SUMMARY

What is a trauma center? Emergency rooms and departments are able to treat ill and injured people, while trauma centers are able to handle the most severe, life threatening situations. When an injured person is brought into a trauma center with a complex injury, a sophisticated, highly trained interdisciplinary team of health care professionals provides the services needed to save that person's life and prevent further disability or physical deterioration.

Physician specialists: an integral part of the trauma team. Trauma care requires a highly trained medical staff, functioning as a multidisciplinary team. Patients with traumatic injuries often require a level of care that involves the services of physician specialists, including neurologists, orthopedic surgeons, general surgeons, cardiologists, plastic surgeons, and anesthesiologists, to ensure appropriate screening, stabilizing, and treatment of trauma patients.

The problem: a shortage of physician specialists available for emergency call. For many years, many trauma centers across the nation have been facing a crisis securing physician specialists for emergency call. The on-call specialist shortage is particularly acute for The Queen's Medical Center since it is the lead and only trauma facility in the State of Hawaii. For complex care, there is nowhere else nearby to obtain treatment.

Impact of the shortage of physician specialists. With trauma injuries, seconds count; the chances of survival significantly decrease and the side effects of injury significantly increase if appropriate care is not given in the first hour immediately following the injury. A shortage of physician specialists can jeopardize a trauma team's ability to provide care. It also increases the risk of delay in patient treatment which in turn increases patients' risk of harm.

Typically, the cost of running an emergency department is far higher than the total payments received from patients treated.1 According to the American Hospital Association, one-third of the nation's hospitals already operate in the red.2 A significant percentage of hospitals are incurring high additional costs from having to pay physician specialists to provide emergency call coverage. Between 2000 and 2004, thirty trauma centers closed as hospitals faced volume increases, higher costs, liability concerns, and low or no payment for trauma services. Some of the cities that have seen trauma centers close include: Los Angeles, California; Tucson, Arizona; Birmingham, Alabama; El Paso, Sherman, and Texarkana, Texas; and Tulsa, Oklahoma.3

A weakened trauma center decreases a state's state of readiness to respond not only to a normal flow of critically injured patients but to unforeseen disasters and emergencies as well. The tragic events of September 11 and Hurricane Katrina illustrate that trauma readiness and availability is every bit as much an issue of public safety as police and fire services.

Causes of the on-call physician specialist shortage. The reasons why fewer physician specialists are taking emergency call tend to fall into four categories:

• Uncompensated care. Across the nation, the costs of practicing medicine and delivering trauma care have steadily increased, while reimbursements to physicians -- from health plans, managed care, Medicare, Medicaid, and safety net programs for the uninsured -- have dramatically decreased. A Hawaii orthopedist notes, for example, that over the last decade reimbursement for knee surgeries has dropped from $4,000 to $1,400. Orthopedic surgeons are now paid less for a total hip replacement than they were in 1976.

  According to the American College of Emergency Physicians, about half of all emergency services provided in the country are uncompensated and about forty-two per cent are significantly underpaid or paid only after considerable delays. While hospitals and physicians have absorbed uncompensated costs in the past by shifting them to patients who could pay, it has become increasingly difficult to recover those costs with the flat fees provided by many health plans.

• Lifestyle. Few would envy the life of an on-call physician specialist. They are often called to emergency departments many times a day to deal with complex cases, taking them away from their practices and families and limiting their ability to see their own patients. Because of the shortage of specialists, those who do take call often share a heavier call schedule. In hopes of achieving a better work-life balance, many specialists have reduced or eliminated emergency call.
• Supply and demand. There is a national shortage of specialists in many areas critical for trauma coverage. The physician workforce is aging and physicians are retiring, slowing down, relocating, or leaving the practice. An increasing number of physician specialists no longer need to have staff privileges at hospital emergency rooms because they work in outpatient surgical centers and specialty hospitals. Over the past decade, the number of physician training slots also has declined.
• Medical liability concerns. Rising malpractice liability insurance premiums, in combination with lower reimbursement rates, render the practice of certain specialties less and less cost effective. There is increasing pressure from malpractice insurers for physicians not to provide emergency room coverage. Several liability insurers have simply stopped providing medical liability coverage for certain physician specialties.

  During malpractice crises, concerns are expressed that liability costs will drive high-risk specialist physicians from practice, creating access-to-care problems. Indeed, liability pressures may be leading to greater consolidation of high-risk specialty care services in a smaller number of providers. While the problem is multi-factorial, with reimbursement and managed care arrangements contributing significantly, physician specialists perceive liability to be the strongest driver.

