Wanted: doctors willing to take ER call
From the November ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.
By Phyllis Maguire
Richard Frankenstein, FACP, remembers the last straw in his decision to stop taking emergency room call. He admitted an uninsured patient with multiple chronic illnesses who stayed in the hospital for eight weeks, much of that in intensive care. Dr. Frankenstein often visited her twice a day, "even though that's not my primary hospital." For two months, his already-packed day began one hour early and ended one hour late.
In return, said Dr. Frankenstein, a pulmonologist in southern California, he got pulled from his own patients and received almost no compensation for his efforts. "That commitment dragged me away from my primary responsibilities," he continued. "I'm no longer on staff there, and that situation was a major reason I resigned."
Like Dr. Frankenstein, physicians around the country are increasingly unwilling to take call or serve on backup emergency panels for community hospitals. More physicians are reducing the number of hospitals where they serve on staff, and on-call physicians are refusing to accept emergency patients outside their own managed care networks. Some primary care physicians don't even want to admit their own patients through the ER.
Physicians say they are walking away from emergency call because they're tired of working long hours for next to nothing. Some, like Dr. Frankenstein, say that emergency call takes away valuable hours that they need to spend with office-based patients. For others, on-call duty brings so much additional bureaucratic hassle and legal liability that physicians say they are being scared away.
Specialists in short supply
While there are few statistics on the number of physicians refusing to take emergency call, anecdotal evidence suggests a nationwide problem.
According to a 1999 survey conducted by the California Medical Association and the California chapter of the American College of Emergency Physicians (ACEP), 60% of hospitals in the state claimed they experienced "very" or "somewhat" serious problems with on-call physician emergency back-up.
Physicians in southeastern Pennsylvania say that problems with emergency call coverage are making intractable recruiting problems even worse. And Nabil El Sanadi, MD, president of ACEP's Florida chapter, said that emergency physicians in his state claim that medical staff available to take emergency call and backup has plummeted 25% to 30% in the last three years.
Surgical specialists—like general surgeons, orthopedists and urologists-are in particularly short supply. But in many community hospitals, particularly in areas with large uninsured populations and high levels of managed care, medical specialty panels are also growing perilously thin, leaving fewer specialists to respond to ER calls.
Emergency physicians report daily pandemonium as on-call specialists decide not to admit or treat patients, unless those patients are insured by health plans with which the specialist has a contract. Emergency physicians then have to dial through their medical staffs' list of specialists, seek help from on-call physicians at other facilities or negotiate with a health plan to pay the on-call physician—all while an acutely ill patient waits to be treated.
Dr. El Sanadi, chair of emergency medicine at Ft. Lauderdale's Broward General Medical Center, said that to get specialists to agree to provide coverage in exchange for a stipend, he often has to "go up the chain of command" two or three times each shift. He first calls the chief of service, then the chief of the department and finally the hospital CEO.
While most horror stories focus on specialists' reluctance to take ER call, primary care physicians are also increasingly hard to find. ER panels once helped generalists establish themselves in a community, but general internists—like other specialists—now find that ER rotations bring only un- or underinsured patients, or insured patients already assigned to other primary care physicians.
"That's how the old guys built practices," said Diane M. London, ACP-ASIM Member, a member of a primary care group in Natick, Mass., who takes ER call at least once a month. "But these days, it's just your turn at free care."
"We've won the battle for access," said Loren A. Johnson, MD, president of ACEP's California chapter, referring to a federal law that guarantees access to emergency services as well as "prudent layperson" laws passed by many states. "But we're losing the war for reimbursement." (For more information, see "Emergency access is mandated-but without money" at www.acponline.org/journals/news/nov01/mandate.htm.)
While some states reimburse hospitals for some uncompensated care, uninsured patients often pay physicians nothing, and payments for Medicaid patients are not much better. HMO payments are often delayed and deeply discounted, while payment for insured patients gets switched to other physicians if the on-call physician in the ER is not on the patient's health plan panel.
Liability and hassles
As physicians are quick to point out, money is not the only factor driving the crisis in emergency call. In today's regulatory and legal practice environment, they say, emergency care means more legal liability and increased hassles.
San Francisco general internist Toni J. Brayer, ACP-ASIM Member, recalled admitting a homeless patient with multiple medical problems who remained in the hospital until he could be placed in a home and enrolled in Medi-Cal, the state's Medicaid program. When Medi-Cal challenged the patient's hospital charges, Dr. Brayer was socked with several rounds of paperwork to justify what for her had been charity care.
"Once I meet them, I give them my all," Dr. Brayer said of the un- and underinsured patients she treats while on call in the ER. "But as physicians, we all just don't want to meet them."
Spurring that reluctance is the fact that many unassigned patients are unable to follow a prescribed treatment plan, can't afford medications and can't even get to a physician's office to apply for free prescriptions. "It forces a physician to be not only a specialist but also a social worker," said Todd Taylor, MD, vice president of public affairs for ACEP's Arizona chapter. "Many physicians say they just can't handle that."
