Specialist shortage shakes emergency rooms; More hospitals forced to pay for specialist care

Physician Executive, May-June, 2005 by Maureen Glabman

Dr. Alex Valadka has taken emergency room call in the nation's fourth largest city, Houston, for 12 years. But only since last July did the 43 year-old neurosurgeon get paid for it.

One of two institutions where he practices. The Methodist Hospital, doles out $500 for each day he agrees to come in to treat emergency patients for cervical spine fractures, cerebral hemorrhages and more.

"Doctors brought it up. The hospital administration said, 'no,'" Valadka, says. "Eventually they realized it was a trend."

All Methodist community physicians are compensated now for covering the ER, whether or not they are called. Samplings of daily rates include $100 for pediatricians, $250 for general surgeons, topping off at $500 for cardiologists. "The stipend does not cover losses from being in your office and seeing patients, but it's better than nothing," Valadka says.

About 30 percent of the nation's hospitals report they pay some specialists for ER call, according to a 2004 American Hospital Association survey of hospital leaders. About 2 percent of that number pays all specialists.

Most began the practice within the last two years. "It is becoming more common to pay physicians for on call ER coverage," says Caroline Steinberg, vice president, trends analysis, AHA, Washington, D.C. Medical defense coverage and reimbursements for the poor are sometimes additional.

Stipends were little known only a decade ago. A confluence of changes in medicine altered what doctors provided voluntarily as a social imperative, as a means to build young practices and as a way to sustain old ones. A tide of uninsured patients, rising medical liability insurance rates and physician lifestyle issues converged to make ER call exceedingly undesirable. Doctors are demanding compensation.

"Historically, hospitals provided work shops for physicians in exchange for physicians having a responsibility to the community at large," AHA's Steinberg says. That workshop environment changed considerably when hospitalists started relieving primary care doctors of admissions in the 1990s.

At the same time, the growth of alternative practice venues, combined with technological and scientific advances that made outpatient surgeries possible, encouraged some surgical specialists, once dependent on hospitals, to reduce or drop their privileges.

Specialty coverage required

ER physicians cannot possibly know everything about every specialty. Having trauma doctors with scalpels at the ready is crucial not only for the public welfare, but for hospitals legal standing and financial viability.

Hospitals must provide specialty coverage or they risk loss of substantial federal subsidies for trauma centers. They could incur violations in EMTALA laws, revocation of their licenses and termination of Medicare and Medicaid provider agreements.

For example, if a hospital offers lucrative services like orthopedics and vascular surgery on its upper floors, it is obligated to provide the same service in its ground floor ER. A service breach in the ER can cost up to $50,000 for each infraction.

But a drought in specialists who refuse to see ER patients who come in at odd hours for medical crises has run head on into a hospital mandate to provide care, placing U.S. emergency departments on the critical list.

Physicians refusing to take call was the number one complaint found in ACPE's recent ethical behavior survey (March/April 2005, The Physician Executive). Nearly 60 percent of the survey respondents said they were very concerned about the issue.

In South Florida, the problem was extreme for the North Broward Hospital District, a group of four public hospitals with two trauma centers that started paying specialists on call in November.

"Many physicians were saying they were going to drop off call because of an inherent medical malpractice risk--patients come in a more acute state where outcomes are less certain," says Mark Knight, the district's chief financial officer. "At one medical center, we had problems with virtually every specialty, though it was about 20 percent system wide."

Competing hospitals were already luring district doctors away by offering call stipends. And, hospitals in the country just to the north, Palm Beach, were transferring serious neurosurgical cases to district hospitals because of a severe shortage of that specialty. In addition, Knight says 70 percent of admissions start out as ER patients.

Using a model developed by Delray Beach, Fla.-based HealthCare Appraisers, North Broward began paying doctors fees that range from $164 per day for a pediatric surgeon to $2,500 per day for neurosurgeons and orthopedic surgeons covering trauma centers. Physicians may also bill Medicare, Medicaid and private carriers for their services.

The formula takes into account a variety of factors, such as frequency of on call events and the number of physicians participating in call. Malpractice defense insurance and guaranteed, fee-for-service payments for uninsured patients are additional. Doctors must sign two-year contracts. "It has materially relieved the coverage issue," Knight says.