How new EMTALA guidelines regarding on-call physicians are giving hospitals greater flexibility to work around shortages. It’s 3 a.m. Do you know where your on-call physicians are? Hospitals are just now beginning to grasp the implications of changes to the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) that the Centers for Medicare and Medicaid Services approved in October.

Included in the FY2009 inpatient prospective payment system final rule, the CMS guidelines seek to clarify when and how unstable patients are transferred. If an unstable patient is to be transferred to a receiving facility with specialized capabilities, the receiving hospital has an EMTALA obligation to accept the patient, as long as the transfer is appropriate and the hospital has the capacity to treat the individual.

Also under the new rules, hospitals can meet the EMTALA requirement for maintaining an on-call physician list by participating in a formalized community call plan among hospitals. The list must be maintained “in accordance with the resources available to the hospital” and include sufficient guidance that a hospital is obligated to provide on-call services based on the resources it has available at the time, including the availability of specialists.

The sharing of on-call resources “sounds pretty good at first blush,” said Tony Colarossi, partner with the healthcare consulting business at Plante & Moran, a CPA and business consulting firm based in Southfield, Mich. Plante & Moran has healthcare clients in 22 states divided evenly between hospitals and senior care facilities.

Facilities will be consulting staff attorneys and proceeding cautiously because of three primary concerns, Colarossi said. First, antitrust issues could be raised because of collaboration between competing facilities. “I don’t think CMS has opined on that issue,” Colarossi said.

Second, facilities are concerned with remaining in compliance with HIPAA regulations as patients are transferred from one facility to another. Finally, physicians and practice groups will want hospitals to devise plans that share the burden of on-call coverage while giving physicians work/life balance.

Colarossi believes that CMS promulgates regulatory changes in good faith, providing as much clarity as possible. However, language in a regulation can often be interpreted in more than one way, leaving hospitals unsure of how to proceed. 

For example, can a specialist perform elective surgery while he’s on call? The consultant believes the new rules could facilitate a dialog that helps both hospitals that need on-call specialists and physicians and practice groups that provide these services.

However, drafting a plan that meets CMS muster while assuaging the various stakeholders will depend greatly on the population in the area. “What works in Detroit will be different from what works in Decatur, Ala.,” said Colarossi.

Bridging the gap

Dr. Steven Liu, a partner in a San Diego-based hospitalist group, says the use of hospitalists can help bridge the gap between patient arrival in the ED and specialty care.

“Hospitalists have had a moderate impact on EMTALA,” said Liu, who’s also chairman and chief medical officer at Atlanta-based Ingenious Med, which provides charge-capture software primarily for physicians who serve in-patients. “For medical, nonsurgical, and non-OB patients, hospitalists are good at stabilizing patients until a specialist can get there.”

In addition to hospitalists, Liu has seen a rise in other hospital-specific physicians such as laborists for OB/gyn cases, along with hospitalists specializing in surgery and neurology. “I wouldn’t be surprised if hospitals fund, subsidize, and promote this if physicians are interested in doing it,” said Liu.

Hospitals have wide leeway to follow EMTALA guidelines that can vary on the size of the facility, its location, and the number of specialists in the area, said Jeff Birch, an RN who works for Soyring Consulting, St. Petersburg, Fla.

In large metro areas, particularly those with a large university hospital, residents often are the first responders, an option not available in smaller hospitals or communities. With smaller facilities, hospitals will sometimes hire specialty physicians as hospital employees and rotate on-call duties among those in a particular specialty.

In areas with an emphasis on a particular specialty (think orthopedics in a resort area), hospitals can schedule on-call help during peak times, such as weekends or during ski season. Smaller hospitals in areas with few specialists can contract with a specialist to handle a “reasonable” number of     calls during a certain period of time. Contracts with specialists or groups can call for reimbursement on a case-by-case basis during the on-call period or a flat rate to be on call for a certain number of hours.

Hospitals can also share calls, negotiating the times when each accepts trauma cases and making sure local medical responders know when those times are. Specialists can be on call at two hospitals simultaneously. In those instances, CMS asks that both hospitals be informed and that the physician has a backup plan should two cases arise at the same time.

An emerging consideration is how on-call physicians are reimbursed for their services. An estimated 25% of patients are self-pay, which can mean difficulties getting paid for services rendered. 

Birch said flexibility is critical for hospitals to provide quality emergency medical care. “Smaller hospitals have a harder time attracting specialty physicians,” Birch said. “And physicians in private practice are reluctant to be on call because it can interfere with family life.” 


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