201. It is a shame that medicine has come to this. That being said, our hospital will have to do it also as it has become a major issue with many of the Medical Staff.

202. Surgeons are paid to take trauma call. No other specialists are paid.

203. It's going to be necessary. The physician reimbursement in our market is so low that docs simply cannot afford to "give away" their time. Idealists, hospital administrators, and other fools may scream and holler that it's unethical, but a lot of docs don't want to take trauma/ER call. It's still a free country. Some hospitals in our area have tried to enforce "all medical staff will take ED call", with the result that specialists have moved to other hospitals. Trauma call has become so specialized now that virtually all hospitals have to pay general surgeons to take trauma call. Much fewer than half of all general surgeons are ATLS certified. A major patient safety issue is that ED/Trauma call can result in a tired surgeon the next day, and many surgeoons are unwilling to risk losing a night's sleep before doing major cases. So hospitals have not only to pay for the time involved, but also for the opportunity costs of leaving the next day open. Finally, the perceived malpractice risk of taking ED or trauma call has discouraged many physicians from continuing to participate. In high risk states like ours (Missouri), this is a major consideration. Putting it simply: if hospitals want to offer an ED and/or a trauma center, their medical staffs may not support that effort. In any case, few physicians are going to work for nothing.

204. The "problem" is understandable, but it is still somewhat dissappointing: the largest problems here seem to be with some of the high-end specialists, who, granted, are referral targets for the whole state (Maine) but who are already reimbursed far more than PCPs, who take ER call as a given part of the privilege and responsibility of Staff membership and do not expect subsidies from the hospital.

205. Rather than start down the road to pay for ER call, we are employing specialists. We get better coverage and ancillaries. We have hired neurosurgeons, general/vascular surgeons, pediatricians, neurologists. All the other groups have backed down and agreed not to ask for ER money, fearing we would hire specialists in their area and compete with them with our 50 primary care employed physicians. WE have calculated this is cheaper and more productive in the long run than paying every specialist for every night, and still having no loyalty or ancillaries. Of course we are in SOuth Florida, where malpractice is outrageous and costs of business and living is outrageous, so physicians are much more willing to go the salaried route.

206. hospital should pay MD to take ER call

207. Any payment to physicians for ER coverage should be for services provided, and not for 'CALL'... 24 hrs a day a physician is on 'CALL' for his/her group so 'CALL' per se is NOT a lifestyle changer. Primary care physicians and payors should make it clear to their colleagues that ER coverage is an expectation of referrals and business. The 'social contract' has NOT gone away ... we collectively have just allowed ourselves to 'blow it off' which is NOT consistent with the oath we have taken

208. Sooner or later specialists will have to be conpensated for taking ER call, especially those who now see their call being largely that of taking care of indigent or uninsured patients. Just look at the data on neurological surgeons!

209. We are opposed to the concept because there would be no way to contain the eventual costs of such a concession. It will be cheaper to hire hospital based specialists in the long run.

210. Even with adequate numbers of physicians within some specialities, practically all specialties are seeking payment for on call coverage.

211. We have talked a little about it but feel it would be like opening pandors box. Once you pay one group you may end up having to pay all groups. Also we feel it is a physician's responsibility to your community to help provide call coverage.

212. No problem as long as specialist is broadly defined, a neurosurgeon taking call is paid and a family physician taking call is paid -- the FP will probably do more work, but that aside, its extra work for any doc and it is only fair to pay all or none.

213. Reluctant to open the gates.

214. The demands keep on ratcheting up. The inability of hospitals and physicians to contract together creates a situation where hospital reimbursements may rise while physician's compensation stay the same or even fall. The physicians look to the hospital to make them whole.

215. Although the answer to first question is "NO", there is significant grumbling under the surface, suggesting that we may face the problem in the next 1-2 years.

216. For specialists on call for more than one hospital, getting paid for one and not the other raises serious ethical questions about response to one hospital vs. the other, as well as the potential of transferring patients for convenience.

217. no comments

218. We have few problems getting specialists to take ED call. Problems occur in the area of plastics. We have resolved the issue of NS ED call. We considered very briefly the option of paying for call coverage. We will not be paying for coverage for the time being.

219. We have a Level II Trauma Center. We are paying general surgeons to be trauam team leaders. In addition, neurosurgeons, orthopedics surgeons and plastic surgeons are paid to provide coverage for the Trauma Service. There is no payment for non-Trauma ER coverage.

