Physicians on Call: California's Patchwork Approach to Emergency Department Coverage

The Performance Alliance

The state's system for securing on-call emergency department specialist coverage remains costly, complex, and on the edge due to payment concerns, liability questions, and a shortage of specialists.

February 2011

In 2005, CHCF's On-Call Physicians at California Emergency Departments: Problems and Potential Solutions delved into the growing challenge of ensuring on-call access to physician specialists in California's emergency departments (EDs). This new study provides updated information on on-call coverage in hospital EDs. The study was conducted by The Performance Alliance in cooperation with the University of Southern California Center for Health Financing, Policy, and Management and included a survey of hospitals conducted with the California Hospital Association.

The new research shows that erosion of ED specialty call in California EDs is unabated. Slightly more than half of hospital executives surveyed believe that provision of on-call ED coverage in California has become more difficult, while 88% say that payment for specialty call has become "a cost of doing business," and four-fifths report that securing specialty coverage is among their organization's top-10 business challenges or priorities. To address the problem, myriad call coverage strategies have been introduced among California's hospitals, including:

  • Compensation strategies to replace straight stipends, such as productivity-based-guarantee and hybrid models, deferred compensation programs, and clinical comanagement agreements
  • Provider strategies to replace mandatory call, including exclusive call contracts, ED-call independent practice associations, hospitalists, use of physician assistants and nurse practitioners as first responders, and telemedicine and remote presence robotics
  • Care improvement strategies to reduce the burden of call, such as a multidisciplinary taskforce to improve ED efficiency, rapid triage programs, ED observation units, ED fast-track programs, and internal EDs
  • Organizational and delivery system strategies such as medical foundations, contracting out, community call plans, regional call coverage, and regional transfer call centers

Sharing the burden of call coverage has broad conceptual appeal for hospitals, but implementation of community call in California has been limited by state licensing regulations, geography, and competitive factors. Technology deployment is also seen as having significant positive effects on ED specialty care in the future. The impact of health reform on specialists and EDs looms large, however, and will require new and collaborative approaches that recognize a shared responsibility between hospitals and specialist physicians for ensuring access to quality, affordable care.

The report is available as a Document Download.