Urgent message: Despite the best staff planning, urgent care centers sometimes need to turn to locum tenens firms to fill the “bench.” Understanding the challenges these firms face is one key to success.
ALAN A. AYERS, MBA, MAcc Practice Velocity
Regardless of how aesthetically pleasing an urgent care facility, how convenient its hours, how creative its marketing, or how sophisticated its technology, the ultimate “product” is its clinicians and the solutions they provide for patients’ immediate medical problems. Without a provider ready and able to serve the public on a walk-in basis, an urgent care center is incapable of delivering value. So, what happens when an urgent care center is without a provider? It can turn patients away, it can close its doors, or it can fill schedule gaps with locum tenens and temporary clinicians. The need met by locum tenens providers is clear: They enable an urgent care center to sustain operations.
Ideally an urgent care center should be staffed by equity owners and employed clinicians whose personal interests are aligned with the long-term success of the operation. Such providers understand that positive medical outcomes and good patient experiences result in satisfied “customers” who not only return for services themselves, but tell friends and family to do likewise.
When a physician-owner or employed physician is incentivized by productivity and is vested in the financial returns of the practice, he/she focuses on providing clinically effective and cost-effective care. Locum tenens providers are usually paid hourly for being present in the center and they’re typically self-employed, so their personal interest is not to maximize, patient satisfaction and center revenue but rather, to minimize the professional liability of an assignment. This lack of interest in the center’s success results in:
- A narrow focus on treating and discharging based on the immediate presenting medical condition versus developing collaborative relationships with patients because the locum tenens provider likely will not be at the center if/when the patient returns. Patients often complain about this lack of continuity in care.
- Risk-aversion (a desire to avoid potential malpractice claims) leading to conservatism in diagnosis and treatment. For example, ordering unnecessary lab tests or imaging studies, refusing to prescribe narcotics, or referring more complex cases to the emergency room. In addition to lost patient revenue, additional services can lead to financial losses on flat-rate insurance contracts.
- Shortcomings in chart documentation leading to under-coding of E/M levels of service, miscoding of procedures, or omitting procedure and ancillary codes because the locum tenens provider gets his/her hourly rate regardless of the revenue he/she generates.
- Referring patients to specialists who don’t need such referrals and not referring patients who actually require specialist care. Referral of patients to specialists the locum tenens provider knows instead of to in-system or in-network providers also is common.
- Extended wait times because locum tenens providers – not incentivized on productivity – may spend more time in patient encounters as a result of unfamiliarity with systems and processes or fell less compelled to keep flow moving.
Unlike owners and employed clinicians, locum tenens providers are usually disengaged from the culture and management of the center, which can undermine the cohesion of center teams. Friction occurs when the locum tenens provider introduces new ways of doing things or refuses to follow the center’s operating procedures. When new clinicians circulate through a center, medical assistants become confused as to medical orders, patient/procedure set-ups, and chart documentation.
The financial bottom line of an urgent care center that relies on locum tenens can suffer – because in addition to these issues with coding and referrals, inefficiency in flow, and lost patient loyalty – locum tenens are often expensive. A center not only pays the provider’s hourly wage, but it also incurs agency fees and travel costs.
Locum Tenens and Occupational Medicine
For center that provide occupational medicine services, additional issues with locum tenens providers can impact relationships with employers who send patients to an urgent care center for workplace injuries, physical exams, and other compliance and prevention services. Temporary clinicians are often:
- Unwilling to or unskilled in communicating with employers in workers’ compensation cases, resulting in dissatisfied clients and lost accounts.
- Unwilling or unskilled in selling the center’s services to prospective customers (or conducting case reviews with existing customers), resulting in lost sales opportunities.
- Too quick to prescribe medications and/or assign time off/limited duty to injured workers, resulting in reportable workers’ compensation cases that raise the cost of claims for employers. Time off from work (as opposed to medical claims) is the primary cost drive in workers’ compensation.
- Unfamiliar with Occupational Safety and Healt4h Administration standards or Department of Transportation procedures and forms, resulting in errors that can jeopardize a client’s compliance with federal regulations.
Unless a locum tenens provider has specific experience with workers’ compensation and employer services, his/her involvement with occupational medicine can result in a longer case duration for workplace injuries and increased risk to employers on compliance services.
Minimizing the Risk of Locum Tenens Providers
The surest way to avoid the issues associated with locum tenens providers is to have a “bench” of trusted clinicians available to work in the center as needs arise on the center’s schedule. Some centers establish relationships with medical residents or primary care providers willing to “moonlight” at the center – which work particularly well for planned absences including vacation, maternity leave, and continuing medical education. But unanticipated events such as provider resignations and personal and family illness still occur, so when a center has no alternative but to use locum tenens providers to fill shifts, an urgent care operator can mitigate the risk by:
- Arranging the center’s staffing schedule so that locum tenens providers work solo during the least busy hours or days of the week.
It’s also important to ensure that medical staffing agencies understand the center’s scope of practice, culture, systems, and patient base. While some agencies have a reputation for getting “warm bodies” into center, those that “work” for their agency fees ensure that the providers they place are a great “math” – capable of meeting patient needs and functioning on the center team as a “vested” provider. The better “fit” its candidates, the more satisfied a staffing agency’s clients, so partner with the staffing agency be setting clear expectations as toe the skills, experience, and personal attributes expected of a locum tenens provider. Also avoid “throwing” clinicians “into the fire” by working with the agency to define a clear “on-boarding” or training process.
Develop a Long-Term Staffing Strategy
Urgent care is rapidly growing as an important component of the nation’s medical delivery system. Not only do consumers embrace the convenience of extended-hours walk-in service, many find access to a regular primary care physician increasingly limited. But all statistics pointing to a primary care physician shortage in the United States also mean that recruiting physicians to work in urgent care centers is only going to become more difficult in the future. The timeline for replacing or filling a physician opening can already exceed 9 to 12 months depending on a center’s geographic location. As an urgent care center sees increased utilization, expands its hours, and opens new locations, the strain on its existing providers will continue to increase. The best defense is business continuity plan that anticipates and addresses physician staffing needs.
Certainly an urgent care center should have a contingency plan to cover planned absences like paid time off continuing medical education, and pregnancy as well as unplanned absences including personal and family medical leave. In addition, the contingency plan should address variations in center volume due to promotional campaigns (such as back-to-school physicals) and seasonal variations (such as summer injuries, spring allergies, and winter flu).
Long-term factors that affect a center’s provider staffing needs include:
- Organic growth of the business through marketing and repeat business
- Addition of new insurance contracts and insurance benefit changes such as reduced co-pays for urgent care
- Changes in scope of practice due to reduced availability of medical services in the community
- Addition of ancillary services like travel medicine or immigration physicals
- Addition of new locations
Urgent care operators can avoid being caught off-guard by incorporating provider staffing into all strategic business discussions. Business changes should be planned sufficiently in advance to ensure clinical coverage – whether by full-time, part-time, temporary or locum tenens providers. Otherwise, failure to account for provider staffing can seriously inhibit a center’s ability to grow and take advantage of market opportunities.
The “product” of an urgent care center is its clinicians and the services they provide. Successful urgent care centers constantly account for provider staffing – anticipating short- and long-term variations and ensuring a plan to cover all provider shifts. But despite its best efforts to cultivate a “bench” of available providers, a center may still find itself in need of the temporary support provided by locum tenens. Key to success is understanding the typical challenges of utilizing locum tenens providers, working with medical staffing agencies to ensure that temporary providers have the necessary experience and are a good cultural fit, aligning the center and the provider’s financial interests, and investing time and resources in training and on-boarding.