101. Paying specialists might be necessary if you have no one on staff in a certain specialty.

102. We're a level one, urban trauma center. Ortho, Gen Surg, Neurosurg and Plastic Surg (at least) are paid to take call.

103. I work at an academic medical center. We get referrals from hospitals who can't get specialists to take call. We have begun to offer coverage (via referral to us) for smaller hospitals as a paid service.

104. Unlike Calif. we still feel an obligation to our hospital despite the onerous obligation of "unattached call.The expense to our small health authority hospital might be devestating.

105. we pay for general surgery, 2000/night neurosurg/2100/night and ortho 2000/ night We alternate call with another hospital in town

106. Should be done without pay as part of medical staff obligation to provide emergency care

107. as a community hospital in the inner city we can't afford to pay for on call so we rely on medical staff bylaws to force the docs to provide the coverage. However we have lost psychiatry and neurosurgery completely. Surgeons and Ob-gyn are very unhappy about having to take ER call

108. They should be treated like other primary care providers( internist, pediatrician ).

109. This is not an easy challenge given the shortage of specialties and the obvious shortage of reimbursement. This is one more examples of the "law or unintended consequences" of creating an ER specialty that competes with the community PCP under the subsidy of hospitals, and the shortage of PCP's who previously cared for the patients before they created the clogged ER.

110. I think this is a Pandora's box. Guaranteed payment for ER call undermines any presumption that physicians will help cover the needs of the community out of sense of professional responsibility. I am sympathetic to the concerns of physicians who feel ER call is too frequent, too onorous, to rife with litigation risks, and too often requires a physician to provide care outside of his/her scope of practice. Nevertheless, the community that provides us with the status and standard of living that we have (admittedly not what it was just 10 years ago) deserves some payback by physicians.

111. Any Specialists with high malpractice premiums should be compensated to offset the risk of taking emergency room call.

112. The hospital is currently considering paying certain "highly utilized" specialties (orthopedics, neurology, general surgery, GI) a flat fee for coverage of the ER in excess of the defined "community obligation" of 1 in 7 nights. The flat rate amount is yet to be negotiated. MDs want $1000, hospital wants to pay $500 or $250 for beeper plus FFS if called in on-site.

113. My personal sense is that this may make on-call a bit more palatable. Time away from practice and malpractice risk are increasingly becoming major impediments for practitioner willingness to take call, particularly if the most likely patients to be admitted to or consulted by them are uninsured....

114. When the outside trauma specialists wouldn't take call, the hospital hired their own team. This turned out to be very expensive for the hospital, but seemed to send the message to other groups that were considering asking for call money. I haven't heard of any disputes since.

115. The excessively onerous EMTALA provisions are causing physicians to re-assess the hospital privileges and the number of exposures to ER Call that they have. This may increase the frequency of which the remaining physicians take call. The Medical-legal climate is making physicians wary of who walks into the ER. Physicians are changing their by-laws to eliminate the mandatory call provisions by their speicalty. Some hospitals are paying for ER call to maintain certain service lines by doctors who would not necessarily practice in that given hospital. Some hospitals are hiring various emergency "hospitalists", e.g., OB, IM, Neonatalogists, Trauma Surgeons, specialty surgeons, who can be compensated from total revenue billing the patients seen in those product lines and still "make a profit" or still make "revenue in excess of expenses".

116. If we pay for critical coverage by specialists than we would feel obligated to pay for all ER coverage. We have alwys viewed this as a responisbilty incurred by being a member of the medical staff and obtaining the benefit of a place to practice and receive referrals.

117. Very close to being the only way to have coverage.

118. very familiar with this!....the trauma group, either through augmented cohesion or the emo- tional clout of their specialty, essentially went on strike over this.....and won BIG!... their threat was to cause enormous increase in the (state police monopoly of) helos transitting to an from us to urban baltimore....the state and the hospi tal combined to buy them off....they used to get the BILLINGS only, but now get hundreds an hour plus the billings. the other specialists either have not had the cahones, the cohesion, or the chance to play hard ball....the result is that all other specialists (including the impoverished pediatricians!) get nichts,niente,nada for the identical service pro vided.....not that with emtala, all specialists must be right on the case toot-sweet, so there is not a gradient in response demanded..... i was enraged!...how does the top 1-2% of the MEDICAL STAFF in terms of income (trauma, ortho, neurosurg) warrant SUBSIDY from the institution while the other 98% get not one thin dime?!.... all the other specialists (so far) are successfully bullied by the "credentials" aspect, ie you give us free coverage or we will bounce you off staff....sounds like extortion to me.

