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Two sides of the same coin

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November 8, 2018
by Brian J. McKinnon, MD, MBA, MPH, FACS

Many years ago, I opened an issue of the U.S. Naval Institute's Proceedings Magazine. In it I found a column entitled, “Nobody asked me, but….” The intent of the column was to provide a venue for officers, often junior officers, to give commentary on current naval practice or policy. I am certain other publications had similar columns, but what struck me was that the column allowed for constructive, honest, and public critique of an organization, the U.S. Navy, that was not outwardly thought of as being inwardly reflective.

I don't feel that our profession has the same reputation of not being inwardly reflective, although I can't recall our profession having a readily available venue for constructive, honest, and public critique. With that in mind, I began to gather my thoughts on the challenges with which otolaryngologists must contend.

As background, I currently practice at Philadelphia ENT Associates, with an academic appointment at the Drexel University College of Medicine. My previous experience has been as a physician in the military, the Veterans Administration, academics, and private practice. My formal education in pursuit of my MBA and MPH also shape what I wish to focus on in this editorial: achieving financial sustainability and achieving economic sustainability

Currently, our practices face tremendous financial stress. Those in the public sector and those in academics are under the greater financial stress. The public sector and academic practices historically have not been prudent managers of their resources; academic practices have been particularly poor in achieving consistent financial sustainability. These practices form the safety net of our healthcare system, as well as the core of the resident and fellow training system.

With increasing enrollment in health exchanges and Medicaid, and facing reimbursement based on outcomes, many of these practices are ill equipped for the business challenges of reduced reimbursement combined with the increased cost of improving care. Academic programs that are financially unsustainable often are left to limp on-an “always sick, never dead” approach. It is intellectually difficult for these programs to institute the most basic revenue and cost-management systems, despite often having very fine business schools affiliated with the parent educational institution. They view themselves as “good stewards” of their patients' health but fail to realize that stewardship requires the maintenance of a financially sustainable healthcare system. Prudent financial management can markedly improve disease management.

The issue for private practice is somewhat different, in my opinion. The challenge for private practice is to achieve a business that is economically sustainable within the community. Private practices, if not financially viable, will close. Generally, they have fairly good business processes in place, unlike many academic practices. The threat to these practices is the perception that the reporting requirements for MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and MIPS (Merit-Based Incentive Payment System) are insurmountable for smaller groups; or worse, that the cost of reporting successfully is more expensive than the penalties.

If private practices begin to avoid participation in MACRA and MIPS, the lack of quality reporting will ultimately harm all of ENT, not just private practice. Reimbursement will be based on the data returned through MACRA and MIPS; poor-quality data, or data based on a very narrow segment of physicians, will adversely impact the “value” assigned to the care otolaryngologists provide.

Further, in their drive for margin, these practices may lose sight of another important fact that is critical to economic sustainability. The otolaryngologist's charge to the community is a social contract; failing to respect that social contract, with its benefits and obligations, by practicing in a manner no longer economically sustainable within the community, will result in the loss of the economic benefits gained by the social contract. The community is not just those patients who are cared for by the practice, but it also includes fellow otolaryngologists regionally and nationally. Narrowly defined interests usually result in similarly limited achievements.

While our Academy and specialty societies deserve much credit for the resources they have placed in their members' hands, these resources could make an assertive and concerted effort to educate the public sector and academic practices on their respective fiscal and economic responsibilities and help them develop and use the skills in responsible stewardship of their roles. Further, our Academy and specialty societies could make an assertive and concerted effort to educate those in private practice on the long-term importance of quality reporting and the need to engage with the Academy, so that the Academy can better provide guidance for successful participation and provide feedback to the public, public officials, and private/public payers on the burden current reporting requirements place on private practice. These actions by the Academy and specialty societies would serve to remind those in academics what their stewardship requires, and those in private practice of the benefits and obligations of their social contract with the community. Such action is essential to the continued high-quality care of our patients, and to the future success of our specialty.

Associate Professor and Vice Chair, Department of Otolaryngology-Head and Neck Surgery, Associate Professor, Department of Neurosurgery, Drexel University College of Medicine, Philadelphia
Ear Nose Throat J. 2018 October-November;97(10-11):338-339