Utilizing Locum Tenens: The Challenges of TEMPORARY Provider RECRUITMENT

1. Utilizing Locum Tenens: The Challenges of TEMPORARY Provider RECRUITMENT Don O’Bryan obryandr@msha.com

3. MSHA • 14 Hospitals, private, not-for-profit health system • 9 hospitals in Tennessee, 5 hospitals in Virginia • 29-county service area, 1.2 million people • 1,623 licensed beds • 1,050 medical staff members • 250+ employed physicians • 12,000 team members (including volunteers) • 229,484 Emergency Department visits per year • 61,000 Admissions per year • Strong Patient-Centered Care philosophy • New system CEO last January

4. Survey • How many of you are responsible for locums coverage? • How many of you have actually filled a temporary coverage situation through a locums firm? • How many of you love that part of your job?

5. 2014 Staff care Survey says….. • 90% of hospitals used locums in 2013 (up 16.4% from 2012) • Top specialists used 1. Primary Care 2. Behavioral Health 3. Hospitalist 4. Emergency Medicine 5. Surgery 6. ??????

6. Number of Firms providing locums services is …….

7. CAPS 2013 • I listened to the locum tenens presentation last year • There were times during the presentation when I found my blood pressure rising • I realized it was because our current locums process needed some serious attention • No one in the organization wanted to own this • This presentation is a continuation of last year’s presentation from the hospital’s point of view

8. Definition Locum, short for the Latin phrase locum tenens (lit. "place holder"), is a person who temporarily fulfills the duties of another. For example, a locum doctor is a doctor who works in the place of the regular doctor when that doctor is absent, or when a hospital/practice is short-staffed. *Wikipedia

9. Common Reasons for the use of locums There are lots of good reasons to hire a locum physician • To fill in for an absent staff member (who may be ill, on vacation, on sabbatical or maternity leave) • To cover while staff physicians attend CME courses • To supplement permanent staff during busy times • To staff new positions or facilities while physicians are recruited * Locum Tenens.com

10. Benefits of using locums • Maintain patient base and revenues while providing continuity of care. • Due to independent contractor status, no administrative costs related to physician payroll, taxes or benefits. • Malpractice insurance provided. • Opportunity to observe a permanent candidate before offering a long-term commitment. • Assist retention of overworked staff. *Linde Healthcare.com

11. Why would a provider want to do locums • The flexibility to practice medicine on a part-time basis • The flexibility to be free from administrative hassles and focus on patient care • The ability to have more control over a work schedule • The ability to earn overhead-free income • The opportunity to experience different practice settings • The opportunity for tax advantages • Travel! • Treated like royalty. *Weatherby.com

12. MSHA Case Study

13. Evaluation of MSHA’s use of Locums (Internal Evaluation) • I realized I didn’t know enough about locums in general • Higher utilization of locums across the system than anticipated • Paid major $$$ for temporary coverage • We were not adequately budgeting for locums • MSHA entities had numerous individual contracts with various firms (one firm had six different contracts with MSHA) • There were many individuals at multiple layers of our operations dealing with locums firms • There was no effort to clear names and pre-qualify candidates

14. other info • The amount of internal manpower and time needed to process a provider was alarming. • Permanent provider staffing at rural facilities is very tight. Loss of a provider would automatically result in ordering a locums provider verses seeking alternative staffing solutions • There was no effort to reduce the cost related to locums provider assignments • Plenty of room for improvement

15. Who’s interacting with firms? • Physician Relations / Liaisons • Practice Managers • Regional Directors • Executive Assistants • Administrative Assistants • Chief Medical Officers • Medical Directors • Hospital CEOs • Physician Recruiters (in a low % of cases)

16. The situation required focus

17. Summary of the Problems associated with locums • Cost • Usually an immediate coverage threat • Contractual challenges • Quality of some locums providers • Matching provider’s availability to the need • Lack of standardization between firms • Internal manpower needed to deal with all phases of the locums process • Coordinating between locums and permanent solutions • A lot of “reverse marketing” from the firms

18. Organizing for the Use of Locums • Develop internal policies and procedures specific to temporary coverage situations • Make the policies and procedures easily accessible to those who need it • Determine standard locums firm contract language • Get to know the firms and their structure • Create a way for internal coverage requests to be made in writing. • Be prepared to database every candidate • Verify and document everything.

