Certain well-established care delivery models for otolaryngologists have long defined the specialty. But, like pharmacology, surgical techniques and treatment therapies, practice models evolve. And while traditional models continue to dominate the scope of most otolaryngology practices, the field is seeing a gradual shift to new constructs. Among them:
- The growing market share of the largest health plans, in particular, the Mayo Clinic of Rochester, Minn., Kaiser Permanente of Oakland, Calif. and the Cleveland Clinic. Each of the three is a fully integrated system whose physicians often say that working in a model of such breadth with access to so many resources can allow providers to focus more on clinical duties, without the practice management issues faced by solo providers.
- The use of physician extenders in outpatient otolaryngology practices. The model’s proponents argue that using physician assistants and nurse practitioners can increase a practice’s cost efficiency, improve patient satisfaction and promote physician productivity.
- At least two otolaryngologists nationwide generate their entire patient load and surgical pipeline from admissions to an academic or community hospital.
- ENT Today spoke to otolaryngologists working under each of the three models to illustrate how they work.
The Biggest of the Big
Daniel Alam, MD, head of the Section of Facial Aesthetic and Reconstructive Surgery in the Head and Neck Institute at the Cleveland Clinic in Ohio, joined the health plan in 2002, straight out of training. So he’s the first to admit he’s a bit biased on the benefits of working for one of the country’s largest health delivery models.
The advantages—Dr. Alam calls them “creature comforts”—start with not having to deal with the billing and coding issues that solo practitioners must manage. Those business-side skills are instead overseen by the infrastructure of the Cleveland Clinic, which operates nine regional hospitals and 16 family health centers across the U.S. and Canada.
“The day-to-day interaction of you with a patient is identical,” Dr. Alam said. “You’re not limited in what you can do surgically, who you can operate on … but the actual financial modeling of what you do is very, very different. Who’s handling my billing, my this, my that? I don’t have to worry about that.”
Another advantage, Dr. Alam said, is that the clinic is self-insured, which means that the malpractice costs decried by many physicians are far from the minds of clinic employees. Dr. Alam said he has never been sued but is comforted knowing that he is backed by the legal and financial might of a large organization. The insurance issue is one reason physicians accept lower salaries and lower potential earning power to work for the clinic, he added.
“Just look at the tort issues and rising malpractice burdens,” Dr. Alam said. “If that becomes 25% of your burden … you can take a 10% pay cut and still come out ahead.”
Still, Dr. Alam understands that working for a conglomerate is not ideal for all otolaryngologists. Clinic employees come to work, provide care for patients and collect a paycheck. They have less control over their schedules and their patient loads than a solo practitioner does. They can’t choose to work added hours to reach higher financial thresholds.
“It has to do with the personality of the individual and the type of practice they’re interested in developing,” Dr. Alam said. “The advantage of a Cleveland Clinic model is it gives you all the advantages of a tertiary-care hospital, but we don’t have any of the [business-side] burden.”
Even with the potential downsides of schedule control and the earnings ceiling, Dr. Alam expects the largest health plans to get larger. As the government reforms payment systems to reward efficiency, it only makes sense that the most efficient organizations will thrive.
“Everything from buying gauze to buying warfarin … we can do cheaper because we have the contracting power and capacity,” he added. “And we can subdivide out our process to make them more efficient. It’s about an efficient system. And society and the world demands more efficiency out of its healthcare because of the spiraling costs.”
—Daniel Alam, MD
Working Well with Others
Byron Norris, MD, is a fourth-year resident in the department of otolaryngology and communicative sciences at the University of Mississippi Medical Center in Jackson, Miss., but his brief career experience has already taught him one thing: Physician extenders can be a very good idea for an outpatient otolaryngology practice.
Dr. Norris presented a paper at the 2010 American Academy of Otolaryngology-Head and Neck Surgery annual meeting, “Effective Use of Physician Extenders in an Outpatient Otolaryngology Setting,” that highlighted the ways in which nurse practitioners, physician assistants and residents can be used in high-volume settings to improve efficiency and patient satisfaction. In short, the model uses physician extenders to free up attending physicians or, in private practice, an independent practitioner, to perform the highest-acuity, highest priority tasks. In a typical patient encounter, an extender enters a room first to take a patient’s history, perform an introductory physical exam and collate medical images or test results, streamlining a physician’s first encounter.
