House

Have i told you lately how challenging I never thought buying a home would be?  It wasn’t the loan process.  It wasn’t finding the house. It wasn’t that i wanted something high in the price range or terribly crazy. It was the IRS. 

2015 they say they never got my taxes despite them saying they should have.they were electronically submitted twice, mailed and 3 weeks ago faxed. They have given time ranges of 3weeks to 6 months.   i still don’t have the transcript of them being entered. I gave up.  

My mortgage broker is at the top of his company and my brother.  He has been there 9 years and a lender for years before starting.  I knew he was good but he was able to get some exceptions based on who he is and my financial past helped.  It’s not that it was easy or normal and I know i stressed him out.  

Thing is i have been a rule following good boy for nearly 38 years and beurocracy and things out of my control were affecting me.   

I have to say i will time and again always go to him because I know no other mortgage broker would have gone through allllll the hasslesfrom proof of 1099 income, rental properties, strange stock investments, and just one crazy life with a history of moving 38 times in 38 years.  

If you have any mortgage needs i don’t hesitate to recommend him.  You should know that his company will require 2 years 1099 income history, if you are 1099. If W-2 just a contract or statement of employment and verification of income are needed.   

To get Matt please E-mail: MWildy@mloausa.com

Tell him I said he is amazing and you heard on locumCRNA.com ... no i don’t get anything for this.... just want him to know his little bro knows he is amazing!  

Holiday

Merry Christmas Eve, 

This means the Holidays are here!  You would not believe the trouble that surrounds this time of year.  Scheduling work is more challenging as most groups are not looking for summer vacation or the recruiters seem to know this time of year can be more challenging so pay can be less.  I see groups looking for just the holiday week coverage thinking 105 is great pay for that.  It’s sad that groups, recruiters, or CRNAs take advantage of other CRNAs by paying so little.  These rates have been the same since the early 2000s where R.N. travel rates have continued to climb steadily.   

I’ve seen many new CRNA owned companies coming out for CEUs, jobs, & other.  We are becoming more resourceful and entrepreneurial.  Just like going to a new group or workplace please do your diligence in knowing the people you are working with.  I’m going to be speaking for the first time with Education Adventures for CRNAs.  I have a one hour trial lecture with them in Costa Rica where I hope to talk on the pros and cons of locum anesthesia and what i believe some of the requisites, helpful qualities, and needs of the market are through my experiences in the past 7-8 years.  

Christmas can be a challenge for some and even for those that don’t “do” Christmas it’s a period that comes with down-time.  Less activity, less to do and work is minimal.  Look out for those that might have challenges, recent loss in the family, seem to be super happy but no plans.  Sit and chat or ask how they are doing.  Lend an ear or just be a happy person that’s there for them!   

I hope you have an amazing holiday season and from my family to yours.  Have an excellent holiday season and I’ll be chatting with you right here! 

Lessons Learned

As a locum, one must remember the business is part of the game.  Speaking with groups, recruiters, doctors, & CRNAs is part of that.  I’m still learning but here’s what I know so far. 

Keeping doors open can be your best opportunity.   — don’t burn the bridges you traverse frequently.

Understanding the market in the areas your discussing can help you but you may not want to tell everyone that you know the market rates.

Until you have a signed contract you have nothing.  If you sign a contract ... honor it.

Be able to state things clearly but be flexible.

Knowing your abilities and being able to spin them in a good light will help you.

Negotiations for a long contract are possible but the company or group may want an interview just like being full time permanent staff.  

Never stop learning and keep your skillsets.  The skills that you have need to be tended and nurtured so as you continue your career keep your skills up.  If one place has a lot of one but none of the other... the next place should have what you are missing.  

Speaking of skills and education.  Review the CEU tab, State Meetings tab, and if you like us visit the Store for some small items we receive a small royalty on.

1099, 1099, 1099 And w2 just not the same

Here we have the classic problem of people stating that they are locum and they are not.  Wait, what do you mean I’m not locum?  Let’s look at some examples and define locum.  

Broadly defined a Locum CRNA is on that is in place of another CRNA.  This means that the individual is covering for a CRNA on vacation, sick leave, maternity leave, or the full time FTE has quit and they have not hired for that position.   This means we are covering for an exact and defined position.   

