1. We use a rule of thumb: Hourly rate estimated based on practice productivity rate/4 (pay for one in four hours for call. Hourly rate estimated from expectd aveage income divided by work hours. If they get work to do we subtract their production from the call pay.

2. Prefer a model that supplements specialists for uncompensated care. Ultimately, however, it is the market that dictates what the specialists will be paid to take call.

3. Orhtopaedics, trauma call. level 2: $85/h (2,000/day) with cola +3,000/year stipend for education.

4. Our primary care physicians are being paid a small stipend to take "unassigned patient" call but our specialists aren't compensated for this coverage since they aren't the "front line" coverage.

5. A very bad idea to implement. Specialist are using this as blackmail to ensure coverage for their specialty. They should provide these services as part of their hospital priveledges.

6. Eventually, it is a real posssibility that to ensure adequate specialist cover for our departments and more especially our patients we will need to pay a stipend of sorts.

7. Our health system is moving in the direction of employing the physicians instead of paying for call

8. Sirs: The Physician Executive Magazine has presented specialists unwilling to take call as an ethical problem. This from the viewpoint of nonphysician executives who've never taken a day of call in their lives! I was in a bad situation where a nonphysician CEO could not understand why my Anesthesia group complained that our in-house call was every other day as conditions detiorated. My sympathies are with the specialists, not with the administrators in this case.

9. With declining physician reimbursement, and increasing numbers of uninsured/poorly insured individuals seeking ER treatment, the days of physicians "exposing" themselves to volumtary ER call are rapidly fading.

10. Our multispecialty group pay a bonus for onerous call to our physicians based on a formula developed by our Medical Director that takes into account call frequency and severity. We are looking to the hospital to begin to share the burden of this cost.

11. Specialists will bill for their visits. In case of trauma, our specialists went on strike, they were often stifed! The trauma unit was shut down. The hospital negotiated a payment system with certain coverage provisions to resolve the matter.Drs. should get paid for their services. Specialists should be on call.

12. UNinsured patients are the problem. You need incentives and the high risks and related malpractice costs: the alternative may be for hospitals to pay at least half the malpractice costs, only in medicine does a guy pay to assume risks and then get sued and bear the burden alone.

13. should only be done in extreme circumstances. our hospital pays for trauma surgeon coverage, as we are level one and they must be physically present. no other service gets paid, call is expected as part of being on staff.

14. a slippery slope

15. Given the declining reimbursement rates for elective surgery, the increasing medical liability premiums, and consistent medico-legal exposure from emergency room coverage, reimbursement for this activity is only fair.

16. We're a foundation system in a 100k town, which dampens the urgency for us, at least to date.

17. Could be a disaster for small/rural hospitals.

18. The Hospital created a joint vneture with a company called Emergency Associates. They all the doctors to take call for no PCP patients (with & without insurance). They usually get paid 120 to 130% of MC FFS. The specialists get paid the same way usually asa consultants. Some specialists like cardiologists get paid an stipend amount to take call for the Chest Pain ER call.

19. We have some specialists who would like to be paid, but we are holding the line. Our medical staff by-laws require the taking of call, with some exceptions for 1-2 person specialties. We had a little challenge recently when the Trauma director resigned, citing "inadequate reimbursement", but have since renegotiated that contract with a different member of the same group, without having to give away the farm. Our hospital simply doesn't have the funds to cover this expense. One of our sister hospitals 180 miles north is paying for some call, but I do not know details. I believe that taking call is part of our job, and should not be reimbursed separately.

20. I think it is outrageous to have to pay MD's to take emergency care of patients.

21. This is a very difficult and sometimes troubling issue for our organization. How do you determine which specialties get compensated for ER call? Our primary care and medical subspecialties provide ER call without compensation. However, our surgical specialists say they will not provide anymore coverage unless they are compensated. What do we tell out internists, family physicians and others who are willing to do this without compensation. This is a box I wish had not been opened.

22. My hospital requires manditory ER call in order to be on the staff up to the age of 55. It is a large City - county hospital and is the dominant hospital in the community. It has, on occasion, when certain critical specialities such as Neuro-surgery had no one under the age of 55, been required to pay for coverage. However, when a younger specialist comes to town, they no longer need to pay for coverage.

23. Multi hospital system where the Board and Medical staff leadership has takent the position that physicians need cover call only for their primary hosptial, and not any of the others. System campuses are now specializing, leaving no call coverage for in house consults for the non specialty services (such as a gyn consult in a cardiac, vascular and neurosurgery specialty hospital).

24. Sounds like a reality. We pay ER doctors themselves to "be available", whether or not they're actually seeing patients the entire time they are present there.

25. As lifestyle issues rise in importance, the unpredictability of ER call, especially for truama, becomes a significant negative in recruiting and retaining physicians.

