Situation Critical: Otolaryngologists See Diminishing Returns for Taking Emergency Call

“Physicians are angered by providing emergency care to insured patients whose insurance coverages deny payment for mandated care,” said Dr. Harris, who is also chair of the Medical Staff Quality Assurance Committee at a large community hospital in Fullerton, Calif. “Insurance arrangements compelling patients to return to designated providers for follow up, regardless of the quality of care they’ve received, make emergency room call frustrating.

“Once upon a time, it was worth it to you to be on call. That’s the way you built your practice. And there’s still that fantasy around. As a matter of fact, I can remember being kept off call by my competitors. But the whole world turned around over the last 15 years, and nobody even realized it.”

“There’s nothing worse than taking call and looking after a patient at a hospital, and then having them transferred to their Kaiser Permanente doctor who was not on call that night,” said Dr. Davison. “That just annoys the living daylights out of me!”

A study Dr. Davison published in Plastic and Reconstructive Surgery in 2004 highlighted this problem (114(2):453–457). Reviewing a total of 300 patient visits during a 30-month period of ER coverage at three hospitals (an inner-city tertiary care center, an urban university hospital, and a suburban tertiary care center), Dr. Davison found some unexpected results. The inner-city hospital did have the highest percentage of uninsured patients (67%), but it was the suburban tertiary hospital where the lowest rate of reimbursement was seen, despite the percentage of uninsured patients (50%) being lower than that of the inner-city hospital.

Opting Out

The solution for many otolaryngologists–head and neck surgeons is simply to stop taking call. Although he took emergency calls earlier in his career, Dr. Harris has not done so for several years. Echoing the results of Dr. Davison’s study on reimbursement rates, Dr. Harris noted that his reasons had less to do with treating uninsured patients than treating those with insurance coverage. “You have to go through this hassle and people accuse you of ripping them off.”

He recalls one incident almost 15 years ago, when he responded to a 3 AM call to stop an 80 year old patient’s nosebleed. The man, on a fixed income, asked whether Dr. Harris would accept what Medicare allowed for the consultation. Dr. Harris agreed, but secured the patient’s promise that if the amount was low that the patient would appeal the bill. The explanation of benefits allowed a $3 payment on a $150 bill. After an appeal, Dr. Harris eventually was granted a hearing with the Medicare examiner. Taking half a day off, he appeared and contested the low payment. “I won the case,” he said grimly. “I got nine bucks: that’s what happens when you win with these people.”