ABSTRACT
Recent polls find hospital physician
leaders are having major problems maintaining
ED call coverage, there is no consensus
on whether to pay physicians for call,
and that most feel that physicians refusing
to care for uninsured patients is a major
ethical problem (1).
The basic issue is how to maintain call
coverage, and the experience
of trauma centers over the past 15 years
provides excellent guidance on how to do
it right – and wrong. A proactive
leadership strategy is the key to an effective
solution, which before payment, should
address medical staff structures, hospital
support, and emergency care operations.
1. THE ED CALL CRISIS HAS ARRIVED
Obtaining Emergency Department (ED) and
trauma call coverage is a far-ranging and
far-reaching problem that physician executives
must confront constructively. The issue
is of national importance and has increased
urgency in regions where managed care penetration
and the number of uninsured patients are
highest.
Major factors eroding physician support
for voluntary ED call include:
Call Conflicts With Private Practice
The unpredictable demands of ED call are
frequently incompatible with private
practice. No physician wants to neglect
scheduled office patients or delay scheduled
procedures. The economics of office practice
preclude extended office hours.
Call Conflicts with Physician Lifestyle
 Since a fair amount of ED calls occur at
night or weekends, physicians see the impact
of ED call coverage as undesirable to their
lifestyle and well-being. Physicians, along
with Air Force pilots, are placing a higher
emphasis on time with their families.
Increasing Burden of Uninsured Patients
The emergency department’s share
of uninsured patients is expanding along
with the overall uninsured population.
Hospital & ED
Capacity Constraints
Hospital and ED capacity has contracted
for the last decade while the sheer volume
of ED visits has increased 20% (2).
In addition to increasing numbers of
uninsured
patients,
recent studies demonstrate that insured
patients are relying more on the ED because
physician office appointments are increasingly
harder to obtain.
EMTALA Inequities
The 1986 Emergency Medicine Transfer and
Active Labor Act has created an unfunded
mandate with harsh penalties for noncompliance
by either the physician or the hospital,
and the service pricing policies and exclusionary
panels of many insurers add the risk of
under-reimbursement to nonpayment.
Physician Shortages
Relative shortage in key specialties
complicated by high demand reduces
availability. Physician
specialties most in demand often cover
the gamut, but shortages in surgical
subspecialties, dentistry, OFM, psychiatry
and to a lesser
degree some medical specialties (GI,
Nephrology, and Pediatrics) are most
common (3).
Reductions in residency support due
to hour limitations
place the direct response burden back
on the staff physician.
Trend to Outpatient Surgery/Specialty
Hospitals
Specialty physicians are placing surgical
suites in their offices and establishing
specialty hospitals (heart, orthopedics,
etc.), effectively severing their hospital
ties and obligations. Other surgeons
required for trauma call panels (i.e.,
plastic and
oral surgeons) who rarely need the hospital’s
OR and find required trauma call onerous,
can simply resign their hospital privileges
with few adverse consequences.
Malpractice Turmoil
Episodic encounters with patients of
high complexity who lack established
relationships
or assured follow-up present high-risk
liability scenarios often coupled with
no compensation to offset rising premiums.
As a result of these multiple factors,
private practice physicians are increasingly
rejecting the notion that emergency call
is a community service and are demanding
that it be voluntary and compensated. This
essentially represents an economic shift,
like the rising price of gas that must
be dealt with as a new reality.
2. GENERAL PRINCIPLES FOR PROCEEDING
Lessons learned over the past decade
in the more intense settings of trauma
centers
indicate that while there are no easy
fixes, understanding the causes and
potential solutions regarding ED call,
coupled
with a proactive and farsighted approach,
will bring hospitals and their medical
staffs to the best possible solution.
Creating the Proper Framework
Negotiation with one’s own medical
staff over call payments can become very
divisive, and principles learned from addressing
call issues in trauma centers include:
- Leadership is essential, and
building an ad hoc leadership team
to address this
complex issue may be necessary.
- A
well-defined process is essential. Benchmark
institutional financial performance.
