When reductions in Medicare reimbursement finally put the busy urology practice of John R. Stripling, MD, into a negative cash flow situation, he closed up shop after 20 years in Atlanta and began life as a locum tenens—or temporary substitute—physician.

“I just couldn’t make it anymore. The reimbursements got to the point where I couldn’t cover my expenses,” recounts Dr. Stripling, who has been practicing urology for three decades. “Now there’s a 21.3% Medicare cut hanging over our heads, and since about 50% of the patients in most urology practices are Medicare patients, that makes us even more vulnerable than other specialists.”

The burdensome regulatory changes he sees coming also influenced Dr. Stripling’s decision to change his career path.  “I’m just not going to practice if I’m going to be dealing with rules all the time on what I can and can’t order. I choose not to be part of that kind of medical system.”

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After a brief stint with a larger urology group in Florida, Dr. Stripling turned to locum tenens assignments. His first contract brought him to Laurel, Miss., a city of about 11,000. He saw approximately 175 cases in the five months he was there, and declined an invitation to stay on permanently. “I don’t want to go back into a permanent position until the [proposed Medicare cuts and regulatory issues] are settled,” he asserted.

After a mere seven months of locum tenens work, Dr. Stripling has already turned down two additional offers from different clients to remain on-site as a full-timer. He passes on these opportunities in part because he loves the travel involved with locum tenens work and getting to know people in different parts of the country, as well as the lack of financial risk. “I can walk in every day and know I’ll make a certain amount of money and my expenses are covered,” he said.

Dr. Stripling acknowledged, however, that locum tenens life can be fraught with uncertainty—“I could get kicked out in 30 days, at the end of an assignment [that doesn’t get extended or replaced with a new one].” But balancing that is his belief that he is “a topnotch urologist who would be in demand anywhere.” Ultimately, however, “I want to keep my options open until we see what Medicare is going to do,” Dr. Stripling explained.

The offers for full-time employment are not unusual at all, according to Bernadette “Bernie” Cole, vice president/locum tenens at Medical Doctor Associates (MDA), a Cross Country Healthcare, Inc., company (www.mdainc.com). This is the medical staffing firm that placed Dr. Stripling in his latest assignment in Paragoul, Ark. “Three of our locum urologists went permanent already this year,” Cole told Renal & Urology News.

Despite perceptions that locums tenens physicians are only pursuing this type of work because they can’t find a “real” job, permanent employment is not typically the end-game for these providers, as illustrated by the case of nephrologist Margaret King, MD, a career locum tenens physician. “I think locums are filling a really big need, and you have to be a good doctor to be able to do it,” she said. “I’m very proud of my training at University of California, San Francisco, and I know the thinking used to be, ‘Well, if you’re a locum, it probably means you can’t get a job,’ but actually I think it’s quite the opposite, because everywhere you go you have to go through this huge credentialing process.”

Twenty years ago, Dr. King had concluded her residency and fellowship at UCSF, and went to work for a nephrology practice in nearby Sonoma County, Calif., where she still lives. “We didn’t work too well together, so I left that job but I wasn’t sure what I wanted to do.”

She got deep into the process of opening her own practice despite the fact that her heart was just not in it. Her friend—another nephrologist with his own practice—finally posed this question to Dr. King: “What would you do if you won the lottery?”

When Dr. King responded that she would probably buy an Airstream trailer and travel the country, her friend responded, “Well, you don’t need to win the lottery to do that; you can become a locums!”

“Now that plan excited me,” Dr. King recalled. “It has worked out well, and I’m very happy. And I meet a lot of nephrologists and other people in my travels who are very interested in locum work. They say to me, ‘As soon as I get my last kid out of college.’”

Anytime is the right time

Chris Franklin, vice president of the surgery division at LocumTenens.com, explained that there are three basic candidate pools. “One consists of those people who come right out of residency or fellowship and want some time to figure out what they want to do and where they want to do it. The second pool is that of the semi-retired physicians.

Then the third pool, which is really growing, is the doctors who look at shrinking reimbursements and decide, ‘I can make more money, be more fulfilled, and not spend so much time chasing down payments and that sort of thing if I just go and become locums physicians.”

The locum tenens opportunities available for a provider range from short-term to long-term assignments, in locations near and far. For example, New Jersey-based urologist Arthur Crowley, MD, MPH, prefers to take assignments that do not require him to spend the day in the airport. Instead, he is happy to drive to Pennsylvania for a weekend-long job on which he will provide on-call coverage.

