Is the crisis in emergency care threatening our ability to deal with trauma?

In October 2006, the AAOS Bulletin reported on the growing crisis in emergency care, including the challenges facing orthopaedists who take call. A year later, it seems that little has changed, except for the intensity of the problem.

“The number of visits to emergency departments is up 18 percent, but the number of emergency departments is down 12 percent,” said Jeffrey Anglen, MD, AAOS fellow and president of the Orthopaedic Trauma Association (OTA), who addressed the AAOS Board of Directors in September. The resulting squeeze, he noted, means that many people are not getting timely and appropriate emergency care and that multiple pressures are being placed on orthopaedic surgeons who take call.

In addition, Dr. Anglen said, inappropriate transfers (“patient dumping”) are putting more stress on regional trauma centers; in Indianapolis, where he practices, at least three inappropriate transfers are made to the local trauma center daily.

A strategic discussion
Later during the meeting, the Board held a strategic discussion on the AAOS response to the crisis in trauma care. Although part of the discussion centered on a proposed Standards of Professionalism on orthopaedic surgeons’ on-call professional responsibilities, participants focused more on specific, concrete steps that could address the lack of hard data, the economic complications, and the growing concern that a younger generation of orthopaedic surgeons may not share the older generation’s response to call duties.

“We cannot forget that orthopaedic surgeons have a professional and humanitarian responsibility to treat indigent patients,” said First Vice-President E. Anthony Rankin, MD.

The AAOS leadership committed to ongoing discussions with leaders at OTA and the Pediatric Orthopaedic Society of North America, as well as with the American Board of Orthopaedic Surgery. It also supported efforts to work with these organizations to develop the data needed to support requests for increased reimbursement for trauma care.

Is EMTALA the reason?
Some analysts in the healthcare industry say that changes enacted in 2003 to the Emergency Medical Treatment and Active Labor Act (EMTALA) are among the reasons for the pressures being placed on trauma centers. Originally designed to ensure that patients receive adequate emergency care regardless of their ability to pay, some now claim that EMTALA is being used as a reason for transferring indigent or uninsured patients from community hospitals, which may not have specialists available, to trauma centers, which may have them available—even if the patient’s condition does not warrant specialized trauma care.

Two recent studies addressed the question of whether patients are transferred to Level 1 trauma centers for reasons other than medical necessity. Although one study found that uninsured patients transferred to the Washington University trauma center in St. Louis have less complex injuries than the insured patients transferred there, the second found that “patients with no insurance or categorized as self-pay were not transferred at higher rates than insured patients” although transfer rates were higher than expected for patients with low injury severity.

Dr. Anglen and others brought their concerns to the EMTALA Technical Advisory Group (TAG) meeting in May 2007. Although orthopaedic surgeons “have a responsibility to … make sure that mechanisms are in place so that emergency patients with musculoskeletal problems receive timely and appropriate care,” said Dr. Anglen in his testimony, “hospitals have a duty to provide adequate resources and the government has a duty to provide adequate compensation for the care of the indigent.”

He called for measures that would lower the burden of call and decrease disincentives to physicians who provide call coverage.

The EMTALA TAG responded with a series of recommendations that would broaden the allowable delivery methods for on-call coverage. For example, if a hospital does not have the capacity to provide services at a given time, it may use a backup plan that includes providing care through the use of telemedicine, other staff physicians, transfer arrangements with other facilities, or participation in a regional or community coverage arrangement.

Recently, an advisory opinion from the U.S. Department of Health & Human Services (HHS) inspector general’s office addressed the issue of payments to physicians for providing emergency department (ED) on-call coverage. Although the specific circumstances cited were found to be appropriate, the opinion acknowledged some arrangements could potentially violate antikickback statutes.

The federal response
On June 22, 2007, the House Committee on Oversight and Government Reform, chaired by Rep. Henry A. Waxman, D-Cal., held a hearing to assess the government’s response to the nation’s emergency care crisis. In his opening statement, Rep. Elijah Cummings, D-Md., noted that HHS “appears to be ignoring the mounting emergency care crisis,” and, in fact, it had “recently taken some actions that will make matters worse.”

He was referring to proposed rules that would “cut hundreds of millions” in supplemental Medicaid funding from safety net hospitals that furnish emergency care and Level-1 trauma services. Although Congress enacted a 1-year moratorium on the measure, HHS insists that the rule will not have a negative effect on safety-net providers.

In response to the findings, Rep. Waxman joined Sen. Barak Obama, D-Ill., in introducing the “Improving Emergency Medical Care and Response Act of 2007.” The legislation would support multiyear demonstration projects that design, implement, and evaluate innovative models of regionalized, comprehensive, and accountable emergency care systems. The legislation would fund the projects with $12 million through 2013.

The AAOS supports this legislation as integral to the care of patients with trauma injuries and other conditions requiring emergent care and will work with other groups in the Trauma Coalition to promote passage of this legislation.

Note: This information is presented for educational purposes only and is not intended as legal advice, nor is it intended to influence physicians to take any specific action. Orthopaedic surgeons should consult healthcare counsel before entering into any negotiations.

On the frontlines
AAOS Now revisited orthopaedic surgeons interviewed last year to see how—or if—the on-call situation in their areas had changed. Here’s what we found.

Brian J. Galinat, MD, of Wilmington, Del, reports that two hospitals had to drop from Level 3 to Level 4 trauma designations due to lack of orthopaedic coverage in their emergency departments (EDs). “The status at our Level 1 center is stable,” he says, “but we are exploring modifications in our arrangement with the hospital.”

Adam S. Bright, MD, of Sarasota, Fla., found that negotiating a per diem stipend for physicians who took ED call at the county hospital opened the door for negotiations with other area hospitals. “The other private hospital started a similar program to reimburse physicians,” he says, “despite having told us that they would ‘never’ pay for ED coverage by specialists.”

In Nevada, Fred C. Redfern, MD, reports that hospitals are “using the ED call schedule to reward doctors who bring in elective cases. If your case volume is not high enough,” he says, “you can’t get in the rotation for call.” He also notes that the on-call stipend provides “a significant income supplement for many orthopaedic surgeons, offsetting the cutbacks in reimbursement from private insurance.”

The stress of taking trauma call is having an impact in Urbana, Ill., where Chris J. Dangles, MD, has his practice. “We lost one of our three orthopaedic trauma surgeons, resulting in the rest of us taking more call,” he reports. “The attrition in our trauma surgeons was directly related to the stress of the job.”

Although Atlanta’s Grady Hospital is facing a record deficit and possible shut-down, in Macon, Ga., Frank B. Kelly, MD, reports that “our system has improved significantly” and that the situation has further been improved with the hiring of a full-time trauma specialist.

John G. Kloss, MD, of Boise, Idaho, reports that the article triggered several queries from regional providers requesting information on contract negotiations. In addition, “we went through a renegotiation process with the major trauma facility with a favorable outcome,” he reports. The issue is still “on the front burner.”

Disclaimer: This information is presented for educational purposes only and orthopaedic surgeons should consult their own healthcare counsel before entering into similar negotiations. This information is not intended as legal advice nor is it intended to influence individual physicians to take any specific actions.