220. Most specialists would rather not take ER call because the pay is not worth the trouble.

221. Taking ER call is a responsibility inherent in the practice of any specialty. To demand payment for this service is unconscionable if not unethical. Physicians who hold hospitals "hostage" over this issue by refusing to provide services if they are not paid should be reported to their respective specialty societies and the state medical boards for derelection of duty.

222. Our hospital's position on pay-for-call is that it is an uncontrollable expense that does not add to the scope of services or quality of care. In fact, the dollars diverted to pay-for-call reduce the ability to increase nursing staff and services.

223. when the hospital pays, the specialists take call, otherwise not

224. The availability of specialists and their demands for call pay has been the single most vexing part of my 17 year administrative caree. I'm increasingly convinced that we are approaching a meltdown of the emergency system--which will be the next sign of the unsustainablility of the American healthcare system.

225. We continue to consider taking ED call to be fair return for using the community supplied hospital facilities.

226. Present concern is having general surgeons provide the extra and more immediate needs of taking trauma call. We are exploring ways in which to reimburse these community based general surgeons for leading a trauma team/effort even when they do not have to provide immediate surgical services. Any thoughts, ideas or experiences would be of interest.

227. Had the trauma system held hostage by one group BUT it has worked out thay are acting better coverage is better and it is worth the money and not worth the fight to stop it. It was not a cancer that spread to every specialty just certain ones with significant call issues

228. I feel that should be part of hospital priviledges--the requirement to at least share call with similar specialists.

229. It is now a very complex issue. The reality is that in certain situations we must pay some specialist to provide outstanding care. I am at a Level 1 trauma center and we pay our trauma surgeons a relatively modest amount to be in house every night. Paying specialist is pandora's box in the end and it should be an exception not a rule and I think it goes against the duty's of being physciain.

230. EITHER PAY OR CLOSE THE ER PLASTIC HAND ENT EYE all resign the staff and work at the Surgicenters- or go courtesy and if

231. In our community, reasonable call by specialists is considered and accepted as a professional obligation of medical staff membership.

232. Our hospital requires specialists to take ER call as part of their credentialing privileges. As time has gone on, this is becoming increasingly problematic. Those that respond get overutilized, while those that don't, seldom get called. Much of the time, ER Calls end up being for patients without any insurance. So even when the specialist is diligent and comes in, they don't get any reimbursement. Further, EMTALA guidelines establish that the physician must provide follow-up visits, so they end up seeing the patient in the office without compensation. There is increased medical-legal liability since these patients often do not have an established relationship with a primary care physician.

233. Our network is only paying specialists currently for 'trauma' call but we are under increasing pressure from the OB/Gyn's, Ortho & Gen surgery to pay in our community facilities

234. 98% of admissions are from 1 multispecialty group affiliated with hospital. Tertiary care is shipped to local tertiary care center so some specialties not needed.

235. Specialists will not only shirk ER call if not paid, they will shirk ER call if not paid a significant stipend. some specialists are getting $1500 per call night because the number of uninsured patients is increasing at our hospital.

236. Wee do pay certain specialist to take Trauma Call as we are a county trauma center. ER call is not paid for any specialty at this time.

237. Trauma surgeons are compensated.

238. We do pay trauma surgeons and neurosurgeons to take trauma call, however, since response time is 15 minutes or less and often they don't wind up operating on these cases.

239. Glad you're focusing on this - it is becoming a very major issue.

240. Neurosurgery is always the biggest challenge.

241. This topic really brings out the ugliest in our fellow doctors. Our hospital has been paying both specialists and PCPs to cover the ER. The fight comes to dividing up the stipend. Each doctor feels that he/she should be paid a lot more at the expense of the others. Everyone has a sad story. The docs getting the biggest stipends seem to be the least happy about the whole thing.

242. We currently pay general surgeons for trauma call as they are supposed to make sure they are immediately available (not in routine surgery) during that period.

243. Disgusting - Physicians have forgotten what they are all about. Unfortunately the federal gov't has tied our hands in other ventures that might gain back some physician loyalty to our institutions.

244. Medical personnel are entitled to compensation based on time made available, just as any other professionals. Whether it is a retainer or an hourly rate, compensation is appropriate as long as the agreed upon access rules are followed.

245. Just beginning to discuss pay for call. It is a growing issue locally. Our three hospital system simply cannot afford to pay specialists of all kinds to take call and it will be extremely difficult to decide which, if any, of the specialties will need to be paid to be available. Of more utility would be devising ways to address the needs fo various specialties, ie, hospitalists, easier OR scheduling, faster lab turnarounds, without resorting to 'pay for call.'

