No national solution in sight for addressing access issues

According to the AAOS position statement on emergency orthopaedic care, “The AAOS believes that orthopaedic surgeons can stimulate change to improve the emergency orthopaedic care access problem. However, orthopaedic surgeons cannot accomplish this alone. The AAOS believes that all stakeholders—including orthopaedic surgeons, the government, hospitals, policymakers, and payors—must work together to improve access to emergency orthopaedic care in the United States.”

Emergency department (ED) coverage has become an increasingly hot topic for both orthopaedic surgeons and hospitals. Both the AAOS and the Orthopaedic Trauma Association (OTA) have position statements on the topic. These statements note the need for adequate coverage by trained orthopaedic surgeons as well as the need for shared responsibility among hospitals, the public, and physicians in facilitating the provision of this care.

The issue of ED coverage is also pressing for pediatric orthopaedic specialists, who additionally feel the pressure of referrals of pediatric fractures from other orthopaedists. At the 2009 annual meeting of the Pediatric Orthopaedic Society of North America, some solutions were presented, which can be generalized to all ED coverage.

Despite the guidelines outlined by these organizations, a clear, nation-wide solution has not been established. Many communities continue to face challenges in ensuring adequate ED coverage.

Scope of the problem
The crisis in ED coverage is the result of several factors. The Emergency Medical Treatment and Active Labor Act (EMTALA) created a mandate for hospitals to provide coverage in specialty call, but not for specialists to be part of a hospital’s call schedule. A survey of ED directors around the country found that inadequate specialty coverage is widespread, varying from 59 percent of hospitals in the north-central region to 71 percent of hospitals in the south.

Although ED coverage was once a way for physicians to build a practice, for many physicians, it is now a nightmare of high risk and low or no compensation. Providing ED coverage carries the financial burden of a burgeoning uninsured patient population. ED visits have increased 7 percent in the past decade, and these increases are disproportionately occurring among the under- or uninsured population. In Southern California in 2008, uninsured patients accounted for 25 percent of all ED visits.

In addition, a generation of surgeons is entering the workforce with an attitude toward work that differs from prior generations. Limited hours during residency may make this generation feel less comfortable with providing emergency care all night and then continuing the next morning to meet the obligations of the office practice and elective surgery. Generalizations about Generations X, Y, and the more recently emerging Millennials suggest that these groups place greater emphasis on a balanced life than prior generations. They may be unwilling to forsake family and personal well-being to provide ED care to fulfill a vague social contract that applies only to physicians.

Some surgeons cite their lack of competency in orthopaedic trauma skills. In 2005, the American Orthopaedic Association (AOA) polled its members and members of the OTA. In the face of a looming access crisis to emergency orthopaedic care, most respondents favored requiring all orthopaedic surgeons to maintain competence in general orthopaedics and agreed that ED call is part of a social contract in medical education.

The issue of liability
In recent years, a trend toward compensation for orthopaedic surgeons who provide on-call services has been noted. Payment for the direct costs of professional time, however, does not address indirect costs, such as an increased litigation risk. As a result, both the OTA and the AAOS have called for meaningful liability reform.

In 2009, Rep. Mary Bono Mack introduced HR 1678, “Mitigating the Impact of Uncompensated Service and Time Act of 2009.” This measure, which has been referred to the House Ways and Means Committee, would allow physicians to take a bad-debt tax deduction to partially offset the cost of providing uncompensated care required by EMTALA. HR 1998, the “Health Care Safety Net Enhancement Act of 2009” would provide some liability protection for EMTALA services and is currently under consideration by the House Committee on Energy and Commerce.

The final shape of tort reform and emergency care coverage provisions in healthcare reform legislation now being consided by Congress is unknown.

Steps toward solutions
Possible solutions have been proposed by various entities outside of the AAOS, including the OTA, the AOA, the American College of Surgeons, and hospitals. Many communities have implemented local solutions. The California Ortho-paedic Association and California OTA members are exploring legislative avenues to provide a stable economic support for the state’s trauma care access problems. During the 2009 Fall Meeting, the AAOS Board of Councilors State Legislative and Regulatory Issues Committee voted to provide funding to support advocacy efforts by the Georgia Orthopaedic Society to create a state trauma network.

The OTA Web site details five specific models of orthopaedic trauma delivery that can address the specific needs of many different communities. General solutions to address the financial, liability, and lifestyle aspects have included the following:

• Change the reimbursement structure for ED coverage. Hospitals can establish a set stipend or pay agreed-upon rates for service. Across the country, some hospitals are reimbursing at Medicare rates, others at Medicare plus an agreed percentage. Other creative solutions for physician compensation have been described, including hospital contributions to tax-deferred investment accounts for providers.
• Allow a tax-deduction or financial offset for uncompensated ED care. HR 1678 addresses this possibility. Another option would be a subsidy by either the hospital or state for medical liability insurance for surgeons covering the ED.
• Consider physicians providing EMTALA-related services as federal employees under the Public Health Service Act. This would reduce liability risk.
• Improve hospital resources for trauma cases. Based on the OTA’s recommendation, this would include adequate operating room access, personnel, equipment, and radiology support. Adopting this “best practice” can enable the efficient delivery of trauma care by a team performing at peak effectiveness without the need for middle-of-the-night surgery on a routine basis.
• Remove the issue from the table. Hospitals could obtain their own emergency department coverage through various mechanisms, such as full-time, employed “orthopaedic hospitalists” or contracted surgeons under a third-party “locum tenems” model.

Orthopaedic groups in a community can provide their own ortho-paedic hospitalists to provide the coverage; each group could independently hire a trauma specialist or several groups could form a coalition. Recognizing that the hospitalist is fulfilling the on-call obligation for the entire practice would need to be considered when arranging compensation. Existing examples include salary models that guarantee the hospitalist a salary or a percentage of the income of the practice. Within an orthopaedic practice, the surgeons providing required call duties (particularly overnight) would have “comp” time for these hours of service.

In summary
Patients with acute musculoskeletal issues need to be evaluated and treated by orthopaedic surgeons who have the appropriate skills. The system to support the delivery of trauma care to patients must be sustainable for each individual community, the hospitals, and the physicians.

Each surgeon makes an individual decision about his or her ability to provide ED coverage, but changes in health care in the past generation have made the classic system of ED call untenable for many orthopaedic surgeons. The options presented (or creative new ideas) should be considered by hospitals and surgeons to provide ongoing quality orthopaedic trauma care on a timely basis to patients.

Alexandra Elizabeth Page, MD, is a member of the 2009–2010 AAOS Leadership Fellows class. She can be reached at alexe.page@gmail.com