AAOS Bulletin - October, 2006

Meeting the challenge: Orthopaedists on-call

AAOS members share their success stories in addressing the crisis

By James H. Beaty, MD, Robert C. Fine, JD, and Mary Ann Porucznik

Many AAOS members consider on-call service as an ethical responsibility to their communities and an integral part of the orthopaedic profession. But the increasing stresses on the U.S. emergency medical system are negatively affecting both the numbers and the commitment of orthopaedists who participate in emergency department (ED) services. As a result, more older orthopaedists are opting out of call if they can, fewer younger orthopaedists are agreeing to take call, and those who have no choice often feel overburdened and undercompensated.

This article explores how AAOS members in various communities have dealt with call issues and emergency care services.

Negotiating in Nevada

When Timothy J. Bray, MD, arrived in Reno, Nev., 20 years ago, it was still a small town. “The local hospital wanted to improve its trauma services and agreed to support the trauma mission financially,” he recalls. Over the years, the local orthopaedic groups and the hospital worked together to establish a stable, coordinated call system now known as the orthopaedic trauma panel.

Members of the panel receive a stipend for each 24-hour commitment. Each physician bills privately for surgical services provided during the on-call period. The hospital guarantees physicians 100 percent of Medicare payment rates for indigent or uninsured trauma patients, and a “contract fee,” payable each time the physician responds to care for a trauma patient.

“The hospital administration was lukewarm to the entire trauma system idea at first,” says Dr. Bray, “but then the program developed into an excellent trauma care model and became profitable.” Representatives from the trauma panel and the hospital work together to help contain costs, find peripheral funding sources and develop educational opportunities. Now, he says, “If the hospital trauma system started to lose money and asked us to renegotiate the call terms, we’d consider it—as long as they would agree to an outside audit.”

For Dr. Bray, the “big ticket” items during the contract negotiations always center on quality patient care and physician quality-of-life improvements, such as the addition of hospital-based orthopaedic trauma physician assistants (PAs), designated operating room (OR) times or priority scheduling and a call room with Internet access.

Halfway across the state in Las Vegas, Fred C. Redfern, MD, faced a much different situation. “At one hospital, the chief of staff made it mandatory for all physicians who had courtesy privileges at the hospital to take call,” he remembers. “Privilege allows you a place to practice your craft, but hospitals can’t provide care without your services, so many physicians resigned rather than agree to that requirement.

“Our basic message is that, as orthopaedic surgeons, we provide a valuable service and our time deserves compensation,” he continues. “The hospital had contractual obligations with insurance companies that required it to have specialty coverage. The hospital was getting paid, but the on-call doctors weren’t. We were asked to be available and to care for patients who couldn’t pay us. In addition, we were feeling the effects of the higher malpractice risk through increasing medical liability premiums.”

Negotiations were prolonged and often strained. One hospital actually closed its orthopaedic department for several years. Physicians were accused of patient abandonment and threatened with lawsuits. “The hospital administrators had very little respect for the doctors and treated us as tools, rather than partners,” says Dr. Redfern.

“We (orthopaedists) contacted a lawyer and discussed the issue with the medical staff attorney during the negotiations,” he recalls. “We were concerned about antitrust issues, but in the end, it was the hospital’s contracts and the financial incentives from the insurance companies that made the difference. The fact that those incentives weren’t being shared with physicians was a good motivator for the doctors to work together.”

Once physicians negotiated an on-call stipend at one hospital, they were able to convince other hospitals in the area to pay stipends as well. Now the trauma center has hired a dedicated ED staff (physicians and PAs), and backs them with a dedicated OR.

The cost of call
In Sarasota, Fla., AAOS member Adam S. Bright, MD, found that his group, all of whom were on staff at the county hospital, was taking a disproportionate percentage of call nights after the hospital expanded its ED two years ago.

“We’d been providing about 40 percent of ED call,” he says, “and if that had kept increasing, we wouldn’t have had an elective practice anymore. In addition, about 90 percent of the care was unreimbursed. We made presentations to the chief executive officer, the chief financial officer and the board of directors.”

