The Ballooning Cost of ENT
I. Introduction
This essay is to explore where the development of a physician can go wrong, expose a particular systematic flaw allowing flagrant healthcare fraud, and propose how we can reduce the potential for future abuse.
Does the propensity for risk-taking unethical behavior, at the expense of our patients, develop before or after training? Is the lure of obtaining wealth so strong that it supersedes our concern for fellow humans and induces us to perform unnecessary and unindicated procedures? Is the consumption-driven monetary machine that drives high tuition costs and physician debt to blame? Does the complexity and illogical reimbursement of the health insurance system obfuscate the true nature of the machination? Does a physician initially rationalize fraud as a means to obtain a fair reward for all of the effort and sacrifice through training but then continue the act due to its ease of performance?
To understand the journey of a physician, you must first look into the experiences shared by all developing doctors. The general rule is most medical students chose medicine as a career to improve the health, and thereby the lives, of other humans. For many, the roots of their motivation are based upon an experience as a helpless observer to a family member or friend, an impactful experience as a volunteer, or as themselves an afflicted patient. This is exemplified when first-year medical students ritually swear a modified version of the Hippocratic Oath. Most recognized is the “I will do no harm” clause, but as the oath progresses, the voices of the young physicians resound with promises to be ethical, practice humility, and hold the health and dignity of the patient above all else. It is a pivotal moment in the career for most physicians as the door opens to a deeper understanding of the human experience, and the next seven to ten years of training are unimaginably rich in personal development.
Fast forward to the completion of residency and most young physicians have well-defined goals. At the top of the list is practicing competent medicine independently. This is closely followed by paying off student loans and increasing one’s standard of living. Most physicians experience a 300–1000% raise in salary upon entering into their first post-residency position, but after paying taxes, student loans, mortgage, disability insurance, and other bills, one’s wages quickly evaporate into debt-filled obligations. The third goal is learning the business of medicine. This oft forgotten part of medical education is challenging, but if embraced and mastered, managing a practice can be fulfilling and enhance the financial reward of being a physician.
In most surgical subspecialties, there are strategic ways to increase productivity and improve the bottom-line. As a physician implements methods to improve the overall margin, he or she realizes that the quickest way to raise their salary is to increase revenue. This is accomplished via several mechanisms including: 1) increasing patient volume, 2) increasing procedure volume, 3) augmenting services offered, and/or 4) billing higher levels of service. In the majority of settings, an equilibrium is reached after 2–5 years when a physician reaches a steady-state of productivity and is satisfied with the financial reward for the services delivered. As technology progresses, however, new devices and medications enter into the clinical realm that can disturb this balance. What if I told you there was a technology that allowed you to increase your salary up to 500% while seeing less patients, doing more procedures, and adding auxiliary services to your practice? Within otolaryngology, this is currently the case, and the imbalance of physician reimbursement to quality and complexity of services delivered for this procedure is leading to a rapidly growing and unnecessary burden on our current healthcare system.
In the following sections, I will illustrate one significant example of perturbation caused by introduction of balloon sinuplasty into otolaryngology private practices. It is a controversial story intertwined between naïve healthcare policy, opportunistic physicians, and profit-driven corporations, but ultimately, it is a lesson how inadequate policy opens the door for healthcare fraud and violation of the physician-patient relationship. My hope is that this catches the attention of policy makers to illustrate the divergence between physician reimbursement and patient outcomes.
2. “Sinus” Problems
Comprehensively explaining the pathophysiology and treatment of sinusitis is beyond the scope of this article, but I would like to explain basic terminology and illuminate the nuance of “sinus problems” from a patient versus an otolaryngologist perspective. Nearly every person will experience a sinonasal symptom during their life. The most common symptoms are difficulty breathing through the nose, drainage from the nose, nasal congestion, decreased sense of smell, and nosebleeds. The causes are varied, but most individual’s symptoms ultimately derive from inflammation. The source of the inflammation may be a type 1 allergic reaction (i.e. common allergies), viral infection, irritant (i.e. smoking), bacterial, or autoimmune. For most patients, they cannot distinguish between a nasal problem and a sinus problem. The nose is a 3–4-inch-long cavity that houses the nasal septum and the sets of turbinates; deviation of the nasal septum and/or enlargement of the inferior turbinates due to allergies are common causes of nasal obstruction and congestion. The paranasal sinuses are 4 sets of air-filled spaces lined with mucosa including the maxillary, frontal, ethmoid, and sphenoid sinuses. The drainage pathways from the sinuses to the nose (ostia) are small relative to the size of the sinuses. When the mucosa lining the ostia becomes inflamed, this obstructs the flow of mucus from the sinus into the nose and eventually into the throat (mucociliary flow). Accumulation of mucus in a space where bacteria live provides an excellent medium for infection to develop, and in some instances, this leads to a bacterial sinus infection. This process is what happens when you get a cold that then turns into a bacterial sinus infection 5–10 days later.
