A Tale of Contract Negotiation

travel PT contract negotiationAfter a few hours of skiing this morning, I had one heck of a day wheeling-and-dealing a travel contract. I ended up with a couple extra hours and thought I would quickly share the experience.

Kate and I are trying to return to a small, remote community hospital that we worked at a couple years ago. We absolutely loved the community and would love to return this summer for 3 or 6 months. We’ve been speaking with the rehab director over a few weeks and have established that there are 1.5 jobs (60 hours/week) available for the two us this summer. We’ve just been waiting, and waiting, for some details and pay numbers to come through. We had previously worked for this hospital through an agency, but the hospital requested we do an independent contract if we could. Finally, this past week, the ball got rolling, we filled out applications with the hospital and a proposed pay package came to us. I was pleasantly surprised with what the package offered – a rental car and housing included but a little too modest hourly pay. I sat down to crunch some numbers and with my estimates of housing cost, rental car, etc, the package fell well short of what we would be making at the same facility through an agency. I figured there was some wiggle room and while a rental car was a nice perk, we don’t really need a rental car and could perhaps negotiate it into a higher hourly pay. When I got on the phone with HR this morning, I was briskly informed that there was no room for negotiation – the offer we received was the final offer. Could we remove the rental car and turn that cost into hourly pay? No. Could any of the money be offered as tax-free per diem? No. How much are they paying for the condo? …a lot more than we would pay for a condo on our own. Bottom line, there was no wiggle in the pay package and I had to insist that we figure out a deal through a staffing agency because we would make a lot more moolah working the same exact job. But, the insanity wasn’t finished yet – just inform our recruiter to work with the hospital to set up the gig, right? No, the hospital has a policy that travel jobs must be posted publicly through a “vendor management system” (more on this later).

That’s the story on how this contract has come to be, but there’s a lot of nuance to break down and comment on that I believe offers some insight into the travel industry. First, non-negotiable!? Why wouldn’t we be able to negotiate a different pay package? While I did enjoy what was offered to us directly by the hospital, a lot of the value of the total compensation was spent on things I don’t need. Also, the tax free benefits available through an agency give them an edge on what the hospital could offer me. Here’s the factors that I believe led to the breakdown in the hospital’s ability to offer Kate and I jobs directly:

  1. A rental car. This is a huge cost. When going to remote areas, we tend to buy a Craigslist car and sell it at the end for minimal loss. If the money the hospital was pouring into renting us a car was converted into hourly pay, we  would have completed a deal directly with the hospital.
  2. Housing – When working for an agency, we typically take the housing stipend and find our own housing rather than taking housing offered through the agency. We do this, because with a little footwork, we can find housing that is better suited to our needs and costs less than the generic, supplied housing. This is exactly what happened with the hospital’s offer – we had budgeted $1200/mo for housing, and they were estimating $2000/mo. Sure it’s convenient to have housing set up for us, but not at a total of $2400 above our budget over the course of a 3 month assignment. (post-script update: We secured housing for $1100/mo – in the same exact condo complex the hospital was offering us housing in. This works out to $2700 more dollars in our pocket versus our initial  contract offer from the hospital.)
  3. Tax advantage – The hospital told me they had looked into their ability to do tax free payments (like per diem) and that they had chosen not to take it on for the tax difficulties it presented. When a portion of your pay is tax free, it really ads up. That was one reason I initially liked them supplying the housing. When they rent it for us, it’s like getting money before it is taxed. A great benefit!
  4. The nail in the coffin: HR literally told me, “We only pay a few more dollars per hour when we work with an agency, so we’re fine with that option.” A few dollars per hour!? That really ads up. Offer ME that money, man! Come on.
Kate and I enjoying the waning moments of our spring-time skiing before jetting off to the next contract in a couple weeks.

Kate and I enjoying the waning moments of our spring-time skiing before jetting off to the next contract in a couple weeks.

While I believe those are the main factors that ultimately led to the breakdown in our ability to work out an independent contract, the insanity was not finished. I mentioned that they had to use a vendor management system (VMS). There are several big VMSs and our contract was posted through the one I am most familiar with – if you have traveled for a while, you have probably had a job that was posted with this system. What exactly is a VMS, you ask? It’s the 4th party in a 3 party contract. VMSs collect job postings from facilities by handling a large portion of the foot work for the facility. These VMSs blast those jobs out to a bunch of different staffing agencies who subscribe to be a part of their listings. Have you ever had multiple agencies post the same job at the same time? If so, that job is posted through a VMS. Some larger companies that own multiple staffing agencies also own a VMS so that they can collect exclusive postings from facilities and post them solely through the staffing agencies that they own – big, shady business. The VMS that this job was posted through (where the facility, the clinician, and the recruiting agency were all known entities) charges a price of 4% of the total contract. So, again, rather than just paying the therapists, more money is being thrown at paying another company a good chunk of the available pay.

