Hospital responses vary, but trend is clear
The crisis in emergency care coverage isn’t going away—and neither is the need to compensate those physicians who take call. That was the consensus of the participants in a Webinar sponsored by HealthLeaders Media on June 17, 2008. But developing the right on-call compensation model is tricky and requires a collaborative effort by medical staffs and hospital administrators.
“A sustainable solution includes payments and operational improvements that are shared across the board,” said moderator Joshua D. Halverson, a senior manager with ECG Management Consultants, which sponsored the Webinar. And although the Webinar was directed to hospital administrators, the information presented may be useful to physicians who are still struggling to address the issue in their communities.
Noting that physicians are increasingly able to provide many services outside the hospital and that physician quality of life is taking precedence over call, Mr. Halverson said that physician discontent with providing call coverage is unlikely to decrease.
As a result, he recommended that healthcare organizations address both operational approaches aimed at reducing the physician burden and direct payments for call coverage.
Decreasing the burden
According to Mr. Halverson, many hospitals are using the following five strategies to help reduce the call burden for physicians:
- Outsourcing—Contracting with an outside group of specialists to provide coverage
- Hospitalist programs—Using hospitalists, including specialty hospitalists, to address the needs of patients with nonurgent conditions
- Traumatologists and other surgical specialists—Hiring or contracting with specialized trauma surgeons in general or orthopaedic trauma surgeons
- Physician assistants (PAs)—Using PAs as the “first line of defense” to stabilize patients (when appropriate and in coordination with the on-call physician) until the physician arrives
- Dedicated operating rooms (ORs)—Reserving an OR for emergency department (ED) call patients and physicians
Reimbursing physicians for providing indigent care (at Medicare or commercial rates) is the most common payment methodology used by hospitals, noted Mr. Halverson. He also pointed out that any payment methodology must comply with relevant regulatory requirements and be consistent with fair market value principles.
“It’s critical that hospitals involve their medical staffs in seeking a solution to the problem of call coverage,” he said. “An incremental (specialty-by-specialty) approach can often resolve short-term crises, but involving the entire medical staff in the process has a better chance of building a long-term, stable solution.”
Possible payment solutions
Mr. Halverson then reviewed several payment solutions. Payments for uncompensated care may be conceptually appealing, but are often administratively burdensome and expensive to manage.
Stipend payments are usually tiered, based on the burden of call. Orthopaedics and cardiology are generally in the top tier; second- and third-tier specialties include general surgery, obstetrics/gynecology, pediatrics, hand surgery, and pulmonology. Stipends for second-tier specialties are generally 40 percent of the stipend for top-tier specialties. Third-tier specialties would receive no payments.
An “activation fee”—a payment to physicians each time they are required to present to the ED while on call—is typically about $250, said Mr. Halverson. However, establishing a single rate for all specialties is challenging and the payment may not be sufficient to cover the inconvenience to the physician. In addition, this model may violate regulatory standards by promoting “double dipping,” in which the physician is paid by both the hospital and a payor for services provided.
In any case, hospitals would have to structure payment systems carefully to avoid violating antikickback statutes.
The Scripps solution
The second panelist—Chris Van Gorder, FACHE, president and chief executive officer of Scripps Health—discussed the development of the Scripps’ ED call strategy. A major step in the development of the strategy was the establishment of a physician leadership cabinet (PLC) to foster trust and increase physician responsibility and involvement in decision making. The first item of business (in 2000) was ED call reimbursement.
“Physicians and administrators as adversaries is a no-win position,” said Mr. Van Gorder. To engage the medical staff, a task force of physicians and administrators was formed to review the hospital’s financial information. With access to all the same information, participants could develop shared goals and conclusions.
Scripps now has a mixed compensation model (stipend and fee-for-service) but is evaluating a new model that would contract with a large multispecialty group to manage all on-call scheduling. Under this model, the group would receive a fixed monthly fee to provide ED call coverage, as well as quarterly incentive payments based on jointly established and agreed-upon quality indicators.
The rural challenge
At Thomas Memorial Hospital in Charleston, W.Va., the situation is very different, explained Robert J. Gray, vice president of business development and operations. This 260-bed, community hospital has 45,000 ED visits annually and pays no one for taking call. “If we started, we couldn’t stop,” said Mr. Gray. “How could we pay one specialty without paying others?”
Instead, the hospital has contracts with two general surgeons who provide all ED call services. Each surgeon serves 2 weeks on/2 weeks off, and is on call 24 hours a day. They are assisted by an in-house hospitalist. The hospital guarantees a base income for the surgeons, who agree to bill and collect from patients.
“For us, it works,” said Mr. Gray, who also admitted that “the program is only as good as the doctors you recruit.”
Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at firstname.lastname@example.org