Krueger, Kristine J. MD; Halperin, Edward C. MD, MA
Physicians historically have taken emergency on-call duty in exchange for hospital admitting privileges. Doing so allowed them to build relationships with other admitting physicians, provide care for newly admitted patients, and build their practices. At academic health centers (AHCs), public subsidy of medical education and residency training has traditionally been accompanied by the unwritten expectation that physicians will accept unpaid on-call responsibilities.
Over the last two decades, however, market forces have shifted care away from hospitals, and many specialists now work in privately owned ambulatory care centers. Physicians' dependence on hospitals for building their practice has greatly diminished,1 and fewer physicians are willing to provide on-call services. Those who are willing often request payment for being on call.
Public hospitals and large AHCs have been buffered from on-call physician shortages because they employ many physicians, including residents and fellows, who serve as first-line responders for emergency and in-house urgent care needs. As adequate specialty coverage decreases at community hospitals, patients with higher-acuity problems are being diverted to AHCs in order to ensure access to subspecialty on-call providers. These transfers expose physicians in training to the political dynamics of on-call coverage and teach them that being on call is an optional duty in community practice post training. The result is that AHCs shoulder a disproportionate amount of emergency care, much of which is uncompensated.2
Additionally, AHCs' emergency departments (EDs) have become more crowded, serving as walk-in clinics and the entry point for individuals unable to access medical care in any other way.3 In 1986, the Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted to prevent EDs from diverting or refusing care to patients who were unable to pay. Under the law, the federal Centers for Medicare and Medicaid Services (CMS) mandates that acute care hospitals and ED physicians evaluate and stabilize any person with an emergency medical condition, including providing or coordinating subspecialty care and services.4 Failure to comply with EMTALA results in hefty penalties or revocation of the provider's participation in Medicare. Although the intent was to ensure that patients receive necessary emergency care regardless of their ability to pay, because many community hospitals are not required under EMTALA to have specialty on-call providers available, transfers of patients to AHCs for specialty services have actually increased. The rise in malpractice insurance costs and cutbacks in reimbursement for providing care to uninsured or underinsured patients have created an additional burden for nonsalaried, on-call emergency care providers.
Hospitals' efforts to mitigate this burden and restore availability of subspecialists for hospital and emergency services have included employing hospitalists and paying specialists to be on call. Despite these efforts, serious shortages for on-call specialty services remain. AHCs need to take the lead in critically evaluating the multiple factors creating on-call shortages and then formulate and implement practical solutions.
Being On Call Affects Physicians' Lifestyles
For many physicians, on-call duty is a nuisance and the beeper is a ball and chain. Even if they are on-call at home, they know they cannot rest, entertain, or travel very far from the hospital. A major consideration when negotiating for jobs is the on-call rotation schedule, which routinely assigns junior faculty to more nights, weekends, and holidays than their more senior colleagues. Although many physicians choose to work beyond the usual age of retirement, few older physicians are willing or physically able to endure the rigors of being on call, and they are often relieved of this chore. In some private practices, physicians reduce their on-call burden by paying their partners to be on call or arrange to share on-call responsibilities with other group practices. Newly graduated physicians view being on call as a major detraction and impediment to socialization and family life. A recent survey of hospital leaders cited physician lifestyle as the top reason for reluctance to take on-call duty, followed by liability and financial concerns.5
Today, nearly 50% of graduating medical students are women, compared with an average of 15% just 25 years ago. By 2015, women are expected to make up 40% of the physician workforce.6 When female physicians choose specialties and career paths, they often consider total work hours, on-call demands, and a lifestyle that would best accommodate pregnancy, maternity leave, and child care responsibilities.7,8 Although it is possible that the rising proportion of female physicians will influence the on-call problem, the issue may be more generational than gender-specific: The proportion of physicians willing to take on-call duty is falling because of young physicians' choices related to lifestyle. Many young physicians are determined to have balance in their work and home life, avoid the previous generation's high divorce rates, and spend more time at home with their families than their parents did.9
Being On Call Affects Physicians' Health and Performance
In an environment of increased transparency regarding outcomes and medical errors, AHCs are socializing physicians to limit or monitor their work hours and encouraging them to get adequate rest so they will remain mentally sharp. The impact of sleepless nights on medical errors and physicians' health was a driving force behind the Accreditation Council for Graduate Medical Education's 2003 decision to restrict residents' work hours to 80 hours or less per week, including on-call hours.10
Sleep is required for the consolidation of learning and for the optimal performance of cognitive tasks.11 Studies of sleep deprivation have shown that one night without sleep negatively affects the performance of specific higher cognitive functions of the prefrontal cortex and can cause impairment in attention, memory, judgment, and problem solving.12–15 A recent study found an increased rate of complications in operations performed by surgeons who slept fewer than six hours between their nighttime on-call duty and their daytime scheduled cases.16