Lunacy, complete lunacy. But, you know what? Kate and I are returning to the jobs we want this summer. The contract eventually worked out through a staffing agency and we’re happy with the deal. It’s too bad that when you have a facility and a clinician that want to work together, it takes two other private companies to organize the employment. But, as long as facilities refuse to pay clinicians the money they are willing to pay to outside companies, traveling therapy will remain a strong industry and a great career choice for therapists all across the country.

There might be a second chapter to this story. We only have 60 hours of work between the two of us this summer. I’m currently working on establishing a contract with the state to do some part-time work in a very cool, very unique consulting situation. They are a little concerned with my temporary status, but I think I could do some great work for them in the time that I do have. I know, I have given you no details here …top secret… for now. Hopefully this part-time job will work out and I’ll have some very cool, very unique stories to share with you all. See you out there on the open road!

Locum Motion

This website is about being a traveling therapist, right? Then, why so often, do I get myself off-topic blogging and twittering about issues in PT and healthcare? Answer: Because I like it. Only once in a long while do the stars of the interweb align so that I can write about travel therapy and healthcare issues at the same time.

We call ourselves travelers. Traveling therapists, traveling nurses, travel PT or OT assistants – we are all “travelers”. But not MD’s, they, call themselves locum tenens, or just locum for short. Locum!? What the heck does that mean? locum tenens; locum – place, tenens – to hold; all together now, “Place holder”. Turns out locum tenens is actually a Medicare term that applies to someone temporarily filling in for another provider. When someone qualifies to work as a locum, they are able to skip a lengthy credentialing process to be able to bill Medicare patients. The list of providers that are currently eligible for locum status during temporary employment include Physicians, Dentists, Certified Registered Nurse Anesthetists (CRNAs), Nurse Practitioners (NPs) and Physician Assistants (PAs).

There is a Medicare bill currently working its way through congress that would extend locum tenens status to Physical Therapists in certain situations. Currently, in PT private practices, if a temporary therapist is brought in, it can take 3 months to be able to bill to Medicare under their own NPI. Most private practices doing their billing above board and truly the “right” way avoid travelers for this reason. I’m not sure what happens when a private practice hires a therapist through an agency – what I believe happens, is that the private practice bills under one therapist’s NPI. The practice of billing for an entire practice under one NPI, as far as I am aware, is frowned upon, but not illegal. I have done a couple independent contracts with private practices who have made me become in-network at their facility with Medicare, it’s a long process (2-3 months), mostly paperwork, and discourages a lot of employers from getting involved with short-term staff. This bill could change the whole arrangement.

bill

Forget how this whole bill to law thing works? Click above and return to being as smart as you were in middle school.

This new Medicare/locum tenens bill, titled the Prevent Interruptions in Physical Therapy Act (House bill: H.R. 556 and Senate bill: S. 313) would create some exceptions for certain PT private practices. The bill, if passed, would decrease interruptions in patient care that may occur through a PT’s temporary absence due to illness, pregnancy, vacation, or for continuing ed by allowing practices to hire PTs on a locum tenens basis. That would cut out the whole Medicare credentialing process that currently takes place when hiring a temporary PT. While this bill is certainly patient-centric, I do see a secondary opportunity here for travelers. If there’s a current process that inhibits some clinics from taking on travelers (Medicare credentialing), and that process is eased, there’s a lot of opportunity for an increase in the number of available travel assignments. As this bill stands in the Senate, locum tenens status would only be allowed in areas designated as non-Metropolitan Statistical Areas, or areas designated as Medically Underserved Areas (MUAs) and/or Health Professions Shortage Areas (HPSAs) – that’s a lot of private practice clinics that could soon hire temporary employees with less fuss when billing through Medicare. Ideally, the bill would be amended to include ALL areas in the country, not just those of special designation – that would be pretty sick. (it’s a Medical pun, get it?) Be sure to let your Senators know that ALL Medicare beneficiaries deserve uninterrupted access to PT, not just those in underserved areas.

All traveling PTs, everyone in private practice, and all recruiters should be pretty psyched about this bill and should definitely be contacting their Congress Men and Women today. Jump over to APTA’s website to get more information on the bill. From there, you can link straight on over to contact your Senators and Representatives. Get on it now!

SLPs and OTs, don’t worry, I haven’t forgotten about you. If the legislative bug gets you revved up, you have good resources to contact the people who represent you in congress. For OTs: http://capwiz.com/aota/home/ and for SLPs: http://takeaction.asha.org/

I do get fired up about issues, and this one is more special to travelers than most issues are. It was too good not to write about, but I realize healthcare politics can get a little dry. I promise more excitement in my next post!

Places in Time

I was listening to NPR on the way home from work today and heard a segment that caught my ear. I grew envious of the author in the piece who had lived on a remote Alaskan island for two months to study the island’s history and write a book about it. I thought, “Man, I wish I had a job I could just take around to a cool places like that.” I then laughed hysterically at myself, because I do have a job that I can take where ever I want – if that remote Alaskan island ever needs a PT, I’m there.

