Emergency Departments (EDs) are required ethically and by law to provide a full panel of physicians who provide specialty services to patients who present to the ED for care. This panel of physicians is separate and distinct from the emergency physicians who provide the initial level of care in EDs. Two examples of patients who would require the services of a panel of specialty physicians would be:

• A patient with a heart attack would be stabilized by the emergency physician, but would require admission and further treatment by a cardiologist or internal medicine specialist.
  
• A patient who is diagnosed with appendicitis by the emergency physician would require a surgeon to actually remove the appendix.

The physicians who are members of this specialty panel are commonly referred to as the "ED backup physicians" and in most cases are members of the general medical staff. Each hospital is required by law to have accessible ED backup physicians in each specialty available within the hospital. For example, if the hospital has an orthopedic department, then orthopedic surgeons must be available to provide care to emergency department patients who require orthopedic evaluation. Despite the law, 60% of California's hospitals have at least a somewhat serious on-call coverage problem, according to survey results by Loren A. Johnson, MD, published in Lifeline, the monthly newsletter of CAL/ACEP).

ED backup physicians in most cases only provide care for patients who do not have a private physician. If a patient has either a private physician or is member of an HMO and requires specialty care in the emergency department, the private physician or HMO is contacted and arranges for specialty care.

In the past, members of the medical staff generally volunteered to be part of the ED backup panel. But as the number of uninsured patients requiring emergency care increased, providing ED backup services became economically unattractive for most members of the medical staff.

In addition, as more fee for service patients were enrolled into HMOs, the number of paying patients utilizing the services of the backup physician decreased. Therefore, it became difficult for the backup physician to offset the losses from the uninsured patients with payments from the insured patients. This is a process commonly known as "cost shifting."

The willingness of backup physicians to provide emergency services is further eroded by the decrease in their private practice income because of the invasion of managed care.

In many hospitals, the unavailability of ED backup physicians can reach a crisis point. Since the hospital has the responsibility to provide the services of ED backup physicians, several possible solutions are commonly entertained. Outlined below are three possible solutions to the unwillingness of members of the medical staff to serve as ED backup physicians. These three solutions are the Mandatory Call  Solution, the Stipend Solution and the Fee for Service Solution.