I recently encountered a social media post discussion about declining physician on-call availabilities, and how it seems ever more difficult for patients and emergency departments to gain access to on-call services.^1,2,3

For rural hospital systems, lack of access is nothing new.^4,5 When rural patients present urgently or emergently with more critical, complex, or specialized needs, these services are frequently not available locally.⁶ This represents an ongoing availability quandary and escalating physician “shortage” problem that have plagued rural health systems for decades.^7,8

But now we are seeing expanding physician shortages nationwide and increasing difficulties with on-call availabilities even in urban and referral areas.^9,10

What’s Going On?

One postulate offered within this recent on-line discussion was that newer physicians are less likely to agree to, sign up for, or accept employment options that require “on-call” services, preferring to now work only “business hours.”

However, in my recent experiences, I find that frequently, it is the facility’s administrative managerial system that is doing away with physician on-call options, and this is being done for financial reasons!

For facilities, the maintenance of physician “on-call” access, along with any supporting staff, such as on-call nurses or other staff and infrastructure support that an on-call service may require, can become profoundly expensive. This is especially true for those services that provide more specialized or intervention-based services and/or may involve an entire on-call team.⁶

Specialists and subspecialists remain the most expensive and some of the shortest-in-supply physicians, especially proceduralists (and especially if they are now being paid by the hour, or involve enhanced on-call premiums), or an on-call “team” for a facility to support. In an era of increasing nationwide physician and nursing shortages, such services become even more costly to provide and maintain.

These on-call costs add to the soaring overall costs health care facilities are now facing challenged by declining federal and third-party payer remunerations, bundled payment limitations.¹¹ In addition, hospitals and health care systems are also having to prepare for ways to combat upcoming revenue losses and increasing unpaid bills evolving from the additional estimated 17 to 20 million Americans who are scheduled to lose Medicare, Medicaid, or Affordable Care Act health coverage over the next one to three years.^12–18

Adding to this conundrum, new federal regulations may possibly slow medical debt collections.¹⁹

Health care facilities thus anticipate that expense-side issues and unpaid medical bills will continue to escalate as revenues further decline. With on-call access being some of the costliest services to provide, uncompensated or undercompensated services rendered can be a huge disruptive factor for a facility’s financial bottom line.

How are Health Care Systems Responding to These Challenges, and the Impact on “On-Call” Services?

The single largest operating expense hospitals face, per most economists, is employee compensation.^20,21,22 Therefore, cost-containment efforts include analyzing total costs of providing on-call services and costs associated with keeping these often most expensive physicians, their supporting staffs and infrastructure systems available “on call,” as compared to revenues and “benefits” received by providing these services.²³

Many of these analyses now show that for a variety of “on-call” situations, costs are now exceeding revenues received.

Aside from valuations of indirect financial benefits such as marketing and addressing patient access issues that “on-call” availabilities may provide or address, many hospitals are finding it increasingly difficult to meet their bottom-line operating expenses.^20,24,25 Therefore, they are even more intensively undergoing pressures to question their services provided^.26

Hospitals face difficult choices as they seek ways to cut back on expenses.²⁷ We are seeing overnight and now even weekend and “holiday” on-call availabilities reduced or eliminated if the financial bottom-line determinations show that costs are exceeding revenues and if there are no requirements or contracts to provide such services.

For facilities “caught in the middle” of meeting requirements for on-call services and with accelerating shortages of specialist physicians and support staffs, increasing service provision costs, and expenses escalating beyond revenues, “on-call” requirements, costs and compensation may become critical determining factors in decisions to shutter some clinical service lines.^28,29,30

Results

When hospitals cut back or reduce available clinical resources, delays or denials of patient care services could lead to declining patient outcomes.

These conditions will continue to worsen until and unless we see major changes in our current system of health care delivery and finance.

Dr. Severance is an internationally recognized health care strategist and analyst, named as a top 50 health care global thought leader and influencer for the past three years in the health tech realm by Thinkers 360, with more than 50 recent publications and presentations on health care workforce/workforce system and financial issues. He consults and advises multiple organizations and companies on health care systems and delivery, preparedness and workplace-workforce clinical and economics issues.

References

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3. Kate Johnson, Study Highlights Dire Lack of Emergency On-Call Specialists. MDedge, January 1, 2009. Available at: https://www.mdedge.com/content/study-highlights-dire-lack-emergency-call-specialists.
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5. Jeff Colyer, et al., Access to Emergency Medical Services in Rural Communities – Policy Brief and Recommendations to the Secretary. November 2022. Available at: https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/rural/access-to-ems-rural-communities.pdf.
6. Shenai MB, Guthrie BL, and Moores L. Assessing the Economic Efficiency of Physician On-call Payments. Cureus, December 2018. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC6389016/.
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8. Harry W. Severance. Why Doctors Increasingly Turn Away From Rural Clinical Practice. KevinMD.com. November 23, 2024. Available at: https://kevinmd.com/2024/11/why-doctors-increasingly-turn-away-from-rural-clinical-practice.html.
9. Harry W. Severance. Opinion: Demand Up, Beds Down—The Emergency Dept. Crowding Crisis. ACEP Now.org. June 17, 2025. Available at: https://www.acepnow.com/article/opinion-demand-up-beds-down-the-emergency-dept-crowding-crisis/?singlepage=1.
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16. Nathaniel Weixel. Hospitals across nation brace for Medicaid cuts under ‘big, beautiful’ law. The Hill.com. July 13, 2025. Available at: https://thehill.com/policy/healthcare/5397653-hospitals-medicaid-cuts-rural-areas/.
17. Jamila Taylor. 17 Million Americans May Lose Health Coverage Under The One Big Beautiful Bill. com. July 22, 2025. Available at: https://www.forbes.com/sites/jamilataylor/2025/07/22/17-million-americans-may-lose-health-coverage-under-the-one-big-beautiful-bill/.
18. Madeline Ashley. Nearly 20 million could lose insurance under modified GOP bill: JEC. Beker’s Hospital Review. June 30, 2025. Available at: https://www.beckershospitalreview.com/finance/nearly-20-million-could-lose-insurance-under-modified-gop-bill-jec/.
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27. Patrick Boyle. Hospitals make painful choices as federal cutbacks add to economic headwinds. AAMC News.com. August 7, 2025. Available at: https://www.aamc.org/news/hospitals-make-painful-choices-federal-cutbacks-add-economic-headwinds.
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29. Tarsilla Moura. Hospital closures rise in 2025 amid ongoing financial pressures. OR Manager. March 25, 2025. Available at: https://www.ormanager.com/briefs/hospital-closures-rise-in-2025-amid-ongoing-financial-pressures/.
30. Harry W. Severance, More Hospitals Are Closing. Why? ACEP Now. January 11, 2024. Available at: https://www.acepnow.com/article/more-hospitals-are-closing-why/.