I hear about peoples’ travels to far out and cool places and immediately want to be there. The only problem is that I can only be in one place at one time. Working typical 13 week travel contracts, a person can only see four different places in one year max. When I first started out traveling eight years ago, I had a short list of places I absolutely had to live in – Hawaii, Alaska, and a ski town. Three assignments, you figure you can chisel that out in nine months, right? Wrong. It took me six years to get to those three places.

We took 4 weeks off for our wedding and honeymoon including this zip-lining in the Dominican Republic. You're absolutely free to take whatever time off you want between assignments, but no PTO.

We took 4 weeks off for our wedding and honeymoon including this zip-lining in the Dominican Republic. You’re absolutely free to take whatever time off you want between assignments, but no PTO.

There’s so much time in travel PT that people don’t account for. If a three month contract is going well, it’s not unusual to negotiate a contract extension (typically another 13 weeks at a time*). Sometimes, particularly in home care or far-off places, the facility will request that the contract be six months instead of three. Usually a contract is longer when there are anticipated costs to the facility like an extended training process or extra relocation expenses. Living life 13 weeks at a time can get really manic, so most of the travelers I know who have traveled for a while have found a way to slow the pace of the constant 13 week shuffle. For instance, those of you who read often know that my wife and I spend half our year returning to the same seasonal jobs in Colorado. Returning to the same jobs provides us a little stability  while leaving 7 months each year to be true traveling therapists. Other travelers I know make a habit of extending their contracts whenever they can – their typical contract is not three months, but more like six or nine after extending their contract a time or two. One thing to know about extending contracts is that you do have a year cap on how long you can work somewhere before giving up your “traveler” status. I’m honestly not sure what determines this, but I do think it has to do with the IRS, tax home, and not being able to continue to receive tax-free per diem and housing.

*If you do negotiate a contract extension, always ask for a raise, even if it’s a small one.

In addition to extended contracts, the other place I’ve lost a lot of time over the years is between assignments. When I say I’ve “lost time,” I only mean that I’ve completed fewer traveling assignments because of all my time off. Most agencies don’t offer paid time off (PTO) unless you’ve done a few consecutive assignments with them. The bad news is you likely won’t get paid for your time off. The good news is that nobody else has a stake in your time off, and you can take as much time as your bank account can tolerate. I spend a lot of my time between assignments visiting family and friends back home, but I also use the time between assignments for some of my best adventuring. There were a couple years where I was ending up with 10+ weeks off per year! Luckily I’ve reeled that in a bit and tend to only have a week or two between assignments.

So far, I’ve talked about two positive things that can account for unanticipated time – prolonged assignments and vacation time. The third way your next travel assignment can be delayed is because you can’t find a job. I’ve written recently on the discussion board about staying flexible as a traveler. The more flexible you are, the less likely you are to remain unemployed. The only times I have ended up unemployed are few and far between – and I’ve never been more than a week without a job. Should you ever find yourself in a position where the job you want is just not popping up in time, re-evaluate and see what your other options are – other adventures await! There are great opportunities available in travel rehab, the only reason you would ever remain unemployed for a sustained period of time would be your own stubborn solidarity to a particular city or a particular practice setting.

Arriving in Juneau on our boat/roadtrip back from Alaska in 2012. One of the coolest uses ever of two free weeks between assignments.

Arriving in Juneau on our boat/roadtrip back from Alaska in 2012. One of the coolest uses ever of two free weeks between assignments.

As you plan to take on traveling as a career, or even for just one year, there will be many places you’ll want to see. You can’t see them all at once, so allow time to get to where you want to be. There will be positive experiences that keep you in areas longer than you intended, and there will be obstacles to getting exactly where you want to go. But, with a little patience, you can turn  traveling therapy into one of the greatest life opportunities ever.

When my wife and I started traveling, we thought we’d travel for two years. We eventually saw everywhere on the original list of places we wanted to see, but haven’t shaken the travel bug yet. Eight years later, we still think two more years will do the trick. Yeah right! Maybe we’ll find our way to that remote Alaskan island someday.