19. GET TO KNOW NALTO National Association of Locum Tenens Organizations (407) 774-7880 www.nalto.org

20. NalTOCode of Ethics The ethical principles established by NALTO for the physician locum tenens industry are designed to maximize the relationships between physicians, clients, and locum tenens companies through honesty, professionalism, and integrity. All NALTO company members and the physicians they represent are held to the ethical standards. You can download the full Code of Ethics on their web site.

21. NALto (cont.) Relationships between locum tenens companies, clients, and physicians are based heavily on negotiated contractual agreements and professional business practices. A NALTO company member will reasonably fulfill all agreements made with both clients and physicians and will also strive to preserve all confidences on information concerning business practices. Similarly, a NALTO locum tenens company will strive to protect the integrity of their relationships with physicians by completely disclosing information relevant to the physician, requesting permission before distributing a CV, and striving to maintain strong relationships with a large network of clients.

22. MSHA Temporary Provider Staffing (Internal Process) • Designate one person to coordinate all internal requests for locums • This person would also serve as the point person for locums company reps • Developed a form for requesting a locums and made it available on our intranet department site • Collect all information relative to a locums assignment • Verify all information with the requestor and the administrator paying for the locums • Determine possible alternatives to locums

23. Request form • Specialty • Date needed • Approvals • Account number to charge • Physician location • Site manager • Type of coverage required • Skills needed • Orientation details • Providers used in the past • EMR info

24. MSHA Temporary provider Staffing (external process) • Get the contract right • Determine the prequalification standards for candidates who are to be presented for an assignment • Send the completed form and the minimum standards to appropriate locums firm(s) • Clear names before giving ownership of that provider to the firm • Enter info into our provider database

25. Pre-qualification • Assure each physician is carefully matched to meet the criteria and availability requirements • Do not mass-submit names of candidates • Submit the Professional Questionnaire with explanations for ANY "YES" answers • Verify State licensure, CSR, board certifications, CMEs, and employment history (All candidates must be board-certified within five years of completion of residency.  New residents considered on a case-by-case basis) • Two physician references with contact within six months • One physician reference from most recent assignment. • Thorough review of all CVs for gaps and off-cycle school programs • Check for Medicare / Medicaid sanctions, board actions, and loss of privileges • Check criminal and civil history.  Run an NPDB and AMA report on all providers • Provide a complete Contact Sheet to our MSO (includes all education and affiliations) • If private background check information is available, submit it

26. Locum Tenens Firm contracts

27. Contracts: Standardize the info • Choosing the correct entity name • Liability insurance minimums • How you alert a firm of a coverage need • How you want candidates presented from the firm • Length of time to clear a candidate • Confirmations – to sign or not to sign • Travel arrangements for providers • Removal of inappropriate providers • How invoicing is to be done for assignments • Include NALTO language

28. Contracts: Standardize (Cont.) • Ownership of the name (length of time) • Contract buy-out fee (could be reduced based on the use of the provider) • Separate Confirmation / Fee Schedule - Hourly rate - Daily rate - Overtime language - Call - Holidays - Look for other info that may amend the terms of the base agreement

29. Location issues If you’re not in a tourist destination, you may have a more difficult time filling the assignment with a higher quality provider and/or you may have to pay a premium.

30. qualification / Credentialing • Many firms have a credentialing service that is NCQA and/or Joint Commission certified • Regardless, when dealing with firms, develop and communicate your minimum standards for all prospective candidates • Conduct your own background on all candidates presented to protect your political capitol • Designate a physician to conduct an interview (phone, video interview, face-to-face) • Be prepared to assist Medical Staff Services

31. recent candidate example • Firm contacts our trauma department to see if they can use an immediately available provider with an open schedule. The reverse marketing tactic had the practice all excited and ready to secure the surgeon. I asked for the opportunity to pre-qualify the candidate. I found that the surgeon had two major lawsuits - one for a surgery that resulted in death of a patient and one for operating on the wrong body part. Both of these would be considered sentinel events in our medical staff application process.

32. When the provider shows, You might get this

33. Or, When the provider shows, you might get this

34. Orientation • Orientation will likely occur on the first day of the assignment • You are being charged by the firm for the provider’s time during orientation • Develop a fast-track process • Coordinate all aspects of the orientation process

35. Summary - Solutions for locums • Begin a process improvement discussion about locums with your leadership • Develop a plan that’s right for your situation • Designate one person to “own” locums • Develop “preferred” relationships with an appropriate number of reputable firms • Consider one or more of the following: 1. a company that coordinates firm coverage via a vendor communications system 2. a company that provides complete managed services for locums 3. develop your own stable of PRN physicians

36. QUESTIONS