Everything You Must Know About Physician Emergency Call Coverage
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Learn more about factors to consider when to pay for call coverage and basics of call coverage agreements.
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Everything You Must Know About Physician Emergency Call Coverage
- 1. 1 Everything You MUST Know About Physician Emergency Call Coverage
- 2. Today’s agenda • MD Ranger intro • A brief history of call coverage • Commercial reasonableness, or: to pay or not to pay? • Paying for call: rates and analysis • Basic elements of coverage agreements • Effective strategies for setting call rates 2
- 3. 250+ Physician Benchmarks • Call coverage rates • Medical direction payments • Administrative and leadership services rates • Hospital-based service stipends • Diagnostic testing, etc. • Clinic & hourly rates Online Platform • Benchmark lookups • Contract proposal tools • Contract reports by facility and service • Total facility costs + benchmarks Compliance Documentation • Contract-specific FMV documentation reports • Reports to assist with real-time monitoring and annual reviews Research and Support • Resources for education and training • On-call experts to help subscribers use benchmarks and tools 3
- 4. The foundation of your compliance process Standardize processes and rates Document FMV Access 250+ payment benchmarks Review contracts and monitor with ease Have smarter, data-driven physician negotiations Mitigate compliance risks 4
- 6. 6 Our benchmarks • Call Coverage (50+) • Medical direction (85+) • Hospital-based services (20) • Administrative (non-director) • Medical Staff Leadership • Diagnostic/other services e.g. ROP, autopsy, dialysis • Hospital-based stipends • Clinics, professional services • Telemedicine • Residency/teaching/GME • Uncompensated care • Meeting attendance, peer review, IT/EHR and quality initiatives • 13 Pediatric services, with more emerging each year Hospital-characteristics drill down for ADC, bed size, trauma status, urban/rural, stroke centers, and more. Used in academic medical centers, integrated delivery systems, and hospital organizations.
- 7. Our methodology: key differences • Providers vs. facilities • Verified data • Thorough data audits • Physician contract experts on- call to review/advise on challenging contracts • Comprehensive scope of benchmarks based on full hospital contracting practices 7
- 8. About me 8 • Chief Marketing Officer at MD Ranger • Decade plus experience in health care, specifically pertaining to the hospital/physician relationship
- 9. 9 A BRIEF HISTORY OF CALL COVERAGE
- 10. Once upon a time 40+ years ago…. • Physicians on the medical staff took call as a part of their privileges • Seen as a way to build their independent practices 10
- 11. Shifts in emergency care • EMTALA (1986) • State laws • Growth in burden of uninsured and Medicaid in the ED 11
- 12. (Additional) federal regulations Seventies: AKS Eighties: Stark 12
- 13. Market forces and hospital/physician relationships • Attitudes shift for coverage and leadership duties • Market consolidation of both physicians and hospitals • Hospital pressures to reduce costs 13
- 14. Physician costs on the rise 14 *Office of Statewide Health and Planning Department (California)
- 15. Call coverage costs on the rise, too 15 $- $300 $600 $900 Medical Specialties Surgical Specialties All Services Per Diem Payments 2013 2014 2015 2016 2017 Source: MD Ranger, Inc.
- 16. TO PAY OR NOT TO PAY 16
- 17. Much to consider Is coverage for the position necessary and does it meet commercial reasonableness tests? Should you factor opportunity cost? What’s the market rate for the service? What is current hospital policy for paying for coverage? How much will paying for coverage in this service impact other physicians on the medical staff? Does the position significantly reduce a physician’s potential compensation related to her practice? What’s the ED volume? 17
- 18. Not all positions should be paid • Not all coverage positions should be paid, even services that are most commonly paid • There are likely good arguments for paying or not paying a physician to take call 18
- 19. Services most likely to be paid for call 19 0% 20% 40% 60% 80% 100% PercentofSubscribersWhoReportPaying Service Source: MD Ranger, Inc.