“It allows the attending physician to see more patients in clinic, so then you have increased numbers of surgeries scheduled, which relates to increased revenue,” Dr. Norris said. “There’s less time needing to be spent in clinic, so there’s more time for administration and research, which provides for happier attending physicians and then also leads to easier recruitment and also stability. Everybody’s happy here because … you’re not leaving with 20 charts to dictate at the end of a busy clinic day. You’re leaving with a need to review the notes dictated by someone else, so faculty retention is at an all-time high in part because of this setup. So it’s a domino effect.”
Dr. Norris sees that “domino” as a good outcome, because it can potentially increase a physician’s volume and revenue with less expense than adding a second physician. It could also help patients if it leads to decreased wait times.
The collaborative model, brought to the University of Mississippi Medical Center in 2003 by department chair Scott Stringer, MD, MS, does require managerial oversight. New team members must undergo orientation and training that can last more than a year before being able to handle patient encounters on their own, a particularly key ingredient if the model is to be applied to private practices.
Dr. Norris recommends that otolaryngologists allow midlevel providers to see patients autonomously, which will decrease overhead and increase revenue. “In the private world or in another group practice, it would be beneficial if the mid-level providers are used in the spectrum of the methods that we’ve outlined,” he said.
Dr. Norris wishes there were more evidence-based data on the viability of collaborative practice models but has found little research outside of that related to primary care practices. Still, anecdotally, he believes it’s clear that the team approach to otolaryngology is effective, particularly in chronic conditions that require time-intensive encounters.
“Patients appreciate the additional time that is spent; even though it’s probably a shorter time with the physician itself, it’s a greater time with a physician plus an assistant,” he said, noting that a physician extender can reinforce plans outlined by the physician. “The assistants are there after the encounter is over with the attendings to answer questions, go over any details. I think it’s a more relaxed process, leading to greater patient satisfaction.”
Paging a Hospitalist
Stanley Dudek, MD, has been an otolaryngologist at Sparrow Health System in Lansing, Mich., for 32 years. He’s been an “oto-hospitalist” for the last four. The nascent job title—Dr. Dudek is one of only two known “otos”—describes a new breed of otolaryngologists whose job duties are tied to hospitalized patients. In Dr. Dudek’s case, he is a salaried employee on call for the hospital from 7 a.m. to 5 p.m. Although his compensation exceeds his billings, not only was his institution willing to accept him as a “loss leader,” it welcomed the setup.
“What the hospital gains is [that] patients are often seen ‘right now,’” he said. “The emergency room is very happy because the patients don’t sit around all day waiting for an ENT guy to finish their elective surgery, their whole day of patients and [then] come in and see the patients.”
Dr. Dudek said he typically sees patients within 12 hours of a consultation request from another physician. Many of the patients have abscesses that need draining, including peritonsillar and retropharyngeal cases. “So what happens is cases that would have gotten admitted out of the ER, I can get them drained and taken care of and they don’t have to get admitted and … some of my utility to the hospital is a cost savings that doesn’t show up on paper as income generated,” he said.
The hospital isn’t the only one benefiting. Dr. Dudek no longer worries about staffing issues, billing disputes and, perhaps most importantly, collection cases. “I’m still getting some collection stuff in from four years ago from my private practice,” he said. “That was always the most unattractive part of running a private practice, the bill collecting part.”
Dr. Dudek works about four hours a week in clinics where he sees only a few hand-picked cases, usually either long-time patients or hospital staff and their friends and family. But the bulk of his time is spent in different departments of the hospital, from the emergency department to cardiology to the neo-natal unit. He refers complex, major or time-consuming procedures to other physicians or other institutions when necessary.
He said it is important to emphasize to physicians who might be considering joining the wave of oto-hospitalists that the job lacks the financial rewards of private practice and the glamour of major procedures. Often, his job involves draining abscesses or performing straightforward tracheotomies. It does, however, require knowledge of a wide swath of procedures. He wonders if that makes the job suited to young physicians straight out of training, who have not yet been exposed to several years of the types of complex and novel cases a hospital generates.
“I would think it would be better not [to go into this job] straight out of residency, to get a certain amount of experience under your belt,” Dr. Dudek added. “When you’re young, you want to go out and apply all your skills. You want to gain that experience with patient care … To have as much as broad-based experience as possible is what somebody would need to do this job well.”