ACPE poll: physician leaders distressed by specialist shortage; On call pay controversial.Some physician executives are outraged at even the mere suggestion of paying specialists to take emergency room call. "I must be old school because I believe taking ER call is part of a physician's obligation to his/her community ... I am embarrassed to see physicians feel they are not responsible to provide any charity care to their fellow man," wrote one respondent to a recent ACPE ACPE Accreditation Council for Pharmacy Education ACPE American Council on Pharmaceutical Education ACPE American College of Physician Executives ACPE Association for Clinical Pastoral Education, Inc. poll on specialist pay. Other physician leaders said paying for call is inevitable. "Today's new physicians want the pay but not the work. Hospitals that rely on the 'voluntary' medical staff may go the way of blacksmiths' shops." "It is a shame that medicine has come to this," another wrote. "That being said, our hospital will have to do it also as it has become a major issue with many of the medical staff." The divisions run wide ... "Physicians have incredible financial pressures to stay in practice. All they can sell is their time. There is no reason for physicians alone to shoulder the entire burden of community health care." and deep ... "This is indicative of arrogant specialists." A couple respondents even went so far as to call specialist pay "blackmail blackmail, in law, exaction of money from another by threat of exposure of criminal action or of disreputable conduct. The term was originally used for the tribute levied until the 18th cent. " and "extortion extortion, in law, unlawful demanding or receiving by an officer, in his official capacity, of any property or money not legally due to him. Examples include requesting and accepting fees in excess of those allowed to him by statute or arresting a person and, with ." While the pay or not-to-pay question is obviously a hot button for physician executives there was one thing the poll respondents mostly agreed on: the specialist shortage is hurting hospitals. The majority of poll respondents, 64 percent, said they struggle with the problem of getting specialists to take ER call. Only 29 percent said it wasn't a problem. Sent to 3,000 physician executives in hospitals and group practices across the country, the poll drew 814 participants, a 27 percent response rate. When it comes to paying specialists to take call, the group was split down the middle--46 percent said their hospitals pay specialists, 44 percent said their hospitals don't. Yet, of those who said their hospitals don't pay specialists, nearly half (46 percent) are considering the controversial idea. Perhaps the most interesting responses were found in the comments posted by 445 respondents to the poll. Some blasted the idea, berating any doctor who would ask to be paid for taking call. Others gave hearty approval, pointing out that failure to pay for call could lead to even bigger headaches for hospitals. Here's a sampling of their comments. Pro pay Given the declining reimbursement Reimbursement Payment made to someone for out-of-pocket expenses has incurred. rates for elective surgery elective surgery Surgery Any operation that can be performed with advanced planning–eg, cholecystectomy, hernia repair, colonic resection, coronary artery bypass , the increasing medical liability premiums, and consistent medico-legal exposure from emergency room coverage, reimbursement for this activity is only fair. As the risk of practice escalates, and as payment for services decreases, ERs will have no choice but to reimburse re·im·burse tr.v. re·im·bursed, re·im·burs·ing, re·im·burs·es 1. To repay (money spent); refund. 2. To pay back or compensate (another party) for money spent or losses incurred. specialists for taking call. The emergency room is an epicenter of actual and potential liability in my practice. It is also a major source of office, family and personal time loss. Our hospital is currently proposing compensation for ER call. If compensation does not evolve, I am history in the ER. My personal sense is that this (paying specialists) may make call a bit more palatable pal·at·a·ble adj. 1. Acceptable to the taste; sufficiently agreeable in flavor to be eaten. 2. Acceptable or agreeable to the mind or sensibilities: a palatable solution to the problem. . Time away from practice and malpractice risk are increasingly becoming major impediments IMPEDIMENTS, contracts. Legal objections to the making of a contract. Impediments which relate to the person are those of minority, want of reason, coverture, and the like; they are sometimes called disabilities. Vide Incapacity. 