2019 HSC Section 2 - Practice Management

1,200 PAs working within otolaryngology, or about 1.2% of all PAs in medicine (April Rodgers, Executive Administrator SPAO-HNS, e-mail communication, December 4, 2017). This represents an almost doubling of the otolaryngology PA workforce over the past decade, with the ratio of otolaryngologists to PAs shifting from 16:1 in 2005 to 10:1 in 2013 24 (also American Academy of Physician Assistants Surveys, unpublished data 2008, 2010, 2013, 2017). Within the current otolaryngology PA workforce, the 2016 SPAO-HNS scope-of-practice survey reported the average otolaryngology PA has 10 years of experience (eight years in ear, nose, and throat) and sees nearly 5,000 patient visits, including 1,800 postoperative visits, and performs 400 office procedures per year (SPAO-HNS Work Benefit Survey, unpublished data 2016). To date, the establishment of a long-range strategy of how PAs or NPs can be utilized to meet predicted work- force shortages within otolaryngology has not reached consensus. Our study supports the need for discussion because 89% of solo practice otolaryngologist, represent- ing predominately older physicians nearing retirement age and working in less population-dense HSAs, reported no use of practice extenders in our survey. In fact, the larg- est utilizers of practice extenders currently are MSSO or AGO group practice models that tend to be in urban HSAs reporting no shortage of otolaryngologists in any study to date. Correlating previously reported national otolaryn- gologist and PA workforce density data, minimal regional future expansion of the otolaryngology workforce will be achieved with the use of PA otolaryngology extenders based on the current overlap of PA and otolaryngologist population density data. 4,25 Because nurse practitioner regulations allow for more independent practice in several states, there is a greater the- oretical potential that NP otolaryngology extenders could help fill a medical otolaryngology access-of-care gap in low- otolaryngologist-density regions with proper training. How- ever, again, overlapping national otolaryngology density data with NP national restriction-of-practice regulation data yield only a few regional pockets across the United States where potential expanded medical otolaryngology access could be achieved in areas where the otolaryngology work- force density is lowest. 4,26 Nationally, with constant changes in state regula- tions governing PA and NP licensing, there is a growing concern that state-by-state scope-of-practice modifications are being driven more by the political and regulatory cli- mate within each respective state rather than established competency or training, resulting in a increasing calls for national scope-of-practice standards. 27,28 This evolving process adds significant challenges in the evaluation of any long-range integration strategies involving otolaryn- gology physician extenders to help counter any future workforce shortages within our specialty. For ancillary service extenders, the only certificate offered by the AAO-HNS is for audiology extenders for- mally acknowledged as oto-techs. 29 The certification pro- gram requires physician sponsorship and incorporates didactic training with a 6-month supervised skills assess- ment. The lack of adoption of oto-tech integration reported

TABLE II. Comparison of NC/SC 2016 and AOA 2017 Ancillary Services by Group Size.

1–3 OPG 4–9 OPG 10 1

OPG

CT

NC/SC 2016 33% 77% 77% AOA 2017 35% 57% 81%

in our survey is likely directly correlated with the 2010 clarification by the Centers for Medicare and Medicaid Services (CMS) for incident to audiologic services billing. 30 Because of a consistently reported 40% early career attri- tion rate of audiologists and a growing demand for audio- logic services within an expanding elderly population, predictions of a growing workforce shortage of audiolo- gists have been made. 31 The audiology workforce dynam- ics will likely be further adversely impacted by the introduction of the Over-the-Counter Hearing Aid Act of 2017, as this market disruption will potentially impact demand for audiologist professional services within the hearing aid dispensing business models. 32,33 Certified audiology extenders, such as oto-techs, will need increas- ing recognition to fill this workforce shortage. 34 AAO-HNS advocacy for audiologic CMS reimbursement policy changes will be necessary to ensure adequate patient access to audiologic services through the use of oto-techs within the future practice of otolaryngology. Further discussion and study on the need and impact of physician extenders as a long-range planning strategy to expand access to otolaryngology care are needed. Evalu- ation of the training and certification requirements of the extender workforce is also warranted to assess and stan- dardize subspecialty skills within this workforce. Ancillary Services Correlation of ancillary service integration is found between our survey and the recent 2017 Association of Otolaryngology Administrator Benchmark Survey. 10 Com- paring the two survey datasets, we found a greater degree of POS CT integration and ENG integration for the four- to-nine–otolaryngologists per group (OPG) models and a higher ultrasound integration for the one-to-three–OPG models in our study, indicating a continued expansion of availability of these services despite smaller group size (Table II). Accreditation by third-party agencies for POS CT is required for most contractual POS radiologic billing North Carolina/South Carolina Otolaryngology and Head and Neck Surgery Societies; OPG 5 otolaryngologists per group; TNE 5 transnasal esophagoscopy; U/S 5 ultrasound. U/S NC/SC 2016 19% 36% 82% AOA 2017 6% 33% 48% Hearing Aid NC/SC 2016 92% 95% 91% AOA 2017 71% 86% 100% ENG NC/SC 2016 37% 95% 94% AOA 2017 41% 48% 57% TNE NC/SC 2016 7% 18% 68% AOA 2017 12% 24% 62% AOA 5 Association of Otolaryngology Administrators; CT 5 computed tomography; ENG 5 electronystagmography; NC/SC 5

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