week $ 6,100 Source: Medical Group Management Association; Staff Care, Inc. Income Comparison Income offers/perm staff 42 weeks/temp Radiologic Technologist $47,683 $53,240 Nuclear Medicine Tech $53,200 $72,400 CT Technologist $53,200 $67,360 Vascular Technologist $55,800 $73,800 Ultrasound Sonographer $53,625 $64,000 Source: Allied Consulting; Med Travelers

20 For more information regarding this market analysis, please contact: Statesman Drive Irving, Texas Proud sponsor of the Country Doctor of the Year award

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