Wednesday, December 26, 2007

Physician Payment - Paying Doctors for ER Coverage

Doctors, as rational professionals, at times protect their time with family, life style. Incomes, and avoid malpractice risks by asking to be paid for emergency room coverage.

Many think doctors should provide such coverage as an act of charity, as a professional duty, and as a way of showing fealty to hospitals. And more often than not, probably 75% of the time, doctors do.

Yet, lack of specialty ER coverage has become a critically important issue. In a survey by the Schumacher Group, a Lafayette, Louisiana ER management firm, 34% of hospitals say coverage lack poses a public safety threat. Still, doctors are more and more unwilling to cover without compensation because of malpractice risks, lifestyle burdens, and economic factors.

Here are % of hospitals paying extra for the following specialists (2005 survey of 1328 ER directors)

• General surgeons, 25%

• Orthopedists, 20%

• Neurosurgeons, 16%

• Ob/Gyn, 12%

• ENT, 7%

• Ophthalmology, 6%

• Plastic surgery, 6%

• Psychiatry, 6%

• Hand surgery, 5%

• Vascular surgery, 4%

• Gastroenterology, 4%

Below are hourly rates for specialties, on-house and off-site (Source: Sullivan, Cotter, and Associates On-Call Pay Survey)

• Anesthesiology, $80. $32

• ER, $72, N.A.

• OB/GYN, $85, N.A,

• Primary Care, $45, N.A.

• Psychiatry, $75, $18

• Surgery, $48, N.A.

• Surgical specialties, $81. $31

• Trauma, $95, N.A.

Are these rates too much to ask? After all, doctors covering ERs,

• stand a low chance of being paid a high chance of being sued,

• don’t know the patients and may never see them again,

• may compete with the hospitals who are asking them to cover,.

• are distracted from their home and personal lives while being on call,

• must take time away from their practice, thus losing income, while traveling to and from the hospital or doing required procedures.

There may be other factors as well. A November study by the Center for Studying Health System Change, says doctors are shifting focus from hospitals to their practices and outpatient facilities. Treating ER patients takes time and money from their practices. When treating patients in their own centers, doctors can also collect facility fees – just as hospitals do in their ERs.

Lack of specialty coverage in hospital is a problem, because treatment delays can cause deaths or permanent injuries. But it’s a problem hospitals are correcting by contracting with physician groups for ER coverage, paying stipends to covering doctors, and paying doctors for treating uninsured patients while on call


FeminizedWesternMale said...

"Are these rates too much to ask?"

No -- they should make as much as they squeeze out. Only physicians and patients would imagine providing directly uncompensated care. All other parties with a hand in healthcare snicker at these relics/dupes.

shadowfax said...

So who pays? As an ER doc, I'm pretty invested in getting the call list fully covered (ours is, fortunately). But hospitals aren't the wellspring of money so much anymore, and paying for physician *availability* by definition isn't going to be covered by patient revenues. It particularly bothers me when a certain specialty demands payment for being on call, surgical subspecialties being the major offenders on this, when the rest of the call staff is not.

It all goes back to the government's unfunded mandate, EMTALA. It requires me to see everybody regardless of payment, and requires, to a lesser degree, the on-call system for specialists. My view is that if the government is going to require these of doctors, the government should directly compensate us for the burden imposed.

Great post.

Ophthalmology said...


There is a simple reason surgical subspecialists demand to be paid. TIME I keep a mental note of the time it takes to repair ophthalmic trauma. From the time an ER calls,I drive straight in, exam/diagnose, schedule stat surgery, operate, and drive home is no less than 5 hours. This with an operative time in the 1 to 2 hour range. The above does not include the postop, the liability calculation, ancillary staff/facillity costs within my office for followup.

While trying to avoid the whole cognitive versus procedure arguement for compensation, there is something very unfair about doing a physical action like micro-surgery and not being paid a penny for that "privilege" Yes perhaps if I performed an H&P it would be unfair to not be paid but in my mind it just seems less unfair that the time, risk, and post-op obligation of a surgical patient.

If you are an ER physician you make money or get paid either directly thru billing patients and insurance or salary from the hospital. You work a defined shift and even if each patient is not reimbursed you will make a living and not be paid for every hour you work? If you are a true practice/corporation and you do lose on each patient you wouldnt last long.

You mentioned hospitals are not the wellsprings of money anymore. I am not suggesting you are simplistic but that might be a financially simplistic statement. Most hospitals are doing just fine compared to other business. Hospitals are usually monopolys or oligopolys in their given market with state certificate of need proctection, and state/federal peer review immunity. A formidable business with high levels of entry to stifle out the competition. The next time you listen to a hospital beg poverty take a look at the reimbursement and all the pass thru expenses allowed that compensate hospitals but leave physicians and outpatient surgical facillity uncompensated.

Furthermore as hospitals consolidate their control of adjacent primary and secondary facillitys thereby increasing catchment area, physicians are serving a MUCH larger patient population. When you take call for a major hospital system, if you add up all the hospitals and "feeder" hospitals it can be anywhere from 10 to 15 hospitals. In my specialty, Ophthalmology, one physician takes call 24/7 for all the hospitals. When the ER physician is angry that I don't come in immediately to see a patient, I am amazed at how uninformed the ER doc is regarding thin coverage and the triage necessary to function within such a system.

One of the dangers in contracting with the hospital is the mindset of the medical staff and medical adminstration that you are now a defacto employee of the hospital. Hospital admins and chiefs of staff have very little insight into the balance required of outpatient oriented practices and providing ER,inpatient hospital coverage. When you contract with a hospital they expect you to act accordingly like an employee regardless of what the contract states.

Yes EMTALA is an unfunded law requiring hospitals and physicians to provide free care, unfortunately hospitals with all their political clout seem to be unable to work with physicians to overturn EMTALA. I would be curious to see how hospitals write off such care.

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The ER coverage is the most serious issue of our healthcare system seriously