2013 SURVEY OF TEMPORARY PHYSICIAN STAFFING TRENDS. 2013 STAFF CARE, Inc. 5001 Statesman Drive, Irving, Texas 75063 (800) 685-2272 www.staffcare.

We ve earned The Joint Commission s Gold Seal of Approval 2013 SURVEY OF TEMPORARY PHYSICIAN STAFFING TRENDS 2013 STAFF CARE, Inc 5001 Statesman Drive, Irving, Texas 75063 (800) 685-2272 www.staffcare.com Certified by the Joint Commission

2013 SURVEY OF TEMPORARY PHYSICIAN STAFFING TRENDS IN THIS REPORT OVERVIEW/METHODOLOGY PART ONE KEY FINDINGS QUESTIONS AND ANSWERS ANALYSIS PART TWO KEY FINDINGS QUESTIONS AND ANSWERS TRENDS AND OBSERVATIONS PART THREE REVIEW OF 2012 ASSIGNMENTS TRENDS AND OBSERVATIONS PAGE 3 PAGE 4-6 PAGE 7-15 PAGE 16-21 PAGE 22-23 PAGE 24-32 PAGE 33-40 PAGE 41-42 PAGE 42-47 OVERVIEW Staff Care is a leading healthcare staffing firm specializing in matching temporary (i.e., locum tenens) physicians, certified registered nurse anesthetists (CRNAs), physician assistants, nurse practitioners and dentists with hospitals, medical groups, government facilities, community health centers and other healthcare organizations nationwide. Established in 1992, Staff Care is a company of AMN Healthcare, the innovator in healthcare workforce solutions, and is certified by the Joint Commission, National Committee for Quality Assurance (NCQA) and offers an in-house Certified Verifications Office (CVO). This report marks Staff Care s tenth Survey of Temporary Physician Staffing Trends. The purpose of the survey is to track trends in the locum tenens physician staffing market and to provide benchmark data that may be useful to physicians, healthcare executives, policy makers, academics, journalists and others who monitor developments in the healthcare staffing industry. This year, for the first time, nurse practitioners and physician assistants are included in the survey. METHODOLOGY Staff Care s 2013 Survey of Temporary Physician Staffing Trends is based on surveys sent by e-mail to healthcare executives and locum tenens physicians, nurse practitioners, and physician assistants nationwide. The survey also includes an examination of the temporary physician staffing assignments Staff Care conducted in calendar year 2012. Data from past Staff Care surveys are included where applicable. Part I of the survey examines why healthcare facilities, including acute care hospitals, medical groups, state-supported facilities such as behavioral health centers, community health centers, and others use locum tenens physicians and how they evaluate the quality and services provided by locum tenens practitioners. Part II of the survey examines why physicians, nurse practitioners and physician assistants choose to work on a locum tenens basis, how they select temporary practice opportunities, how they are perceived by colleagues and other related matters. Part III of the survey indicates the type of locum tenens staffing assignments Staff Care conducted in calendar year 2012. The breakdown of temporary practitioner days requested by specialty is offered as an indicator of current physician supply and demand trends in locum tenens. For additional information about this survey contact: Phil Miller (469) 524-1420 info@staffcare.com 5001 Statesman Drive Irving, Texas 75063 800-685-2272 www.staffcare.com Proud Sponsor, Country Doctor of the Year Award Member of the National Association of Locum Tenens Organizations Copyright Staff Care, Inc. 2013 Published March 2013 Parts I and II of the survey were conducted over the five-month period from October 1, 2012, to February 1, 2013, and the final survey report was released in March, 2013. Respondents were self-selected and included Staff Care clients and non-clients, as well as physicians, nurse practitioners, and physician assistants who have been matched to temporary assignments by Staff Care and those who have not. 3

