Calling for Backup

As the emergency room has become the primary-care provider for millions of uninsured and underinsured Americans, on-call coverage has become an increasingly contentious issue between hospitals and their admitting physicians. At most hospitals it’s still standard protocol to serve time on-call in the ER in exchange for medical staff privileges. But tradition may be on its way out as many specialists now consider call coverage to be a legal and financial risk that’s not worth taking.

Under the 1986 Emergency Medical Treatment and Active Labor Act, which aimed to prevent hospitals from turning away patients who are unable to pay, Medicare-participating hospitals with an ER must maintain an on-call list of participating physicians.

But a technicality within EMTALA specifies that while hospitals are required to provide services, physicians are not. The oversight may be slight, but it’s significant. “Those who do participate under mandatory or voluntary medical-staff rules feel exploited. Many have resigned from this responsibility, leaving huge gaps in our ability to treat patients,” says Loren Johnson, M.D., director of emergency services at Sutter Davis (Calif.) Hospital and chief medical officer of Sutter Emergency Medical Associates in Sacramento. “EMTALA is a well-intended law aimed at taking care of patients, but as an unfunded mandate, it has severely damaged our emergency care infrastructure and has become a false promise for patients,” he says. Some go so far as to call EMTALA “America’s biggest health plan,” Johnson adds.

No more volunteers

Paying for on-call coverage has become the solution of choice. The percentage of hospitals paying stipends to specialists jumped from 8 percent in 2004 to 36 percent in 2005, according to an American College of Emergency Physicians survey of ED directors. The idea may still be a novelty in many areas, but as physician-hospital ties continue to loosen, the notion of offering payment in exchange for ED coverage is popping up with greater frequency.

A number of factors are driving physicians away from ED coverage. Many say they face increased risk of liability because the same uninsured and unassigned patients who frequent ERs are perceived as more likely to file malpractice suits. But lost financial opportunities rank as the most common complaints. Costs range from providing care to those who can’t pay to time spent away from paying patients waiting in the office.

As physician-owned facilities—which generally lack emergency services—enter a market, physicians have tangible alternatives to the community hospital for privileges and may be able to free themselves of on-call duties more easily.

Holdouts remain, for now

A brief by the California HealthCare Foundation estimates that the total amount of stipends paid out by California hospitals rose from $200 million in 2000 to $300 million in 2005. While payment for coverage has been in place for several years in some states, not all parts of the country are feeling the pinch just yet.

Donna Sweet, M.D., director of Internal Medicine Education at 450-staffed-bed Via Christi Medical Center in Wichita, Kan., says the hospital has been able to keep ED coverage mostly a bylaws issue. Currently, Via Christi subsidizes only trauma surgeons and oral surgeons for call; the rest provide coverage on a voluntary basis. “There are physicians who don’t participate, and if so we don’t keep them on the medical staff,” says Sweet. “However, if you have a spot where you’re really uncovered, then you figure out if there’s some group you have to pay to do it.”

But Sutter’s Johnson says paying select physicians isn’t always a sound decision. “Paying a select group of complainants is a formula for jealousy and failure and a tremendous generator of hostility on the part of the medical staff,” he says. “As soon as you pay one, you’re going to have to pay all the others, and you’ll have a pretty long line of angry physicians outside the administrator’s door.”

Rather than have the administrators dictate the terms, Johnson says, a hospital is wise to ask the medical staff to undertake the task of figuring out what kind of payment plan works best. By allowing them to come to their own conclusions about fair value compensation, the physicians can take ownership of the plan.

Boca’s design

Boca Raton (Fla.) Community Hospital has taken a comprehensive approach to paying physicians for call. Its nearly two-year-old per-diem plan pays specialists for the days they’re on call. The hospital used physician forums to debate issues, and a group of representatives from medical leadership, the ER, administration and the board analyzed the payment models and oversaw implementation. The per-diem plan won out over other options due to its simplicity, says Richard Greenwald, M.D., vice president of medical affairs. Paying a standard amount negates the need to collect payment for the physicians based on their fees and redistribute it as other plans require, says Greenwald.

Boca Raton’s committee created a range of 17 specialties that need mandatory coverage to provide adequate care, including psychiatry, cardiology, neurology, general surgery, thoracic surgery, vascular surgery, orthopedic surgery, pediatrics, urology and plastics. The committee then developed a grid to add objectivity to a mostly subjective process. According to Greenwald, the grid tried to predict the liability risk, the frequency of call, and the likelihood of actually being summoned. The grid further separated the selected specialties into two payment tiers based on need.

When internal medicine and neurosurgery calls were found to be lacking in numbers, Boca Raton took steps to balance the coverage. To help cover internal medicine, the hospital created a hospitalist program. To fill the neurosurgery gap, the hospital worked with its neurosurgeons to recruit a new physician to the area.

Before Greenwald “went over to the administrative dark side,” he covered the ER as a gastroenterologist. Although he says the idea of paying physicians for call was “foreign” at first, administrators realized that the 50-year-old bylaws no longer held water. “Physicians were increasingly looking at ER call not as an opportunity to help build their practice, but as a much more onerous responsibility,” he says. Many hospitals in Broward County, just south of Boca Raton, were moving to paid call plans, so the medical center leadership opted to be proactive and develop a payment system before it became a problem.

Because they were involved with administration in a collaborative basis, Greenwald says Boca Raton’s physicians have taken more of a team approach to the effort. “There’s a single plan as opposed to a bunch of individually negotiated plans based on who’s making the most noise at the moment.”

Kara Olsen is a staff writer with HealthLeaders magazine. She may be reached at kolsen@healthleadersmedia.com.