The presentations reviewed the history of the call schedule, drew attention to the new pressures being placed on those who took call, and presented the results of the state orthopaedic society’s survey on the impact of taking call. Among those surveyed, more than 90 percent reported that taking call was emotionally taxing, unlikely to be reimbursed and disruptive to their personal lives. Three out of four respondents reported that the necessary equipment to treat ED patients was not readily available, and more than half were personally involved in litigation related to ED cases.

“There is a cost to providing care, and it’s not just the cost of care itself,” says Dr. Bright. At the end of the presentation, he outlined several solutions, including compensating doctors for their time, compensating them for uncompensated care and hiring more dedicated orthopaedists on staff.

The final contract, which took several months to negotiate, provided the on-call orthopaedists with a per diem stipend, as well as guaranteed block time in the OR on the day after call to treat any emergencies. “We got a good value, and the hospital got a good value,” says Dr. Bright.

Brian J. Galinat, MD, of Wilmington, Del., agrees that reaching a satisfactory agreement can take time—lots of time. “Hospitals are big; they move slowly,” he points out. “Expect to spend six months to a year negotiating.”

For Dr. Galinat and other surgeons at the Christiana Care Health System, the final result was an improvement. The hospital now pays physicians a stipend, provides some funding for uncompensated care, provides a full-time orthopaedic trauma PA during the day on weekdays and also has dedicated OR time for fracture cases every day.

An improved working relationship among the physicians taking trauma call has developed. Dr. Galinat explains, “The patients get better care because they now have access to the care they need. If someone comes in with a bad ankle injury, and a hand surgeon is on call, he will stabilize the patient and transfer care to an ankle specialist the next day.”

A similar situation exists in Urbana, Ill., where Chris J. Dangles, MD, works with a multispecialty clinic that provides call coverage to the local Level I trauma center. While several physicians share call responsibilities, they are supported by two salaried trauma specialists. “We do what we have to at night,” says Dr. Dangles, “and they provide all the follow-up care.”

Support services are important
In Oregon, Idaho and California, orthopaedic surgeons working with Level II trauma centers and community hospitals also developed workable arrangements using similar strategies: Understand the worth (dollar value) of the orthopaedic care you provide to the hospital; make sure that someone who can make the decision is “at the table” and be willing to propose alternatives.

Thomas K. Wuest, MD, in Eugene, Ore., is proud of the “perks” he was able to negotiate. “It’s easier for a hospital to provide services,” he says. “If they’re more willing to give those perks than to pay, make sure you get services that will make your life easier.”

Dr. Wuest was able to negotiate a number of services, including providing physicians with access to hospital medical records and images from their homes, dedicated time in the OR, and appropriate ancillary services—from PAs to anesthesiologists.

“If you get the support to help you accept call willingly, it makes a difference in your referrals as well,” notes Dr. Wuest. “And that can have an effect on your elective patients. With the changes we’ve made, taking call is a piece of cake because I don’t have to worry about the things I can’t handle. Knowing you have dedicated time in the OR means you don’t have to do cases in the middle of the night. That’s better for the emergency patient, for your elective patients and for yourself.”

Skilled staff is what makes the difference to San Mateo, Calif., orthopaedic surgeon Stephen S. Hurst, MD. “We negotiated for a PA or a registered nurse first assistant who is available after 5 p.m. to help with cases that need to go to the OR,” he says. “We have a really superb, skilled staff. We regularly do in-service education with the hospital staff, which helps keep the skill level high.”

In addition, the hospital is supposed to have a designated trauma OR after 5 p.m., and at 7:30 a.m. the next day. Surgeons have a flexible response time—up to an hour to respond to call—because the community hospital doesn’t get any Level I trauma cases. Recently, orthopaedic surgeons negotiated a 15 percent increase in the stipend paid for call services, based on what other hospitals in the area were paying.

The result is a higher level of care for patients, according to Dr. Hurst. “It’s reflected in the patient satisfaction surveys,” he says. “The happier the orthopaedic surgeons are, the better for patients. When we’re being recognized for our efforts, patients can sense that we’re less grumpy.”

