Does your group have a plan for anticipated or unanticipated changes in its work profile? What would you do if a partner requested a temporary leave to pursue a master’s degree in business administration? How would you respond when a member announces one day, “I want to go off call”?

Most groups must face such transitions at some point, but deciding what to do on a case-by-case basis at the time of each request can be emotionally damaging, build resentment, and set confusing precedents. The time to determine the rules for group transitions is before the crisis.

Physician transition plans permit your practice to adapt to changes in physicians’ work schedules and priorities. The first part of any transition plan is to define “normal performance expectations” in your group. Make sure contracts define what is expected of a physician in terms of call, workload, time-off, and billings. These definitions will be needed when the group faces transitions, such as a request to go off call.

Finding a balance
On-call responsibilities are often a common source of transition conflicts because they affect all members of a practice most of the time. Because taking call is often considered an unpleasant responsibility, perceived unfairness or inequity can bubble to the surface quickly if a group member wants out and no plan for making the transition is in place.

Many different approaches are available. At one extreme, a practice may require each physician to continue to take call or cease working in the practice. More commonly, however, a practice will allow a partner who meets certain qualifications to decrease call for a limited period.

One big misconception is that reducing call will negatively affect a physician’s production and compensation. A physician who goes off call, in fact, will often increase his or her production. Without call, the physician no longer faces those tired post-call periods and those long afternoons waiting to get into the operating room to perform post-call surgeries. Eliminating call reduces the disruptions in a physician’s regular schedule and often leads to an increase in elective procedures on paying patients.

If dropping call doesn’t have a negative impact, the group may need to impose a significant financial penalty. Otherwise, group members would have no disincentive to quitting call. If the financial penalty is too severe, however, ceasing to take call essentially requires a partner to quit practicing.

Penalties may take several forms. One option would be to charge a fixed price per weekday or weekend of missed call. The price should be set by the group before a request to take time off call is made. Financial and group interests should be central to the decision-making, and personal emotions should be kept low.

Such an arrangement should also discourage private “selling” of on-call responsibilities among group members because this makes consistent governance difficult.

Another option would be to reduce the percentage of shared compensation for those who do not take call. Those who participate in call would receive a full share, but those who don’t participate would receive a reduced share. Although many other options exist, the principle remains the same—to encourage members to participate in the group call obligation by offering a financial incentive to those who do, and a financial disincentive to those who don’t.

Make it a group decision
The group—not the individual—should set the ground rules of quitting call. These decisions should be made before a call crisis arises. This enables participants to put the practice’s interests first, not their individual desires. The following considerations may be contributing factors:

• Age—Practices commonly allow a partner to go off call when the partner reaches a certain age.
• Length of service—Time in the group is another common parameter and may be combined with age. A group may specify that a partner have 10 years or more of service to be eligible to go off call at age 60.
• Length of time off call—Another parameter the group may consider is how long a partner is permitted to take off call before retiring or changing partnership status.
• A common practice is to allow only those who are within 5 years of retirement to go off call. This helps control the number of physicians not taking call and allows the group to begin doing some future planning.
• Number of physicians with off-call status—The group may need a core number of physicians to take call so that it can meet its call obligations without placing undue burden on other group members.

Recommended reading
See “Transitioning out of call” on page 38 for an example of a transition plan for reducing on-call obligations. Although this is only an example, it highlights some of the issues a group may need to address in preparing an off-call policy. The important point is that the group must plan ahead to manage transition more smoothly with less resentment and greater fairness.

Other sources for transition plans include Physician Compensation Plans by Bruce A. Johnson and Deborah W. Keegan (published by the Medical Group Management Association) and the practice management courses sponsored by the AAOS.

Robert H. Blotter, MD, represents small group practices on the Practice Management Committee. He can be reached at rblotman@hotmail.com

Transitioning out of call
Physicians may elect to reduce on-call activity at some point in their careers. This sample transition plan outlines the eligibility requirements and stipulations for such requests.

Physician eligibility—Age and tenure
Physicians must have at least 15 years of service. They may cease weekend call at age 59 and weeknight call at 64. This is elective and not mandatory.

Stipulations for on-call reduction

• Notification: The physician must provide notification at least 1 year in advance of going off call. Any other request to reduce call must be submitted to the executive board, which is under no obligation to grant such requests.
• Maximum Time: The maximum period for time off call is 4 years for weekend call and 2 years for weekday call.
• Cost: Physicians will not be eligible for any payment from the on-call fund and shall pay $1,000 per day of call excused to the on-call fund.
• Fail-Safe Provision: There must be at least 5 physicians in the group who are available to take call. If there is an insufficient number of physicians available to take call, the most recent off-call physician will be required to recommence on-call status, followed by the next most recent physician until a sufficient number is obtained. All physicians are expected to take a reasonable amount of call in an emergency (on-call physician death, injury, or disability). This period of temporary emergency call will not count against maximum time off call.
• Buy and Sell of On-Call Obligations: Buying and selling of on-call is prohibited unless approved by the executive board.
• Status at End of Off-Call Period: Employment as a partner is terminated once the physician is off call for a period of 4 years. At this time partner status ceases and practice buy-out begins. At the end of the 4-year off-call period, the physician and group can elect to enter into a year-to-year employment contract based on the needs of the group.