AAOS Bulletin - October, 2006

Emergency, on-call issues demand attention

By James H. Beaty, MD

Our nation is experiencing a crisis in its ability to care for patients with emergent orthopaedic injuries and other medical problems. All over America, patients are finding it difficult—and sometimes impossible—to obtain emergency care in a timely manner. This crisis is being driven by (1) an ever-increasing patient population seeking emergency care, (2) a decreasing number of hospital emergency departments, (3) inadequate hospital resources to support emergency care services, and (4) an increasing shortage of specialists willing or able to take call.

A look back
In the past, most orthopaedists expected to take call and provide emergency care services as a routine part of their professional lives, as well as a part of their duty to society. Emergency care also was traditionally a good source of revenue and a good way to build a practice, because many emergency patients had private or Medicare fee-for-service insurance. When emergency care was uncompensated or undercompensated (e.g., Medicaid), losses usually could be offset with revenue from patients with adequate coverage and from the orthopaedist’s elective practice. In addition, some emergency patients continued seeing their orthopaedists for follow-up care and elective services, and often their family members also became patients.

This was the situation before the 1990s and, in particular, before managed care, the Medicare Resource-Based Relative Value Scale (RBRVS), sharply falling payment levels, rising practice costs, increasing uncompensated care, mounting paperwork and a medical liability insurance crisis—all of which eliminated most of the financial benefits of providing emergency care. With the pressures of today’s practice environment has come the growing realization among orthopaedists and other physicians that they are now being urged to provide emergency care with poor compensation, high liability and often less-than-adequate hospital and staff support.

Here and now
Based on these realities, taking call and providing emergency care services have become points of contention. At the same time, they have also become reasons for alarm among all those who care about the ability of our health care system to care for patients with orthopaedic or medical emergencies.

This section of the Bulletin explores several facets of the emergency care crisis. The centerpiece is an article sharing the experiences of orthopaedists who have been successful in working with their hospitals and payers to improve reimbursement for on-call coverage and to negotiate for other resources. Other articles in this section include:

  • The position statement proposed by the AAOS Trauma/On-Call Project Team and approved by the AAOS Board of Directors at its September meeting
  • The Orthopaedic Trauma Association’s (OTA) “On-Call” position statement
  • The OTA’s list of requirements for successful orthopaedic trauma services in community hospitals and academic health centers
  • An article by Andrew M. Pollak, MD, chair of the Board of Specialty Societies (BOS/COMSS), on funding for the Maryland emergency care system
  • An article by Kathryn Pontzer, JD, deputy director of the AAOS Washington office, on the Emergency Medical Treatment and Active Labor Act Technical Advisory Group (EMTALA TAG)

Key points
In responding to the crisis in providing emergency care and on-call services, AAOS members should remember several key points:

  • As orthopaedic surgeons, we should take the “high road” and lead the effort in our own communities to improve the quality of care for injured patients as we attempt to improve the situation for orthopaedic surgeons taking call. Orthopaedic surgeons are the best qualified physicians to provide care of patients with musculoskeletal injuries.
  • No single financial, political or practice solution will work for all communities. The complex differences among orthopaedic groups of varying sizes and practice styles as well as among communities (small or large, rural or metropolitian) necessitate individual solutions.
  • Each orthopaedist must be part of the solution in his or her own community. This requires initiating communication with other physicians, with hospitals and with payers to improve the quality of care for patients and the practice of orthopaedics.
  • Medical liability reform is essential to a long-term solution to the emergency care crisis. Without reform, the current medical liability system is a deterrent to orthopaedic participation in on-call and emergency services.
  • Physicians alone cannot bear the responsibility for a solution to this national crisis; hospitals, payers, local and national government officials, and the public must all become involved.

AAOS is presenting these articles for educational purposes only. They are not legal advice. Orthopaedic surgeons should consult their own health care counsel before entering into similar negotiations.

I would like to thank the AAOS Trauma/On-Call Project Team for the countless hours they devoted to this effort to improve our specialty: Bruce D. Browner, MD; Dwight W. Burney III, MD; Steven S. Hurst, MD; Andrew N. Pollak, MD; James V. Nepola, MD; James R. Kasser, MD; Paul Tornetta III, MD; David Teuscher, MD; Susan A. Scherl, MD; Kristy L. Weber, MD; and Robert C. Fine, JD, CAE.

I would also like to thank the leadership of the OTA, the Pediatric Orthopaedic Society of North America, and the American Orthopaedic Association for their spirit of cooperation in this endeavor. I hope you find these articles interesting, thought-provoking and helpful as you seek ways to improve this situation in your community.

James H. Beaty, MD, is AAOS first vice president and chaired the AAOS Trauma/On-Call Project Team. He can be reached at jbeaty@campbellclinic.com

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