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Surgeons are among the highest-paid professionals in Utah, but only if patients actually pay, and many who seek treatment at hospital emergency rooms do not.

That's certainly true at Intermountain Health Care's Cottonwood Hospital, where a November 2003 study showed 60 percent of ER patients cared for by select orthopedic surgeons were unable to pay. Since then as many as 22 such specialists have resigned rather than work the ER. The most recent exodus came last month after IHC threatened to report surgeons who duck ER duty.

Those who left say their dispute isn't with the increasing number of patients who lack money or health insurance, but with IHC, which boasts about offering charity care but refuses to fully compensate many of the doctors who provide it.

"We just want a little acknowledgement and to be treated fairly," surgeon Paul Winterton says.

Instead, Winterton and four surgeons who canceled or downgraded their status at Cottonwood were temporarily and erroneously blacklisted from all IHC hospitals. An internal e-mail circulated among IHC secretaries said the doctors "will NOT EVER do a surgery at IHC again."

IHC quickly apologized, in writing, for the "miscommunication" and insisted there was no malice behind the memo. But Winterton says the mix-up demonstrates a culture of disrespect for physicians. "In their eyes, we're providers, not physicians."

IHC has formed a task force to study emergency-room compensation. But the dilemma is not just a Utah issue. Most U.S. hospitals insist that physicians with active privileges take a turn covering the ER, a 24-hour repository of slipped discs, cracked hips and broken legs - injuries that require months of follow-up care, making emergency rotations quite costly for orthopedic surgeons. Only half of all hospitals pay doctors for their time and even fewer offer a fee for being on call, said Marc Mariani, president of the Utah State Orthopedic Society.

"Doctors feel an ethical duty to cover the ER and administrators exploit that," says Mariani, a St. Mark's surgeon who canceled his privileges at Cottonwood two years ago. "Some are saying, 'It's not worth it anymore. I'm out. I'm done.' Even at St. Mark's, there are rumblings of physicians saying, 'We're not going to do this unless the hospital will pay us because, after all, it's the hospital's ER.' "

But the problem is more acute at Cottonwood, where complaints of preferential treatment are common among non-IHC physicians. Much of their frustration centers around The Orthopedic Specialty Hospital (TOSH), an exclusive but related surgical center next door. TOSH is owned by IHC and employs mostly IHC physicians who have the luxury of admitting patients to Cottonwood without having to cover the ER.

That changed last fall when the orthopedics department, faced with a shortage of volunteers, made covering the ER mandatory for all orthopedic specialists and threatened to report those who refused - even specialists whose malpractice insurance may not cover them if they stray from their area of expertise.

Soon after, doctors at TOSH started tracking the patients. In November, they presented a report to the hospital that showed 60 percent of ER referrals were uninsured. Robert Horne, a general orthopedist who resigned from Cottonwood last month, says that in three years he provided $250,000 in free care and unlike IHC, he cannot write it off.

Armed with such statistics, orthopedic specialists at Cottonwood asked for a $750 per day stipend, noting IHC pays doctors to be on call at its trauma hospitals in Salt Lake City, Ogden and Provo. IHC denied the request.

"We can't pay people $750 a day just to carry a beeper," IHC spokesman Jess Gomez says. "That equals $300,000 a year, multiplied across all departments, and you're talking billions. With hospital privileges comes the responsibility to provide on-call coverage to see patients in the ER."

Mariani says most doctors would be satisfied if hospitals simply shared the cost for the patients they treat, especially because emergency rooms are fertile ground for malpractice claims. So far, patient safety has not been compromised, he says, but that could change if all hospitals pass mandates like the one at Cottonwood. Most surgeons carry privileges at several hospitals and they could be forced to double up their emergency-room rotations.

"There was a time when covering the ER was a great way for young physicians to stay busy and get patients," Mariani says. "But if you have a mature practice, it's a real strain. I can't imagine the day would come where we all just walk away, but there are physicians who are talking about it."