In some hospitals, primary care physicians do not want to admit even their own patients through the ER, let alone those who are unassigned. George J. Walters, DO, director of emergency medicine at Riddle Memorial Hospital in Media, Pa., said that in the last year, he has received memos from primary care physicians who no longer want to admit patients covered by health plans that don't pay primary care differentials for inpatient care. Instead, they tell him to find specialists—who at least receive fee-for-service reimbursement—to admit those patients.
Dr. Walters said he now relies on two specialty groups, one for geriatrics and the other for pulmonology, to admit primary care handoffs. George Lieb, ACP-ASIM Member, is one of the pulmonologists.
"It is a burden for us, but we spend a lot of time in the hospital anyway seeing our own patients," said Dr. Lieb, one of three physicians with Certified Lung Associates in Ridley Park, Pa. "For us, one more doesn't make much difference, but it does for a primary care doc who has only one patient in the hospital and doesn't get paid. It's part of the way primary care is changing."
The big picture
Hospitals' difficulty finding physicians to take call is part of a bigger crisis in emergency care, an area that has been rocked by profound changes in the past decade.
In part, specialist panels are disappearing because of a major shift in practice settings. As medical procedures migrate to outpatient settings, physicians in many specialties—gastroenterology, nephrology, plastic surgery and ENT, for example—have become free agents, no longer tied to hospitals for office space or a patient base. Many specialists are questioning why they need staff privileges and the 2 a.m. phone calls those privileges entail, particularly at hospitals where the patient mix is heavily uninsured or filled with Medicaid patients.
Primary care physicians—particularly in California—are often aligned with independent physician associations or HMOs, not hospitals. This means that senior physicians on medical staffs looking to turn over their call duties to younger colleagues are finding no new recruits.
In addition, the public has radically changed how it uses emergency services. According to the American Hospital Association (AHA), emergency room volume increased 8% between 1992 and 1999, when there were nearly 104 million emergency visits to U.S. hospitals. The explosion in ER visits comes from not just the uninsured, but insured patients tired of waiting to see their primary care physician or a specialist to whom they have been referred.
Patient expectations, physicians say, are also driving the surge in ER visits—and doctors' flight from on-call duties. In the past, southern California's Dr. Frankenstein explained, specialists were rarely needed in the middle of night. Today, he said, cardiologists and gastroenterologists are routinely expected to perform procedures at all hours and pulmonologists invariably spend call managing patients on ventilators.
The struggle for solutions
Hospitals in California have tried to spend their way out of the on-call crisis, funneling $200 million a year into per-diem stipends for on-call physicians. But while stipends may be a temporary band-aid, analysts say they are not a long-term solution. With a third of the country's hospitals operating in the red, according to an AHA spokesperson, cash-strapped hospitals can't make stipends a permanent feature of emergency call.
Hospitals have also tried changing their bylaws (or enforcing bylaw language already in place) to impose punitive measures against physicians who curtail or shirk call. Yet analysts say that those hospitals run the risk of driving away specialists even faster. Rather than sabotage their referral base, some hospitals are actually relaxing bylaws to make call coverage more physician-friendly.
Menorah Medical Center in Overland Park, Kan., for example, recently changed its bylaws to make taking emergency call less onerous for specialty group physicians. Instead of insisting that all group members—even those who infrequently take call at Menorah—must sign off on patient charts, the hospital now allows other group members to sign off on charts for their colleagues. (The medical center also relaxed bylaw requirements on committee work and staff meeting attendance to make life easier for medical staff.)
Many hospitals across the country are turning to hospitalists to help alleviate ER call problems, at least for general internists. At Winchester Medical Center in Winchester, Va., for instance, general internists shouldered increasingly onerous ER call schedules as family practitioners in the area gave up admitting privileges. With on-call internists often handling up to seven ER evaluations (and, usually, admissions) of unassigned patients per day, they increasingly pressured the hospital to add hospitalists to the staff.
Since August, four full-time hospitalists have been admitting and treating all unassigned patients. Instead of taking ER call, general internists are now part of a primary care roster, and they take turns providing care to unassigned patients once they are discharged.
Some hospitalists in California, however, have balked at becoming the physician of record for unassigned patients in communities with large uninsured populations, saying that their salaries do not adequately provide for their delivery of uncompensated care. And for many communities, hiring hospitalists is just not an option.
California physicians are seeking legislative solutions. One bill the state legislature is considering would ensure timely payment of emergency care claims. Another bill would coordinate specialty emergency services by region—and give emergency care the same public service status that police and fire departments have, funding it with state or local tax revenue.
While potential solutions are debated, one thing is clear: The momentum of medical staff defections and physician resistance to call coverage is growing. As malpractice premiums rise and an economic downturn perhaps leads to more uninsured patients, the safety net of emergency medicine and the physicians who provide it is becoming increasingly frayed.
"It is the canary in the mine," southern California's Dr. Frankenstein said of emergency call coverage. "It is the leading edge of a health care workforce crisis that threatens the entire system."
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