PART ONE KEY FINDINGS OF PART I INCLUDE: Primary care physicians are in the greatest demand as locum tenens. Of those facilities that sought locum tenens doctors in the past year, 35 percent were seeking primary care physicians. Behavioral health professionals such as psychiatrists are second on the wish list of healthcare facilities. Thirty-one percent of facilities that sought locum tenens assistance last year were seeking behavioral health practitioners. The foremost use of locum tenens physicians is to fill in for physicians who have left. Fifty-eight percent of those surveyed indicated they use locum tenens physicians to fill in for physicians who have left their facilities. In an era of increasing physician employment, physician turnover is increasing, causing health facilities to turn to locum tenens physicians to fill gaps. The physician shortage is driving the use of locum tenens physicians. Fifty-seven percent of survey respondents indicated they use temporary physicians to maintain services while they seek to fill open permanent positions. As the physician shortage becomes more pervasive, many facilities now rely on locum tenens doctors to maintain services as they seek permanent candidates. SURVEY OF LOCUM TENENS PHYSICIAN USERS, INCLUDING HOSPITAL, MEDICAL GROUP, COMMUNITY HEALTH CENTER AND GOVERNMENT HEALTH FACILITY MANAGERS Number of Surveys Completed = 205 Health reform is prompting new reasons to use locum tenens physicians. Five percent of those surveyed indicated they use locum tenens physicians to maintain services while transitioning to the employed physician model. Health reform and attendant market changes are leading to the increased employment of doctors, and facilities are using locum tenens services as a stopgap during this transition. KEY FINDINGS Locum tenens physicians those who substitute for their colleagues when they are temporarily absent from their practices have been a fixture of the medical profession for many decades. Information technology is another new reason for using locum tenens physicians. About four percent of survey respondents said they use locum tenens physicians during electronic medical record (EMR) training. It may take several weeks for physicians to learn new EMR systems, and some healthcare facilities use locum tenens physicians to maintain services during these down periods. However, the widespread use of locum tenens physicians and other healthcare professionals placed on temporary assignments through staffing firms in multiple healthcare settings is a relatively recent development. This practice began in the 1970s, when government grants were allotted to make temporary physicians available in medically underserved rural areas, accelerating the use of locum tenens doctors. Managed services providers are an emerging trend in locum tenens staffing. About 8 percent of those surveyed indicated their facilities use a managed services provider to oversee multiple locum tenens staffing companies and to manage the temporary staffing process. Locum tenens companies began as niche players in the health care staffing industry, filling physician days on a limited basis in mostly rural areas. Today, by contrast, locum tenens staffing is a multi-billion dollar industry and temporary physicians and other providers are used by healthcare facilities in a broad range of settings and locations nationwide. For the sixth consecutive year, at least 72 percent of healthcare managers surveyed indicated their facilities had used locum tenens physicians sometime during the previous 12 months. While locum tenens physicians may have been an anomaly at many hospitals and medical groups in the past, survey results indicate they are a customary component of most medical staffs today. 4 Part I of Staff Care s 2013 Survey of Temporary Physician Staffing Trends examines the use of locum tenens physicians in hospital, medical group and other settings. It seeks to determine how prevalent is the use of locum tenens physicians and why healthcare facilities use temporary doctors. The survey also examines how health facility administrators evaluate the quality of care provided by locum tenens physicians and whether or not they are worth the cost. The majority of health facilities use at least one locum tenens physician per month. Forty-five percent of administrators indicated they typically use one to three locum tenens physicians per month, 7 percent said they use four to six, and 4 percent use seven or more. The remaining 44 percent said that in a typical month they do not use locum tenens physicians. 5

QUESTIONS ASKED AND RESPONSES RECEIVED Over one-third of healthcare facilities book six or more temporary physician days per month. While the majority of survey respondents indicated they book five or fewer temporary physician days per month, 37 percent are robust users of locum tenens and book six or more physician days per month. Approximately16 percent book 26 or more temporary physician days per month. 1 Have you used temporary (locum tenens) physicians to supplement your existing staff any time during the last 12 months? Over 40 percent of healthcare facilities now employ telemedicine. In an era of widespread physician shortages, many healthcare facilities are using telemedicine as an extension of their medical staffs. Some 43 percent of those surveyed said their facilities have integrated telemedicine into at least one of their departments. Yes No 7 7 8 7 7 2 2 1 2 2 The majority of health facility administrators rate locum tenens physicians as good to excellent. Sixty-five percent of those surveyed indicated that the general skill level of locum tenens physicians is either good or excellent. Thirty-four percent rated their skill level as adequate, while only 1 percent rated the skill level of locum tenens physicians as unsatisfactory. 2 If yes, what specialties?* Though cost is considered one of the drawbacks of using locum tenens physicians by many administrators, 85 percent said locum tenens physicians are worth the cost, up from 79 percent last year. Responses to Part I of the survey are listed in the following page. Primary care (family medicine, internal medicine, pediatrics) Behavioral health Hospitalist Surgery Oncology Emergency medicine Anesthesiology Internal medicine sub-specialties Radiology Nurse Practitioner 3 3 19% 1 1 Physician Assistant Certified Registered Nurse Anesthetist *Question asked for the first time in 2013 3 Are you currently looking for locum tenens physicians to supplement your existing staff? Yes 3 4 4 40% 5 6 7 No 6 59% 59% 60% 4

6 In a typical month, how many locum tenens physicians do you use? None 4 3 3 3 3 4 If yes, what specialties?* 1 3 4 6 4 50% 5 3 5 7 or more Behavioral health 39% Primary care (family medicine, internal medicine, pediatrics) 3 Hospitalist Oncology 1 9% 7 In a typical month, about how many days of locum tenens coverage do you use?* Surgery Emergency Medicine Nurse Practitioner Internal medicine subspecialties Anesthesiology Radiology Physician Assistant Certified Registered Nurse Anesthetist *Question asked for the first time in 2013 None 1-5 6-10 11-15 16-20 21-25 26-30 4 9% 31 or more *Question asked for the first time in 2013 5 More difficult Less difficult The same How difficult is it to find locum tenens coverage today compared to 12 months ago? 1 1 30% 2 1 70% 2 6 2 6 1 5 1 6 As the employed model becomes more pervasive, hospitals, medical groups and other facilities will need to put renewed emphasis on physician retention strategies to ensure medical staff stability. 8 9

Why do you or would you typically use a locum tenens physician? (check all that apply) 8 9 What are the benefits/drawbacks of using locum tenens physicians? Fill in for staff who have left Fill in until a permanent doctor is found Vacation/continuing medical education Fill in during peak usage times Meet rising patient demand Maintain flexibility to upsize or downsize staff as needed* Maintain services while transitioning to physician employment* Maintain services during EMR training* Reduce readmissions/medical errors* 5 4 4 2 6 5 3 < 5 4 9% 6 5 9% 3 3 1 6 50% 1 1 Benefits Allows continual treatment of patients Prevent revenue loss Prevents existing staff burnout Immediate availability Cost Reduce medical errors/readmissions Ensures quality based reimbursement Other 6 6 7 3 80% 3 3 3 4 2 2 4 3 2 2 1 3 5 3 3 Test market a new service Ensure quality-based reimbursement* *Question asked for the first time in 2012 0% 0% 2 Drawbacks Cost Familiarity with department/practice 7 8 8 5 8 5 60% 6 3 50% Credentialing issues* 3 Learning equipment/procedures 2 3 4 19% 2 Managing multiple locum tenens staffing providers* Unable to bill for locum* 1 1 *Question asked for the first time in 2013 10 What is your perception of the general skill level of locum tenens physicians? Good 49% Good 39% 2012 Unsatisfactory Unsatisfactory 2011 Excellent 1 Excellent 1 Adequate 3 Adequate 4 10 11

