Three Palm Beach County hospitals were cited by State authorities Thursday for alleged violations of the Florida laws that parallel federal EMTALA regulations for on-call physician refusals to see a 38-year-old patient with a gastro-intestinal bleed. The patient was transfered to a Broward County facility for treatment allegedly because gastro-enterology specialists at the three hospitals refused to participate in the hospital-mandated call system.

Hospitals nationally, and specifically under Florida laws that are slightly stricter than the federal EMTALA regulations, are required to have specialty services at their hospital available on-call to the emergency department. According to the published reports, only 2 gastro-enterologists out of a dozen would take call at the three hospitals, and the remaining doctors had threatened to resign from staff unless paid $1,000 per day to be on call. Local papers report only 20 of 92 gastro-enterologis in the county will take call.

The on-call time bomb continues to tick nationally as hospitals try to enforce call requirements to meet federal law and stay solvent, while physicians increasingly refuse call.

Federal EMTALA regulations were revised in 2005 to prohibit physicians from taking call for their own patients if they refused take call for the ED. The regulation mandated hospitals enforce their call schedule requirements or face citations that could ultimately result in fines of up to $50,000 per incident or loss of all Medicare funds. Physicians who refuse assigned call can also be fined up to $50,000 per incident and may be barred from treating Medicare patients.

Local newspapers report that an apparent group action to get paid call is involved in what amounts to concerted action to avoid call, because the gastro-enterology specialty is now less dependent on hospitals for their practice. Surgery centers and office capabilities have expanded to move much of their practice away from the hospital setting. Federal ant-trust laws, however, prohibit collective actions by doctors.

Hospitals throughout the nation are experiencing similar situations along with constant government and insurance cuts in payment for services and rising prices of their own. In some cases hospitals report threatened bankruptcy from the demands for on-call specialty payments and struggle to get specialists to come in for routine consultations on paying patients. Many lawyers also question whether the pay-for-call practice that is becoming more common in many urban areas with scarce specialties is even legal under the federal and state anti-kickback and fraud laws.

Specialty coverage in many areas of the country and in many specialties is so difficult to obtain that many industry experts expect a rising toll of deaths before patients reach necessary care via interhospital transfers. Destination hospitals for such transfers are also declining because of their own on-call problems. While many hospitals have chosen to hire their own physicians to alleviate the call issue, these expenses often are unsustainable due to the large uninsured volume that many of these hospitals receive.

The problem, however, is not entirely one of paying specialists enough to get them to come into the hospital. Many physicians argue that the on-call obligation cuts into their ability to earn money in their own practices and that they are facing declining reimbursements that make it harder for them to make a living also. The issue is not new, however, and was a critical concern when the federal EMTALA laws were pasted in 1986. The law served as a bandaid by mandating hospitals provide call, and the hospitals had the tool available of requiring call under their hospital bylaws. Doctors needed hospitals to build their practice and to perform many of their services. Today, like the gastro-enterologists in Palm Beach County, they need the hospital less and less. The ethics of former years, where physicians viewed hospital membership and service as a moral and professional commitment seem to be losing influence over a large portion of the medical community.

Beyond issues of economics, ethics, and professionalism, the fact is that for many physicians -- especially younger physicians -- it is not a matter of how much money it would take to get them to take call, because it is first and foremost an issue of lifestyle. There simply is not enough money at any price to make them live the demanding lifestyle of physicians in by-gone years. Older physicians are retiring earlier to escape the demands of practice and avoid the regulatory and legal environment that has lessened their autonomy as professionals.