246. Other hospitals in our area have gone down this "slippery slope". We have made it clear that we are adamantly opposed to this, as is our medical staff in general, and we will not pay for call.....any specialty. We have considered reimbursement to our physicians at some level for care of the uninsured seen through the ED, although we have not proceeded with this at this time, and likely will not.

247. large hospital er coverage is a cost of doing business not a community responsibility

248. Hospitals are most likely going to need to regularly pay specialists to come to the ER and assume the care of patients who have come to or been brought to their ER's. This will impact the hospitals' budgets, big time.

249. Inevitable, those administrators who refuse to consider it will be left behind

250. not necessary at my institution

251. In theory, this is a very slippery slope. Soon, everyone will feel that they need to get paid to cover call for the ER. The only situation that would keep you out of this situation is contracting with a specialty group to cover call for an essential service that does not currently have privileges at your facility.

252. hospitals dont want to pay for this, they regard it as an requirement for having medical staff appointments in certain specialties

253. We do pay orthopedic surgeons, general trauma surgeons, neurosurgeons, spine surgeons, and OMF surgeons for TRAUMA call

254. It is an unreasonable expectation to pay for ED call. Physicians use the hospital, its equipment to care for patients at no cost to them. What seems to be occuring now is that the On call physicians will only take the insured patients. Those w/ self pay or public aid status are being turned away unless they can pay cash (usually $300). This applies to both adults and pediatric patients. This I find reprehensible.

255. ONly Ortho is getting paid to be on call.

256. The only specialty we have had problems with is Psychiatry - due primarily to a combination of poor re-imbursement, carve outs from the major local insurer and an increasing number of psychiatrist leaving the inpatient arena for only outpatient services. We have only a geropsych unit and have had to pay for coverage for all other inpatient psych needs on the med/surg floors, as well as non-geropsych ED patients.

257. Neurosurgeons have approached the hospital for payment as it is a level 1 traume center and requires nsurg coverage. They are being spread thin,increasing liability insurance is forcing them to be aggressive here.

258. This is a growing problem in our community particularly with surgical specialties but also effecting medical specialties that have few physicians(I.D., Rheumatology & Endocrinology).

259. If physicians want to be on staff they should be mandated to take call until they reach a certain age. At our hospital that age is 62 with executive comm. approval.

260. 1. ERs need to be covered by board certified ER physicians. 2. If ERs have a heavy load of orthopedics or neuological injuries perhaps there needs to be extra training or certification. 3. Why would a hospital want to pay surgeons and internist who have established their own outpatient imaging centers that are in competion with the hospitals, an extra salary. 4. Why not reward the surgeons, internist, radiologist and other that are not in competion with the hospital with extra payment who back up the ER physicians.

261. Very bad idea with no discernible end. However, probably neccessary.

262. Don't do it -- very slippery slope!

263. We are not a trauma center, so trauma call is not an issue. Attending physicians are required to take ER call in their specialties if they want to be on Active Staff.

264. This is looming as the issue of the near future. Almost all specialities can opt out of call in some form. The needed specialities will be able toname a price. The downside for the physician is they will lose Med Staff backing if they become an employee and the hospitals would be idiots to not put restrective parameters if they have to pay. DOn't forget the residents coming out are not going to want to work the hours worked by physicians now.

265. Not a good idea

266. Specialists should quit whining and do their fair share like everyone else.

267. We're starting to get pointed inquiries about ED call pay from Surgery, Ob/Gyn, and neurosurgery.

268. I feel that it is the specialist's duty to take call at any hospital they have privileges.

269. not needed in our neck of the woods

270. I beleive in underserved areas it is the only way that you cn get specialists to take ER call. If Medicaid reimbursement was better for the specialists the hospitals would not have to deal with this problem.

271. I think it's reasonable since the majority of these patients are not covered by insurance and the liability is great.

272. only area they provide extra compensation is trauma

273. Even though the consult in the ER is minor, the specialist end up spending considerable time in travelling, seeing the patient and taking care of the problem. It's very time consuming and severely compromises the next day involving previously scheduled office or surgeries. There has to be an incentive for the specialist to run to the ER every time he/she gets summoned.

274. Currently doing this for pediatric orthopedics and general orthopedics. It appears that we will need to consider it for ENT in the near future.

275. we pay all of the specialist that take trauma call including General surgery, orthopedics, anesthesia,neurosurgery, hand surgery (separate from orhto), plastic surgery, ENT surgery, opthamology,pediatric surgery and oral surgery. Besides trauma call pay we are also paying primary care doctors for unassigned ER call as well as hiring 16 hopitalists to also cover unassigned ER call.