- 20. Understand everyone’s perspective • What is the physician asking for? What is the underlying causes of the payment request? • What is your organization’s position on call compensation? Is there a precedent or medical staff bylaw requirements? 20
- 21. Comfortable paying? Now what? • Is it commercially reasonable to do so? • What is commercial reasonableness, and how can you determine if the position and situation in question is commercially reasonable to pay? 21
- 22. Commercial reasonableness An arrangement that is a sensible, prudent business arrangement, from the perspective of both parties involved, even in the absence of potential referrals. 22
- 23. Determining commercial reasonableness 23 How common is it for hospitals to pay? Can data be used as part of the argument that payment is necessary? Build the case based on facts that differentiate your facility; consider a valuation too
- 24. FMV and commercially reasonable do not mean the same thing • FMV and commercial reasonableness are not the same • A payment rate may be within fair market value but not be commercially reasonable 24
- 25. PAYING FOR CALL: RATES AND ANALYSIS 25
- 26. Each hospital is unique (but similar enough) • Each hospital is different (size, service offerings, market, payer mix, etc.) • Hospitals are similar enough that one can look to peer hospitals for guidance in setting rates. Market data is a good way to do this, as long as it is high quality and detailed enough for your needs. 26
- 27. Median coverage per diem rates for frequently paid services: • General surgery: $900 ($1,000 T) • Orthopedic surgery: $970 ($1,270 T) • Gastroenterology: $540 ($600 T) • Cardiovascular services: • $550 general cardiology • $850 for cardiovascular surgery • $670 for interventional/STEMI 27
- 28. Significant factors that influence rates 28 Specialty Number of campuses Hospital size Trauma status
- 29. Factors that do not influence rates 29 Urban/Rural US region Ownership status Payer mix
- 30. Highest compensated call specialties 30 $0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 Neurosurgery - Trauma Trauma Surgery Orthopedic Surgery - Trauma Neurosurgery OB Anesthesia Neuro Interventional PerDiemRate Service Source: MD Ranger, Inc.
- 31. Largest dollar increases in median call coverage per diems since 2009 31 $- $50 $100 $150 $200 $250 Plastic Surgery Anesthesia - Obstetric Obstetrics/Gynecology Urology Cardiothoracic Surgery Increase Service Source: MD Ranger, Inc.
- 32. Largest percent increases in median call coverage per diems since 2009 32
- 33. Call coverage payment methods 33 0% 20% 40% 60% 80% 100% Hospital-Based Specialties Medical Specialties Surgical Specialties Contract Distribution Calendar Per Diem Per Episode Unit Guarantee Other Source: MD Ranger, Inc.
- 34. BASIC ELEMENTS OF COVERAGE AGREEMENTS 34
- 35. Key elements of coverage agreements • Specify which one (or more) of the following mechanisms of compensation are used: per diem payment, per episode payment, or uncompensated care payments • List rate • Clarify whether service includes coverage of in-house referrals from other physicians for unassigned patients (in addition to ED coverage) 35
- 36. Key elements of coverage agreements • State whether or not there are restrictions on the physicians activities • Identify in the agreement if there is a second on-call physician, and discuss how payment will be handled if yes • Establish who is responsible for the schedule to ensure continuous coverage and name the individual (or party) in the contract 36
- 37. Key elements of coverage agreements • State in the agreement if exclusive rights are granted to the panel or to the medical group • Decide if it’s best to have a panel in which physicians are restricted from any material private practice income generating activities—this can be reasonable to ask if specialization in acute inpatient care leads to better clinical outcomes. 37
- 38. 38 EFFECTIVE STRATEGIES FOR SETTING CALL RATES
- 39. K.I.S.S. • Your process should have straightforward policies and procedures. • Try sticking to one or two templates to more easily monitor compliance instead of having different compensation frameworks for each physician contract. 39
- 40. Creating a standard physician contracting process is more important than ever 40 Standardize benchmark levels across specialties Consistently use externally validated benchmarks Routinely review contract rates and documentation
- 41. Three approaches to determining call coverage rates 41 Market data will suffice for the vast majority of call agreements Market Data Proprietary Formulas FMV Opinions
