Situation critical for call panels: Is there a cure? 

Hospitals are at risk if panels aren’t filled 

A large number of emergency medicine observers agree that the inability to fully staff ED call panels has reached a critical point.

"My sense is that the availability of on-call specialty services is perhaps the most critical situation that we now face in emergency medicine," asserts Todd B. Taylor, MD, FACEP, vice speaker of the Irving, TX-based American College of Emergency Physicians and vice president for public affairs at the Arizona College of Emergency Physicians in Tempe.

Why has the problem become so serious?

"Physicians are no longer willing to take call to the ED because of declining reimbursement and an increase in the number of underinsured and uninsured patients." says Art Gruen, MD, FACEP, president and CEO of Emergency and Acute Care Medical Corp. (EA) in Rancho Santa Fe, CA, a management services organization with an independently contracted medical group providing call panel and stipend solutions and programs.

The lack of coverage creates medical, ethical, and legal problems for hospitals, Taylor says. The emergency physician feels set up to fail because he is being asked to do the impossible: be available to take care of an emergency, and then get bashed because he does not have the backup to provide the service the patient needs.

The problem is extremely stressful for ED managers, he notes. "It slows down the whole process, occupies beds, and you are constantly shopping for a doctor or a specialist," he says.

What’s more, the Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals that offer emergency services to maintain a list of on-call physicians. "A major dilemma arises from the fact that EMTALA does not require physicians to serve on on-call rosters but nonetheless requires that such rosters be maintained by the hospital," write Taylor and his co-authors in the Annals of Emergency Medicine.1

There are several key strategies to overcoming the call panel problem:

• Pay physicians by stipend. A flat fee can be guaranteed whether the physician is called or not. They can range widely, according to Taylor. "I’ve heard as much as $2,000 per day for certain specialties," he says. EA manages this function for their clients, doing the contracting with physicians, collecting the data on the unassigned population, doing the financial reporting, and then sending the checks to the physicians. "The stipend is the primary method most hospitals use" to address the call panel issue internally, Taylor adds.

• Implement fee-for-service programs. When the physicians provides a service, they receive a straight fee per unit of service (RVU, or relative value unit). In ordinary practice, a physician practice will code and bill for services provided using the Current Procedural Terminology system, he says.

"The payment will depend on the arrangement that practice has with the payer," Taylor says. "In this setting, an on-call physician is guaranteed a payment, usually a percentage of Medicare."

Gruen says EA typically will pay 80% of Medicare. If you are a low- to medium-volume hospital, you might wish to use a hybrid model. The stipend pays for availability, and the fee is based on actual services.

"The advantage of a fee-for-services [method] is it pays people for what they do, rather than what they don’t do [as with a stipend]," Taylor notes.

• Establish regional calls panels. Even in the best of circumstances, there may be a shortage of physicians in a given general area. So, for example, in Santa Clara County, CA, there are prearranged transfer agreements among the EA hospitals.

CPT coding is another important aspect of handling call panels. EA has developed a mechanism whereby patients’ records are securely transferred to its offices and then coded. "Getting the record to the biller and coded [properly] is challenging," Taylor concedes.

What are the benefits of such arrangements? "The hospital wins because the call panels are covered by docs who know they will get paid," Gruen says. "The patients win because they no longer have to wait around for the internist doc to find an orthopedist."

Unless this issue is adequately addressed, EDs are likely to end up using the "university model" for emergency care, Taylor says. "They typically employ all their docs," he explains. Regional specialty centers will take care of certain problems, he predicts.

"For example, in Tucson now, if you have an intracranial hemorrhage, there’s only one place you can go," notes Taylor, referring to University Hospital at the University of Arizona Medical School. "Some others have only spotty coverage for neurology," he says.

Reference

1. Johnson LA, Taylor TB, Lev R. The emergency department on-call backup crisis: Finding remedies for a serious public health problem. Ann Emerg Med. May 2001; 37:495-499.

Sources

For more information on filling call panels, contact:

  • Art Gruen, MD, FACEP, President/CEO, Emergency and Acute Care Medical Corp.; Director, Emergency Services, Sharp Memorial Hospital, Rancho Santa Fe, CA. Phone: (858) 759-4765. E-mail: art.gruen@eamc.com.
  • Todd B. Taylor, MD, FACEP, 1323 E. El Parqué Drive, Tempe, AZ 85282-2649. Phone: (480) 731-4665. Fax: (480) 731-4727. E-mail: ttaylor@acep.org.