Jack of All Trades

On my very first travel assignment, almost 8 years ago, I quickly started appreciating parts of PT that I never thought I would be working in or ever need to recall from the most doodled-on pages of my college notes. But, there I was, 6 months into my career – that I had originally intended to be as a professional sports PT – and I was standing by a whirl pool doing debridement on a homeless guy. Alex, an experienced PTA with a crazy amount of passion for Physical Therapy, had recently taught me the ins-and-outs of the simple wound care we were performing and why we were doing what we were doing. On this first travel assignment, I was also baptized into the world of prosthetics. Alex taught me about shrinking the stump and different techniques for wrapping and making simple adjustments to the prosthesis itself. Alex was a neat guy who took a “non-traditional” path to being a PTA and was one of my best early mentors. Along with Alex, there was a handful of PTs with varying degrees of experience who were all willing to help me through my first travel assignment. Me, Non-Traditional PTA Alex, and a few other PTs were conquering all the issues of the good blue collar people of Lowell, Massachusetts – and were definitely not doing professional sports PT. The funny thing is, I enjoyed it. Prosthetics was a cool field. Wound care wasn’t anything I cared for, but it was different and new. I even got some early ER experience and found some excitement in the mayhem I would find every time I walked through those doors – cops, crooks, drunks, and broken parts of all kinds. I ended up spending 10 months in Lowell getting some quality mentoring and all kinds of experience in a wide spectrum of PT. This was the first place I experienced the kind of place where you treat “whatever walks in the door” (or rolls in the door), it certainly would not be the last. After a few contract extensions, I triumphantly left that assignment, nearing a year and a half of PT experience under my belt – I knew it all, nothing could surprise me now!

[Just something to listen to while you read – enjoy! About Kaunakakai, where we currently live.]

I’m somewhere around 20 travel assignments now – I’ve worked in about 30 clinics. It amazes me that I have learned something significant and useful on every single assignment. My new knowledge on each assignment comes from both the things my bosses and co-workers are doing well and the things that could be done better. Much of the time, I’m learning something positive directly from colleagues who have become specialists in their own unique mixture of whatever walks in their door. Often my education is purely experiential in working with a new population, a new culture, or in a new setting – home care, inpatient rehab, private practice, acute care, hospital outpatient, ER. There is just so much variety of what you can do with PT and how you can deliver it. At the end of every assignment I make a note of what I may have learned and confidently think, “Now I’ve seen it all, I can’t possibly see something at my next assignment that I haven’t seen before.” I’m being a little sarcastic here, but seriously, after a while, there can’t be too many surprises left… right!?

I knew on this current assignment I would have to be a true generalist and pull from many different parts of my skill-set. On this island, there’s no OTs, no SLPs, no nothing other than one other PT working at a community health center up the road. To really up the anti, there’s just absolutely no where else to find any specialists, there is open ocean between us and anybody else – referring out to someone more equipped for a particular job isn’t an option. We are essentially the only option for whatever ailment you can dream up. I took a phone call last week from a case manager in the large hospital system we are a part of. The main hub of this system is over in Honolulu, and there are many smaller community hospitals throughout the islands that are a part of this health system – although, I can’t imagine any one of these small community hospitals being any smaller or more isolated than Molokai General Hospital (MGH). Anyways, this case manager in Honolulu was wanting to send a Molokai resident back home but wanted to make sure we had both PT and OT for her referral. I explained to her that we do not have an OT here at the hospital and there are absolutely no OTs on the entire island, but that we are used to filling many roles and can handle the patient. The case-manager seemed unimpressed with a reply of, “OK. Thank you,” and hung up. After the call, I realized that in a way, I am fulfilling a very Molokai role. Nobody expects to have every resource available on Molokai, but many people fill multiple roles and help the community as best they can by wearing many hats. Many employees in the hospital have their main role, but then serve an adjunct role as the as infectious disease coordinator, or employee health director, or any other job title you can picture being a full-time position in most hospitals. A funny sidenote: I was talking with someone who was one of 3 employees of the local paper, a transplant to Molokai. She described how word got out that she was decent with computers, and people (mostly older people) started showing up with their computer issues at the newspaper office for her to help. People here don’t expect to have every amenity or service, but they help each other out however they can.

Kate and I have enough years experience behind us in enough different settings that we are able to confidently carry out the vast majority of our responsibilities. At MGH we cover inpatient, outpatient, ER, and SNF (14 beds in the hospital – 7 rooms). We are serving as hand therapists, neuro PTs, the Ortho Specialists that we actually are, and essentially work in the role of rehab specialist on every condition from the age of 1 to 100 with only modest resources. We have a surprisingly great clinic, gym, and staff, but are routinely having patients order equipment they need online – there is a local pharmacy, but it’s pretty limited in the DME department. Kate has taken on the wound care, and while I appreciate having learned some about wound care in the ol’ days with Alex, I’ll pass, thank you. My learning experience on this assignment was revealed to me early on when I realized all the additional roles I would be filling:

Social worker – Kate and I both worked our butts off last week to get 2 SNF patients discharged. We called family members, called outside services, and essentially fully arranged and negotiated these patients’ discharges. Kate even went to her patient’s house to help her transfer out of her car and into her home. Not what you would call billable hours, but good work that achieved great results.We are also a part of a team that is charged with delivering a decision on whether or not to admit SNF patients. The list of variables to consider is huge, since to even get here as a SNF patient, you are typically flying commercial on a puddle jumper. Also, you have to be thinking discharge ahead of admission – there’s no home therapy services, there’s no long-term nursing home, there’s no assisted living. If a person can’t ride a commercial flight with a nurse or be expected to discharge home – they shouldn’t be admitted in the first place.

