Most hospitals have slim margins, and budgets are set based on anticipated average patient reimbursement at Medicare rates. Some private insurers pay higher rates than Medicare, and the differential is often used to offset the cost of treating Medicaid patients. Medicaid reimburses at about half what Medicare pays, which is usually not enough to break even. Out of financial necessity, Medicaid patients are often given limited access to care and services. This is done in some subtle and some not-so-subtle ways. In a recent conversation with an orthopedist friend of mine, he confided in me candidly:
“Some of my colleagues in private practice can’t pay their office overhead if they treat Medicaid patients. So we see poor people with severely arthritic joints left in pain at home. In addition, with bundled payments, the surgeon gets a fixed amount for the patient’s operation and recovery. What incentive is there to send the patient to a rehab facility? It just takes money away from the surgeon. So the poor have to suffer with very long wait times to see someone who will operate on them, and then afterwards they’re on their own for recovery. Patients who go straight home are at higher risk of falling and may have much poorer outcomes. Surgeons get financial incentives for good outcomes, so it becomes a double disincentive to treat Medicaid patients. You don’t get enough for the operation, and you’re likely to get penalized for their poorer outcomes. Some surgeons I know wont touch a patient with Medicaid for any elective procedure. I have ethical problems with that – so I work at a non-profit hospital where we treat everyone. But I have to do higher volume to break even. I work 90 hours a week and barely see my family. I don’t know how much longer I can do it.”
It is common practice among nursing homes to have a limited number of “Medicaid beds.” The facility simply declines to admit more than 20% of patients with Medicaid. I hear case managers on the phone all day long, looking for a post-acute care facility who will accept a Medicaid patient. For the few non-profit facilities who don’t turn them away, deep financial costs are incurred as they struggle for survival.
The reality is that Medicaid rates are so low that having this insurance is not much better than none at all. As I’ve explained previously in the outpatient world (see an example of an insanely low Medicaid reimbursement for eye care), Medicaid is tantamount to charity care. The news that 21.3 million Americans might receive Medicaid coverage in the next decade should not be hailed as a leap forward. As I see it, that’s just a larger group of people with debilitating arthritis who can’t get hip and knee replacements and are left to suffer in pain at home.
*This post was initially published on the Barton Blog.
I have been working locum tenens assignments for over five years, and I’m enjoying it even more now than I did in the beginning. This is probably because experience has taught me how to handle the variety of challenges and unknowns that are a part of the job. Excelling in these environments leads to more assignment opportunities, meaningful professional relationships, and repeat business. If you’re interested in honing your locums skills, here’s how to do it:
1. Be prepared
Before traveling to your assignment, prepare a clipboard that will contain all the key information you will need while on assignment. This should include:
- Your state license number, DEA number, and NPI number
- Your login and passwords (you may receive them in advance or on day one of your assignment).
- Common CPT and ICD-10 codes
- A blank org chart that you can fill in with names of your supervisor and other key personnel. (E.g. Chief of Staff, Nursing supervisor, Medical Records, Admissions Coordinator, Risk Management, etc.)
- Frequently called phone numbers (e.g. pharmacy, lab, hospitalist service, etc.)
You can do this with a tablet or smartphone if you prefer, but I find that most hospitals still prepare paper handouts for me during orientation – so an “old school” clipboard works well.
2. Dress professionally
They say you never get a second chance to make a good first impression. I find that scrubs and a white coat are clean, professional, and easy to travel with. It’s hard to know what the dress style will be at your assignment, but no one complains about a doctor in scrubs and a white coat. Scrubs are comfortable, and coats have plenty of pocket space for equipment. If you feel more comfortable in dress shirts and slacks, that’s fine too. Just remember that you may have long days and be on your feet for many hours, so plan accordingly. Footwear can make or break you!
3. Be tech savvy
It’s difficult to acclimate to new hospital documentation processes, but do your best to do so quickly and without complaining. You may not like the EMR at your assignment, but it’s not going to change, so you may as well dig in and figure out how to make it work for you. Do your EMR training in advance if possible. Plan to be able to compose your documentation on day one. Standing out as a locums often hinges on your ability to adapt to technology quickly.
