Home Forums Discussions General Discussion Back-up medical call

This is not related to EMRs but has been a hot topic for the past two decades in our medical community. The pool of physicians willing to have hospital privileges have diminished to a point that a few of us private doctors (and there are only a few left standing) find ourselves providing hospital mandated freebie care. For every one of my patient I admit to the hospital, I'm having to admit and take care of 2.5 backup patients (most of whom have no intention of reimbursement--they come from the Indian Health Service, City jail, County jail, FQHC facility with no hospital coverage, illegals with no papers, people kicked out of other medical facilities, druggies, etc.). I am at a point where I am thinking of dropping hospital privileges (which would put me at risk of being taken off of some insurance company contracts that mandate 24 hour coverage and active hospital privileges). I have also thought about filing a legal action for the hospital mandating such coverage as antitrust (as their requirement is driving non-hospital owned physicians into the ground). A physician (who is paid by the hospital as some quality control person) has warned me that if I discuss dropping privileges with other physicians, it would in itself be antitrust violation. Imagine that!

I'm wondering if there are more enlightened medical communities out there in ACville that have developed a more equitable and reasonable way of dealing with back up call. Is there anyone actually getting paid for call (our hospital has stated that paying us for call would be a Stark violation, although they pay the orthopedic surgeons thousands of dollars per day of call!).

Does the hospital think starting a DO school in Yakima will provide them a steady stream of Morlocks to do their evil bidding? : )

Personally, I say screw the guy who basically threatened antitrust. It may not be good self-preservation, but I am fed up with being treated this way. It's like the HIPAA police. Bring 'em on. Bring on antitrust. I would think they would have bigger fish to try. I would stand out on the hospital grounds with a megaphone and talk to any doctor about dropping Medicaid or forming a union.

Roy:

First, the financial side: have you sat down and done a really detailed cost/benefit analysis of what it would *actually* cost you to drop your hospital privileges?

Time is money, and it sounds like the time you spend at the hospital is poorly-paying time. All other variables aside, dropping the hospital work would seem to free up time for better-paying pursuits.

Second, the political side: as long as you continue to play by the hospital's rules, you are taking the financial hit for them, and insulating them from the problem. There is no incentive for them to make this situation better as long as you are willing to do what they want. As things stand now, the problem is *your* problem, not theirs.

However, the moment you (and your "band of brothers") drop out, this problem becomes the *hospital's* problem, not yours.

You don't have to discuss it with the other docs in town. Just do it for yourself. If asked, explain why; I don't think anyone could call that a conspiracy. If your position is logical, it will be even more logical for those remaining in the call schedule after you are gone, and they will likely follow suit.

You don't have to drop out in a mean way; it can be done with sincerely expressed regrets. You don't have to burn any bridges. If the problem ever gets solved, you could re-apply for privileges, if you haven't already found a better way of life.

Amazingdave,
You know... that's a funny comment. This non-profit hospital had just donated $1,000,000 (that's right, one million dollar) to this for-profit DO medical school (which has yet to open it's door or accept one student). Speak about diversion of community funds! And the CEO (according to Form 990 from about three fiscal years ago) has made over that amount a year for compensation. They do these things by making us minions perform psychiatric consultations, medical consultation, hospital admission without compensating us. In fact, the hospital charge the doctors for potato chips or locally picked fruit or a bottle of water in the doctor's lounge.
Is this typical of other hospitals around the region?

Roy,

In my community NP's do not have any sort of hospital privileges and I've not found it a problem with insurances. I do have to document who will admit for me...but then our hospital does have a hospitalist group.

The physician who sees my Mom dropped his hospital privileges as well and he also has had no problems with insurances as far as I can tell. When the issue of hospital came up this week (for Mom), he was just going to call "some friends" and have Mom admitted if necessary (it wasn't).

Where I live, ARNP and PAs can perform virtually any function (their scope is definitely much wider than the family practitioner). But there's a catch... there are no self-employed ARNP with hospital privileges. There is no prohibition against ARNP having hosptial privileges, however, there hasn't been any ARNP approve for hospital privileges unless there is a physician taking responsibility for the ARNP.
Does your hospitalist group require all patients be seen by them or can you occasionally see your own patient (i.e. newborns, pediatrics and some special patient). I don't like the idea of not having the ability to see patients in the hospital (although I may be forced to drop privileges with back-up call being so onerous).

Roy,

I've had "very limited" privileges in the past when I was working for the hospital in the old stand-alone urgent care. It was the only way I was able to see pts there, as well as the ER (where I sometimes saw urgent care folks if there was not adequate staff for urgent care). In addition it allowed me to round on the "long term care" unit only (no longer in operation).

Our hospital and the hospitalist group is not exactly NP friendly - especially to those who are working independently. My previous experience has always been good, but then I was not working independently then. It's really a shame...I cannot even send someone over to the infusion center when all they need is a bit of fluid or maybe a unit of blood - my folks all have to go through the ER. The only way I would be able to see my own patients is to have someone "take responsibility" for this rouge NP...something I doubt I will do (long rather bitter, and totally unnecessary story. I should clarify however that I am not opposed to working/collaborating with the right physician – I’ve just not met the right one in a long time).

Of course, there's nothing that says that you can't go by and pay your hospitalized patients a social call, if you like. I often drop in on my patients post-operatively, even when I'm not consulted to follow them medically.

You can even be involved in their care, paging the hospitalist and inquiring after your patient's well-being, and making sure they're being looked after properly. They don't stop being your patient.

