Good help is hard to find — especially when a specialist is needed for a consult in the emergency department.
More than 70 percent of emergency departments reported inadequate on-call coverage by specialists in the most recently available national study. That percentage could rise given that ED utilization is increasing and the nation's physician shortage is projected to reach 90,000 by 2020.
The shortage can impair the quality of care that a hospital provides by delaying consults or transferring patients in need of emergent care by hard-to-reach specialists. Physicians who can help often exacerbate the situation by limiting their ED call availability or using any availability they may have to demand better compensation and employment terms.
So how can CEOs and chief medical officers provide quality care while controlling costs? Here are three of the primary reasons for the shortage of on-call specialists with solutions to each.
Problem 1: Perception that ED patients are self-pay and seeing patients in an office setting is more efficient and profitable.
Though pay varies by specialty and payer, private insurers typically do reimburse specialists for scheduled appointments more than government insurance programs do for seeing patients in the ED. This is significant, given that either Medicaid or Medicare is the primary payer for half of the nation's total visits, according to data from the 2010 National Hospital Ambulatory Medical Care Survey.
While patient flow improvement processes and teams are nothing new to emergency department directors, ED physicians and nurse managers, hospital administrators need to marshal the support of the specialty service department chiefs and enlist them to communicate the importance of response times and completion of consultations to the overall health of the institution.
Empowering specialists to contribute to, and share in, your hospital's overall success throughout the whole hospital and not just the ED, can make covering the ED more palatable.
Paying a specialist a flat fee for being on call and tying the payment to agreed upon response and consultation times, while allowing them to still bill insurers directly, also can improve coverage. Other physicians may request a similar allowance though, so you should be ready to meet such a demand or prepare a response as to why you will not.
Problem 2: ED-call schedules are intrusive.
Specialists often see ED-call coverage as an intrusion into their personal lives and a disruption to their practices.
If your hospital's and/or health network's influence is great enough, or you employ the physicians, you can require ED call coverage as a condition for maintaining privileges and/or employment. Or if you would prefer to use the carrot instead of the stick, you could support specialists by working collaboratively with them to improve access to your operating rooms and other resources necessary for them to efficiently provide patient care at your hospital.
Problem 3: There is more to lose than to gain in covering the ED.
Specialists often perceive that there is a greater likelihood of a patient filing a malpractice claim from being treated in the ED than for an elective consult and such a practice pattern will result in increases in liability insurance premiums. Though this may not be true in all cases, it is a problem because physicians' perceptions make it a reality in negotiations.
You can take the argument off the table by acquiring and managing physician practices and employing physicians. In the employment agreements, you can negotiate for a certain amount of ED coverage for each physician. This can be an effective way to guarantee that you have coverage; however, you need to bear in mind, that if a physician leaves the practice and the call rotation changes, you may have to revisit the call issue and have to ask one of the physicians to pick up extra call days to make up the difference. Or, again, you could provide call per diems to help specialists defray some of their liability insurance costs.
You also could seek legislative relief by asking state lawmakers to subsidize coverage, if your state does not already do so, and/or supporting the American College of Emergency Physicians' push for national legislation that would provide liability protections for emergency and on-call physicians under the Public Health Safety Act.
Some hospitals have completely outsourced specialty coverage, such as for surgicalists, ortho-hospitalists and neurohospitalists, for emergency and in-house coverage to regional or national contract groups, including responsibility for scheduling ED call coverage. And, you may want to consider this alternative if your service area's population is expanding too fast for the supply of specialists to keep up. If this is the case, research the provider carefully to ensure that it can provide the types of specialists you most need.
But if you choose to keep hiring specialists directly, do bear in mind that good help can be found. It just takes more looking.
Aaron Risen is a managing partner of Med Link, a St. Augustine, Fla.-based physician staffing agency specializing in trauma and surgical critical care, neurosurgery, neurology, intensivists, hospitalists and emergency medicine. He can be reached at aaron@thesurgeonslink.com.