Does the Size of Travel Nursing Companies Matter for the Travel Nurse?
I’ve been in the travel nursing industry since 2006. For as long as I can remember, travel nurses and agency staff alike have highlighted the differences between large travel nursing companies and small travel nursing companies. So, in this article, we’ll define big versus small travel nursing companies and discuss how the size of an agency may or may not affect the services they provide.
What People Say About Travel Nursing Agency Size
Before we begin, let’s take a look at some of the most common narratives pertaining to the size of a travel nursing agency. For example, people typically claim that small travel nursing companies provide better service than their larger counterparts. Another common narrative is that smaller travel nursing agencies pay more for the same assignments.
As we’ll discuss below, these narratives aren’t always so cut and dry. Understanding the nuances will help you find travel nursing agencies that can meet your needs. But first, let’s take a look at what it means to be big or small as a travel nursing agency.
Large, Medium and Small Travel Nursing Agencies
Now I’ll admit that fitting agencies into categories can be a bit unfair to them. Doing so can characterize the agencies, and these characterizations may not always be 100% accurate. However, categorizing the agencies provides a framework that helps us understand their challenges, advantages, disadvantages, and organizational differences. Understanding these issues will assist you in getting the most out of your travel healthcare experience.
Perhaps the most common method of categorizing agencies is by size. For all intents and purposes, there are large, medium, and small agencies.
Large Travel Nursing Companies
The largest travel nursing agencies include companies like Aya Healthcare, AMN Healthcare, Medical Solutions and Cross Country. Some of these companies are publicly traded, and others remain privately held.
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Most of them have annual revenue greater than $1 billion. Aya Healthcare, currently the largest company in the industry, may have annual revenue greater than $7 billion.
Viewed this way, large travel nursing companies represent a relatively small percentage of the total number of travel nursing companies.
Despite all of the negative press they receive, they’re big for a reason. They’re very good at what they do.
Common Organizational Characteristics
Many large agencies have highly structured internal staff organizations with specific teams responsible for handling each aspect of the business. For example, Account Management teams are responsible for serving current client (ie hospital) needs, and signing up new clients. Travel nurse housing departments are responsible for finding and securing housing for all employees requiring this service.
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Travel departments handle any flight arrangements or transportation details. Compliance and credentialing departments handle all issues pertaining to credentialing and compliance. Payroll teams handle all issues pertaining to payroll. Benefits teams handle all issues pertaining to company-provided benefits.
Recruiters are responsible for contacting and signing up new travelers. There may even be customer service teams to handle all inquiries from travelers currently working with the company.
The idea is that everyone stays in their lanes in an effort to achieve maximum operational efficiency.
Small Travel Nursing Agencies
Small travel nursing companies include companies like ADN Healthcare, Lark Medical Staffing and Smarter Healthcare Partners. These companies are typically founder led. Also, it’s more likely that they are not backed by private equity or venture capital firms.
Most of them have annual revenue less than $50 million. Viewed this way, small travel nursing companies represent a relatively large percentage of the total number of travel nursing companies. In fact, they are the largest cohort in terms of quantity.
Common Organizational Characteristics
Organizationally, small agencies are almost the exact opposite of large agencies. Small agencies have far fewer internal staff than their larger counterparts. These companies may operate from a home office, remotely or utilize only a small office space.
Typically, recruiters at small travel nursing companies are responsible for nearly every aspect of the recruitment process. This might include credentialing, housing, benefits, and certain aspects of payroll like time card collection.
It’s also common for the owner of a small staffing company to directly manage the recruiting and account management aspects of the business. While these companies may have employees to fill roles like payroll, benefits or bookkeeping, this type of dedicated back-office support staff is relatively limited.
Medium travel nursing agencies
There’s a reason that I’m describing medium agencies last. They’re kind of a cross between the large and small agency. Medium sized travel nursing agencies include companies like Advantis Medical Staffing, Stability Healthcare and KPG Healthcare. These companies may or may not be founder led. They may or may not be backed by private equity or venture capital firms.
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Most medium agencies have annual revenue between $70 million and $500 million. Viewed this way, there are far more medium agencies than large agencies, but far fewer medium agencies than small agencies.
Common Organizational Characteristics
Organizationally, medium sized travel nursing agencies may operate like small agencies, large agencies or a combination of the two.
Nothing Is Set In Stone
As I mentioned above these characterizations don’t always hold true. For example, FlexCare Medical Staffing has an organizational structure that makes the service they provide to travel nurses more akin to the description I provided for small companies. Specifically, they have a service feature they call “SinglePoint”. Essentially, travel nurses speak only with their recruiters about all service-related matters which makes the service FlexCare provides more like a smaller agency’s service.
So, do smaller travel nursing agencies provide better service than their larger counterparts?
