Podcast Transcript: The Future of Otolaryngology is in the Office

[Ashley Agan MD]
Patients have to get used to the way you run your practice too. It starts whether it's the phone call, the call room, the check-in. It's your whole team and how you run it, so this is the practice. I wanted to ask in terms of in-office procedures, is it hard to get insurance, is it easier just to go to the OR for insurance approvals and things like that? Is it more accessible or less accessible to a patient, the in-office procedures?

[Madan Kandula MD]
That's a good question. From an insurance standpoint, it is more challenging to get approvals for office-based procedures than OR procedures. That's a truth in my opinion. For a practice like ours, this is what we do every day, and so it's the right thing for our patients, to offer office-based procedures, and so we take that burden on ourselves. We are the ones who will fight with insurance companies and fight with our colleagues who are sitting on the wrong side of that equation, in my humble opinion, from denying authorizations, those sorts of things.

We'll take that fight and that fight is, to me, we're a very mission and purpose-driven organization. Part of that is understanding that it's the right thing to offer these services to our patients. Just because it's a bit harder for us to do that doesn't make it less right. It just means that somebody's got to do a little bit more work and we're willing to do that. Yes, just to state it bluntly, with our practice, it would be easier for us. Insurances would have an easier time of it if we had ASCs in every metro area that we were in and we were just driving those cases into the operating room. There'd be less hassle about authorization than there is for office-based procedures, which is insane when you think about it at face value. Long story short, I think for our colleagues who are looking at doing office procedures, it is an uphill battle. I think that it's a shame but it's true. There's a learning curve, which is significant. It's a whole different beast getting your practice to be capable of doing office procedures well. Part of that gets to the authorization. There's a lot of hurdles there that you have to decide that you're going to want to clear before you even go down that road.

I would advise people listening to take that seriously and make sure like, "Yes, this is something I want to do," and "Yes, I'm willing to fight the battles that need to be fought and so forth and so on." Because if you aren't clear with yourself on that, you're going to run into those barriers and it's just going to stop you in your tracks.

[Ashley Agan MD]
Can you give us some specific hurdles that you went through, whether it was clinic 1, clinic 7, clinic 13?

[Madan Kandula MD]
Let me go just very granular and basic. Pre us doing office-based procedures, we didn't. The most extensive procedures I did in my office before balloon sinuplasty became available to do in the office would've been scopes, biopsies, ear tubes in adults, stuff like that. The typical stuff that ENTs do in the office. Those are very discrete kinds of things. To do an in-office nose and sinus procedure, there's an entire numbing process that's just more elaborate than what we need for scopes and things like that.

All of those things, getting at that point my PAs on board, getting my office staff on board, but just the actual logistics of we're going to take time to do something and learn how to do it while we're doing it, people don't want to do that. There's that. Then from an authorization standpoint, when balloon sinuplasty first had CPT codes that allowed it to be done in the office, there were many insurance carriers that didn't cover it at all. Anthem was one specifically for many years that didn't cover it. Now, the challenge for me at that point was thinking about, when I'm sitting in front of a patient, "Gosh, is this an Anthem patient? Anthem doesn't cover in-office procedures. Is that something I should bring up, that they're not going to cover it?" Those sorts of things. Then it's just simply doing the annoying work of justifying our medical decision-making to our, at the end of the day at this point, it is our colleagues, it's our ENT colleagues who work for insurance companies. I'm calling them out, but I'd say the system is so unpleasant to deal with. When I say the system, I'd say the authorization system. You're taking a three-dimensional patient with three-dimensional issues and you're boiling it down into not even two dimensions, you're boiling it down into bullet points, and you're having some bean counter, look at those bullet points to decide if this is authorized or not authorized. Then you're having one of our colleagues look over the shoulder and say, "Yes, that's what it ought to be." Then you have a surgeon and a patient that are simply trying to achieve an outcome. Then everybody's like, "It's hard. I don't know what's going on." I know exactly what's going on, and again, we're guilty on this one. I'm going down a little bit of a rabbit hole. To do office procedures, you've got to fight battles, authorization battles, logistics battles.

