Situation Critical: Otolaryngologists See Diminishing Returns for Taking Emergency Call

What Dr. Vanlandingham finds frustrating is when an otolaryngologist refuses to take call about an urgent situation, such as a patient with a posterior nosebleed. He must then transfer that patient to another hospital’s emergency room, where the patient may often wait another three to four hours for the specialist to be called. “Besides the inefficiencies, my main concern is patient safety,” he said. “As an emergency physician, I wish on some nights that taking call were a mandatory part of licensure for all specialists, but then, of course there would be other problems associated with that solution.”

Variances among Regions

Although EMTALA is a federal statute, its consequences are felt in widely different ways according to state and local economics. For instance, in California, mandated (and also unfunded) seismic retrofitting weighs heavily on hospital budgets. In Florida, said Dr. Donaldson, hospitals cannot, by state law, opt out of providing emergency services—and yet, Medicare and Medicaid reimbursement rates are low.

“The first issue I see in San Luis Obispo County,” said Candy Markwith, CEO of Sierra Vista Regional Medical Center, a Tenet Healthcare–owned hospital in San Luis Obispo, Calif., “is the lack of physicians in general. Being on rural reimbursement rates,” she said, “presents a challenge to us in our ability to recruit physicians to our area.” That challenge is exacerbated in a locale with high housing prices (the county is a central California tourist destination), and by the fact that physicians coming out of school have very large student loans—with choices of employment all across the country. “In a county our size [total population, approximately 300,000], with four hospitals, it is very difficult for some of the subspecialists to be available 24 hours, all the time,” she said.

A Path to Solutions?

Suggestions about solutions to the on-call coverage crisis often align with the stakeholder group suggesting them. Hospitals would like to see more funding; physicians would like to see more and higher stipends; and patients want to ensure that they will receive appropriate care in emergencies.

Dr. Harris believes that hospitals’ difficulties in maintaining call panels to comply with EMTALA are a direct result of the industry’s own actions. Dr. Harris noted that prior to the mid 1980s, “a covert contract was in place between the hospital and the medical staff. In return for complying with the written portion of the contract requiring physicians to cover the emergency room, the hospital honored the unwritten portion: physicians’ access to the prime arena for networking with referral sources and building a practice.