In the March 2008 AAOS Now, Thomas K. Miller, MD, called for an “alteration in reimbursement” for those physicians and facilities unable or unwilling to provide emergency care. I can understand his frustration with what he deems are inappropriate referrals. After taking call for 25 years in community hospitals, however, I know that reimbursement is the major reason that my colleagues are now reluctant to take on these very cases. Lowering reimbursement will only make the situation worse.

Health care in the United States has changed. The major medical centers—where the trauma centers are typically located—now compete directly for patients with community hospitals. Many community hospitals have closed; those that are left have fewer staff, less equipment, and less operating room availability.

Dr. Miller implies that outpatient surgical centers may be a reason that some community physicians are too busy for trauma care. In my area, outpatient facilities and clinics are frequently sponsored by these same large medical centers, and they are not open nights or weekends. This leaves the community physician to provide emergency services to patients during those times, a reverse of the referral pattern he disclaims.

Tiered reimbursement is a costly and questionable process. In a tiered program in Massachusetts, all orthopaedic surgeons are considered level II, simply because the program has no significant data for orthopaedic surgery.

I do not have an immediate solution for inappropriate trauma referrals. An effective utilization of resources through a clearly defined triage system would be ideal, but not likely to occur soon.

Daniel W. Bienkowski, MD
Stoneham, Mass.

Dr. Miller’s response in AAOS Now will, I hope, continue a national debate on “on call” that addresses such questions as: What is general orthopaedics? Who will do general orthopaedics? Will there be legal and financial support for those who do? Has specialization become an “enfant terrible,” ready to eat its parents?

Dr. Miller’s hospital has started by defining core skills required to take call. If general orthopaedics is a set of ICD and CPT codes, it is definable. If so, we have to preserve that skill set by rewarding all the Dr. Millers.

Next we have to find and train the next generation of generalists. As a generalist, I don’t want to be the designated “nightologist,” while elective cases go to the speciality guys during the day. Pehaps the private practice model that my generation knew will have to be rethought.

James B. DeTorre, MD
Albemarle, N.C.

Dr. Miller presents the point of view of many orthopaedic surgeons practicing in larger cities, larger hospitals, and level I trauma centers.

I practice at a “peripheral hospital” and am the only orthopaedic surgeon on staff. The next nearest practicing orthopaedic surgeon is more than 100 miles away, and the nearest trauma center is 150 miles away. I take call officially 4 days per week and unofficially make myself available for consultation and care 7 days per week, unless I am not in town. So I see and treat locally about 95 percent of the orthopaedic patients who come to the emergency department. I do not receive any additional financial support for unassigned call.

Even though our hospital “provides orthopaedic services on a routine basis,” there are times and circumstances when we cannot or should not do so. When I am on vacation or unavailable, the hospital has no orthopaedic coverage. Despite my being a board-certified orthopaedic surgeon, it is not appropriate for me to treat certain injuries or conditions. I have no experienced surgeon to assist me in more difficult cases; no vascular surgeons, neurosurgeons, or infectious disease specialists to consult when indicated; no onsite radiologists for more advanced imaging studies, no nuclear medicine, and a magnetic resonance imaging machine that comes in on a truck twice a week. We use three excellent nurse anesthetists but do not have an anesthesiologist. We have no intensive care or specialty orthopaedic unit and have only 18 beds. Because of cost constraints, we keep only basic trauma equipment in stock, but no intramedullary rods.

If I transfer a patient, it is because, in my opinion, the transfer is in the patient’s best interest and for optimal care, not based on the day of the week, the time of the year, or a “wallet biopsy.” Frequently I provide follow-up care to patients first treated at a hospital. I do so at little or no cost to the patient and no reimbursement to me, because the surgeon at the referral hospital billed for the global service instead of modified surgical care only.

Many surgeons in larger facilities have no concept of what it is like to practice in a small rural facility. It is vastly different from how we were trained. Most surgeons who practice in rural areas do so because we can provide a real benefit to our patients. We already earn less than our peers in larger settings. Dr. Miller’s proposal would just send all of our patients to his facility, because I could no longer afford to practice here.

This obviously is a very complex issue with at least two viewpoints, but to be chastised because we need help with a patient is unjustified. To enjoy the benefits of a group setting, in a large hospital with multiple services and staff, and in a larger city with its amenities and conveniences, one should be willing to accept the few patients that we send without complaining. Alternatively, try practicing in a rural community and walking in our shoes.

David Yanoff, MD
Salmon, Idaho

Dr. Miller highlights some of the problems associated with on-call services and the direction of patients to higher-level trauma centers for on-call orthopaedic care.

He speaks for many of us when he states that “as a private practitioner who does not receive financial support for participating in unassigned call,” he incurs direct costs and opportunity costs in caring for on-call patients. The issue at hand, however, is not that other hospitals and surgeons should be paid less for on-call services but that Dr. Miller and all surgeons should receive proper financial support for services they provide.

This is not a violation of the Hippocratic Oath or any ethical principles. We all provide compassionate and skilled care to the individual patients we see. However, as a policy matter, surgeons cannot continue to take on the inadequacies of the reimbursement system by redistributing their own resources. The solution to the problems that Dr. Miller properly highlights is proper pay for services rendered regardless of the setting.

John M. Keggi, MD
Middlebury, Conn.