Being on call is also associated with significant medical, mental health, and safety risks for physicians. A comprehensive review of on-call work and health showed that nighttime work interrupted sleep patterns, aggravated underlying medical conditions, and increased the risk of cardiovascular, gastrointestinal, and reproductive dysfunction.17 A study of work-related fatigue among emergency medicine residents indicated that 75% of residents' motor vehicle accidents happened after they had worked a night shift, and the number of accidents and near-misses was positively correlated with the number of nights worked per month.18 Self-reported mood questionnaires completed by British general practitioners correlated high levels of anxiety, depression, frustration, tension, and cognitive behavioral dysfunction with the number of on-call shifts.19–22
The Extent of On-Call Physician Shortages
During the last two decades, on-call physician shortages were first observed in states with high managed care penetration. By 2001, lack of on-call specialty coverage in EDs was labeled a crisis that threatened the integrity of the emergency medical system.23
The American College of Emergency Physicians (ACEP) has conducted several nationwide surveys to assess the extent of the on-call shortage and contributing factors such as location, community-level supply of specialists, the cost of liability insurance, and the impact of ambulatory surgery centers. In ACEP's 2004 and 2005 surveys, two-thirds of ED medical directors reported having inadequate on-call coverage. Coverage problems were more prevalent in urban than in rural hospitals, and the greatest shortages were in hand surgery; plastic surgery; neurosurgery; ear, nose, and throat surgery; and psychiatry.24 By 2006, ACEP's survey indicated further shortages: Directors of 73% of EDs and 57% of trauma centers reported inadequate on-call specialist coverage, owing in part to the growing demand for ED care. In addition to the aforementioned surgical specialist shortages, there were new reports of significant shortages of neurologists, ophthalmologists, and obstetrician–gynecologists.25
The public expects the highest quality care to be delivered 24 hours per day, seven days per week, at the lowest possible cost, and with the highest degree of safety to ensure the best possible outcomes. For emergency medical conditions, this is a tall order.
Adverse patient outcomes for emergency conditions are directly related to the unavailability of specialty services. In 2002, the Centers for Disease Control studied factors associated with sentinel events occurring in EDs, including patient deaths and permanent disability, and found that 21% of such events could be attributed to lack of specialty physician services.26 A recent study reported that 1 in every 100 deaths from first myocardial infarctions occurring on weekends is unnecessary and can be attributed to lack of availability of cardiac care specialty services within the first 48 hours of a patient's arrival in the ED.27
Patient and physician expectations have also created demand for specialists and specialty services that are difficult to meet. Whereas patients would once permit ED physicians to repair simple lacerations, they now expect to be sutured by plastic surgeons to ensure the best cosmetic outcome. Physicians today prefer to use modern multislice CT scanners that offer much greater resolution than older models, revealing subtle fractures and intracranial or intra-abdominal pathology. However, the newer scanners also require more maintenance, and the results take longer to read, which has led to increased demand for radiologists to provide immediate interpretation with communication of findings to the ordering physician. (About 75% of lawsuits against radiologists involve delays in communication of abnormal findings.28) The demand for ED radiologists is so great that many hospitals employ “nighthawk shift workers” and often outsource interpretation to practitioners from other countries to keep up with around-the-clock demands for ED film readings.29
Practical Solutions to the On-Call Crisis
In 2005, ACEP published recommendations designed to help hospitals restore on-call specialist availability.30 A primary recommendation was that hospital bylaws mandate on-call requirements for credentialing and granting privileges, coupled with an on-call physician quality assurance program. Yet many hospitals, particularly community hospitals, remain reluctant to impose these requirements for fear of losing physicians. ACEP also suggested establishing regional on-call pools and seeking legislative or regulatory solutions, such as an on-call requirement for hospitals and physicians who participate in Medicare, for licensing of specialty hospitals, universal reimbursement for EMTALA-mandated care, and professional liability relief for EMTALA mandated care.30
In 2005, at the American Medical Association Medical Staff Section Assembly, Dr. Todd Taylor31 argued that the on-call shortage is a global health care system problem and attributed 80% of the problem to organizational issues and 20% to financial concerns. Taylor, who was then council speaker of the ACEP's House of Delegates, offered recommendations for corrective action: Hospitals could contract directly with providers at market rates; hire “surgicalists” and pay them on a fee-for-service basis; contract with independent practice associations that manage ED on-call services; require health plans to provide adequate coverage for physician services; improve coordination with local emergency medical services; and establish certification for centers of excellence such as stroke care, cardiac care, and neurosurgical care and consolidate specialists at those centers.31 As most level 1 trauma centers are housed within AHCs and require specialty on-call coverage, it is essential that AHCs play a pivotal role addressing the on-call crisis.