26. Of course, hospitalists are increasingly employed by the hospital with responsibility for ER call built in to their job.

26. Of course, hospitalists are increasingly employed by the hospital with responsibility for ER call built in to their job.

27. We pay Trauma surgeons and has started a whole host of problems. Currently creative ways have been discussed but not implemented due to lack of political will and fiscal constraints.

28. The market is quickly establishing that hospitals must pay physicians to take ED call. However, this is no panacea--I refer you to the recent publication "Call Coverage Strategies" issued by the Clincal Advisory Board. Our hospital is paying some specialists as needed--but keeping it quiet so that they won't have to pay ALL specialists.

29. We have a limited number of sub-specialists on staff at our rural hospital. The Medical Staff feel that it is their responsibility as part of their being granted privileges at our hospital to cover the Emergency Department to the best of our ability. When a sub-specialty with only a single practitioner is unavailable for call we have a written transfer agreement with a larger institution to accept our patients (after a medical screening and stabilization in accordance with the EMTALA mandates). While there have been some rumblings about getting paid to take call for the most part they are in the minority. Thankfully, most of our Medical Staff still believe that physicians are here to "take care of all patients". I am proud to be a member of this Medical Staff as I know that this belief is not universal.

30. We are fortunate so far not to have to address this issue-but it likely will surface sooner or later

31. It is an obligation and responsibility for all physicians on the Medical Staff as a condition of privileges to take their appropriate back-up for the ER as defined by the Executive Committee.

33. It only makes sense.

34. For small specialty groups in a community, it seems quite reasonable to pay them for call because call is so frequent.

35. We have considered against this strategy...We have instead begun a Hospitalist program for "unclaimed patients" and other complex medical admissions. As a smaller semi-rural Hospital, 120 beds, we cannot be all things to all patients. We have instead decided to focus our areas of subspecialty excellence and work more closely with our Tertiary Center affiliate to lower barriers for expedited transfer; ie Neurosurgery, sick Peds, Cardiac PCI, complex trauma. This seems to be working well; and interestingly, we have also become a referral center for smaller hospitals down the food chain. We are easing transfers from them to our ICU and what surgical subspecialists we do have, esp. Ortho, Ophth., ENT.

36. if specialists are paid to do ER call then PCPs must also be given the same remuneration. The continued prejudice as to PCP vs specialists payments must end now.

37. This is no longer open to debate - it has become a fact of life. The previous linkage between membership on a medical staff and a requirement to take unassigned call became uncoupled 5-6 years ago in our market.

38. Getting them on the on-call list has not been a problem. Actually getting their assistance is a problem. Example: Opthamology- the physicians have become so specialized, some of the listed on-call people do not have the expertise or general ability to handle the patient's condition. GI has similar restrictions, although not as bad. Pedi vs. adult.

39. I believe it's an eventuality for all hospitals as physicians are more tightly contstrained for time and money.

40. Feel strongly it should be done...partic. for the folks who deal with emergencies such as General Surgeons

41. A payment plan must be equitable. We did a plan based on a blend of the Medicaid/Medicare reimbursement schedule. There were certain requirements that the specialists had to meet and were included in their contract. The plans were worked out with input from medical staff an specialists.

42. We have had to pay call for unassigned ob patients due to liability problems

43. I used to be guaranteed my customary fee for service at another hospital ER back in the 80's as an incentive to cover ER call if the patien did not have insurance, etc.

44. We currently pay for trauma call only

45. With the advent of Hospitalists, who provide 24 hour coverage at ourhospital, payment to the specialists is directed via the hospitalist network. Hospital pays the hospitalist and the specialtyied contract with them for the services. Reimbursement for non covered patient is 150% of MEdicare charges.

46. (My local hospital) does not pay certain doctors for call unless they are in the "clique". I,personally, find this highly discriminatory. If everyone were treated professionally, we'd have a better hospital. Paying for call sweetens the incentive for coverage.

47. Our system, staffed by ED MDs, has the generalists (Internists and Family Medicine MDs) take unattended call. The subspecialists are oncall for their specialty. We all consider this part of the cost of practicing medicine. To take care of the wheat, you have to sift through the chaff. Setting up a payment structure to do this would be exceedingly divisive and expensive for no added benefit.

48. I believe the best model is employment of critical specialists and inclusion of ER coverage in employment contracts.

49. Specialists have been paid for years. Currently a new group has come into the area and coverage of the call roster without payment is possible. The senior staff is resistant to both providing 24/7/365 coverage and not being paid. The connection between providing coverage and priveleges has long been lost, although the by-laws reflect this. Administration recommends a policy wherein services which require physicians to cover more then 6 nights/month will receive compensation.

50. It seems this will be "a slippery slope." If now orthopedists require payment, will ENT, neurosurgery, general surgery be far behind. As a Family Physician, I an required to take ER "No Doctor" call. Will I be able to ask for payment?

