Solutions that meet the needs of hospitals, providers, and patients

When it comes to providing emergency trauma care, hospitals mandate on-call coverage, including specialist coverage, in a manner that best meets the needs of their patients, physicians, and resources. As a result, there is no single “best solution” for providing appropriate orthopaedic coverage. Instead, each hospital and community must consider local, individual requirements when establishing an ED call panel.

At the 2010 California Orthopaedic Association (COA) annual meeting, Michael T. Laird, MD, described the evolution of three distinct call panel solutions that enable hospitals in a relatively rural area in California to effectively manage their orthopaedic trauma needs. The hospitals are located in four regions along the state’s central coast and serve a combined population of more than 400,000 residents.

A single contracted provider
Fifteen years ago, on-call participation at the local for-profit, 114-bed acute care hospital in Templeton, Calif., was mandatory and uncompensated. By 2002, physicians had begun negotiating for on-call stipends. At the same time, the hospital amended its bylaws to make on-call participation voluntary, and two providers dropped off the hospital’s call panel.

By 2005, despite the stipend, which had been increased from $200/day to $500/day, the hospital was still experiencing difficulties ensuring adequate on-call coverage, and urgent cases were being transferred to a hospital 20 miles away.

Two years ago, after an unsuccessful attempt to hire locum tenens and to bring in a new provider to help cover its on-call needs, the hospital extended its contract with a specialty care provider organization to include orthopaedic services. Today, the arrangement ensures year-round, 24/7 orthopaedic trauma coverage. According to Dr. Laird, the solution benefits patients and physicians. It eliminates the need to transfer orthopaedic trauma patients to other area hospitals and it relieves surgeons of the burden of taking call, allowing them to concentrate on their elective practices.

Community-based private practitioners with stipend
The second solution was developed by three hospitals that served San Luis Obispo, Calif. One on-call orthopaedist at a time covered all three hospitals and would enlist help when necessary. Taking a turn on the call panel was required for orthopaedists who wanted full staff privileges, and call was equally shared among the providers.

In 2005, the county hospital closed. That same year, Dr. Laird began negotiating for an on-call stipend with the remaining two hospitals (one for-profit facility and one nonprofit hospital). The for-profit hospital eventually agreed—after a threatened boycott and formation of a Trauma Team Concept—to a $1,500/day stipend.

When the nonprofit facility was purchased by a regional healthcare group, it began negotiations that resulted in a $500/day stipend. The for-profit hospital then lowered its compensation from $1,500/day to $1,000/day, but built in raises of $50/day/year. Currently, both hospitals can offer year-round, 24/7 orthopaedic trauma coverage equally divided among private practitioner providers.

Similarly, 15 years ago, two hospitals served Santa Maria, Calif. Taking call was mandatory to maintain hospital privileges, divided equally among the providers, and not compensated. In 2000, several local changes altered the healthcare landscape. One hospital closed; the remaining hospital brought in a new group of providers; and many other providers left, retired, or changed practice.

In 2005, negotiations for on-call stipends were successful. Today, the facility offers year-round, 24/7 orthopaedic trauma coverage divided equally among four private practitioner providers and are paid a $1,000/day stipend.

Hospitalist and private practitioners with stipend
Yet another solution to orthopaedic on-call coverage at a community hospital took shape in Arroyo Grande, Calif. Originally call was unequally divided among members of the call panel. The orthopaedic provider who took the most complained of poor patient compliance, the large number of uninsured patients, liability issues, difficult lifestyle, and lack of hospital support.

When Dr. Laird started his practice, he took over the majority of orthopaedic call. When he began negotiating for an on-call stipend, his requests were denied. At the same time, the hospital amended its bylaws to mandate call. Dr. Laird subsequently dropped off the hospital’s call panel and withdrew his privileges for 3½ years. The hospital then hired an orthopaedic hospitalist.

In 2005, the hospital was purchased by a regional healthcare group. Taking call was no longer mandatory and a $1,000/day stipend was approved for volunteer providers. The hospitalist remained and currently provides three quarters of the hospital’s orthopaedic call, with two private practitioners providing the remaining orthopaedic trauma services. It’s a solution, according to Dr. Laird, that has worked out relatively well for the hospital and the providers.

Each of these community-based hospitals had trouble maintaining effective orthopaedic trauma coverage, said Dr. Laird. Over the last 15 years, however, all were able to improve their coverage by designing unique call panel solutions to better serve the needs of the communities, the hospitals, and the providers.

Maureen Leahy is assistant managing editor for AAOS Now. She can be reached at leahy@aaos.org