119. Unfortunately, I see this issue as evidence that some physicians wish to carve out niches that enhance their "life style" rather than sharing the obligation to care for patients.

120. We have tried top be creative and pay only for esential very hard to obtain servicesa dn not really name it call pay .

121. Rural community with limited specialist availability

122. Only orthopedic group in town is extort only other hospital in town by refusing to take ER call unless they are paid to.

123. As a large staff model HMO, it is an expectation for our specialist to cover ER call ( as part of their contract ). This is simply a part of the physician's responsibility.

124. Paying for ED call is inevitable.

125. We are a state psychiatric hospital only. We do pay psychiatrists to take call.

126. The specialists are on a call rota and this responsibility is part of their Alternative Funding plan. The government money for call is paid into the departmental funds as per the amount of call provide by the plan in negotiation with the hospital. We,Canadians, do everything differently.

127. We have been paying for trauma call, Gen Surgery, Ortho and Neurosurgery, but now all lines of service are requesting pay for call. With physicians margins being compressed, this becomes an attractive revenue source for what has been a professional/civic responsbility for community based physicians historically.

128. We have some holes in the schedule for Hand Surgery, and occasionally the schedule for Plastic Surgery. Obstetrics and Anesthesia are seeking Hospital support for on call.

129. We have developed a hospitalist program, which has solved some of these issues.

130. This is an ethical as well as a financial issue. Physicians who reap the economic, cultural, interpersonal, and educational benefits of a particular community should also be leaders, concerned about the overall health and greater good of that community. Call should be reasonable (no less than every 5th night; possibbly every 4th for less busy specialties). Hospitals and their administrators should be cognizant of the physical and emotional burden that call places on their phycisians. Hospitals should also adopt Hospitalist programs so that consultants can be consultants, rather than admitting physicians. If such a humane approach to call cannot be atained, then it is reasonable to ask for financial compensation, because that physician is more exposed to less productive work days. However, in that situation, all the money in the world cannot replace lost time with family or the abcsence of a reasonable quality of life. Physicians need to strongly make their case and not allow hospital administrators to villify them internally or in the community for their unwillingness to take call under adverse conditions. Physicians in turn will lose in the court of public opinion if they frame their argumunt solely on the basis of compensation.

131. The liability crisis is driving essential specialists away from the ER and into surgicenters wherever they can do it.

132. I must be old school because I believe taking ER call is part of a physician's obligation to his/her community. Hospitals keep their doors open to everyone regardless of their ability to pay as part of their community service. I am embarrassed to see physicians feel they are not responsible to provide any charity care to their fellow man.

133. In general, I would hope and expect that the specialists would take call as part of their professional duties. It's understandably frustrating, however, if they are taking call on patients from whom there is going to be no chance for remuneration. If a hospital is having a difficult time filling the roster then they should make sure they have appropriate bylaws in place for who should be active staff and have to take call vs who may be courtesy staff and avoid call.

134. Call is a responsibility of the House of Medicine.

135. Hospitals in this area are at this time unwilling to pay specialists for call. They have expanded their ER and Trauma capabilities, and hired hospitalists, which clearly increases the work load for specialists (and the number of unfunded patients seen)

136. the ones getting paid want more the ones rarely called in to ER want call pay for stand by the higher reimbursed specialties wish more dollars and larger share of payout the requested rates per hour more than cover the annual cost of full time surgeon(s)

137. great idea! Should also apply to any physician on ER call duty for the department, as hospitals are provided a service

138. The time is coming however, our institution is struggling with which specialties get paid and which don't. This is a very difficult topic. Of course, all want to be paid but this is not really practical.

139. Today's new physicians want the pay but not the work. Hospitals that rely on the "voluntary" medical staff may go the way of blacksmiths' shops.

140. Have made some of our specialists "full-time employees" to deal with problem areas and may have to add more to deal with this problem.

141. Our hospitals are seriously looking at this as an option. At times, some of the specialty services are not covered.

142. Our integrated foundation model employs most physicians. We pay by an RVU system, which is payer neutral, and the organization takes the risk of collections. Therefore, we don't specifically pay for call, with the exception of the trauma surgeons. The American College Of Surgeons, the accrediting body for trauma certification, requires that the trauma surgeon comes in for all traumas, even if it is an orthopedic or neurosurgical case. So we do pay them an annua stipend for that extra work.