51. There seems to be a plethora of individuals clammoring for call in high reimbursement specialties. Others have been more difficult. We have never gotten to the point of needing to renumerate someone for merely taking call.

52. All the physicians on the hospital staff are members of the group practice and call, whether out patient, in patient, or ER is part of the job description.

53. This is becoming a very difficult area. With the emergence of the botique hospitals without ER's and competition to keep scarce specialties on staff, ER coverage as a condition of staff membership doesn't seem to be working. Trauma specialties and even OB/Gyn are paid by some of the hospitals in town.

54. Slippery slop concept as if specialist get paid why not primary care physicians.

55. We have had specialists push to get paid for ER call, then quit the staff when it didn't work in their favor. We are currently recruiting to replace these specialists to join the hospital owned group.

56. Only neurosurgery, orthopedics and specialties dealing with jaw fractures are being paid.

57. hospitals SHOULD pay the specialist to take call

58. Most problematic specialties are oral surgery, ENT, plastic surgery, OB, neurosurgery, and soon general surgery will probably be on the list.

59. The issue in our state, with 23% of its population uninsured, and another 21% on Medicaid, is having a sufficient pool and array of specialists to do follow up and management of patients after ED visits. The ED wait time in our urban, tertiary care facilities is very high, causing divert status to occur on a frequent basis due to overcrowding. It is very difficult to obtain rapid specialist response to ER requests for consultation for certain scarce specialties. Hospitals have had to resort to compensating these specialists to take ER call. However the root cause is not addressed by these measures - there's no primary care home for these uninsured, self pay, and Medicaid pending patients. Thus the ED utilization is therefore quite high, for things that could have been prevented, or managed in a primary care office.

60. We have had one or two subspecialty services where the issue came up, but we were able to work out arrangements of coverage that were acceptable without resorting to paying for the coverage.

61. We have had a group of neurosurgeons drop their privileges over "pay for ER call" issue.

62. The decision was not to pay medical staff physicians to take call. The hospital is helping with recruiting if more physicians in a specialty are needed. A hospitalist program is also starting soon to help relieve some of the pressure for unassigned patients.It was felt that if the hospital started to pay any group of specialists, it was just opening Pandora's Box and soon everyone would want to be paid. The hospital's bottom line is pretty thin already and paying for on-call services is not finalcially feasible at this time.

63. In the community in which we exist,there are facilities that pay certian groups to take call. What we have found is that the access to them is justa s difficult if not evevn more so. our CEO is evry meuch against that type of set up and we have been able to get the docs to work with us so far. just in case you would wonder about size, the hsopital of which i am a part is the largest not-for-profit inour dtate so there is a huge driving force economically to avoid this precedent.

64. We limit it to anesthesia, though others have asked. Anesthesia has special needs in our market and it's clear they simply can't make enough money to provide a competitive package given the demands of their exclusive contract. So our precedent is to compensate for on-call if they can't make MGMA median and have demands that are onorous.

65. There is payment for surgeons up to Medicare rates. Also, the hospital subsidizes the adult and pediatric hospitalists. However, there is no payment for the remainder of the medical staff who also take ER call or take the ER call that the hospitalists don't take if they are full/capped.

66. We pay only one specialty; there are inducements to other practices, that includes the understanding that they will take call.

67. While the subject has been broached by the orthopedists, the administration is adamant about not paying.

68. It makes sense for some specialties, I am not sure everyone has thought about where this is leading?

69. New paradigm: Before rendering care to save a life or releave emergent suffering, be sure you collect a fee.

70. Unfortunate, but probably inevitable consequence of recent developments in health care delivery (decreased reimbursement, increased risk and risk-adversity, absence of tort reform, etc., etc.).

71. There is no connection between pay and performance. The doctors take the call but still have an attitude that they are doing the patient and the hospital a favor. Furthermore, there is no good mechanism for following these patients up. The doctors want to treat them entirely in the inpatient setting and never set eyes on them again. These patients receive longer inpatient care in some circumstances when they could be outpatient if there were resources to pay for the follow up.

72. Our fear is opening Pandora's box and then having to pay ALL physicians to take ER call.

73. Inevitable especially for those specialties in short supply such as neurosurgery.

74. i work in an academic medical center. however, i also consult for the state department ofhealth regarding trauma systems and this an issue. specialists, especially ortho and neurosurgery are in short supply. general surgeons are getting older and do not want to take trauma call. this is on the verge of a crisis.

75. Seems like this will be a monstorous rent in the provision of care to patients. The safety net is vunerable enough without allowing specialists to decide when and for how much they will come to see patients in the ER. We already struggle with ortho, who often gives patients appointments for follow up and then refuse to see the patient in their office because they don't have insurance.

