Today’s medical business environment couldn’t be more representative of our times: It’s technologically advanced and supply challenged. It’s increasingly specialized, yet in need of staffing. It reaches new heights in public transparency even as it continually strives to attain equity in care.
To better understand the key shifts and sweeping trends impacting otolaryngology, we turned to three prominent medical business leaders: Eric Gantwerker, MD, MMSc, associate professor in the department of otolaryngology at Zucker School of Medicine at Hofstra/Northwell, Uniondale, N.Y., and vice president/medical director at medical technology start-up Level Ex; Larry Simon, MD, MBA, medical director for Blue Cross and Blue Shield of Louisiana in Baton Rouge; and Marion Couch, MD, MBA, PhD, senior health advisor of Whole Health Institute, Chapel Hill, N.C., and former senior medical advisor to the administrator of the CMS. Here, they offer their analyses of today’s unique business climate and their advice on how otolaryngologists can address challenges and maximize opportunities.
Trend: Advanced Education and Training
Dr. Simon: “As otolaryngologists try to keep up with the vast array of knowledge now available in digital medicine, additional therapeutics, and specialized surgical instrumentation, the more attractive fellowships become, especially if they want to be experts in something. We also see more people doing fellowships for job hunting purposes. Although this is probably a less prominent or significant reason for fellowships, it can be a benefit, but it also depends on your chosen market. To practice in a small rural community, you’re less likely to do a fellowship because you’ll want to focus your residency training on having as broad a scope as possible. If you want to go to a large urban area like Houston or New York City, you’ll want to differentiate yourself more by seeking a fellowship in the most common service you plan to offer.
In the current fee-for-service payment world, most otolaryngologists are revenue generators. And I think that as more health systems and insurers and the CMS payment models go to value-based care, these surgeons might be considered an expense. —Marion Couch, MD, MBA, PhD
“I think we’ll start seeing more physicians obtain degrees beyond the MD, such as an MBA, MMM, or MPH, as a way of gaining extra skills to function in today’s medical world. Otolaryngologists and surgeons today must consider public health issues in ways they’ve never had to. If you’re going to thrive in 21st century medicine, you must understand pandemics, supply chain issues, and even different leadership styles.”
Dr. Couch: “I think MBAs are becoming more common among physicians, especially those in leadership, and I recommend it. I think doctors being able to understand operational flow issues, read a balance sheet, calculate net present value and ROI [return on investment], and generally think like a businessper son will help us navigate the transformation taking place in medicine—one in which we’ll need to apply a common language and common concepts with administrators.”
Issue: Supply Chain Challenges
Dr. Gantwerker: “Supply chain disruptions are a huge issue in terms of biomedical equipment. I deal with kids with tracheostomies. First, the factories were having problems and then the sterilization processors were having problems, which continues to this day. It seems like the infrastructure itself has recovered somewhat, but we haven’t seen supply pick back up. I know that the CPAP industry is being hugely affected as well. People have been talking about bringing more manufacturing stateside but when you get down to raw materials like motherboards and chips, that still comes internationally because we live in a global economy.”
Dr. Simon: “There are two problems that supply chain disruptions can cause: issues with inventory and issues with cost. Costs may temporarily go up and hopefully come back down as supply chain issues are resolved. Smaller practices with less buying power and fewer reserves will probably be impacted the most. The impact may fluctuate over time, with costs rising and falling depending on the supply chain inventory. Regarding in-house inventory, businesses might need to keep more supplies on hand than they have in the past to protect themselves.”
Trend: Subspecialization
Dr. Gantwerker: “Subspecialization is a growing trend, which is why so many residency graduates are doing fellowships. In cosmopolitan areas of the country, you have these super subspecialties in which, even beyond your fellowship, there’s a certain disease entity for which you’re the expert. So, say, if someone has dizziness, they can go see a super subspecialist who has a very programmatic way of addressing the problem that other physicians don’t have the time or interest to do. In my specialty last year, for instance, when the Complex Pediatric Otolaryngology subcertification came out, there was some discontent from general practitioners who also see children, but it was really intended for the very complex cases because these subcertification holders manage these patients more often and have the resources necessary for treatment.
“I think financial pressures lead clinicians to focus on areas that are financially incentivized, sometimes despite a lack of best evidence for efficacy. We’re seeing an explosion of lingual frenulectomy and balloon sinuplasty, which have become discussion topics at the national level. There’s a lot of financial incentive for balloon sinuplasty, and I believe the jury’s still out on precise indications and efficacy. We’re also seeing a massive increase in tongue ties and lip ties in the pediatric population, driven by complex factors but also by financial incentives for specialists like pediatric dentists. Fortunately, more practice guidelines and evidence are being generated and more practitioners are now getting on social media to better educate the public on this.”
Dr. Couch: “Maybe we need to folow what our orthopedic colleagues did. They realized that, as more systems wanted to look at outcomes and value, the old model in the fee-for-service world—of seeing only operative cases—wasn’t going to work.
