The Real Question Behind Emergency Department Call Coverage

Dear Editor,

Dr. Holt’s recent article, “Taking Otolaryngology Call in the ED and Hospital: Duty or Burden?” (ENTtoday. https://tinyurl.com/3vbwp752) raises an important and uncomfortable hypothetical: What happens when no otolaryngologist is willing to take an emergency department call?

It is a valuable discussion that deserves thoughtful engagement, but respectfully, the article misses the most fundamental change that has occurred in healthcare over the last several decades: The economics and structure of medical practice have been completely transformed.

A generation ago, physicians routinely staffed emergency departments as part of their commitment to the community and their partnership with hospitals. At that time, physician reimbursement was substantially higher relative to overhead, the cost of medical education was dramatically lower, malpractice exposure was different, and the opportunity cost of years of training was far less severe.

The entire healthcare ecosystem has since changed.

Hospitals have become consolidated health systems, and facility fees have risen substantially.  Simultaneously, these health systems now receive significant direct and indirect governmental support through mechanisms including graduate medical education payments, trauma subsidies, disproportionate share funding, and tax advantages associated with nonprofit status. Meanwhile, physician professional services reimbursement, particularly when adjusted for inflation, has steadily declined. Independent practices face increasing staffing costs, regulatory burdens, prior authorization demands, technology expenses, and shrinking margins.

At the same time, the payer mix associated with emergency call is worsening. Although the uninsured rate declined after passage of the Affordable Care Act in 2010, recent changes related to Medicaid enrollment requirements and modifications to enhanced exchange subsidies under HR1 are expected to increase the uninsured population once again, placing additional uncompensated care pressure on both physicians and hospitals. Even among insured patients, rising deductibles and copays have created a growing underinsured population, leaving many patients unable to pay their medical bills and shifting increasing amounts of uncollectable debt onto independent physician practices that already operate under significant financial pressure. The result is that emergency call can no longer be viewed through the lens of a 1980s or 1990s medical staff model.

Even the American Academy of Otolaryngology–Head and Neck Surgery has acknowledged this shift [in a position statement], noting that many otolaryngologists no longer maintain the historic financial relationships with hospitals that once justified uncompensated call coverage and that providing emergency services without compensation has become increasingly unsustainable (AAO-HNS. https://tinyurl.com/3bdektdc).

Today, the hypothetical raised by Dr. Holt is not primarily about physician duty. It is about institutional responsibility.

Who bears the responsibility for ensuring specialty access for the community?

Today, that responsibility appropriately falls to hospitals and health systems, which are specifically structured, subsidized, and regulated to ensure community access to care. Emergency Medical Treatment and Labor Act (EMTALA) obligations belong to hospitals, not private practices. Trauma designations belong to hospitals. Nonprofit community benefit obligations belong to hospitals.

The sustainable solution is therefore not moral outrage directed toward specialists, nor should specialists suffer moral injury from the hypothetical phone call Dr. Holt suggests. The solution is proper alignment between hospitals and physicians, thus eliminating the need for the phone call in the first place.

For private practice physicians, this alignment generally occurs through one of two models:

Pay-for-call arrangements—where physicians receive fair market value compensation for being available to provide emergency coverage; or

Professional services or lease arrangements—where hospitals contract with physician groups to provide defined emergency and inpatient coverage responsibilities.

These arrangements have become increasingly common nationwide because they recognize economic reality while preserving access for patients.

In employed and academic models, the structure is even more clear: Taking call is simply part of the physician’s employment responsibilities as outlined in their employment agreements.

None of this diminishes the professionalism or ethical commitment of physicians. Otolaryngologists continue to provide lifesaving airway care, trauma care, hemorrhage management, and emergency surgical services every day across the country. But asking physicians alone to absorb the growing financial and lifestyle burden of uncompensated emergency care, while the economics of healthcare have shifted dramatically around them, is neither realistic nor sustainable.

The real challenge is not whether physicians care about their communities. They do.

The challenge is building healthcare delivery systems that responsibly share the burden of maintaining emergency access in a modern healthcare economy.

Sincerely,

Neil Hockstein, MD

Dr. Hockstein is an otolaryngologist specializing in head and neck surgery and currently serves as chair of the Delaware Health Care Commission. He holds faculty appointments and leadership positions at ChristianaCare, Thomas Jefferson University, and The Wistar Institute. An active head and neck surgeon, Dr. Hockstein cofounded Parallel ENT & Allergy and currently serves as its chief medical officer.