Hardball: Specialists are not taking ER calls unless they are reimbursed appropriately. “The study found that specialist physicians aren’t as interested in being on-call for emergency department duty for several reasons, including lack of reimbursement for uninsured patients, the perceived higher risk of malpractice litigation, time away from their practices, and late and unpredictable hours.
At Grandview and Southview, the plastic surgeons requested the hospitals reimburse them at 120 percent of what Medicare and Medicaid reimburse the hospitals for procedures. When the hospitals refused, the doctors pulled their services, McIntosh said.”
Related posts:
- How the general surgeon shortage affects patients
- Restricting resident work hours leads to a shortage of surgeons
- Plastic surgeons
- Emergency room specialist call
- Culture of surgery
- Plastic surgery: Buyer’s remorse
- This is your reward for continuing to take Medicaid patients
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{ 25 comments }
It isn’t just specialists. Internists who draw consults in the ER often don’t get paid anything if the patient is indigent and without coverage.
I see this all the time in my practice. For anyone called to the ER who isn’t working for the hospital, it is catch as catch can. Often you get nothing for your work except an account that is unpaid. Is there a higher risk of litigation there? I think so.
I don’t feel sorry for the hospitals. Those that serve large numbers of indigent and non-paying patients shouldn’t feel entitled to confiscate the labor of their medical staff any more than they should be entitled to make their nurses work for free. If they want to run a full-service emergency department with a deep bench of specialists, then they should pay for that. If that makes the ER a losing proposition, then close the ER or demand appropriate public financial support for what is usually an expensive public service.
Specialists aren’t slaves. They don’t owe anyone, hospitals or their patients, their labor for free.
What about the ER physician seeing the patient initially? They don’t get reimbursed either for this type of patient, yet the government mandates that all patients must recieve a “medical screening exam” in order to detect any “emergency medical conditions.” Furthermore, the hospital is required to provide specialist on-call coverage for these types of patients in whom an emergency medical condition is identified. (basically anyone requiring inpatient treatment for their illness).
You shouldn’t feel sorry for the hospitals or the specialists, you should feel sorry for the patients.
Closing the ER may seem like a fine solution, but where will you go when your parents are having chest pain, acute abdominal pain, vomiting their guts out at 3AM, or postoperative sudden shortness of breath the day after they are discharged from surgery? Or when your 2 year old asthmatic’s lips are turning blue? Or when your pregnant wife or daughter is having pain and cramping in her first trimester of pregnancy?
Like it or not, the ER is the entry way for nearly all acutely ill patients, rich or poor, with physician relatives or not. At my hospital, 70% of inpatients come through the ED. In many cases it is simply the fastest way of getting test results for emergent conditions, even though in the patient’s perspecive, it seems like “forever”. (Six hours is really pretty fast, when the alternative is an outpatient workup).
Kevin, you should really stop allowing anonymous comments on your blog, it’s just annoying that people won’t own their opinions
-Doc Shazam
I sympathise with the plight of the on call specialist to a degree. But not to the degree that they get paid as much as I do for working an entire shift in the ER just for being on call. Some of these prima donnas rarely get called and when they do they whining and moaning is pathetic. If I took the advice from some of these specialists at 0200 in the morning I would be in jail.
I have just seen this uninsured patient for free —- now it is time for you to earn your stipend you have extorted from the hospital.
“Kevin, you should really stop allowing anonymous comments on your blog, it’s just annoying that people won’t own their opinions
-Doc Shazam”
Doc Shaszam,you are just as anonymous to everybody as I am.
Just as CJD is still anonymous.
Or maybe you should have said, “allow only intelligent comments”.
To the second poster: unless your last name really is Shazam, why should you care whether other commentators sign in?
So you think it’s OK for the hospital to confiscate the labor of others simply beacuse the labor actually benefits someone (i.e., they need help), or use extortionate terms for medical staff membership that require unlimited unpaid work from specialists
for no better reason than it is convenient? Sounds like you don’t run a specialty practice.
My local hospital really doesn’t do much for me. I rarely have to operate there. When I do, my patients have to have insurance or other means to pay them.
They make money off the OR time; my service to the ER is not a quid pro quo arrangement, they benefit from my availability both ways.
I should feel sorry for the patients? Why? They are the ones who are getting what they “need” on an expedited basis with nothing being held up because of lack of coverage or inability to pay. When I go to the ER, I do the consultation. The last thing I get to see, after the care is delivered and the consultation paperwork is done, is the demographic facesheet. If it says “self-pay”, I usually know what that means. So I can only hope that the patient actually does pay but usually it means that that my billing office gets a song and dance and nothing else. And if you think anything meaningful comes out of a collections effort, then you don’t know anything about private practice.
We have a public that thinks it is entitled to what it needs when it needs it and the payment can wait. That kind of privilege is expensive. Fine, then let the public fairly pay the costs of that service, including the specialist doctors that come to see indigent patients in the ERs that are mandated by law to provide care.