11 Colleagues Accepted by Not accepted Tolerated Unsure At your facility, how are locum tenens providers viewed by: 6 6 59% 5 6 2 2 0% 2 2 1 2 In comparing locum tenens physicians to permanent physicians on their staffs, 59 percent of healthcare facility managers said that locum tenens physicians treat the same or a greater number of patients per day than do permanent physicians. 13 Please rate locum tenens physicians compared to your permanent medical staff in the following areas: Gross charges generated per day Administration Accepted 69% 6 6 5 6 Same Fewer 5 3 4 5 6 4 5 49% 4 3 Not accepted More Tolerated 1 2 2 2 19% Unsure 1 1 Patients Accepted by 6 5 5 6 6 Not accepted 0% 0% Tolerated 1 1 1 1 Unsure 19% 3 3 2 2 12 Please rate locum tenens physicians compared to your permanent medical staff in the following areas: Patients treated per day 14 When conducting your search for locum tenens physicians, with how many search firms/staffing agencies do you generally work? One 2 None 2012 2011 One 1 None 1 More Fewer 39% 5 5 40% 3 Four or more 2 Four or more 1 Same 59% 39% 4 5 6 Two to three 4 Two to three 5 12 13

17 What is your facility s position regarding companies that provide management of multiple locum tenens staffing services?* 2012 3 5 We use a managed service provider We do not use a managed service provider We are considering using a managed service provider I am unfamiliar with this concept *Question asked for the first time in 2013 18 Has your facility integrated telemedicine into any of its departments?* 15 What are the most important factors in selecting a temporary staffing firm? (check all that apply) Quality of physicians provided Availability of candidates Cost Customer service Contract flexibility Manages the locum tenens process* Malpractice insurance Provides a locum tenens billing service* Other 7 8 8 7 6 6 4 4 3 2 2 7 7 6 3 2 9% 8 5 5 4 2 6 5 49% 3 7 49% 50% 3 2 *Question asked for the first time in 2013 4 Yes 19 2 Primary Care 5 No If yes, which ones? 4 Radiology *Question asked for the first time in 2013 3 Behavioral Health 1 Other 16 Rate the importance of the following factors when selecting a locum tenens candidate. 20 How would you rate the value of locum tenens physicians to your facility? Availability Training Very important Somewhat important Unimportant 89% 7 2 2012 Worth the cost 8 Worth the cost 79% Not worth the cost 1 Not worth the cost 2 2011 Cost 6 30% 14 15

