President's Message
No Doctor on call

By Samuel Wilson, M.D.

The baby boy was suffering with an acute asthmatic episode when his mother brought him into the hospital emergency room late that night. She was still dressed in her slightly rumpled waitress uniform, and she held her child wrapped in a blanket in her arms. Her face showed her anxiety and fear and she tried to soothe her fretful baby as she paced the floor of the waiting room that was filled on that weekend night with many other patients suffering from various and sundry problems. The child was evaluated and treated, and after a long while it was determined he needed admission and specialty care from a pediatrician, but there were none available. The pediatric call panel was voluntary and there was no one on call. The nearest pediatrician who might take the case was 50 miles away - the mother protested, saying that her car would never make it and anyway, she couldn't take that much time off from work. She would be let go and she needed the job.

This is a hypothetical scenario, although similar real-life situations have occurred at hospitals in our county. Insured or not, emergency room patients are sometimes shocked to find there may not be a specialist available when they need one. (http://www.calnurse.org/cna/news/usatday061699.html)

I have been in similar situations and have been embarrassed to face a patient or relative with the reality that we didn't have the on call doctor they needed. So what happened and how did we get to this place?

The issue involves:
1. Access to care -communities have a right to expect needed emergency services and to know if its not available near by.

2. Self determination - physicians have a right-to decide now much voluntary service they will give a community balanced against their obligations to family.

3. Quality care - a physician up all night taking emergency call may be too exhausted to care of patients he has scheduled to care for the next day.

4. Reimbursement -physicians have a reasonable expectation of compensation for services provided to emergency patients.

Much stems from the complexities of a health system that is seeking to control costs - by employers, government and insurance companies. On the other hand there are health care consumers who want all the advantages of the best new technology and training but know nothing of its cost and are accustomed to paying a nominal amount if anything. The primary care or specialty doctor who used to come in to the ER to take care of the patients now says it is not worth it because of inadequate reimbursement and liability issues.

A recent report released by the California Senate Office of Research reveals that emergency room patients often wait hours - sometimes days - for treatment from specialists who refuse to come to a hospital unless they are assured adequate payment. The crisis affects patients with and without health insurance. The report noted that the problem stems from doctors who are not willing to work for rates offered by Medi-Cal and other health plans. Emergency rooms are also crowded with patients who are uninsured and are seeking the kind of care they should be receiving in a doctor's office. As a result, some patients are shipped from hospital to hospital until an appropriate specialist is found.

As payments to hospital emergency departments are on the decline, hospitals are being paid for only a little more than half of all visits to the ER. The largest declines are observed among the privately insured, while payment rates by the uninsured remained stable. The results question the common misperception that the uninsured are solely responsible for the financial crisis facing the nation's emergency departments. Visits to the emergency department have increased during the past decade and problems such as overcrowding have gotten worse as more and more hospitals close their emergency departments.

In previous times, the specialists would be adequately compensated for some unpaid costs of caring for the uninsured by charges paid by insured patients. Now physicians must see many more patients and most are disgruntled by the inadequate compensation even from insured patients.

What can be done?

The California Medical Association and its leadership are working through its legislative advocacy programs to address these problems of inadequate compensation and reimbursement issues and provide a solution through legislation at the state and local levels. CMA has joined with emergency room nurses, firefighters, paramedics, emergency physicians, hospitals and community clinics and formed the Coalition to Preserve Emergency Care (CPEC), which is sponsoring an initiative "The Trauma and Emergency Care Act of 2004".

The initiative will be placed on the November 2004 ballot to stabilize the emergency medical system in California. Through a stable and predictable funding source - increasing the existing 911-telephone surcharge intrastate phone services by three percent - (representing approximately $0.50 cents per month for the average residential customer), the initiative will generate approximately $600 million annually for uncompensated emergency and trauma services. On-call and ER physicians will split 30 percent of the total (approximately $200). The initiative ensures that all physicians receive compensation for services rendered to uninsured patients. These funds are in addition to the Emergency Services Fund (Maddy Fund) dollars. The new infusion of funds will allow physicians to be reimbursed for the difference between what the patient pays and the billed charges, which represent the true cost of care. The combination of funding from the new fund, the old Maddy fund, hospital reimbursement subsidies, and patient self-pay cannot exceed billed charges.

The CMA staff is available to hear your problems and offer possible solutions. In turn, your support is needed to help pass this initiative. The specialty on call crisis needs a solution and we must work together to solve it. We are asking each SBCMS/CMA member to contribute $95 and every hospital medical staff to contribute to this important measure. Please call Linda Stratton, Executive Director, San Bernardino County Medical Society, 909-825-6526, for additional information and read her column on page S3 of this issue.

Dr. Wilson's Recent Reading List:

Flags of Our Fathers, by James Bradley (Author), Ron Powers (Author). The Battle of Iwo Jima, fought in the winter of 1945 on a rocky island south of Japan, produced one of World War II's enduring images: a photograph of six soldiers raising an American flag on the flank of Mount Suribachi, the island's commanding high point.

Faith of My Fathers, - John McCain's autobiography by John McCain (Author), Mark Salter (Author)

The Purpose-Driven Life: What on Earth Am I Here For? by Rick Warren