- 42. All approaches have strengths and weaknesses • Market Data: • Pros: cost effective, flexible, easy to scale, immediate access • Cons: doesn’t work in all cases, like when there’s no market data available • Proprietary formulas: • Pros: easy to scale, immediate access • Cons: aren’t transparent to the parties involved, setting up can be expensive • FMV Opinions: • Pros: most detailed and specific • Cons: difficult to scale, expensive, slow turn around42
- 43. MD Ranger subscribers: 43 Use market data for the majority of physician contracts Perform valuations for more complex agreements Always document proof of FMV whatever method
- 44. Consider alternatives: • Not paying • Uncompensated care payments • Per episode payments • Combination payments 44
- 45. Multi-facility call agreements = savings 45 $100/day $100/day $200/day $100/facility $140/day $200 * 70% = $140/day $70/facility
- 46. Need help setting call coverage payment rates and documenting FMV? Call us. 46 Do you feel confident in your organization’s physician contracting and FMV documentation process? Are you confused how much to pay physician leaders for their time? Do you feel like your organization has risky agreements? We can help! Reach out: apullins@mdranger.com or 650-692-8873
Editor's Notes
- Hi everyone, thanks for joining us today for our webinar on best practices for physician call coverage contracts and compensation. I’m Allison Pullins from MD Ranger, and I’ll be hosting today’s webinar. A couple of housekeeping items. First, my colleague Julia Ogburn is on the line to help with any incoming questions or comments. If you have any, please feel free to type them into your GTW console. If Julia is unable to follow up with you during the webinar, she will return your message by email or phone very soon. If you have feedback or questions to share with me, I will show my contact information at the end of the webinar so we can be in touch. I’d love to hear from you. Lastly, we will send everyone a copy of the presentation by the end of the week and we’ll make a video available within a week too. I also hope it goes without saying that MD Ranger experts are always available for questions or for a chat. Especially if you have follow up questions after the webinar today, I encourage you to send me an email or give me a call.
- Here’s how we’re going to spend our half hour together today. First, I want to do a quick MD Ranger intro. We have some new folks on the line and I want to make sure that they know what we do Then we’ll talk about the history of paying for call coverage—because it wasn’t always the case that hospitals paid doctors to take call. Then, we’ll talk briefly about commercial reasonableness and whether or not you should pay your doctors to take call in the first place After that we’ll talk about call rates. This is when we’ll share some MD Ranger call coverage data in this section. Then we’ll review essential elements you should have in all your call arrangements with physcians, panels, and medical groups, and then we’ll wrap things up by discussing a few effective strategies for setting call rates. If you’re an MD Ranger subscriber, and we have a few on the line, don’t hesitate to follow up with your MD Ranger contact to discuss best practices for call coverage in more depth.
- MD Ranger is an online platform that integrates over 250 physician compensation benchmarks with a suite of compliance and financial tools. Our Online platform, including look-up tools and FMV documentation tools A secure, web-based Contract Data Tool to collect and organize contracts Analytics to benchmark contracts, review expenditures, identify compliance issues, and compare facilities Cost and compliance reports to compare your contracts to MD Ranger benchmarks Resources and research to support compliance efforts And Support from experts in physician compensation, FMV documentation, and compliance
- IN fact, we aim to be the foundation of their physician contract compliance programs, all in an integrated online platform MD Ranger helps subscribers standardize their physician contracting process in the way that is best for their organization. Because our benchmarks and online platforms can be integrated into all types of compliance and legal processes, we can be a resource to all types of organizations. . These types of financial arrangements can be very risky to organizations and to physicians—given federal regulations and hightened scrunity by the government. Our subscribers use the MD Ranger platform to mitigate that risk and monitor risky arrangements.
