Financial Implications for Physicians Accepting Higher Level of Care Transfers

Mark I. Langdorf, MD, MHPE; Sharon Lee, MD; Michael D. Menchine, MD, MPH


Western J Emerg Med. 2013;14(3):227-232. 

In This Article


According to a recent national survey, maintaining on-call specialist panels has become an increasing problem nationwide, with 74% of ED directors reporting problems.[5] Between 2000 and 2006, surveys of California EPs indicate increasing problems obtaining timely specialist care for 9 of 20 specialties (mostly surgical), and that the number of specialty call panels for community hospitals is, on average, declining. Community practitioners who care for underserved populations reported the most problems.[1,2]

Although we obtained billing data for 12 specialties, including internal medicine, pediatrics and family medicine, the HLOC service required of the transfer was most often a surgical subspecialty. Furthermore, the 41 ophthalmology patients in our system were admitted to internal medicine or pediatrics. Consequently, the most common services required for HLOC transfers were surgery with trauma (including burns) at 52% (294/570), neurosurgery 15% (87/570) and neurology 14% (81/570). This in turn reflects our tertiary center's status as an American College of Surgeons Level I Trauma Center, and The Joint Commission-certified Primary Stroke Center. The next most common groups of patients were ophthalmology, orthopedics and head and neck surgery (at 6–8% each).

At our tertiary care center, specialties that hospital surveys indicate have the most trouble maintaining call panels (neurosurgery, otolaryngology, orthopedics, and ophthalmology), paradoxically had higher-than-average reimbursement per RVU compared to other specialty's higher level of care patients. Plastic surgery had lower-than-average reimbursements per RVU, but this is likely inconclusive with only nine HLOC patients (Figure 2, Table 1).

For specialties with complete reimbursement data (n=8), average professional fee reimbursement for HLOC patients was higher than all-patient reimbursement rates only for EM and neurosurgery. Of the other problematic surgical subspecialties (head and neck surgery, orthopedics and ophthalmology), HLOC transfer reimbursement was lower for ophthalmology, but unavailable for the other 2. This implies that neurosurgery and EM may benefit from accepting HLOC patients, but not ophthalmology. At our center 319/570 (56%) patients arrived through the ED, and though they may contribute to crowding and flow problems, these patients appear to reimburse better than the average ED patient (Figure 4, Table 1 and Table 2).

For HLOC transfer patients, all specialties studied at this center (n=12) had lower reimbursement per RVU than national benchmarks [$49.81 vs. $65.62 (weighted average of national RVU/patient reimbursements proportional to the number of HLOC transfers by specialty in this data set)]. Therefore, our site had substantially lower reimbursements compared to the national data, likely a reflection of our challenging payer mix as an academic institution. Previous studies have found that receiving hospitals have a poorer payer mix than transferring hospitals, which in turn shifts the burden for care of these patients from the private to public/academic sector.[6]

While the hospital realized $2,586,200 in profit from these 570 patients, the total professional fee reimbursement was $948,450, or $1,663 per patient.[7] We have no way of calculating professional costs to care for these patients, so cannot comment on physician "profit," but reimbursement per RVU was $49.81, or 131% of RBRVS. Some specialties may consider this attractive, while others not. From an ED perspective, HLOC transfers generate 133% of RBRVS compared with 115% for all other patients, and are therefore economically advantageous at this site. Couple this with the obvious patient need for special expertise in the tertiary center, as well as provision of patient material to support training and procedural needs, and these HLOC transfers should be viewed as desirable.