I’m 1099 and take a full time salary in one place with a contract for 42 weeks a year at one facility with the expectation that this contract is indefinite for years.  This is a 1099 provider that has a job.  Generally, speaking the IRS would frown on this and state that 1099 is not necessarily the best way to report your income and the employer could receive fines stating that you should be w2.  Under the definitions of 1099 the independent contractor chooses when he or she works, where, & determines the best way in which the job is to be performed.  This is technically true but if you look at past precedent you would also find that the IRS has asked for other 1099 to prove that the contractor is choosing contracts at more than one place and is not based in one long term should be w-2 job. 

im 1099 and I go to 4 hospitals in my area.  They pay me a different rate based on what they pay a daily worker and it’s higher than the w-2 rate.  I must be a locum right? Not exactly,  if you are staying in one area and u are filling in days you are very likely Per Diem.  Per Diem is Latin for daily. A per Diem individual can be used because the hospital or group doesn’t need a full time or specifically a part time person but a gap exist so a per Diem individual can come in a full the day.  This person typically has a w-2 job but wants to pick up a Day here or there.  Since they have a job they don’t need “benefits”. Thus they receive 1099 pay.  The problem is here that the individual has healthcare, PTO, disability, malpractice and retirement etc so doesn’t calculate or pay those out of 1099 pay.  The group may pay w-2 at 85$/hour and offer a 1099 person per Diem 105-110/hr.  Sounds awesome because we know every 5$ on a full time basis is $10,000 annually.  The problem is you didn’t calculate based on a locum calculation and you have undercut even your w-2 counterparts pay and become cheaper labor than even the regular full time folks.

I am a full-time 1099 traveling locum CRNA.  I have gone to long term hospitals and short term.  I filled in for the group that had a changeover of management. Then I filled in for a girl on maternity leave, and then I did vacation relief for a group over the summer.  This person only has 1099 income, goes to more than one location and may plan a couple months at a time or fills urgent short term needs in critical access facilities.  This person travels to wherever the need is.  We pick-up life wherever that need is for the duration of the need from 7 days to a month at a time.  This is rarely if ever shorter than a week.  We calculate our 1099 pay based on the necessity, cost of housing, food, gas, regional entertainment or lack there off, health disability and life insurance, time off needed in the year, and travel to and from assignments.  We factor in time away from family or if a spouse can’t work because we travel. Our rates should never undrcut a w-2 worker even the rate we work for from an agency.   Our rates shouldn’t be below $140 all inclusive per hour and should in areas of the country be as high as 180-200$/hR.  We have to be business astute and undestand taxes, business, retirement and finance.   

The W2 worker has a job that is not expected to leave.  They receive benefits and stability.  They accept a pay rate lower than all the 1099 positions as they don’t need to worry on taxes, retirement benefits, and vacation.  Most places cover malpractice and even disability insurance.  Because the group provides all this the pay is typically matched to the area and to the lowest denominator that will keep and retain a percentage of staff at the hospital and is generally calculable.   

These are literally just my thoughts and opinions on the description of each and are not intended to be all inclusive of every situation. 

If you are loving the site.... make sure you check all of it out.  If you want to support the cause there is a Support tab that has a sample contract and some things from Zazzle for sale that are CRNA specific :)

A New Kid on the Bloc

A new kind of agency is emerging out of the cries for transparency and concern that CRNAs are working for the same pay as ten years ago.  Yes, we have seen some recent movement in the pay of CRNA locum providers in the past year. However, it still seems our pay is sometimes below or at that of w-2 providers with benefits factored in.   Part of this slight increase could be attributed to the education of providers and the demand for CRNAs to fill gaps as anesthesia management groups grow. 