- We began producing benchmarks in 2009 have have grown from a database of 4,000 to 28,000 contracts since. This is a map of our subscribers and contract database MD Ranger has more than 225 participating healthcare organizations. We work with all types of facilities from large urban trauma centers to small, rural critical access facilities, surgery centers, dialysis centers and everything in between.
- Here is a comprehensive list of the types of different physician agreements we benchmark. We drill down all our benchmarks by meaningful hospital demographics, like hospital size, trauma status, and more.
- We have some key differences in our approach and methodology that I wanted to share. First of all, when it comes to sample size and reporting benchmarks, we take a more conservative approach. ATSZ guidelines require that a minimum of five providers be included to publish a compensation benchmark. While some surveys interpret the word provider to mean physician, we interpret it to mean hospital owner or corporation—not physician or even hospital! This ensures that our sample size has enough data to produce meaningful benchmarks. Instead of collecting data from physicians themselves, we get our data from hospitals and healthcare organizations contracting with doctors for services. We feel this approach is more reliable, especially when it comes to reporting annual hours. MD Ranger goes about collecting its data from hospital and health system partners. When they join MD Ranger, they share all their physician contract data with us. This allows us to calculate some unique benchmarks on total hospital spending and frequently of payments that no other survey replicates. Some of these benchmarks include the percentage of hospitals in our database who report paying for a service in the first place, total numbers of administrative roles by specialty, and total hospital spending.
- In case you don’t know me, here’s some quick background info on me.
- Over the past decade, physician contracting has become more and more important and more complex. Physicians have always been key stakeholders in hospital and health system operations but as these relationships transform, not to mention as our entire delivery system transforms, things become more complicated and more challenging. Just a few decades ago, hospitals rarely paid physicians a stipend for call—. Today, however, it’s a different stories. In many markets across the US, hospitals are compensating at least a handful of specialities to take call—if not a couple of handful’s worth. We publish 50 different specialty rates for call coverage payments—so clearly, hospitals are paying many different types of doctors to take call.
- So before the early to mid eighties, healthcare was a different world—particularly hospital-physician relationships. Physicians in specialties like OB and surgery simply took call because it was considered a part of the gig. If you had priv. at the hospital and your specialty was needed on an emergency basis, you were available for call like all your peers. Additionally, it was seen as a way to build your own independent practice.
- It was back in the 80s where things began to shift into the environment we see today, and that is, in many markets physicians will not take call, especially for some specialties with heavier burdens and higher call rates, without getting compensated. One of the first changes we see that influence the transforming attitudes are federal regulations around emergency departments. These requirements have shaped the way both hospitals and physicians view taking call coverage. The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay. EMTALA does not impose any requirement on physicians that they serve on a call schedule. It is the hospital which imposes an obligation on physicians in order to meet the obligation imposed upon it Another change was that of the increasing population of uninsured patients presenting in the ED.
- Speaking of federal regulations, it was also around this time that laws governning the way hospitals can pay doctors came onto the scene. We can’t go down the rabbit hole of stark and AKS today; however, MD Ranger has a ton of free resources online about these topics.
- All this discussed and more began to transform attitudes in physicians towards coverage and leadership duties at the hospital….but there are additional pressures from other market forces that should be mentioned too. Things like, pressure on the hospital to reduce costs while still producing exceptional clinical outcomes, the consolidation of both hospitals and physicians, as well as employment trends.
- The fact is: hospitals are spending more and more on physicians and it is reflected in the data. This graph shows you California hospital physician costs per ADC as a percent of total expense—the state keeps very good data and we frequently use it to analyze hospitals in the state. including AMCs or county hospitals—just community hospitals.. These data come from community hospitals in the state. And do not include employment arrangements.
- Our data also demonstrate that hospitals are paying physicians not just more for call coverage, but for administrative services too. Though call coverage rates themselves have remained relatively stable, more services are being compensated, thus driving up costs to hospitals and health care systems.
- Now we’re going to start talking about call coverage payments and before you ever decide to pay a physician or group to take call you need to decide if it is commercially reasonable to do so. Let’s explore that concept now. Commerical reasonableness is a complex topic, and really deserves its own webinar or three! Keep in mind this is an extremely high level overview of the concept of what is commercially reasonable.