Honestly, most of our colleagues are literally not allowed to do these procedures, not because of the medicine, but because they work in systems that literally will not allow their docs to do office procedures. Try to think about fighting that battle and you're not going to win. Honestly, you think about like an academic medical center, you're not going to win that battle. You're not going to convince the powers that be that it's better for you, little ENT, to do this procedure in your office versus we got an OR, we got an anesthesiology staff, we got nurses. They're sitting there waiting for you, and the economics are better for us. When you take that patient to the operating room, good luck to you, my fellow ENT colleague to try to convince them to do what's right medically, for them. I think I went in a lot of weird areas there but I'm just saying all those things intertwine. The only reason we can offer the care that we offer at ADVENT is that we aren't part of a system like that. We don't have bricks and mortar that we have to justify. We don't have a CT scanner that's sitting in the basement that the system wants you to send your patients to.

We can make choices, our patients can make choices. Those little decisions over time, it's not quite 20 years, but over time, it's just simply saying, "What's the right thing for a patient?" In-office imaging, is that right for our patient? Absolutely, no question. I don't think anybody would question that concept. Office-based procedures, is that the right thing for my patients? Absolutely. Home sleep testing, absolutely. Oral appliance therapy is something we offer on-site at our clinics. Is that the right thing? Absolutely. You just think about it and you just go one after another and you say, "Yes, yes, yes."

When your fate is controlled by your knowledge and the actual medicine, the barriers that pop up are things that you just figure out a way to either blow over or go around or go over. I think in medicine in general, we've lost that skill. We don't know how to fight for ourselves. We don't know how to get things done anymore and it's a problem. That's happened over my career. Honestly, when I came out of residency, it was still back in the area where if new technology and new treatments were coming along, your goal was to figure out if that was the best thing for your patient, and then you'd adopt it, and you'd fight to make it happen. Now, those battles can't even happen anymore because all too often, our colleagues are no longer in control, it's the suits that are in control. We did it to ourselves is the reality.

[Ashley Agan MD]
For your practice as far as having people to fight the insurance battles or justify all these things, approximately, how many people do you need per office or per patient group, or per doctor? If I was thinking, "Oh, I'm going to start an office-based practice," do I need to have at least one person that's doing that full time? How much work is that? Is that enough work to keep one person busy all the time?

[Madan Kandula MD]
Yes, unfortunately, probably so. Depends on your volume and it depends on your commitment but if, say you've got that a smaller practice or solo practice, or even a small group practice, I don't know that it's a full-time job out of the gate if you don't have the volume there but it's a job. Whoever's doing the authorizations for your surgeries and CTs currently, this is a teachable skill set and it's a learnable skill set by getting the reps, and the reps are just, part of it is just understanding what the insurance criteria are for each specific insurance carrier as it relates to each specific procedure that you're doing.

Understanding that and then testing it out and seeing how things go and then sometimes you'll get things authorized and then they still won't pay on the back end, which is insane to me but that does happen. You need somebody who's standing and doing that kind of thing. If you're just starting out, whoever's doing that work can do this as a one-off thing but once you get going with this, it's something that's, I'd say for most folks who do a lot of in-office work that I know of tend to be solo docs or one or two people practices that just do a lot of in-office work. I think for those types of practices that are doing high volumes of in-office work, they typically have an individual who pretty much is solely fighting these battles. That takes a while before you have that need, but you definitely have the need to some extent right out of the gate.

[Ashley Agan MD]
For patients who cannot get insurance approval, let's say, you've done everything, jumped through all the hoops, and it's just like, "No, this is just not covered." Do you have cash basis where you can offer patients a route to get things done if their insurance company is being stubborn and not willing to work with you?

[Madan Kandula MD]
Yes. There is, We take the authorization battles on ourselves and sometimes we lose. For a patient that we feel medically that, let's just use balloon sinuplasty as a specific example, we feel like that would be beneficial, but the insurance carrier is denying it. Then we have the conversation with the patient as to this is the reality and this is the out-of-pocket that this would mean for you. We try to minimize that bite as much as possible. Then a patient can make the choice.

