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Panel discusses how to integrate trauma care into a practice

Issue: September 2013

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In this age of hospital consolidation, accountable care organizations and increasing governmental oversight, orthopedic trauma call has become considerably more complicated. Gone are the days of simply being required to take emergency room call as a prerequisite for hospital privileges. This Orthopedics Today Round Table was designed to offer the reader a look at various models employed throughout the United States, by members of different groups with disparate methodologies, in the hopes of providing insight and possible solutions for this issue.

Roy Sanders, MD
Moderator

Roy Sanders, MD: What is the call coverage arrangement in your hospital that works best for you? Is it all the call, divided call, one day a week, one week a month, etc.?

David Jacofsky, MD: Our philosophy at The CORE Institute is that alignment with the hospital is of paramount importance. As we move into an era of accountable care organizations (ACOs) and bundled payments, our relationship with the hospital will be inextricably tied. A hospital that has an adversarial relationship with a physician practice may have the ability to completely control the purse strings of that practice via patient steerage to groups with whom they are aligned. As such, we have always offered to cover all the available call at our partner hospitals. We believe this is relationship building. Additionally, as we deploy evidence-based algorithms and training modules, it is easiest to control outcomes if we are managing the largest percentage of patients being seen in the emergency department (ED). In a co-management structure, those participating in call coverage need not be part of our actual physician group, but rather, part of the co-management program. We have seen decreasing length of stay, improving outcomes and decreasing variable costs with this model.

Peter L. Althausen, MD, MBA: Our orthopedic surgeons take call at all four hospitals in the city. Only one is a designated level 2 trauma center. At the trauma center, call is covered by members of the orthopedic trauma panel, a 15-member group dedicated to providing this service. Ten of these members are partners in our practice, and three members are fellowship-trained traumatologists. All daytime call is covered by the fellowship-trained traumatologists, while night-time and weekend call is split evenly between trauma and non-trauma partners.

At our office, we have created call teams consisting of trauma and non-trauma partners who share in the coverage of trauma and general emergency room (ER) call at all hospitals in our city. Each team covers a specific weekday night (Monday through Thursday) so spouses, clinic staff and the physicians themselves have a regular and predictable schedule. Weekend call (Friday through Sunday) is shared on a rotating basis to promote equality. The fellowship-trained traumatologists are available Monday through Friday to accept all fracture cases from partner and non-partner orthopedists across town each day. This provides the most efficient use of the trauma operating room (OR), specialty-focused care and the least interruption to the elective practices of non-trauma call takers.

Kenneth J. Accousti, MD: Our call is divided equally among all the orthopedic surgeons who wish to take call. Currently, we have 12 physicians from three different groups on the call panel, which works out to two to three calls per month. We cover a level 2 trauma center as well as a second hospital and a free-standing ER. There is also a back-up call schedule, which is in place in case the primary call person is engaged in a case and cannot respond to an emergency because he is at the other hospital or ER. Main call and back-up call are covered by partners within the same group, which makes scheduling somewhat easier.

There is also a third hospital that is not a trauma center and is not affiliated with the main hospital system, and there is a separate call for this hospital as well. Physicians cannot cover call at both hospital systems on the same day. A physician who is on both call panels ends up with around four to five calls per month total.

Hank L. Hutchinson, MD: We have two hospitals in Tallahassee, Fla. One is a busy, level 2 trauma center and the other is a smaller, for-profit hospital that has a moderately busy ER. We are fortunate to have 20 partners in our group and 14 partners on the call schedule. Two partners are non-surgeons, and four partners are older than 55 years and have come off of the call schedule. What seems to work best for our group is to have everyone take call one day at a time. This seems to distribute the burden of call as widely as possible and give everyone in the group a more predictable clinical practice.

Being on call only twice a month makes it more bearable. We also all have a physician assistant or nurse practitioner take call with us. They handle all of the group patient calls and are available to see consults and assist in the OR and ER as necessary. Use of midlevel providers both while on call and during the regular work week to assist with rounds, clinic and surgery is the only way a busy trauma practice can remain manageable.

Sanders: What sort of cases does your group treat? Do you stabilize and refer or transfer, or do you do all the surgery yourself or within your group? Address acetabular fractures and complex periarticular fractures as well.