Do Smaller Travel Nursing Agencies Provide Better Service than Larger Travel Nursing Agencies?
If we look only at the reviews travel nurses leave for agencies on review websites, then one could make a fair argument that smaller travel nursing agencies provide better service than their larger counterparts. However, your experience with any travel nursing company may depend entirely on your recruiter. Moreover, these reviews can’t account for many services that go on behind the scenes. Let’s unpack these issues.
Do Smaller Travel Nursing Agencies Have Better Reviews?
I’ve been collecting review scores for travel nursing agencies from multiple popular review websites annually for nearly ten years. I do this for our annual list of the best travel nursing companies.
Small and medium travel nursing companies tend to dominate our annual list of the best travel nursing companies. Therefore, it would seem as though these companies tend to have higher review scores than their large counterparts.
That said, there are caveats that we need to consider. First, there are far more small and medium companies than there are large companies. Therefore, it’s possible that the small and medium companies dominate our list due to sheer volume.
Similarly, several large companies have made our annual list repeatedly. For example, Medical Solutions, Triage, FlexCare and Fusion have all been on our annual list multiple times.
The point is that in order to conclusively say that small companies have better reviews, we’d need to do an analysis that measures companies with great reviews as a percentage of the total number of companies in that category.
Finally, I’ve come to learn that many agencies actively solicit reviews from their travel healthcare professionals. That doesn’t mean the reviews are fake.
Instead, it means that companies that do this will have review scores that more accurately depict their service. That’s because people who receive bad service are more motivated to leave reviews in the first place. So, companies that don’t solicit reviews are prone to receiving a disproportionately higher number of bad reviews.
The Narrative That Smaller Agencies Provide Better Service
That said, the most common narrative pertaining to the issue of service on social media and blogs dedicated to travel nursing contends that small and mid-sized agencies tend to offer more personalized and personable service.
As the story goes, at small and mid-sized agencies, you’ll often have only one point of contact, your travel nurse recruiter. You’ll contact your recruiter for anything and everything, and your recruiter will know everything there is to know about all aspects of your contract and your personal circumstances. In addition, you’ll work with only one recruiter no matter where you take a job, or what specialty the job is for. All of this tends to ensure continuity of service.
When it comes to large agencies, the conventional wisdom contends that you’re just a number. As the story goes, large agencies deal in volume at the sacrifice of service. You’ll have to talk to the benefits department for any problems with your medical benefits, and to the housing department for any problems with your housing, and to the payroll department for any problems with your pay. You’ll find that these departments may be unaware of the conversations you’ve had with your recruiter regarding these issues, so you’ll have to explain again. As a result, the process is more tedious.
These narratives exist because there’s some truth to them. Therefore, you’ll definitely want to ask questions geared toward determining how agencies operate from a service standpoint when you’re evaluating travel nursing agencies.
How Travel Nursing Recruiters Affect Service
However, at the end of the day, the specific recruiter you work with plays a big role in the service you’ll receive from any company, large or small.
For example, AMN Healthcare, one of the largest travel nursing companies, has pretty poor online reviews. You’ll also see many nurses on social media stating that they received bad service from AMN Healthcare.
However, every time that happens, a large number of nurses chime in saying that they receive amazing service from AMN Healthcare. In nearly every case, those nurses describe how awesome their recruiter is.
Similarly, I’ve seen nurses complain about horrible service received from a recruiter working with a smaller company that has amazing online reviews.
How Circumstances Affect Service That Travel Nursing Agencies Provide
Sometimes, unique circumstances can affect the service a travel nurse receives from a particular recruiter or travel nursing company. For example, I agree that it’s great to receive personal service from a recruiter who is your single point of contact with a company. However, that recruiter is also responsible for every aspect of service for every other travel nurse that he or she works with. That can get overwhelming for the recruiter at times.
During such periods, the recruiter may need to prioritize more urgent tasks ahead of yours. Service levels can suffer as a result.
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Additionally, you may not recognize that your recruiter is failing you in less obvious ways during these periods. For example, the recruiter may be failing you on finding your next job. This is one of the reasons that larger agencies tend to have higher retention rates. You may be just a number, but you’re a number that they really want to keep. The recruiters and Account Managers at large agencies tend to be laser focused on making sure that you’ll have your extension or next job lined up in advance because that’s the primary focus of their job.
Relationships Matter
The Account Managers at medium and large travel nursing agencies are typically dedicated to servicing the needs of the facilities and VMS’s they work with as well as landing contracts to staff new facilities and VMS’s. Therefore, larger agencies tend to have stronger relationships with their clients.
As a result, larger agencies tend to have higher placement rates and higher retention rates than their smaller counterparts. This means that travel nurses tend to have a higher chance of landing jobs through larger agencies.
