2019 HSC Section 2 - Practice Management

eligibility from CMS and private insurers. 35,36 Given the increasing integration of POS CT and U/S services within otolaryngology practices, residency training and continuing medical education for scope-of-practice com- petency and certification requirements will have increas- ing importance for practicing otolaryngologists. 37–40 Otolaryngic Allergy Services OA has seen a growing presence within otolaryngol- ogy training since the mid 1980s, when just over 40% of residency programs reported having an active allergy division. 41 OA education and training has significantly expanded to over 62% of residency programs by 2006 and 79% by 2013. 42 Within our survey, 93% of academic departments reported OA services. Further evidence of the clinical penetration of OA within otolaryngology can be found in the AAO-HNS 2014 Socioeconomic Survey, where allergy-related relative value units (RVUs) were the most commonly reported of all RVUs reported. 9 Additionally, Pillsbury et al. reported that within the MEDSTAT databases of otolaryngology claims submitted in 1995, both managed care and fee-for-service analyses, immunotherapy services were the most commonly per- formed procedure, being performed three times more commonly than basic audiometric testing, which was the second most commonly reported procedure. 4 Despite these trends, differences in perceived and realized OA competency are consistently reported between otolaryngology residents and otolaryngology residency program directors. 42–44 The AAO-HNS SRFs from 2011 to 2015, highlighted resident perceptions of insufficient training in allergy as a significant educa- tional priority for improvement in residency education (AAO-HNS Section for Residents and Fellows Annual Survey, unpublished data 2010–2015). Given that OA services were reported as an integral part of practicing otolaryngologists’ scope-of-practice by 84% of respond- ents in this survey and 78% in the AOA 2017 survey, this perceived training dichotomy represents a potential challenge, as more experienced allergy-trained otolar- yngologists retire from the workforce and are replaced by new physicians with self-reported allergy-specific res- idency training concerns. 10 Today, the American Academy of Otolaryngic Allergy (AAOA) provides the largest postresidency edu- cation platform for advanced allergy education and training, with almost 2,400 members, approximately 27% of all actively practicing board-certified otolaryngol- ogists. 45 Within the AAOA membership, 503 are fellows who have passed advanced competency examinations and allergy practice modules. Otolaryngology residents constitute a separate category of membership, represent- ing 461 members in 2017, many attending advanced OA training courses during their residency training (Jami Lucas, AAOA Executive Director, e-mail communication, January 2, 2018) Otolaryngology is uniquely positioned for the devel- opment of a patient-centered Sino-Allergy Home (SAH) given the high prevalence of comorbid symptoms of sinus and OA disease states. An integrated, cost-efficient

platform utilizing POS CT, nasal endoscopy, sino-nasal procedures (office and ambulatory surgical based), allergy testing/immunotherapy, and well-established, validated, disease-specific outcome instruments provides a unique opportunity for otolaryngology to develop a patient-centered care model (PCCM), specific for sino- allergy disease, that cannot be duplicated by any other medical specialty. The clinical advantages and cost- effectiveness of allergy based PCCM within allergy/ immunology practices has been demonstrated to increase patient retention and treatment compliance and can serve as a blueprint for integrative strategies to improve patient outcomes within an expanded SAH. 46–48 With the evolution of consumer-based healthcare, a response to escalating patient out-of-pocket expenses via an effi- cient POS care model for sino-allergy disease manage- ment will be critical when competing for patient-selected care pathways. Because compliance can inversely corre- late with cost, the need for a more patient-centered edu- cation model to improve the awareness of patients’ investment in their long-term health status will be nec- essary as these out-of-pocket costs continue to rise. ASCs have become a key low-cost option for outpa- tient procedures utilized by otolaryngology patients. 49,50 Today, 27 states currently maintain some form of CON- imposed regulations governing the formation and expan- sion of ASCs. 51 The larger state-by-state CON debate extends well beyond just ASCs, but for otolaryngologists practicing in CON states, this remains a key restriction of facility service issues, as the POS CT CON debate has largely been resolved. 52,53 The findings of our survey confirm significant physician belief that ASCs benefit their patients and reduce the patient’s healthcare costs for ambulatory surgery. It is interesting to note that regardless of ASC access or ownership, the majority of otolaryngologists surveyed favored CON reform. When interpreting our study results, it is important to clarify that North and South Carolina are both CON states. Limited analysis of the financial relationships within these facilities has been reported previously. Our results indicate that a joint venture with a hospital part- ner business (48%) was the most commonly reported model. With growing vertical integration trends nation- ally, this shared risk model allows the ASC to benefit from access to the vertically integrated network within an HSA. As a point of future consideration and debate, cur- rent CON laws, in light of the passage of the Affordable Care Act with the resulting large-scale consolidation and hospital closures in conjunction with the expansion of consumer-driven patient choice resulting from increased out-of-pocket medical expenses, may no longer be neces- sary and may in fact prove detrimental to patient access and competition within these market dynamics. 54–56 Ironically, within a CON state, vertical integration may inadvertently reduce patient choice, an inverse to expectations born from higher patient out-of-pocket Ambulatory Surgery Centers (ASC) and Certificate of Need (CON)

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