143. Generally, the amounts asked by the specialists are exorbitant.

144. We are increasingly hearing that our surgical specialists are itching to give an ultimatum to the hospital but it hasn't happened yet. The main factor that could trigger this is if we try to bring on individuals with "sub-subspecialities" like breast surgery or anorectal surgery, whose scope of privileges would not make them capable of taking call (we have a general surgery call, but it would be rather silly and transparently manipulative to have a breast surgery call or anorectal surgery call). The general surgeons, of whom there are only 3, taking call every 3rd night and working very hard, claim they would stop taking call if we credential individuals who in effect compete with them but who do not share the burden of call, and they have support in neurosurgery, ENT and orthopedics and we would face a revolution. There is a certain fairness in this that is hard to fault, but it does have the effect of limiting the hospital's ability to expand its staff and presumably gain market share. In addition, Medicaid and self-pay (read non-pay) cases gall the surgeons, who have to commit time, effort and medicolegal risk to care for these patients with minimal or no compensation. As Medical Director, I have been trying to convince my CEO to find a way to pass some financial reward for individual no-pay cases to the surgeons, within legal constraints. We do have hospitalists who deflect effort from the Internists and FP's by taking their service cases, so why not something for the surgeons? However, there are complex financial, political and enurement issues. We have always felt that a flat payment for on-call will open up Pandora's box and be fiscally suicidal. The paradigm that "we're all in this together to serve the community" as a united hospital and medical staff no longer exists. It's pretty much "what have you done for me lately" and the docs increasingly describe their relationship with the hospital as "I make money for you" (and don't see that "you help me make money for myself"). The idea of service as a quid-pro-quo for the latter is gone. The reasons for this are fairly obvious, substantially the result of the fall in stature and income of practicing physicians and the increasingly complex comptetitive and regulatory environment in which they work, where they often see the hospital as a competitor or a disciplinarian rather than a partner or a source of opportunity. Their control of the hospital is minimal, as contrasted with the unregulated days of yore, when the administrator class in hospitals served the doctors rather than a huge regulatory/payor/competitive industry. In addition, a frequent side effect is unpleasant behavior on the part of the consultant/specialist when called by the ED or a hospitalist. This problem is another avatar of the perverse structure of the health care payment system, which has changed much faster than the delivery system. It's a rather clever strategy (perhaps unconscious but nevertheless real) of the payers and the trial bar to create dissention between different segments of the provider community. It enhances their control. I quote from George Orwell's "1984" (Part 3 Chapter 3) [Scene: O'Brien, agent of the Party, is torturing the protagonist Winston Smith]: 'The real power, the power we have to fight for night and day, is not power over things, but over men.' He paused, and for a moment assumed again his air of a schoolmaster questioning a promising pupil: 'How does one man assert his power over another, Winston?' Winston thought. 'By making him suffer,' he said. 'Exactly. By making him suffer. Obedience is not enough. Unless he is suffering, how can you be sure that he is obeying your will and not his own?"

145. What we really need is to get the primary care physician for a patient back involved in the ER care--they know the history, the problems, which often are very relevant in good care, and , without, are the cause of many quality problems. ER docs don't think about the intersection of primary care and ER care, and it is very relevant, particularly with patients with complicated of chronic illnesses.

146. it has become an issue due to our designation as a level II trauma center. the trauma surgeons and neurosurgeons receive stipends that, directly or indirectly, compensate them for their ED coverage and the orthopedists and others are raising questions about their compensation for ED coverage as well.

147. Bylaws require all members of the Medical Staff to take ER call for 20 years, or until age 55 with at least 5 years of service. The one specialist that we have to pay has already satisfied his Bylaws obligation, but is willing to help provide coverage for a fee.

148. In situations where my hospital might be of "secondary importance" to the physician, but where I need that service available for ER support, I think it may be reasonable to prvide a stipend for availability. It should not approach the level of compensation the physicians would receive if they wer looking at an annualized salary, but a recognition of their time spent. In fact, this model may be appropriate for ALL physicians on medical staff who are expected to cover the emergency room as part of a medical staff requirement.

149. It seems inconsistent that at the some facility a critical specialist can command a fee for taking call from home and other more common specialists (and primary care docs) take call as a matter of good hospital citizenship. This is even more remarkable when the critical specialist turfs cases to the other docs, e.g. neurosurgeon (paid to be on call) turfs the workup of an indigent shunted kid with emesis to the oncall generalist.

150. It has occurred i our area but on a limited basis. Our solution has been to allow cross coverage between specialists at neighboring hospitals and transferring pts if necessary.

151. We are considering paying Surgeons to take trauma call.

152. Specialists should not be paid to take call. On average they receive more compensation for a narrow range of services and in my experience manage a lot of the problems they are consulted over from the ER by phone or request next day office follow-up. This will only widen the divide between specialist and primary medical care.