The Travel Nursing Company’s Job Volume
In addition to service, job volume is another key issue to consider when you’re comparing travel nursing agencies based on their size. In general, large agencies tend to have a larger selection of jobs than their smaller counterparts. This is because they have contracts to staff more facilities than smaller agencies. That’s part of what makes them large.
You can expect medium agencies to have fewer contracts and small agencies to have even fewer still. This is not to say that all is lost for these agencies when it comes to providing you with the options you need.
In fact, some medium and small agencies have job volumes that are similar to, and sometimes greater than, their larger counterparts. How is that possible?
Well, some of the largest agencies in the business simply do not play nice with each other. So, these agencies do not share their MSP job orders with each other. Meanwhile, some medium and smaller companies play nice with everyone. Therefore, they can gain access to job orders from everyone and ultimately wind up with quite sizeable job volumes.
Additionally, some medium and small agencies do an excellent job of focusing on a specific niche, or region. For example, there are agencies that specialize in working with Operating Room Registered Nurses, or Ultrasound Technicians.
Other agencies may focus on a specific region, or market. For example, some agencies provide services only for California, or only for Florida, or only for some large metropolitan area like Chicago. Niche agencies may have available jobs for their specific area of focus which can be comparable to the offerings of even the largest agencies.
Ease of Use
Ease of use is another service-related issue we must consider when comparing travel nursing agencies by their size. Larger agencies tend to have websites, job boards, and native smart phone apps that are much more user friendly than those of their smaller counterparts.
Travel Nursing Pay and Travel Nursing Company Size
Of course, we must also consider the issue of pay when we compare travel nursing agencies by their size. You’ll routinely see people on social media say that smaller agencies pay better because they have lower overhead costs.
The logic seems sound on the surface. That logic contends that larger companies have larger offices, more internal staff, larger advertising budgets, and so on. As a result, they have to keep a higher percentage of the bill rate to cover the costs, which results in less pay for the nurse.
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While this may be true to some degree, my experience has proven that there is much more going on than this simple logic accounts for.
You see, large companies realize economies of scale that small to mid-sized companies are unable to realize. For example, larger companies buy in bulk and therefore receive bulk discounts on things like medical insurance, lodging, office space and more.
Similarly, larger companies actually tend to spend less on a per unit basis for things like advertising. As I mentioned above, they tend to have higher placement rates and higher retention rates. These metrics dramatically improve their unit economics.
Larger companies may also operate with fewer internal staff per contractor. So, while they may have more internal staff overall, they might still have better unit economics for this key metric of profitability for any staffing agency.
Additionally, large agencies may be generating revenue in other ways. For example, AMN Healthcare owns a continuing education site called RN.com. In fact, AMN Healthcare operates over 20 websites.
Other companies have highly successful blogs that allow them to advertise their services. I can’t be certain about this, but I suspect that all of this revenue makes its way to the bottom line, and could possibly afford these large agencies the leeway to offer better pay rates.
Finally, larger companies start out with higher bill rates on any jobs for which they act as the MSP. This is because the MSP typically charges sub-vending companies a management fee which is a percentage of the bill rate.
How Do Smaller Agencies Compete?
All of that said, all is not lost for smaller agencies. For example, smaller agencies could operate with lower gross profit margins. For example, a large travel nursing agency might keep 25% of the bill rate while a smaller agency might keep only 15% of the bill rate.
Also, smaller agencies may offer much more flexible pay packages. Larger agencies have a tendency to maintain boiler plate type travel nursing pay packages. For example, they’ll often offer the same stipends no matter where you go.
In this case, the smaller agencies’ flexibility might help them avoid certain expenses while helping travel nurses keep a higher percentage of their own gross pay. For example, if a smaller agency offers higher non-taxable stipends, then their payroll costs will decrease. In turn, they could pass that savings on to their travelers.
Smaller agencies may also exhibit greater flexibility with housing options for their agency-provided housing. Large agencies often have specific housing locations in any given area. Also, with larger agencies you may have no say at all in the housing choice. They will often put you only where they have availability.
Meanwhile, smaller agencies may be willing to provide you with several housing options, each with different prices. You can then select the option that best suits your needs. This can come in handy when you’re travel nursing with pets. A smaller agency may be better able to accommodate pets because they’re willing to search for a housing option that accepts pets.
At the end of the day, I’m not guaranteeing that large agencies will pay you more. All I’m saying is that you can’t assume that they will pay you less.
There are many advantages to being large. Many of these advantages involve significant cost savings. As a result, a large agency may be able to pay you the same as, or more, than a smaller competitor. In order to know for sure, you’ll need to conduct an apples-to-apples comparison of all the pay packages you receive.
With all of this in mind, it’s important to once again note that these are all generalizations. As we all know, generalizations don’t always hold true. And as many travelers will tell you, whether or not you have a good experience with a travel nursing company will most likely boil down to your recruiter.
