WASHINGTON — On-call services should not be a condition for participating in Medicare, a federal advisory panel on the Emergency Medical Treatment and Labor Act has recommended.

While most panel members panned the idea of an on-call/Medicare link, they were divided over whether to turn their disapproval into a formal recommendation to the Centers for Medicare & Medicaid Services.

The measure to recommend that CMS not link on-call participation with Medicare participation was approved in a close vote (7–6 with one abstention). The technical advisory group advises the Department of Health and Human Services and the CMS administrator on issues related to the Emergency Medical Treatment and Labor Act (EMTALA).

Hospitals cannot force physicians to be on call, although individual hospital policies may require on-call services as a condition of privileges. To address the shortage of on-call physicians, hospital associations had floated a proposal to the technical advisory group to link on-call participation to Medicare participation or hospital privileges.

Technical advisory group members who voted against making a formal recommendation to CMS at this point said they “were concerned about angering or offending the hospital associations who brought the idea to begin with,” said Carol Bayer, M.D., a panel member and vice president for medical affairs at East Jefferson General Hospital in Metairie, La.

If such a link were enacted, however, “physicians would quit Medicare in droves,” Dr. Bayer told this newspaper. Participating in Medicare “has never been linked to anything like this before.”

Some panel members, such as Charlotte Yeh, M.D., an emergency physician and CMS regional administrator for Region I in Boston, thought the issue deserved further review by the technical advisory group's on-call subcommittee before making a recommendation to CMS.

“Given the multiple factors affecting availability of on call, and the importance of solutions that both meet patient care needs and yet are practical enough for both hospitals and physicians, taking the time for analysis will result in a stronger position,” she said.

But James Nepola, M.D., an orthopedic trauma surgeon in Iowa City, and author of the recommendation, thought there was enough evidence to oppose the on-call/Medicare link. “We've had testimony, we've had studies, and we've had surveys on both sides of this issue. Cultural changes are taking place in medicine right now that don't bode well for emergency medicine,” Dr. Nepola said. “Young physicians are moving as quickly as they can to study fields that do not require emergency work at all. They are moving toward boutique practices, which I abhor.”

For that reason, the technical advisory group should take affirmative actions “so that physicians can go in without this problem before them,” Dr. Nepola said. The panel should also be addressing physician concerns such as liability reform and adequate resources and compensation for on-call services. “We need to move toward solutions like warnings for hospitals, not big penalties, and get rid of things that are not going to work.”

Physician and hospital groups offered their own views about the Medicare/on-call link at the technical advisory group's June meeting. Requiring on-call services as a condition of participating in Medicare “would far exceed the scope of the EMTALA statute,” the American College of Surgeons argued in written testimony.

It is also contrary to the regulations and the interpretive guidelines, which state that each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital's patients, the ACS stated.

Many neurosurgeons are already being required to provide continuous call 24 hours a day, 7 days a week, 365 days per year, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons testified, reporting from a survey of more than 1,000 members.

“Despite the fact that EMTALA does not mandate continuous emergency call, hospitals are nevertheless imposing this requirement on nearly one-third of neurosurgeons,” the groups testified.

Going beyond Medicare, the neurosurgeons requested that CMS adopt a rule that would prohibit hospitals from requiring around-the-clock call of physicians.

In its own surveys, the American Hospital Association illustrated a continued struggle to recruit specialists for on-call services. Nearly one-third of the hospitals surveyed reported paying physicians for specialty coverage, and 40% of the community hospitals had to place their emergency departments on diversion for some period of time, said Kathleen DeVine, chief executive officer of Saint Anthony Hospital in Chicago, who testified on behalf of the AHA.

“If CMS wants to deal with any more specificity around on-call coverage, then physicians, those whom hospitals rely on to provide on-call care, must be brought to the table,” she said. “Hospitals cannot do it alone.”

EMTALA was enacted in 1986 to ensure public access to emergency services regardless of ability to pay. The Medicare Modernization Act of 2003 required that HHS establish a technical advisory group to review EMTALA regulations. The advisory group is required by law to meet at least twice a year.

Panel Decides Not to Link On Call to Medicare : Hospital associations had floated the proposal to address the shortage of on-call physicians.