2. for practitioner willingness to take call, particularly if the most likely patients to be admitted to or consulted by them are uninsured. Paying for ED call is inevitable. Either pay or close the ER. I am not opposed to it, in fact when I used to take call, I would have liked to have been paid. Payment, if compliant with fair-market-value standards, is reasonable. Its time has come. It should be mandatory. The hospitals have been riding on the good will of the doctors too long. All meetings should be paid as well as any work done by doctors on the hospital's behalf on committees. We are enormous suckers. No pay We have some specialists who would like to be paid, but we are holding the line. Our medical staff bylaws The rules and regulations enacted by an association or a corporation to provide a framework for its operation and management. Bylaws may specify the qualifications, rights, and liabilities of membership, and the powers, duties, and grounds for the dissolution of an require the taking of call, with some exceptions for 1-2 person specialties. We had a little challenge recently when the trauma director resigned, citing "inadequate reimbursement," but have since renegotiated that contract with a different member of the same group, without having to give away the farm. I think it is outrageous to have to pay MDs to take emergency care of patients. While the subject has been broached by the orthopedists, the administration is adamant about not paying. Seems like this will be a monstrous rent in the provision of care to patients. The safety net is vulnerable enough without allowing specialists to decide when and for how much they will come to see patients in the ER. We already struggle with ortho ortho-, comb straight or correct. , who often give patients appointments for follow up and then refuse to see the patient in their office because they don't have insurance. Call is a responsibility of the House of Medicine. The hospital cannot afford to pay specialists to take call. Once you pay one specialist, all will demand the same. Then every year the rate will rise. Who thinks this will be affordable unless the reimbursement changes? Disgusting--Physicians have forgotten what they are all about. Specialists should quit whining and do their fair share like everyone else. Partial pay Only neurosurgery neurosurgery /neu·ro·sur·gery/ (noor´o-sur?jer-e) surgery of the nervous system. neu·ro·sur·ger·y n. Surgery on any part of the nervous system. , orthopedics and specialties dealing with jaw fractures are being paid. We limit it to anesthesia, though others have asked. Anesthesia has special needs in our market and it's clear they simply can't make enough money to provide a competitive package given the demands of their exclusive contract. So our precedent is to compensate for call if they can't make MGMA MGMA Medical Group Management Association MGMA Metro Global Media, Inc. (stock symbol) MGMA Metal Gutter Manufacturers Association (UK) MGMA Michigan Gospel Music Association median. Currently doing this for pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children. pe·di·at·ric adj. Of or relating to pediatrics. orthopedics and general orthopedics. It appears that we will need to consider it for ENT ENT ears, nose, and throat (otorhinolaryngology). ENT abbr. ear, nose, and throat ENT ear, nose and throat. ENT Ears, nose & throat; formally, otorhinolaryngology in the near future. New generation [ILLUSTRATION OMITTED] It is a generational thing. The older generation feels that ED call is an obligation; the younger generation feels that it is an imposition. Pay plans We have had specialists push to get paid for ER call, then quit the staff when it didn't work in their favor. When the outside trauma specialists wouldn't take call, the hospital hired their own team. This turned out to be very expensive for the hospital, but seemed to send the message to other groups that were considering asking for call money. I haven't heard of any disputes since. We have worked with the specialists groups to provide locum tenens LOCUM TENENS. He who holds the place of another, a deputy; as A B, locum tenens of C D, mayor of the city of Philadelphia. coverage on occasion to give some relief for vacations, illness, etc. On the other hand, we have demonstrated we will actively recruit for employed specialists to provide the services we need and actively compete with the current group of specialists if they fail to provide the needed services. So far, the carrot and threatened stick has worked. All of our specialists are not employed and are not being paid to take ED call. Rather than start down the road to pay for ER call, we are employing specialists. We get better coverage and ancillaries. We have hired neurosurgeons, general/vascular surgeons, pediatricians, neurologists This is a list of the most important neurologists, with their dates of birth and death and nationality.