ANALYSIS REASONS FOR USING LOCUM TENENS Part I of Staff Care s 2013 Survey of Temporary Physician Staffing Trends provides insight into how often healthcare organizations use temporary (locum tenens) physicians, why they use these physicians, the benefits locum tenens physicians provide, how they compare to permanent physicians and the perceived skill levels of locum tenens physicians. WHO IS USING LOCUM TENENS PHYSICIANS AND WHAT TYPES OF PHYSICIANS ARE IN DEMAND? The 2013 survey suggests that the use of locum tenens physicians continues to be common among hospitals, medical groups, and other healthcare facilities. About 74 percent of healthcare facility managers surveyed indicated that their facilities had used locum tenens physicians to supplement their existing medical staffs sometime during the last 12 months, about the same as last year and similar to three of the past four years. THE EMPLOYED PHYSICIAN MODEL Healthcare organizations use locum tenens physicians for a variety of reasons. The most common reason for using locum tenens physicians, cited by 58 percent of survey respondents, is to fill in for staff who have left, up from just 22 percent in 2009. This finding reflects a larger trend taking place in healthcare today a shift from the traditional independent physician practice model to the employed physician model (a trend also referenced in Part II of this report). As independent practice owners, physicians typically have a deep financial and emotional stake in their practices. Under the independent practice model, physician turnover was rare as doctors were unwilling or unable to leave what were essentially their small businesses. As hospital and large medical group employees, however, physicians have become more like other employed professionals, and have more mobility in their careers. Below are physician relocation rates in various specialties as tracked by data firm SKA: Of those who used locum tenens physicians in the last 12 months, the plurality (35 percent) were seeking primary care physicians (family physicians, general internists, pediatricians), followed by behavioral health practitioners (31 percent), hospitalists (19 percent) and surgeons (12 percent). Ten percent of those surveyed were seeking physician assistants or nurse practitioners. Because healthcare facilities frequently use locum tenens physicians to maintain services while seeking hard-to-find permanent candidates, the use of locum tenens doctors reflects which specialty areas are experiencing the most acute shortages. The 2013 survey suggests provider shortages are particularly acute in primary care, behavioral health, inpatient medicine and surgery. A broader discussion of locum tenens and physician supply and demand is included in Part III of this report. The majority of healthcare facility administrators (56 percent) indicated they use at least one locum tenens physicians in a typical month, while 11 percent use four or more. Use of locum tenens physicians is measured in temporary physician days. A small medical group might use one locum tenens physician for one day during a month to cover for a doctor out on continuing medical education (CME), while a hospital might use three locum tenens physicians over a period of three months for a total of 180 days to cover for one physician on disability and to maintain services while seeking to fill two permanent positions. The majority of those surveyed (63 percent) book five or fewer locum tenens physician days during the course of a typical month. These are either smaller facilities with stable staffs, or larger facilities that have been successful in recruiting and retention and have few gaps and little physician turnover. The remaining 37 of survey respondents indicated their facilities book six or more temporary physician days during a typical month. These may be facilities in traditionally underserved rural or inner city areas that have difficulty finding doctors, or larger facilities that experience turnover, have multiple gaps in their staffs due to vacations, CME, illness and related reasons. The majority of those surveyed (70 percent) responded that finding locum tenens physicians is no more or less difficult today than it was 12 months ago. Sixteen percent said that finding locum tenens physicians is less difficult today than it was 12 months ago, compared to 14 percent who indicated finding locum tenens physicians is more difficult today than it was 12 months ago. Some facilities may find locum tenens physicians easier to staff because locum tenens candidates may be more abundant in their areas than they were in the past. Due to a variety of factors referenced in Part II of this report, a growing number of physicians are electing to work locum tenens, making it potentially easier for some facilities to find the locum tenens physicians they need. For the majority of survey respondents, however, finding locum tenens physicians is either more difficult than it has been in the past or just as difficult. Annual physician relocation/turnover As the employed model becomes more pervasive, hospitals, medical groups and other facilities will need to put renewed emphasis on physician retention strategies to ensure medical staff stability. Locum tenens can be incorporated into this process in two ways. One, long hours and overwork can be a key cause of physician burnout and turnover. Locum tenens physicians can be used to alleviate the pressure on permanent staff, filling in during peak usage periods and allowing permanent staff members to take vacations, CME and other personal time. Two, locum tenens physicians can be used to maintain services and patient base in those cases where physician turnover cannot be avoided. This may make it easier to attract new candidates who will not be faced with building an entirely new patient base when they locate to a new practice. THE PHYSICIAN SHORTAGE Survey respondents indicated their second most common reason for using locum tenens physicians is to maintain services until a permanent doctor is found. This response reflects another growing trend in healthcare -- the national physician shortage. Historically, locum tenens doctors have been used to hold a place for ill, vacationing or otherwise absent doctors pending their return. Today, national doctor shortages have prompted hospitals, medical groups and others to use temporary doctors to maintain services in lieu of permanent doctors, who may be difficult to find. 16 17 Psychiatrist Family Medicine Internal Medicine General Surgery Obstetrics/Gynecology Orthopedic Surgery 1 1 1 9% Source: SKA Physician Move Rates, April, 2011

THE IMPORTANCE OF LIFESTYLE Many physicians today are interested in a controllable lifestyle and seek vacation time and other time off when evaluating employment opportunities. This has led to a significant reduction in the overall physician workforce as measured by full time equivalents (FTEs) as physicians work fewer hours than they have in the past (see chart below). Hours worked per week by physicians 1977 1997 1996 2008 55 51 Equals 36,000 fewer physician FTEs Source: Journal of the American Medical Association as cited in HealthLeaders, February 25, 2010 Changes in physician practice styles have contributed to the increased use of locum tenens doctors. Though filling in for vacationing or otherwise absent physicians no longer is the primary reason facilities use locum tenens physicians, it is still a leading reason they do so. Thirty-six percent of those surveyed indicated they use locum tenens physicians to fill in for doctors who are out on vacation, illness or for other reasons. HEALTH REFORM AND FLEXIBLE STAFFING Health reform and various market changes that come with it are changing virtually all aspects of healthcare delivery, including locum tenens staffing. New delivery models such as Accountable Care Organizations (ACOs) are putting a premium on delivery of care within defined budgets while meeting specific quality parameters. Staffing is an important part of this equation, as the right number and kind of healthcare professionals can be crucial to reducing medical errors and hospital readmissions, for which many hospitals and other providers may be at financial risk, as well as to achieving quality goals. For the first time, healthcare administrators were asked if they are using locum tenens physicians to ensure quality-based reimbursement. About 1 percent indicated that they are. Though this is a small number, the rationale for using locum tenens physicians for this reason is still relatively new. A small number of respondents (less than one percent) said they use locum tenens physicians to reduce readmissions and medical errors. Though not now prevalent reasons for using locum tenens, more facilities may turn to locum tenens physicians in the future to address emerging payment and quality issues. The era of health reform brings with it various pressures on provider reimbursement through cuts or changes to Medicare and other forms of payment. It is increasingly important for hospitals and other facilities to manage their resources, including those devoted to staffing. Through the use of locum tenens physicians, health facilities can right staff, quickly adding clinicians when needed during peak periods and down-staffing when appropriate. Seven percent of survey respondents indicated they use locum tenens physicians to upsize or downsize as needed. THE BENEFITS OF USING LOCUM TENENS The main benefit of using locum tenens physicians, cited by 64 percent of those surveyed, is to maintain continuity of patient care. When full-time physicians are absent for any reason, patients may not be able to access the care they need, or they may migrate to other sites of service. Locum tenens physicians allow healthcare facilities to maintain the continuity of care that is important to both quality outcomes and to patient satisfaction and loyalty. By seeing patients who might otherwise have gone elsewhere, locum tenens physicians also allow medical facilities to maintain revenue streams. The opportunity cost of not having a physician in place can be considerable. According to a study by physician search firm Merritt Hawkins (like Staff Care, a company of AMN Healthcare), physicians on average generate $1.5 million a year on behalf of their affiliated hospitals. The chart below indicates how this breaks out on a pro rated monthly basis for several medical specialties: Revenue generated by physicians for hospitals pro rated over one month Orthopedic Surgery General Surgery Internal Medicine Family Practice Psychiatry $176,480 $176,041 $139,862 $138,569 $107,509 Source: Merritt Hawkins 2010 Survey of Physician Inpatient/Outpatient Revenue New delivery models rely on robust information technology systems to be effective, and many hospitals, medical groups and other facilities are implementing or enhancing their electronic medical record (EMR) capability. There can be considerable physician downtime as this transition takes place, as it can take weeks of training for physicians to acclimate to new systems. About four percent of those surveyed indicated they are using locum tenens physicians to maintain services while their staffs complete EMR training. Thirty-eight percent of those surveyed said that preventing revenue loss was a benefit of using locum tenens physicians, while 31 percent identified the immediate availability of locum tenens physicians as a benefit. As referenced above, using locum tenens physicians also can be part of a physician retention strategy, helping to prevent the burn-out of existing staff. Thirty-one percent of administrators surveyed indentified preventing staff burn-out as one of the benefits of using locum tenens physicians. 18 19