276. In our hospital, this is the responsibility attached to privileges.

277. The issue of specialists getting paid for call has surfaced in 2 instances in our system. 1. When manpower needs are such that call is needed nore than one night in 3, which is the local accepted standard. 2. One of our hospitals has started a Trauma Service(Level 2). The call requirement for this interferes with the elective work of some services like Orthopedics and Neurosurgery. These services have stated they would only cover trauma called if given additional compensation.

278. We pay for trauma call, but not routine ER call. It has come up recently though by our hand surgeons and by our oral surgeons.

279. Other financial incentives Malpractice payments / partial

280. It is starting with Neurosurgery, but everyone is expecting it to grow to other specialties.

281. So far we have been able to have our staff agree that call is a responsibility that one has with the privilege to practice at this facility.

282. The burden of call and the liklihood of being reimbursed for services is very differrent in some clinical scenarios than in others. Some climical programs, such as trauma care, have stringent availability rules, required to achieve program designation. When there is an imbalance of potential benefit to risk, it is reasonable to expect the transfer of funds from the agent most likely to benefit (hosptial), to the agent taking the risk (physician).

283. Paying specialists for call initially generated interest and an increase number in the call pool. However, as the realization hit that unattached patients (especially trauma patients) require prolonged care with low to no reimbursement, specialists are again dropping out of ER call.

284. Our medical staff overwhelmingly considers taking call as a "price" for being on the staff.

285. Specialists develop a practice in accepting referrals. Any emergency room patient who a specialist is asked to see, by nature becomes a referral. Not all of these patients are insured or have a means of payment. I believe speciaists are obligated to provide those services. This process is like life--- with the good kernels of wheat always come some chaff!

286. There is a $500 per day stipend for trauma surgeons. Otherwise there is none but others are pressuring us such as ortho and general surgery. Also cardiologists are asking for PAMI call pay.

287. Specialists are reimbursed at Medicare rates for treating unfunded patients. We do not pay stipends for simply being on call.

288. A pure nightmare. We had to pay a general surgeon in order to have full coverage throughout the month, but have so far been able to avoid others.

289. Our hospital pays some surgical, but no medical specialists to take call and is encountering increasing problems with this here in MD.

290. Professional blackamil has become a way of life for a lot of specialists. They are frequently the only game in town and the hospital realizes this. Our trauma program alone costs us 2 millon in on call fees which use to be provided free!!

291. pay for trauma coverage only (trauma surg, ortho and neurosurg)

292. Our bylaws require that all physicians on staff are required to take at least 10 days a month on call to include one weekend in order to cover their specialty. If we have a specialty that does not have enough practitioners to fill the entire call schedule, we will at times pay them extra money to cover extra days on call e.g. general surgery. Given that we are a small, rural hospital, there are still times when we do not have urology, ortho, or ENT coverage because we cannot expect any individual to do 24/7 call.

293. Most ER service calls are covered by full-time physicians employed by the hospital's faculty practice. Voluntary physicians are also required to share some of this burden. Most do not complain as long as the call schedule is not more than a few times per month.

294. Depends on the balance of supply and demand the leverage of the parties over other issues within the hospital / medical staff relationship.

295. It's 'double-dipping, and a blatant form of extortion!

296. We presently reimburse our Trauma surgeons for taking backup call because of coverage for 2 nearby Level III centers but this is above and beyond requirements for hospital privileges

297. The lack of on-call consultants to provide services to ED patients with emergency conditions (let alone for non-urgent referral services) is HUGE problem, the scale and scope affecting the very underpinnings of our entire emergency care and trauma response systems. It is national in dimension and affects nearly every Emergency Department in the country to one extent or another. Will this be a how-to type guide to the process or an exploration fot he problem? Can I forward this questionnaire to other physicians knowledgeable about the problem?

298. Large hospital ERs are not ERs. They are Trauma Centers and the hospitals make money on them. Staff physicians should not be expected to be on ER call as part of their staff responsibilities and it should not be considered part of a physicians's community responsibility.

299. In our area, specialists avoid call if they can because of uninsured pts, liability and impact on lifestyle. Even when they are on-call, oftentimes, especially surg subspecialists, will just direct the ED MDs to transfer the pt to a tertiary facility sight unseen. No more doing things for the greater good or community. Ironically, the MDs who take the brunt of the load are the PCPs - Pt has to come to you because we have no one to take them. Will they get paid for taking ER call too? I didn't think so.

300. At one of our hospitals we currently pay for psychiatrists only. At the other we do not pay for any (no inpatient psych there).