Mileage

When traveling to a new assignment, you have the option to fly to the site and be provided with a rental car, or you can choose to drive your own car. If you decide to drive your own car to the site then agencies will reimburse you with the mileage it took to get there. They will also provide you with the mileage it takes for you to return home (even if you end up just going to another assignment from there). If you choose this route, you will likely make a profit.

For example, if your site is 500 miles away and you were reimbursed $0.545/mile then you will get $270. After deducting $100 that you spent on gas, you will profit $170.

Another mileage benefit that some agencies provide is mileage to and from the site while you are on assignment. That means even though the agency is housing you, they will reimburse you mileage each time you drive to and from the site from your temporary apartment or hotel. Daily mileage is often given when you are doing a local assignment. However, depending on the agency, some will provide this benefit even when you are away on an assignment.

I wouldn’t necessarily expect this from all agencies, but it is a nice benefit when an agency does offer this. It will typically be listed on your contract as general “mileage”. Some agencies may specify your home city and your destination city to display that you will only receive mileage from this commute.

I am used to living about 5-10 minutes away from work so having daily mileage isn’t always essential. Yet, there was an instance where I worked for a rural community health center and the closest hotel was 1 hour away. I wasn’t thrilled about commuting 1 hour each way, but the daily mileage definitely made up for it. I made an extra $300+ each week from mileage alone. After deducting the cost of gas, I profited $200/week. Not bad, especially since it is tax free.

Proving Myself as a Locums

To my fellow locums out there, I don’t know about you but each time I tackle a new assignment I feel like I have to “prove myself”. I have to prove that I am a good locum tenens provider. That I am a quick learner, that I can see a lot of patients, that I can be thorough – covering health maintenance and quality measures; and that I can document well – not missing any important codes.

The funny thing is often the site has low expectations. They just need someone that’s going to be able to jump in and provide coverage while they recruit someone permanent or their permanent provider returns. Most of the time they aren’t expecting superman or superwoman.

Working as a traveling nurse practitioner for almost 3 years now, I have come across several other locum tenens providers. It’s interesting to see the variety from the locum tenens pool. Many other locum tenens providers are fine doing the bare minimum. Some don’t pay attention during our meetings or read their emails to learn how they can improve their documentation or care for the patients at this particular site.

I think it is the overachiever in me that feels like I need to exceed expectations. I guess I should take the pressure off of myself. In fact, locum tenens means filling a temporary need. The site and staff are usually so happy to have us helping out that they don’t even bother judging us.

 

 

Am I a Diva?

I am wondering if my “I don’t take bs” attitude translates into me being a diva. As demonstrated in my prior experiences, I often stand up for others and myself. I think since I have worked in so many different settings, I know what a GOOD work environment is. I know that it is absolutely possible to work somewhere that is pleasant and not overwhelming. I also know what a GOOD recruiter is and what a GOOD deal looks like, so I do not want to settle.

There are 2 main aspects of working locum tenens that sometimes irritates me and causes my “inner diva” to come out.

  1. Being overwhelmed at work. Whether it is due to being scheduled with too many patients, lack of leadership in the office, no admin time, or lack of assistive staff.
  2. When recruiters speak to me as a car salesman, acting like taking this job is equivalent to buying a car. They say things like: even though this job doesn’t pay well nor is it in an ideal location, at least you will have work.

My responses to these problems:

  1. When asked to see certain patients (last minute) I will say NO just to make a point. I will request a change from either management or from my agency. If they are reluctant to change anything I will use the “it’s my license on the line” talk. In the back of my mind, I always consider just leaving if things do not improve.
  2. “At least you will have work”. Hi, I am not desperate. I’ll just say NO if I don’t like something. For instance, sometimes a recruiter will try to get away with giving you poor housing options, such as staying at a motel 8 (ew). When you demand better options they will say “can you at least stay there for this week until we find something else?” The answer is NO. No, I will not travel all the way there for a “possibility”.

Do I overreact sometimes? Yes, I am human. But who else will speak up for myself if not me?

So am I a Diva? Perhaps at times 😛

 

Health Insurance

I receive many questions about health insurance as a traveling nurse practitioner so I thought it deserved its own post. As a locum tenens provider, you have two main options to obtain health insurance (besides getting it through your spouse).

If you are working with a 1099 agency then you will have to purchase private health insurance. These plans can be costly, sometimes $300-400+ each month. The good thing is you can deduct these premiums on your taxes at the end of the year. The bad thing is that both premiums and deductibles are high.

