Finding specialists to answer ED call getting even harder

Emergency departments are finding it increasingly difficult to get specialists to provide on-call coverage, a growing problem that threatens patient access to quality and timely care at hospitals, a new study said.

The study, released in November by the Center for Studying Health System Change, said hospitals have struggled during the past decade to get specialists to be on call at their EDs. But hospital executives and others interviewed for the report said the situation is worsening.

"Across the country, the traditional role of physicians taking call is unraveling," said study co-author Ann S. O'Malley, MD, a senior researcher at the center, which also studied on-call problems in 2005.

The new study found several reasons why specialists avoid taking call. Many physicians are shifting focus from hospitals to their practices and outpatient facilities as more procedures are done outside of hospitals. Treating ED patients takes time and money away from office practices.

"Doctors can get fees for the procedure and get facility fees for doing it at their own center. That's the biggest reason," said Dr. O'Malley, whose study is based on researchers' visits to 12 communities, including Boston, Cleveland, Indianapolis, Miami, Phoenix and Seattle.

Specialists also are concerned that providing ED treatment raises their liability exposure, the study said. In addition, many doctors believe payment for on-call care is inadequate.

Patients are feeling the impact: 21% of deaths or permanent injuries related to ED treatment delays are due to lack of available specialists, the study said. Some patients are transferred to other hospitals, and the increased workload on specialists who are willing to take call increases the potential for bad outcomes.

Hospitals are trying to remedy the problem through contracts with physician groups that require ED coverage, daily or monthly stipends to specialists, or payments to doctors for uninsured patients treated while on call, according to the study. One hospital guarantees doctors Medicare reimbursement rates plus 20% for treating some uninsured patients.

Previous studies have detailed similar on-call troubles. A 2005 survey by the American College of Emergency Physicians said on-call coverage had deteriorated, and 73% of ED medical directors reported inadequate specialist coverage, up from 67% in 2004.

This year, the ACEP created a task force to recommend improvements.

"This is really a big issue," said ACEP President Linda L. Lawrence, MD, of Fairfield, Calif. "Lack of on-call coverage affects all patients."