An acute bacterial sinus infection is treated with antibiotics, nasal saline rinses, decongestants, and sometimes oral steroids. If a patient develops 4 or more separate infections per year, they are defined to have recurrent acute rhinosinusitis (RARS). If the inflammation persists over 12 weeks, they are defined to have chronic rhinosinusitis (CRS). CRS may be associated with nasal polyps (CRSwNP) or without nasal polyps (CRSsNP). The source of the ongoing inflammation is the perpetuation of an inflammatory response within the sinus. Treatment of CRS involves prolonged antibiotic courses, topical steroids, and oral antihistamines, and it may also include allergy testing, immunotherapy, and systemic steroids. If there is evidence of persistent disease on a CT scan or nasal endoscopy despite the “maximal medical therapy,” the patient is offered a surgical intervention.
All too often, however, patients present saying they have a “sinus problem” when in reality they have a nasal problem. This is important to note because if a patient with a self-diagnosed sinus problem that was actually a nasal problem underwent sinus surgery (which universally involves reducing the size of the inferior turbinates), even when the patient did not need sinus surgery, they will feel improved postoperatively and report satisfaction due to the reduced inferior turbinates.
3. The Incidence Issue
Within the medical field, there is a reflexivity for diagnosing a bacterial sinus infection by primary care providers and physician assistants/nurse practitioners at urgent cares. This may be true in certain cases, but often, this is due to inflammation secondary to allergic rhinitis or a viral-mediated infection. The American Academy of Otolaryngology-Head and Neck Surgery has guidelines that recommend waiting at least 10 days or until a “double worsening” — where the symptoms improve but then worsen within 7 days — prior to treating with antibiotics. It is important to have faith that many primary care practitioners abide by this guideline, but the pattern of patients presenting to an ENT office suggest widespread liberal antibiotic prescription patterns.
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Once the patient arrives at an otolaryngologist’s office, they undergo a standard workup including a history and physical exam including nasal endoscopy. The nasal endoscopy is useful to evaluate for obstruction of the nasal passages as well as active bacterial infection or polyps. Most symptomatic patients do not have active infections or polyps, so the nasal endoscopy may show a degree of inflammation but is typically inconclusive. To formally assess the sinuses for inflammation, infection, and potentially predisposing anatomy, it is imperative to obtain a CT scan.
Up until this moment, the majority of otolaryngologists share similar practice patterns. What follows and will be described in the following section is a path that splits into two categories with one road focused on integrity and patient outcomes and the other focused on maximizing revenue and number of procedures. Once the latter pattern has been established, the otolaryngologist also becomes a contributor to the incidence problem. Every patient in their office with a whiff of nasal congestion or drainage becomes a candidate. An elderly woman coming in for a hearing evaluation leaves with an antibiotic prescription and a CT sinus scheduled at her next visit (which, by the way, is performed and interpreted by the otolaryngologist and not a radiologist). A teacher with a hoarse voice, a firefighter with a ringing in his ear, and a farmer with a skin cancer all jump aboard the sinus train if the right questions are simply asked. The otolaryngologist beats his chest and says he is treating mild sinus disease and improving lives, but the story of the reimbursements suggests a different motivation.
4. Policy Problems
The reimbursements for medical procedures are defined by the fee schedules established by the Centers for Medicare and Medicaid Services (CMS). The reimbursement schedules are publicly searchable by state and define the minimum a provider will be paid. Private insurance companies typically pay more than this rate. There are many instances where the policy has obviously been implemented without knowledgeable physician input as the rate of reimbursement does not correlate to the time, difficulty, and risk of the procedure. This could not be more evident than in the rates for sinus procedures.
Two types of sinus procedures exist. The first is called functional endoscopic sinus surgery (FESS) which has been around for decades and is well-established as the gold standard. Within the last decade, a new technology has been introduced by medical device companies called balloon sinuplasty. The former involves removing small pieces of tissue to open the drainage pathways of the sinuses and decrease the mucosal burden of disease. The latter involves using a balloon to widen the sinus ostium and enlarge the drainage pathway without removing tissue. The difference in the attainable size of the drainage pathway is tremendous as FESS results in much wider openings due to the removal of tissue. Think of knocking a wall down in your house compared to opening a cracked door.
