To the editor.

Thank you for your fine survey and articles in The Physician Executive May-June 2005 on the specialty back-up challenge facing hospitals, medical staffs, and their leaders. On call availability is a largely overlooked component of our patients' (and our own) access to emergency care under EMTALA.

Maureen Glabman's article highlighted the nearly $1 billion incurred by hospitals to sustain call panels through stipend payments. This may be an extremely conservative estimate. Recent California Medical Association and California Healthcare Association reports suggest over $300 million in annual stipend expenses for the state's approximately 10 percent share of national ED visits. Data is scarce, as hospitals and physicians have disincentive to report huge costs that are difficult to track or associate with actual patient services.

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The article lists several means to achieve the global goal of reliable call panel coverage. Though common, stipend payments are unproven as a long-term solution. Physicians still carry the financial risk and remain under-reimbursed for care provided to uninsured patients. Recurrent competition among specialties (and hospitals) for larger stipends is commonplace and unseemly. Hospital costs have no relationship to care provided, and no ceiling. Physician morale and hospital relationships may continue to deteriorate. Ultimately, despite costly investment, stipended call panels shrink and participating physicians' risk grows.

By contrast, in San Diego, Calif., we are fortunate to have sustained outstanding specialty back-up availability for over a dozen hospitals. A fee-for-service, on-call compensation model addresses specific determinants of physician and hospital satisfaction: paying physicians fairly, at market rates, while satisfying EMTALA and other compliance and patient care concerns for the hospital.

Dating to Sharp Memorial Hospital's 1991 refusal to institute call panel stipends, guaranteed productivity-based RVU compensation for physician services encourages physicians to remain active on ED back-up, though participation is voluntary. The collaborative response covers the ED and trauma service's "unassigned" population: uninsured or out-of-plan patients without access to a specialist.

Reimbursement rates are determined with the hospital to align incentives for all parties. Back-up physicians consistently see a significant increase in income for unassigned patients, eliminating their office billing cost and financial risk. Aggregate payout to the specialty physicians derives from net collections and hospital-shared funding agreements.

Physician satisfaction and patient specialty care access are exceptional. Another measure of the program's success is its extension to over 34 hospitals and 3000 contracted specialists nationwide. In line with recent EMTALA interpretations, the service may also facilitate regional call panel solutions within and across hospital systems.

Functioning call panels clearly offer more timely patient care, improve ED throughput, and reduce transfer risks.

As physician leaders must fight the battle for patients needing specialty care, responses will range across the spectrum of individual hospital to health system issues. Thank you for your attention to helping define the challenges facing this crucial aspect of our health care safety net.

Bradley Zlotnick, MD, FACEP 

Staff Emergency Physician

Sharp Memorial Hospital

San Diego, Calif.