Government responses to improve the availability of physicians for emergency call. The states have employed many strategies to help trauma care and improve the availability of on-call physician specialists, including:

• Developing dedicated public sources of funding to reimburse physician specialists for uncompensated trauma services. These funds were found to be effective and essential for maintaining trauma centers and ensuring the on-call availability of physician specialists. However, trauma fund moneys cover only a small fraction of uncompensated trauma costs. Additional funding sources are direly needed. Current revenue sources for dedicated trauma funds include: surcharges tacked onto fines for convictions for traffic violations and substance abuse- and firearm-related offenses; surcharges tacked onto fees for driver's licenses, motor vehicle registration renewals, and the sale, lease, or transfer of motor vehicles; taxes on cigarette sales; tobacco settlement funds; sales and development taxes; and budget appropriations.
• Implementing tort reforms, such as caps on damage awards in malpractice lawsuits, that place limitations on traditional legal rules and practices to decrease claim filings and damage award amounts. Underlying this response is the presumption that too many malpractice claims are filed and that damage awards tend to be excessive. These reforms may have a positive effect on physician supply in some instances and may reduce the number of lawsuits filed, the value of awards, and insurance costs. However, evidence on how premiums were affected is mixed and findings are at best inconclusive. In this regard, researchers who study the tort system have found only a loose connection between changes in claim filings and outcomes and premium spikes. Policy makers should be wary of exaggerated and misdirected statistics offered in support of partisan positions.
• Implementing patient-centered and safety-focused reforms that strive to reduce the incidence of medical error. Underlying these reforms is the realization that capping damages on the back end of litigation does not address all of the factors on the front end that lead to litigation. These reforms also recognized that:
  • Tens of thousands of people die in hospitals each year as a result of preventable medical error, yet a malpractice claim is filed by only one of every eight negligently injured patients;
  • Most claims are resolved at great expense and too slowly to correct mistakes;
  • Most medical errors do not result from individual incompetence or recklessness, but from faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them; and
  • Ineffective communication with patients ­ not poor treatment or negligence ­ puts physicians at most risk of malpractice lawsuits.

  Patient-centered and safety-focus reforms ensure that "adverse events" and errors are reported, tracked, and analyzed so that physicians and hospitals can identify system weaknesses and learn from their mistakes before more consequential events occur. These reforms encourage open, frank communications between patients and physicians, apologies, and quick resolution of claims through mediation to avoid bitter and protracted lawsuits. For example, a growing number of states are passing laws that protect an apology from being used against the physician in court.

• Improving state licensing boards to enable quick investigation and prosecution of physicians who have demonstrated a pattern of negligence. State medical boards are accountable for the quality of health care provided by physicians within their jurisdictions and for assuring that physician licensees are competent to practice medicine. They have been criticized for taking too long to investigate negligent providers; for not dispensing stiff penalties for those found guilty of negligence; and for not providing adequate public information about those physicians who have had disciplinary action taken against them. These boards can only perform their mission if they are properly organized, effectively empowered, and adequately funded.
• Improving the ability of insurance commissions to review and evaluate rates and malpractice trends. This includes developing systems to ensure the collection and tracking of comprehensive data on medical malpractice claims, including, for example, the number of claims filed, the losses associated with these claims, premium amounts, and the number of open and closed claims.
• Implementing stop gap strategies, such as premium subsidies and state-run insurance programs to help physician specialists meet immediate insurance premium obligations and find liability insurance in the short term. Typically thought of as short-term or providing an option of last resort, these strategies may not solve the systemic issues that exist in the medical liability insurance market.

Mandatory call: pros and cons. Neither federal nor state law affirmatively requires an individual physician to serve on-call. Most hospitals mandate some level of on-call coverage as a condition of staff membership. While hospital-mandated call is effective in many states, many hospitals are reluctant to enforce call mandates for fear of losing or repelling physicians. A mandated approach, whether imposed by a hospital, a state licensing board, or state law, may backfire if other on-call issues, such as physician burnout, uncompensated care, and liability insurance availability and affordability, are not addressed.

Conclusions. Having more than one cause, the shortage of on-call physician specialists at trauma centers clearly requires more than one solution. Pursuant to the Resolution that requested this study, the Department of Health will be submitting a separate study with Hawaii-specific information on these issues. With this information, policy makers will be able to begin the process of determining what short- and long-term solutions to apply in their efforts to improve the on-call availability of physician specialists to The Queen's Medical Center, the only trauma center in the State of Hawaii.