The Doctor is In ... Eventually

State health officials are considering lifting a requirement that Texas emergency rooms have a physician on-site at all times — as long as a doctor can get there within 30 minutes.

The proposed change is designed to ease financial strain on small specialty hospitals, which are required to have emergency rooms, but see very few emergency patients. These hospitals say they shouldn’t have to pay to have an ER doctor there 24/7, particularly when there’s a large community hospital or major trauma center nearby.

“In low-volume hospitals, in rural hospitals, it’s a poor use of resources to staff a physician in the ER around the clock,” said Tony Wahl, CEO of the Texas Spine and Joint Hospital in Tyler, a specialty hospital less than a mile from a major trauma hospital. “Ambulances don’t come here. Patients don’t come here. ER doctors are scarce enough. If you have a hospital that sees just 10 ER patients a month like we do, it’s a drain.”

But opponents say the proposal would create confusion and risks for patients, who come to emergency rooms with the expectation that a doctor will be there to treat them immediately. And they say it’s just another way for “boutique” hospitals that specialize in high-dollar surgical procedures to expand their profit margins. Typical emergency room ailments — and the under-insured patients that come in with them — are often money-losers for community hospitals.

“They’re trying to avoid costs, to avoid people who don’t have insurance, to avoid the responsibility of being part of the community provider network,” said Ed Berger, vice president of advocacy and government relations for the Seton Family of Hospitals. “They’re trying to carve out a little niche, to do their thing without having to bother with the challenges and frustrations of operating an emergency department.”

The debate over emergency room staffing began in 2007, when lawmakers considered a bill that made around-the-clock ER doctors mandatory. The bill, which expanded existing rules, didn’t pass. But the Department of State Health Services instituted a similar measure the following year.

The agency’s move frustrated specialty hospital executives, who approached lawmakers seeking a repeal. But a repeal bill considered during the 2009 legislative session didn’t pass either. In response to concerns from specialty hospitals, the health agency started devising possible revisions this fall, and expects to make a decision in the spring.  

“Our hope is to reach a decision that meets the needs of the hospitals and patients but in no way compromises the quality of care,” agency spokeswoman Carrie Williams said.

The proposed rule change, which is still in draft form, would require that an emergency medicine doctor be present in a hospital emergency room within 30 minutes of a patient’s arrival — and reachable by phone instantaneously. Hospitals without doctors immediately available would have to notify local ambulance services and 911 dispatchers, and report it on their signs and marketing materials.

Proponents of the change say for years, hospitals across Texas have had doctors on-call but not on-site, and it worked just fine. They argue not even the Joint Commission, the non-profit organization that accredits and certifies U.S. health care organizations, requires ER doctors to be on-site around the clock.

And they say the change would help not just specialty hospitals but small rural hospitals, which don’t have the financial resources or economies of scale to compete with larger community hospitals.

“In some communities out in the country, it’s hard to get a physician to even live in your town, let alone to sit in an emergency room 24/7,” said Sen. Robert Nichols, R-Jacksonville, who filed the bill last session to repeal the ER rules. If the current rules stay on the books, he said, “instead of improving emergency rooms, we’re going to eliminate a bunch of them.”

But opponents of the 30-minute rule say the rural hospital argument is a red herring. The existing rules provide exceptions for hospitals in counties with fewer than 100,000 residents and allow hospitals facing economic hardship to apply for waivers, though other area hospitals must sign off on the waivers.

And they say if a medical facility wants the benefits of being called a hospital, it must act like one — complete with a fully-staffed emergency room — or get licensed as something else.

“When patients are driving down the highway and see the blue ‘H’ sign, they expect to get an emergency room that’s staffed by a physician,” said Matt Wall, associate general counsel for the Texas Hospital Association. “We think keeping the status quo is in the best interest of patient safety.”