Over the past decade, in an effort to ensure coverage, hospitals have increasingly been paying specialty physicians for providing on-call services. The opinions of physician leaders and administrators on this type of arrangement range from outrage to encouragement. Proponents argue that physicians should be able to sell their time like any other commodity and that there should be no expectation that physicians shoulder the entire burden of community health care. Opponents counter that paying for on-call coverage may open a Pandora's box and, if left unchecked, could bankrupt AHCs, which suffer tremendous financial pressure by overallocating their diminishing pool of resources.32
AHCs use various methods to compensate practitioners, including private subsidies, privately owned practice plans, and state or school funding for base salaries. Therefore, medical school deans' views of on-call payment also vary. Whereas some suspect greed as a motivating factor, others accept that payment for being on call is fair and warranted: If adequately compensated, physicians may be more willing to limit their routine daytime work hours in exchange for nighttime and weekend shift work.33 The issue is not unique to the U.S. health system. In Britain, health care workers are paid as much as time and a half for working “unsocial hours,” and they receive higher payments for working Sundays.34
Since 2004, the consulting firm Sullivan, Cotter and Associates35 has conducted several surveys of as many as 160 health care organizations across the United States to monitor on-call physician shortages, on-call pay practices, rates of pay, and pay data by specialty. Nearly half the survey participants have been from trauma centers, and approximately two-thirds of the medical groups have indicated they provide on-call services to trauma centers. In the firm's 2008 survey, 85% of respondents reported difficulty finding physicians to provide on-call services, and 16% reported that they had discontinued service lines because of a lack of on-call specialists. From 2006 to 2008, median expenditures for retaining on-call coverage increased by 88% for trauma centers and by 91% for nontrauma centers, with two-thirds of those surveyed reporting increased on-call pay expenditures over the last year and none reporting decreased costs.35 A 2009 survey conducted by the Medical Group Management Association36 revealed a wide discrepancy in on-call payment rates: General surgery per diem rates ranged from $388 to $2,000, whereas payments for neurology ranged from $500 to $3,000.
Researchers have also monitored on-call pay in individual states. In Oregon, from 2005 to 2006, the average total stipends for specialty on-call services increased by 84%, from $227,000 per hospital in 2005 to $487,000 in 2006. During the same time frame, 67% of hospitals in the state lost the ability to provide coverage for at least one specialty service. Half of Oregon's hospitals reported managing lack of coverage by transferring patients to other hospitals.37 In California, surveys conducted in 2000 and 2006 revealed similar findings: On-call availability worsened despite increased on-call payments. The percentage of hospitals whose medical staff rules required on-call services dropped from 72% in 2000 to 54% in 2006, and 75% of hospitals in 2006 reported paying for coverage of at least one specialty on-call service. In the 2006 survey, 80% of ED physicians believed that patient insurance status negatively affects on-call physician responsiveness and follow-up care.38
Legal Considerations for On-Call Services and Payments
EMTALA was amended in 2003 in an attempt to ease the on-call specialty shortage by allowing providers to operate in one hospital while simultaneously being on call at another geographically close hospital. The unintended consequence of these changes included further delays in definitive and timely management of surgical services.39 With the increased need to transfer patients from one ED to the next to access medical/surgical specialists, it is unclear which entities are liable for medical harm that results from delays in care.
