ERCrisis:Calif. ERs can't get specialists to work on
call
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" "If we are going to start expecting hospitals to take over when government, health
plans and other third-party payers are supposed to pay for it, we might as well
throw out the entire system," Spurlock said. "
TA
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From the December 10, 1999 print edition
sacramento.bcentral.com
Emergency rooms can't get specialists to work on call
Kathy Robertson Staff Writer
Many California hospitals -- including some in Sacramento -- do not have
adequate physician back-up in their emergency rooms to meet the needs of their
communities, according to a task force formed to study the issue.
The problem is not with emergency room physicians, but what happens when a
patient needs a specialist in a hurry.
Fewer and fewer specialists are willing to come when called for help, because
being on-call to the ER is a nightmare job with little or no pay.
That puts emergency room doctors in a game of phone tag to find a surgeon or
other specialist who has the needed expertise -- and a desire to be there.
"I've personally seen patients come to harm," said a local emergency room
physician who asked to remain anonymous. "It's certainly been a serious problem
in Sacramento for a some time."
It's getting worse, according to a task force of doctors, hospital executives and
others formed by the California Medical Association and California Chapter of
the American College of Emergency Physicians.
They recommend a number of solutions. Doctors need to provide back-up when
appropriate, in exchange for fair pay by managed-care plans, the government and,
possibly, hospitals.
There's also support for a ballot initiative that seeks to garner part of the money
from California's settlement with the tobacco industry to augment health services
in the state -- including emergency room call.
Bad pay, awful hours: Federal law requires hospitals to treat everybody who
comes into the emergency room whether they can pay or not, but fails to provide
funding to do so. Hospitals used to simply shift costs to paying patients. That's
tougher to do under managed care, which pays hospitals a low, flat monthly rate.
And hospitals, many in financial trouble themselves, are in no position to pick up
the slack.
The contractual agreements between provider networks and health plans further
complicate the issue. Often, doctors called in are out of the payment loop.
"On-call physicians get hammered by a refusal ... to pay for their services," said
Dr. Loren Johnson, an emergency department physician at Sutter Davis Hospital
who co-chaired the task force. "It doesn't take many of those to talk physicians out
of getting up at 2 a.m. to ruin their day and not get paid.
"That kind of abuse and mistreatment," he added, "has destroyed our emergency
system."
Doctors also fear the risk of lawsuits.
In addition, a trend toward increased specialization among doctors means an
orthopedist who's called in for a pelvic injury may know more about knees and
feet. When there are few willing to take the call, the patient may not get the best
person to do the job.
"Doctors are getting more and more reluctant to take a call ... and care is
jeopardized by the delay," said Dr. Norm Label, president of Emergency
Physicians Medical Group in Sacramento.
There are only a handful of neurosurgeons in town to cover all the Sutter and
Mercy hospitals. "They are always on call. They have no private lives at all,"
said Bill Sandberg, executive director of the Sacramento-El Dorado Medical
Society and a member of the task force.
Kaiser doctors are employees within a closed medical system that typically treats
only its own patients. The University of California at Davis has a medical school
faculty and scores of interns and residents to provide back-up. It also gets
additional federal money to offset the large proportion of indigent patients.
Who should pay? Hospitals and health plans are sensitive about the issue. Both
groups participated in the task force to a degree. Hospitals refused to approve the
final report and health plans dropped out.
Hospitals shy away from any suggestion that their emergency rooms are not up to
snuff, but talk of stipends to doctors who perform back-up call makes them crazy.
"At between $500 to $1,000 a day times 365 days a year, the impact would be
humongous," Sandberg said.
"The worrisome part for hospitals is that ultimately, patient care is at risk -- and
that's something we all need to take very seriously," said Dr. Bruce Spurlock of
the California Healthcare Association and another co-chair of the task force.
He sees payment for back-up services as the responsibility of health plans and
government payers who contract with hospitals for care.
"If we are going to start expecting hospitals to take over when government, health
plans and other third-party payers are supposed to pay for it, we might as well
throw out the entire system," Spurlock said.
"It's an issue that involves physicians, hospitals and health plans -- but it's
primarily between hospitals and physicians," said Walter Zelman, executive
director of the California Association of Health Plans, a trade group.
The state Department of Health Services is looking into the issue, said spokesman
Ken August. And the feds are increasing oversight; the office of the inspector
general has made it clear that hospital audits must include a survey of back-up
services available for emergency care.
Local hospital officials had no comment. |
