On-Call Specialty Shortage Resources
Report on Strategic Priorities for a Comprehensive On-Call Plan - January 2008
An ACEP task force was appointed in 2007 to address a Council Resolution calling for design of a comprehensive plan to address the decreasing availability of on-call specialty capabilities. The task force prioritized strategies for ACEP to adopt, many in concert with other organizations, to increase public and policy maker awareness of needed relief.
Workforce Presentation from 2009 Leadership and Advocacy Conference
Edward Salsberg, Director of the Center for Workforce Studies, has generously shared his presentation materials on workforce trends with ACEP.
April, 2006 On-Call Specialist Coverage In U.S. Emergency Department (PDF)
2004 On-Call Specialist Coverage in U.S. Emergency Departments
ACEP: Policy on EMTALA and On-call Responsibility for Emergency Department Patients. Revised and approved by ACEP Board of Directors April 2006
ACEP Emergency Medicine Practice Committee. May 2005.
"Availability of On-Call Specialists" Information paper outlines the causes of the crisis and options for mitigating the crisis.
ACEP/RWJ On-Call Surveys. 2004 & 2005 sample surveys of ED medical directors to assess the effects of current regulations and the practice climate on the availability of medical specialists who provide care in the nation’s emergency departments. By 2005, nearly 75% of directors reported problems with inadequate on-call availability.
American College of Surgeons. "Emergency Workforce Summit" March 9, 2006. Chicago. Surgical subspecialties shared results of individual society member surveys including ACS, Neurosurgeons and plastic surgeons. 75% say that their hospitals require call and 75% say they take call. ACS members reported that 16% had liability coverage provided by hospitals, and 4% said their liability insurers offered discounts to those limiting or discontinuing call.
American College of Surgeons.
"A Growing Crisis in Patient Access to Emergency Surgical Care." Based on meetings hosted 3/05 and 3/06. ACS article discussing the surgical workforce shortage of surgical specialists available to cover EDs. ACS supports more regionalization and federal tort liability protection for on-call specialists.
California HealthCare Foundation. January 2005. "On-Call Physicians at California Emergency Departments: Problems and Potential Solutions." Authors of study found no single solution will resolve the on-call problems, but a variety of strategies including: Legislated payment standards; Regional competitive contracting; mandatory on-call duty for hospital medical staffs; tier-based stipends or productivity-based guarantees; greater use of hospitalists or other qualified medical personnel; regional physician pools for high demand, and transfer agreements among hospitals.
California State Legislature, Senate Office of Research: AB 2611 Working Group. 2002. "Stretched Thin: Growing Gaps in California’s Emergency Room Backup System." A compendium of principles to improve on-call situation in CA.
Center for Studying Health System Change. November 20, 2007. Hospital Emergency On-Call Coverage: Is There a Doctor in the House? Recent site visits to 12 metropolitan areas document worsening problem. http://www.hschange.org/CONTENT/956/
Center for Information Technology Leadership. "The Value of Provider to Provider Telehealth Technologies" Sponsored by the U. TX AT&T Center for Telehealth, this study estimates savings from real time specialist intervention on ED transports between hospitals, nursing homes, prisons, etc. While it is not an "on-call" article per se, it may represent a glimpse of benefits of evolving commmunication technology.
U.S. DHHS. Final Report of the EMTALA Technical Advisory Group. April 2008. The 19-member TAG chaired by David Seigel, MD, FACEP, was empaneled for 30 months to provide recommendations to the Secretary DHHS on how to improve EMTALA operations. The on-call issue was discussed at length but not resolved, but many other recommendations including payment for EMTALA services would help.
U.S. DHHS. Office of the Inspector General. September 27, 2007. Advisory Opinion 07-10 is the first to address a hospital's payment to physicians for providing on-call and indigent care services. In the opinion, the OIG declined to impose sanctions on the hospital applicant for paying most physician specialists on the hospital's medical staff in return for their on-call and indigent care services. Advisory opinions are rendered on a case by case basis.
General Accounting Office. (GAO) August 2003. "Medical Malpractice: Implications of Rising Premiums on Access to Health Care." Report found that liability crisis influences physicians to leave certain states and/or restrict their services to certain procedures for purposes of on-call.
Florida Medical Association, Robert G. Brooks, MD, MBA; Nir Menachemi, PhD, MPH White Paper: Access to Specialty Care April 2007.
Johnson, L; Taylor, T; Lev, R. Annals of Emergency Medicine. May 2001. "The emergency department on-call backup crisis: Finding remedies for a serious public health problem." Report of the on-call crisis, stipends cost California hospitals an estimated $200 million annually (as of 2000).
Kane, C. AMA Physician Marketplace Report.. February 2003. "The Impact of EMTALA on Physician Practices." AMA’s final national sample survey from 2001 estimated that emergency physicians had $138,000 of bad debt in 2000.
Lott, J. Hospital Association of Southern California. September 11, 2006. "Emergency Room On Call Physician Coverage on Life Support." Forty percent of physicians have curtailed or completely stopped taking call. Less than one-third of hospitals now mandate call as a condition of medical staff participation. Recognition of on-call shortage.
