Hospital Emergency On-Call Coverage: Is There a Doctor in the House?

Diminished Willingness to Take Call Threatens Care for Insured and Uninsured Patients

News Release
Nov. 20, 2007

FURTHER INFORMATION, CONTACT:
Alwyn Cassil (202) 264-3484 or acassil@hschange.org

WASHINGTON, DC—As emergency departments face ever-rising demands, hospitals are confronting greater problems obtaining emergency on-call coverage from specialist physicians, according to study released today by the Center for Studying Health System Change’s (HSC).

Factors influencing physician reluctance to provide on-call coverage include decreased dependence on hospital admitting privileges as more services shift to non-hospital settings; payment for emergency care, especially for uninsured patients; and medical liability concerns, according to the study. Hospital strategies to secure on-call coverage include enforcing hospital medical staff bylaws that require physicians to take call, contracting with physicians to provide coverage, paying physicians daily or monthly stipends, and employing specialists.

"Many hospitals are struggling with inadequate on-call coverage, which threatens patients’ timely access to high-quality emergency care and may raise health care costs," said Paul B. Ginsburg, Ph.D., president of HSC, a nonpartisan policy research organization funded primarily by the Robert Wood Johnson Foundation.

"The traditional role of physicians taking emergency call as part of their obligation for hospital admitting privileges is unraveling across the country, posing risks that insured and uninsured patients, alike, may not get timely and appropriate care," said HSC Senior Researcher Ann S. O’Malley, M.D., coauthor of the study with Debra A. Draper, Ph.D., HSC director of site visits; and Laurie E. Felland, M.S., HSC health researcher.

The study’s findings are detailed in a new HSC Issue Brief—Hospital Emergency On-Call Coverage: Is There a Doctor in the House?—available here. The study is based on HSC’s 2007 site visits to 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. HSC has been tracking change in these markets since 1996.

In the past decade, the rate of overall emergency department (ED) utilization rose 7 percent in the United States, increasing from 36.9 to 39.6 visits per 100 persons, according to the National Center for Health Statistics.

While adequate on-call emergency coverage is predominantly an issue for hospital EDs, it also is increasingly a problem for inpatients requiring urgent specialty consultations, the study found.

Other key study findings include:

• Specialties that are particularly difficult to secure for on-call coverage include orthopedic surgeons, neurosurgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, neurologists, ophthalmologists and dermatologists, according to hospital executives. In a few cases, a shortage of certain specialists contributes to inadequate on-call coverage. But physician unwillingness to take call appears to be a more pressing issue for many hospitals.
• Hospitals are pursuing a variety of strategies to secure specialist emergency on-call coverage, including enforcement of hospital bylaws requiring call, payment for on-call coverage, paying physicians’ professional fees for patients who are unable to pay, and other administrative arrangements aimed at improving the physician work environment. For example, some hospitals in Little Rock and Miami reported reimbursing physicians at least at Medicare rates for patients with no other coverage. An Orange County hospital guarantees physicians Medicare rates plus 20 percent for treating certain uninsured patients.
• An increasing number of hospitals are moving beyond contractual or stipend arrangements toward a direct employment model with specialist physicians. Along with securing on-call coverage, hospital employment of specialists may be part of a larger service-line competitive strategy.

The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by the Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.