On-Call Issues Persist

I have been asked to speak at the Orthopaedic Trauma Association’s 2011 meeting in San Antonio on October 15. The Association recently polled its members asking them to identify a topic for the plenary session and orthopaedic on-call compensation emerged as a common concern. In preparing for the presentation, I came across the OTA On-Call Position Statement posed on OTA’s web site.

Excerpts from the statement read as follows: “The financial burden for the provision of emergency musculoskeletal services on call should be borne jointly by hospitals, the public and physicians. The challenges associated with disruption in medical practice and lifestyle are borne by the physicians alone. Therefore orthopaedic surgeons must be compensated for their on-call services. Payment for such services should reflect the work and liability associated with these services.”

On-call issues for hospitals and physicians have clearly evolved over time. Several market forces affect on-call coverage. These include: micro-specialization, quality of life for physicians, uncompensated care, physician shortages, emergency department utilization and malpractice. In my experience, micro-specialization, in particular, creates real and unique issues. For example, can or should an orthopaedic surgeon whose practice is limited to shoulder joint replacement be required to participate in general orthopaedic emergency department call? Can or should an ENT generalist take call for pediatric ENT cases?

Various legal and regulatory requirements also affect on-call coverage and compensation for call. Among these legal and regulatory requirements are: EMTALA, federal and state anti-kickback statutes and regulations, federal and state Stark laws, Medicare and Medicaid payment issues, tax issues for not for profit hospitals and anti-trust statutes and regulations. The Office of the Inspector General has also weighed in on on-call compensation in a number of Advisory Opinions.

There are a myriad of ways to structure on-call coverage and to determine the fair market value of call coverage and a substantial number of factors impacting the valuation of call coverage. Because decisions on whether to pay for on-call coverage and how much to pay are legally and politically complicated, it is important for providers to engage legal and valuation experts to provide guidance. Separate counsel may be required for hospitals, physicians and medical staffs as they will have competing and conflicting interests. Each solution to a hospital or a physician provider’s on-call concerns should be specifically designed to meet that provider’s needs. On-call coverage and compensation for call cannot be one size fits all.