Jacofsky: With a group of about 50 fellowship-trained providers, we handle all the trauma we see. Although the individual physician on call may stabilize a patient with a complex injury, for example an upper extremity surgeon may span and debride an open femoral periarticular fracture, the definitive treating physician would be a member of our group. In this example, it would be either a traumatologist or a knee specialist.

Althausen: Our group has fellowship-trained orthopedic surgeons in all disciplines, except oncology, and primarily treats all fractures, orthopedic injuries and conditions. We refer out most tumors as our hospital does not have the support physicians and staff to provide high-quality, comprehensive oncology care. Our philosophy is all patients deserve the highest standard of care and we seek to provide this. Each orthopedic surgeon who takes call is comfortable washing out open fractures, reducing dislocations, placing external fixators and performing fasciotomies. All acetabular and complex periarticular fractures are treated by our traumatologists, while complex hand injuries, foot injuries, sports injuries and revision arthroplasty cases are cared for by partners with fellowship training in each discipline.

Accousti: This depends on the surgeon taking call. Some surgeons will refer fairly complex, multi-extremity trauma while most tend to treat whatever they feel comfortable. We have just hired a fellowship-trained traumatologist, so our group will keep periarticular fractures or pelvic ring injuries. The other groups will also tend to refer their complex cases to us for treatment.

Hutchinson: Our group takes care of all complex orthopedic trauma cases in our region. We have slowly become a regional referral center for complex cases. I am the only fellowship-trained traumatologist in our group, but all of my partners are comfortable taking care of fractures and stabilizing the more complex fractures with external fixators or traction as necessary. We have two fellowship-trained hand surgeons and two fellowship-trained foot and ankle surgeons in our group who take care of the more complex cases in their fields. I handle all of the pelvis and acetabular fractures that need to be treated operatively. I also take care of most of the complex periarticular and periprosthetic fractures as well. If I am out of town for more than a week, they could be transferred to another hospital if necessary. The ability to look at radiographs immediately from my phone or computer has helped tremendously with the management of the more complex fractures and contributed greatly to my partners’ ability to share information with me as necessary.

Sanders: What financial arrangements, if any, have you worked out with your hospital? What can you suggest as an ideal situation for a group involved in taking trauma call?

Jacofsky: This is a complex question. Physicians generally think of “compensation” for call in terms of actual dollars paid per night. We take a more global approach that includes variables such as: a) are we able to negotiate a co-management arrangement with the facility?; b) are we able to leverage better control over block time use, OR operations and hospital efficiencies if we agree to take call?; c) how large is the ACO or hospital-owned insurance plan managed by the hospital in terms of covered lives and will this arrangement for call have an impact on our ability to participate in a legally compliant way with payer reform strategies proposed by the hospital?; and d) what sort of payer mix is seen at the facility and how will our payment for relative value units (RVUs) be affected? Obviously, direct pay for call is great, but I believe it is only a small piece of the puzzle.

Althausen: Our orthopedic surgeons take call at all four hospitals in the city. Only one is a designated level 2 trauma center. We are paid a stipend to take call by each hospital for general ER call as well as a stipend to take trauma call. Trauma call is exclusive; however, the other three hospitals’ call can be covered by a single individual. Call pay is substantial and certainly incentivizes physicians to be involved in call. All partners younger than 50 years must take call; however, call is optional for partners older than 50 years. Part of the call arrangement at the trauma center involves access to a designated trauma OR and reimbursement for indigent care. Both of these are critical elements for a successful call agreement between private practice physicians and hospital systems.

This is an ideal situation for our group because we have three fellowship-trained traumatologists who cover for non-trauma partners during the day. Non-emergent cases, which present from 5 p.m. to 7 a.m., are transferred to the traumatologists or appropriate partner (i.e., hand to hand, foot to foot) each morning for definitive care. This allows us to maximize the call stipends for our group, allow non-trauma elective practices to run uninterrupted, maximize efficiency of the trauma OR, and share equally in night-time and weekend call among trauma and non-trauma partners. Group members pay trauma partners a portion of the stipend to cover day call. This rewards trauma partners for their efforts and is easily covered by the financial rewards of running uninterrupted clinics and elective OR lines. We would recommend any large group covering call hire a traumatologist. This allows for the highest quality of care, keeps patients from being transferred, improves hospital revenues and keeps hospitals from looking to hire their own traumatologists.