There are no surgeons. When someone cannot or will not go off island for an Orthopaedic or other surgical consult, we are the next best thing. The PCPs, many of whom we have gotten to know well in a short time, are quick to refer anybody with an ache, pain, or movement dysfunction to us for more specific diagnosis and treatment. We are determining weight bearing status for acute fractures, managing follow-up appointments, and suggesting when someone might need additional imaging. It’s a unique experience to be working with a patient that you know should have surgery, but that off-island surgery is just not a realistic option in his world. I could write another entire blog about performing PT in reality – treating within people’s financial limits, having realistic/sustainable goals for patients, knowing when someone has reached their own individual ceiling of health. When a guy shows up needing a metal plate in his ankle, but that metal plate is a plane ride away that he’s not going to take, that’s when some real-world PT is needed and when we need to decide what the best conservative treatment option is for the patient.

I do feel well equipped for this assignment that requires a wide range of skills and a certain depth of knowledge. I would not recommend this assignment for anyone without a few years experience across a few settings. It’s nice to be in an environment where we get to use a full range of our skills as PTs. Most of the time PTs will work in a setting that sees only a very small slice of the full scope of practice. Sports and ortho is still my bread-and-butter, but I have gained a lot of skills and knowledge in other areas over the years. When I am back in Colorado in the winters, I work for a hospital that practices orthopaedics at a very high level. The patients with various sprains, strains, and fractures are handed down from a team of Orthopods and ER docs that absolutely nail their diagnoses. It’s a nice luxury, but to be honest, my diagnostic skills atrophy severely in the winter from disuse. As I’m bending and straightening joints all day, patients ask , “You had to go to school for 7 years for this?” I defensively explain how making their knee bend is only a very small part of what I learned in school and that PTs are trained across a large variety of diseases and dysfunctions. But, back here, I’m using every last bit of those diagnostic skills and every ounce of my education across a very broad spectrum of pathologies. The health community here may not have specialists or surgeons, but to be as comprehensive as possible, everyone else must work their role to its limits. It’s fun, challenging at times, and definitely a new learning experience.

How Should I be Paid?

With any job, there are a number of different ways you can be paid. There’s straight-forward salary, hourly, or some sort of productivity-based pay. Of course, when considering pay for a typical job, there are things to consider besides just the money – health care, retirement, life insurance, employment-related discounts, and the list goes on. In traveling physical therapy, the list gets a little bit longer and more complicated. A traveling therapist has more say in how he or she would like to be paid and needs to determine how much he would like to weight his taxed versus untaxed wages. There are IRS limits on how much you can take tax free in each zip code, but I have been told that taking those upper limits with low taxed pay can be a red-flag for an audit. So, I typically take $20-$30 hourly (taxed) and get the rest of the pay as stipends/reimbursements. I know a lot of travelers think hourly should be near the normal hourly amount a perm PT makes with the reimbursements being in addition to normal pay, but that’s just not the way it works. A more adventurous travel assignment can have some perks that can make the math of take home pay a bit more complicated: a loaner car from a boss, employee housing, a coworker’s mother-in-law apartment, or other non-monetary compensations.
Productivity arrangements in healthcare can get iffy real fast, think anti-kickback laws. I am not a fan of pay-per-code or percentage of billing situations. These can quickly turn an honest therapist nasty. It’s just too tempting to bill an extra modality or therex that may not be necessary when you know your own bottom line is linked to it – I don’t like it one bit. I’ve seen a number of positions, particularly for therapists in management, where bonuses (boni?) are paid for meeting certain productivity thresholds – number of patient visits or units billed. I occasionally see pay-per-visit systems go awry with a therapist seeing many patients at once, episodes of care dragging on, care extenders over-reaching their scopes of practice, patients getting less attention, and therapists getting burnt out. But, I can’t speak too harshly about pay-per-visit, since it is how I’m getting paid right now. Luckily I’m in a practice where all treatments are provided by PTs 1-on-1 for an hour. With the focus of 1-on-1 patient care, I find the arrangement ethically acceptable, but it’s definitely got its pros and cons. I’m well paid for my hour with a patient, but there is nothing worse than an initial evaluation that no-shows and leaves me unpaid with nothing to do for a full hour. I would encourage anyone considering a pay-per-visit position to first strongly scrutinize the care patients are receiving, and secondly, to ask for a little more money than you normally would, because the chances of batting 1.000 for attendance in any given week are slim.

Advance Healthcare Network

From Advance – Click to access their full report

New travelers are always asking me what they should get paid – I don’t know. Pay varies so much regionally and even town to town. It can be real tough to know if you’re making all you can of if a recruiter is taking you to the cleaner’s. Just find a recruiter you trust and get as much as you can out of each contract. I may try to establish a database where travelers can anonymously input how much they got paid on assignment. It would likely be a small sample size, but may provide all of us some information about what other traveling PTs are getting paid in each state. As I mull over that idea, here’s a nice piece that Advance puts out each year based on their survey results of PT pay. I just stumbled across the APTA Workforce Data page, not as sexy or user friendly as the Advance survey, but lots of good info in there if you click around (APTA Members only).

