Long Island ERs grapple with shrinking on-call staff

Long Island Business News, Jan 11, 2008 by Alison Snyder

Community hospitals on Long Island are struggling to find specialists to offer on-call coverage for emergency departments.

Failure to access the right physician, such as a cardiologist, trauma surgeon or obstetrician, quickly in an emergency could worsen a patient's condition and in turn, may also raise health-care costs.

To Joshua Kugler, chief medical officer and chair of emergency services at South Nassau Communities Hospital, a number of factors, such as more doctor autonomy, malpractice worries and payment issues, conspire to create an emerging problem.

"It's this perfect storm that's absolutely brewing and imminent when it comes to delivering emergency department health care," he said.

A survey published by the Center for Studying Health System Change released in November found a growing reluctance for specialists - such as neurologists, ophthalmologists and surgeons - to take emergency on-call coverage, fueling tension between hospitals and physicians.

Nationally, 73 percent of emergency departments had inadequate on- call coverage, according to the study. Long Island follows suit.

Kugler blames changes to the Emergency Medical Treatment and Labor Act, which requires emergency rooms to care for all patients regardless of their ability to pay.

In 2003, the Centers for Medicare & Medicaid Services, a federal agency which administers Medicare, Medicaid, and the State Children's Health Insurance Program, changed the EMTALA regulations, allowing specialists to be on call at more than one hospital at a time and permitting them to limit the on-call time they take.

Compounding the problem is that emergency departments are seeing a steady increase in volume, growing from 90 million patient visits in 1993 to 114 million in 2003, according to the National Hospital Ambulatory Medical Care Survey.

Closer to home, South Nassau saw its number of emergency visits rise to 51,000 in 2007, up from 48,000 in 2006.

Physicians are not to blame, however. Kugler said physicians are working harder for less. Aaron Glatt, CEO at New Island Hospital in Bethpage, said malpractice is a major reason specialists avoid being on call.

"Not only the cost of malpractice, but those emergencies where you don't know the patient and you don't have a personal relationship with them are the cases where you're most likely to get sued," he said.

Kugler said physicians are better reimbursed for office visits than for emergency room visits, causing doctors to focus more on treating patients in their offices.Physicians are also reluctant to take on-call cases because they believe such payment is inadequate, and for the uninsured, nonexistent.

Hospitals are doing their best to come up with solutions, as delays in seeing a specialist may worsen conditions and in turn, multiply costs.

Glatt said it's been particularly difficult for New Island hospital to get psychiatry coverage, so much that the hospital brought one on staff.

Employing physicians is just one of the strategies New Island is using to combat the problem. It now staffs only physicians in its emergency room (instead of a mix of doctors, nurse practitioners and physician assistants, as is the practice in most ERs), and Glatt said the hospital has contracted with physicians for coverage, in a few cases.

Hospitals have also enforced medical staff bylaws requiring physicians to take call and in some cases have even paid physicians stipends.

Southside Hospital, a member of the North Shore-LIJ Health System, has largely avoided the problem. According to Medical Director Jay Enden, the hospital has been able to call on the resources of the system when needed. Southside has between 60,000 and 65,000 emergency visits each year.

These methods may have helped to ease the situation, but the outlook is bleak. Kugler said the problem will only get worse, unless there is a concerted effort to change the status quo from government, hospitals and physicians.

"Until we get that critical alignment, the storm is really going to come to fruition," Kugler said. "If all these things continue at the rate they're going, we're really at the tipping point. It won't take a natural or man-made disaster to paralyze the system. We're already paralyzing it."