New report highlights crisis with on-call panels

Will recommendations solve complex problem?

"The patchwork of call panel arrangements is unwieldy, expensive, and may compromise the quality of care for patients in the emergency department." This dramatic finding is part of a new report that outlines the seriousness of the call panel situation in California, often considered to be a state that precedes the rest of the country, and offers recommendations to remedy the situation.

The report was funded by the Oakland-based California HealthCare Foundation (CHCF) and produced by The Performance Alliance of Anaheim, CA, in collaboration with the University of Southern California Center for Health Financing, Policy and Management in Los Angeles.

Their findings come as no surprise to ED physicians, who have been wrestling with the problem for years. "I read the CHCF report, and it simply reaffirms other reports," says Paul Kivela, MD, MBA, FACEP, president of the California Chapter of the American College of Emergency Physicians (CAL/ACEP), an attending physician at Queen of the Valley hospital in Napa, and co-author of his own study of the on-call coverage situation in California. (See resources, below.)

The situation in California may be a bit extreme compared to other areas of the country, but experts warn it’s only a matter of time before they are faced with similar crises. "It’s unfortunate, but inevitable; California is where it all starts — here, or Florida, or New York," says Wesley Curry, MD, FACEP, CEO of California Emergency Physicians (CEP) Medical Group, an Emeryville, CA-based partnership of physicians that provides emergency physician services in about 51 EDs.

In other states where Medicaid reimbursement is more appropriate, they will be shielded from it for a longer period of time, but nobody is immune to this problem, Curry emphasizes. "Unfortunately, we may just be five to 10 years ahead of other areas," he says.

Kivela agrees. "In many cases, California is the bellwether. I’ve talked to people out of state where call panel coverage is not yet such an issue, but they are aware it is headed in that direction," he explains.

The challenge seems to be finding solutions, sources say. The CHCF report offers a combination of possibilities, including:

  • taking legislative action, such as payment standards for on-call physicians;
  • introducing regional competitive contracting for on-call coverage;
  • instituting mandatory on-call duty for hospital medical staffs;
  • creating physician compensation incentives such as tier-based stipends or productivity-based guarantees;
  • restructuring the delivery of on-call services through use of hospitalists or physician assistants;
  • establishing transfer agreements among hospitals.

Kivela remains unconvinced that anyone has found the silver bullet. "We tried an initiative this year, but it failed," he says. "There are numerous other solutions being proposed, although I believe they are only partial fixes."

Some merit seen

Partial though they may be, the solutions offered by CHCF have merit, Curry notes. For example, he says, regional competitive contracting for on-call coverage "actually has promise." Essentially, this solution would involve putting together a group of physicians responsible for coverage in multiple hospitals, Curry adds.

"You could potentially get a critical mass of physicians," he says. "It’s not likely they would be called to the same hospital at the same time."

However, Curry notes, because hospitals are basically in competition with each other, some may not be interested in such an arrangement. "Also, there is the issue of sharing of availability [on-call] fees," he adds. "There are hospitals that pay north of $5 million a year to arrange that."

Payment standards for on-call physicians seems to make the most sense, Curry says. "Paying physicians to be on call, or some mechanism where they get paid a fair amount for what service they provide, is a good idea," he continues, but adds that funding such payments in California is a problem. "The [state’s] Maddy Emergency Medical Services [EMS] fund does pay for uncompensated care, but it’s nearly bankrupt in every county by July," Curry. continues.

Restructuring the delivery of on-call services through use of hospitalists or physician assistants is another solid proposal, he says. "We have already used hospitalists here, and it’s been very successful," Curry points out. "That’s definitely a solution people should look at — but that only [solves the problem] on the internal medicine side."

One definite nonstarter, he says, is mandatory on-call duty. "I think it will backfire," he predicts. "Orthopedic surgeons, for example, will stop working in hospitals, as they have in Florida and in other states."

The key to developing effective solutions is to remember the main causes of the problem, observers say.

"It still boils down to money, turf, and, in many cases, lifestyle," Curry asserts. "People are less willing to respond to being an on-call physician when they perceive significant costs for liability coverage, a lack of reimbursement, and also the intrusion into the usual schedules of their office practices." That’s why, for example, the hospitalist solution makes sense; they have no outside office hours to interrupt.

"You must determine whose problem this is," he continues. "Hospitals do not want to feel like they have a bunch of physicians on payroll, but the physicians do not want to feel they are doing this work for free, because it only benefits the hospital." This continues to be the primary sticking point, Curry says. "So more hospitals are paying physicians to be available," he says.

One thing is clear, says Kivela; something has got to be done soon. "EDs in California are closing; we’ve lost six in the L.A. area in the last 14 months, and since the summer, it’s been escalating to nearly one a month," he says. "This creates domino effect, because the facilities adjacent to the ones that are closed will not be able to provide the on-call coverage needed."

Suggested reading

  • Rudkin SE, Oman J, Langdorf MI, Hill M, et al. The state of ED on-call coverage in California. Am J Emerg Med 2004; 22:575-581.

Sources/Resource

For more information on the call panel crisis, contact:

  • Wesley Curry, MD, FACEP, CEO, California Emergency Physicians Medical Group, 2100 Powell St., Suite 920, Emeryville, CA 94608. Phone: (510) 350-2777. Fax: (510) 879-9100.
  • Paul Kivela, MD, MBA, FACEP, President, CAL/ACEP, Attending Physician, Queen of the Valley Hospital, 1370 Trancas No. 336, Napa, CA 94558. Phone: (707) 207-0477. E-mail: pkivela@myifp.com.

For a copy of On-Call Physicians at California Emergency Departments: Problems and Potential Solutions, go to the California HealthCare Foundation web site (www.chcf.org) and click on "Emergency Departments’ Unstable On-Call System Examined." Or contact:

  • California HealthCare Foundation, 476 Ninth St., Oakland, CA 94607. Phone: (510) 238-1040. Fax: (510) 238-1388.