HOW ARE LOCUM TENENS PHYSICIANS PERCEIVED? Healthcare facility managers were asked to rate the general skill level of locum tenens physicians. The majority (65 percent) rated locum tenens physicians skills as either good or excellent, up from 57 percent in 2011, while 34 percent rated the skill level of locum tenens physicians as adequate. Only 1 percent of administrators rated the skill level of locum tenens physicians as unsatisfactory. When locum tenens physicians first came into wide use, the quality of these physicians sometimes was questioned. Today, locum tenens practice has become more widely accepted by health care facilities, and physicians practicing locum tenens are rigorously screened, in part because staffing firms are at risk for their malpractice insurance. The 2013 survey suggests that the quality of locum of tenens physicians is generally considered to be high or at least satisfactory. Healthcare facility managers also were asked to indicate how locum tenens physicians are viewed by various parties, including permanent physicians on their staffs, administrators, and patients. The majority (63 percent) said that locum tenens physicians are accepted by permanent staff physicians, 69 percent said they were accepted by administrators and 64 percent said they were accepted by patients. If not accepted by peers, administrators and patients, locum tenens physicians are at worst tolerated by these groups. 2 percent of survey respondents indicated that locum tenens physicians are not accepted by fellow physicians, administrators or patients. TELEMEDICINE USED TO EXTEND SERVICES For the first time, healthcare facility administrators were asked in the 2013 survey if they have integrated telemedicine into any of their departments. As a response to physician shortages, or because they may not be able to support full-time physicians in certain specialties, some facilities are using telemedicine to extend the types of services they provide. While the majority of those surveyed (57 percent) have not integrated telemedicine into any department, a substantial minority (42.9 percent) have done so. Of those that have, 42 percent use telemedicine for radiology services, allowing radiologists from other locations within the area, state, nation or even internationally to read imaging studies. Thirty-eight percent use telemedicine for behavioral health, allowing psychiatrists, psychologists and other behavioral health professionals to remotely diagnosis and counsel patients. An additional 24.1 percent use telemedicine to provide primary care services. Healthcare facility managers were asked to rate the general skill level of locum tenens physicians. The majority (65 percent) rated locum tenens physicians skills as either good or excellent, up from 57 percent in 2011 In comparing locum tenens physicians to permanent physicians on their staffs, 61 percent of healthcare facility managers said that locum tenens physicians treat the same or a greater number of patients per day than do permanent physicians, while 39 percent said they see fewer patients per day than permanent physicians. Fifty-nine percent of those surveyed said locum tenens physicians generate the same or greater gross charges per day than do permanent physicians, while the remaining 41 percent indicated locum tenens physicians generate fewer gross charges per day than permanent physicians. Locum tenens physicians may generate more charges though they see fewer patients than permanent physicians by handling generally more complex or urgent cases. Some patients may choose to delay a physician appointment for a minor problem until the permanent physician returns, but will see a locum tenens physician if their problems are serious and require immediate attention. In addition, many facilities are unsure of how to bill for the services of locum tenens physicians or for the down-stream revenue they generate. In 2011, Staff Care introduced a new service to assist facilities in this process, which may allow the locum tenens physicians they use to more closely approximate the charges billed by their permanent staff. MANAGED SERVICES PROVIDERS The locum tenens staffing process at some healthcare facilities is becoming increasingly complex. Coordinating the schedules of multiple locum tenens providers staffed by multiple temporary staffing firms can create logistical and billing challenges. In response, healthcare facilities may elect to outsource the entire locum tenens function to a managed services provider, which will oversee all locum tenens staffing issues, including scheduling, recruiting, logistics, and billing. Healthcare facility administrators were asked for the first time in 2013 about their position on companies that provide management of multiple locum tenens staffing services. Eleven percent said they are currently using such a company or are considering doing so. However, the majority (57 percent) are not familiar with this relatively new service concept. WORTH THE COST? Healthcare facilities pay a daily rate for the services of locum tenens physicians, a rate that can range from several hundred dollars to over $1,500, depending on the specialty. Balanced against this are the various benefits locum tenens doctors provide, including the ability to maintain both medical services and revenue. On balance, the great majority of healthcare facility managers surveyed (85 percent) indicated that locum tenens physicians are worth the cost, up from 79 percent last year. 20 21

