1. Problems In Consultant Retention Prepared by: Dan Freess, MD PGY-3 University of Connecticut Member EMRA Health Policy Committee

2. Objectives Describe the problem of consultant retention Explain why it is occurring Describe solutions to the problem Review future political and policy changes relating to the problem

3. Introduction Increasingly common to have no on-call coverage –Nights more common –Some have days without specialist coverage Results: –Increased transfer of patients –Care by non-specialists when indicated IOM Report descirbes as: “one of the most troubling trends in emergency care.”

4. Introduction Recent Poll of ED Directors stated limited coverage in the following specialties: –38% Plastic Surgery –36% ENT –35% Dental –26% Psychiatry –23% Neurosurgery –18% Ophthalmology and Orthopedics 73% had a problem with at least one specialty

5. Why It Is Occurring 1.The transition away from hospital based practices: –No longer integral part of practices –Many no longer hold hospital privileges –Hospitals’ lose ability to force on-call coverage

6. Why It Is Occurring 2.The use of Surgicenters: –Allow specialists to perform procedures outside of the hospital OR –No Emergency Departments in these facilities –Cost shifting insured away from hospital –No call requirement

7. Why It Is Occurring 3.The increased availability of hospitalist services: –Specialists now act as consultants –Specialists will refuse call, instead seeing patients in the morning after stabilization

8. Why It Is Occurring 4.Competition for specialists: –Hospitals competing for scarce specialists –Difficulty in attracting and retaining specialists –Incentives for retention are often to exclude call –Worse at community and rural hospitals

9. Why It Is Occurring 5.Bargaining power of physician groups: –Trend toward large physician groups –More difficult for hospitals to negotiate for coverage. –For example, if all the neurosurgeons or ophthalmologist are in one group, it’s very difficulty for hospitals to say, “take call or else.” If the group says no, often there isn’t anyone else to attract.

10. Why It Is Occurring 6.Financial disincentives to taking call: –Increasingly large amounts of uncompensated care. –Consultants do not get direct state or federal reimbursement for uncompensated care like hospitals –Capitated or DRG-based insurance payments prevent specialist billing of on-call services.

11. Why It Is Occurring 7.Malpractice costs and liability: –On-call services are considered “high risk” –Providers are caring for patients they do not know, when the patients are very ill, often in a less than ideal environment.

12. Why It Is Occurring 8.The unfunded mandates of EMTALA: –Under most hospital staffing agreements, on- call specialists fall under this same mandate. –Unless specialists are paid by the hospital, this further creates a financial disincentive

13. Practice-Based Solutions Mandatory call for all staff physicians: –“no call, no privileges” policy –Requires hospitals coordinated regionally. –Drive more specialists to eliminate their hospital-based practices –Hardship on community and rural hospitals who could no longer negotiate call

14. Practice-Based Solutions Limit the time burden on consultants: –Hospital employed hospitalists and midlevels –Tele-medicine –Regionalized on-call staffing agreements

15. Practice-Based Solutions Limit the financial burden on consultants –On-call flat fees –On-call income guarantees –Productivity based stipends –Hospital-provided on-call liability coverage. **The current economic downturn has slowed the implementation of many of these plans.

16. Policy and Legislative Solutions On-call requirements for participation in Medicare: –Immediately increase the pool of on-call physicians. –May transition the on-call attrition rate to the Medicare attrition rate. –Would not affect pediatric specialist coverage.

17. Policy and Legislative Solutions On-call requirement for the licensing of specialty hospitals: –Partially eliminate specialists ability to have hospital-related practices without call. –Practical problems of policing –Problems with non-staff integration

18. Policy and Legislative Solutions On-call requirement for state licensing: –Possibly the simplest of all solutions. –Create interstate competition if not universal –Difficult to define what specialties would be required to take call

19. Policy and Legislative Solutions Governmental reimbursement or malpractice coverage for EMTALA mandated care: –If legally required to provide care, should be paid market value for their services –If physicians are legally required to care for patients, they should be provided liability coverage for treating those patients.

20. Conclusions Multifactorial Problem Broad impacts on hospitals and EDs There are no quick fixes All must work together to find solutions.

21. Further Information EMRA Advocacy Handbook www.acep.org > Practice Resources > Issues by Category > On-Call Specialty Shortage American College of Emergency Physicians Emergency Medicine Practice Committee. Availability of On-Call Specialists: An Information Paper. May 2005.

22. References 1.Menchine MD, Baraff LJ. On-Call specialists and higher level of care transfers in California emergency departments. Academic Emergency Medicine 2008; 15(4):329-336. 2.American College of Emergency Physicians Emergency Medicine Practice Committee. Availability of On-Call Specialists: An Information Paper. May 2005. 3.Freess D, Schlicher N (Ed.). “Problems of Consultant Retention.” EMRA Emergency Medicine Advocacy Handbook. 2009: EMRA; 24-28.