Accousti: We are reimbursed a set fee for call coverage per day. We are required to cover a level 2 trauma center, a second hospital that is about 25 minutes away from the main hospital, as well as a free standing ER that is affiliated with these two hospitals. If the back-up physician is engaged and he has to come in to evaluate the patient, a set fee is also provided for this service if used, which is half what we are reimbursed for taking call. The second hospital system in our area also provides a set fee for call per day and this is sent to an IRA-type account for a minimum of 3 years, after which the vesting period is reached and the physician can withdraw the funds. We are also paid a “come in fee” for emergencies if we have to respond to a call within 1 hour of being notified by the ER.

In our group, the call money goes directly to the physician taking call and that is not shared by the group, even for non-shareholder partners.

Hutchinson: Our group has a contract with the hospital to provide orthopedic trauma coverage. We divide the funds based on RVUs for unfunded patients taken care of with fractures. A portion is also given as beeper money. There is also a stipend for the orthopedic trauma director who helps supplement the unfunded majority in my practice. As an orthopedic trauma surgeon in private practice, I think a lot of variables have to be lined up just right to have a sustainable practice and lifestyle. A lot of partners who all take call and OR availability are probably the two biggest issues that help in my situation. We have an OR available for a 7:30 a.m. start everyday and on holidays. This keeps us from operating much at night.

Sanders: Do you think a group should take the call themselves, being generalists (or non-trauma trained, but fellowship trained in other specialties)? Or should the group hire a trauma surgeon or should the group have the hospital hire a trauma surgeon?

Jacofsky: I am not sure that one size fits all in terms of a model. We have found that having non-traumatologists with an area of anatomic specialty to manage the bread-and-butter trauma combined with a small number of traumatologists to manage the more severe and complex fractures has worked well in our large practice. Each practice, in conjunction with their hospital, needs to assess the case mix and volume to determine what makes the most sense. If 98% of a facility’s trauma is low energy, and the facility does not have other specialist trauma support outside of orthopedics, it makes little sense to support a traumatologist at that site. Conversely, level 1 trauma centers are likely best managed by those with more depth of training in the area of fracture care.

Althausen: Any large group should hire at least one traumatologist. Dedicated traumatologists allow for most efficient use of designated trauma OR, keep patients from being transferred and allow non-trauma partners to run uninterrupted clinics and ORs. In the process, overall group revenue is maximized by increasing efficiency while providing injury-specific and patient-centered care. It is our philosophy that generalists should share in the burden of night-time and weekend call. Traumatologists are not simply call takers; they are fellowship-trained fracture surgeons. When non-trauma partners stop taking call it is easy to forget the stress, difficulty and importance of call. In our current situation, partners are happy to give a portion of the call stipend to traumatologists because they continue to recognize the service these individuals provide. In exchange, trauma surgeons continue to have access to interesting cases, are financially rewarded for their efforts and are able to have a more predictable schedule with equal access to night and weekend off time.

Accousti: This depends on the type of setting in which one takes call. It also depends on the comfort level and training of the person taking call. I trained at a trauma-heavy residency and although I specialize in shoulder surgery, I enjoy treating periarticular fractures of the lower extremity. At our level 2 center, most injuries we see are low-energy fractures and there is a steady, but not overwhelming, volume of trauma cases. Those covering call at our hospital are in private practice, and we manage to balance our call responsibilities with our daily schedules. This would not work at a level 1 trauma center. We also have a fellowship-trained orthopedic traumatologist in our group to deal with more complex injuries, including pelvic ring and acetabular fractures.

Hutchinson: I think the whole group of orthopedic surgeons should take call. Our arrangement has allowed all of us to have a sustainable practice model. Most orthopedic trauma cases are done during the day, including hip fractures. We are comfortable handing off cases to one another as necessary. This is only possible with a guaranteed orthopedic trauma room as well as a second room available at noon for any other cases at the trauma center. We also have a noon room available daily at the non-trauma hospital. All of these arrangements make taking care of the trauma manageable.

As far as who should hire the traumatologist, I think that would vary from place to place. In a large orthopedic group, traumatologists fit in well and tend to do well if they have the right support from their partners and access to the OR. If the hospital has lower volume or multiple small orthopedic groups, I think it would make more sense for the hospital to hire the traumatologist. Either way, the traumatologist must always be diligent to ensure that the right resources are available prior to signing any contract.