Published 6/1/2010
Maureen Leahy

Easing the burden of on-call coverage

Survey finds increased compensation may offset other limiting factors

Maintaining appropriate levels of on-call coverage, especially specialist coverage, in the emergency department (ED) can be a balancing act for hospitals. Similarly, a surgeon’s decision to participate in ED call may take multiple factors into consideration.

As a result, many facilities are re-evaluating their on-call schedules and procedures. What does this mean for orthopaedic surgeons? In California, it may mean good news.

A recent survey conducted by the California Orthopaedic Association (COA) finds that more hospitals are offering orthopaedists compensation to help offset the burden of taking ED call. Michael T. Laird, MD, presented the results at the COA annual meeting and compared them against initial survey results from 2000 and 2004.

The 2010 poll involved 394 COA members, up from 280 members in 2000 and 336 members in 2004. Participants represented all age groups and all orthopaedic subspecialties in both rural and urban practices throughout the state. More than 200 hospitals and all major acute care systems in the state were also represented.

Although fewer hospitals are requiring surgeons to take call, fewer surgeons are choosing to do so. Providing on-call ED care was mandatory for 56 percent of the surgeons (vs 75 percent in 2004), while 63 percent of the surgeons reported taking call compared to 69 percent in 2004.

Areas of concern
On-call participation has declined nationally in recent years due to various factors. Many of the COA survey respondents identified liability exposure to the high-risk patient as a reason for not wanting to participate on a call panel. The survey also explored additional factors as they apply to orthopaedic surgeons, including limited operating room (OR) availability, the increasing number of uninsured patients, inappropriate transfers, and compensation.

According to the survey, 43 percent of the respondents viewed on-call access to the OR as a significant burden. Even among surgeons who indicated that an OR is usually available for them while on ED call, only 29 percent reported being able to access it quickly. Moreover, EDs have become a safety net for millions of uninsured patients and as a result, many physicians may not be getting paid for providing emergency specialist treatment. When asked if their hospital guarantees payment for uninsured patients, 67 percent of the survey participants responded no. In addition, 80 percent of the surgeons reported being required to provide follow-up care for uninsured ED patients.

Inappropriate orthopaedic patient transfers can result in the delayed delivery of appropriate patient care and further overcrowding in the ED. In addition, one recent study found that patients who were inappropriately transferred were twice as likely to be uninsured than insured (see “Study questions ED transfers,” AAOS Now, March 2010). Thirty-five percent of the COA survey members, representing 39 hospitals or areas, responded that inappropriate transfers occurred. In 49 percent of the cases, not having an orthopaedist on call at the transferring hospital was the reason for transfer.

The survey also revealed that more surgeons are receiving compensation for taking call coverage in California. According to the poll, 72 percent of COA members are paid for on-call duty, up from 26 percent in 2000 and 56 percent in 2004 (Fig. 1). Most receive an average daily compensation rate of between $751 and $1,000 (Fig. 2), which is slightly less than the national median payment as reported by the Medical Group Management Association.

COA members reported using various methods to achieve payment for call (Fig. 3). Significantly, 84 percent of the respondents are paid whether or not they are actually called in. Higher payment rates were reported for taking weekend call and trauma cases, and 86 percent of the surgeons are allowed to bill separately for their services.

The survey also revealed that medical staff by-law exemptions based on age exist for 44 percent of the respondents. Exemptions begin at age 51 and peak at ages 61 to 65. By-law exemptions based on subspecialty designation are considerably lower, at 6 percent.

Although the burden of taking call for orthopaedic surgeons in California is being increasingly off-set to some degree monetarily, the need for an established trauma call panel remains, according to Dr. Laird. Only 19 percent of the COA members queried were affiliated with facilities that utilize a separate trauma call roster, yet 38 percent identified an established trauma call roster as an incentive to taking ED call. Other nonmonetary incentives included better OR scheduling, limited call responsibility, and “other arrangements” (Fig. 4).

Balancing the needs of the patients and the needs of physicians in providing orthopaedic on-call coverage in the ED remains a challenge on several fronts. To meet those challenges, “we need to continue to obtain more information, follow trends, and disseminate the data,” concluded Dr. Laird.

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