| name | bill-rate-margin-modeling |
| description | Decompose staffing margin into bill minus pay minus burden, itemize the burden stack, and locate whether a compression is pricing, pay, burden, or mix — before anyone calls it a pricing problem. Reach for this when gross margin or spread is moving and the cause is unclear. |
Skill: Bill-rate / margin modeling
A "margin is down" finding with no decomposition sends operators to reprice when the problem is often a burden line or a mix shift. This skill decomposes before diagnosing (§3 #3).
Step 1 — Write the identity
Margin $ = bill − pay − burden. Margin % = (bill − pay − burden) ÷ bill. Compute both for the period in question and a healthy baseline. Never reason about margin % without the dollar bridge — a % move can be a denominator (bill-rate) effect.
Step 2 — Itemize the burden stack
Employer payroll taxes (FICA/FUTA/SUTA), workers' comp, professional/general liability + malpractice (heavy in locums), benefits, housing/lodging/per-diem stipends + travel (travel nursing), credentialing/onboarding cost, and bench/idle time. Pull each as a line; compression hides here more than in the headline markup. See ../../knowledge/healthcare-staffing-economics.md §1.
Step 3 — Run the four-way attribution
Decompose the margin move into:
- Bill rate down — rate-cycle pressure, MSP caps, or mix to lower-bill segments.
- Pay rate up — candidate-supply scarcity forcing pay.
- Burden line up — which one (malpractice? stipends? bench?).
- Mix shift — more low-margin per-diem / less high-margin allied, at the portfolio level.
Quantify each contribution; usually one or two dominate.
Step 4 — Place it against the rate cycle
A travel-nurse bill rate is only "low" relative to a dated benchmark — anchor to the SIA/NATHO series (~$133→$90/hr, 2022→2025) with the date. An operator anchored to 2021 peak rates will misread a normalized rate as a crisis (§3 #9).
Step 5 — Check bench/idle and redeployment
Unbilled bench time is a margin leak that looks like a rate problem. If idle time is the driver, the lever is redeployment rate (the cheapest placement), not pricing.
Step 6 — Flag the compliance landmines, don't advise on them
Per-diem stipend structure (IRS tax-home rules) and worker classification (1099 vs. W-2, gig-platform reclassification) are margin levers and legal exposures. Surface them; route the actual treatment to the client's tax/legal counsel. Do not give the advice.
Step 7 — Output the bridge
A waterfall from baseline margin to current margin with each driver's contribution, the dominant line named, and the recommended lever (reprice / renegotiate burden / shift mix / cut bench) with its expected movement.
Reference
Economics + burden detail: ../../knowledge/healthcare-staffing-economics.md. Decision tree: ../../knowledge/staffing-decision-trees.md (Margin/spread tree). Template: ../../templates/bill-rate-margin-model.md.