People have all kinds of needs. Some people go hungry, and that is a shame. But we as a society don’t let the local government loot the local Safeway just because there is food there and not somewhere else. We issue food stamps to those we decide have a valid need. The same terms of fairness should apply to the services of doctors.
CH
Why the hell should we chastise Specialists who don’t want to come to the ER at ungodly hours to see uninsured patients, often drunk or high, not get paid, then get sued for their trouble. I’m an ER doc so I have to see these people, I don’t blame my colleagues who don’t want to put up with all this crap if they don’t have to. I think we’re headed towards what’s already happening: One big tertiary hospital with specialty residents (ENT, Ortho) sees all the “Specialty” needs patients at night and on weekends while the specialist goes the way of the Mom and Pop Store in the community hospital. When is the last time you saw an opthalmologist in your community ER at 3 am?
1:15
I don’t chastise them and I completely understand. Though at my hospital I have seen what some specialists have done as very close to extortion
the demographic sheet says “self pay” for the ER physician as well.
self pay= no pay.
Lawyers like to call there free work “pro bono”. To us it is just another day on the job.
The only difference is that the lawyer gets to decide when and for whom he works pro bono. Not so with the doctor in the ER.
CH
And we are just as likely to be sued by the family of the homeless drunk (who hasn’t spoken to the guy in 10 years but pops out of the woodwork when he croaks) as the insured breadwinner.
Hey Doctors!
If you can’t stand the heat, get out of the kitchen!
“Hey Doctors!
If you can’t stand the heat, get out of the kitchen!”
Spoken like a true moocher!
Hey Doctors!
If you can’t stand the heat, get out of the kitchen!”
I pray for you that you’re not in a state where this has already happened and your wife (or you) is trying to deliver a high risk pregnancy but has to travel 100 miles cause all the OB-GYN’s left.
“The only difference is that the lawyer gets to decide when and for whom he works pro bono. Not so with the doctor in the ER.”
It’s not pro bono for the physicians because they STILL GET PAID BY THE HOSPITAL.
Pro bono means work you do for free – no compensation.
“It’s not pro bono for the physicians because they STILL GET PAID BY THE HOSPITAL.”
Not true for the majority of physicians. I care for many indigent patients, with no reimburesment, and all the risk. My hospital does not pay me or any other doctors for care.
I have never been paid a cent by any hospital for my ER or inpatient work, or for being available on call. The same is true for most doctors, unless the hospital provides compensation for standing call, which is the subject of this thread.
Some people obviously don’t have a clue how medical compensation actually works. Capitalizing idiotic remarks only draws attention to their ignorance.
Hey Doctors!
Then don’t take calls for the ER and don’t see patients in the ER and don’t utilize the hospital. What’s hard about that? You have to be making some money somehow, otherwise you’ll all stop using these hospitals for your patients. This baffles me being a layman.
“It’s not pro bono for the physicians because they STILL GET PAID BY THE HOSPITAL.”
Said by someone who doesn’t know a thing about medical practice. I have worked as an ER physician for 15 years at multiple different hospitals. At none of them was there any arangement where I was paid by the hospital. Not a single cent. At my current hospital the “self pay” rate is about 25%
Hey Doctors!
Then don’t take calls for the ER and don’t see patients in the ER and don’t utilize the hospital. What’s hard about that? You have to be making some money somehow, otherwise you’ll all stop using these hospitals for your patients. This baffles me being a layman.
That is exactly what many doctors are doing!!!!! The layman is the one that will be hurt. When you seriously hurt or injured you will be taken to an ER. There may not be a plastic surgeon, hand surgeon, neurologist, orthopedist or whatever “ologist” to take care of whatever specialized problem that you have. You are likely to not even to get a board certified Emergency physician.
The ER is the “canary in the coalmine” for the collapse of the medical system.
“Then don’t take calls for the ER and don’t see patients in the ER and don’t utilize the hospital.”
I would love to be the ER doc on when this moron slices off 3 of his fingers using a power saw and I have to explain to him we have to ship him 150 miles away to the nearest hospital with a hand surgeon because we have none because they won’t take call due to the liability risk. He loses his limb due to time constraints, that’s “what’s so hard about that?”
To Anon 3:17 As long you inform the community that you don’t have certain services, we will accept. If you don’t have a hand specialist or an eye doctor to take care of emergencies then tell the community but don’t keep it a secret and pretend your hospital is capable of handiling it when it is not. I don’t want to wait in your ER for 3 hours and be told I have to be shipped to fix my hand. Well I can do the shipping myself. I don’t need a doctor for that. My point is that for all the whining that I’m hearing, you are all making money out of the present system or you just want more money for less work and less accountability. P.S. I’m not a moron. My IQ was 145 with the Stanford-Binet IQ test.
“As long you inform the community that you don’t have certain services, we will accept. If you don’t have a hand specialist or an eye doctor to take care of emergencies then tell the community but don’t keep it a secret and pretend your hospital is capable of handiling it when it is not.”
1:If you walk into an ER with a severe hand injury the ER has to deal with it even if that means shipping you to another ER out of city AND STATE (I have seen both). To tell someone waiting “we don’t have a hand surgeon go down to the next hospital” in the waiting room is not legal. CJD and Elliot would live to have an open and shut case like that.