CMS does not require hospitals to provide on-call coverage for all specialties at all times. If a hospital does not have on-call coverage for a particular specialty, it may transfer the patient to another hospital if the benefits of the transfer outweigh the risks. Hospitals must have written policies and procedures to follow when a particular specialty is not available or the on-call physician cannot respond because of a situation beyond his or her control. If hospitals contract with individual physicians for emergency coverage, the expectation is that those providers are available without delay. Under such contractual agreements, the physician could be held liable if a patient were harmed by waiting for services because the physician was operating in one facility while being on call in another. Finally, CMS considers all relevant factors—including the number of physicians on staff and other demands on those physicians—and allows hospitals flexibility to adopt their own policies and procedures to meet EMTALA obligations as long as patients' needs are met.40
CMS clarified its on-call policies under EMTALA in a Medicare hospital payment rule proposed in 2008. CMS will allow a regional group of hospitals to designate one of the facilities as the on-call site for a specific time period or service or both. Community on-call flexibility is expected to offset the difficulties that individual hospitals face when trying to provide for on-call specialty emergency services.41
Some opponents of EMTALA believe it is an unfunded, unconstitutional mandate; they argue that health care is not an individual right and, as such, that physicians have the right to provide their services voluntarily, not by mandate.42 Opponents of payment for on-call coverage contend that hospitals could be in violation of antikickback statutes. In 2007, however, the U.S. Department of Health and Human Services Office of Inspector General43 issued an advisory opinion stating that on-call payments are allowed, provided there are sufficient safeguards to limit the possibility of fraud and abuse, and stipulated guidelines for such payments: The per diem rate must compensate each physician for the burden of being on call and account for the likelihood that the physician will be required to provide subsequent inpatient services; on-call physicians are obligated to provide continuing care to ED patients regardless of their ability to pay; physicians in each specialty must receive the same per diem payment without regard to the individual physician's referrals to, or business generated for, the hospital; the hospital must have a legitimate, unmet need for on-call coverage and indigent care services as demonstrated by its previous outsourcing of ED care and related treatments to other facilities; and an independent third-party analysis must conclude that on-call compensation reflects the fair market value for the services furnished.44
AHCs' Role in Resolving the On-Call Crisis
Although doctors loathe crowded EDs and unfunded government mandates to provide care in high-liability environments with insufficient resources, the on-call shortage tugs at our moral heartstrings. We understand that illness strikes without regard to the clock and that it is our moral and ethical duty to be healers who devote our lives to the amelioration of suffering and preservation of life. But payment as an inducement for on-call services is not a viable long-term solution to the larger problem of how to provide access to subspecialty care after hours or in emergency situations.
Physicians in training at AHCs are receiving confusing and intellectually inconsistent messages about their future on-call responsibilities. We are teaching medical students and residents that getting a good night's sleep improves their ability to learn and provide care and that it reduces medical errors. Many medical school curricula and residency training programs advocate work–life balance, and it is generally accepted that this will lead to healthier lifestyles for physicians. Yet, the physicians doing the teaching may not be promoting or adhering to safe on-call practices themselves, because there are no posttraining workweek restrictions or recommendations for safe numbers of on-call hours. On-call duty therefore remains a conceptual obligation without finite structure. Today's working physicians are thus increasingly unwilling to accept as normative volunteering their services after hours, especially following a heavily scheduled workday. Opting out of on-call duties should not be viewed as ethical misbehavior; rather, it is a reflection of pragmatic reality. We are teaching doctors to minimize medical mistakes and personal stress by working fewer and less sporadic hours without providing them the necessary resources or coordination of services to meet these goals once they have completed their training.
Resolving the on-call crisis will require cooperation from both public and private stakeholders in health care. AHCs are uniquely positioned to be leaders of change by emphasizing the importance of providing on-call services throughout medical school and residency training. Students' attitudes and future behavior toward on-call duty are predictably more malleable during their training than after they graduate. Curricula should include lectures and case examples of health care disparities, EMTALA, and CMS and other mandated regulatory controls; workshops should address best practices for resolving on-call service access problems. Consistency of the messages conveyed about on-call coverage will also be important: Academicians are most influential when they practice what they teach, and thus they need to advocate for overhauling our currently dysfunctional on-call system.
AHCs must also take action to implement the many reasonable suggestions that have already been proposed, but not yet tried. AHCs have an ethical obligation to promote successful on-call processes; they must develop and implement specialty shift-work models that offer predictable and safe work hours, compensation for services at fair market value, and adequate time for rest between shifts. Published outcomes data generated from such models have a high likelihood of influencing physicians' work practices and behavior regarding on-call coverage. It is also imperative that AHC leaders support their faculty and adopt on-call solutions that take into account the available workforce and explore opportunities for community on-call agreements or resource sharing. Academic physicians need to translate their opinions and experiences about on-call practices into efficient, fiscally and organizationally sound strategies to ensure that health care services are delivered successfully any time of the day or night.
The authors would like to thank the department chairs of the University of Louisville School of Medicine for their participation in the “Disputation Regarding Payment for On Call” during summer 2008.
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