Recognizing emergency needs within the community, neurosurgeons have traditionally accepted the task of participating on an emergency call roster. Flexibility and latitude in adjusting elective fee schedules were such that neurosurgeons in aggregate felt adequately compensated for this activity. As a greater percentage of patients have become covered by Medicare, Medicaid or tightly controlled managed care organizations or lost coverage altogether, this “cost shifting” in time and resources has become progressively more difficult. Many neurosurgeons now opt out of taking emergency call because they no longer perceive the risk/reward benefit to justify participation, and they simply cannot afford the loss of time and revenue this service entails. see note 1
Survey on ERs
A report from the Office of the Inspector General (OIG) of the Department of Health and Human Services in 1992 addressed the problem of specialty trauma call coverage in the nation’s emergency wards. Sixty-six percent of specialty physicians surveyed said that fear of increased malpractice liability persuaded them not to participate in on-call activities. Forty-seven percent of the physicians considered the COBRA laws a serious drawback to participation in emergency care, and 44 percent said that reimbursement for emergency services was inadequate.
The OIG concluded that many specialists did not want to participate in trauma care because they were engaged in more reliably compensated activities such as a limited private practice with solely elective surgery. Among all specialties surveyed, the problem was deemed worst for neurosurgery. Nearly half of the hospitals claiming to have neurosurgical services in their emergency departments had difficulty ensuring coverage. see note 2
In many communities, neurosurgeons are still expected to take call as a condition of medical staff membership. EMTALA regulations dictate that specialty availability on a hospital call schedule must extend to the hospital emergency room, obligating medical staff to trauma call. As hospital systems expand, market and in many cases profit from participation in trauma care delivery, the neurosurgeon’s time available for reliably compensated elective activities diminishes. The situation is disproportionately worsened by comparatively fewer available neurosurgeons relative to other high-demand trauma specialists (such as orthopedists). Even though neurosurgery is a small specialty, 57 percent of all high acuity trauma patients have some neurologic injury, and half of the 150,000 injury-related deaths that occur annually in the United States involve a serious brain injury that is primarily responsible for the patient’s demise. see note 3
Ideally, if a hospital has made a commitment to neurotrauma care, it is responsible for assuring neurosurgical availability without coercion. Maintaining a medical staff that enthusiastically supports a trauma program is not an easy assignment for the average community hospital. Contractually agreed upon call stipends are a reasonable way to assure adequate neurosurgical coverage by an institution that has made such a commitment.
Guaranteeing Availability
Neurosurgical availability is key to the success of a trauma program. Contracts between trauma hospitals and neurosurgeons can guarantee neurosurgical call availability, as well as mandate neurosurgical participation in quality assurance, education, protocol and program development, including trauma program outreach. Contracts improve the institution’s ability to meet EMTALA obligations, help assure the institution meets standards for trauma center verification, and improve coordination among trauma specialists.
In addition, the pending Balanced Budget Reform Act of 2000 includes a section (ยง204) that may allow hospitals to include on-call stipends in their hospital cost reports, whichwill provide the hospitals direct means of obtaining Medicare reimbursement for these expenses. Such contracts may provide the funds necessary to bring needed neurosurgical workforce to a community and may be the only way some neurosurgeons can afford to remain on a medical staff that requires participation in trauma.
Most disadvantages of a contract for neurotrauma coverage and program development that concern hospitals are more perceived than real. For example, the “snowball” effect of various other trauma specialties lining up for costly stipends has not materialized in hospitals that have instituted this practice for neurosurgery, except for trauma surgeons or trauma anesthesiologists that are required to cover in-house.
Thus estimating fair market value becomes critical in structuring a fair neurotrauma contract. The best yardstick of this value in a community may be local or regional data as long as demographics, trauma level, average ISS scores and the like are comparable.
Socioeconomic Factors
The Council of State Neurosurgical Societies (CSNS) recently completed a national Internet survey on key socioeconomic parameters of emergency neurosurgery and neurotrauma. The survey addressed the contractual and practical agreements between neurosurgeons and the hospitals and systems in which they practice. Ninety-one percent of the 263 respondents participated in trauma, about half urban, half suburban or rural. Sixty-two percent of respondents were in private practice, 28 percent in academics, 10 percent were salaried. Level 1 trauma centers accounted for 40 percent of the institutions, Level 2 about 30 percent and Level 3 and undesignated about 30 percent. About one in three respondents had a formal contract for neurotrauma coverage with their institution.