Because on-call physicians are seeing increasing numbers of uninsured patients, John G. Kloss, MD, of Boise, Idaho, appreciates the coverage provided by the Level II trauma center where he serves. Dr. Kloss has had considerable experience in negotiating trauma contracts; he was president of the medical staff in 1994 and helped initiate and negotiate the first contract—as well as all subsequent contracts for orthopaedic trauma.

Over the years, Dr. Kloss noted, “The mix of patients started to change. The number of uninsureds was increasing and they were coming from farther away.” After much negotiation, the latest contract provides reimbursement to physicians for patients who are identified as “uninsured” when they arrive in the ED. The result is that physicians receive a rate comparable to private commercial policies for treating uninsured patients.

In addition, each specialty (general surgery, orthopaedic surgery, neurosurgery, hand surgery and spine surgery) has a separate contract and per diem rate.

“Small groups and small communities should consider a hybrid arrangement that provides a reasonable per diem and a guaranteed level of reimbursement for the uninsured,” advises Dr. Kloss. 

Small town dynamics
In rural areas and small towns, the burden of providing on-call care is often borne by a single group practice. That’s the case in Dalton, Ga., where John T. Norman, MD, practices. Three out of the four surgeons in his practice currently take call, but for seven days each month, there is no orthopaedic coverage.

Although the practice is actively recruiting for another surgeon, attracting qualified orthopaedists to a small town is difficult. In Dalton, the hospital is helping by paying for a locum tenes until the practice can fill the position.

Surgeons on call receive a stipend (higher on weekends than on weekdays), but are responsible for billing and collecting from patients. “It works better than when we submitted charges to the hospital and they paid us based on Medicare rates,” says Dr. Norman. “We tried to negotiate, within reason, but we were prepared to give up our privileges at the hospital if we couldn’t reach an agreement.”

“There’s got to be some cooperation between hospitals and physicians in small towns, or private practices will cease to exist,” adds James W. Scott, MD, who practices in Tifton, Ga. “I love being a small-town doctor, but we need more manpower in small communities. It’s becoming a moral and ethical dilemma for older orthopaedists who want to keep an orthopaedic presence in the community but can’t do it alone and can’t find help.”

Bringing it down to business
According to Richard P. Mackessy, MD, of Linden, N.J., the recent upsurge in mergers among hospitals in an area provides an opportunity for orthopaedic surgeons to make a change—in the medical staff bylaws. When three hospitals in Dr. Mackessy’s area merged, the new medical staff bylaws specified that taking call would be voluntary.

In the end, how a hospital treats call and the surgeons who take it is a business decision. “Physicians tend to talk about what’s right or wrong,” he says. “But that doesn’t make sense to a businessperson.”

According to Dr. Mackessy, hospitals need to see a return on their money. So, if orthopaedic surgeons want to receive a stipend or other perks for taking calls, they have to be able to show that they can generate profits for the hospital.

“It’s not just operative cases,” he points out. “There’s also all the preoperative testing, the imaging studies, the postoperative therapy and the referrals. That’s attractive for a hospital with a large uninsured or underinsured population.”

“Negotiate from a business position,” agrees Dr. Bray. “You know what it costs to be a partner in a private practice and what it costs for you to be away from the business. Use that as a starting point for your negotiations.”

Frank B. Kelly, MD, of Macon, Ga., knows that taking a business approach can be very effective. “Have an organized presentation,” he advises. “Know what other hospitals in your area are doing and how they handle call. Get the statistics on call; know whether orthopaedic calls occur more frequently and involve more intense or severe injuries than other call specialties. Use that information in making your presentation.”

Dr. Kelly notes that while some specialties actually get called very infrequently, orthopaedic surgeons assume a significant, disproportionate share of call. As a result, when the hospital instituted a tiered stipend system for paying doctors who took call, orthopaedists were classified in the higher tier.

Improving care
In each of these cases, orthopaedic surgeons sought ways to improve their on-call experiences, resulting in better care for both emergency and elective patients. The recommendations of the AAOS Project Team on Trauma Care/On-Call Issues also focused on improving care.

