Increasing Demand for On-Call Pay
On-call compensation: to pay or not to pay?
We are a moderately sized pediatric teaching hospital with a level 4 NICU and designated as a level 1 Pediatric Trauma Center. We have a 66% Medicaid patient population. The vast majority of our physicians are employed by an independent University practice plan. Historically our subspecialists have taken call as part of their clinical responsibilities as members of the medical staff. Over the last 5 years many subspecialists have requested additional compensation to take call. We have provided some surgical specialists with call compensation in order to maintain our Level 1 Trauma Center status. However extending on-call compensation to the remainder of our surgical and medical specialties is not financially sustainable. On-call pay is an additional expense without any associated revenue. Our challenge is to maintain our current cohort of subspecialty coverage without adding significant added expense.
Current call compensation is provided for: Neurosurgery, EEG, Cardiology, Hand Trauma, ENT, General Surgery, Psychiatry
Call compensation is NOT currently provided for: Pulmonology, Infectious Disease, Hematology/Oncology, Allergy/Immunology, Gastroenterology, Ophthalmology, Orthopedics, General Neurology, Urology, Endocrinology, Genetics/Metabolism, Nephrology, Rheumatology, Dermatology
Participant comments on Increasing Demand for On-Call Pay
The disparity in compensation for on-call services is not sustainable in the long run.
This has always been part of physician responsibility, paying extra for it seems a bad practice to begin with.
I think it should be abolished for all, instead it would be better to have another list of criteria to take physicians off the on-calls service, like seniority, clinical and research productivity, faster discharge time, patient satisfaction among many other things.
Being off on-call service should be considered a privilege to be earned.
Our physician compensation model is based on median compensation for median productivity (per a few different compensation surveys). For departments who take call, we’ve offered to reduce the productivity pay component and create a call pool that the department can use to pay for call. Median compensation in the surveys is total pay (including call pay). This is a way to pay for call (which is becoming very difficult to avoid) but be budget neutral.
We must first understand why physicians took call historically. Historically, call was a responsibility that physicians accepted to grow their practice and gain exposure to the community. Most physicians would have already been appropriately compensated for their work and as such accepted this burdensome responsibility. Over the years call has become something that increases the risk for being sued and it work does not equal appropriate compensation. There is no reward monetarily or regarding time. To expect physicians, to continue to take call without giving back will ultimately result in the hospital losing quality doctors and more importantly increasing doctor frustration and potentially a drop in productivity. My suggestion, is that you have to give to get. Rather than compensation, can you give the doctors the next day off or a reduced work load without financial penalty. I believe you need to also identify cost saving opportunities that could potentially offset the call pay. Challenge each department to find the savings that could be reallocated to call pay. Remember, not paying with either time or money is not an option. Its simply a recipe for disaster.
Wages in our hospital are combined: a fixed salary and variable part to be earned by individual performance indicators. For the on-call problem a ‘inconveniency surcharge’ was introduced: a 8% surcharge on top of the fixed part of the ( 100%) salary in wich there are 7 levels. A young specialist starts in group 0 and over the years you proceed to a higher level. So everybody knows that being on-call is well payed for (since it is 8% of the 100% fixed salary even if you work less than this 100% (so less than five days a week)). There is no discussion anymore. When you are employed for a longer time the 8% of your rising salary (higher group) is enough to be satisfied with. Sometimes you are lucky and you don’t have to come to the hospital that often: that is the difference and so the focus has changed.
Off course there are differences in intensity of work during on-call hours: as a dermatologist I know that a on-call consultation takes less time than for instance a cardiology-consult. The percentage of surcharge could be different for different specialties. If you take historical data you can determine what specialty should be higher awarded: not for specialism but for time spend being and working on-call. I would be satisfied with the fact that every specialism is compensated in some way even if there is a difference in percentage.
the system could be financed by calculating the total of costs wich is already reserved for on-call activities and divide this among the total group of specialisms.
Similar to your approach, we pay for call coverage only for physicians required by the trauma system. This list is found in the Washington administrative code book for us. This keeps the decision to pay objective and difficult to criticize as playing favorites. The logic is this is an added responsibility that the physician did not get to vote on. For others, call is part of physician work.
For the covered groups, we use the 50th percentile of MGMA to set the rate. A scoring system that relies on frequency of call, number of hospitals covered, number of admissions when on call, number of surgical cases when on call provides added refinement. This allows us to differentiate work loads among the various specialities.
We have negotiated a higher reimbursement from the payers for emergency medical services and procedures. The added revenue is distributed among the medical and even the para-medical support staff that attends the call. No one wants to leave home in the middle of the night to attend a call by choice. So, if someone is doing that then they need to be compensated. Disparity in paying a certain group and not the other just causes dissatisfaction and resentment.
I believe it is unsustainable to compensate some physicians for being on call and others not. Since there is increasing pressure on all physicians and since, in my eyes, it is unethical to put the biggest burden of calls mostly on young shoulders (like resident’s shoulders), I think we have to recognise that being on call is work that should be compensated. Probably better than compensating only those specialties that are required by the trauma system, I think it is better to differentiate using other parameters, like the gravity of the calls for the different specialties. Of course there will be discussions, but I think it is possible to find objective criteria.
I am not a physician and realize this raises another set of questions, but is it possible to differentiate the types of on-call services? I see the above comment about trauma system versus other types of call as one possibility, but I am anecdotally aware of “on call” not always meaning that a physician has to come in or otherwise engage (conversely, members of non-clinical service lines often take weekend “call” questions about operational and patient experience issues, but suggesting that they be paid any type of “call” premium or overtime would be a crazy concept).
The on-call payment model does not seem sustainable long-term, so perhaps there is an opportunity to experiment with other types of incentive-based compensation that reflects the time and effort commitments of the various providers? Good luck!
My initial reaction was to question the rational behind the decision to pay some and not all. In my opinion, this is not sustainable and should be abolished totally. I think its ok to fairly compensate physician based on productivity and quality of care. So its better to have a general language in the contract, if these are employed physicians, stating clearly the expectations of their clinical duties and responsibilities. Adding extra pay for calls may only complicate issues, so if call is included in quality/productivity/wRVU clause, it may make the difference. So in summary, I think constituting a compensation committee with representation from the different specialties to discuss and decide on this matter will be a good starting point. Good Luck.
Compensating for on call especially if the specialty involves coming in to do procedures or surgeries off hours is something that has to be preserved, unless it is rolled into the overall compensation package. Every other field does that. Separating calls that require just carrying the pager/cell phone but does not involve coming to hospital and those that involve coming in will be helpful. Consider setting up parameters – for those specialties who do not have to come in off hours – on when a specialist should be called. Have these individual specialties come up with the criteria that will minimize the number of elective calls they get at night. This may make calls without compensation acceptable for them.