PART TWO KEY FINDINGS OF PART II INCLUDE: The majority of locum tenens physicians are experienced practitioners. Over 88 percent have been in medical practice for 11 years or more, while 6.2 percent have been in medical practice for five years or less. Eighty-two percent of physicians surveyed said they find working locum tenens to be as satisfying or more satisfying than traditional, permanent practice. Flexibility and political neutrality are the main attractions of locum tenens. Physicians ranked freedom and flexibility as the primary benefit of working locum tenens, followed by no politics. Location is what attracts physicians to particular assignments. Physicians ranked location as their number one consideration in selecting a temporary assignment, followed by length of opportunity and pay. Most locum tenens physicians begin practicing on a locum tenens basis before retiring from permanent practice. Sixty-three percent of survey respondents began working locum tenens either in mid-career or right after residency. SURVEY OF PHYSICIANS AND ADVANCED PRACTITIONERS WORKING ON A LOCUM TENENS BASIS Number of Providers Surveyed = 981 While 14 percent of physicians said they plan to work locum tenens for less than one year, 38 percent said they plan to work locum tenens for six or more years. The majority of locum tenens physicians work three or fewer assignments each year. Seventy-one percent of physicians work only a handful of temporary assignments each year (between one and three), while 10 percent work seven or more. KEY FINDINGS In a survey of some 14,000 physicians Merritt Hawkins conducted for The Physicians Foundation (www. physiciansfoundation.org), over half of doctors indicated that they plan to make a significant change in their practices over the next one to three years. Over 20 percent said they would cut back on hours worked, over 13 percent indicated they would retire, 10 percent said they would find a non-clinical job, and over 6 percent said they would work locum tenens. Should over 6 percent of the nation s 750,000 active physicians turn to locum tenens in the next three years, over 48,000 doctors would be added to the ranks of those working on a temporary basis. Why are a growing number of physicians choosing to practice locum tenens? What are some of the characteristics of locum tenens physicians, and to what extent do these physicians feel they are accepted by colleagues and patients? What is their ideal assignment length, how far are they willing to travel, and how do they compare locum tenens practice to permanent practice? Part II of Staff Care s 2013 Survey of Temporary Physician Staffing Trends, completed by physicians, physician assistants and nurse practitioners who work on a locum tenens basis, examines these and related questions. For the purposes of this report, all respondents will be referred to as physicians, though it is understood this group includes some physician assistants and nurse practitioners. Locum tenens physicians are accepted by their peers and patients. Ninety percent of physicians said they are accepted by colleagues and 96 percent by patients while on temporary assignments, while 86 percent said they are accepted by administrators. Physicians tend to work through more than one staffing company. Sixty percent of physicians surveyed said they work with two or more staffing companies, while 11 percent said they work on their own. Patient care is not the only value. While physicians indentified maintaining patient care as the primary value they bring to assignments, other values also were cited, such as maintaining services during a transition to an employed physician model, generating revnue and assisting with EMR transition. The majority of physicians surveyed (53 percent) said they are only willing to travel regionally to a locum tenens assignment. The remaining 47 percent, however, said they would travel nationwide. Longer is better. Most physicians surveyed (61 percent) indicated their ideal locum tenens assignment length is at least one month or more. Thirty-nine percent prefer shorter assignments of one month or less. 22 23

QUESTIONS ASKED AND RESPONSES RECEIVED An analysis of these and other findings of Part II of the survey follows survey results below. Responses from previous years survey were included where applicable. 3 How many years have you been in practice? 1 What is your specialty? Less than one year 1 to 5 years Primary care (Internal medicine, family medicine, pediatrics) Behavioral health (psychiatry, psychology) Anesthesiology 1 1 6 to 10 years 11 to 20 years 21 or more years 6 Surgery Internal medicine sub-specialties Radiology 4 How long have you worked locum tenens? Nurse practitioner Physician assistant Emergency medicine Hospitalist Oncology Less than one year 1 to 5 years 6 to 10 years 3 3 1 11 or more years 1 2 What is your age? 5 How long do you intend to work locum tenens? 30 or younger 31 to 40 41 to 50 51 to 60 61 to 70 1 3 2 Less than one year 1 to 5 years 6 to 10 years 1 4 2 71 plus 1 11 or more years 24 25 1

6 At what stage of your career did you first work as a locum tenens? 9 If yes, how would you rate working as a locum tenens versus working in a permanent position? Right after residency Mid-career After retiring from permanent practice 1 49% 3 Locum tenens is MORE satisfying Locum tenens is LESS satisfying Both types are EQUALLY satisfying 1 1 19% 1 19% 1 6 19% 6 6 2 6 1 6 7 About how many locum tenens assignments do you work during a year? 1-3 7 5 6 5 60% 4-6 19% 2 19% 2 2 7 or more 1 1 10 Are you currently in a permanent position? 8 Have you ever worked in a permanent position? Yes 39% No 6 Yes 9 No Yes 90% 2012 2010 2011 2009 Yes 9 No Yes 9 11 Yes 2 Are you currently looking for a permanent position? No No No 7 26 27