Pandora's Box Pandora’s box contained all evils; opened up, evils escape to afflict world. [Rom. Myth.: Brewer Dictionary, 799] See : Evil [ILLUSTRATION OMITTED] Our fear is opening Pandora's box and then having to pay ALL physicians to take ER call. This is a very difficult and sometimes troubling issue for our organization. How do you determine which specialties get compensated for ER call? Our primary care and medical subspecialties provide ER call without compensation. Our surgical specialists say they will not provide anymore coverage unless they are compensated. What do we tell our internists, family physicians and others who are willing to do this without compensation? This is a box I wish had not been opened. Crisis at hand The amount we are paying is becoming an unacceptable drain on our resources. We do not have a viable alternative currently, but we are near a crisis situation at this time. Get a life As lifestyle issues rise in importance, the unpredictability of ER call, especially for truama, becomes a significant negative in recruiting and retaining physicians. Hush money hush money n. Informal A bribe paid to keep something secret. hush money Noun Slang money given to a person to ensure that something is kept secret Noun 1. ? The market is quickly establishing that hospitals must pay physicians to take ED call ... Our hospital is paying some specialists as needed--but keeping it quiet so that they won't have to pay ALL specialists. On call privilege We have a limited number of subspecialists on staff at our rural hospital. The medical staff feels that it is their responsibility as part of their being granted privileges at our hospital to cover the emergency department to the best of our ability. When a subspecialty subspecialty, n a limited portion of a narrowly defined professional discipline. E.g., surgery is a specialty of medicine and pediatric vascular surgery is a subspecialty. with only a single practitioner is unavailable for call we have a written transfer agreement with a larger institution to accept our patients (after a medical screening and stabilization in accordance with the EMTALA EMTALA Emergency Medical Treatment & Active Labor Act, see there mandates). While there have been some rumblings about getting paid to take call, for the most part they are in the minority. Thankfully, most of our medical staff still believe that physicians are here to "take care of all patients." We have had a group of neurosurgeons drop their privileges over "pay for ER call" issue. Paying specialists to take ER call speaks to the issue of where medicine has drifted today. Physicians receive much benefit from hospitals. Indeed, most specialists could not function without hospitals. This issue would not surface except for physician discontent with their level of compensation. Prejudiced pay? If specialists are paid to do ER call then PCPs (primary care providers) must also be given the same remuneration. The continued prejudice as to PCP PCP abbr. 1. phencyclidine 2. primary care physician Pneumocystis carinii pneumonia (PCP) vs. specialist payments must end now. I think it is really sad that we pay subspecialists to take call but the primary care people are expected to do it for free. More inequities in a system already sick. It is completely inappropriate that specialists be paid for their call duties where PCPs are not. Where's my money? (My local hospital) does not pay certain doctors for call unless they are in the "clique (mathematics) clique - A maximal totally connected subgraph. Given a graph with nodes N, a clique C is a subset of N where every node in C is directly connected to every other node in C (i.e. C is totally connected), and C contains all such nodes (C is maximal). ." I personally find this highly discriminatory. If everyone were treated professionally, we'd have a better hospital. Paying for call sweetens the incentive for coverage. Payment required New paradigm New Paradigm In the investing world, a totally new way of doing things that has a huge effect on business. Notes: The word "paradigm" is defined as a pattern or model, and it has been used in science to refer to a theoretical framework. : Before rendering care to save a life or relieve emergent emergent /emer·gent/ (e-mer´jent) 1. coming out from a cavity or other part. 2. pertaining to an emergency. emergent 1. coming out from a cavity or other part. 2. coming on suddenly. suffering, be sure you collect a fee. Hospital hijacking hijacking Crime of seizing possession or control of a vehicle from another by force or threat of force. Although by the late 20th century hijacking most frequently involved the seizure of an airplane and its forcible diversion to destinations