At the other end of the spectrum, Dr. King spent the better part of three years working in Hawaii, only coming back home once or twice during that time. She is currently working in Spokane, Washington—her fifth assignment for the same practice since 2001.

“There really is no typical assignment,” Franklin observed. “We could be providing coverage for somebody going on vacation, going to a conference to accrue CME credits, or going on medical leave, or for a practice that needs to fill the gap while trying to hire a permanent physician.”

Because anything can happen on the road whether the assignment is long or short, both Dr. Crowley and Dr. King, who are both currently on jobs for CompHealth (www.CompHealth.com), strongly recommend that locum tenens physicians choose staffing companies with ultra-responsive 24-hour customer-service numbers.

Dr. Crowley learned that lesson when a representative from a different staffing company told him to take responsibility for his own flat tire on a car he had just rented, and Dr. King realized just how valuable her CompHealth rep was to her when, after being chased into a hospital closet by the angry relative of a patient, she called her CompHealth rep for solace and assistance in ending the contract—even though she was on assignment for a different staffing company.)

Vetting process is thorough

Once a provider decides to turn to locums work, he or she can expect to be put through an extensive credentialing process. For example, MDA has an in-house credentials verification organization certified by the National Committee for Quality Assurance (NCQA). “Everything we have access to is checked before we contract with a provider: Everything they list on their CV, their education, their work history, their licenses,” MDA’s Bernie Cole said. “Then our liability carrier looks at everything again.”

A hospital or other client using a locum tenens physician will then examine this information a third time. “So if a doctor has some recent blemishes, it will be apparent from the beginning and he won’t be able to work as a locum tenens,” Cole said.

The physician also benefits from the agencies’ attention to detail. “We lay out everything up front with the provider and the practice so that everybody is aware right out of the gate exactly how things will be structured,” Franklin said. “We do as much due diligence as possible on these assignments to create the best match between the client and the physician.”

Although agreements can vary from placement agency to placement agency, physicians usually can look forward to having all the logistics of a locum assignment handled for them once they have been approved for the job. The arrangement provided by CompHealth is typical of the larger, established agencies: “When you accept an assignment with us, we pay for and arrange all your travel and housing needs,” said Alisa Horton, manager of operations for CompHealth’s locum tenens business. 

“We schedule and book air travel, provide private, fully furnished housing near the worksite, and arrange for a rental car or other local transportation.”

(As Cole of MDA commented, “When you take into account that locum tenens physicians get so much per hour and then have so little overhead because their malpractice, travel, housing, and rental car are paid. The pay is close to comparable to what they’d make on their own.”)

Perhaps even more helpful is the assistance with licensure. Like MDA and LocumTenens.com, “CompHealth coordinates and pays for the physician’s license in each state where [he or she] accepts an assignment,” Horton said. “The physicians benefit from our streamlined process to navigate each state’s rules and requirements and our relationships with state licensing boards.”

Malpractice insurance is also covered by the placement company. Many companies use claims-based policies, but MDA is widely known for offering the more valuable occurrence form professional liability insurance, which covers the physician for anything he or she does while interacting with patients on a given assignment, regardless of how long it takes for a suit to be brought. In contrast, a company can cover a claims-made policy as long as the company is in business, and if it goes out of business, might purchase a tail policy to cover past events that evolve into a malpractice claim.

“A patient-care interaction in Colorado in 2006 can be part of a suit in 2016,” explained locum tenens nephrologist Miriam Weiss, MD. “I basically sought out MDA because they have an occurrence malpractice policy, and that just made me feel more secure. When you step in as a locum doctor, differences in style may lead to misunderstandings, because patients are attached to their usual doctor, and may feel especially vulnerable when they see a new face.”

To avoid such problems, Dr. Weiss makes it clear to the patients from the start that she is a temp, acts as warmly and professionally as possible, and, in her words, goes “above and beyond the call of duty in communicating with colleagues what’s going on.”

Dr. Weiss turned to locum tenens work after retiring in 2005 from Case Western Reserve University, where she was a professor of medicine and had a lab for the study of diabetic kidney disease. She then got her master’s in bioethics (while also doing locum work) and is now taking advantage of the flexible locum lifestyle so she can spend as much time as possible working on her current “medical anthropology” project, which employs narrative medicine to explore the stories of living-donor kidney-transplant patients. (Dr. Weiss refuses to use her locum patients for her research project.

“The study I’m doing is not connected to my locum work,” she remarked. “My role as a locum doctor is to do the best job I can to substitute for the physician I’m covering. ”)