153. Currently our ER is covered however another hospital in our community is not. This iscausing significant discontent because, due to EMTALS, much of their ER work is being transferred to us. Serious problems are looming.

154. I think it is a dangerous slippery slope to which we don't need to go close to. Once we cross the line of paying, then then next question is how much and that will be an forever shifting line. The net result will be about the same amount of coverage for the ED at a much greater expense to the hospital.

155. With all the issues confronting hospitals currently, this issue is clearly a top priority for many organizations attempting to ensure access to high quality care and maitain profitability. Subspecialty care is increasingly burdening the board rooms of many hospitals and seems to be growing from increasing malpractice premiums which most specialists seem to believe is heightened by taking ER call. Other tout that ER patients are more litigious than the general population. The issue, like many in our field, is complex and ultimately shouldered by the ED's and their patients.

156. the general surgeons and specialists do not want to take call any more,they have their own surgicenters and are not in as much need of the hospital services

157. I believe it would make it easier to have orthopaedic surgeons take call if they were compensated either directly or if the hospital assumed some burden for liability insurance coverage to offset the increased risk due to uncompensated care.

158. May be neccessary in some fields of extreme shortage like Nuerosurg.

159. we have not wanted to start paying for critically short specialties, ie neurosurgery, because of the slippery slope of then having to pay for everyone else.

160. In institutions with high rates of indigent and medicaid patients, revenues generated from patient care make it undesirable for many surgical specialists to take call. When the number of specialists on a given medical staff in a given specialty are very small, on-call status may total 10 nights per month. Financial inducements may be the only method to insure specialty availability.

161. there should be always a certified ER consultant in the ER to deal with real emergencies. A significant number of patients in our hospital that come to the ER can actually be seen in a low acuity set up where a specialist can do the job. A good triage system is essential. Definitly an ER consultant is prefered always,but ther are not enough of them.

162. It is impossible to get many of the sub-specialists to take call without paying them, because of the high incidence of indigents, without any coverage even Medicaid, is just too much. Also, the malpractice risks in taking care of ER drop-in patients is awful.

163. Our hospital pays two specialties they think they need, not the rest of us.

164. I don't think they should be paid.

165. My primary hospital is a Level III trauma center. They have trauma surgeons on call 24/7 and they get paid by the shift that they cover. The neurosurgeons and orthopedic surgeons are paid for ER coverage but I don't know of any other services.

166. Absolutely needs to happen. Physicians have incredible financial pressures to stay in practice. All they can sell is their time. There is no reason for physicans alone to shoulder the entire burden of community healthcare.

167. This is indicative of arrogant specialists.

168. One of the hospitals I work with paid for call for a very difficult specialty (neurosurgery). Essentially, "all hell broke loose" among the remainder of the medical staff all of whom thought they should be paid also. The administration quickly developed an alternative approach and plans not to pay for call for any specialty in the future.

169. Not only do we have trouble with certain specialists taking ER call, but also accepting consults in the hospital. Even when paid, we still have problems with certain specialists responding to ER consults. The issue is not only money, but lifestyle, schedule disruptions, burn-out, etc.

170. The hospital cannot afford to pay specialist to take call. Once you pay one specialist, all will demand the same. Then every year the rate will rise. Who thinks this will be affordable unless the reimbursement changes??

171. Large uninsured population in our area. Follow-up costs in the office (orthopaedics) are a major financial drain.

172. From my perspective there are so many issues with specialists receiving payment for call coverage, no one would want to open that bag of worms. If the specialists get paid, the generalists will want the same thing. Paying them would not entice them to take call, nor would it make it easier on the ER or the hospital. They will not be any less painful to deal with. In my opinion, most subspecialists in my hospital system have very little competition and they are not hungry for business or referrals. They don't want to grow practices--add partners, or increase market share. Consults and admissions are an annoyance to many of them. They consider the hospital to be privileged to have them on staff, not the other way around, and several often threaten to take their patients elsewhere (which they will not ever do).

173. It is only very selectively applied.

174. with the current climate of high liability and No reimbursement and senior mds only a significant incentive will keep the er covered by specialists

175. We are doing it for a number of specialties: Orthopedics, Neurosurgery, ENT. I think it is a bad precedent, as it will lead to all specialties demanding ED coverage pay. I am still of the old-fashioned bias that taking ED call is part and parcel of being on the medical staff of the hospital. An alternative that the hospital has considered is hiring a number of specialists as full-time employees, with the stipulation that they take ED call as part of the job. The independent specialists have expressed displeasure with this approach, but have not suggested another alternative.

