Panel offers possible solutions to ED crisis

“An increasing number of patients are seeking care through the emergency department (ED),” said Michael J. Bosse, MD, as he opened the symposium “Orthopaedic emergency room coverage: Where are we going?” at the AAOS Annual Meeting. “But up to 75 percent of EDs lack appropriate specialty coverage.”

• The following factors have contributed to the crisis, noted Dr. Bosse:
• Many EDs and trauma systems are underfunded.
• The total number of EDs has dropped over the years.
• Reductions in physician reimbursement coupled with increases in practice costs make it more difficult for physicians to take call.
• The number of uninsured patients is increasing.
• Shifting practice patterns toward specialization has reduced the number of surgeons who are comfortable performing general orthopaedics.

During the past 15 years, the ED paradigm has changed, noted Dr. Bosse. With fewer physicians taking call, the burden on those who do is increasing. Many patients are being shunted to regional centers because community hospitals no longer have either the manpower or expertise to treat them.

AOA survey results
To get a better understanding of the issue, James F. Kellam, MD, and a team of surgeons from the American Orthopaedic Association’s (AOA) Orthopaedic Institute of Medicine conducted a Web-based poll of orthopaedic surgeons in 2008. (See “New report issued on orthopaedic ED care” in the March 2008 AAOS Now). They received responses from 1,527 orthopaedists, giving the task force statistically valid results with a margin of error of +/– 5 percent (P = 0.05).

The survey found general agreement that a problem with ED coverage existed, even though 75 percent of respondents took general ED call. Based on responses to questions about why surgeons took call and what barriers exist in taking call, the task force attempted to develop a list of solutions. Although they found that orthopaedists practicing in a variety of settings may face similar barriers, contributing circumstances are best addressed at the local level, making “top down” solutions less likely to be effective.

“We as surgeons have to work together,” said Dr. Kellam. “We have to start thinking about how, in our communities, we can coordinate care and take the chaos out of the situation. It’s not an area for greed or competition. We have sick patients who need our care. We have to figure out how best to do it.”

By developing a coordinated care system among surgeons and hospitals, surgeons across practices and even across hospitals and towns can arrange call schedules for minimum disruption to lifestyle and surgical practice. Hospitals must provide support and a referral system so a surgeon does not have to manage a complex injury outside his or her scope.

Dr. Kellam also suggested that the ED call model may need to be changed, positing the concept of an orthopaedic hospitalist.

The orthopaedic response
According to Jeffrey Anglen, MD, many surgeons bristle at the idea that it is the physicians’ responsibility to solve the ED coverage issue. He cited one surgeon who argued that because the actions of lawyers created the problem, it was the responsibility of the bar association to find a solution.

“If the bar association solves this problem,” said Dr. Anglen, “physicians are not going to like the solution very much. If medical leadership doesn’t take ownership and address the issue, the government ultimately will.”

Dr. Anglen pointed to comments made by U.S. Rep. Pete Stark (D-Calif.), who has argued that physicians receive a huge taxpayer subsidy for medical school and that providing ED coverage should be part of the payback. Rep. Stark has also suggested changing the conditions of Medicare participation to require ED participation.

Unlike attorneys and politicians, noted Dr. Anglen, medical leadership is the group most likely to develop a solution that puts the care of the patient first, that ensures the best quality of care, and most importantly, that preserves professional autonomy and control.

Other specialties have already stepped forward to address the shortage in orthopaedic ED coverage. The curriculum of the acute care fellowship training program overseen by the American Association for the Surgery of Trauma includes performing fasciotomies, reducing dislocations, splinting fractures, and applying traction.

“It’s not a very long step from the splinting of fractures to CPT codes for closed treatment of fracture care,” said Dr. Anglen. “It’s not very far from putting in femoral traction pins to putting on external fixators.”

He also noted that an emphasis on physician pay rather than physician responsibility is counterproductive because no one outside the physician community perceives physicians to be underpaid.

“If the solutions that we bring to the table all involve more money to doctors either directly in terms of payments, or indirectly through lowering our practice costs,” he explained, “it’s not going to be politically very palatable. We have to sell it to the other stakeholders.”

Why not an SOP?
Although standards of professionalism (SOPs) on ED coverage have been proposed, they have not yet been adopted. When an ED coverage SOP was discussed by the California Orthopaedic Association board of directors, said James T. Caillouette, MD, the board decided that such a mandate would be problematic for several reasons, including its impact on physician/hospital negotiations.

“We recognized that although hospitals can’t actually use an SOP as a point of negotiation … they will,” said Dr. Caillouette.

An ED coverage SOP could also increase division within the orthopaedic community and would not account for the inherent risks of private practice.

In California alone during 2008, 7.5 million patients who were either uninsured or under­insured received ED care from either private practices or county and teaching centers, noted Dr. Caillouette. “For us to serve our mission,” said Dr. Caillouette, “to provide care for as many patients as possible, it’s important that physicians make a margin. I’ve worked for many not-for-profit organizations; I’ve been a fundraiser for many 501(c)3 organizations, and in organization after organization, the truth is: no margin, no mission.”

The Reno Model
In nearby Reno, Nev., a trauma panel (21 community orthopaedic surgeons and a traumatologist director who meet on a monthly basis) has been used for the last 18 years. Timothy J. Bray, MD, explained that smaller communities like Reno are dependent on the general core skills of on-call orthopaedic surgeons.

The “Reno Model” is a hybrid that blends the needs of private trauma practice with the regional needs of a referral trauma system by assigning a full-time private practice traumatologist to the hospital. The panel has also negotiated a “very favorable” hospital stipend.

“We’ve been able to address most of the issues over the last 6 or 7 years,” said Dr. Bray. “We have a spine panel; we have a group of plastic surgeons who work with us in revascularization and flap coverage; we have time open for emergent orthopaedic care; and we now have a quarterly quality assurance panel, where we look at cases and critique one another in an honorable fashion.”

“The advantage of this system is that trauma is covered daily,” he said. “We move cases through the hospital system efficiently and effectively. We assist in hospital operating room education, quality assurance, and cost containment. The bottom line is it makes money for the hospital.”

The system also supports nontrauma surgeons by enabling them to transfer difficult fractures to the traumatologist. The application of “damage-control orthopaedics” is critically important as part of the solution in community environments, he said. Dr. Bray also emphasized that surgeons need to maintain their core skills.

“These are fun, challenging cases,” he said. “You’re not going to see something like this walking into your office. You don’t want to let your skills slide so you no longer have the ability to provide these patients with appropriate care in your community.”

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org