Work with physicians to improve ED call coverage, avoid shortages

Incentives may help, but also can take hard line with resistant doctors

It's a constant worry for risk managers: Do you have enough physicians taking emergency department (ED) call duty? Will those on call actually respond when summoned? Are they taking ED calls from other hospitals at the same time?

Though it is a longstanding problem, risk managers must not let ED calls slip into the category of "just another worry with no solution," say the health care leaders who have addressed this potentially disastrous problem. Unless you come up with a way to ensure a good ED call response in your facility, you run the risk of huge liabilities every minute your ED is open for business, they say.

A confounding factor is that there is no single solution that will work for all hospitals, says Maurice A. Ramirez, DO, BCEM, CNS, CMRO, an emergency physician at Pascoe Regional Medical Center and president of the consulting firm High Alert, both in Kissimmee, FL. Ramirez says risk managers must work with physician leaders to develop a solution that addresses the particular difficulties in your community or with your facility's ED call coverage. Failure to do so will likely result in violations of the Emergency Medical Treatment and Labor Act (EMTALA), in addition to various other regulations.

Any shortfall in coverage could be caused by a variety of factors, and often a combination, he says. Those problems include not having enough specialists to cover the entire month of calls, even when they take their obligated 10 days per month of call duty. Another factor might be that a physician takes calls at numerous hospitals, so he or she always is busy when your facility calls.

Or it could be that physicians are on call but just don't come in when summoned. That can be one of the most difficult issues to address, Ramirez says. When you face that problem, the best solution may be to play hardball. In most cases, he notes, the hospital must report the refusal.

"When you call a doctor on call and say the magic words, 'Doctor, I require your assistance to further evaluate this patient,' or words to that effect, and the doctor does not come in, you have no choice," Ramirez says. "You must report that doctor to the state agency that oversees EMTALA compliance. Depending on their guidance, you may or may not have to report it to the [Centers for Medicare & Medicaid Services] at the federal level."

In addition, the hospital should bring the physician before its medical staff and executive committees.

"That doctor has violated the federal law and created a violation of the federal law for your facility," Ramirez says.

Fines fall on hospital, not doctor

Ramirez points out that physicians no longer are subject to personal fines on the federal level for refusing ED calls; the potential for fines falls solely on the institution.

"The American Medical Association and the specialty associations have made sure that their member physicians know this. The physicians know that it's not on their shoulders anymore," he says. "We used to be able to say, 'Doc, unless you want a $120,000 personal fine with 18% interest, you need to come see this person.' Now they know that's not the case, and it's the institution's problem."

That leaves the hospital with essentially two options: beg and plead, hoping the physicians will help you out, or get aggressive. Ramirez advocates the latter, at least when it is clear that the physician on call is shirking his or her duties.

For starters, he says, document the situation thoroughly so that if you have to self-report an EMTALA violation, you can show that the hospital did everything possible to get that physician to come in. Ramirez, an emergency physician who sometimes finds himself trying to coax reluctant physicians to come to the ED, says his protocol is to call the doctor every 30 minutes X 3, every 15 minutes X 2, and then every five minutes until they respond — all carefully documented. If the physician responds but refuses to come in, the documentation should clearly state what facts were conveyed to the doctor and his or her response.

Ramirez also urges risk managers to support the emergency physicians who report difficulty with getting other doctors to respond to calls. Too often, he says, administration grills the reporting emergency physician and puts him or her on the defensive, looking for a reason to let the on-call specialist off the hook by saying that the patient's condition was not clearly communicated.

"The clinicians need to know that when these situations occur, you want them to call the risk manager right away. The risk manager should be brought into the loop as soon as possible, while the dispute with the on-call physician is still happening," Ramirez says. "The risk manager should not only take the call but should come in and make sure that everything is being documented in real time. You want the chart to show that you were handling the problem in the best way, so that you might be able to avoid some or all of the fines."