176. We use this to cover high risk specialties, and also consider employment if necessary for coverage we need. It is part of doing business today - I see hospitalists, call pay, and MD employment as all necessary in 2005 to provide adequate coverage with necessary quality and safety for patients.

177. I think it is really sad that we pay subspecialists to take call but the primary care people are expected to do it for free. More inequities in a system already sick.

178. Another hospital in our area is paying millions to get their trauma call schedule covered and they still can't get neurosurgeons and orthos to step up. makes the physicians in our community look really bad......the impression is that they are holding out for more money. of course it is more complex than that, but paying for schedule coverage doesn't seem to be the full answer.

179. Should be part of hospital staff duties!

180. Only Trauma Surgeons receive a nightly call stipend.

181. ER call is a requirement of staff admitting privileges.

182. HOSPITAL HAS A TRAUMA PROGRAM THAT REQUIRES SPECIALIST COVERAGE AND PROVIDES THE FUNDING SOURCE USED FOR PAYMENT TO THE REQUIRED SURGICAL SPECIALISTS

183. I suspect this will ultimately come to pass. Most of the surgical sub-specialists in my field (Ear, Nose, & Throat), rarely need to use a hospital anymore. Surgeries are outpatient, primarily, ER referrals are no longer a way to "build" a practice, and most ER consults are on indigent, litiginous patients. It is even getting difficult to get inpatient consultations done in a timely fashion. On the otherhand, most inpatient consultations could easily be seen in the office on a "first-appointment available" basis, and hence are not really appropriate for on-call consultation to begin with.

184. Special circumstances relate to Plastic & Hand Surgery, Facial Trauma surgery; those specialties (it seems) where there is enough elective cash-basis only work to discourage the high-liability cases of low-paying, high litigation risks. How to create incentives for one specialty and ignore the others (Internal Med, Cardiology, Gen Surg, etc)?

185. It would be MUCH better than having the ER "specialists" we have now.

186. some specialists currently get paid a very large amount and some get nothing.. there is no rhyme or reason how the admistration currently decides this

187. Many more specialists would consider taking call if they were paid.

188. Paying only Neurosurgeons, General Surgeons, Vascular Surgeons, and Orthopedists. Pay 100 to 300 dollars per night.

189. Er Call is soooo much fun, why not share the wealth.

190. The amount we are paying is becoming an unacceptable drain on our resources. We do not have a viable alternative currently, but we are near a crisis situation at this time.

191. especially oral surgery and neurosurgery

192. It is a slippery slope. I think that all of us owe society a reasonable donation of our services. If our own family members were needing emergency care in another city, I would hope that a colleague would be willing to help. That means that I must be available here for his/her family if they need me here. If the donation of time and effort is greater than 3-6 nights/month(depending on volumes), then a financial guarantee for uncompensated care might be supported by the hospital combined with medical staff assistance . Perhaps each Med Staff member pays $500 per year matched by the hospital to insure that at least a Medicare level payment is guaranteed beyond a basic level of professional gifting to the community.

193. ED call disproportionally affects some specialists that are few in number but high in DEMAND. Opportunity costs, none existent ED reimbursements and high malpractice exposure also justifies such payments. Voluntary ED coverage will not keep these specialists alive in this environment

194. Hospitals, Taxpayers, Employers get ready, it is coming for sure.

195. Without some type of compensation for some specialties, we would not be able to provide full coverage.

196. I think it is a slippery slope to get on. I believe some form of compensation for uninsured/uncollected payments may be necessary. Once you start paying them to take call, it becomes an expected part of having their name on the schedule, even if they do nothing that day. Ultimately, the specialists begin extorting payments out of hospitals to keep them supporting the ER. Once that starts, then the price gets bid up. Better to stick with some guaranteed payment for actual services rendered, eg. Medicare rates for uninsured/uncollected. Then the rates are fixed by an external agency and not negotiable.

197. Primary Care Physicians do not get paid to take be in the call rotation or to take "no-doc" call. It is completely inappropriate that Specialists be paid for their on-call duties where PCP's are not. If the trend continues, what will stop all primary care and admitting physicans from demanding the same treatment?

198. Since ER call for my speciality ob/gyn involves frequent laboring patients the drs. in my spedciality have insisted on compensation for over a decade. For profit hospitals have no right to insist on voluntary on call medical staff when they profit greatly by their presence.

199. All medical and surgical specialties, including IM and FP are now paid for call.

200. All MDs who are obligated to take cal for ER or ER backup (no-doc patients) should be paid to take call (ie, internists, pediatricians, ob-gyn etc)