Every day in the United States, nearly 300,000 patients request care at hospital emergency departments. Many have serious illnesses or injuries that require consultation with medical specialists, hospitalization and/or surgical intervention.
Yet the emergency and acute care system is in the midst of a growing crisis because of a shortage of specialists who are willing to provide on-call coverage to hospital emergency departments. Many hospitals have huge gaps in specialty services available to emergency patients, particularly in the surgical subspecialties such as neurosurgery. An increasing number of on-call specialists in the United States is not willing or able to provide on-call services to hospital emergency departments because of inadequate reimbursement, increased patient volumes, and demands on personal time.
“Physicians should not be forced to take excessive calls or provide disproportionate amounts of health care without compensation,” said Michael L. Carius, MD, FACEP, president of the American College of Emergency Physicians (ACEP). “However, to begin to solve the on-call problem, it is important that physicians and hospital medical staff recognize the shared ethical, moral and legal responsibilities to provide medical screening exams and to stabilize the emergency conditions of all patients who come to emergency departments.”
The Emergency Medical Treatment and Labor Act (EMTALA) places responsibility on hospitals to ensure the availability of emergency care for all who need it, regardless of their insurance status, citizenship or ability to pay. As part of this obligation, hospitals offering emergency care must make specialists and sub-specialists accessible to treat and stabilize emergency medical conditions. Any service that the hospital routinely provides on a scheduled basis must also be available for patients in the emergency department. On-call duties come with the privileges of practicing in hospitals, and on-call physicians are responsible for EMTALA compliance.
Medical staff by-laws, policies, rules and regulations, and procedures therefore must be consistent with EMTALA requirements and define the responsibility of on-call physicians to respond, examine and treat patients. Although no physician is required to be on-call at all times, hospitals must develop contingency plans for on-call coverage when particular specialties are not available, or on-call physicians cannot respond.
Under EMTALA, physicians who do not respond to a call can face a federal fine of up to $50,000 and exclusion from participation in the Medicare and Medicaid programs. Hospitals are required to report violations.
“EMTALA is not to blame for the difficulty emergency medicine professionals face with specialty backup, but the lack of funding for this mandated care is the underlying issue,” said Brent R. Asplin, MD, MPH, a member of ACEP’s Federal Governmental Affairs Committee. “This funding vacuum creates a climate in which it is difficult to support not only specialty backup, but also the care provided by emergency physicians and hospitals. It is not a question of whether providing this care is the right thing to do; it is a question of whether the current funding structure is sustainable over the long run. From what we are seeing today, clearly it is not.”
ACEP has been involved on many fronts to address issues related to implementation of EMTALA. ACEP was instrumental in having a study included in the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 to address the impact of EMTALA on hospitals, emergency physicians and on-call specialists.
Both the U.S. General Accounting Office (GAO) and the Department of Health and Human Services Office of Inspector General (OIG) continue to investigate the on-call problem. The GAO’s first report, which was released in June 2001, focused on EMTALA enforcement. Its next report will examine uncompensated care. ACEP will work closely with the GAO on this report.
“It is important fooor all specialty organizations to continue to articulate that the EMTALA mandate represents a commitment by the United States to provide universal access to all emergency care services, regardless of a person’s ability to pay,” said Dr. Carius. “ACEP believes that physicians should be compensated for their services, but that providing quality medical care for patients is the physician’s most important responsibility.”
The OIG also has found that many hospitals have difficulty filling on-call rosters, particularly in the area of neurosurgery, among other specialties. This is particularly problematic in states with high managed-care penetration or a large proportion of uninsured people.
Some managed care providers are denying coverage and delaying payments for emergency care services. For example, they may refuse to pay physicians who provide emergency care to patients who are out of network, or outside the managed care contract. If a medical specialist employed by a patient’s managed care organization is not available, hospitals are obligated under EMTALA to provide a specialist. However, managed care organizations are not required to pay for such services. While hospitals have absorbed those costs in the past by shifting them to patients who could pay, it increasingly has become difficult to recover those costs with the flat fees provided by managed care organizations.
When the California Medical Association and ACEP’s California Chapter recently studied the shortage of physicians willing to participate on hospital on-call panels, they found that 60 percent of hospitals had at least a “somewhat serious” problem with on-call coverage.
“Since neurosurgeons are a vital component of emergency care, their active participation on on-call backup panels is essential,” said Dr. Cairus. “Unfortunately there are just not enough neurosurgeons to provide on-call backup to every emergency department in the country. We hope specialists can work together in their local community to share the responsibility and burden of providing on-call backup to their local emergency departments to help keep America’s safety net from unraveling.”
Colleen Horn is public relations manager of the American College of Emergency Physicians.