“Orthopedic surgeons are leading the way in saying, ‘We handle musculoskeletal disease.’ I see an analogous mindset and attitude in otolaryngology, where we handle upper-respiratory tract cases in a way that better addresses what that person needs. It’s a way to engage more patients to guide them to the right care. One way to do that is to develop care teams, in which accountable care organizations that have population health responsibility will refer an otolaryngology problem to groups, and that otolaryngology group has a team of clinicians so that the surgeon isn’t seeing all the problems. If someone comes in with a nonsurgical problem, the nurse practitioner or physician assistant will see that patient. We don’t overwhelm the surgeon with every patient. You have a care team that helps you see the right patient at the right time. I think this would expand otolaryngology’s influence in healthcare.”
Issue: Staffing Shortages
Dr. Gantwerker: “The Great Resignation is hitting hard. Right now, we’re recruiting for nurses, nurse practitioners, MLAs, secretaries, call center people, surgical schedulers—everybody. It’s near impossible to get people, especially at our practice, because there are limited work-from-home options. There’s a realization in the workforce that certain jobs can be done from home and that they come with great advantages. They don’t have to take the in-hospital nursing job or work in the clinic; they can take a remote job that may pay better and offer more flexibility.
Is recruitment of people looking for at-home work experiences being forced upon us? Absolutely. But if we don’t move into the 21st century and start thinking about remote workers, we’re going to suffer from a recruiting standpoint. —Eric Gantwerker, MD, MMSc
“On the other side, I think that healthcare needs to start entertaining more remote options for people like surgical schedulers and office staff. Is recruitment of people looking for at-home work experiences being forced upon us? Absolutely. But if we don’t move into the 21st century and start thinking about remote workers, we’re going to suffer from a recruiting standpoint.”
Dr. Simon: “It’s difficult to predict what staffing challenges are going to be like as the pandemic moves on. I think if the current trend of diminishing COVID severity and growing vaccination and communal immunity continues, people may feel more comfortable coming back into medical offices to work. We’ll also have to see how the use of physician extenders evolves.
“As for what can be done to prevent shortages, this is something that the Academy of Otolaryngology does very well in terms of promoting the value and safety of the entire workforce so that people feel comfortable working in otolaryngology offices. We’ve learned a lot about how to keep the practice of medicine safe, and the academy continues to work to find ways to help practices attract and retain strong employees.”
Trend: Artificial Intelligence
Dr. Gantwerker: “I consult for an AI company, and I believe we should integrate this technology as a point-of-care decision-making tool, mainly because there’s too much medical knowledge for any one person to hold. Based on the parameters and characteristics of the patient, AI can analyze patterns and make suggestions about their management and treatment, including diagnostic testing. As the experts, we can then interpret the data and make decisions at the point of care. These tools are already being implemented in dermatology and in the emergency room. In radiology, AI is being used as a triage tool to do a first-pass analysis of scans to determine whether patients are high risk and should be moved to the top of the queue.”
Dr. Couch: “It’s a fascinating area. There’s so much work in caring for people and so few otolaryngologists; if someone or something can help me get an accurate answer on an imaging test or help me with decision-making, I welcome that. I do think that people are overstating the value of it as there must always be a clinical acumen piece. So much of medicine is about this trusting relationship and an understanding of total-person care. But I think otolaryngologists will only benefit from true machine learning or AI advances.”
Trend: Value-Based Care
Dr. Couch: “The fee-for-service payment model is under tremendous pressure. Otolaryngology practices will never be reimbursed at a rate that keeps up with their expenses. Moreover, the payers’ desire to increase reimbursement is zero, so there’s no path forward in the traditional fee-for-service world. That’s why it’s important to introduce the concept of value-based care. Value is the relationship between quality and access divided by cost.
“With few exceptions, I’ve always had colleagues in otolaryngology who were high-value clinicians (good outcomes with low cost), who were evidence-based, who always wanted the best possible outcome for their patients. And they were pretty cost effective. I think otolaryngology is well positioned as we consider value-based care payment models, because there will be a preference for referrals and working with high-value clinicians. In the current fee-for-service payment world, most otolaryngologists are revenue generators. And, I think that, as more health systems and insurers and the CMS payment models go to value-based care, these surgeons might be considered an expense. So, the challenge is to embrace value-based care so that you don’t fear going from a revenue generator to an expense. You become part of the plan to create value.
“Now we’re thinking about how physicians can be part of accountable care organizations that are taking on the health of a population and are paid for quality outcomes. Then the high value otolaryngologist becomes part of the referral system for that population of patients. If the group of clinicians has met their quality performance metrics, they get a bonus, and if they reduce total cost of care they share in that savings.”
Trend: Fostering Future Leaders
Dr. Simon: “Otolaryngology continues to attract some of the best and brightest minds in medicine. Physicians as a group are very determined and resilient people who want to make the world better, and they remain so despite remarkable adversity in recent times. Over the past two to three years, we haven’t seen any declining interest in medical school—if anything, younger generations of doctors coming out of residency and medical school are doubling down on efforts to address healthcare disparities, on finding ways to increase access, and on providing high-quality care for lower costs. So, despite all the doomsday predictions in the media, doctors remain incredibly dedicated. And that makes me optimistic.”
Linda Kossoff is a freelance medical writer based in Woodland Hills, Calif.