Explore this issue:February 2014
In the session “Wake Up! Facing the New Challenges in Otolaryngology Practice,” panelists proposed ways to address several hot-button issues.
Richard Waguespack, MD, president of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and clinical professor of otolaryngology-head and neck surgery at the University of Alabama, offered tips for dealing with the emergence of accountable care organizations (ACOs).
In ACOs, primary care doctors, specialists, hospitals, and other providers are integrated into a care and financial entity to boost quality, outcomes, and value in delivering healthcare. They’re meant to be an answer to a system that is now often fragmented, uncoordinated, full of duplication, and expensive.
Dr. Waguespack said that, for independent providers, it’s important to stay aware of what’s happening in your community. Sometimes, if the entity in which you work is creating an ACO, you will have little choice but to participate. But even if that’s not the case, your hand might be forced, he said.
“If I’m not in that ACO, my lines of referral are going to dry up either directly or because [I] have the reputation in the community of not being value-based,” he said. “I would say that one thing to consider is assessing how your practice appears to be as far as value-based models that are coming forward. If you’re considered in the community to be someone who just is fee-for-service-driven, this may not be a very friendly environment long term.”
Wendy Stern, MD, an otolaryngologist with Northeast Ear Nose and Throat in North Dartmouth, Mass., said mid-level providers are helpful in leveraging your time as an otolaryngologist, but she issued caveats.
How the mid-level provider is hired—whether by the physician directly or by the hospital or clinic—impacts how you bill and how you’re reimbursed. “It’s something you need to think about,” she said. Most mid-level providers are salaried, and the average salary is about $95,000 a year. The providers typically start bringing return on investment after about nine months, she said.
There are big differences in the training and philosophy of physician assistants (PAs) and nurse practitioners (NPs), Dr. Stern said. PAs have college degrees with two years of undergraduate science, and their education is done through the medical school model. Many will rotate with medical students or residents and view themselves as part of the physician team.
NPs are educated in the nursing school model and have advanced degrees, usually a master’s. They are licensed to practice independently and “see themselves as colleagues,” Dr. Stern said.
Navigating these arrangements requires care, she said. “These people are not trained in ENT—we are trained in ENT, and they may turn out to be our competition,” she said. “When we train these mid-level providers, it’s really essential that we keep in mind that they’re part of the physician team—and we need to be at the helm of that team,” she added. “If we pick the right mid-level provider and set the right circumstances, we should all be happy.”
Rahul Shah, MD, a pediatric otolaryngologist at Children’s National in Washington, said that doctors have no choice but to take patient satisfaction seriously.
The “patient experience domain score” makes up 30% of CMS’s Total Performance Score for hospitals, and a staggering amount of data is available on the Web for patient consumption, Dr. Shah said. “It’s absolutely amazing [that] in the last couple of years the patient as a consumer has been elevated to such a role that impacts our practices,” he said. With patients on boards or board committees, coming to board retreats, and participating on advisory boards, they are “a force to be reckoned with,” he added.
—Rafael Portela, MD Miami, Fla.
But, at his center and others, providers with low patient satisfaction scores have seen those scores rise to the middle or top of the range. Simple advice like sitting down, unplugging your devices, facing the patient, making hand contact, emphasizing quality over quantity, and, at the end of a visit, asking whether a patient has questions, can go a long way, he said.
“It’s the new hot metric,” Dr. Shah said. “It’s here to stay, but I’m pretty confident [that] with some easy tactics we can improve our scores.”
—Sapideh Gilani, MD, Brigham and Women’s Hospital and Harvard Medical School
Maintenance of Certification
Sonya Malekzadeh, MD, FACS, coordinator for education for the AAO-HNS and chief of otolaryngology-head and neck surgery at Veteran’s Administration Medical Center in Washington, DC, reviewed what the Academy offers to support members in their maintenance of certification (MOC) efforts.
MOC is a lifelong learning and competency program in four parts, including completion of 25 CME units a year, along with a self-assessment module, an exam, and professional and patient surveys on performance.
AAO-HNS support includes CME sessions organized by specialty track at annual meetings, plus recordings of past sessions, with six free units available per year; online courses and lectures; home-study courses; “patient management perspectives,” which are case-based scenarios focusing on clinical decisions; and a mobile app that contains study questions and other features.
“Certification matters,” Dr. Malekzadeh said. “It should be the goal of every otolaryngologist to become board certified and to remain board certified. As a physician, it demonstrates a commitment to lifelong learning and really is our ethical and professional duty to continually seek improvement.”
In addition, to patients, “it does provide a level of assurance that our physicians are keeping up to date with their knowledge and skills.”
ICD-10 Diagnosis Coding Changes
Dr. Waguespack sifted through the vast changes to coding that are to come with implementation of ICD-10, and emphasized the importance of documentation. “It’s going to be extremely important for your documentation to support the coding,” he said.
There are still some issues to iron out—for instance, there is still no code for pulsatile tinnitus. There also seem to be a fair share of quirks to the new coding. Some categories are broad with no way to get more specific—there is only “epistaxis” and “cough,” with no subgroupings. But for asthma, there are many qualifiers, such as mild intermittent, mild persistent, uncomplicated, and “with acute exacerbation.”
Otolaryngologists should plan for hiccups in cash flow, coding errors, a drop in productivity, and an increase in stress at their practices. To help with these issues, practices should consider a financial line of credit, ensure staff is trained and educated on the new codes, and possibly use benchmarks to strive for as the transition takes place, he said.
“Normalcy,” Dr. Waguespack added, is expected four to six months after the implementation date of Oct. 1, 2014.