If you choose to work through a W2 agency, then these agencies will provide you with health insurance. They usually offer 3 insurances to choose from, each of them is affordable. For instance, now I am using health insurance from my W2 agency and I pay $34/week, so $136/month is not bad. This insurance plan allows me to find an in-network doctor in each state I am working in.

Another good thing about W2 agencies that provide health insurance is that if you stop working with them for up to 30 days, you are still covered under their plan. So this is nice for those of us that like to take breaks in between assignments or time off to travel abroad. You won’t lose coverage for taking a few weeks off. However, they will retroactively deduct payments on your upcoming pay checks.

As I alternate between W2 and 1099 agencies frequently, my health insurance also changes. As long as I provide “proof of loss” of insurance, I can enroll in a new plan mid-year.

I can’t tell you which option is better for you. This varies depending on your age, medical history, and preferred method of payment. For instance, a healthy 25 year old may opt for increased paid through a 1099 agency and less benefits; versus a 48 year old may prefer paying higher taxes with a W2 agency in order to have good health insurance.

Locum Tenens Myth

One of the most common questions I receive is regarding the stability of being a locum tenens nurse practitioner. Is there consistent work? Are there periods or gaps with no jobs available? Looking back at the past year, 2017, one thing is clear. I worked way too much! More so, I worked more than I originally planned. I meant to spend most of 2017 traveling abroad but accidentally got caught up in work.

As soon as I finished my assignment in Virginia and needed to be home in Miami after Hurricane Irma, I was able to start working on another assignment. The only ‘gap’ was the 1 week road trip I purposely took on my way down to Florida. Once I completed my assignment in Miami, I had another assignment waiting for me, in which I started the following Monday.

To further illustrate the consistency and abundance of locum tenens job, is how quickly I was able to obtain an assignment after leaving the site in Tampa, Florida. I decided to leave that assignment early (I made this decision on a Wednesday). The following day, Thursday, I notified my recruiters that I would be available for another assignment. Friday was my last day in Tampa, FL, and during my lunch break I was already being interviewed for another job. By Friday afternoon, I had already been offered and accepted my next assignment. This new job started the following week. Luckily, it was right after new years so I had Monday off to recuperate.

My family and friends were impressed about how quickly I was able to get a new assignment. Personally, I wasn’t surprised because that’s just part of being a traveling nurse practitioner. I work with about a dozen recruiters at any given time to provide me with as many job prospects as possible. That’s why I always encourage my readers to credential with various agencies, and not limit yourselves to just one or two. There is a primary care provider shortage in America – someone is bound to have a job opening for us! J

Part 4: How I became a “Martyr”

Just one week after I left, I already heard from the other nurse practitioners that things were changing for the better. There was an announcement that all walk-ins and hospital discharges are supposed to be seen by their PCPs. If only that had been implemented while I was there, it would have prevented a whole lot of problems.

There is a new nurse practitioner there, in which this is her first job practicing as an NP. I had told the CMO that they were scheduling her with way too many patients and that no one is available for her to ask questions. (Note: she worked at the other clinic from me, not mine, otherwise I would have helped her). She told me that after I left, the Medical Director told her that she was seeing too many patients, and they were going to start giving her 30 minutes per patient. He also told her that if she had any questions she could ask any of the doctors including him.

Lastly, another major announcement is that the Medical Director will actually be stepping down and there will be a new Medical Director taking his place within the next 3 months.

Although I would have preferred to avoid the recent past turmoil, I am glad that by me speaking up for my peers and myself, circumstances are improving for them. Sometimes you have to sacrifice yourself in order to help others.

As far as working with this company again in the future, it is definitely a possibility. I think it was insinuated that I would not be taking the permanent traveling gig at this time. Considering the Tampa/Lakeland market was mainly for me to make sure other markets were just as great as the Virginia one, but it clearly didn’t work out. Nonetheless, the CMO clearly took my concerns seriously and did not waste any time to implement change. He has my utmost respect and I hope to work with him again in the future.

Part 3: Why I Decided to Leave an Assignment

T’was the Friday before Christmas. I had the usual full schedule and there were plenty of walk-ins. It was 11:30 am, lunch started at 12:00 pm and I had 2 patients waiting for me. This is when I was asked if I would see a ‘walk-in hospital discharge.’ Remember from my previous posts that these are supposed to be schedule appointments but became ‘walk-ins’ on a regular basis.

I responded with “no I cannot see the patient because I already have 2 patients here and unless she has an urgent issue the patient should be scheduled for a hospital discharge appointment.”