Based on comparisons to limited prior surveys, contractual arrangements with hospitals for the provision of neurotrauma care appear to be growing more prevalent.4,5 Stipends for neurosurgical trauma call coverage are more common than is generally thought. Nineteen percent of respondents in the CSNS survey were directly reimbursed for trauma call availability, and more than 31 percent received some form of financial incentive to participate, such as a guaranteed percentage of billings, hospital billing services, or malpractice coverage or supplementation. As expected, the specifics varied depending on hospital and community characteristics. Call stipends were about twice as frequent in private and salaried practices (21 percent) as in academic practices (11 percent), and tended to be in a lower range (mode $500-1000) in academics and salaried positions than in private practice (mode $1,000-1,500 range). As a general rule, call coverage was more frequent, less likely to be reimbursed (or reimbursed at a lower rate), and more likely to be mandatory at Level 3 and undesignated trauma centers than Level 1 or 2 centers.
More than 75 percent of all respondents reported call coverage to be mandatory at their institution. Half the unreimbursed respondents reported trauma call to be disruptive to their practices “most of the time,” while about a third reported the same level of disruption if stipends were in place. Hence, stipends appear to allow a practice to adjust in part to the additional time and resources required to participate in trauma call.
Creative Contracts
Neurosurgeons and their hospitals have developed a variety of creative arrangements for making trauma coverage both fiscally and physically responsible. Smaller community hospitals with a limited number of neurosurgeons have worked out cross coverage arrangements, periodic locum tenens or temporary transfer agreements to shield their neurosurgeons from the burden of excessive call requirements. Hospitals may bill patients directly and reimburse a guaranteed percentage of the neurosurgeon’s trauma receivables or simply provide billing services for the neurosurgeon. Hospitals may supply on-campus office space to allow for ready neurosurgicaal availability.
Since neurotrauma coverage is commonly perceived as increasing exposure to medico-legal liability, some institutions have agreed to pay for additional malpractice coverage and in some cases cover the entire amount. “Neurotrauma director” positions may be created for neurosurgeons most involved in program development, along with a negotiated annual consulting fee.
Typical contracts include several sections. Hospital obligations should be spelled out regarding equipment requirements (CT, MRI, microscope, etc.), staffing requirements (ED, ICU, OR, 24-hour radiology, etc.), and transfer agreements with other hospitals. Transfer agreements are ideally worked out in the context of a state or regional trauma system and should include pre-defined criteria to avoid EMTALA violations. Unavoidable unavailability of the surgeon and back-up call requirements, if necessary, should be addressed.
Trauma program requirements (trauma coordinator, secretarial support, etc.) are the hospital’s responsibility. The contract should define neurosurgical responsibilities such as frequency and duration of call, and back-up availability. These duties should be negotiated appropriate to trauma level, average acuity, trauma volume and available workforce. No neurosurgeon should be expected to cover a trauma service beyond the limits of a safe and reasonable workload. The contract should spell out required committee involvement, anticipated protocol development and updating, and expectations for participation in medical and nursing staff education and trauma outreach programs. Reimbursement type, amount and methodology, and whether the contract is with individuals or groups should be decided. Defining peer review and quality assurance parameters is important.
In summary, neurotrauma contracts can be a win-win. The hospital can reduce EMTALA exposure, improve performance in the trauma center verification process, and ensure neurosurgical participation in quality assurance and program development by supporting the concept of voluntary trauma contracts. For the neurosurgeon, these contracts help alleviate the double burden of providing mandatory uncompensated care even as reliably compensated elective practice is negatively impacted. Everyone negotiates for and knows what their agreed-upon responsibilities in the provision of trauma care will be. Excessive and unsafe workload on the neurosurgeon can be avoided. These legal agreements appear to be increasingly prevalent nationwide. Contractual relationships between neurotrauma centers and trauma neurosurgeons that include reimbursement for guaranteed availability will greatly facilitate neurosurgical participation in trauma care as they become common practice.
John McVicker, MD, is a senior partner of the Rocky Mountain Neurosurgical Alliance, Englewood, Colo.