12 What are the benefits/drawbacks of working as a locum tenens? (check all that apply) Benefits Freedom/flexibility No politics Travel Pay rate Professional development A way to find perm Drawbacks Away from home Uncertainty of assignment Lack of benefits Quality of assignment Pay rate 8 8 8 3 79% 4 4 4 2 50% 4 3 2 1 4 4 1 2 19% 1 1 9% 4 4 4 2 19% 6 6 6 3 6 60% 5 30% 2 5 5 2 0% 59% 4 2 0% 2 1 5 3 1 1 14 15 How do you select a firm? (check all that apply) Location of opportunities Customer service Pay rate Reputation/name recognition Number of opportunities Malpractice insurance Other 6 6 6 6 5 4 3 4 3 6 4 4 4 2 0% 60% 4 3 4 2 0% 2 1 1 1 How do you select temporary opportunities? (check all that apply) 5 50% 3 3 2 1 13 None 1 2-3 4 or more With how many locum tenens agencies do you work? 1 1 9% 1 29% 4 3 4 19% 2 49% 1 2 5 1 3 4 28 29 Location Length of opportunity Pay Patient load Type/size of facility Available shifts Quality of equipment 8 89% 8 2 2 6 60% 3 30% 2 7 6 29% 2 3 1 69% 6 3 3 29% 29% 1 29% 1

16 What value do you bring to a hiring facility? (check all that apply) 19 As a locum tenens provider, how are you viewed by: Maintain patient care 2012 2011 8 9 Prevent staff burn-out Generate revenue 4 5 4 6 90% 2012 Colleagues 8 2011 Colleagues Add a specific skill 3 4 Assist with EMR transition* 1 Reduce medical errors/readmissions* Maintain services during transition to physician employed Provide support during high-volume periods 2 40% 5 *Question asked for the first time in 2013 9% Accepted Tolerated Not accepted 1 Accepted Tolerated Not accepted 17 How far are you willing to travel? 9 2012 Patients 9 2011 Patients 4 Nationwide 2 Specific region only 1 Home region only Home state only < Accepted Tolerated Not accepted 0% Accepted Tolerated Not accepted 18 What is your ideal assignment length? 39% 39% 8 2012 Administration 7 2011 Administration Less than one month 1 to 4 months 5 to 8 months 1 9 to 12 months Accepted Tolerated Not accepted Accepted Tolerated Not accepted 30 31 2 0%

TRENDS AND OBSERVATIONS 9 2010 Colleagues Accepted Tolerated Not accepted 8 2009 Colleagues Accepted Tolerated Not accepted Part II of Staff Care s 2013 Survey of Temporary Physician Staffing Trends offers insights into the characteristics of locum tenens physicians, nurse practitioners and physician assistants -- what attracts them to locum tenens practice, their temporary assignment preferences, and how they are viewed by peers, administrators and patients. As referenced above, this report references physicians but also includes nurse practitioners and physician assistants. WHO IS WORKING LOCUM TENENS? The survey offers a profile of the characteristics of physicians who choose to work as locum tenens. The majority of these physicians are over 50 years of age and have multiple years of medical practice experience. Seventy-seven percent of survey respondents are 51 years old or older. Over Seventeen percent are 71 years old or older. Historically, the ranks of locum tenens physicians have been composed of older physicians who have either retired from permanent practice or are looking to slow down and semi-retire. These are seasoned physicians, 88 percent of whom have 11 or more years of medical practice experience. However, some younger physicians also are attracted to locum tenens practices. Seven percent of survey respondents are 40 or younger and 6 percent have five or fewer years of medical practice experience. Younger physicians often embrace locum tenens practice as a way to test drive various practice opportunities to discover which types of practices and which geographic settings suit them best. 7 2010 Patients 9 2009 Patients Physicians were asked at what stage of their careers they first worked as locum tenens. Thirtyseven percent of respondents waited until after retirement before working their first locum tenens assignment, while 49 percent first worked locum tenens while in mid-career. However, about one in seven locum tenens physicians (14 percent) first began working locum tenens right after residency, indicating that residents now are aware of the locum tenens practice option. 2 Accepted Tolerated Not accepted Accepted Tolerated Not accepted The survey suggests the ranks of locum tenens physicians are being increased by physicians who are relatively new to this practice style. About 32 percent of respondents said they have been working as locum tenens for six years or more. However, the remaining 68 percent have been working locum tenens for five years or less, while about one-third (31 percent) have been working locum tenens for less than a year. 8 2010 Administration 1 Accepted Tolerated Not accepted 8 2009 Administration 1 Accepted Tolerated Not accepted For the majority of respondents, locum tenens is a short to mid-term career option. Over 62 percent of physicians surveyed indicated they intend to work locum tenens for five years or less, and of this group 14.3 percent said they intend to work locum tenens for less than one year. This is the same percentage who indicated they started working locum tenens right after residency, suggesting that residents view locum tenens as a short-term transition to a longer-term practice setting. The survey indicates that the majority of locum tenens physicians (62 percent) are not currently in permanent practice, though close to 40 percent currently are in full-time positions. While most locum tenens physicians are only working on a temporary basis, a significant minority are in permanent practice, but moonlight as locum tenens physicians during vacations, weekends, holidays or other down time. The survey suggests that most locum tenens physicians (74 percent) are not pursuing permanent positions. However, about one-quarter (26 percent) are seeking permanent practices and may be working locum tenens as a means to that end. 32 33

