In a desperate move to get doctors back into Tucson's emergency rooms to care for patients, hospitals here have started paying for that service.

That may sound like a logical thing to do, but it is no less than a revolution in emergency medicine — one that could trigger a wave of hospital bankruptcies, hospital officials fear.

"The only successful means of dealing with this crisis right now is paying them," said Greg Angle, CEO of St. Joseph's Hospital, one of several Tucson hospitals lacking vital ER coverage by physician specialists.

"But this is becoming a very, very slippery slope, endangering hospitals' bottom lines. The jury's still out on this. It's too new to know if hospitals can really afford it.

"But I can tell you it is costing us a very substantial amount of money to do it," he said, as much as $3 million a year.

In the good old days — just a few years ago — the idea of paying doctors to go on-call for emergencies was unthinkable. The age-old deal was that if doctors had privileges to practice at hospitals, then those doctors were obligated to take emergency calls there on a rotating basis with fellow specialists.

At a time when there was no shortage of specialists, and when most had privileges at three or four hospitals, the system provided full specialist coverage at Tucson's ERs, creating a solid safety net for emergency patients.

Now in tatters, that safety net began unraveling during the past decade, as economic pressures on physicians changed dramatically, making it no longer financially productive — or even fair, in some cases — to cancel their daily practices and rush off to the ER when called.

"Doctors are one of the few professions where salaries have actually declined over the years," Angle said. "Under managed care, their reimbursement by health plans and Medicare is dropping, while their malpractice premiums keep rising.

"So, the only way to make a decent income is to get more volume in their daily practices, and every time you're called to the ER eats right into that."

Then there is the ever-rising number of uninsured patients — a huge issue in a border state — who tend to inundate ERs, the only place many can get care.

"If a patient is uninsured, the doctors usually don't get paid at all for treating them," Angle said. "So, gradually, they have pulled away from taking emergency call. And the only way to get them back is to make it worth their while — compensate them."

Doctors have cut back their ER obligations by resigning their hospital privileges. Today, it's rare for a doctor to have privileges at more than one hospital. Many specialty surgeons, who operate out of their own outpatient surgical centers, don't need hospital privileges at all — leaving them with no ER obligations.

Fueling this trend was a much-criticized federal ruling in the mid-1990s, decreeing that if doctors had privileges at several hospitals, were treating an emergency at one and got called to another and couldn't get there, they could be slapped with federal fines for failing to respond to an emergency.

"That set off a wave of resignations from the hospitals, who suddenly found themselves with dropping coverage in their ERs," said Tucson neurosurgeon Dr. Eric Sipos.

Perhaps the most critically needed specialists in emergency care — because brain and spinal problems often can't wait — neurosurgeons were among the first to be paid for ER duty in Tucson. When Tucson Medical Center — home of the city's busiest ER — started paying them in March, that guaranteed vital neurosurgical coverage there Monday through Thursday — a major improvement.

"But on the busy weekends, no. So that's when we spend most of our time on the phone, calling in favors, or trying to get patients into UMC (trauma center), or to Phoenix," said Dr. Ronald Widman, TMC's director of emergency services.

Even though ER physicians admit that paying these specialists has eased this crisis somewhat, they don't like doing it, knowing it is draining precious resources from other services, and putting their hospitals in financial jeopardy.

In Tucson, paying a single specialist to cover the ER can cost up to $1,000 a night. Hospital CEOs estimate paying for adequate specialty coverage — neurosurgeons, orthopedic surgeons, hand surgeons, vascular surgeons, general surgeons, gastroenterologists, and ear, nose and throat doctors — is going to cost them $1 million to $3 million a year. With total hospital revenue margins running at only about $5 million to $6 million, in a good year, that's a huge — and likely unsustainable — hit on the bottom line.

"This trend is not going away, and it could bankrupt a hospital," Widman said.

Chagrined that hospitals are "capitulating" to the specialists' demands for payment, Dr. John Bush, ER physician at St. Joseph's Hospital, said: "We've opened a Pandora's box now. This will drain the meager profit margins hospitals must have to get the nurses so badly needed to run a hospital. This makes me furious at the gut level.

"I just have to ask the specialists themselves why they no longer feel a civic duty to lend their expertise in helping patients in emergencies, why they make themselves unavailable to ERs where humanity presents with the real problems?"

The wrenching validity of that question is why one specialist, Sipos, is working with Carondelet Health Network — owner of St. Mary's and St. Joseph's hospitals — to create the Carondelet Neurological Institute, now under construction and due to open early next year.

By packing the $30 million institute with the most sophisticated, high-dollar, neurologic technology available, and dedicating beds only to the care brain and spinal patients, they hope to make it an irresistible magnet to attract more neurosurgeons to Tucson.

And they've pledged to provide 24/7 neurosurgical emergency care at nearby St. Joe's.

"That means other ERs can transfer their neuro patients to St. Joseph's and CNI and not have to send them out of town," said Sipos, slated to be the institute's new medical director. "It will put an end to all that shopping around for these critical patients."

What ER physicians also want is a citywide call system that notifies all ambulances, paramedics and ERs where the various specialists are available on-call during any given day or night shift. With that, the paramedics can take patients directly to the care they need.

"I don't see why we can't do this with all the specialties," said TMC's Widman. "It just makes sense. It does not make sense to keep taking patients where you know you can't care for them."

As logical as that may sound, there has been resistance to this idea. Transporting a patient all the way across town to a specific ER can tie up a paramedic unit for more than an hour. Hospitals, and the doctors themselves, fear getting "dumped on" if word goes out they have certain specialty coverage.

"And a paramedic can't always tell what specialist is needed — that can be especially difficult when it's a neurological problem," said Dr. Herb McReynolds, chief of emergency services at St. Mary's.

Even so, "this likely could and should work, for the sake of better patient care," said Taylor Payson, executive director of the Southeast Arizona Emergency Medical Services Council, which directs all ambulance and paramedic service in the region.

"The biggest problem is making sure the information we have is accurate and timely, so we know where the doctors really are. The ER situation changes all the time.

"But I think it could be workable."