“Hospitals will have to decide, if they’re going to provide ER service, that they have to pay a per diem for the people to do that,” Dr. Davison said. “And that per diem ought to be a flat fee that you receive just to carry the pager. Just to be inconvenienced in your life, that number, to my mind, needs to be between $1200 and $2000 a day per physician.”
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June 2006The solution for many otolaryngologists—head and neck surgeons is simply to stop taking call.
Dr. Davison also has strong feelings about the divisions within specialties. Physicians have become divided, he said, into two camps: “the grandfathered camp and the new graduate camp. The grandfathered camp frequently used the model of developing a practice from the ER. But they have sold out the new camp, saying —anybody who had privileges at the hospital prior to 1986 doesn’t have to take call and everybody who starts now has to take call.’ The burden of covering often goes to the more junior physicians. If we decide as a society, either plastic surgeons or ENTs, that we have a moral obligation to cover the ER, then everybody should have to cover, and take an equal share.”
Searching for Solutions
Like many others who have studied the current status of ER coverage, Dr. Davison knows this “is not an easy problem. The hospital has got an unfunded mandate too. So it’s not really fair. They’re not the bad guys, but it is more in their best interests, and not in the physician’s best interests [to cover call].”
A May 2005 American College of Emergency Physicians Information Paper, “Availability of On-Call Specialists,” proposes a variety of legislative, regulatory, and purchasing agreement solutions to mitigate the on-call crisis. Dr. Vanlandingham believes that one of the suggested approaches, outlining creation of group purchasing organizations by hospitals, might be one possible solution. The group purchasing organizations could request proposals from contracted groups of physicians to fill call panels. This approach might be particularly helpful in rural areas, where a group of otolaryngologists could contract to cover several hospitals in a county-wide region. “It’s a burden to the otolaryngologist on-call at another hospital two miles from mine to take care of all of our ENT transferred patients when the hospital is not chipping in to help compensate for on-call coverage,” he conceded.
Dr. Donaldson suggested that solutions particular to Florida must be three-pronged: tort reform to address the liability issue; pressure at the public policy level to raise reimbursement levels; and providing an adequate supply of specialists graduating from programs. Physicians must act in concert to effect change in federal reimbursement formulas, he believes. The Florida Pediatric Society recently filed a suit against Medicaid in federal court, charging that the low Medicaid reimbursement rates (65% of the already low Medicare rates) constitute a denial of access to care for the state’s low-income children. Actions similar to these may alleviate some of the stresses on the country’s delivery of emergency room care, but the situation is unlikely to improve anytime soon, say many who study the issues.
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