The next thing I know, the patient was checked-in under my name. I was told that the front desk “lead” said I HAD to see the patient because we cannot turn away any walk-ins. I proceeded by approaching the front desk “lead”. I told him “I already said I could not see the patient. So I am not sure why she is checked in under my name.” He responded with “she is a walk-in hospital discharge, so she has to be seen.” I said “these should be scheduled appointments. Regardless I cannot see her as I already have two patients here, but maybe someone else can.”

I went to lunch late anyways, and when I returned the Medical Director was waiting for me. He pulled me aside and pretty much said to me:

“I was told you turned away a walk-in hospital discharge. You know we do not turn away walk-ins, not here and not in Virginia. You have upset a lot of people here. I think you should take the rest of the day off and think hard if this is a place you want to return to.”

Like the great leader that he is, he didn’t even bother asking for my side of the story. I didn’t “turn a walk-in away”. I just said I could not see the patient, and they should have asked someone else, but they did not.

I was happy to leave early to be honest because I was able to drive down to Miami in the day-time (for Christmas). As the company is based out of Miami, I decided to use the time I was home to speak with the Chief Medical Officer. I told him about all of my concerns (not following the model and us nurse practitioners being mistreated) at the Tampa/Lakeland market, and what had happened the week prior. He said he would like for me to meet with the Medical Director and “hash things out” by giving him my perspective. I told the CMO that I had already tried approaching the Medical Director about my concerns prior to the incident last week, but he ignored me, as he ignores all of us. The CMO then said he would try to address my concerns himself.

When I returned to work after Christmas, I decided it wasn’t a place I wanted to remain at. As much as I enjoyed working with some of the other PCPs and my supportive staff, I was only there for the model. And since the model wasn’t being followed, nor was management receptive to any suggestions, I knew it was time to go. I notified my recruiter about everything that had happened and told her to find out when was the earliest date I could leave.

I originally still had another month of that assignment, but the Medical Director agreed to let me leave at the end of that week. Like always, it was bittersweet saying bye to everyone. However, most of them understood why I was leaving and agreed that since I have the luxury to do so, there was no point in me staying there longer. I am hopeful that things will improve within the next year, and maybe at that point I can return.

Part 2: Enough is Enough

I think going back to Virginia and seeing some of my old patients, and how they were doing so well, supported my previous thoughts that the Florida market was not following the model. Our model is focusing on primary care and prevention to keep patients healthy, with less sick days (less days in the hospital), and living longer.

Here are some examples of how the model was not being followed:

–Patients did not bring their medications to each visit. How are we supposed to perform medication reconciliation after a hospitalization? How do we monitor medication compliance? How do we reduce polypharmacy?

–Hospital discharge appointments are ineffective. Patients are supposed to follow up with their PCP but the front desk keeps putting them with non-PCPs due to ‘availability’. The entire purpose of this appointment is to prevent them from going back to the hospital, who better to do that than their PCP that knows them well. Also, often there are no records from the hospital so we don’t even know what happened to them while they were there. Let’s just say the re-admission rates are high in this market.

–Patients are being scheduled randomly. The entire model focuses on the PCP and patient relationship. Total hospitalization rates are high in this market because patients do not have an established relationship with their PCP. This means when they are sick they go straight to the hospital instead of notifying their PCP. Patients shouldn’t see a non-PCP unless it’s a walk-in or their PCP is on vacation.

–HEDIS measures are not being done. As I have been seeing other PCP’s patients, I noticed that most of them do not have HEDIS measures done and it is the end of the year. Aren’t we supposed to be focusing on primary prevention, recommending mammograms, screening for depression, and starting them on a statin if they are diabetic etc?

Some other red flags: the social worker was asked if she could do a home visit on a suicidal patient and she said no. Apparently that was ok. Another instance was when I suspected a patient to have a DVT and approached his PCP, who recommended the patient go to the hospital. The patient declined going to the ER and I asked the PCP if he wanted to speak to the patient for a bit (since he had more of a relationship with the patient than I did), and the PCP said no. Apparently that was ok as well.

In response to the medical directors email, I wrote back to him with my concerns that we were not following the model but he never responded. I wasn’t surprised, since he never replies to any of our emails. Nor is he present to have an actual conversation with. I then realized that there was no leadership/management in this market, which is the primary root of the problem.

Part 1: Trouble in Paradise

Regarding my experiences working in the clinics in Tampa/Lakeland, Florida, I will be breaking it up into 4 parts.

