As the U.S. healthcare system focuses increasingly on value, otolaryngology practices of all types are trying to come up with new ways to improve efficiency. A group of panelists at the Triological Society Combined Sections Meeting discussed how to continue performing academic work in this environment, better deliver efficient cancer care, use physician extenders in private and academic settings, and use the electronic medical record in private practice.
“Medical practice efficiency is critical in today’s healthcare environment,” said moderator David Eisele, MD, director of otolaryngology–head and neck surgery at Johns Hopkins University School of Medicine in Baltimore. “Third-party payers and regulators have created requirements that have increased our practice costs, created increased physician workloads, [and] caused practice efficiency challenges, with both negative impact on our doctor-patient relationship and reduced reimbursement for our care.”
D. Bradley Welling, MD, PhD, chair of otolaryngology at Harvard Medical School in Boston, said a big challenge in today’s environment is balancing academic work, which is typically something that uses up resources, with clinical activity, which generates resources. “Finding the right balance is not easy,” he said. “If you do too much academic work, the coffers in the department go dry. And if you do too much clinical work, then you don’t meet your responsibilities as an academic department.”
To help with efficiency at his center, physicians and staff measure and set goals for factors such as patient time to appointment, time to be seen after arrival, wait time in the emergency department, number of dropped calls, and operating room utilization, among others. Physicians work toward incentives, including publications, grants, clinical productivity, team goals, and patient satisfaction. There are also early-career incentives, including assistance with child care, he said.
Dr. Welling suggested keeping research clinically relevant and using the OR “as part of your lab.” He also advised “accepting opportunities as much as you can to serve in the area of interest but being careful not to get too distracted by things that really don’t point you in the direction of your science.”
He said that building up an endowment is critical and that it’s probably worthwhile to invest in development professionals. He also said it’s important not to lose sight of the importance of recruiting quality faculty members and providing good patient care.
Cherie-Ann Nathan, MD, chairman of otolaryngology at LSU-Health Shreveport, outlined major challenges facing the cancer field: There are more than 15 million patients in the U.S., with 1.7 million new patients diagnosed each year, and the numbers are expected to grow. Further, these patients are being cared for in a country with one of the highest healthcare costs and worst outcomes among developed countries, with inequalities along racial, socioeconomic, and geographic lines. Cancer mortality rates even vary from county to county. “We definitely have challenges, and it’s critically significant in cancer care because of the rapidly growing demand,” she said.
Which types of healthcare centers will be caring for these patients in the future? Patients prefer to be seen by their oncologists even after five years, but just one in eight patients are seen at academic centers; most are treated at community hospitals, Dr. Nathan said.
With numbers showing that the higher the volume of surgical cancer treatment a center has, the better the survival rates, the National Cancer Institute has instituted a pilot program designed to bring more U.S. patients into a system of high-quality care centers, with the hope of reducing healthcare disparities and improving information sharing among community care centers. When they were followed, standards developed by the Leapfrog Group, a coalition of 130 public and private organizations attempting to decrease mortality and reduce errors in care, helped improve survival, according to one study (Surgery. 2004;135:569-575).
More questions need to be answered, however, Dr. Nathan said, including whether to move to a three-tier system in which patients will be referred from community centers to regional medical centers to tertiary centers. But patient concerns need to figure prominently in the solution, she said. “Who’s going to drive this model? Is it going to be purchasers, CMS (Centers for Medicare and Medicaid Services), managed care, or is it going to be our informed patients?” she asked. “There are realities we’ve got to understand that our patients face. Can they really get to us from these rural areas? We have patients where even the cost of gas is not affordable, and they don’t have the social infrastructure to make it to their appointments.”
Physician extenders not only facilitate patient care, but may be the key to maintaining the viability of traditional, independent private practice. —John McElveen, MD
Physician Extenders in Private Practice
John McElveen, MD, founder of the Carolina Ear and Hearing Clinic in Raleigh, N.C., said that physician extenders such as physician’s assistants (PAs) and nurse practitioners (NPs) can bring advantages to private practice but have to be incorporated into a practice in a way that makes sense. “All nurse practitioners are not created equally; they are only certified based on their training,” he said. “Some nurse practitioners are limited to seeing adult patients, while others can see both adult and pediatric patients. You want to make sure you’re hiring the right one for your specific patient demographics.”
Dr. McElveen said those in these positions can help lower salary, insurance, and liability costs and reduce the amount of “digital paperwork” for otolaryngologists, but it is important to be cognizant of their actual cost to the practice, too, he said, noting that even though the national average salary for a PA or NP is about $97,000, the actual cost—after payroll taxes, benefits, and other expenses—is approximately $117,000. With an overhead cost of about 52%, the PA or NP break-even point for revenue would be about $245,000 a year, he said.
Once an NP or PA is hired, the credentialing process should be started early, following up with the hospitals, insurance companies, and Medicare to make sure they have received everything they need. Dr. McElveen also suggested getting NPs and PAs certified to use the Epic EMR system for use at hospitals, allowing remote access, utilizing the Academy’s instruction courses, familiarizing them with office equipment and the microscope, and using ear models and modeling clay for training on cerumen removal under a microscope. “Physician extenders not only facilitate patient care, but may be the key to maintaining the viability of traditional, independent private practice,” he said.
Physician Extenders in the Academic Setting
Melissa Pynnonen, MD, MS, professor of otolaryngology–head and neck surgery at the University of Michigan, said it’s important to understand the training backgrounds of PAs and NPs and to know how to make them a more valuable part of the practice. “An otolaryngologist spends four years in medical school and five or six years in surgical residency, and during that time they not only learn the science, but they learn how to function in a hierarchical team, and that cultural education and experience is what APPs [advanced practice providers] do not have,” she said. “As a result, they may not know how to escalate a medical concern.”
They also require clarity of their roles, she said. Nurse practitioners come from a nursing background and are used to taking orders, so they may have difficulty working independently at first, Dr. Pynnonen noted. “Not only is this an expensive waste of your investment, but this can create conflict with the nurses, because they’re not sure who’s supposed to be doing what,” she said.
NPs spend two years in school for their NP license, and this includes only 500 clinical hours, much of which might be introductory time and might not be true education or experience, she said. And PAs have only six to eight weeks of elective rotation, which may or may not include otolaryngology. “They need as much supervision as you would provide a young medical student,” she said. “Your support of them and your relationship with them needs to be positive and robust.”
This should include a willingness to supervise them in clinic, with a formal orientation plan and learning objectives. A good place to learn is in the OR, Dr. Pynnonen said. “We all developed our expertise with opportunities to do surgical procedures in the operating room,” she said. “And I think it’s really helpful for the APPs to develop basic skills in that more relaxed setting.”
Tom Collins is a freelance medical writer based in Florida.