Transcript Problems In Consultant Retention

Problems In Consultant Retention
Prepared by:
Dan Freess, MD
PGY-3 University of Connecticut
Member EMRA Health Policy Committee
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
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.”
Introduction
• Recent Poll of ED Directors stated limited
coverage in the following specialties:
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38% Plastic Surgery
36% ENT
35% Dental
26% Psychiatry
23% Neurosurgery
18% Ophthalmology and Orthopedics
• 73% had a problem with at least one specialty
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
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
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
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
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.
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.
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.
Why It Is Occurring
8. The unfunded mandates of EMTALA:
– Under most hospital staffing agreements, oncall specialists fall under this same mandate.
– Unless specialists are paid by the hospital,
this further creates a financial disincentive
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
Practice-Based Solutions
• Limit the time burden on consultants:
– Hospital employed hospitalists and midlevels
– Tele-medicine
– Regionalized on-call staffing agreements
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.
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.
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
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
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.
Conclusions
• Multifactorial Problem
• Broad impacts on hospitals and EDs
• There are no quick fixes
• All must work together to find solutions.
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.
References
1.
2.
3.
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.
American College of Emergency Physicians
Emergency Medicine Practice Committee. Availability
of On-Call Specialists: An Information Paper. May
2005.
Freess D, Schlicher N (Ed.). “Problems of Consultant
Retention.” EMRA Emergency Medicine Advocacy
Handbook. 2009: EMRA; 24-28.