Solicit physician input. Address non-financial
Issues. Float ideas and get feedback.
- Value, not cost, should be the major
factor in determining payment. Quality
care,
service (interaction with staff, availability,
and patient satisfaction) and service
volume offer key metrics.
- Always take the long view and seek
to resolve this issue for the next decade
and
not just the next year.
- Do not push physicians into forming
a cartel.
- Adopt a systems perspective
and try to fix the problem on the front
end
by addressing demand management through a strategic
approach to primary care support and safety-net
clinics.
- Evaluation of results
will assure you are getting value for
your investment,
and that physician support for emergency
call remains stable.
Do Not Neglect Operational Solutions
It is ironic that the very part of the hospital
designed for speed and efficiency has now itself
become a bottleneck with resultant delay, diversion
and dissatisfaction, which extends to the many
physician participants as well. For many physicians
the contrast between their offices where they
are most efficient and the ED environment of
ambient delay is marked.
When patients present to the ED, they are
likely to have high complexity illnesses associated
with medical, surgical, psychiatric and drug
related co-morbidities that require specialty
consultation and referral in approximately
25% of cases. This requires both the responsiveness
of a large and diverse medical staff and
a
strong operational system that makes their
response as efficient as possible.
A focus on managerial and operational solutions
will yield immense benefits because the
basic processes that impact the hospital are
very
important to physicians as well. These
include: Demand Management, Registration, Triage,
Diagnostic testing, Social Service, In-patient
Bed Control,
Billing and Collections.
Placing the ED within the context of all
other services will better show bottlenecks
and vicious
cycles. For example, the protracted laboratory
and imaging test turn-around times in
outpatient and inpatient venues feed a tendency
to
over-stage patients in the ED by getting
all possible
tests thereby overburdening staff and
resources and distorting true demand. This
instigates
a strategy of making every request a stat request
Physician demands for emergency call payment
are often accompanied with complaints about
the support they receive once they arrive and
include:
- Insufficient support in the emergency
department, in terms of a lack of nursing
staff, inconsistent
support from emergency physicians, or the
lack of needed equipment and supplies.
- Timely
access to the OR for urgent/emergent patients
they become responsible for while
on call. Spending time trying to get an
ED patient scheduled in the OR is very frustrating.
- Needless waiting for diagnostic
test results from the lab or radiology.
A concerted effort to resolve hot-button
issues will establish credibility and trust
with call
physicians. Steps that make call more palatable
and less disruptive to physicians include:
- Use specialty defined protocols
to call in a specialty only when needed
- Have
patient ready when specialist arrives
- Nurse
Practitioner or surgical tech support for
basic evaluation and treatments
- OR block
time for ED cases that came in the previous
night
3. DEALING EFFECTIVELY WITH KEY ISSUES
Addressing the Medical Staff Structure
Medical staff organizations with their attendant
departmentalization are generally fragile,
complex structures, and often prove inadequate
for constructively addressing emergency call
issues. They were not designed for transactional
purposes. With the exception of specific
niche franchises such as ED physicians,
anesthesia,
NICU, or trauma care, medical staff physicians
are poorly organized and represent a group
of independent contractors often in competition
with each other.
Avoid The Balkans of Hospital/Physician Relations
Where existing problems in hospital/physician
relations are present, call issues are more
likely to erupt, and the divisive process
for dealing with them can further damage
the collaboration upon which hospital relationships
with their medical staffs are built. It is
very important to not ignore a gathering
storm, because rising frustrations and tensions
make reasonable solutions even more elusive.
Paying private practice physicians for emergency
call does not resolve the underlying problems.
As we have noted, physicians still find it
disruptive to their practices and lives, and
often the next step is demand for additional
payment. As this spreads from specialty to
specialty, it becomes a very slippery slope.
Payment, which requires a new contractual
relationship between a hospital and members
of its medical
staff, opens the door to new solutions, however.
Hospitals have new choices in terms of the
physicians they contract with, and the structure
of the services provided. These opportunities
should be fully considered, because payment
systems tend to get set in stone once they
are started.
