AANS Neurosurgeon | Volume 28, Number 4, 2019


Neurosurgery Call: Challenges and Opportunities

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Emergency Department (ED) call has become an increasingly hot-button issue for many neurosurgeons whether in private practice as part of an academic practice or employed by a hospital system. Historically, physicians were expected to provide uncompensated call coverage as a condition for maintaining privileges or employment with the hospital. In recent years, this has changed as more physicians expect to be paid for these services. Notably, neurosurgeons are finding unpredictable ED call increasingly difficult to manage as it often disrupts their daily practice, elective surgery schedules and their ability to balance family and lifestyle commitments.

Increased Demand for Call
There is an increasing shortage of neurosurgeons willing to participate in ED call. This is exacerbated by increased ED utilization and physician shortage. Older neurosurgeons are electing to discontinue call after reaching a certain allowable age. Others are severing their hospital ties and obligations for less onerous office surgical suites, ambulatory surgery centers (ASCs) and specialty hospitals. While it appears overall ED capacity has contracted somewhat, new trauma centers and trauma center upgrades to Level 1 and 2 are on the rise. This puts greater pressure on those remaining, mostly younger, neurosurgeons to fill the growing gaps in coverage as well as creating both challenges and opportunities for neurosurgeons.

At the same time, neurosurgeons’ practice income and salaries continue to erode. Prospects for significant increases are difficult to ascertain with initiatives such as developing quality and value-based purchasing bonus initiatives, risk-based contracting, Accountable Care Organizations (ACOs) and shared savings plans.

Neurosurgeons are beginning to depend on call coverage compensation as an increasing component of their overall income. According to the Neurosurgery Executives’ Resource Value and Education Society (NERVES) Socio-economic Surveys, call compensation has increased in recent years, especially for Level 1 and 2 trauma centers. Of particular significance (from the most recent 2015 NERVES survey) was that median call pay as a percentage of median total neurosurgeon compensation was 20 percent. Given that one-fifth of a neurosurgeon’s income may be represented by call pay, neurosurgeons should pay close attention to how it is earned and the potential pitfalls of participation.

A valuable tool for every neurosurgeon, regardless of whether they are in private practice or in an employed situation, is the NERVES Socio-economic Survey. The survey is published every year by the NERVES organization and has consistently proved successful in reporting valuable practice data. On-call data has recently been improved to include not only comparative daily stipend rates for all regions of the U.S. but also more specificity in areas like frequency and specialty call. The latest edition, with data representing 90 individual practices and 692 neurosurgeons nationwide, is now out and available for purchase. If you participated in the survey, you may access it free of charge.

A Balancing Act
Today’s neurosurgeon must balance the various aspects of his or her practice, including reducing disruption to his or her daily practice, maintaining an acceptable work-life balance and supplementing a continually decreasing income. Call pay will continue to play an integral part in that balancing act. Evaluating your hospital’s call requirements, participating in call and negotiating pay for call or an employment agreement are extremely important to a neurosurgeon’s compensation and lifestyle.

The most common form of call pay is the daily stipend. In addition, there are other ways to supplement the daily stipend as set forth below. The following are the most common factors that affect reimbursement for call:

  • What is the Trauma Center status: Non-trauma, Level 1 or 2?
  • What is the hospital location, size and status: rural or metropolitan, tertiary facility or community hospital or critical access hospital?
  • What is the frequency of call: number of days and frequency; weekdays, weeknights, weekends and holidays?
  • What is the likelihood of being called in when on-call: Is the trauma center busy?
  • Which method of response required: personal presence vs. telephone consults; is there a defined response time?
  • What is the local payor mix: commercial, government and/or indigent mix? How cooperative is your hospital and medical staff leadership? Do they value neurosurgeon expertise or view the neurosurgeon as just a commodity?
  • What is the case mix acuity and intensity of care provided?
  • Restricted vs. unrestricted call, as it pertains to exclusivity and backup call requirements
  • Is back-up call required, and is there additional compensation for it?
  • What are local market rates and availability of neurosurgeons in the market area in comparison to demand?
  • What is the ability to bill for services provided in addition to the daily stipend?
  • Is there any reimbursement for services to indigent patients above the daily stipend: non-covered services, charity, self-pay or no pay?
  • What are the follow-up care requirements: in-patient or at the neurosurgeon’s office?
  • What is the malpractice risk? Does trauma call raise your premiums?
  • What is your employment status? If you are an employed neurosurgeon, is call part of your base salary, or is there extra pay for trauma call?
  • Do your hospital’s medical staff bylaws or your employment agreement require that you cover call even if there are other neurosurgeons paid for trauma call?
  • Will your hospital assist with paying malpractice insurance premiums if you work in a high-risk location?
  • Can you be paid for call in excess of the number of days you are expected to cover?
  • Will the daily stipend increase if you cover more days than expected?
  • Will the hospital provide ancillary staff to assist with phone calls, floor visits, staff and departmental interactions and be available to take first call and calls from non-physicians?
  • Is there support from hospitalists, intensivists, ED physicians and primary care providers (PCPs)?
  • How many hospitals will you cover? Multiple contracts will require coordination.
  • Will you be required to round on or provide inpatient consultations for other practices’ patients? If yes, will you be additionally compensated for this service?
  • Is there only primary call, or is there also specialty call, such as endovascular, and is it compensated differently?
  • Do staff bylaws allow departure from call requirements after reaching a certain age?

All call agreements should be either negotiated or evaluated with the assistance of your attorney. In addition, a study may be required at the onset of the initial term and possibly on renewal of the agreement or if there is a significant change in circumstances. Pay special attention to a call contract where the contract rate may significantly exceed fair market value or the current market rate. Data from the NERVES Socio-economic survey may provide additional support during and after the contract process.

1. https://oig.hhs.gov/fraud/docs/advisoryopinions/2012/AdvOpn12-15.pdf

The Neurosurgery Executives’ Resource Value & Education Society (NERVES) is an organization comprised of administrators and managers of neurosurgery practices across the U.S. They manage in all areas of neurosurgery including hospital based, private and academic practices. One of the many benefits of NERVES membership is access to the online listserv for all members. This listserv is a forum where any administrator or manager can ask questions of the entire membership and receive suggestions from other experienced members. It is a very active listserv with many postings each day. If your practice’s manager or administrator is not a member of NERVES, we hope that you will support or encourage them to join. Membership information can be found on the NERVES website.

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