In shift, doctors 'on call' get pay

Some Massachusetts hospitals have started paying surgeons and other medical specialists up to $1,000 for "on call" emergency room shifts, breaking with decades of medical tradition.

Until recently, specialists accepted on-call shifts in return for admitting privileges. But many now expect to be compensated for keeping their beepers on during nights and weekends. The change in the relationship between specialists and hospitals is being debated in the medical community, with some doctors viewing it as a betrayal of long-held values.

"Most of the older physicians felt it was their responsibility to do this. New physicians don't see it that way," said Dr. Kenneth Peelle , president of the Massachusetts Medical Society . "I think it's unfortunate that we have gone in this direction."

Younger doctors tend to consider themselves contractors in a competitive market that is dominated by insurance companies seeking to control healthcare costs. Some specialists first began seeking compensation for emergency-room call coverage in the early 1990s, mostly at for-profit hospitals in the South and West, according to the American Hospital Association. In the last three years, the practice has become common, and more than one-third of US hospitals offer the payments, according to the hospital group. Such payments are relatively new in Massachusetts, where large teaching hospitals can rely on medical residents to handle on-call shifts in emergency rooms.

Federal law requires emergency rooms to provide specialists such as cardiologists, surgeons, and orthopedic doctors, to handle all types of medical emergencies. To meet the requirement, they use rotating rosters of specialists who can be summoned on short notice.

Dr. Mark D. Pearlmutter , chief of emergency medicine for Caritas Christi Health Care and a member of a national advisory panel on emergency room care, said a lack of on-call specialists is becoming a crisis in the United States, forcing hospitals to respond with cash. Caritas Christi has so far resisted the trend at its six hospitals, with the exception of St. Anne's Hospital in Fall River, which does pay for some specialists to be on call, Pearlmutter said.

"I would like to think that there is a larger reason why we all went into medicine," he said. "Ethically, morally, and professionally, we as physicians have a responsibility. Part of our service to our community and to humanity is to provide the on-call service."

The growing proliferation of physician-run outpatient surgery centers has made some specialists less dependent on hospitals for their livelihood, while others are placing increasing value on keeping regular hours.

Without money as an incentive, an increasing number of physicians are less likely to want to go to an emergency room at 2 a.m. or on weekends, said Dr. Carlos Fonts , chief of surgery at Cape Cod Hospital in Hyannis, which placed itself on the front edge of the trend last year when it began paying $500 to $1,000 to many specialists for on-call shifts. Cape Cod Hospital chief executive Stephen L. Abbott said its pay-for-call program will cost about $2 million this year.

Fonts, who is paid by the hospital for on-call emergency-room duty, said the payments specialists receive for routine medical services and procedures have not kept pace with inflation.

"When you made a fair living, taking an ER call was a gesture of good will. That's changing, and it stems from a lack of reimbursement," he said. "It's more just an issue of fairness. I don't know of any other profession that offers their services for free."

Cape Cod Hospital has a two-tier system for the on-call payments. The least experienced specialists are expected to accept the duty without being paid. Dr. John Willis, a Hyannis orthopedic surgeon who graduated from medical school in 1993, said he will not qualify for compensation for two more years and is responsible for an emergency room shift every seven or eight days. As a result, he is considering cutting his ties to the hospital.

"It's indentured servitude," said Willis, who called the traditional system of unpaid on-call shifts "antiquated."

"You can look at 10,000 different variables in healthcare that are all a change from the old ways that we have to contend with every day," he said. "The hospital is big business, but they're making us do the dirty work."

On average, some specialists who receive on-call payments are among the biggest earners in the medical profession. Pay for orthopedic specialists averaged $403,000 in 2006, according to an analysis of salary surveys by the trade publication Modern Healthcare . Cardiologists made an average of $370,000, and general surgeons earned about $284,000, according to the survey.

With the exception of Beth Israel Deaconess Medical Center, Boston's largest teaching hospitals said they do not make payments to on-call specialists, and generally use medical residents and fellows to cover emergency rooms. Beth Israel Deaconess said it has made on-call payments for years, increasingly to specialty doctors who have to spend the night at the hospital. Beth Israel requires some high-demand specialists such as surgeons to spend the night at the hospital, because of its high emergency room volume, said Michael Epstein, Beth Israel's chief operating officer.

Community hospitals such as South Shore Hospital in Weymouth and Saint Anne's Hospital in Fall River have also started paying specialists to be on call. Jordan Hospital in Plymouth, caught between South Shore Hospital and Cape Cod Hospital, is studying the issue. The Massachusetts Hospital Association said it has not measured the financial impact of the trend.

Hospitals and emergency room doctors say emergency room patients would be at risk if fewer specialists were on call. A recent survey of 181 Boston-area emergency room doctors by the American College of Emergency Physicians found that 45 percent believe their emergency rooms are not adequately covered by on-call specialists, and 16 percent said the shortage causes delays in patient care. Emergency room staffs often resort to "dialing for docs" while a patient awaits treatment, according to physicians interviewed by the Globe.

Federal law requires hospitals to maintain a roster of specialists -- on the premises or off site -- to treat emergency room patients. If the appropriate specialist is not available, hospitals are obligated to find care for patients elsewhere.

But meeting those requirements is becoming more difficult, say doctors and hospital officials, and not just because freshly minted specialists want more time off or can attract business independent of hospitals.

Specialists often treat uninsured patients in emergency rooms, increasing the likelihood that they won't get paid. While hospitals are reimbursed by the state's free-care pool, physicians do not receive reimbursements. The medical community is also discussing how much follow-up care specialists must provide such patients.

"We traditionally in healthcare have relied on voluntary arrangements between hospitals and physicians," said Carmela Coyle , senior vice president of policy at the American Hospital Association. The breakdown of that system, she said, "is tearing at the very core of healthcare."

Christopher Rowland can be reached at crowland@globe.com.