The argument for balloon sinuplasty is that it has less recovery, higher tolerability, and can be performed more quickly in the office setting under mild sedation and local anesthesia. This is in comparison to FESS which has traditionally been performed under general anesthesia in the operating room, takes more time, is more difficult, and has more surgical risks. This has led to policy makers, undoubtedly under the influence of corporate lobbyists, setting vastly higher reimbursement rates for balloon sinuplasty with a justification that a large proportion of the fee is due to the equipment and value of keeping the patient out of the operating room where there are anesthesia, equipment, and facility fees.
On the surface, this seems like a terrific advancement of technology capable of delivering healthcare services in a win-win situation for all involved — faster recovery for patient, higher physician reimbursement, and less money spent by insurance companies on sinus surgery. The picture is much more complex than meets the eye. First, this only holds true for the insurance company if the denominator stays consistent. What is the effect if the percent of the population being offered sinus surgery increases? The risk barrier to sinus surgery when it involved going to the operating room used to self-select only those with moderate or severe disease. Now, there is a much larger population with mild disease that are willing to undergo an in-office surgery. Second, performing limited ESS in the office setting is now a reality, and it has the same faster recovery aspect of balloon sinuplasty which can be attributed to the lack of general anesthesia and decreased operative times. Therefore, I would ask the question why the reimbursement rates for in-office FESS are not significantly higher if the reduction of costs by avoiding the hospital is achieved?
5. A Cunning Deceit
The science to support balloon sinuplasty is currently weak as there are no high-quality studies comparing balloon sinuplasty alone versus balloon sinuplasty with inferior turbinate reduction or comparing balloon sinuplasty versus in-office endoscopic sinus surgery. Most studies rely on subjective patient symptom surveys (i.e. SNOT-22) and do not involve repeat CT or other objective studies of disease. Even with this being the case, there is likely a logical role for balloon sinuplasty in a select group of patients.
The major problems facing this procedure are based on a desire for higher physician income. These include unwarranted expansion of the target population to increase procedural volume and lack of oversight by insurance providers to ensure accurate diagnosis. The former problem was described above. The lack of oversight by insurance companies leads to cunning physicians being able to easily augment their reimbursement by increasing the number of sinuses that are involved. For example, a patient is going through the evaluation process, and her CT scan shows mild mucosal thickening in the bilateral maxillary sinus. The CT scan was performed in the otolaryngologist’s office, and the otolaryngologist is interpreting the CT scan and creating a report that will go to the insurance company as support for approving the procedure. With little concern for retribution, the physician can also state that there is mucosal thickening in the frontal and sphenoid sinuses even though the CT scan is normal. The insurance company never actually sees the images and solely relies on the physician’s report to approve the procedure. Do you see a conflict of interest here? Once the physician sees success and becomes adjusted to taking the small risk, this practice pattern becomes habitual.
Now, the problem is apparent, and yes, it is criminal. Physicians that are willing to sacrifice integrity for substantial financial gains have been given an opportunity due to poor policy and lack of oversight. Otolaryngologists can increase the population of patients becoming candidates for sinus surgery as well as fraudulently increase the amount of surgery performed per patient. This can lead to life-changing income on the level of yearly salaries increasing from six to over seven-figure salaries. Now, an otolaryngologist can schedule 10 sinus surgeries in a single day when in the past it would have taken at least 3 weeks to perform as many operations.
6. Fixing the Fraud
There is a very clear and easily implementable solution to this problem. First, awareness of this problem needs to increase to prevent this scourge on the specialty of otolaryngology from growing. Otolaryngologists as a group are intelligent, compassionate, and some of the most skilled surgeons that ranked at the top of their medical school classes, so they need to recognize and implement change at the level of their academy. Next, insurance companies need to demand the actual CT images or demand radiologist-read reports prior to approving surgeries, and this should include CMS when they evaluate a claim on the back end. Finally, additional high-level studies should be performed to evaluate the efficacy of balloon sinuplasty as it is currently controversial from a pathophysiological standpoint.
I hope this has been an insightful read. I would love to hear your thoughts on the article. If you have questions or comments, you can email them to honestmedicine4all@gmail.com.
