Locums agencies bill hospitals about 1.6 times what they pay you. The math from SEC filings and a calculator for your own offer.
633 verified submissions from EM physicians1099-equivalentfigures as of October 2026
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Negotiating with EM locums agencies can be an opaque and frustrating process. The agency is the only party in the negotiation that knows how much the hospital actually pays to staff the physician, while the physician only sees what they are offered. The contracts that contain hospital bill rates are considered trade secrets and often kept under non-disclosure agreements in order to preserve this asymmetry. Fortunately for us, two major locums agencies were public companies in 2025 and filed their earnings with the SEC, giving us an opportunity to see how much physician labor is actually marked up.
Locums agencies bill roughly 1.4x to 1.8x what they pay you, with the central estimate closer to 1.6x. Where you land in the range largely depends on how you estimate variable costs, such as malpractice and travel expenses. The bill rate is what the hospital pays the agency per hour. The pay rate is what the agency pays physicians. The SEC filings report neither of these values, but they can be derived from the values they do report: revenue, cost of revenue, and gross margin.
Both AMN and Cross Country Healthcare reported 10-K SEC filings in 2025. AMN reports locums and permanant search together inside a Physician and Leadership Solutions segment, while Cross Country Healthcare reports a Physician Staffing segment that is almost purely locums. Cross Country Healthcare went private again in July of 2026, so its 2025 10-K filing is the last public view of a nearly pure physician locums staffing business. Cost of revenue is reported by AMN and Cross Country Healthcare to be physician pay, travel, lodging, allowances, and insurance. As we'll see later, the reported gross margin actually leaves out their operating costs, such as recruiting, credentialing, and other overhead.
| Company · segment | Year | Gross margin | Revenue ÷ direct cost |
|---|---|---|---|
| Cross Country Healthcare · Physician staffing | 2023 | 21.9% | 1.28× |
| Cross Country Healthcare · Physician staffing | 2024 | 20.3% | 1.26× |
| Cross Country Healthcare · Physician staffing | 2025 | 20.4% | 1.26× |
| AMN Healthcare · Physician and leadership solutions, excluding permanent placement | 2023 | 26.8% | 1.37× |
| AMN Healthcare · Physician and leadership solutions, excluding permanent placement | 2024 | 24.9% | 1.33× |
| AMN Healthcare · Physician and leadership solutions, excluding permanent placement | 2025 | 23.5% | 1.31× |
Cross Country Healthcare's Physician Staffing segment achieved ~20-22% for the previous three years in a row. AMN's Physician and Leadership Solutions segment shows a higher margin, but its numbers have to be adjusted. This segment reports permanant physician and interim leadership search in addition to locums staffing, which comparatively have much lower cost due to the lack of travel and malpractice. We're able to remove permanent search due to separately disclosed margins, however the interim leadership numbers cannot be teased out, leaving a margin of 23.5-26.8%. Using the highest and lowest reported gross margins reported above, the range is 20.3-26.8%. Notice AMN's gross margin has been decreasing for three straight years, citing downward pressure driven by higher provider pay packages.
It's important to note that the margin is not the difference between the hospital bill rate and the physician pay rate. Plugging in the 20.3% to 26.8% band from the filings into our equation shows that agencies bill 1.26x to 1.37x of their direct cost. The difference is actually larger since physician pay is only a portion of direct cost. To arrive at the hospital bill rate, we use
| Segment | Physician pay, housing, travel, insurance | Recruiting, credentialing, overhead | Segment profit |
|---|---|---|---|
| AMN Healthcare, Physician and leadership solutions, FY2025 | 72.4% | 19.4% | 8.1% |
| Cross Country Healthcare, Physician staffing, FY2025 | 79.6% | 11.9% | 8.5% |
The agencies report their direct costs as separate from operational costs. Expenses such as recruiting, credentialing, and overhead for the agencies are actually contained within the previously reported margin, leaving only ~8% in either segment as actual profit.
The filings list their direct costs as physician pay, travel and lodging, and insurance. While the filings list a description of what their direct costs are, they do not discuss the composition. In order to determine the relationship between bill rate and pay rate, we have to determine what proportion physician pay makes up of the direct cost. The cost of malpractice insurance in emergency medicine is variable and largely dependent on where you work. Public sources for malpractice premiums are generally hard to find, but as it turns out, the state of Maryland publishes malpractice premiums as part of a consumer advocacy initiative. The general estimate runs from about $20,000 per year up to $90,000 per year. Assume a lower estimate for locations in middle America, rural locations, or states with strong tort reform. Assume the middle to high end of this range for coastal locations, states with less physician protections, and metropolitan areas. The cost of travel and lodging depends on method of travel and duration of blocks. We can estimate costs at the low end to represent about $10/hr for physicians only requiring lodging, up to $37/hr at the high end for physicians requiring last minute, out of state travel and rental cars.
| Per hour | Low costs | Central | High costs |
|---|---|---|---|
| Physician pay (national 1099 median) | $290 | $290 | $290 |
| + Malpractice | $14 | $38 | $63 |
| + Travel and housing | $NaN | $NaN | $NaN |
| = Direct cost | $NaN | $NaN | $NaN |
| Pay as a share of direct cost | NaN% | NaN% | NaN% |
| Bill to the hospital (20.3%–26.8% margin) | $NaN–$NaN | $NaN–$NaN | $NaN–$NaN |
| Bill ÷ pay | NaN×–NaN× | NaN×–NaN× | NaN×–NaN× |
An estimate, not a filed figure. The central column is the midpoint of each range. Sources: Maryland Insurance Administration, medical liability rate guide, October 2025 · GSA FY2026 per diem rates, Federal Register 2025-15771 · Bureau of Transportation Statistics, average domestic air fare, Q1 2026 · CoStar/STR, US hotel results for 2025 · Empower, car rental prices 2025 (citing Hopper).
$290/hr is the median rate reported among the 283 physicians who reported 1099 income to Moonlighter's dataset. The table uses this rate and the assumed costs to estimate the markup on the bill rate for different scenarios. Physician pay is at least 74% of an agency's direct cost under the most generous assumption of other costs. A higher than median rate or lower costs drive that share even higher.
Enter a rate to see it.
Enter the rate you were offered and your costs using your actual numbers or an estimate based on the table above. Knowing what the agency bills in your name can help you negotiate a fair rate. When a hospital will contract directly, the markup can be split.