The traditional career path of physicians is rapidly changing due to a litany of influences: the Affordable Care Act (ACA), the huge numbers of hospital consolidations and practice acquisitions, an aging population, and the rising physician shortage. Throw in physician burnout and it's easy to see why many physicians are opting to retire early, scale back their hours or exit the medical profession altogether. A 2013 Deloitte survey of more than 20,000 physicians found that 57% said the practice of medicine is in jeopardy.
The evolution of locum tenens physicians
The locum tenens (Latin for "to stand in for") staffing industry started in the 1970s through government grants allocated for temporary physicians in underserved rural areas. Anne Anderson, a member of the board of directors for the National Association of Locum Tenens Organizations (NALTO), with currently more than 65 company members, told Healthcare Dive that clients 20 years ago were “very skeptical of doctors wanting to work locum tenens – was it someone who can’t get a job anywhere else?” The market has since changed, Anderson said, from mostly retirees a few years ago looking to supplement their savings to more residents today. “We’re getting more residents, especially millennials who want to travel and work differently than other generations. They see locums as a way that can meet some of their personal goals.”
Locum tenens is advancing – a Physicians Foundation 2014 Survey showed 9% of doctors choosing locum tenens, up from 6.4% in 2012. “This is an increase of 30% over two years which was eye-opening for us and we expect that trend to continue to increase,” Sean Ebner, president of Staff Care, a locum tenens staffing company, told Healthcare Dive. The company's 2014 Survey of Temporary Physician Staffing Trends estimated 40,000 physicians work as locum tenens, representing more than 5% of the total physician workforce in active care, which is estimated at 740,000.
It’s interesting to note more physicians are seeing locum tenens as a career choice. “We see more physicians choosing this as a full-time option rather than part-time,” said Ebner. This is leading to big growth in staffing. “We have not seen growth in locum tenens like we have in the past two years since we have been keeping track. The Staffing Industry Analysts Report last year gave growth projections in the 20% range and forecast 14% for this year,” added Ebner.
Burnout driving locum tenens
The uptick in locum tenens is related to a string of connected factors that many say start with the ACA. A recent national survey of 1,000 physicians by CompHealth, a large locum tenens staffing agency, showed 36% of all physicians and 45% of those in private practice are more inclined to leave the medical profession because of the ACA. Melissa Byington, president of CompHealth, told Healthcare Dive in an email her company works with “a lot of doctors who are burned out on medicine and are thinking about leaving the profession entirely," adding, "Locum tenens – either full-time or on a temporary basis – allows these doctors to avoid some of the things that caused the burnout in the first place: Office politics, mountains of paperwork, and the feeling that they have no control over their schedule.”
CompHealth’s survey also showed 76% of all physicians felt they were not properly compensated for their time by ACA reimbursements and 44% said they spend less time with their patients since the law’s implementation – with 68% reporting too much time spent on entering data and 59% on too much paperwork. In addition, 40% of respondents said they supplement their income via secondary jobs including “moonlighting” (extra shifts at a hospital or clinic), locum tenens and consulting.
Byington said physicians who work locum tenens as a second job appreciate the extra pay, “but often find the extra assignments actually help them feel more engaged with their full-time job – they get the chance to experience a new practice setting, work with different people, and step away from the monotony of their day job.” Furthermore, she added, “We hope that doctors would look to locum tenens rather than leave medicine. There’s a major physician shortage in our country and we can’t afford to lose any more doctors.”
A severe physician shortage, more hospital consolidations
The nationwide physician shortage is especially felt in primary care and behavioral health – the two most requested specialties for locum tenens. The Association of American Medical Colleges (AAMC) estimates by 2025 there will be a shortage of 12,500 to 31,000 primary-care physicians and up to 63,700 non-primary care physicians. “Behavior health is in high demand due to a shrinking workforce that is not being reconstituted as fast as it needs to be,” Ebner explained. “This had led to a surge in [demand for] psychiatric nurse practitioners (NPs) due to the shortage of MDs.” In addition, Ebner said with the number of physicians coming out of residency being flat since 2012 and an increasing census, “you’re going to have a major [physician] shortage without the ACA figuring into it.”
Hospital consolidations and acquisitions of physician groups have been gaining steam over the past few years, with over 100 transactions in 2015 – higher than it’s been in the previous five years. Kit Kamholz, managing director with Kaufman Hall, a management consulting firm, told HealthLeaders Media that hospitals have to contain costs and develop competencies to be successful in value-based business models and population health management, which is leading to many partnerships. A trend Kamholz recognized over the past two years has been partnerships between hospital providers, physician providers, and insurers.
“You see a lot of movement within healthcare with systems acquiring physician groups, consolidation, third-party outsourcing, and hospitalists in emergency medicine continuing to accelerate and that changes the paradigm for a lot of physicians,” Ebner explained. When a physician practice is acquired and senior physicians leave, he added, those left have to carry a bigger workload. “On the burnout side, you have a disaffected person who wants to take [their] career into their own hands and run locums. Many do that permanently.” However, Ebner said that the use of locum tenens is also being used “more and more to prevent burnout. When you have spikes in the census and high demand, different types of things happen. If you can alleviate the workload with locum tenens it improves patient outcomes and employee morale because it lessens that burden.”
A changing industry
There have been big changes in healthcare, with many prompted by the ACA. Those ripples have extended into the locum tenens industry, which according to Staffing Industry Analysts reached $3.1 billion in 2015. “We estimate that there are more than 150 agencies that exist,” Chris Franklin, president of LocumTenens.com, told Healthcare Dive in an email. Franklin said more clients “are turning to innovative solutions for improving the efficiency of their care delivery to patients, including flexible staffing models and using advanced practitioners to improve access to care.”
Instead of viewing locum tenens as a last resort, more healthcare organizations now see it as part of their staffing strategy. “When hospital leaders are surveyed, we commonly hear that physician retention is a top concern. Employed doctors want to work fewer hours and take less call, so we now have hospitals who regularly use locum tenens physicians to reduce surgery backlogs, or to give their employed physicians time off,” Franklin explained.
It seems locum tenens provides a link to maintain quality patient care during a turbulent time in the healthcare industry. “I had always thought that having the skills of a physician would be able to allow me to travel and interact with places and people in a meaningful way, have adventures, roll up my sleeves, get my feet wet, that sort of thing. It turns out that this is true. Doctors with certain skills, especially internal medicine and hospital medicine, are wanted all over the country, especially in small towns and rural hospitals, and locums are hired often to avoid catastrophe while hiring a permanent physician,” Dr. Janice Boughton wrote in a blog titled, “My first year as a locum tenens physician."
Franklin credits physicians for the shift in the industry with hospitals now seeking locum tenens as part of their staffing strategy in a recent article in The Staffing Stream. “It works out amazingly for these physicians who want to call their own shots, and for the healthcare facilities and patients, who depend on their talents. And as the president of a locum tenens staffing company, I couldn’t be happier that it’s the physicians we work with who are changing the face of our industry in such a positive way,” Franklin wrote.