Dr. Rao is a health policy researcher in emergency medicine at the Yale University School of Medicine and a former Robert Wood Johnson Clinical Scholar. Follow him at twitter.com/mithrao.
Workforce shortages have a profound impact on patients and the health care system. On-call coverage of emergency care particularly has loomed in the forefront. A 2006 Institute of Medicine report, “Hospital Based Emergency Care: At the Breaking Point,” showed that physician specialists are often unavailable to provide emergency and trauma care.
The ability to consult a specialist is critical to the success of care provided by emergency physicians. The law says if a hospital can provide specialist care to its inpatients, it must also do so for its ED, and the Emergency Medical Treatment and Active Labor Act (ETMALA) says hospitals have to maintain on-call coverage as best as possible. (Federal Register 2003;68: 53222.) This vagueness in direction left it to hospitals to establish their own “reasonable coverage” standards for on-call care. The problem, however, is getting specialists to agree to take call, with two-thirds of emergency department medical directors reporting an inadequacy of on-call specialist coverage. (On-Call Specialist Coverage in U.S. Emergency Departments, www.acep.org/WorkArea/downloadasset.aspx?id=33266.)
In years prior, emergency call was considered a responsibility of practicing physicians, but through a combination of issues, that mentality has changed. Specialists often have difficulty getting paid for emergency and trauma care because of high numbers of under or uninsured patients, who account for more than 16 percent of ED visits. Because no established relationship exists between the doctor and patient in these circumstances, procedures performed while on-call hold high legal liability. (Hospital Emergency On-call Coverage: Is There a Doctor in the House? www.hschange.org/CONTENT/956/.)
This leads to higher insurance premiums for specialists electing to take call. This issue is compounded by newer generations of specialists who feel that on-call demands are a negative element to their work-life balance and interfere with their families and private practice. All these issues create a highly undesirable environment for specialists, leading to almost three-quarters of hospitals reporting a shortage of specialists willing to take call. (Hospital-based Emergency Care: at the Breaking Point, www.iom.edu/?id=48896.)
In response, hospitals have created a payment system for nightly or monthly coverage by specialists, circumventing the uninsured care risk for the specialist and providing a financial incentive to take call. Hospitals that cannot afford this measure are forced to do without on-call coverage, and have to transfer emergency patients to the nearest hospital that can provide specialist care. This, in turn, leads to financial loss for the hospital and increased costs to the health care system in the form of higher medical transport and triage costs.
Quality of care and patient outcomes are negatively affected by this specialist on-call shortage. Twenty-one percent of patient deaths and permanent injury can be attributed to ED treatment delays linked to specialist shortages. (Delays in Treatment, www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_26.htm.)
ED patients are now waiting longer for specialist care, and are often forced to travel or be transferred significant distances for care of urgent but routine issues. Physicians who elect to cover call find themselves facing an ever-increasing workload and declining morale.
All is not doom and gloom, however. There are ways that states can change current policy to help solve this problem, such as regionalizing on-call. Instead of having multiple Level II trauma centers with specialist coverage on a given night, this redundancy could be eliminated by having one specialist per region. This way, call will be spread out among the institutions, allowing for sharing costs and reducing the amount of call any specialist needs to take.
Physicians who currently choose to take emergency call pay higher malpractice rates, which proves to be a severe disincentive to participation. One option would be for the state to declare these specialists covering emergencies to be temporary workers of the state, and shift the cost burden of malpractice coverage. This may help provide some protection from lawsuits. The state also could indemnify covering physicians and pay them for their work, further reducing the cost burden. This could be accomplished through a state annuity to all physicians participating in ED call, and would help offset the financial loss of caring for the uninsured.
As I continue to study this problem, I would love to hear your views and suggestions. Write to me at EMN@lww.com.
This article first appeared in the March 2008 issue of General Surgery News.