Tuesday, August 5, 2014

Moonlighting, Locum Tenens, Concierge Medicine and Physician Assistants

Moonlighting for Physician Assistants
Updated: 08/06/2015
Moonlighting is by definition, “having a second job in addition to one’s regular employment.” While moonlighting is very popular amongst the physician community, physician assistants (PAs) may also find moonlighting useful to boost income sources and pay off student debt, or simply to increase the amount of experience in their current area of practice or another. As PA students are not yet certified in their clinical phase, they may not moonlight. However, if a PA-C wishes to moonlight as a resident or during a fellowship, they may legally provide medical care as licensed physician assistants. Currently, no survey shows the number of PAs who are moonlighting, but it seems that interest in these positions as secondary jobs are becoming more popular. Declining reimbursements and skyrocketing student loan interest rates seem to be the main drivers of this type of work, but it’s up to the PA to determine how much work is enough before they are burning themselves out.

According to the Accreditation Council for Graduate Medical Education (ACGME), residents are restricted to 80-hour work weeks, averaged over a four-week period, inclusive of all in-house call activities and all moonlighting. This limit was created to enhance the education of residents while allowing for necessary rest, conducive to productive learning. However, there is no limit for currently practicing physician assistants (PA-C) that are not enrolled in a residency or fellowship program.

Moonlighting approval requires written consent from a residency program director with clearly outlined goals and objectives of moonlighting. Programs may also retract your moonlighting privileges if they are interfering with your performance in their program. Only a few residency programs are known to offer moonlighting, such as Baystate’s EM Residency, which allows you to pick up shifts per diem. Arrowhead Orthopaedics, however, does not tolerate moonlighting during their PA residency. Check with your residency or fellowship to ensure whether moonlighting is acceptable if you plan on doing it.

Moonlighting “per diem” - a term you might come across in your clinical career. Per diem simply means “per day” or “for each day” in Latin, where a PA can work specific days or shifts in addition to their current job. This type of work is often classified as “prn” work, which simply means “as needed.” TeamHealth is one group with clinics around the country that offers this type of work. These positions often do not offer benefits, but the rate offered tends to be between $50-75/hour depending on the area of medicine and location.

A few steps to ensure harmless moonlighting:
  • Ensure your moonlighting organization allows you flexibility from your moonlighting position if your primary job require your presence
  • Don’t work for competitors. Even if your employers contract doesn’t specify that you can’t work for competing groups, working for competitors can have a negative effect on your relationship with your co-workers and your employer in general. Always find moonlighting positions outside your primary field of work where no competition is found.
  • Check your primary job’s employment contract for disincentives to moonlighting. For instance, some contracts might state, “While employed by employer, any remuneration generated by employee belongs to employer.”
  • Be certain that your insurance coverage is intact in a secondary office because your employer provided coverage will only cover you in your primary job. Portable medical malpractice coverage is the most useful for moonlighting PAs as it will cover you wherever your work takes you. Visit MedEdge for more info.

Locum Tenens Physician Assistants
Locum tenens is a phrase in Latin meaning “to hold the place of” or “to substitute for.” It all began in the 1970s when the University of Utah was given a grant to staff physicians in rural health clinics. The program was very successful and hospital administrators began asking for locum tenens physician staffing assistance. Today, physicians, nurses, and physician assistants contract with locum tenens agencies to provide services to hospitals, outpatient medical centers, government and military facilities, group practices, community health centers, and correctional facilities. This 40-plus year industry grows larger every year as more providers choose this way of medicine.

Locum tenens provides practitioners with flexible schedules that are key for working short-term assignments. Locum tenens positions also offer great travel opportunities, they are an extra source of income, and offer invaluable clinical experience. They are mainly used to staff needs during peak seasons, where it is most cost effective to supplement the permanent staff rather than staffing at the maximum levels at all times. They are also known to fill in for providers on vacation, sabbatical, maternity leave or a temporary to permanent vacancy. You do not have to be a part of any office or administrative politic or be on any committees. Assignments vary by location and demand. Some companies will offer travel, hotel costs (if necessary), liability, and will do most of the paperwork necessary for credentialing.

3 Tips to Remember (from Ann Horton, PA-C)
  1. Always maintain a copy of your malpractice insurance with each job
  2. Ask your supervising physician to write an undated letter of reference for future jobs as they may become difficult to get ahold of in the future
  3. Be prepared for the hassle of work verification

Locum tenens physician assistant positions are available in all states and various contracts are available on any given day. Visit LocumTenens.com for more information.

Physician Assistant Locum Tenens Staffing Companies

Concierge Medicine
“Boutique practices” participate in concierge medicine, a new generation of “3-tiered” medical care. The 3-tiers represent the 3 types of patients in America: those who cannot afford medical care, those who can afford the minimum medical services they require, and those who can afford the medical services they want in addition to their needs. In concierge medicine, a provider or practice provides around-the-clock medical care to a select few patients that pay more for special attention and care. Many of them offer extended hours, phone services, telemedicine, in-home visits, and accompanied visits to specialists as an extra service. These providers typically have a smaller patient loads and can provide longer office visits, but the fact of the matter is that they are truly reducing access to patient care by providing services to these select few patients that can afford their prices. Concierge medicine was born out of frustration of physicians dealing with 3rd party payers (i.e. insurance companies) in addition to wanting to make more money. Some PAs argue that concierge medicine is necessary for some clinics to turn over a profit because they accept cash payments and limit the insurance carriers accepted. But concierge medicine has one limitation for PAs - aside from owning a practice, patients often want “doctors,” not midlevel providers. If all is good in the hood, everything should be okay, unless patients don’t like what they hear or don’t feel “cured.” It seems that the practice may actually lead to more malpractice suits if the services provided aren’t up to their standards. Other PAs who have started their own PA-owned practices have found it troubling to maintain their patients because insurance companies won’t cover their practice since it is PA-owned. If we look at how many hospitals have offered V.I.P. rooms or suites to patients who’d like some extra comfort while in the hospital, we see that concierge medicine might have existed for some time. But is this “first class” medical care providers are offering ethical? Is this why we choose/chose to become PAs? Ethically, this is a highly debated topic, and I look forward to seeing more from AAPA in the future.


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