Strangely, back to the earlier conversation or an angle on this is that very same patient who is denied in-office balloon sinuplasty oftentimes more often than not, the insurance will approve a sinus surgery in an operating room setting. That might be a road to go down, depending on the severity of somebody's disease state. Which just seems obscene to me, insane to me but that's the case. It makes no sense at all. Healthcare insurance doesn't need to make sense, but that one is like, "How do you explain that to somebody?" Literally, people are like, "You're telling me they would rather me go under anesthesia and go into the operating room than have this done in the office? That's what you're trying to tell me?" I'm like, "That's what I am telling you." They're like, "That's insane." I'm like, "Yes, that is insane. You might want to reach out to your insurance company to talk about their mental health because literally, that's insanity. It doesn't make any sense" Part of it’s because nobody ever calls it out. It's insane, and we see this all the time, but who can you talk to about that?

You're not going to get anybody's ear at that insurance company. They don't care. They literally don't care and it just boggles my mind sometimes. Part of my hope, and I'm going to do a better job of this moving in a forward direction, is I think if normal people heard the crazy things that we all experience just being physicians and surgeons in this country, it's mindbogglingly unbelievable some of these things. Part of the reason these things exist and they continue to exist is that people don't hear about them, they don't. Everybody knows things are screwed up in healthcare in this country, but they don't know that it's this screwed up, but it is.

[Gopi Shah MD]
I wanted to ask you, in terms of somebody starting out, how do you figure out cost and equipment? Do you rely on loans? Do you work with industry? How do you get started because you have your microscope and your scopes in your ENT clinic, but then you need special tools and machines and things?

[Madan Kandula MD]
Yes, to some extent. It depends. Fortunately, I'm minimalist in my needs as well, both in the OR and the office. I try to keep it as simple as possible, which it's good for my sanity, but it's also good from a cost standpoint but with anything, healthcare's expensive. Surgery is expensive. Office-based surgery can get expensive to some extent, but industry will work with you. You could work with industry to soften the blow of getting things started. They've got an obviously vested interest in seeing that you're successful in this endeavor. Industry can do that. You can get loans.

In our early phases at ADVENT and when we started doing in-office procedures, it was just paying for it with bootstrapping, is the way that in other industries they call it. We're just paying for these expenses through taking care of the other patients that we have. In the grand scheme of things, you do need to make sure that the economics make sense for you to even go down this road, but if they do, the numbers don't have to be extraordinary to be sufficient. You need to understand it. I don't know what that means.

At this point, if somebody's starting out and then they look at the numbers, look at what is your average reimbursement for the typical case that you might be doing in the office. Look at your startup costs, think about that, be realistic about that. Understand there's a ramp phase. Understand that all of those things happen. Understand that you, the person that you look at in the mirror is the most likely person to sabotage the whole thing. Meaning when you're stuck in that first case, second case only seeing the pain and feeling the pain and only seeing the expense and not seeing the reward for this. Again, it's the person that looks back at you in the mirror is going to say, "Why are you doing this? Just go to the operating room, your life will be a whole lot easier." I guarantee you more people have been stopped in their tracks from doing in-office procedures by the person who looks back in the mirror than anybody else. It's not like, "Who's going to keep you away from doing this?" It's you more than anybody else. It's not the economics. When you look at it, industry really would love to help you. Again, they've got a vested interest in seeing you successful.

I can honestly say from my conversations with industry, all aspects of industry as it relates to our specialty, because many of those folks come from ortho and neurosurgery and other things like that. Consistently when I broach this area of conversation, they're always like, "What the hell is up with ENTs? You guys are weird." Literally, because it's like we are surgeons and yet we have this, I don't know what it is, that we have this mindset of self-loathing. It's not just our colleagues talking to ourselves, meaning that there's this constant chirping of, "That person does a lot of in-office stuff and what's wrong with them and blah, blah blah. I know that medicine is the right way to do it."