Part 1 (this post): Trouble in Paradise

Part 2: Enough is Enough

Part 2: Why I Decided to Leave an Assignment

Part 3: How I became a Martyr

 

My initial reaction working in the Florida market (with the same company I worked with in Virginia) was “this seems easy”. The patients were not nearly as sick and complex as the patients in Virginia. This was due to many reasons such as socioeconomic status and lack/benefit of familial support.

Unfortunately, as the weeks went by, I realized how disorganized the clinics were. For instance, when I first stepped into the clinic I would only have 4-5 patients scheduled. By the time the day ended, I would have seen about 15 or so patients. This meant 10+ patients were either same day appointments or walk-ins.

For a clinic that is only a quarter of the size of the one in Virginia, there were way too many same-day appointments and walk-ins. In addition, after a patient is discharged from the hospital they are supposed to see their PCP within 4 days. Usually these are scheduled appointments. For some reason, almost every other day, there was a “walk-in hospital discharge”. This animated how disorganized the front desk was. They welcomed walk-ins for medication refills and same day appointments to obtain a pain management referral. All of these which are typically handled over the phone, via phone messages or referral requests.

I waited to see if things would improve. They did not. One day I had 15 patients scheduled (none that I was familiar with), and there were 8 walk-ins alone in the morning. I became extremely frustrated when the new (new to the clinic and me) patient I was going to see had to spend 30 minutes on the phone to update his insurance before he could be seen, and of course I was still expected to see him (late). Then with the walk-ins galore, none of the other PCPs had room in their schedule to see them, and I was expected to see them all. At one moment I had a new (late patient), a follow up patient (that I did not know), and 3 walk-in patients waiting for me. I felt like I was going to explode. Fortunately, I was able to ask one of the other PCPs for help when they had a no-show.

The above issues occurred on a daily basis. I was only able to take a 15 minute lunch at the most, would leave 1-2 hours late each day, and always with a headache.

I approached the center manager requesting that I have blocks be placed on my schedule that will give me room to see the walk-ins, instead of having a full schedule with patients that belong to other PCPs. This is pretty much what we did when I worked in Virginia. She told me to just communicate with my front desk person about how I wanted my schedule to look like.

Thus, I looked at my schedule for the following day, a Friday (aka tons of walk-ins), and saw I had a full schedule like usual. I chose about 4 patients that could be rescheduled for a routine follow up with their own PCPs (it’s not like their PCP was on vacation), leaving me with room to see walk-ins. As my front desk person was calling patients to reschedule them, the center manager overheard and made her stop.

The following day the Medical Director of the clinics emailed all of us Nurse Practitioners (yup just the NPs) with this nasty email:

“Each of u should desist from telling the front desk how to schedule ur patients. They cannot arrange your schedules based on what you tell them. Your schedules are set by me and are based on the needs of the patients and markets.
At present the market needs are such that your schedules will remain as they are.”

The other nurse practitioners were upset, as was I, since they too started confronting the front desk about their schedules. Remember from my previous post “The NP Perspective” that we were all being abused.

I chose not to respond at that time because it was the Friday before I was going to Virginia for the holiday party, and figured I would just deal with this later.

My Apartment on Assignment in Florida

Upon starting my assignment in Florida, I opted to stay in a hotel for the first 1-2 weeks and an apartment for the remainder of the assignment. The first couple of weeks at the hotel gave me the opportunity to check out a few apartment options in person before having to settle on one. A bonus was that these extra stays at the hotel enabled me to renew my platinum status with Marriott for the upcoming year!

I had two main options to choose from, one apartment was close to work but small and outdated. The other apartment was about 15 minutes from work but modern and expansive. I was spoiled living 5 minutes away from my job while staying at the hotel. In the end, I decided to go with the newer apartment that was 15 minutes from work.

I was baffled by the price because the apartment was double the size of my apartment in Virginia, more modern, but 25% less pricey. It was booked through traveler’s haven. They furnished the apartment and provided all necessary items, such at kitchenware, towels, bed linen – even a vacuum! They also set up the cable and Internet prior to me moving in.

Here are some pictures below. I am enjoying living in Florida again as it is much more “new” and “brighter” looking than other states.

The Kitchen was pretty spacious!

This pantry is even bigger than the one in my house!

The dining set was nicely placed and even place settings were put on the table.

The family/living room had more space than I even knew what to do with!

Above is my a partial view of my bedroom. Below is a partial view of my huge bathroom.

I wanted to share my living arrangements again because I still get questions about what to expect when traveling as a locum tenens nurse practitioner.