Specialists across the country are demanding payment for being on call to the emergency department, and many hospitals are acceding in an effort to keep full coverage.
But even though more than one-third of hospitals now pay their on-call specialists, experts in emergency medicine say the on-call specialist crisis isn't one that can be solved by money. “Money talks, but only to a point,” said Dr. Todd B. Taylor, an emergency physician in Nashville, Tenn., and speaker of the American College of Emergency Physicians Council. “Money is not going to solve this problem because of the other issues involved. At some point, you bankrupt the system.”
For example, Dr. Taylor said he calculated that paying all on-call specialists “the going rate” ($1,000 a night and up) would cost hospitals in just the state of Arizona $176 million annually. “And that's assuming you could find people willing to do it at all. I've seen many specialists who say 'You can't pay me enough to do this.'” he said. “If you don't solve the liability issues surrounding being on call, at some point nothing else matters.”
The American Hospital Association found in survey data from 1 year ago that 38% of hospitals paid “for at least some coverage,” said Caroline Steinberg, AHA's vice president for trends analysis. “It seems to be a growing trend,” she commented.
And, in a study released in January online in the Annals of Emergency Medicine, researchers from Oregon Health & Science University (OHSU), Sutter Emergency Medical Associates, the University of Iowa, and the Office of Oregon Health Policy and Research reported that 43% of Oregon's 54 hospitals pay a stipend to at least one specialty, and 31% of hospitals guarantee pay for uninsured patients treated on call. Stipends ranged from $300 per month to more than $3,000 per night, with a median stipend of $1,000 per night to take call.
The statewide survey, conducted in the summer of 2005, showed coverage shortages in most specialties, with the most acute shortages in orthopedics and neurosurgery. More than half of all hospitals expressed difficulty in maintaining specialists on call for three or more specialties.
Orthopedists, neurosurgeons, and trauma surgeons were the specialists most likely to receive stipends, as reported in the survey. But survey author K. John McConnell, Ph.D., a researcher in emergency medicine at OHSU, noted that he also is beginning to hear about hand surgeons, obstetricians, otolaryngologists, and urologists asking to be paid to be on call.
Many specialists now have the opportunity to practice in a 9-to-5 setting, Dr. McConnell said, which makes them less willing to be on call. “There's no evil intent or bad guys—it's just everyone responding to changing dynamics,” he said.
Dr. Taylor agreed that lifestyle issues play a role in the shortage of on-call specialists and in their increasing demands to be paid for on-call duty. But he said that organizational and liability issues each play a bigger role. Hospitals and physicians must learn to arrange services and payment so that a specialist can be on call for 24 hours and then off the next day without losing income or hurting his or her own practice, Dr. Taylor said, adding that specialists “are starting to learn some lessons that emergency medicine learned years ago.”
The AHA has not taken a position on payment of specialists for being on call, but Ms. Steinberg said the group is sympathetic to physicians' problems. “We understand that physicians are being underpaid by Medicare and by private payers, and are facing huge professional liability,” she said.
Otolaryngologist Eric Furst of Springfield, Va., said that he and his ENT colleagues recently approached Inova Fairfax Hospital in an attempt to negotiate payment for being on call. Dr. Furst said that Inova Fairfax, the only level I trauma center in northern Virginia, requires its physicians to take call, and for his section, it amounts to a week at a time two times a year. Several ENT specialists have left because of the demands, he said, which increases the on-call burden for those who remain. “Before you know it, it is a huge financial hit in those weeks in your own practice,” he said.
After its 22 urologists threatened to stop responding to on-call care earlier this year, Inova Fairfax set up a fund to reimburse all 36 medical and surgical specialties that participate in emergency department on call for indigent care.