I dropped my active staff privileges about 4 years ago after finally becoming intolerant of the "free" care I was providing to the unassigned ER patients. The hospital staff had bellowed about this to the administration for years but no one on either side was willing to do anything about it. I was tired of being inundated by patients with whom I had no relationship. It was not uncommon to walk into the hospital the morning after your ER call and have 8 unassigned patients in addition to the 5-10 of your own to see. I was simply getting too old for this. The primary care docs had tried for years to convince the hospital it needed to hire its own hospitalist group to handle these patients but they refused. Why shouldn't they when they could force us (as a mandate to maintainig our active staff priviliges) to do it for them.
After much soul-searching and after getting no satisfaction from the hospital administration I decided to give up my hospital privileges. I notified my patients and in fact did lose several because of this. But, I countered this by extending my office hours and providing in-depth preventive medical care as well as plenty of time for each office visit. Patients who were hesitant at first have now commented how much better care they are getting from me because I am not rushing out to the hospital during office hours, or taking calls from nurses and I almost always manage to stay on schedule. They like the fact that I can now sit down with them and chat for a while before addressing their problems.
Soon after I left the hospital, another and then another and then several other primary care docs did the same. Initially I enlisted the services of a colleague who accepted and cared for my hospital patients. We had shared call for many years so we were both comfortable with the situation. And he was honorable enough not to refer my patients back to himself upon discharge.
After so many of the primary care docs gave up their hospital practice, the hospital was forced to hire a group of hospitalists. This was fortunate for me as the doc who was covering my hospital patients left town for another job. So, I now use the hospitalists and, for the most part, have been pleased.
There is no question I took a financial "hit" when I gave up the hospital. However, I never dreamed I would be so much more happy doing office only. I had originally thought I would return to the hospital when they finally solved the ER unassigned issue but now....no way. My lifestyle is so much better I cannot begin to tell you. I can actually sleep all night without rolling out of bed or throwing the pager across the room. I can actually go to a movie or on a trail ride without the endless calls. I have found a renewed joy for medicine because I can take more time with my office patients. I do not think I will ever go back. There are some things more important than money.
My patients have adjusted nicely. I think they understand that, there comes a time in everybody's life when we have to pull back. I would highly recommend it to those now contemplating giving up hospital practice. As a primary care physician in this day and age, I found I really wasn't much more than the "doctor of record" for my hospital patients. And, just another target for the lawyers. Most of the hospital care is provided by the specialists now days....took me a while to realize it and longer to accept it but my happiness now far outweighs that kick in the ribs.

Leslie

Yep.. go ahead and arrest me - just be sure when you do it that all four major networks are there, that the video lands on YouTube, and that Limbaugh, Hannity, and Beck all know about it.

They say that s**t rolls downhill. I'm tired of the doctors being the ones it lands on.

V.

Leslie,

My partner and I are two of the four remaining docs who do our own hospital admissions at Saratoga Hospital. The hospitalists admit for everybody else. Our patients love that we're the ones taking care of them, and I don't have to admit people I don't know.

Saratoga requires us to see people discharged either from the ER or the hospital on our "on call" day for one follow up visit. Some we accept as patients, some we make very clear that we are not establishing an ongoing relationship with them, and they accept that, or we won't see them.

At least for now, this works.

We gave up admitting at Glens Falls hospital because the on-call was just abusive. The ER doctors were often rude and overly demanding. The nurses in the ER wouldn't take admit orders, and the floor nurse getting the patient doesn't really know what transpired in the ER. The medical director at that time claimed he was powerless to change anything.

One afternoon a woman high on meth and oxycodone drove her car into a tree. She was combative, and by the time they wanted me to admit her they had put her under anesthesia and had her on a vent. I don't do critical care - and managing a patient on a vent and drips to me is critical care. We had our critical care back-up doc handle the admit, but he wasn't happy about it. When the next day the ER doc who handled this patient told me that **I** needed to find a better way to handle patients like that, I let the medical director of the hospital know we were done. Wasn't worth the abuse.

<sigh>


V.

Question on this subjest:
Can two docs who are in the same field (both FP's in this case) still be eachother's call coverage if they have very different panel's of insurance that they do or don't PAR with??? As I've stated before we are seriously considering withdrawing from most if not all plans. Between CHITT portals and managed care busy work that grows larger by the day with no compensation it seems more and more the only real logical solution to this nightmare.

So if one doc hardly PAR's with any products while the other PAR's with many more products can they really be call coverage for one another? I always thought that "swimming buddies" had to have very similar panels so they could then see one another's patients in a pinch. Especially in primary care where there is this stupid "declare a PCP" thing so only that PCP can see that patient; with the execption of call coverage....

I wonder if the requirement by hospitals of having call coverage for a doc who has no contracts, is off the grid, might not be something that could be challenged as a restriction of free-trade? I don't need traditional coverage because I don't PAR with anything that requires it...

This whole game is so messed up

Vinny,

Yep, Limbaugh, Hannity and Beck. Let them reform healthcare. Hell, let them reform everything.

Bert
The last pediatrician in America leaning to the right.

Careful that you don't fall over, Bert. When Pat Robertson endorses Rudy Guliani, you know that hell's about to freeze over!!

Re: Giulini/Robertson, I must quote Dr. Peter Venkman:

"...human sacrifice, dogs and cats living together... MASS HYSTERIA!"

p.s. -- Dittos, Bert.