Who should care for otolaryngology patients when they present to the emergency department (ED)? And how should the physicians who care for those patients be compensated?
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October 2024Those two questions are at the heart of a conundrum that has escalated over the past two decades.
Nearly 20 years ago, ENTtoday noted that “many specialists and subspecialists, who in the past used emergency department call as one way to build a practice, are now refusing to participate in call panels” (ENTtoday. https://www.enttoday.org/article/situation-critical-otolaryngologists-see-diminishing-returns-for-taking-emergency-call/). Those physicians realized that hospitals and patients benefited from the provision of specialty and subspecialty care, but that otolaryngologists rarely did. As that 2006 article stated, “Reimbursements can be abysmally low, and exposure to liability high.”
Since then, the medical landscape has shifted tremendously. Most otolaryngologists are now employees (AAO-HNS. https://www.entnet.org/wp-content/uploads/2023/07/2022-Otolaryngology-Workforce.pdf). Hospitals and health systems have consolidated and coalesced into large conglomerates. Subspecialization is common, and many otolaryngologists today opt to perform procedures in outpatient surgery centers rather than hospitals. These trends are largely positive for patients, as they have increased access to specialty care in convenient and comfortable settings; however, these same trends present additional challenges for physicians, particularly for those who are employees of large health systems.
“Our physicians quickly went from providing care of the local community to literally providing care to all of Hampton Roads, which is about 2.5 million people,” said Barry Strasnick, MD, professor and chair of the department of otolaryngology–head and neck surgery at Eastern Virginia Medical School (EVMS) in Norfolk, Va.
The tipping point came when the local hospital system developed a regional trauma transfer center. Now, at least 11 hospitals funnel patients to the ED and hospitals covered by EVMS otolaryngologists. But, even before that, “we started to see an increased number of patients presenting to the emergency department de novo,” Dr. Strasnick said. “Our call burden just continued to expand.”
Similar scenes are playing out around the country. The pool of otolaryngologists providing call coverage for Swedish Medical Center in Seattle—covering three EDs, nearly 1,000 hospital beds, 80 ICU beds, and transfers from around the Pacific Northwest—dwindled from 28 to nine as physicians left to work at surgery centers or other less demanding settings.
What happened here is pretty indicative of what’s happened to a lot of hospitals around the country. We’re at a real crisis and inflection point on how we deal with calls.” — Joseph Sniezek, MD
“What happened here is pretty indicative of what’s happened to a lot of hospitals around the country,” said Joseph Sniezek, MD, medical director of head and neck endocrine surgery for Swedish Health Services. “We’re at a real crisis and inflection point on how we deal with calls.”
Why Call Compensation Is So Contentious
Under the Emergency Medical Treatment and Active Labor Act (EMTALA), all hospitals that offer emergency services must maintain a list of on-call physicians to provide further evaluation and treatment as necessary to stabilize patients with emergency medical needs, regardless of a patient’s ability to pay (CMS.gov. https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/emtala.pdf).
While physicians have long been driven by the desire to provide medical treatment to the community, their ability to provide care is limited by their physical and emotional capacity. And, as more otolaryngologists have chosen to work exclusively in outpatient environments, demands have increased on those who cover call.
Fewer Physicians Taking Call
“The pool of physicians taking call is shrinking, and as the pool shrinks, the burden falls on fewer shoulders. That can be hard to bear,” said Nancy Jiang, MD, chair of the department of head and neck surgery for the Permanente Medical Group in Oakland, Calif.
At the same time, expectations for call coverage have increased. Covering physicians are typically providing service to a much larger patient population than in years past. On-call otolaryngologists are often asked (and expected) to digitally review charts and images.
“I think the days of only calling the physician if they are needed to do something emergent are gone,” Dr. Jiang said. “If you’re part of a large hospital system and patients are calling the call center for advice, you’re getting pulled in to help with all sorts of non-urgent things.”
But because physicians can now manage many of those requests from home, hospitals and health systems don’t necessarily recognize (or compensate) the extra work. “The hospital could say, ‘Oh, you were on call for the last 24 hours, but you only came in for a one-hour consultation,’” Dr. Jiang said; however, the physician carried the mental, intellectual, and legal responsibility for call for 24 hours.
Further complicating matters is the fact that otolaryngologists have become so specialized.
“If you’re an otologist who hasn’t done anything but otology for 10 or 15 years, you may not be competent to take general otolaryngology call,” Dr. Sniezek said. “If you’re a fellowship-trained head and neck surgeon, you typically don’t do general ENT surgery, sinus surgery, tonsils, or tubes.”
