Health policy and clinical practice/original researchChanges in the Cost and Management of Emergency Department On-Call Coverage: Evidence From a Longitudinal Statewide Survey
Introduction
One of the most striking changes in the management of hospital emergency departments (EDs) has been the provision of on-call specialist coverage. Traditionally, specialists have accepted emergency on-call coverage as a responsibility of the medical staff working in the general hospital setting. Currently, on-call coverage is a controversial, sensitive, and highly negotiated issue among specialists and hospital administrators. A recent report by the Institute of Medicine called the lack of available on-call specialists “[o]ne of the most troubling aspects of the current emergency and trauma care system.”1
Several factors may have contributed to a decreasing willingness to take call. Specialists may be wary of inadequate reimbursement associated with patients treated while specialists are on call, especially because such patients are frequently uninsured.2 Younger physicians have expressed a strong concern with “lifestyle” problems associated with late-night telephone calls and disruptions.3 In addition, malpractice fears have led physicians to reduce their exposure to high-risk procedures.4, 5, 6 Specialists also have new opportunities to practice in ambulatory surgery centers, which usually do not require emergency call.7, 8, 9, 10 Finally, changes in regulatory rules may have led to the ways in which hospitals manage on-call coverage. In 2003, the Centers for Medicare & Medicaid Services published new rules for the interpretation of the Emergency Medical Treatment and Labor Act (EMTALA).11 In the new rules, the Centers for Medicare & Medicaid Services made it clear it would be up to each hospital to adopt its own reasonable coverage standards; there would be no minimum requirement for frequency of on-call coverage based on the number of specialists a hospital had on its medical staff. After the publication of the new regulations, many hospitals adopted partial-call coverage formulas or completely dropped call coverage for many specialties.
Other hospitals have attempted to maintain call coverage by offering nightly or monthly stipends (or other payments) to specialists. On-call payments are not entirely new; for example, compensation for call coverage was reported in the early 1990s, mostly at for-profit hospitals in the South and West,12 stipends were reported as early as 2000 in Florida,13 and in 2002 the California Medical Association adopted a position that hospitals should pay on-call physicians whether or not they are called to the ED.14 What does appear to be new is the frequency of such arrangements. In a national survey by the American College of Emergency Physicians, 36% of ED directors reported that their hospitals paid stipends to specialists for taking coverage in 2005 compared with only 8% in 2004.15
However, there is still a relative paucity of information about the changes in call coverage and the extent to which these changes have affected the delivery of care. These changes are important because they are altering the way in which emergency and trauma care is provided. These changes may also affect hospital financial performance and have the potential to adversely affect patient outcomes.
The purpose of this article is to describe hospitals' responses to changes in on-call coverage, using a longitudinal survey of hospital chief executive officers in Oregon. This survey documents changes in on-call coverage and how stipend payments changed during a 2-year period. Furthermore, we provide some indication of how emergency care may change to adapt to the current problems.
Section snippets
Study Design
A custom electronic survey instrument was used for this study, which was conducted by e-mail. The first wave of surveys was distributed on June 20, 2005, and was completed September 12, 2005. The second wave of surveys was distributed on July 15, 2006, and was completed December 1, 2006. Results of the first survey have been published elsewhere.16 Survey instruments are available from the authors. The institutional review board at the Oregon Health & Science University approved this study.
Setting
Selection of Participants
We surveyed the chief executive officers of 56 Oregon hospitals, representing all hospitals with EDs in Oregon, with the exception of the single Kaiser hospital in Oregon. (We excluded the Kaiser hospital because its specialists are paid on a salaried basis, wherein on-call duties are built into the salaried compensation model and there is no basis for demanding on-call stipends.)
Results
Among 56 hospitals with EDs in Oregon, 43 responded to our survey in both 2005 and 2006, representing a 77% response rate for the longitudinal survey. We received responses from 35 of 44 (80%) trauma centers, 28 of 35 (80%) rural hospitals, 15 of 21 (71%) urban hospitals, and 12 of 18 (67%) hospitals with 100 beds or more.
Table 1 displays hospitals' annual stipend payments to all specialties for maintaining on-call coverage in 2005 and 2006. Total annual stipend burden increased by 84%, from an
Limitations
There are several issues that should be considered in the interpretation of the results of our study. This study is limited by its single-state nature. Oregon is a state with a relatively small number of hospitals (57). More than half of these hospitals are located in rural areas. Furthermore, Oregon's on-call problems have generally not been considered to be the most acute in the nation. Thus, on-call stipend costs reported here might be expected to be lower than in some other states.
Discussion
This study is one of the first to report on the financial arrangements used to maintain emergency on-call coverage and to report on the changes in these arrangements during a 2-year period. We find that the majority of hospitals have made important changes in their provision of emergency care. Approximately two thirds of respondents have lost continuous coverage for at least 1 specialty. Furthermore, there has not been a systematic response to on-call shortages. The most prominent method for
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Supervising editor: Donald M. Yealy, MD
Author contributions: KJM was involved in the conception and design of the study. KJM and RL acquired data. KJM, CDN, and RL analyzed and interpreted data. KJM drafted the article. RL and CDN critically revised the article for important intellectual content. KJM conducted statistical analysis and supervised the study. RL and CDN provided administrative, technical, and material support. KJM had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. KJM takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Financial and material support was provided by the Department of Emergency Medicine at Oregon Health & Science University.
Publication dates: Available online April 3, 2008.
Reprints not available from the authors.