Physicians from many different specialties work as locum tenens. While primary care physicians make up the plurality of locum tenens doctors, surgical and diagnostic specialists, emergency physicians, hospital-based physicians, anesthesiologists, and internal medicine subspecialists all work as locum tenens. WHY WORK LOCUM TENENS? As these survey responses indicate, many physicians have negative feelings about the current state of the medical profession and are pessimistic about the future. In response to this dissatisfaction, a growing number of physicians are seeking alternatives to traditional styles of medical practice. To determine how physicians are reacting to current practice dynamics, The Physicians Foundation asked doctors about their future practice plans: In The Physicians Foundation Survey referenced above, many of the 14,000 physician respondents indicated they feel a significant level of dissatisfaction with the current medical practice environment. Consider these responses to several survey questions: Which best describes your feelings about the current state of the medical profession? Very or somewhat positive Very or somewhat negative 3 6 Which best describes how you feel about the future of the medical profession? Very or somewhat optimistic Very or somewhat pessimistic 2 7 Consider your practice plans over the next three years. Do you plan to (check all that apply). Continue practicing as I am 50% How would you describe the professional morale of physicians you know? Cut back on hours Retire Relocate to another practice/community 2 1 Very or somewhat positive Seek a non-clinical job within healthcare Very or somewhat negative 80% Cut back on patients seen Work part-time (20 hours a week or less) Do you believe that the medical profession is in decline? Switch to a cash or concierge practice Work locum tenens Yes No 8 1 Source: The Physicians Foundation. 2012 Survey of America s Physicians: Practice Patterns and Perspectives (www.physiciansfoundation.org). Survey conducted for The Physicians Foundation by Merritt Hawkins. Seek a job/business unrelated to healthcare Seek employment with a hospital 34 35 Other Close my practice to new patients

In addition to pursuing options such as retirement, concierge practice, or hospital employment, 6.4 percent of physicians said they plan to work locum tenens. The move toward locum tenens and other practice alternatives may be a response to the aspects of medical practice that physicians find the most unsatisfying. In The Physicians Foundation survey, doctors ranked the factors they find least satisfying about the practice of medicine: What factors do you find least satisfying about medical practice? through relative value units (RVUs) or other metrics. As they are not employers, locum tenens physicians do not have to be as concerned about the many Medicare and employment-related regulations governing the workplace as do private practice doctors. Locum tenens physicians choose when and where they want to practice and whether or not they wish to work overtime while on assignments. They can create and manage their own schedules, significantly reducing concerns about the long hours and lack of personal time endemic to traditional practice. POLITICAL NEUTRALITY 1 2 3 4 5 6 7 Liability/defensive medicine pressures Dealing with Medicare/Medicaid regulations Reimbursement issues Long hours/lack of personal time Uncertainty/changes of health reform Non-clinical paperwork EMR implementation In addition, traditional medical practice is fraught with politics, as physicians must work within an often turbulent system featuring multiple stakeholders with conflicting priorities, including fellow physicians, hospital or group administrators, board members, and others. This volatile situation is exacerbated by healthcare reform, which is causing considerable upheaval in the medical marketplace through hospital and group practice mergers and the formation of new delivery models such as Accountable Care Organizations (ACOs). Medical politics and healthcare reform are less of a factor in locum tenens practice, as physicians working temporary assignments are removed from the turf battles, realignment and other sources of conflict that may arise at any particular site. Forty-seven percent of physicians surveyed said that lack of medical politics is a benefit of working locum tenens, the second highest rated benefit next to freedom and flexibility. TRAVEL AND PAY 8 9 10 Lack of clinical autonomy Managed care Pressure of running a practice A FAVORABLE ALTERNATIVE In virtually every instance, locum tenens practice eliminates or reduces the impact of those factors that cause physicians the most professional dissatisfaction, Staff Care s survey suggests. FREEDOM AND FLEXIBILITY When asked to identify the primary benefits of working locum tenens, 81 percent of respondents cited freedom and flexibility. Unlike traditional practice, in which physicians must both handle their clinical duties and assume the responsibilities of managing a business, locum tenens features a minimum of reimbursement or administrative-related paperwork and other so-called hassle factors that erode physician satisfaction. Travel was rated as a benefit by 46 percent of doctors surveyed, suggesting that physicians do not choose locum tenens primarily as a form of tourism. Freedom/flexibility is the main draw of locum tenens, though travel is one of its attractions. Forty-six percent of physicians identified pay as a benefit of working locum tenens, the fourth highest rated benefit cited. Locum tenens doctors may earn anywhere from a few hundred dollars a day to over one thousand dollars a day, depending on their specialty and hours worked. Physicians working locum tenens full-time who are willing to put in some overtime hours can earn approximately what a permanent physician earns. For many locum tenens physicians, however, money is secondary to a favorable work environment. PROFESSIONAL DEVELOPMENT AND PERMANENT PRACTICE Locum tenens work allows physicians to experience a wide range of practice environments with varying standards of care. It offers a positive forum for acquiring professional skills and is something of a medical education for many doctors, a fact reflected in the survey. Twenty-three percent of physicians cited professional development as one of the benefits of working locum tenens. Locum tenens physicians are paid a daily rate by staffing companies and do not have to bill myriad thirdparty payers and then fight to ensure that bills are paid, so reimbursement is not an issue. Malpractice, the leading cause of physician dissatisfaction cited by physicians in The Physicians Foundation survey, also is not an issue because malpractice insurance is provided to locum tenens physicians by the staffing agencies through which they work. Locum tenens physicians can spend time with patients as they see fit, as they are not tied to production formulas that require them to see many patients or hit stipulated work targets An additional attraction of locum tenens, cited by 20 percent of physicians, is that it offers a way to test drive different practice opportunities in an effort to find a permanent position. Working locum tenens assignments for weeks or more at a time allows physicians to get a true sense of what the practice is like. It also allows hospital or medical group personnel to see how well they mesh with the physician. At the end of the assignment it is not unusual for both parties to see it is a good match and for the physician to place on a permanent basis. 36 37