‘Inappropriate’ transfers and ‘inconvenient’ services
As an orthopaedic surgeon participating in general unassigned call at a level 1 trauma center, I found that the article regarding transfers for minor problems (AAOS Headline News Now, Jan. 25, 2008: “Study finds patients with minor injuries transferred to trauma centers”) barely touches the magnitude of this problem.
It is not uncommon for me to find that patients from distant hospitals arrive at our facility after bypassing facilities that refuse (“are unable”) to provide orthopaedic care. Transfers for reasons such as “I don’t do infections,” “I don’t care for periprosthetic fractures,” “We don’t have the equipment for care of long bone fractures,” or even “They might be in the hospital for longer than a day, and I don’t do hospital care” have become the norm. This does not include transfers because “there is no specialty call coverage for our facility tonight.”
During the recent holiday season, I found myself providing on-call orthopaedic coverage for seven peripheral hospitals (distance of 1 to 3½ hours away, in- and out-of-state) that “had no ortho call,” even though those hospitals provide elective inpatient and outpatient orthopaedic services on a routine basis.
As a private practitioner who does not receive financial support for participating in unassigned call, the only way that I (and my partners) can care for these patients is to shorten our work day when we are on call and to have no scheduled patients on the first day post-call so we can “clean up.” That patient care is compromised by delays in treatment, that patients must travel long distances for follow-up, or that services at receiving hospitals are often overwhelmed by the unscheduled influx of patients seem to be of no concern to the practitioners who refuse to participate in comprehensive medical care in their communities. “Someone else” will take care of the issue. The financial impact on those who cover the “after-hours” services that these practitioners refuse to provide is clearly not an issue to them (or the institutions that allow and encourage their elective practice).
Our institution has a “core list” of orthopaedic services (based on CPT codes) that all department members must be able to provide to be on staff. We expect any practicing, board-certified orthopaedist to be able to provide such services. On rare occasions, subspecialty consultation for complex issues or optimal patient care is appropriate. We encourage this [referral to specialty consultation] among our partners and do the same with other local practitioners. Staff physicians are not expected to be able to perform all specialty services (complex trauma, complex hand, and spine), and participation in such patient care is elective.
While the intent of the Emergency Medical Treatment and Active Labor Act may have been to prevent “wallet biopsy-based care” and patient dumping, the end result has been the development of a tiered system of elective vs. “inconvenient” services. Perhaps physicians and facilities that offer only elective services and refuse to provide “after-hours” care would respond to an alteration in reimbursement, reflecting their inability to provide emergent care. Shifting those funds to the physicians who are willing to provide comprehensive care to their communities and to those patients that others refuse to care for would seem appropriate. If facilities and physicians truly cannot provide basic orthopaedic care on a consistent basis, planned communication with secondary referral centers and those physicians who “fill in the gaps” regarding such needs would seem a minimum courtesy.
Thomas K. Miller, MD
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