Some advice for the new traveler: Remember that your recruiter is working on commission and doesn’t get paid if you don’t get hired- it is in their best interest to get you on board even if it lowers their own bottom line. You are a temporary worker for a facility that needs help immediately, you are willing to pick up your life and move to that job to fill a position they desperately need filled – this has big value to it. With all these things working in your favor for higher pay, the costs of travel, furnished apartments, and miscellaneous other will likely cancel out a big chunk of the extra moolah. But, traveling PT can be an exceptional lifestyle that is worth so much in personal experience and growth – so get what you can financially out of a contract, but more importantly, just get out and see some more of this world.

In other news, a series of conversations this week have lead me to believe that the travel PT market is rebounding from a couple of more difficult years, I’m finishing up my SCUBA certification with four dives off the coast of the Big Island this weekend, and (in a crazy out of this world experience that only traveling PT could provide) a hospital has bought Kate and I plane tickets to fly out to interview for a possible once-in-a-lifetime travel assignment this fall – we shall see and more on this later.

Keep living the dream 13 weeks at a time!

Wiki Wiki

The increasing infrequency of my posts is a clear sign that my work hours panned out. Just a wiki wiki (quick) update on the travel and jobs in Kona.

A wave crashes near our campsite in Laupahoehoe last weekend. Real dramatic ocean on this part of the island. There was a tragic tsunami here not too many years back - interesting history everywhere you look.

A wave crashes near our campsite in Laupahoehoe last weekend. Real dramatic ocean on this part of the island. There was a tragic tsunami here not too many years back – interesting history everywhere you look.

The hospital gig, which was a wishy-washy thing from the get-go did not work out. I had tried to get something going at the hospital through one of my go-to recruiters. When he wasn’t able to come to an agreement, my recruiter gave me his blessing to try to establish a contract with the hospital on my own. So I tried. I spoke with the rehab director and later on the contract manager (the fact that they have a full-time position dedicated to manage contracts should have been a dead giveaway to steer clear). They were very encouraging that something would work out for me to be at the hospital. As they requested, I sent them a written proposal of what I would expect in my contract – 2 weeks went by and they requested I establish a contract through one of the recruiters I had used previously. The situation started to feel a little icky since my original recruiter had found the job, and working with another recruiter on the same job can start to cross travel PT ethical borders quickly.  Hesitantly, I went along with it. As everyone who has been doing travel health care for any period of time knows, credentialing for a job can take up a fair amount of time. So, I got underway on getting my paperwork and vaccinations all set for the staffing agency; I did the tedious skills checks online, I requested old varicella titre reports from my alma mater, I took a drug test at one facility, and I went and got my TB test up to date at another facility – all to find out just a couple days later that the contract wasn’t happening. Bummah. At least I got a free TB test out of it…. silver lining? Whatever, ainokea (“I no care”).

Waipio Valley - "Valley of the Kings" - We hiked here after camping in Laupahoehoe. King Kamehameha the Great was raised here and many Hawaiian royalty have had homes here.

Waipio Valley – “Valley of the Kings” – We hiked here after camping in Laupahoehoe. King Kamehameha the Great was raised here and many Hawaiian royalty have had homes here.

BUT, I got lucky, again, and landed on my feet. Everything is coming up James! The private practice prn job now has me booked 40 hours/wk and would gladly book me 50 hours if I let them. That job is doing just fine. And the kicker is that some of the staff at the clinic also work for a local coffee shop up the street, so I have found my Kona Coffee hook-up!

I have to get going, time to get to work. Upcoming island excitement includes a state holiday tomorrow, Kamehameha Day, celebrating King Kamehameha “the great” who united the Hawaiian islands which has previously each been under separate rule. He united the islands primarily through war and execution, and he also ended human sacrifice in the Hawaiian Islands right around the year 1800… different stories for a different day.

We will start SCUBA training this weekend, so that should lend itself to some good stories and pictures.

Aloha!

Feast or Famine

When we last left off (Just Go With It – 5/9/14), I was headed 3,000 miles west out to Hawaii with the verbal assurance that there would be work when I arrived, but without anything in writing. Would there be work when I reached the islands? Would I be a kept man depending on my wife to bring home the bacon? Exactly how much snorkeling can one unemployed PT do in 13 weeks?

After some flip-flopping* back and forth, the work seems like it’s coming. In fact, I think I’ll have too much work in 2-3 weeks.

I arrived here 6 days ago, on Friday night. Luckily, the day before, my employment packet and job offer arrived in the mail from a private practice I have been speaking with. So, I learned how much I was going to be paid hourly if I worked, but had no guarantee of any hours. All there was to do was to get my feet on the ground in Hawaii and hope for the best.

O'hana Papaya

Papaya from the back yard garden! Included in the garden are the following trees that I can identify: 4 papaya trees, 2 mango trees, a hot pepper tree, and a coconut bearing palm tree.