2: Actually I have seen multiple family’s extreme frustation when I have to tell them we don’t have neurosurgery or hand surgery (including threats of legal action)
in the setting of a severe hand injury or a SDH (and
understandably so). They just “don’t accept it”. Of course you lose very critical time with transfers under these circumstances. Additionally we have neurosurgery 3-7 days per week and hand surgery 1-3 days per week on call in the ER how do you propose we tell the community which days we have this coverage?
It is more and more difficult to get certain subspecialty coverage now. Your testing score has very little to do with not understanding how ER’s work medically and legally.
Anon 1036- Your IQ is impressive but your ignorance of reality is appalling. With your IQ you can probably figure out that your hand is cut off, but if your problem is severe pain in the central part of your torso (a very common problem in any ER), we might need to run a few tests to see if you are having a heart attack, pneumonia, pancreatitis (from gallstones, alcohol, medication effect?), leaking aneurysm, ulcers, a hole in your esophagus??? Some of these require urgent surgery, some immediate use of potent medications through an IV, and some require only a prescription for some pills or just a few days of hospital confinement. Your trusty ER physician will do his best to figure out what is going on, while seeing a dozen or so patients who are dizzy, have headaches, twisted an ankle 4 days ago, or has acute lead poisoning (gunshot wound).
The point of this discussion is that when the ER doc (who has to evaluate everybody who walks in, is rolled in, or dumped at the door and gets paid only if you or your insurance company decide to pay him) reaches a conclusion that you need a surgeon/cardiologist/gastroenterologist/psychiatrist to take over to keep you alive and or pain-free, it would be nice for you if one of those folks were available. Increasingly, the cost/benefit equation for those highly trained and valuable specialists is coming down overwhelmingly on the side of not getting involved. Aside from clergy, there is no other profession that tasks itself with the responsibility of being there for you at all hours, no questions asked, payment if any to be determined at a later date, and to standards that are internationally acclaimed. Back when part of the deal was that you were grateful if we did our best, paid us the same way you paid your other debts (as much and as soon as you can), and were willing to accept a less than perfect outcome without filing suit, we were happy to keep up with our part of the bargain. Now that the government tells us that we have 30 minutes to get there or be fined $50K, lawyers offer to come to the hospital to help you file your lawsuit before your sutures are removed, no way to get you to pay your bills, and the contempt of a substantial segment of society, a lot of us are rethinking our position. That’s why you may have to drive 3 hours to get your hand fixed, by which time it may be too late. Some people think that this situation is a step backwards for American society, and are concerned enough to think about trying to reverse the trend. If you disagree, that is another great thing about America. My physician colleagues are happy to care for my family members at 3 am because they know that I will not sue them if things don’t turn out right, and I will be there for them if needed. None of us will be there for you.
“P.S. I’m not a moron. My IQ was 145 with the Stanford-Binet IQ test.”
Maybe you got shortchanged in humility and common sense? Would you still have enough IQ points left after a head injury to get your self to the proper hospital?
All kidding aside, I think you are right that it is proper to be able to know what services a hospital provides. I certainly don’t see deceptive advertising. Even at the large tertiary care ER’s I work at that have excellent specialty back up, the sign outside the ER says something simple like “Emergency Department: Physician on Duty, Basic Services Available”
I don’t know what kind of answer you would get if you asked a hospital what specialties they provide. For instance at the community hospital I work at there are neurolgists, gastroenterologists, hand surgeons, ENT physicians on hospital staff, but they do not participate in an ER call panel. So if you called the hospital and asked if there was ENT physicians on staff the answer would be YES, but if you came through the emergency room and needed one in an emergency at midnight the answer would be NO. It is also a moving target. For instance we have a plastic surgeon that will do ER back up call on Mo, Wed, Fri., on other days there is no coverage.
Hospitals are not likely to advertise what they DONT HAVE out of fear of commiting an EMTALA violation. This is federal law inacted in 1986 that has grown into a monster with lots of unintended consequences. Basically it says that every emergency department must evaluate any one presenting for the presence of any life or limb threatening condition regardless of nationality, insurance, how drunk and obnoxious they are, etc…
Telling you at the triage window that we don’t have a neurosurgeon for your head injury and that you should get in your car and go elsewhere is a clear violation of EMTALA law which has very serious consequences. This is investigated by the feds, results in a personal 50,000$ fine to the physician and the hospital, as well as risking all future payments from Medicare. So the feds have ERs and hospitals held by the balls on this one. It is an unfunded mandate, that in my opinion clearly delays care for some individuals and limits disclosure of what services are really available. So write your Congressman. We have lobbied and marched on the capital building in white coats but policy makers don’t get it yet.
It is not about the money. It is about patient care. I don’t think I would make less or more money if EMTALA wasn’t so cumbersome, or if there was more clear hospital service availability disclosure. However,it would clearly be better for patients if more specialists were willing to back up the ER. When I talk to them it all comes back to inconvenience, nonpayment, and liability, liability, liability.
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