- There’s a lot to consider before entering into a payment relationship—we’ve outlined a few key questions here. Many healthcare organizations have adopted their own commercial reasonableness checklists, or have help pulling together guidelines. MD Ranger is coming out with our own checklist this summer, so stay tuned for that resource.
- Keep in mind that not all physician services—like call—should actually get compensated by the hospital or health system. Even if a service is commonly paid, like orthopedic surgery, it doesn’t necessarily mean that it should be paid at your organiztion, too. It’s key that hospitals perform due dilligence to ensure that each and every physician agreement is reasonable.
- These are the most common services in our database that are paid call. Listed in order by the percentage of our subscribers that pay. General surgery was our highest percent paid for years, but orthopedic surgery edged slightly ahead in 2017.
- When you’re considering a call payment it is important to explore and understand all perspectives The physician most likely sees it in two ways. First, she is asking for payment because of what’s commonly called beeper burden, and that is the impact that not traveling out of the service area or engaging in other activities on her life--notably family obligations. The second is taking on responsibility for patients who are most likely uninsured or underinsured. The hospital of course has a perspective—what is the official position for paying call? Is there are precedent? Are there medical staff bylaw requirements?
- Once you’ve determined that your organization is comfortable paying the physician, you must demonstrate that it is commercially reasonable for you to do so.
- I’ve paraphrased CMS here for the actual definition of commercial reasonableness. A s you can see it’s vague. Establishing is both an art and a science that truly involves knowledge of the specific situation you are facing, but let’s talk about some methods that can help you establish it.
- There is a way to run to data to help you establish commercial reasonabness. You’re asking: how frequently do other hospitals pay for this service. That’s certainly not the only piece to establishing commercial reasonableness. If many or most hospitals pay for coverage, data can be used as part of the argument that payment is necessary. If you believe you must pay for the service given your market, though others aren’t, build the case based on facts that differentiate your facility and consider a valuation that demonstrates commercial reasonableness.
- We are going to move away from CR and start talking about payments but before I do, just want to remind everyone that FMV and CR are not the same thing.
- Now we are going to talk about after you’ve established it’s okay to pay—actually HOW MUCH you pay. We’ll go through some MD Ranger data too.
- I want to acknowledge that every hospital and situation is different. However, hospitals are similar enough that you can look to similar hospitals for guidance when it comes to setting rates. Market data is a great way to do this, as long as it has an adequant sample size and is truly apples to apples
- Let’s take these services and look at how much they are paid at the median per diem Gen: 81 Ortho: 87 GI: 50
- What factors influence rates? Every year we do analysis on what influences physician contract rates, and here is what is statistically significant. Specialty Number of campuses covered Hospital size Trauma status
- Urban/rural DHS status, payer mix Major US geographic region Ownership status (for profit, not for profit
- What specialities are paid the most to take call? The top services are neurosurgery trauma, trauma surgery, and trauma orthopedic surgery. Then come neurosurgery, OB anesthesia, and neuro-interventional. All these services have a per diem of $1,000 or greater.
- We studied positions that have experienced the largest increase in their per diem rates since 2009. These five specialties were reported throughout 2009 to today, and have the highest rates of growth. The graph above demonstrates how much in dollars that the per diems have risen. The highest growth specialities have all risen around 200-225 per diem. This is non-trival: annualized rate of increase is $82,000 per year. The specialities with the largest dollar increases are plastic, OB anesthesia, OB GYN, Urology, and Cardiothoracic surgery.
- Now we are looking at the services with the largest percent increases in their median call coverage per diems. These are psychiatry, urology, plastic, neurology, vascular, and OB GYN. Note that some of these specialities have high percentage increases and higher rates. Others simply experienced a growth in rates that weren’t that high in the first place. Psyhiatry is the best example of this—despite the huge percentage increase in rates, the median per diem for all hospitals in 2017 was $300 per diem. Plastic was $530 at the median, and OB is $620 at the median.