In the end, however, as the Project Team report concludes, “this multifaceted societal problem will only be completely solved through the combined efforts and mutual determination of providers, payers, public institutions and the public at large, working with physicians and physician organizations.”

James H. Beaty, MD, is AAOS first vice president and chaired the Project Team on Trauma Care/On-Call Issues. Robert C. Fine, JD, CAE, is director, health policy & governance initiatives. Mary Ann Porucznik is managing editor of the AAOS Bulletin.

The emergency care crisis

  • According to the National Center for Health Statistics, Americans made nearly 114 million visits (39 per 100 people) to emergency departments (ED) in 2003, a 26 percent increase in volume over the previous decade. (Craig LF, et al. National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary. National Center for Health Statistics, Centers for Disease Control and Prevention, Department of Health and Human Services. Available at www.cdc.gov/nchs/data/ad/ad358.pdf
  • During the same 10-year period, there was a net loss of 703 hospitals and 425 EDs.
  • In 2005, nearly half of all hospital EDs reported that they were at or beyond capacity.
  • Trauma accounts for more than 11 percent of nonpediatric and nonmaternity hospital admissions originating in the ED, according to the Agency for Healthcare Research and Quality. (Agency for Healthcare Research and Quality. Reasons for being admitted to the hospital through the emergency department, 2003. Statistical brief #2, February 2006. Available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb2.jsp
  • Traumatic injury has surpassed heart disease as the most expensive category of medical treatment, resulting in $71.6 billion in expenditures per year. (Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point. National Academies Press, 2006)
  • Nearly three-quarters of ED medical directors responding to a 2005 survey believe they have inadequate on-call specialist coverage. (On-Call Specialist Coverage in U.S. Emergency Departments, American College of Emergency Physicians Survey of Emergency Department Directors. April 2006. Available at www.acep.org/NR/rdonlyres/DF81A858-FD39-46F6-B46A-15DF99A45806/0/RWJ_OncallReport2006.pdf)
  • In a 2005 survey of ED administrators, 42 percent said the lack of specialty coverage in the ED poses a significant risk to patients. (The Schumacher Group. 2005 Hospital Emergency Department Administration Survey. Available at www.tsged.com/survey2005.pdf)

Words of wisdom

  • During your contract negotiations, make sure you see the same numbers the hospital consultant sees. If you need to, hire your own consultant. And make sure you have your own lawyer.—Timothy J. Bray, MD
  • There is a cost to providing on-call care. Let the hospital know what it is. Have an organized presentation and talk businessman-to-businessman.—Adam S. Bright, MD
  • Be patient. Do not settle for a “quick fix.” Hospitals are big and move slowly. Do not be confrontational—even if you are on the verge of withdrawing from coverage of the emergency room. Expect your negotiations to take six to 12 months.—Brian J. Galinat, MD
  • We have the knowledge and the power. Work together. Infighting undermines the negotiations. Act as a united force or you’ll get picked off.—Stephen S. Hurst, MD
  • Be able to demonstrate the frequency, intensity and severity of orthopaedic call compared to other specialties. Consider the entire economic impact…not only the operative cases, but the preoperative care and the postoperative treatment. Demonstrate the impact of providing call on your office practice, and the possible loss or delay in elective surgery.—Frank B. Kelly, MD
  • Negotiate with the decision-maker. Get someone at the table who can make the decision.—John G. Kloss, MD
  • Start with the medical staff bylaws. If they require you to take call to qualify for privileges at the hospital, see if you can change that and make it voluntary. As more hospitals merge, the opportunity to change bylaws increases.—Richard P. Mackessy, MD
  • Don’t just ask for money. It’s easier for the hospital to give you services than money, so make sure you also ask for ancillary services such as electronic access to medical records and imaging studies from your home, a dedicated operating room and trained staff, and other quality-of-life service improvements.—Thomas K. Wuest, MD

Disclaimer: This information is presented for educational purposes only and orthopaedic surgeons should consult their own health care counsel before entering into similar negotiations. This information is not intended as legal advice nor is it intended to influence individual physicians to take any specific actions.

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