Many Groups Getting Stickier About Partners Dropping Call

Many Groups Getting Stickier About Partners Dropping Call

Many groups in specialties in which call duty is substantial — such as cardiology, obstetrics, anesthesiology, orthopedics, general surgery and critical care — are getting stricter about physicians’ attempts to drop or curtail their rotations, and some are putting limits on buying and selling assigned slots.

Sandra McGraw, CEO of Health Care Group, consultants in Plymouth Meeting, Pa., says the underlying reason for diminishing flexibility on call duty is that physicians in these specialties are much busier now than they were just three or four years ago. Physicians “now work so hard that very few people want to take extra call” even though a single extra shift can produce several thousand dollars in extra production credits, she says.

The tight call situation helps to explain wily recruiting markets in most of the above listed fields, especially cardiology and anesthesiology, are so tight. The inability to escape heavy call duties is leading some physicians over 55 years old to retire early. Some groups are limiting the time off options they offer to recruiting candidates and middle aged group members who want to control or curtail their hours for family or lifestyle reasons. And some are docking as much as 20% of physician pay for dropping call.

A few years ago, McGraw recalls, markets in call shifts were fairly robust within groups, and “people were trying to figure out what the value of a shift was.” Groups were becoming more flexible about letting part hers semi retire into a schedule without call. Now, groups are telling senior partners, “You’re in for a penny, you’re in for a pound” — refusing to allow someone to remain a partner if he or she drops call.

Apart from economic issues, partners, especially those 55 or older, are refusing to accept the more frequent call that results when someone else drops rotations, she explains. The ones still taking call are saying, “If I’m doing it, you’re doing it.”

Groups Are Getting Larger

If someone is allowed to hold a regular schedule without call, financial penalties are charged, and the amounts are growing. Sometimes it’s better clinically to have the flexibility of being able to mete out a dollar penalty for not taking call, rather than forcing physicians to take it, McGraw says. Some physicians who may not have taken call for 10 years have little familiarity with emergency room procedures or local personnel, and shouldn’t be allowed to start up again.

“Dr. Smith may be willing to suck it up” by going back to work ER rotations to avoid a pay cut, she says. But the partners in some groups she knows of have said, “We can’t let Dr. Smith back in the ER.”

Two long term economic changes in many groups are contributing to the tighter treatment toward call, she adds. First, most successful groups are growing and working in more hospitals and other facilities. This is leading to more and more layers of rotation. The physician in the first rotation is the first to be called; the one in tile second rotation is called if the first one is already busy, etc. In some large anesthesia practices, there are four layers for each hospital the group services, and the person on first rotation is staying at the hospital. The result is simply that each physician is on call more often.

The second change, partly a result of groups getting larger, is that they are getting more subspecialized. She cites as an example a cardiology group with 10 physicians, including five interventionalists and five general cardiologists (invasive or non invasive). Each interventionalist will have to have a call ratio of at least 1:5, that is, be available to be called in, if not stationed at tile hospital, at least one fifth of the time off weekday, daytime hours. That’s because, while the general cardiologists can stabilize nearly all patients, tile interventionalists may be needed for stents or other procedures that some patients can’t wait for until regular hours.

Thus, she says, an interventionalist would always have to be on the first or second rotation. If you add to the mix that each cardiologist is taking six weeks of vacation per year, that’s in effect more than one group member gone at all times, and an even higher call ratio for the interventionalists.

If one of the interventionalists drops call, the remaining ones’ call ratios would drop from somewhere under 1:5 to somewhere under 1:4, which many physicians find intolerable, McGraw says. The motivation to tightly regulate dropping call becomes clear:

Prices Rise to $1,500 per Shift

If a physician can’t drop call, that means he or she can’t sell call.

Several years ago when the call situation was looser, senior physicians wanting to lighten their call load could sell shifts for as much as $1,000 each to younger associates wanting to maximize their income. Because call duty itself was not so busy and therefore was not generating as much in collections as it is today, there were senior physicians in anesthesiology working from 7 a.m. to 3 p.m., and collecting call sales fees, who were earning more than the associates working much longer hours, McGraw says.

Now — paradoxically because relatively few physicians are willing to take any shifts beyond the ones regularly scheduled the price per shift has jumped to as high as $1,500 in some groups. The recipients are, again, younger associates. With collections per shift running so high, some of them have turned the tables on the senior physicians: earning more than the senior physicians when call income is figured in.

The problem, says McGraw, is that young physicians buying lots of shifts are going to work in the daytime on three or four hours sleep. That not only raises clinical questions, but also questions of burnout and damage to their home lives. “You’re working in a stressful occupation, and then you’re working all night as well,” she says. “If you have a miserable home life, you’ll bring it to work.”

To control the problem, some groups place limits on tile number of shifts a physician can buy or sell, and also enforce vacation policies to avoid burnout, she notes.

Contact McGraw at (800) 473 0032 ext. 3314, or smcgraw@healthcaregroup.com.

RELATED ARTICLE: Family Practice at a Glance

Core pay range (MGMA 25th and 75th percentiles, 2000): $123,000 to $1 78,000 (without OB).

Pay direction: Upward slowly (often less than rate of inflation) in last several years, according to MGMA and several other surveys.

Number (nationwide): Between 65,000 and 70,000. AMA says there were 61,000 FPs in 1997. There are about 60,000 board-certified FPs; AAFP says there were 53,000 in 1999.

Entries to and exits from field per year: Entries exceed exits because field is still relatively young. Family practice has replaced general practice over the last 30 years. There are many new FP residency graduates now, some spurred to enter the field by the ascendancy of the gatekeeper model of managed care in the mid- and late 1990s. But in 2001, the number of residency entrants was down to 2,400 from 2,900 in 1997. There are predictions of a shortage of FPs developing over the next three to 10 years based on a rising elderly population, a stagnant number of entrants into family practice, and a very recent upward spike in FP recruiting (PCR 9/01 p. 9). About a third of new residents are foreign medical graduates.

What family practitioners do/subspecialties: According to the AAFP’s current ad, “We specialize in all of you.” As primary care physicians, they conduct a wide variety of diagnoses and treatments, and do industrial medicine, urgent care and many specialty procedures, such as colorectal scans and treadmill tests. Many FPs handle OB, particularly in small towns.

Common reimbursement methods: Fee-for-service is most common as capitation recedes.

Common group structures: Solo and small group practices (up to six physicians) are most common, but FPs are found in almost every medical organization.

Main professional society: American Academy of Family Physicians, Leawood, Kan., (800) 274-2237 or www.aafp.org.

Other PCR items about family practice: (1) compensation trends in 2000, 5/10/00 p. 1; (2) compensation trends in 2001,9/01 p. 3; (3) compensation and production indicators, 8/O1 p. 5; (4) marketing approaches for family practice, 5/O1 p. I and 7/01 p. 1.

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