Shortage of on-call specialists for your ED? Help may be on the way
CMS to allow shared or "community"on-call programs
By Robert A. Bitterman, MD, JD, FACEP, Contributing Editor
The Centers for Medicare and Medicaid Services (CMS) recently proposed changes to the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations that would allow "community call" programs to be established by groups of hospitals in self-designated referral areas to help address the shortage of ED on-call specialists.1 A community system could provide a specific medical service, such as neurosurgery or hand surgery, and/or a specific time frame, such as just on the weekends. The involved hospitals would need to establish a formal written plan and comply with set minimum criteria determined by CMS, but no advanced approval from CMS would be required.
Each hospital in the program would still be required to medically screen, stabilize, and arrange an appropriate transfer when sending selected patients to the "community call" facility.1
Historical Perspective
CMS is acutely aware of hospitals' difficulty maintaining on-call specialty physician coverage for their emergency departments. It had hoped its "increased flexibility" changes to the EMTALA on-call requirements back in 2003 allowing simultaneous call, allowing elective surgery while on call (in certain circumstances), and not requiring physicians to be on-call all times would improve access to specialty physicians for ED patients.2
The EMTALA Technical Advisory Group (the "TAG"), established by Congress to review the EMTALA regulations and advise CMS on their application to hospitals and physicians,3 believed that the 2003 regulations actually decreased, rather than increased, specialty coverage for emergency departments. The EMTALA TAG recommended to CMS that hospitals be allowed to satisfy their on-call coverage obligations by participation in an approved community/regional call coverage program.4 The TAG looked to CMS to determine the appropriate approval process.
CMS's Proposed Regulations
CMS responded by proposing community call to be a "formal on-call plan that permits a specific hospital in a region to be designated as the on-call facility for a specific time period, or for a specific service, or both."1
Moreover, CMS did not believe it is necessary, nor would it require, a community call plan to be subject to pre-approval by CMS; however, if an EMTALA complaint investigation was initiated, the plan would be subject to review and could potentially be found in violation of the law. It wanted hospitals and their communities to have the flexibility to develop a plan that reflects their local resources and needs.1
CMS did, however, expect the hospitals involved to implement a formal plan, with formal written agreements recognized in their policies and procedures, as well as backup plans.
The TAG and CMS also expressly emphasized that a community call arrangement would not remove a hospital's obligation to perform an appropriate medical screening examination (MSE), or its duty to arrange an appropriate transfer, for any patient who presented to one of the non-designated call hospitals in the plan. CMS anticipates that individuals who arrive at a hospital other than the designated on-call facility, and are determined to have an unstabilized emergency medical condition that requires the services of an on-call specialist, would generally be transferred to the designated on-call facility in accordance with the community call plan.1,4
Finally, to devise an acceptable community call system, CMS will require hospitals to incorporate the following minimum criteria:1
1. The community call system must be a formal plan among the participating hospitals, signed by an appropriate representative of each hospital participating in the plan, and with written policies and procedures in place.
2. Hospitals participating in the community call plan must engage in an analysis of the specialty on-call needs of the community for which the plan is effective.
3. The community call plan must include a clear delineation of on-call coverage responsibilities, that is, when each hospital participating in the plan is responsible for on-call coverage.
4. The community call plan must define the specific geographic area to which the plan applies.
5. The community call plan must ensure that any local and regional Emergency Medical Services (EMS) system protocol formally includes information on community on-call arrangements.
6. The community call plan must include a statement specifying that even if an individual arrives at the hospital that is not designated as the on-call hospital, that hospital still has an EMTALA obligation to provide a medical screening examination and stabilizing treatment within its capability, and hospitals participating in community call must abide by the EMTALA regulations governing appropriate transfers.
7. Each hospital participating in the community call plan must have written policies and procedures in place to respond to situations in which the on-call physician is unable to respond due to situations beyond his or her control.
8. There must be at least an annual reassessment of the community call plan by the participating hospitals.
Potential benefit of community call arrangements
There are a number of scenarios in which community call systems could be highly advantageous. For example, a hospital system with one "main" campus and one (or two) other hospital facilities that are in relative close proximity to each other might find this useful. The hospitals could form their own geographic community call program, designating the main facility as the on-call facility for many services, such as neurosurgery, neurology, orthopedics, urology, or hand surgery, and then not have to require physicians of those specialties practicing at the affiliated facilities to take ED call at those facilities. Such an arrangement would clearly attract physicians to the staffs of the affiliated facilities, and work particularly well if many of the physicians had privileges at both (or all three) of the hospitals.
In communities where specialists, such as neurosurgeons or orthopedic surgeons, were relatively scarce but were privileged and practiced at two or three different hospitals, they could designate one hospital as the on-call hospital for that service and not have to take call at all or simultaneously for the other hospitals in the community. All cases could be directed by EMS to the on-call facility or transferred there if they originally presented to a non-designated call center hospital.
In large cities, competing hospitals or entire mega health care systems could take turns providing call for various specialties; for instance, every other day or one month on then one month off, or alternate weekends might work well. Such a plan would certainly cut down the amount of call days for the specialists, yet still provide continuous 24/7 specialty service to the community.
Over time and with trial and error hospitals/communities should be able to craft many varied and imaginative call programs to improve access to emergency specialty care, while simultaneously lessening the burdens placed on the specialty physicians.
Provider input sought by CMS before it issues a final rule
CMS has welcomed provider and public comments on its proposed elements of a formal community call plan. Additionally, it solicited comments on "whether individuals believe it is important that, in situations where there is a governing State or local agency that would have authority over the development of a formal community call plan, the plan be approved by that agency."1
Hospitals and physicians also should submit any other concerns they have regarding the on-call issues under EMTALA, since the TAG made a host of other on-call recommendations that CMS intends to address at a later date.4,5 In other words, expect still more on-call regulations from CMS in the near future.
Summary
In summary, CMS is proposing that, as part of the obligation to have an on-call list, hospitals may choose to participate in community call, provided that the formal community call plan includes, at a minimum, the elements noted previously.
CMS expects these community call changes will help hospitals attract more physicians to their medical staffs, and anticipates it will afford additional flexibility for hospitals to provide on-call services and further improve access to specialty physicians for emergency care.1 This time, it looks like CMS is spot on.
References
1. Centers for Medicare & Medicaid Services (CMS) Proposed Changes to the Hospital Inpatient Prospective Payment Systems. Included in the 400+ page document are a number of proposed changes to EMTALA. The document is available at: http://edocket.access.gpo.gov/2008/pdf/08-1135.pdf. Accessed on 6/2/08.
2. 68 Fed. Reg. 53,221-53264 (Sept. 9, 2003); 42 CFR 489.24. The EMTALA regulations effective Nov. 10, 2003. The EMTALA rules can be found though the Federal Register Online GPO Access under "separate parts in this issue" toward the bottom of the link at: http://www.access.gpo.gov/su_docs/fedreg/a030909c.html. Accessed on 6/2/08.
3. Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Pub. L. 108-173, 117 Stat. 2066, Section 945.
4. The final EMTALA TAG reports and recommendations are available at: http://www.cms.hhs.gov/FACA/07_emtalatag.asp. Accessed on 6/2/08.
5. Bitterman RA. EMTALA and the ethical delivery of hospital emergency services. Emerg Med Clin North Am 2006;24:557-577.
The Centers for Medicare and Medicaid Services (CMS) recently proposed changes to the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations that would allow "community call" programs to be established by groups of hospitals in self-designated referral areas to help address the shortage of ED on-call specialists.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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