2019 HSC Section 2 - Practice Management

transnasal esophagoscopy was reported by 33% of all respondents, predominantly performed in groups with more than 13 physicians and in AGO or MSSO practice models. Otolaryngic allergy (OA) services were provided by 84% of respondent’s practices. Use of outpatient allergy shots as an active protocol was reported by 68% of oto- laryngologists providing OA services. Outpatient allergy shots were utilized mostly in SSGO practice models (55%). Allergy retesting intervals were studied within those physicians who provide allergy services. Only 1% reported using annual retesting protocols. Sixty-four per- cent retested based only on symptoms, and 34% reported mandatory retesting within a 3- to 5-year interval. On- site allergy vial preparation was reported by 91% of respondents, with only 9% using third-party vendors for allergy vial mixing. Use of allergy-specific electronic medical records (AS-EMRs), a computer software pro- gram in addition to primary clinical electronic medical records, was reported by 25% of those providing OA services. Perceived benefits of an AS-EMR in improved quality of care and safety were reported by 79% and 74% of respondents, respectively. Use and benefits of an ambulatory surgery center (ASC) were also studied. An ASC is specifically defined as being categorically different than a hospital outpa- tient department (HOPD) surgery center. The survey demonstrated that 62% of respondents had access to an ASC. The AGO group model (40%) and hospital- employed physicians (Academic Hospital Otolaryngology Employee (AHOE) 0% and Non-AHOE 43%) reported the least access to an ASC. The ownership structure of the ASC predominated as a joint venture model with a hospital system (49%). Of physicians having access to an ASC, 62% of all of their cases were performed at the facility, and 95% felt that having access to an ASC reduced healthcare costs for their patients. Fifty percent also felt that having access to a lower-cost ASC had a moderate to significant benefit in contracting with pri- vate payers. Overall, 79% of respondents with access to an ASC felt that the access was of benefit to their prac- tice. Certificate-of-need (CON) legislation was studied, and demonstrated that 68% of respondents favored CON repeal. Strong support for CON repeal was expressed regardless of having existing access to an ASC. Workforce: Otolaryngologists Our survey workforce trends correlate with findings of the American Academy of Otolaryngology–Head and Neck Surgery 2014 Socioeconomic Survey (AAO-HNS 2014) and the Association of Otolaryngology Administrators 2017 Benchmark Survey (AOA 2017). 9,10 Hospital-employed physician models are the least commonly reported practice model, indicating that vertical integration (defined as hospi- tal acquisition of otolaryngology practices or direct employ- ment of physicians outside of academic departments) is less pervasive within otolaryngology as compared to other surgi- cal specialties or primary care. 11,12 However, our study does show a growing generational shift in employment DISCUSSION

preference. In our survey, 33% of physicians practicing < 5 years were hospital employed, and within all respondents, 14% were hospital employed, a larger finding than had been previously reported. 13 Our study provides continued evidence that the solo practitioner model appears to be at risk for significant future contraction, exacerbating workforce shortages in less urban health service areas (HSAs) where this model predominates. With escalating educational debt of over $200,000 (reported by 7% of graduating residents in 2011, significantly increasing to 41% in 2015), it is unclear how long these workforce dynamics will remain, as the market forces of supply and demand will eventu- ally favor workforce rebalancing goals (AAO-HNS Direc- tor Member Networks, e-mail communication November 30, 2017; Section for Residents and Fellows Annual Sur- veys (SRF), unpublished data 2010–2015). Based on trends in other specialties, any eventual workforce reba- lancing will likely result in further vertical integration within nonurban healthcare markets due to the physi- cian desire for contractual debt forgiveness pulling them back into underserved HSAs. 14 This rebalancing may already be in the early stages, as within the 2015 SRF survey, 10% of residents indicated career goals of being hospital-employed otolaryngologists, which would tend to populate low-supply regions of the healthcare markets based on current employment demand goals (AAO-HNS Director Member Networks, e-mail communication November 30, 2017; Section for Residents and Fellows Annual Surveys, unpublished data 2015). Workforce: Practice Extenders Our survey showed significant integration of physician extenders within the practice of otolaryngology that had not been previously reported, with a preference for employment of PAs over NPs. The recognized value of physician extenders in otolaryngology is well established with the Society of Oto- rhinolaryngology–Head and Neck Nurses (SOHN), founded in 1977, and the Society for Physician Assistants in Otorhino- laryngology–Head and Neck Surgery (SPAO-HNS), founded in 1991 supporting these respective professionals. 15,16 In terms of credentialing, neither the SOHN nor the SPAO-HNS provides regulatory scope-of-practice guidelines for otolaryngology extenders. 17,18 No formal otolaryngology NP training program exists at this time. As for formal PA otolaryngology training programs, there are only four 1-year otolaryngology fellowships programs, each training one to two PAs annually following graduation from an accredited masters degree PA program. 19–22 Otolaryngology scope- of-practice–specific criteria for these programs are indepen- dently defined within each institution. 23 Two of these PA training programs are within academic otolaryngology departments having otolaryngology residency programs (Northwestern University and Wake Forest Baptist Health), and two are private affiliated (Mayo Clinic Arizona and Dartmouth Hitchcock). For the most part, physician extenders in otolaryn- gology follow more of a site-of-employment apprentice model in gaining scope-of-practice training and compe- tency. According to SPAO-HNS, there are approximately

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