Judy Bee, a management consultant with Practice Performance Group, equates call coverage with the “hideous schedules in residency”: It doesn’t have to be as bad as it is, but it’s become a tradition.

Particularly in a time when younger doctors are coming out of school seeking some semblance of work-life balance, call coverage can be the kind of issue that can break up a practice. But it doesn’t have to be.

“You can use call coverage to your advantage … or it can be a huge disadvantage,” said Bee, who has seen doctors kicked out of a group over the issue.

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Here are some tips from the experts on how to manage calls to make everyone as happy as possible.

Early and often

Practices should look at their employment agreement once a year and find out whether or not it addresses maternity or paternity leave, phasing into retirement, and potential unplanned issues that can impact call coverage. 

“The time to start negotiating is not when you need to make a decision,” Bee said. “Every year it should be on the calendar to review and see if it still makes sense as you grow older and the dynamics of the community and healthcare change.”

The first thing doctors considering joining a practice ask is how much vacation they will get and how often they will take call, said Robert Provenzano, MD, vice president of medical affairs at DaVita healthcare partners. A 1-in-4 is the most traditional schedule: 1 weekend a month or once every fourth night is usually considered “tolerable.”

But practices change and evolve and it’s best to have some sort of plan set up before they occur, not after.

Planning for the unknown

There are a host of reasons why call coverage in a practice might be changing, some of which are expected, and others that might come out of the blue. Whether it’s a pregnancy, illness, retirement, or physician burnout, each should be dealt with in an agreed-upon method by a practice.

If a group lands on a predictable schedule that works for doctors most of the time, then legitimate reasons for change should be defined and ways to deal with them should be determined. For instance, a practice partner may want time off after the birth of a child and 2 months is the agreed-upon leave. If a problem occurs and the partner needs to stay away for a longer period, the doctors should decide in advance how the physician can make up for that extension.

One often-used option is the buyout. Bee said she has had practices call her wanting to know how much to charge for covering call and her answer is always the same: whatever it’s worth. 

Call is essentially worth whatever a partner will take to cover it. She recommends splitting the work of the practice into categories, whether it is just taking calls from patients or performing surgery, and determining what they are worth.

Senior partners are often able to work with younger partners (who Dr. Provenzano said have more energy, are trying to get their name known, and who need extra money) if call is valued fairly. He said many practices don’t allow senior partners to completely exit from being on call, but they can sell it. Another option is to cut back on call coverage but reduce vacation time.

Outside the box

Aside from selling call, there are a few options that can solve the call problem in a practice.

Many practices have a large number of patient calls that don’t necessarily require admissions. These calls that are a “bloody nuisance” can sometimes be handled by mid-level providers, Bee said. A nurse practitioner could manage most of those calls and only refer ones that they can’t handle to the on-call physician.

“Using a mid-level on a rotation is viable and worthwhile, especially if there aren’t a lot of you to share the load,” Bee said.

Another option is to work with other, similar groups in your area. People get particularly fixated with weekend call because of the disruption it can cause to a family. A small group may want to handle their own calls during the week, but have a call group with 2 other practices so they may only have to take call once every 3 months.

A final solution is a newer option that is not yet widely employed: hiring nephrohospitalists. Dr. Provenzano said this position is often a young partner who would have no responsibility outside of the hospital. They would round in the hospital every day and take a disproportionate share of call.

This job can be very demanding, and he said it usually only works for a couple of years before the physician will evolve into a more normal practice pattern. This position can either lighten or eliminate the need for call, depending upon the group. It can be a good way for a group to transition when someone is retiring or there is high burnout.

A nephrohospitalist’s salary is usually 10% to 20% higher than a traditional position because they generate money from their first day on the job.

In the end, Kenneth Hertz, principal with MGMA’s Health Care Consulting Group, said wrangling with the issue of call coverage is really about problem solving. A practice that has a good method for decision making and knows what its core values are will likely have an easier time working out this issue.

If a group can focus on what is best for the whole instead of what is best for each individual doctor, it will have fewer battles with call coverage. Instead of having everyone give input, he recommends choosing just a few doctors who can create a study group to come up with a couple of recommendations for the whole group to decide upon.

“An equitable solution often means that everyone is just a little bit unhappy,” he said.