Position Statement

On-Call Coverage and Emergency Care Services in Orthopaedics

This Position Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

Throughout the nation, patients are finding it difficult and sometimes impossible to obtain emergency care services in a timely manner because of:

• An ever increasing patient population seeking emergency care,

• A decrease in the number of hospital emergency departments,

• A shortage of specialists available to take call, and

• Shortages of other hospital resources to support emergency care services.

A. Increasing Patient Population:

Between 1994 and 2004, the number of people seeking emergency care services increased 18%, rising from 93.4 million to 110.2 million visits annually.¹

One important reason for this trend is the growing number of uninsured and underinsured patients who use emergency rooms as their only source of health care. In addition, our aging population is putting increasing demands on our health care system, including emergency care services.

B. Number of Emergency Departments:

Between 1994 and 2004, the number of U.S. emergency departments (EDs) decreased by 12.4 percent.² There is no reason to believe this trend will reverse, especially because payments for emergency care services continue to lag behind the costs of these services.

About half of all emergency services are uncompensated. In addition, patients with insurance coverage frequently belong to health plans that have pre-certification requirements that emergency departments often fail to meet, higher co-payments for emergency services that patients often ignore and retrospective coverage denials that leave hospitals and providers with unmet claims.³

Under such adverse conditions, we should expect more hospitals to close their emergency departments.

C. Shortage of Specialists Willing to Take Call:

In a 2005 American College of Emergency Physicians (ACEP) survey, three quarters of ED medical directors reported that their hospitals have inadequate on-call specialist coverage. The problem appears to affect all U.S. geographic regions. The consequences of these shortages include more inefficiencies in the provision of emergency services, longer wait times for patients and delays in patient care, increased transfers of patients to other facilities and over-crowding in these facilities.⁴ different survey indicated that 42% of ED administrators felt that the lack of specialty coverage in the ED posed a significant risk to patients.⁵

D. Shortages of Other Hospital Resources:

The supply of hospital personnel is not keeping up with demands. For example, as of January 2005, hospitals across the nation had an estimated 109,000 vacant positions for nurses. There are also shortages of lab and imaging technicians, and pharmacists. In addition, there is a lack of staffed critical care and general acute care beds. Moreover, hospitals are experiencing significant increases in the costs of pharmaceuticals, medical supplies and devices.⁶ In 2005, nearly half of all hospital EDs reported that they were at or beyond capacity and, as a result, were forced to divert ambulances to other facilities.⁷

These variables, plus all the other factors described above, are taking a toll on the nation’s health care system, in general, and our emergency care capabilities, in particular.

The American Academy of Orthopaedic Surgeons (AAOS) believes that orthopaedists and other physicians, hospitals, and government policymakers have responsibilities to address the crisis in emergency care. In addressing this crisis, ensuring that patients have adequate access to care for emergency conditions in the safest possible environment is of primary importance.

A. The Responsibilities of Orthopaedists and Other Physicians:

Orthopaedists are uniquely qualified to provide emergency care for patients with musculoskeletal conditions, including musculoskeletal trauma. Therefore, orthopaedic surgeons have a responsibility to work in their communities with each other and their hospitals to make sure that mechanisms are in place so that emergency patients with musculoskeletal problems receive timely and appropriate care. Physicians in other specialties have the same responsibility for patients with conditions that they are uniquely qualified to diagnose and treat.

B. The Responsibilities of Hospitals:

Hospitals must support orthopaedists and other physicians that provide emergency care services to ensure that patients receive safe high quality care. In the case of orthopaedists, the hospital should provide adequate facilities, equipment, devices and well-trained ancillary personnel, as well as guaranteed operating room time to manage emergency cases the night of admission or the next day. Of paramount importance is that provisions are made to provide the best care possible in the safest possible environment for patients regardless of patients’ insurance status or ability to pay for services.

In addition, hospitals should assume some of the financial burdens that orthopaedists and other physicians now bear alone when they take call and provide emergency services. These include:

• opportunity costs associated with not being able to provide care for elective patients on both the day of and the day after being on-call because of the obligations associated with providing care to emergency patients;

• the extra costs that physicians must absorb when they diagnose and treat uninsured and underinsured emergency patients, including additional liability risks, and

• loss of sleep and other serious disruptions to normal daily routines from being on-call and providing emergency services.

Recognition and mitigation of the costs associated with provision of on call-services is critical to enabling orthopaedic surgeons (as well as other physician specialists) to provide these services to their communities. Hospitals are obligated to assume an appropriate portion of these costs given the federally mandated assignment of responsibility for provision of emergency services to hospitals with emergency departments. In the context of progressive decreases in physician reimbursement relative to both general and medical economic indices from both federal and private third party payers, assumption of the costs for provision of emergency services by physician practices is not fiscally sustainable.

C. The Joint Responsibilities of Orthopaedists and Hospitals:

Hospitals have a federally-mandated responsibility to provide care to emergency patients. Orthopaedists in every community have a responsibility to ensure that emergency patients receive appropriate and timely musculoskeletal care. Therefore, orthopaedists and hospitals must work together to fulfill their joint responsibilities. Together, they must develop workable call schedules based on the local community’s emergency care needs and local orthopaedic workforce issues (e.g., the orthopaedists’ age, years of emergency service, on-call frequency and degree of sub-specialization). They must also jointly develop protocols for transferring patients to other facilities based entirely on the severity of each patient’s condition as determined by the treating orthopaedist. These protocols must include defined agreements with receiving centers for acceptance of transfer of patients for whom musculoskeletal emergency services cannot be provided at the initial receiving center.

D. The Responsibilities of Government:

Government policymakers must take greater responsibility for helping the medical profession meet society’s expectations for having everyone’s emergency care needs met regardless of ability to pay.

• Regulations mandating that Medicaid reimbursement levels be sufficient to ensure adequate access to care for Medicaid beneficiaries must be promulgated, monitored and enforced.
• Federal, state and local governments must either bolster state Medicaid programs so they can pay fair rates for trauma and emergency services or create new sources to finance emergency care services for underinsured patients.
• Best practice models based on successful existing state and local systems should be developed.
• Impediments to access to physician trauma and emergency care services, including an actual or perceived increase in liability exposure must be effectively addressed. Federal and state medical liability reform must be enacted to restore and preserve access to care for patients with emergency musculoskeletal conditions throughout the country.
• Federal laws linking federal revenue for highway construction and maintenance to establishment of a complete system of support for emergency care for trauma patients, including payment for provision of physician services should be considered.

1. Emergency Department Visits Remain at Record High Levels, American College of Emergency Physicians Press Release, June 23, 2006. Available at: www.acep.org/webportal/Newsroom/NR/general/2006/062306.htm.

2. Emergency Department Visits Remain at Record High Levels, American College of Emergency Physicians Press Release, June 23, 2006. Available at: www.acep.org/webportal/Newsroom/NR/general/2006/062306.htm.

3. Costs of Emergency Care, American College of Emergency Physicians, June 2003. Available at www.acep.org.

4. On-Call Specialist Coverage in U.S. Emergency Departments: American College of Emergency Physicians Survey of Emergency Department Directors, April 2006; 2-3.

5. The Schumacher Group: 2005 hospital emergency department administration survey. Available at: www.tsged.com/Survey2005.pdf.

6. Taking the Pulse: The State of America’s Hospitals, American Hospital Association, Winter/Spring 2005; 3-7.

7. A Growing Crisis in Patient Access to Emergency Surgical Care, American College of Surgeons, June 2006; p. 2.

© September 2006 American Academy of Orthopaedic Surgeons

This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons^®.

Position Statement 1172

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