Call Doesn’t Benefit MDs
Almost two decades ago, many otolaryn-gologists realized that “participating in emergency department call panels has become a losing proposition. Reimbursements can be abysmally low, and exposure to liability high” (ENTtoday. https://www.enttoday.org/article/situation-critical-otolaryn-gologists-see-diminishing-returns-for-taking-emergency-call/). And, in 2021, the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) issued a position statement noting that “providing uncompensated hospital services adversely impacts … [physicians’] business and compromises their ability to provide quality care to their patients” (AAO-HNS. https://www.entnet.org/resource/position-statement-reimbursement-for-taking-hospital-call/).
Three years later, most otolaryn-gologists are still not compensated for call coverage. During a Board of Governors webinar earlier this year, 51% of the participants said they were not compensated for call. Otolaryngologists working in academic settings are the least likely to receive call compensation; 72% said they do not. Just over half—56.6%–of otolaryngologists employed by hospitals or health systems receive compensation for call (AAO-HNS. https://www.youtube.com/watch?v=VDHh57IPQu8).
Historically, taking call was one way for physicians to build their practice. Otolaryngologists who provided emergent care for patients in the ED often later saw those patients in office for follow-up care—and perhaps eventually cared for those patients’ family and friends, receiving payment for those services. That’s not necessarily the case today. Many patients are uninsured; many receive otolaryngology care from a provider who has an outpatient-focused practice.
In contrast, providing emergency specialty care to patients can be lucrative for hospitals and health systems. Hospitals are required by EMTALA to provide access, as needed, to patients who require specialty care. Hospitals that do not meet this requirement stand to lose Medicare funding; they can also be sued for damages under EMTALA. Hospitals that have designated trauma centers—and therefore require round-the-clock specialty coverage—benefit financially via direct reimbursement, lump sum Medicare payments, and payments from other hospitals, state programs, and various trauma funds, Dr. Strasnick said.
“It’s important for people to realize that being on call is not a service to the patient but rather a service to the hospital,” he said. “The hospital is really the disproportionate beneficiary, and fair market value should properly valuate this service with appropriate metrics.”
Otolaryngologists Notice Inequities in Call Coverage
Overwhelmingly, the call burden falls upon otolaryngologists employed by hospitals and academic centers. (During the Board of Governors call compensation webinar, just 38.8% of otolaryngologists in private practice indicated they take uncompensated call.) Physicians who have hospital privileges—but are not employed by the hospital—may be able to opt out of the call pool.
That was the case at Swedish Medical Center, which had more than 40 credentialed otolaryngologists but only nine employed otolaryngologists to cover the call burden. As a result, physicians and hospital administration had to wrestle with questions such as, “Should you be required to take call if you have hospital privileges? What about subspecialists like otologists and head and neck surgeons who haven’t done general ENT in a long time? Should the burden of call be based on utilization?” Dr. Sniezek said.
Otolaryngologists have also noticed that many other specialty physicians now receive call compensation. Neurointerventional surgeons receive approximately $1,000 to $2,000 for weeknight call, according to a 2022 survey (AJNR Am J Neuroradiol. 2022;43:1286-1291). A separate 2022 survey found that approximately 60% of orthopedic surgeons are paid separately for weekday trauma call, with most receiving $1,000 to $1,500 for a night of call (Orthopedics. 2022;45:293–296). A 2022 survey of urologists found vast differences within the specialty, with approximately 38% of urologists making $500 to $1,000 per day for weekend hospital call and more than 60% receiving no additional compensation for weekend call; however, 44% of urologists in private practice report earning more than $500 per day for weekday call compared to just 7% of academic urologists (Urol Pract.2024;11(3):569–574).
“Otolaryngologists, I think, are a bit behind,” Dr. Jiang said. “Seeing the way other specialties have changed the way they compensate call is an impetus for us to look at that as well.”
Negotiating Call Compensation
Otolaryngologists now commonly ask about call before joining a practice or health system. In some cases, onerous call responsibilities or lack of adequate compensation drive otolaryngologists away. Equitable compensation is be-coming an important recruitment lever.
The best time to negotiate call compensation is before you accept a job. Ask for what you want and be specific. “When I signed my first contract, it required that I take a ‘reasonable amount’ of call,” Dr. Sniezek said. “I would never sign that contract today because that can be interpreted any way an employer decides.”
When negotiating for yourself or your group, do your homework. Dr. Sniezek said, “Administrators will use fair market value assessments that, in my experience, are not accurate. Speak to colleagues throughout the region about what their call burden is and how they’re compensated. That information is really powerful and important when you go