- Call coverage contracts are overwhelming paid on a per diem basis. However, there are some coverage arrangements that are paid on an annual basis, and some on a per episode basis. Coverage agreements that are paid on a per episode basis are often specialties – or hospitals - with a low volume of calls where it is significantly less expensive to pay when the physician comes in rather than every day. An exception to that is OB coverage which sometimes has both a per diem and a per episode or per delivery payment at least for unsponsored patients.
- Of course when you’ve seen one physician contract you’ve seen one physician contract—however, do whatever you can to get call agreements on some kind of template and do your best to stick with the way you pay physicians and the language you use in your contracts. Given the volume—particularly at large organizations, you want to keep it as simple as you can.
- First, specifiy how you will pay. Then you’ll want to be clear about rates. If there are multiple rates, like a holiday or weekend coverage rate, spell those out as well. Then make sure you spell out exactly what services are included and what the responsibilities of the physician will be while on call.
- Define whether or not the physicians activities will be restricted and how quickly the physician needs to respond to the call. If there is a need for a second on call physician, the agreement should discus how that payment will be handled. MD ranger does benchmark second call rates for a handful of services where it is common to have second call rates. You should also specifiy in the contract who is responsible for scheduling—this is a key piece that can be missed but is very important.
- You should also state if this is an exclusive service in the contract. Decide if it’s best to restrict physicians from income generating activities—for some specialities this is very reasonable to ask but for others it is not.
- Now we’re going ot wrap up by talking about some effective strategies for setting call rates.
- First and foremost, you should have a simple and straightforward process for setting payment rates. This should be a part of your contracting compliance process. Again, stick to easy templates. If they are complicated, imagine doing it over and over again dozens of times. YIKES.
- With your orgganization very likely being asked to do more with less, it’s important that you maximize the efficiency of your physican contracting process. The key elements of streamlining include: Standardize benchmark levels across specialties and require administrative and board review and sign-offs Consistently use externally validated benchmarks Routinely review contract rates and documentation We also recommend Standardize how much you are going to pay in the market ranges—having this will help you with compliance and guidelines should hopefully set reasonable expectations with your medical staff. It’s also mandated that you pay FMV—defining that at your organization is key. Also make sure that routine reviews of contracts are a part of your process—especially keeping an eye on riskier arrangements NOTE: MD Ranger has many resources online on how to best structure physician contracting programs—please check them out if you need support or call us.
- There are three basic approaches to setting coverage rates. Market data Internal or external proprietary formulas Internal or external ad hoc FMV opinions (cost method) you can use market data to find the most appropriate payment rate. We recommend never paying right at the 75th because benchmarks by nature can change year to year. Paying somewhere in the neighborhood works well. Another way is by internal or external algorithms where you plug in some market data and conditions and generate a payment rate A third is getting a valuation done—these often use a combination of market data and the cost method. We find that a vast majority of organizations are using a combination of methods but some only stick to one.
- All approaches have their strengths and weaknesses.
- Here’s how we see most of our subscribers approach setting call rates. Use market data for the vast majority of physician contracts, including call coverage Pull in valuation firms or experts for more complex agreements, again, not typically call coverage Always document their rates with proof of FMV, whichever method they choose
- Another effective strategy for call coverage comp is…not paying at all! Or—at least considering some alternatives to paying.
- If you are a health system not currently leveraging multi-campus agreements, we highly recommend that you consider the strategy because it will save you money. This can be an excellent call coverage payment strategy. The data show a 30% cost reduction for multi-facility call coverage agreements. I’ve shown an example her with two campuses paying two physicians 100 per diems. This will cost the organization $200 per day covering both campuses. Though paying a single physician will cost more per physician to cover both campuses, it saves the organization $60 per diem.
- Thanks for joining us today. We’re glad to have you. If you haven’t already, please sign up on our website to receive MD Ranger materials or follow us on twitter @MDRanger