BlocHealth is trying to prove a transparent model of bringing together platforms of providers searching for competitive but higher rates and groups/hospitals looking to decrease agency fees and overall hourly fees for the temporary workers. Win for both the client hospital or group and the contractor/provider.  This matching process is still a growth project where they are actively searching for exactly what our providers are looking for in the areas they are looking.  This could branch out into a system whereby “Employers” are independently contracting “Providers” through a web-based matching system and negotiating a contract more completely on-line.  Part of this may include a more automated credentialing platform where provider data is streamlined to the requesting hospital expeditiously.  Although there is no completely automated system, at this time, for the job-seeker and employer.  However, BlocHealth is an agency right?  Sure enough, they are an agency and their fees are still in place.  However, using an automated process and setting in motion an atmosphere of a less hands-on approach will allow for lower overhead and expense ratios.  What’s that boil down to?  Sometimes this is less than 1/3 the fees of a standard agency. 

I believe that this will put some of the credentialing process on the provider as there will initially be less funneling of paperwork to the hospital as a larger agency might initially do. This means credentialing would be of some effort on the part of the client.  We’ve all done this paperwork 100 times and have given the same information to either hospitals or agencies before.  This time it’s to get the rate you want and possibly the area you want to work in.   I believe that as the process grows this automation will decrease the paperwork burden. 

They are also up front in saying that at this point they want providers to state realistic rates, time-frames, skill–sets and areas of desired work.  Then BlocHealth is looking for positions that will fit the provider and group.  Where-as most agencies advertise positions open in hopes of getting a CRNA to fill them.  This may be known places that need help or calling in the region to see if groups are in need or struggling. 

Overall, I see intriguing changes for the future that could grow into a good niche with-in the locum world. 

Why do I say all this?  I called and talked to them.  I tried to understand the company dynamic and what it could be.  I put them up on the site and have a referral contract with them and want to know that they are trying to be clear and work for the follow through.  I even filled out my information on their site and found the process to be just about as easy as any other. 

I almost able to do all the paperwork on my phone.  Recently, I was told BlocHealth now has a convenient and easy way of accessing a personal folder on the cloud that contains all provider information in one place. 

I may just work with them in finding contracts for other CRNAs in the future. 

Students

SRNAs:  Because this comes up several times per month and I had an experienced CRNA ask me my thoughts.  Some will say they are appalled I would state this and some would back it 110%.  I'm going to explain the perceptions and then the exceptions and leave it out there.  

Seasoned CRNA: 

I didn't think most agencies would hire new grads.

Me:

No they typically won't. A few reasons and I don't say it to be mean. 1) most are wanting to credential before passing boards. They can't do that because a provider must be qualified to practice in order to be credentialed.  A facility hiring a new grad may go through all the steps of credentialing pending boards and licensure but both boards and licensure take time post graduation. Then the credentialing office verifies those two things and your off to the races.  Unfortunately, locums the facility can't guarantee you will pass boards and be licensed and therefor the same dilemma of time between graduation and taking a first job exists.  2) The SRNA pending CRNA isn't proven safe in an established practice for a period of time. If they have been in practice less than 3-6 months were they let go from a facility for cause either interpersonal dynamics or poor practice?? 3) Locums are used because a facility or practice is short of help and needs someone that has developed their practice and can jump in and provide skilled care in less than optimal conditions. 4). It can be hard to go from student mode to alone especially if most or all your education and training was 1-1 with someone always there.  This transition is helped by going to a practice that has people that can facilitate the growth from student role to provider role.  I believe this can be established in any role but some are definitely more challenging than others.  

For example some ACT keep CRNAs in a very restricted environment that can be more of a hindrance so the CRNA fully develops all of their skills.  Other ACT environments use CRNAs to their capacity but have the Medical Direction model and each does their part in a collegial practice.  Some CRNA only or private groups where both MDAs and CRNAs work on independent cases will say that you are a CRNA and should do only what you know.  Others will teach and build you up to the full capacity of that practice.  Still some only do a certain type of practice, which they are excellent at. However, they lose other skills and if branching out find a difficulty in full scope of practice. Solo practice... Most say a highly skilled CRNA of at least 5 years practice should go to these places.  This depends on training and the experience they had in 5 years.  If they have been doing blocks, spinals, epidurals, lines, kids, adults, critical to fast paced out patient for 5 strong years. That's what the solo practice is looking for along with someone that wants to learn and grow as a provider.  Really, this is what a locum agency and average short-handed facility would like too.