chosen by the air pirates, when ... blackmail [ILLUSTRATION OMITTED] More and more of the specialists are requesting payment for call. The oral surgeons Oral surgeon A dentist who specializes in surgical procedures of the mouth, including extractions. Mentioned in: Tooth Extraction are trying to hijack the hospitals--$700/night with about 40 referrals yearly between two hospitals! Neurosurgeons are starting to not renew their privileges for craniotomies, just restricting themselves to back cases (and) creating a real bind! Professional blackmail has become a way of life for a lot of specialists. They are frequently the only game in town and the hospital realizes this. Our trauma program alone costs us $2 million in on call fees which used to be provided free!! It's double-dipping, and a blatant form of extortion! Slippery slope 'slippery slope' Medical ethics An ethical continuum or 'slope,' the impact of which has been incompletely explored, and which itself raises moral questions that are even more on the ethical 'edge' than the original issue Paying specialists to take ER call is seen by the hospital as the "slippery slope" to financial disaster. Most physicians on staff have no problem taking ER call without specific compensation, since our patient payer mix payer mix Medical practice The type–eg, Medicaid, Medicare, indeminity insurance, managed care–of monies received by a medical practice. Cf Patient mix, Service mix. is favorable and provides adequate compensation. Orthopedic surgeons and some disgruntled dis·grun·tle tr.v. dis·grun·tled, dis·grun·tling, dis·grun·tles To make discontented. [dis- + gruntle, to grumble (from Middle English gruntelen; see general surgeons General surgeon A physician who has special training and expertise in performing a variety of operations. Mentioned in: Appendectomy disagree. As the number of indigent indigent 1) n. a person so poor and needy that he/she cannot provide the necessities of life (food, clothing, decent shelter) for himself/herself. 2) n. one without sufficient income to afford a lawyer for defense in a criminal case. patients grows, this will be an issue. I think it is a dangerous slippery slope (that) we don't need to go close to. Once we cross the line of paying, then the next question is how much and that will be a forever shifting line. The net result will be about the same amount of coverage for the ED at a much greater expense to the hospital. It is a slippery slope. I think that all of us owe society a reasonable donation of our services. If our own family members (needed) emergency care in another city, I would hope that a colleague would be willing to help. That means that I must be available here for his/her family if they need me here. If the donation of time and effort is greater than 3-6 nights/month (depending on volumes), then a financial guarantee for uncompensated care uncompensated care, n health care services provided by a hospital, physician, dental professional, or other health care professional for which no charge is made and for which no payment is expected. might be supported by the hospital combined with medical staff assistance. Perhaps each medical staff member pays $500 per year matched by the hospital to insure that at least a Medicare level payment is guaranteed beyond a basic level of professional gifting to the community. Don't do it--very slippery slope! 'Gonna have a revolution' We are increasingly hearing that our surgical specialists are itching itching or pruritus Stimulation of nerve endings in the skin, usually incited by histamine, that evokes a desire to scratch. It is often transient and easily relieved. Pathological itching with skin changes usually signals dermatologic disease. to give an ultimatum ultimatum (ŭl'tĭmā`təm), in international law, final, definitive terms submitted by one disputant nation to the other for immediate acceptance or rejection. to the hospital but it hasn't happened yet. The main factor that could trigger this is if we try to bring on individuals with "subsubspecialities" like breast surgery or anorectal a·no·rec·tal adj. Relating to the anus and the rectum. anorectal pertaining to, emanating from or affecting the anorectum. anorectal abscess see perianal fistula. surgery, whose scope of privileges would not make them capable of taking call (we have a general surgery call, but it would be rather silly and transparently manipulative ma·nip·u·la·tive adj. Serving, tending, or having the power to manipulate. n. Any of various objects designed to be moved or arranged by hand as a means of developing motor skills or understanding abstractions, especially in to have a breast surgery call or anorectal surgery call). The general surgeons, of whom