Fewer physicians willing to take call
A California task force demonstrated more than half of hospitals have a serious problem with on-call physicians, reports Larry Bedard, MD, FACEP, director of emergency services at Doctors Medical Center in San Pablo and Pinole, CA. "In California, more than 40% of neurosurgeons are being asked to be paid for standing by, with some physicians getting paid up to $2,000 a day," he says.
Many hospitals are unable to afford these fees, and therefore, are experiencing shortages of physicians willing to take call.’ "This has changed the whole dynamics of being on call," stresses Bedard.
There is also a disturbing trend of physicians trying to shirk their on-call responsibilities because of expanding responsibilities under EMTALA. "You can empathize with their desire to have an effective practice, on the other hand, the hospital can’t eliminate a requirement that’s put there by federal law," says Stephen Frew, a Rockford, IL-based health care attorney and consultant.
There are multiple reasons for this problem, says Charlotte Yeh, MD, FACEP, medical director for Medicare Policy at National Heritage Insurance Company in Hingham, MA. "The changes in reimbursement and recognition of specialty care is making it much harder," she explains. "Physicians have to be more productive during the daytime, so it’s much harder to come in at night. There is the risk of no reimbursement even if the patient is insured, if it’s the wrong network."
The potential for receiving stiff penalities for EMTALA violations is discouraging physicians from taking call, says Yeh. "For years, the on-call service was considered voluntary and part of the good will of physicians," she explains. "Now that you attach liabilities to that, it changes the whole character of the on-call system."
EDs typically used to be sources for physicians [who were on call] to build practices, but that has changed. "As you have more salaried physicians, the need to be responsive to the ED and build a practice is diminishing," Yeh notes.
Managed care exacerbates the problem, says Bedard. "We did a survey in our state and were surprised to find how many physicians relate this problem to managed care," he reports. "A plan may decide to pare the list of participating physicians so it doesn’t renew the physician’s contract. But the next time the physician’s on call, the MCO’s family practitioner asks them to take care of their patient’s broken hip. Physicians have been abused by managed care plans, which then use EMTALA to force them to take call."
MCOs often do not reimburse consultants fairly. "Many payors have arbitrarily refused to provide payment for services required by EMTALA," Frew reports. "These folks are getting stiffed on their money on a routine basis."
No law forces a physician to be on call, but once consultant agrees to be on call, he or she has to respond in a timely basis, says Bedard. "According to JCAHO requirements, that usually means within 30 minutes by phone," he notes.
The on-call physician issue needs to be brought to the general public’s attention, Bedard urges. "It may take a bad situation for this to become public. Unfortunately, a patient will probably have to pay dearly before this issue comes to light nationally, he says.
There needs to be a legislative solution to the problem, argues Bedard. "Patient advocate groups are getting more concerned with this issue as more adverse outcomes and problems occur," he says.
One potential solution is putting premium tax on managed care plans to pay the standby costs, based on their market share, to appropriately reimburse on-call physicians," Bedard suggests. Meanwhile, increasing numbers of physicians are likely to refuse to take call, he predicts.
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