Though mandated by the Emergency Medical Treatment and Labor Act (EMTALA) when specialists are unavailable, the transfers “…seem to have gotten a whole lot worse in the last year,” says Mark DeGuenther, MD, a urologist with Urology Centers of Alabama. “Everyone’s general impression is that there’s more transfers from hospitals we’ve never heard from until now.”
Understandably, rural hospitals have a difficult time recruiting or affording specialists, making less on-call duty a possibly alluring recruitment chip. “We’ve seen an increase in newer physicians not wanting to take nights and weekends,” says Rosemary Blackmon with Alabama Hospital Association (AlaHA). “So it’s an issue with hospitals to cover their ED and other parts.”
“If you’re a physician in a small community, you should know that you’re going to shoulder a lot more of that on-call burden,” DeGuenther says. Yet, he says, multiple recruits to smaller communities have reported being assured by rural hospitals that they’d only be on-call ten days a month. “Even some practices with more than one urologist aren’t taking weekend calls,” DeGuenther says.
Some area specialties face unwarranted transfer patients not from rural hospitals, but from other Birmingham facilities. “I have about a third of my on-call patients coming from metro hospitals,” says Ben Fulmer, MD, a neurosurgeon with Birmingham Neurosurgery and Spine Group. “You can tell it’s the weekend, because no one else is available on-call, as opposed to a Monday or Tuesday night.”
Area hospitals, both metro and rural, are reticent about divulging their on-call policies. And though the Centers for Medicare and Medicaid Services (CMS) expects that all specialty services provided by a hospital should be represented in the on-call roster, they have set no minimum call requirements. CMS has even stated that it cannot require physicians to take call.
EMTALA also requires hospitals to provide coverage for specialties they market. Yet people seem unclear exactly where the line marks a specialty as being provided to the point of needing 24/7 coverage.
In Birmingham, resentment builds as specialists begin to sense an inequality of the on-call burden. “Whether you’re doing something at nine a.m. or two a.m., you get paid the same,” DeGuenther says. “And if that patient has no insurance, you’re up all night for no compensation, while you know there’s a urologist in that smaller community getting a sound night’s sleep.”
DeGuenther says he’s called to the hospital about twice each on-call weekend for a transferred patient from a community that has a urologist. However, on weekdays, that number drops to once every two weeks.
Fulmer says all Birmingham hospitals have neurosurgeons. “Yet at St. Vincent’s, we’re taking their emergencies, because they don’t have anyone available. I’m not sure if we’re just naïve or stupid or really nice.”
The problem of dwindling specialist availability for call service runs throughout the nation. Compensation tops the list as a possible solution. In 2011, 65 percent of health care organizations reported paying at least some physicians for call coverage, according to SullivanCotter's 2011 Physician Compensation and Productivity Survey Report. That’s an 11 percent increase from 2010.
Their 2009 survey reported that of the hospitals paying for call coverage, three out of four paid orthopedic surgeons, making that the most paid-for on-call service.
But cardiologists get paid the most. Medical Group Management Association's Medical Directorship and On-Call Compensation Study: 2011 Report found that invasive cardiologists stated the highest median daily rate of on-call compensation, at $1,600 per day. General surgeons earned a median of $1,150 per day, while urologists clocked in at $520 per day.
“Some neurosurgeons are getting compensated for being available at some hospitals here,” Fulmer says. But it doesn’t appear to be the norm for specialists in Birmingham yet. “Being on-call used to be how you got privileges,” Fulmer adds. “But hospitals like having your business, your elective cases, so they might be relaxing that requirement.”
Another solution arising in Alabama, and across the country, utilizes hospitalists. These physicians specialize in caring for hospital patients in order to offer inpatient coverage to physicians. They typically don’t have a separate office practice.
At a recent educational program for Alabama hospitalists, physicians discussed expanding the traditional hospitalist model to cover for surgeons and specialists as well. “For patients needing observation or a post-op overnight stay, the hospitalist could cover for the specialist, contacting them if there are any issues,” Blackmon says.
Regional coordination of coverage between facilities could also help equalize and ease the on-call burden. Being used in several places around the nation, hospitals take turns covering certain specialties, such as neurosurgery, so the city or region has enough coverage while allowing the other hospitals and specialists downtime. “If we all agreed to share the work like that, we could easily provide full coverage without undue burden,” Fulmer says.
DeGuenther points out that rural hospitals, especially, may have little incentive to solve the on-call issue. “A lot of transferred patients are uninsured, so we end up providing uncompensated care, and the transferring hospital is relieved of their obligation to care for the uninsured.”
He believes a solution may be for them to pay into a pool for call coverage or compensate the accepting hospital for that transfer because of lack of specialist. “It could be complicated, but no one’s even looking into offsetting that motivation for transfers,” DeGuenther says.
With 64 percent of hospitals in the U.S. struggling to get specialists, the issue won’t be fading away. “We’re always available. It gets old,” Fulmer says. “Especially since we know there’s a market value for being available.”