Build and Offer A Franchise
The traditional model of active medical staff
participating in ED/Trauma call is increasingly
problematic, particularly in specialties heavily
impacted by call. The flip side of this issue
is that such specialties involve a large flow
of professional fees, which are generally underestimated
by physicians on call. Optimizing these fees
with focused referrals and billing assistance
builds the value of a franchise that can be
offered to physicians interested in emergent
care.
Seek Hospitalist Opportunities
Hospitalist programs have proven themselves
in the effective management of “unassigned” ED
patients, and this concept can be extended
to major specialties, especially surgery and
orthopedics. Hiring or contracting with physicians
who focus on hospital-based patients, versus
their own private practices, can benefit the
patient, hospital and physicians, including
those in these specialties who are then partially
relieved of call responsibilities.
Other Structural Solutions
Other approaches
that may work include:
- Tier coverage for specialties
like Oral Surgery, perhaps by contracting
with dentists
- Become involved in recruiting
physicians for understaffed specialties.
- Consider
approaches to channel uninsured patients
to more cost-effective settings,
such as Project Access.
4. ARRIVING AT FAIR COMPENSATION
There exist a wide variety of payment types
that include flat rate per hour or day, response
fees, stipends, and collection assistance.
In this area information is power but do
not mistake payment survey data for best
practice. Payment rates are volatile and
escalating. However, the process can be rationalized
by tying market benchmarks to other specific
factors:
- Volume of consultation
- Volume of emergent
responses/surgeries
- Number of call days per
month
- Proportion of uninsured patients
- In-house
call versus on-call support
- Presence of a
of residency or physician extender support
Factor in the franchise value of participation
in that a hospital that can attract, filter
and channel specific cases to a specialty is
highly desirable. Not all ED patients lack
resources; many in fact have insurance so collection
and revenue cycle management assistance is
an important offset to direct payments. Institutions
often assist physicians by collecting receipts
and providing additional payments to insure
an average and equitable payment rate.
In dealing with physician leverage, institutional
performance provides a clear constraint but
Stark should be the ultimate backstop. Whether
an employment or contracting relationship
is pursued is always defined by the long-term
strategy set out in the beginning of this process.
5. LOOKING TO THE FUTURE – THE
EMERGENCY SURGERY HOSPITAL
The most recent trend, the ultimate model of
a regional solution, is a hospital and medical
staff that restructures itself to pursue emergency
patients as a core business strategy. By attracting
a critical mass of emergency patients, appropriate
medical and hospital resources can be applied
in a “super” hospitalist approach.
A regional trauma center, a busy emergency
department, and outreach to other emergency
patients can generate the emergency patient
volumes and resources necessary to support
a dedicated medical staff structure.
This approach was first developed for neurosurgery
in Orange County, California, where it has
worked very well for over a decade. The combination
of trauma cases, emergency neurosurgical
cases and unassigned cases at these hospitals
provides
a sufficient patient base and referral stream
to support the on-call neurosurgeons.
6. CONCLUSION
While physician response to patients in the
emergency department can be an ethical
issue, it is primarily an economic issue.
Call provides
value, and a critical mass of physicians
is demanding relief or compensation. This
issue
will not go away, and the physician leaders
who recognize this and take a constructive
approach will find opportunities to strengthen
their hospitals that their competitors
will forgo.
(1) The
Physician Executive, May-June 2005
(2) McCaig LF,
Ly N. National hospital ambulatory medical
care survey: 2000 emergency department
summary. Advance data from vital statistics;
no 326. Hyattsville,
MD: national Center for Health Statistics. 2003.
(3) Rudkin
SE, et al. “The State of
ED On-Call Coverage in California”,
American Journal of Emergency Medicine (22) No 7, 2004. pp. 575-581.
David
M. Klubert, MD, FAAFP, President of Apogee
Informatics Corporation and a former
Chief Medical Officer, can be reached at dklubert@earthlink.net
Greg Bishop, MBA, founder
of the National Foundation for Trauma Care
and President of
Bishop+Associates, can be reached at greg@traumacare.com. |