4. Work hard
Although many locum assignments are short term, it’s still important to work just as hard as if it were a permanent position. Plan to carry the same census as your peers and work about the same hours. You will certainly stand out if you show that you are pulling your weight and are a valuable member of the team. Schedule assignments with facilities in advance and don’t cancel them within a 30-day window.
5. Document thoroughly
If you want to be invited back repeatedly to a facility, make sure you document thoroughly and accurately so that they can bill for your services. Provide them with CPT codes on a daily basis, and make sure you have signed all your charting. If you are off site and medical records call you to complete some documentation, do so quickly and without complaint. They will be grateful!
6. Develop staff report
It’s important to treat everyone with respect. Attend team meetings. Listen well. Avoid the attitude of “I don’t need to learn about this because I’m only here for a short time.” People will remember your attentiveness. Offer your cell phone number to the staff so they can get in touch with you at all times.
7. Be humble
When providers first arrive at an assignment, the natural tendency is to want to change everything to suit their own way of doing things. Resist that urge, and try to adapt to the way things are run. Every facility has its own personality and has developed a working routine. Observe it carefully before making suggestions for changing it. If you see someone doing a good job, be sure to praise them for it.
8. Be clean
Keep a tidy office space. Don’t clutter up common areas, leave old food in the staff fridge, or leave private patient information lying around. You don’t want a facility’s last memory of you to be the rotten egg salad with your name on it!
9. Have a sense of humor
When you’re the new guy/gal you’re bound to make mistakes, forget names, get lost, miss meetings, etc. Instead of being frustrated, just take it in stride and laugh at yourself and the situation. Apologize often, learn from your mistakes, and thank staff for helping you to stay on track.
10. Provide excellent patient care
In the end, the most important thing is that patients get good care. Be thorough, evidence-based, and compassionate. Engage in patient and staff education, citing medical literature as appropriate. Listen to your patients, and engage their families in their care.
If you keep these 10 tips in mind as you prepare for your next locums assignment, I have no doubt that you’ll stand out as the kind of provider everyone wants around!
*This post was initially published on the Barton Blog.
As a locum tenens physician in rehabilitation hospitals, I see patients with some of the most unique injuries. From rare brain infections contracted in exotic lands, to the consequences of ill-advised horseplay with guns or ATVs – I’d begun to wonder if maybe I’d seen it all.
And then I met a grandma from New Jersey, who had a life-changing encounter on a nature trail out west. In her dutiful effort to corral her teenage grandchildren, and keep them following the guide’s directions, she shouted for them to remain on the path. In so doing, her yelling attracted the attention of an ill-tempered bison. The animal rapidly approached from behind without her notice. In the blink of an eye, the bison threw her up in the air with a flick of its horned head.
“As a locum tenens physician in rehabilitation hospitals, I see patients with some of the most unique injuries.”
As she crashed to the ground, she rose up again instinctively (to dust herself off and prepare to run) as the animal came back for a second hit. One of its horns sliced a huge gash in her buttock as she fell head first on the ground, causing brain bleeding. The guide managed to scare off the beast as my patient’s granddaughter had the presence of mind to staunch her bleeding wound by having her sit on her thigh, as the guide called in an air flight to my hospital.
After stabilization in the ICU and several surgeries to correct the gashes, my patient arrived in the rehab unit with a traumatic brain injury. She was quite disoriented, her pain was poorly controlled, and even the slightest noises were very disturbing to her. She had flashbacks of the event and would call out in fear during her fitful sleep.
With careful therapy, low stimulus environment, and better pain management, I began to see glimpses of my patient’s usual brilliance and keen sense of humor. She was determined to improve, and participated eagerly in the full gamut of activities, including focused attention tasks and balance and agility tests.
One weekend I was eating at a local restaurant and noticed bison carpaccio on the menu. I couldn’t resist the opportunity to “get even” for my patient. I ordered the dish and took a photo with my smart phone. On Monday I showed her the image – and told her I had evened the score. Her face lit up from ear to ear. She told me to keep eating buffalo for the rest of my days!
*This blog post was initially published on the Barton Blog.
When doctors complete their residency training, they are under a lot of pressure to land their first “real job” quickly. Student loan deferments end shortly after training, and whopping debt faces many of them. But choosing a job that is a good long-term fit can be difficult, and gaining a broader exposure to the wide variety of options is key to success. That’s why “try before you buy” can be an excellent strategy for young physicians.