People have a lot of dogma generally speaking, but in other surgical specialties, we don't have as much dogma as we do in ours. I don't understand where that comes from. I'm just going off on a tangent, but I'd say back to our industry colleagues, they are flabbergasted that we as a specialty have been so slow to adopt office-based procedures, when it's what patients want. The technology's there, the economics make sense. The only people standing in the way are ourselves. It's ENTs standing in the way of us doing things and when you break it down, the truth there, in my humble opinion is the truth there is, I guess I, just to go full circle back to how we were all trained. I was trained in an academic medical center. In an academic medical center, there's a construct that exists there that is, OR first, hospital first. We all work for those things. We are subservient. Then you go out in the real world and you find, no, actually it's not OR first, and it's not hospital first, it's patient first. Patients don't want to go to the operating room. However much you want to go to the operating room and however much you like to operate, they don't care.

When you give them the choice between the office or operating room, and if it's truly like, "You could go down this road or that road and both are going to be good options for you," they will choose office every single time. Other than if somebody's squeamish about office, but if you know what you're doing and you do enough, you can pick those ones out of the crowd. Regardless, the reason that we aren't doing more office procedures isn't because the demand isn't there and isn't because the economics don't work, and isn't because the technology isn't there. It's because the system, the status quo is rigged to direct people towards the operating room, direct us to think that we need the operating room as that's the only place I can really be comfortable and operate when in fact you can do this in the office. There's no doubt about it.

[Gopi Shah MD]
I just have two quick questions, then we'll put a pin at it as Ash likes to say but in terms of oral appliances do you have a dentist that you work with?

[Madan Kandula MD]
Basically historically we've had dentists that we work with. We've been doing that for a decade at this point, but currently, we're challenged because we've got multiple clinics right now. So we've had a hard time finding dentists in each metro area that we're in. We're looking at trying to just bring that in-house. There's a whole podcast episode on this, so I'm not going to go into all the details. Let me tell you this, oral appliance therapy is something that patients want if they could have access to it. The place where they could have access to it is actually within an ENT office.

That is a big paradigm shift, but the challenge for dentists who are passionate about these things, sleep and sleep dentistry, is they're on the other side of the fence from the health insurance industry. The health insurance industry doesn't want dentists. They don't want to break that wall down because as a whole, once we have dentists and now they're billing through healthcare insurance, that's going to create like “the end of the world” kind of thing. Anyway, all I can say is that our patients at ADVENT, the large majority of the folks that we diagnose with obstructive sleep apnea if given the choice between an oral appliance and a CPAP machine, will choose an oral appliance when they're appropriate candidates. I believe it is my duty to figure out a way to make that possible. It's the same conversation as office versus OR. It's not what I want to do, it's what do I need to do for my patients. In this situation, if patients had that option, they'd be choosing it way more often than they currently are. I'm done sitting and waiting around for somebody else to solve this problem. We are helping to solve the problem in our clinics. We're not there yet. It's actually one of the initiatives that we launched this year and it's rolling right now.

It's a passion project for me, which means, that's a good example for me personally of a situation where I am going to take that ball and I am going to drive that forward. There's people I've had to run over and companies I had to run over and feelings that have been hurt and so forth and so on and I don't care. It needs to be done and we're going to do it. Once we do it, maybe I'm wrong. As forceful as I sometimes sound, maybe I could be wrong, but I don't think I am. I've just seen it so many times. Then I go full circle to this conversation I’d say, “Imagine a world where you have these folks who have breathing triangle issues and you could in a simple manner, get their noses working, get their airways open when they're sleeping at night in a elegant, simple, effective, efficient, so forth and so on.” That's possible today. We don't have to wait on somebody. Back to my simple turbinate reduction. I'd say, "Give a turbinate reduction and give me an oral appliance and give me a world full of people with breathing triangles that are broken."

That's not the right fit for everybody. I'm not saying that it is, I'm saying there's a lot of people who would benefit from that, who just simply don't have access to those options right now. Not by their choice, but because that's how the system is created or it's constructed right now.