Getting enough of, and the required type of specialists to take call in the ED to meet legal and functional requirements has become much more difficult in the last five years for more than half of California hospitals whose CEOS or emergency department managers responded to a survey.
Additionally, 12% of 110 hospital officials who answered questions said the problem is a serious one, while another 55% said it is "somewhat of a problem."
The survey responders said the number of specialists such as orthopedists and neurosurgeons willing to take call is expected to decline relative to the number of newly insured patients who need them in coming years. And, it is worsening especially for rural and critical access hospitals, because specialists are less likely to live in those areas.
The survey, "Physicians on Call: California's Patchwork Approach to Emergency Department Coverage," was conducted by The Performance Alliance with the University of Southern California a Center for Health Financing, Policy and Management and was released by the California HealthCare Foundation.
Of the CEOs and emergency department directors who responded to the poll, 88% say they've had to accept that they have to pay for specialty call as "a cost of doing business" and is "a line item in our budget."
More attention is being focused on how emergency departments can make sure they have the appropriate specialists on call, to provide care and satisfy requirements of the federal Emergency Medical Treatment and Active Labor Act (EMTALA). That's because so many more currently uninsured patients will have coverage under provisions of healthcare reform legislation.
For California's 350 acute care hospitals, that number is expected to 3.5 million to the 7 million people currently eligible for the state's Medicaid program (Medi-Cal).
In 2008, according to another report published in the Journal Academic Emergency Medicine, only 60% of California's emergency departments reported having cardiac surgery, otolaryngology, neurosurgery, plastic surgery, or vascular surgery specialists available. And there's no reason to think the situation has improved in two years.
Medi-Cal reimbursement rates are so low, that about 80% of the program's beneficiaries receive care from 25% of California physicians, part of a declining number of doctors willing to accept Medi-Cal as payment. It's hard, if not impractical, to expect specialists to take ED call without some guaranteed methods of compensation, the survey report explained.
"Because Medi-Cal enrollees are more likely to use EDs than the uninsured, enormous impact on EDs and on-call coverage is envisioned," the report says. Nationally, according to the American College of Emergency Physicians survey in April, 2010, 70% of ED physicians believe visits will continue to rise, while 54% predict that the number of specialists willing to take call in the ED will drop.
The report notes that California's call coverage problems must be handled differently than those of hospitals in most other states because the state's bar on the "corporate practice of medicine" precludes most of the state's hospitals (academic medical centers and government owned facilities are exempted) from directly employing a physician.
To grapple with this dilemma, the report highlights, a number of California emergency departments are launching various strategies to make sure their call coverage meets legal requirements, and to brace themselves from anticipated surges in coming years.
To figure out ways to make sure call coverage requirements are met, hospitals are grappling with a number of compensation strategies. No longer can they be relied upon to provide call merely on the promise of insured or otherwise covered patients. Mandatory call for physicians granted staff privileges, "has sharply declined in recent years," the report said.
Only 60% of emergency departments reported having cardiac surgery, otolaryngology, neurosurgery, plastic surgery or vascular surgery specialists available, the report said. For 10 of 16 specialties, the number willing to take call has been diminishing, according to study published in the Journal Academic Emergency Medicine that was referenced in the California report.
Other points made by the California report include the statistic that on call expenses for trauma designated hospitals in the state have risen 8% annually between 2001 and 2008, "to almost $13 million" average per hospital. But for emergency rooms of hospitals without trauma care, costs have risen 16% per year, from $1.8 million to $4.9 million, for a collective estimated total of $1.6 billion.
• Stipends as a form of paying for specialty physician call are growing, from 63% in 2003 to 81% of the state's hospitals. They remain ubiquitous, but are "susceptible to cost escalation" and are unsustainable, the report said.
• An emerging payment format that encourages hospital-physician collaboration has been the clinical co-management agreement, or "CCMA," in which a hospital contracts with physicians for medical directorships, and which have pay-for-performance metrics above the base pay rate.
• So-called Third-Party systems are less common, but involve organizations that recruit and credential physicians and schedule, pay and monitor them for the on-call staff. The doctors sign over their receivables to the hospital, and in return receive a guaranteed reimbursement.
• Compensation Pools are payment systems in which a hospital allocates a fixed budget from which specialists are paid for otherwise unfunded care.