76. Since we are a large, academic tertiary referral cetner - we are finding many more patients being sent from other community hospitals who are having problems getting on-call coverage. We are also getting more patients who are under-funded, referred to our emergency department from outlying hospitals/communities

77. As the risk of practice escalates, and as payment for services decrease, ER's will have no choice but to reimburse specialists for taking call.

78. General Surgery. Internal medicine for admissions of "unattached" patients. The requirement by CMS to require back-up call if a surgical specialist is doing elective surgery will create new burdens for us. We are a 261-bed community hospital.

79. More and more of the specialists are requesting payment for call. The oral surgeons are trying to hijack the hospitals- $700/night with about 40 referrals yearly between two hospitals! Neurosurgeons are starting to not renew their privileges for craniotomies, just restricting themselves to back cases-creating a real bind!

80. This is not an acceptable sitruation for hospitals or the primary care physicians who are becoming more and more dependent on hospital partners to survive.

81. I answered yes to question 2 because we do pay surgical specialists to take trauma call. This has been a source of contention amongst the medical staff, but it was the only way to keep our level 1 trauma center open. The hospital does not pay anyone for routine ED call, although it has been discussed. Persohally, taking some ED call (* 1 week/month) is a small price to pay for having a well staffed and well equipped facility to practice in. It saddens me to see the lack of commitment to the basic principles of medicine that my peers and I made 25 years ago.

82. Most insured patients have a PCP who directs referrals, even from the accident room. The on call specialist is most often consulted for uninsured patients, who are also the most likely to later file a lawsuit. If such patients are to be accomidated at the larger accident rooms there must be some compensation for the risk and inconvenience (free anesthesia) involved in their care.

83. This seems to be an issue in some areas, and not others. For example, in one county in Maryland, to have hospital privileges, pediatricians must rotate and take call to cover the nursery and pediatric emergencies. However, trauma surgeons were able to shut down a trauma center because of call and compensation issues.

84. Once started there will be no looking back.

85. Paying specialists to take ER call is seen by the hospital as the "slippery slope" to financial disaster. Most physicians on staff have no problem taking ER call without specific compensation, since our patient payor mix is favorable and provides adequate compensation. Orthopedic surgeons and some disgruntled general surgeons disagree. As the number of indigent patients grows, this will be an issue.

86. In our state, Oregon, the burden of taking ER call is increasing due to the rising number of uninsured patients, the complexity of their problems, and the risk of liability. While some charity care is acceptable and part of a social contract, too much is unacceptable.

87. We currently pay for trauma call. It is a big issue. We also are discussing responsibility for in patient consults on uninsured and underinsured patients

88. Where will it stop?

89. The Emergency Room is an epicenter of actual and potential liability in my practice. It is also a major source of office, family and personal time loss. Our hospital is currently proposing compensation for ER call. If compensation does not evolve, I am history in the ER.

90. The hospital only pays the General Surgeon to take Trauma call. The State of Iowa has a trauma system set up which requries a specific time for the Trauma Surgeon or General Surgeon to repsond to a Trauma alert. Thus the payment for the Trauma coverage.

91. This situation needs a method of appropriate fee for service reimbursement, not hourly pay.

92. This is becoming a more widespread practice for a variety of reasons: Competition for specialists. Increasing burden of the uninsured. More frequent use of the emergency rooms.

93. Most of the current call payment is related to trauma call....for general surgeons, pulmonary, ortho, and neurosurgery. The primary care providers in our area are ready to revolt, and potentially drop their hospital privelages, due to the increaasing burden of "unassigned" patients, and the absence of any financial payments to them for ER call.....

94. Reluctantly we have started to pay general surgeons to cover 3rd day of call. Rules and Regs requires 1:3 call, and we have only 2 surgeons.

95. Unfortunately, with decreasing reimbursement to physicians, they are having to look at what they do as a business. This includes a hard look at the low paying hospital work. The only way it works is for hospitals to subsidize the work. A physician shortage is helping to create this as well.

96. I think it is a bad precedent.

97. It is a generational thing. The older generation feels that ED call is an obligation; the younger generation feels that it is an imposition.

98. Some of my partners want to discuss this with the hospital but no discussions to date.

99. The transition from the ideal concept that ER call is an obligation of medical memebrship to one of paying for availability is a costly one for hospitals caused by our governments not supporting appropriate physician reimbursement for their entitlement programs.

100. Before the days of managed care, fee reductions, and massive numbers of uninsured without governmental back-up, and significant malpractice premiums and associated litigation, specialists readily accepted providing ER coverage as a professional and community responsibility. With the advent of considering physician services another commodity, the fiscal has replaced the charitable. Expecting free services from these professionals is not longer reasonable since the medical profession has been converted into the healthcare industry and just another service provider. It's not just the economics but another reflection in the basic health provider model.