When we arrived, we spent the weekend Craigslisting to find an apartment and a cheap car for the next three months. We found an awesome o’hana apartment! O’hana is the Hawaiian word for family, they call what we know as a mother-in-law apartment an o’hana. Because this island is essentially a big volcano with the top portion sticking out of the ocean, everything is on a hillside, and, therefor, everything has an ocean view. Our ocean view mother-in-law apartment is quite the pad – it also has a pool and a fruit-bearing garden in the backyard. Bugs, mostly cockroaches, are simply a fact of life in Hawaii. When we were out here a few years back, I had an old Toyota Camry with a roach problem. This time around, I have upgraded to a Toyota 4-Runner with a roach problem. I think bigger cars come with bigger roach problems…  back to the contract story.

I didn’t have any wok scheduled for this past Monday, so after dropping Kate off at her job, I popped in to visit the contract manager at the community hospital who I’ve been talking with about setting up an agency contract. All I had heard at this point was “we will need you, we will have work for you.” When I arrived on Monday, the story had changed, “It sounds like we may not need you at all,” says the contract manager. Uh oh, I was depending on there being work when I got out here. So, my efforts were refocused on the independent contract with the private practice. Originally I had told them I would be available Mon/Wed/Fri with the hopes of filling in at the hospital on Tues/Thurs, but with the changes in what I was hearing from the hospital, I offered to work all five days per week at the private practice. Right now, I don’t have a lot of appointments scheduled, but I can see how after evaluations are performed, and a few days go by, the schedule will grow considerably into a full 30-40 hours of work. This one private practice job should be just fine.

This morning, I heard from my recruiter on the hospital job, “James, call me when you wake up, I have good news.” The hospital changed their tune – census is up, and they need some extra help. At this time, I’m feeling conflicted about what to do. The private practice is bending over backwards to accommodate me and to try and fill my schedule. At this time, there’s not a very full schedule, but a couple weeks will fix that – unfortunately, they aren’t will to guarantee any hours. The hours patients are there with me are the only hours I get paid. On the other hand, the gig with the agency at the hospital will pay more and there may be a couple days worth of guaranteed hours.

4runner

The roach mobile, o’hana in the background!

When it rains, it pours. I’m currently working about 10 hours this week with a long-weekend quick approaching, it’s been a nice break, but I need to get back to consistent work. On the horizon, I can potentially expect 60+ hours of work any given week. While the thought of bearing down, working long hours, and stacking up piles of cash is appealing to me, I’m in paradise (again) for 3 months, and I’m not going to blow it by working indoors 60 hours a week.

For now, it’s back to waiting. I’ll have to see what the hospital really wants from me before I commit to anything. If they do guarantee hours, the decisions will get difficult – will I choose the higher paying guaranteed hours? Or will I stick by the practice who has not guaranteed me any hours, but has been good to me thus far?

Time will tell, for now it’s back to researching which beach to camp on for my 3+ day weekend.

Happy Memorial Day! Aloha!

*In Hawaii, flip-flops are called slippahs. example: Take ya slippahs off when ya come in da house, brah.

Just Go With It

I’ve returned to my natural state. Everything I own is in a bag. The rear-end of the car is dragging on the tires from the weight of stuff that will ultimately end up in a storage container. Kate just got home from her last day of work with a bottle of wine. The corkscrew is packed away at the bottom of a box, but at least my camping gear is coming on the trip, so my Swiss Army knife is available. We’re each wearing different white Red Sox shirts as I twist the corkscrew portion of the Swiss Army knife into the cork and pull like hell while hoping not to splash red wine on either of us. Success! It’s going to be a good week off.

Map of lava flow hazard zones for Island of Hawai`i

The USGS’ Lava-flow Hazard Zone Map. I guess we’re supposed consider this when looking for housing? It’s going to be an adventure.

It’s been a wild ride to get this next assignment’s contracts in place. Actually, they aren’t really in place, I’m just going in on blind faith with fingers crossed. Kate got an assignment set in Kona, HI through a recruiter. We thought long and hard about whether Kona was where we wanted to go and what our other options were. When it became apparent that there were some more jobs around Kona and a couple opportunities for independent contracts presented themselves, we committed to Hawaii.

People ask me about independent contracts a lot. Let’s be clear, I am no expert on independent contracts, but I do have a little experience. Whatever I’ve done this time around is not the way independent contracts should be done. I’ve verbally accepted two PRN jobs with no idea what the pay is.

It all started well. I have had two different interviews at places that would like me to work for them. Seems simple enough from there, right? Let’s sign the contracts and get started with work. Unfortunately, neither of the jobs has 40 hours for me, but they both say they have 20-30 hours for me. We have talked pay, but I have no commitment from either job on exactly what the pay will be. I supposedly have a job offer in the mail from the private practice, and the hospital I have spoken with has cautioned me that they are run by the state, so “it can be quite a process to set-up a contract.” I’m antsy to have a contract in hand, but Kate keeps reminding me about “Aloha time.” Aloha time is the Hawaiian equivalent of “Don’t worry, be happy.”