there are only 3, taking call every 3rd night and working very hard, claim they would stop taking call if we credential individuals who in effect compete with them but who do not share the burden of call, and they have support in neurosurgery, ENT and orthopedics and we would face a revolution. More than money Not only do we have trouble with certain specialists taking ER call, but also accepting consults in the hospital. Even when paid, we still have problems with certain specialists responding to ER consults. The issue is not only money, but lifestyle, schedule disruptions, burn-out, etc. Old school I am still of the old-fashioned bias that taking ED call is part and parcel of being on the medical staff of the hospital. An alternative that the hospital has considered is hiring a number of specialists as full-time employees, with the stipulation An agreement between attorneys that concerns business before a court and is designed to simplify or shorten litigation and save costs. During the course of a civil lawsuit, criminal proceeding, or any other type of litigation, the opposing attorneys may come to an agreement that they take ED call as part of the job. The independent specialists have expressed displeasure with this approach, but have not suggested another alternative. Not worth it Most specialists would rather not take ER call because the pay is not worth the trouble. Paying specialists for call initially generated interest and an increased number in the call pool. However, as the realization hit that unattached patients unattached patient Patient care A Pt not known to have a regular attending physician when registered in an ER or other 'neutral' health care setting. See Flipping. Cf Attached patient. (especially trauma patients) require prolonged care with low to no reimbursement, specialists are again dropping out of ER call. Show me the money This topic really brings out the ugliest in our fellow doctors. Our hospital has been paying both specialists and PCPs to cover the ER. The fight comes to dividing up the stipend sti·pend n. A fixed and regular payment, such as a salary for services rendered or an allowance. [Middle English stipendie, from Old French, from Latin st . Each doctor feels that he/she should be paid a lot more at the expense of the others. Everyone has a sad story. The docs getting the biggest stipends seem to be the least happy about the whole thing. Breaking point This will break the bent backs of every trauma service in the country. Cool heads prevail This is an ethical as well as a financial issue. Physicians who reap the economic, cultural, interpersonal, and educational benefits of a particular community should also be leaders, concerned about the overall health and greater good of that community. Call should be reasonable. Hospitals and their administrators should be cognizant of the physical and emotional burden that call places on their physicians. Hospitals should also adopt hospitalist hos·pi·tal·ist n. A physician, usually an internist, who specializes in the care of hospitalized patients. hospitalist programs so that consultants can be consultants, rather than admitting physicians. If such a humane approach to call cannot be attained, then it is reasonable to ask for financial compensation, because that physician is more exposed to less productive work days. However, in that situation, all the money in the world cannot replace lost time with family or the absence of a reasonable quality of life. Physicians need to strongly make their case and not allow hospital administrators to vilify them internally or in the community for their unwillingness to take call under adverse conditions. Physicians in turn will lose in the court of public opinion if they frame their argument solely on the basis of compensation.
Do you have a problem getting specialists to take ER call at the
hospital(s) with which you are affiliated?
Response % Response Total
Yes 64% 521
No 29.2% 238
Don't know 3.7% 30
Not applicable 3.1% 25
Total Respondents 814
(skipped this question) 0
[c] ACPE 2005 On Call Survey
Does any hospital with which you are affiliated pay specialists to take
ER call?
Response % Response Total
Yes 46.6% 379
No 44.5% 362
Don't know 7.2% 59
Not applicable 1.7% 14
Total Respondents 814
(skipped this question) 0
[c] ACPE 2005 On Call Survey
If your hospital is NOT currently paying specialists to be on call, has
the idea of paying specialists been considered?
Response % Response Total
Yes 46.4% 338
No 19.1% 139
Don't know 11.5% 84
Not applicable 23% 168
Total Respondents 729
(skipped this question) 85
[c] ACPE 2005 On Call Survey
Bill Steiger is editor of The Physician Executive. |
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