Locum tenens agencies such as Barton Associates work with healthcare organizations and practice locations across the country to offer a variety of temporary assignments for physicians.
These agencies negotiate your salary and call schedule. They also arrange the logistics, covering the costs of travel and accommodations. Once the doctor and the facility agree to terms, the physician simply arrives on the required date(s) and takes on the responsibilities requested. It’s a hassle-free, minimal-commitment arrangement that pays an hourly or daily rate for work.
Locum providers are given the convenient option to receive direct deposits to their bank accounts at regular intervals. Physicians can travel as broadly as they like for assignments, and the agency credentialing team works to efficiently complete any needed paperwork for new licenses and hospital privileging.
I enjoyed “living la vida locum” for six years before I landed my dream job. That’s a long time to be living out of a suitcase, and I doubt that most of my peers would want to do it for that long of a stretch. But an amazing thing happened during those years: With each new hospital experience, I gained insight and knowledge about my specialty. By rubbing elbows and networking with a wide swath of patients and experts across the country, I became a sought-after consultant in my own right.
I experienced different ways of delivering healthcare — from critical access hospitals to bustling academic centers. I learned about best practices and creative solutions that administrators and clinical staff had discovered to improve care quality, given the limitations of Medicare rules and private insurance restrictions.
When I was hired as the Medical Director of Admissions at St. Luke’s Rehabilitation Institute in Spokane, Washington, I came armed with creative ideas and a wealth of experience to draw from. I was a highly seasoned physician who had been exposed to the widest variety of patient populations and practice styles. I knew all about the unique struggles, successes, and solutions of various rehab centers across America. I now leverage that experience to drive change at my institution, and I am virtually unfazed by new problems and challenges.
The career value of locum tenens work is extraordinary. Take the time to look around you at each assignment. Learn what works and what doesn’t work, and file it away for future reference.
Like a bumblebee cross-pollinating hospital or medical practice “flowers,” locum tenens providers have the potential to drive change like no one else. When you’ve seen it all, your insights become invaluable, and you gain the maturity to know when a full-time job is the right cultural fit. Choosing the right job, on your terms and in your time, is the key to finding happiness in healthcare.
Hope is a tricky thing. On the one hand, false hope can lead patients to opt for painful, futile treatments at the end of life. On the other, unnecessarily bleak outlooks can lead to depression and inaction. When health is at stake, presenting information with the right amount of hope can guide patients away from both suffering needlessly and/or succumbing to treatable disease.
I was reading a sad story about a patient whose physician had made her feel hopeless. She was an elderly widow with some real, but not immediately life-threatening, medical conditions. His attitude led her to believe that she was sick and useless – with little to look forward to but ongoing testing, disease progression and eventual death. His professional opinion held special weight for her, coloring her entire outlook. It wasn’t until a friend reminded her of the doctor’s fallibility that she began to question her diagnoses, treatment options, and even prognosis.
When faced with concerning new medical diagnoses, even the most educated among us tend to imagine the worst case scenario. Knowing this, physicians should take care to offer reassurance and optimism whenever it is warranted. Hope provides the energy to course correct, to fight battles that can be won, and to hold on to trust in a brighter future. Why be stingy with it when it is so easily given?
As a rehab physician I have regularly encountered bias on the part of healthy people in regards to certain injuries. I hear them whisper, “I wouldn’t want to go on living if I couldn’t walk” or “That poor man’s life must be ruined.” And yet, these feelings are not shared by those fighting the battles. In many cases, losing an ability focuses the mind on what’s important – and on all the things that can still be achieved and enjoyed. Life is a gift, and while we all still have breath – we can make meaningful contributions.
It breaks my heart to see patients lose hope, and it is sadder still when physicians facilitate the loss. What we say carries psychological weight, and we should recognize the duty we have to deliver information with kindness and respect – focusing on the possible, dispelling unreasonable fears, and emphasizing that inner peace is attainable no matter the circumstance.
In healthcare we ought to always have hope – not for perfect health, or longer life – but in our ability to overcome obstacles, to make good come from bad, and to have a positive impact on others. The choice to live our best life is ours to make, no matter the disease or condition. Never let a doctor steal your hope, but adopt the rehab mission: to add life to years.