There are other options for improving call coverage, such as paying physicians for ED calls, and Ramirez says it is up to the individual organization to find the right mix of strategies that address their unique situation.

Taking a hard line on call coverage still can have drawbacks. ED call coverage can become a negotiating point when physicians are choosing between treating patients at one hospital or another in a large community, notes Ted McMurry, MD, FACEP, medical director of the emergency trauma center at St. John's Regional Medical Center in Springfield, MO. If one hospital requires coverage and makes it clear that it will be tough on any evasion, the hospital across town with a different policy may look more appealing, he notes.

McMurry's own facility has experienced little difficulty with coverage because it employs a large number of physicians through the health system, making it easier to require call coverage and also to make clear that everyone is in the same boat when it comes to potential violations.

"It is important to have strong medical staff bylaws that clearly spell out what the responsibilities are in relation to coverage, but the second part of that is that you have to enforce it," McMurry says. "I would suspect that most hospitals have this responsibility in their bylaws, but if they don't enforce it, then the emergency department ends up having to transfer patients or spend hours trying to find someone."

Commit to treating all doctors the same

Convincing physicians not to evade their call obligations is best achieved by convincing them that they have a lot to lose. Risk managers should remind them that their careers could be at stake — and that the hospital isn't going to pussyfoot around, no matter who the physician is, says Maurice A. Ramirez, DO, BCEM, CNS, CMRO, an emergency physician at Pascoe Regional Medical Center and president of the consulting firm High Alert, both in Kissimmee, FL.

"Educate them and remind them that they are going to lose their privileges over this. Be willing to make an example of that doctor who just refuses to come in when called," he says. "There has to be administrative commitment to this. You can't make empty threats."

The doctor doesn't necessarily have to lose privileges the first time, but there should be sanctions, which are reportable in most states, Ramirez says.

But remember that such a commitment has to apply across the board to any physician who evades call coverage — even that superstar cardiologist who is bringing in lots of patients for high-profit procedures, the one your facility has built an entire program around and who is featured in the marketing campaign. That is the only way to get serious about improving call coverage, and the only way to avoid a lawsuit charging discrimination against a doctor who lost privileges for the same misdeeds.

"That's how notoriously bad doctors keep skating by, because administration is not willing to take the risk that they would have to get rid of their favorite son if he commits the same malfeasance," Ramirez says. "Either you're committed to improving call coverage or you're not."

With the potential liabilities so significant for the hospital, Philip L. Willman, JD, a health care defense attorney with the Moser & Marsalek law firm in St. Louis, says it is well worth the risk manager's efforts to develop creative solutions. Some hospitals go beyond paying for ED calls and even subsidize the specialists' malpractice premiums, he says.

"I know of one hospital that did that to obtain neurosurgery coverage for trauma. They weren't able to get a neurosurgeon to cover the ED primarily because of liability exposure, so the hospital agreed to take on the malpractice cost for that surgeon," Willman says.

Malpractice concerns are reasonable for physicians taking ED calls, often with little or no compensation because the patients lack insurance, he says.

"There is no established physician/patient relationship, no history, and they're faced with treating a patient at 2 a.m. that they know nothing about," Willman says. "I can see why they would worry about the malpractice concerns there, and the risk manager will make the most headway by acknowledging that and coming up with a solution that addresses that concern."

Sources

For more information on improving ED call response, contact:

  • Ted McMurry, MD, FACEP, Medical Director, Emergency Trauma Center, St. John's Regional Medical Center, Springfield, MO. Telephone: (417) 820-2939. E-mail: ted.mcmurry@mercy.net.
  • Maurice A. Ramirez, DO, BCEM, CNS, CMRO, 1200 Providence Blvd., Kissimmee, FL 34744-5151. Telephone: (407) 301-3458. E-mail: Renaissancedoc@earthlink.net.
  • Philip L. Willman, JD, Moser & Marsalek, St. Louis. Telephone: (314) 244-2278. E-mail: pwillman@moser.com.