Rudkin, S; Oman, J; Langdorf, M; Hill, M; Bauche, J; Kivela, P; Johnson, L. Amer. J. of Emergency Medicine. Vol 22 No. 7 November 2004. "The State of ED On-Call Coverage in California." (Abstract). A survey of CAL/ACEP members reflected access to certain specialists, especially for uninsured patients was difficult, in spite of 70% of hospitals requiring call by their medical staffs.
US Court of Appeals for the 10th Circuit; St. Anthony Hospital v. US DHHS. August 28, 2002. Federal Circuit Court upholds finding and CMPs imposed against St. Anthony’s for refusing to take a transfer of a patient needing a higher level of care. Hospital was cited w/ a violation of EMTALA’s "reverse-dumping" provisions.
Tables/Statistics on Physician Supply
Association of American Medical Colleges (AAMC). November 2009.
"Recent Studies and Reports on Physician Shortages in the US"
AAMC. "Help Wanted: More U.S. Doctors." Projections Indicate America Will Face Shortage of M.D.s by 2020.
AAMC. January 2006. "Key Physician Data by State."
Health Resources and Services Administration (HRSA). "Physician Supply and Demand: Projections to 2020." Projected growth between 2005 and 2020.
Regional News Articles
Anderson, J. ACEP News. April 2007. "More Hospitals Pay To Keep On-Call Specialists." Describes the position faced by many hospitals in paying stipends for on-call specialists. (Tomar)
Horvath, S. (Originally published in the Palm Beach Post. February 15, 2005.) "Palm Beach Commission looks at problems and solutions of ED on call crisis." Recognition that Palm Beach Co. has a more severe on-call environment, an Emergency Specialty Care Task Force — including hospital executives, medical society members, doctors and Health Care District of Palm Beach County officials was appointed to make recommendations including regionalizing call for county.
Kisken, T. (Originally published in the Ventura County Star. March 4, 2007.) "Specialists seek on-call payments." Hospital payments to on-call doctors grow while availability continues to dwindle at Ventura County (CA) hospitals.
McClain, Carla. Arizona Daily Star. September 19, 2007. "Tucson ERs Lack Docs You May Need" A well-insured patient with a serious leg injury cannot get a plastic surgeon. All of the local plastic surgeons perform only cosmetic services.
"Oregon Hospital Groups Make ER Palatable." Article on compensating on-call doctors.
Pensa, P. South Florida Sun-Sentinel. February 1, 2008. "Representatives of four Florida hospitals reject plan to bring more specialists into EDs". Efforts to bring more specialists into hospital" EDs "hit a major snag...when hospital officials rejected a 'Band-Aid' solution to this healthcare crisis" in Fla. Dr. Michael Collins, emergency department director at Jupiter Medical Center, said, "Putting hospital call schedules online might pass state and federal regulators but it would not win support from the doctors involved." Physicians "and hospital executives crafted a plan for Palm Beach County's 13 hospitals to voluntarily join a regional system" into which "[h]ospitals would pay...because they would not have their own full complement of surgeons. An online call schedule was envisioned." However, "[r]epresentatives of four hospitals -- Jupiter Medical, Delray Medical Center, Boca Raton Community Hospital, and JFK Medical Center -- rejected the online call schedule as a first step."
Pensa, P. South Florida Sun-Sentinel. January 4, 2007. "Emergency care plan released." Article reports efforts in Palm Beach Co. to address the on-call crisis with rotating coverage at participating hospitals. The County’s Health District would maintain a master call schedule online so EDs and EMS would know where to send patients.
Rowland, C. Boston Globe. April 15, 2007. "In shift, doctors ‘on call’ get pay." Article about a greater number of Massachusetts hospitals paying on-call physicians.
Sawanda, K. Pacific Business News. October 4, 2004. "On-call doctors charge hospitals millions." Article discussing the increasing financial strain on hospitals paying on-call physicians in Hawaii.
Wolfe, K. Palm Beach Post. December 7, 2004. "Florida dealing with lack of specialists Doctors say ER proposal stopgap, at best." State health officials proposed a system to let EMS teams know which hospitals had specialists on call.
Lee, Christopher, Washington Post. December 21, 2007. "On-Call Specialists At Emergency Rooms Harder to Find, Keep"
The Advisory Board. Call Coverage Strategies. 2007. The first part of this presentation documents the problems with which we are all well-acquainted, and the latter slides describe efforts of individual hospitals or communities to provide practical approaches to address the problems.
Reisdorf, E. MD, FACEP, "The Physician Workforce Shortage in Michigan". Presentation of US and MI physician supply/need/distribution by a member of the Council on Graduate Medical Education (COGME), a federally appointed body that advises DHHS and Congress on medical workforce issues. COGME’s 16th Report forecasts a physician shortage of 85,000 by 2020. MI is forecast to have a higher deficit than national average.
Taylor, T. 2005 Interim AMA Organized Medical Staff Section Assembly. November 4, 2005. "Innovative Solutions to On-Call ED Specialty Coverage." Presentation by Dr. Todd Taylor outlining strategies including: ensuring that health plan contracts include specialty coverage in ED; hospitals contract/hire specialty groups to cover ED; impose legislative solutions.
For additional information about on-call specialty shortage resources, contact Barbara Tomar in ACEP's Washington, DC office at 800-320-0610, ext 3017.