The start of the Ironman Kona swim is right around the corner from my job. The locals call it “The Pier,” and I cannot wait to go get some open water swimming in.

Kate’s right, things are going to go fine, we always land on our feet. I have two places in Kona that want me to work for them and want me to start in under 10 days – that’s a pretty good situation. It’s Hawaii, they’re relaxed, and I should be too. No one else is worried, they expect me to show up on the 19th and start work. Nothing left to do but knock on wood, hop on the plane, and hope someone has scheduled me some patients when I get out there.

Remember, don’t do this. Be more business savvy than I have been. When talking finances of a contract, be clear, be confident. Because I have not been clear or confident when talking about the business parts of my independent contracts, there’s nothing left for me to do but wait and start working on my transition into Aloha time. Patience is a virtue, don’t worry brah.

To Be Continued...

Home is Where

“Where do you live?” It’s a simple question that is likely to be asked at the start of a conversation with any stranger. It’s a question that is easy for most people and that the asker expects a quick answer to.

For any traveling healthcare worker who has been at this for a while, it’s a loaded question. My mind races over a series of responses, “I have an apartment in Maine, but I’m rarely ever there.” “Well, the IRS says I live in…” “I live part of the year in Colorado and keep going back there.” I usually settle on the most simple response, secretly hoping the conversation will change topics, “I live here right now, but I move a lot for work.”

But, NO! They can’t drop the inquisition, it always continues on, “You move a lot? Well where’s your home base? Where are you from? When are you going to settle down? What does your wife do?”

I, again, try to keep the answer simple. Again, hoping the conversation can move along from this complicated topic, “Well my wife is a therapist too, so we move from contract-to-contract together. We’re both from New England, but we’ve been doing this a while now, so we have some fairly scattered roots at this point.” Meanwhile, I’m thinking, “This poor guy was expecting an easy answer. There isn’t one.” Traveling PTs don’t fit most people’s pre-determined mold of what a life, home,and job should look like.

There’s a whole host of issues, social and logistical, that complicate the home question both extrinsically and intrinsically. First is the IRS, travelers live by their rules and we do the best we can to try to maintain a life that fits their rules. Unfortunately, certain states have laws that complicate the picture by having loose standards for what a fulltime resident is and taxing people based on that status. I’m looking at you, Maine! I am certain that there is a traveler out there somewhere who has the perfectly wrong combination of living situations and who is taxed as a permanent resident by multiple states.

Don’t get me going on the system for forwarding mail by the post office. OK, do get me going. Every 3 to 6 months I head to the USPS website and submit my change of address forms. To their credit, the post office usually gets me my mail, but sometimes that mail makes a few stops along the way to reach me. I have attended weddings and received the invitation afterwards. Gad zooks!

The years since starting travel have started to really add up for me. I used to be able to intuitively know how many years ago I was in Hawaii, or how many winters I had spent in Colorado. When I showed up back here 3 weeks ago, I went around telling people it was either my 4th or 5th year coming back, I wasn’t really sure… WRONG! After some counting by figuring out what years I was in which apartment, I have come to the realization that this is winter number 6 (out of the last 7) that I am living out here in Colorado. How can we tell people where we live if we don’t even know!?

On the return, Saturday, 3 weeks ago, Kate and I quickly moved into the same employee apartment building that we have lived 3 years prior. On Sunday, we drove 1.5 hours to the local Costco and stopped by our storage area on the way back. It turns out that in our storage area, with all of our skis, 7 pairs between the two of us, was a ton of stuff that we have accumulated. Kitchen supplies, wedding pictures, snow tires for the car I sold this year, a painting I picked out of the trash at work 4 years ago, a bag of clothes to take to the local consignment store, beer brewing kit, computer printer, and our beloved 18 inch Christmas tree. I hesitate to say we keep a lot of junk here, because most of it has a purpose, but we do have a lot of “stuff” here. By Monday morning at 10, we had our ski passes and we were on the mountain where, by chance, we ran into a group of friends and skied with them all day. On Tuesday, Kate and I returned to work where we were greeted with hugs, a one-hour orientation, and quickly slipped into a seamless afternoon full of patients. Yeah, this is familiar, good friends, the old apartment, great job, and all my… “stuff.” Since the first year here, unlike many other places I’ve lived, people are willing to quickly include me in the small group they call “locals.” It’s tempting to call this “home” or to at least be less committal and admit that I live here, because I do have an established life here.

Back on the ski lift, a familiar conversation ensues, “Where do you live?”

“Here.” “… in the winter. This is my 6th season.”

The quick response, “Where do you go the rest of the time?”

Here we go again. Why doesn’t this conversation get any easier? 🙂

I used the word “inquisition” above, so this video seems pertinent. Until next time, travel safe!