Am I saying that new grads have not gone directly into locums or solo practice?  Nope.  Am I saying they are poor providers? No.  I'm saying that it's not recommended and many agencies will discourage the practice of locums for new graduates.  Most request 1-2 years of practice to be comfortable in your role and discussing with medical staff regarding patient care.  

If you feel I've missed something please e-mail me and I am happy to edit this.  LocumCRNAs@gmail.com

Pain and Nausea

As a locum anesthesia provider I like to try different anesthesia groups cocktails for pain and nausea.  I have yet to see one that uses alternative therapies like inhalation, acupuncture, or acupressure.  I just don't see them very often.  I was approached on Linked In about a product and them wanting to put it up as a blog post.  I can't say that I have used or endorse the product as I am just learning about it. Information and being able to know about it if/when it becomes popular is nice.  So here is the information which I was provided. I will include the picture and this is what was written by Joseph.

United Behind the Best PONV Management Choices  

Postoperative nausea is still commonplace in patients following surgery. Nausea drug therapy recommendations for multi-modal use associated with surgical procedures have proven less than optimal. Clearly, prophylactic antiemetic drug combinations have not been always adequate enough to prevent and/or treat existing early and late postoperative nausea.

The decision-making process to shore up the foundation of pharmacological choices for postoperative nausea and vomiting (PONV) management could use a new course of direction that allows for the inclusion of non-pharmacological treatment strategies to achieve widespread optimal prevention results.       

One such choice is the non-pharmacological prophylactic antiemetic practice of the (P6) pericardium pressure point for preventing nausea/emesis in surgery patients practiced by Eastern medicine surgeons. Eastern medicine relies heavily on strict adherence to an effective scientific process involving 360 acupoints in the human body.

For example, the practice of the P6 pressure point seems more readily adaptable in a surgery patient’s environment compared to drug therapy because of its continuous acupoint stimulation process, which is believed to provide for the normalization or re-establishment of the balance of the body’s function related to the stomach and central and peripheral nervous system resulting in optimal management of PONV.

The Pressure Right® non-pharmacological prophylactic antiemetic adhesive device provides the P6 effect for achieving optimal PONV management results. Its locum use in combination with drug therapy can either be implemented prior to the induction of anesthesia or as a treatment strategy. The device’s stimulation process takes effect within 5-minutes and its antiemetic effect can last up to 3-days or 72-hours, which is considered the longest prescribed routine antiemetic effect on the market today.

As a point of reference, the unusually high incidence of PONV associated with aesthetic plastic surgery and laparoscopic patients were dramatically reduced with Pressure Right used in combination with routine antiemetic drug therapy. With aesthetic plastic surgery, no emesis at all and very rare nausea was reported. Furthermore, in laparoscopic clinical trialing of Pressure Right there was only very rare emesis and nausea reported after surgery. In addition, there have been no reported adverse side effects associated with this device. 

Pressure Right has pre-market approval from the USFDA as a prescribed non-pharmacological acupressure nausea/emesis therapy device. It is intended for adult use 18 years and older and is a non-invasive, hypoallergenic and latex-free, pair of adhesive strips to be worn on both wrists. The adhesive strips are designed not to go completely around the patient’s wrists and will not interfere with the surgical procedure.     

Ask about our 7-patient sample package; whereby, Certified Registered Nurse Anesthetists as well as Surgeons and the nursing staff will be able to recognize the immediate and optimal antiemetic effect of Pressure Right. Applying Pressure Right as a treatment strategy for established PONV will demonstrate its optimal effectiveness on patients almost immediately.    

Contact us about Pressure Right. A new form of optimal PONV management awaits you.

Contact: Joseph DiLustro, CEO, Pressure Point Inc. for additional details at:

Email: therapeutics101@verizon.net

Phone: (908) 601-8877 

Wrist Acupuncture Or Acupressure Prevents Nausea From Anesthesia, Review Finds

Date:

April 16, 2009

Source:

Center for Advancing Health

Summary:

Up to 80 percent of patients who have surgery complain of nausea and vomiting afterwards, but stimulating an acupoint in their wrists can help reduce these symptoms, finds a new evidence review.

Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting.

Lee A1, Fan LT.

Author information

Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong. annalee@cuhk.edu.hk

Update in

Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting. [Cochrane Database Syst Rev. 2015]