Surgicalists Could Ease On-Call Shortages

Could a surgicalist be coming soon to your emergency department? If you practice in some parts of the Pacific Northwest, you may have one already as part of an effort aimed at helping solve the specialty shortage.

Even the relatively new stipend system, in which specialists are paid a flat payment to take call, may be replaced by a movement among some hospitals to directly employ surgeons to focus on emergency patients, said John McConnell, PhD, an assistant professor and researcher in emergency medicine at the Oregon Health and Science University in Portland. Part of a team that investigated the diminished specialty coverage in Oregon over the past few years, Dr. McConnell and colleagues had suggested stipends might be a way to address the shortages. (EMN 2007;29[4]:1.) Now, however, another approach seems likely as well.

Rather than paying orthopedists to take call, for example, a hospital might employ a designated fracture service, he noted. One model that could develop in response to on-call problems is hospitals' employment of surgical hospitalists, or surgicalists, as they are sometimes called. This surgicalist model has been proposed by some groups to extend acute care surgery, a model that would combine trauma surgery, broad-based emergency surgery, and surgical critical care.

In Oregon, one of the hospital systems is already undertaking this by employing surgeons for acute care. Another has hired obstetricians as part of the hospital staff. This is the biggest change that I am aware of, Dr. McConnell said.

All along the west coast, where HMOs dominate, there has been evidence of reduction in specialty coverage. At the 2008 annual meeting of the Society for Academic Emergency Medicine, emergency medicine researchers led by Scott Rudkin, MD, showed that on-call coverage had worsened significantly in California community hospitals over the past six years. Mark Langdorf, MD, the chairman of emergency medicine at the University of California, Irvine, and an author of the study, said this shift results from a combination of factors: the relatively low reimbursement by HMOs and insurance companies coupled with concern that emergency patients have high potential for malpractice suits, a result of comparatively poor follow-up and compliance.

Meanwhile, another troubling trend has occurred, he pointed out. Academic tertiary care centers in the western United States have become a repository for patients in need of specialty care; teaching centers have residents and fellows in most specialties serving the emergency department so it is somewhat easier to maintain a call panel. Because of this, even if another hospital nearby has as many specialists on staff, they may choose not to take ED call, forcing patients to be transferred to academic and county hospitals. Poor reimbursement of specialists trumps physicians' altruism, Dr. Langdorf said.

Balanced Billing

Against the backdrop of such developments, emergency physicians are facing another strain, he added: the battle for balanced billing. The ability to balance-bill has been a big help in getting properly reimbursed, Dr. Langdorf explained. Now when the initial reimbursement is low, patient's can be tapped for the remaining amount. When you get the patient involved, they get the insurer to pay, he said, although a California bill has been introduced to abolish this remedy.

The Department of Managed Health Care, which is supposed to regulate HMOs and ensure fair payment, promotes regulations to prohibit balanced-billing and issues token fines when HMOs are caught underpaying physicians or denying legitimate claims, Dr. Langdorf said, adding that he believes faster, stiffer penalties for insurance companies that fail to provide adequate reimbursement for specialty care are one solution, particularly when they target those whose standard practice is to delay payment.

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But payment problems are only one part of the reason that specialty coverage has dwindled, said John Kusske, MD, a professor of neurosurgery at UCI. Dr. Kusske was a member of the technical advisory group for the EMTALA Task Force, where he served as the chairman of the subcommittee that examined on-call issues.

The rise of surgical centers has meant there is less need for hospital privileges, allowing some surgeons to eschew the hospital system entirely, he said. Newer physicians often want a lifestyle different from their predecessors, who younger generations seem to view as workaholic, he added. Physicians also are concerned about the potential for greater professional liability risks arising from the care of emergency patients. A declining number of applicants for certain specialty residencies also affects the supply of physicians available to cover EDs.

There are other, more pragmatic reasons for reductions in specialty availability as well. If you are up all night [in the ED] taking care of someone, how well are you going to do in elective surgery the next morning? he asked. With costs rising to maintain a practice and with reimbursements falling, physicians have to spend more time within their practices to meet these expenses. Lack of payment or low reimbursement for emergency care complicates the business of practice, he said.

One proposed solution, currently under review by CMS, would commit specialists to on-call coverage only periodically. This more defined way of scheduling allows specialists to plan better for time in the ED, he noted. This is shared community call where a designated hospital would be identified for a certain period to provide coverage in a particular specialty, and then later another hospital would be designated so that the on-call physicians could develop schedules that were more in tune with their specific duties outside the ED.

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