Emergency department (ED) on-call systems are on the brink of disaster. Spiraling downward nationally, they fare even worse in California. It’s a simple problem of supply and demand. Hospital executives are finding it increasingly more difficult to get physician specialists (e.g., orthopedic surgeons, neurosurgeons, obstetricians, general surgeons and others) to be on call should their services be needed in the emergency room.Some physicians say that being on call takes too much time away from their private lives.Others say it exposes them to financial losses associated with treating low-pay and uninsured patients. At stake are patient access to and quality of health care.

Consider the following eye-opening statistics: In California, ED visits have increased more than 3 percent annually; visits increased 15 percent from 1998 to 2002 to 10.1 million annually. Forty percent of physicians have curtailed or completely stopped taking call. Less than one-third of hospitals now mandate call as a condition of medical staff participation.

From the hospital perspective, the problems are diverse and a Catch-22. The Emergency Medical Treatment and Active Labor Act (EMTALA) was passed to ensure adequate emergency care for patients regardless of ability to pay. It holds hospitals’ feet to the fire, but neither funds this care nor mandates physicians to provide on-call coverage. Consequently, many hospitals pay huge stipends to get physicians to serve on call panels. In one extreme case, one Southern California hospital pays a physician $4,000 per day to be on call. Many hospitals augment these stipends with payment guarantees for any medical service actually provided by a physician serving on an on-call panel?at Medicare plus 20 percent or something approximating that amount.

Additionally, hospitals must now juggle a growing patchwork of multiple call panels, an outgrowth of managed care. Health plans now demand that managed-care medical groups and hospitals maintain lists of contracted physicians to serve their enrollees. These lists are no guarantee of availability of call panel specialists in scarce specialties or where physicians are assigned to cover large geographic areas. Add to the equation “unassigned” patients, who enter the ED without a designated physician or medical group for backup coverage, and it is easy to see the severity of the situation.

Besides broad health system reform, many piecemeal state or federal relief measures could be considered. For this year, hope centers on Proposition 86–the Tobacco Tax Act of 2006, which, if passed in November, would provide an estimated $750 million to California hospitals for emergency services. Proposition 86 also specifies that hospitals can work together, under public agency supervision, to develop regional plans for providing emergency services to the poor and uninsured and to coordinate the availability of specialist physicians.

Obviously, hospitals need to find solutions to their own unique ED call-panel problems, but these solutions and broad legislative policy need to mature quickly, as overall ED use will continue to grow. ED use by the elderly, who have the largest share of serious medical conditions, is about to soar as baby boomers reach Medicare age. Ambulance diversions due to crowded conditions reduce timely access to care for all.

What do you think is the best way to address this complicated problem?