Published: October 25, 2013

The Childcare Dilemma: Daycare vs. Nanny Care

Pamela C. Roehm, MD, PhD Assistant Professor Department of Otolaryngology NYU School of Medicine Working parents face the dilemma: Who will take care of their children? For otolaryngologists, this issue is complicated by long hours and variable schedules. When otolaryngologists have children, they frequently have them during residency or early years of practice, when hours are long and dollars are few. In the new millennium, the concept of work before family no longer holds precedence for men or women, and more women work outside the home.1, 2 Thus otolaryngologists, male or female, must consider childcare issues. These become more pertinent to the ENT community as more women enter otolaryngology; in 2010, more than half of otolaryngology residency applicants were female.3 Even when women are primary breadwinners, they tend to be primary caregivers for children; this relationship holds true for female surgeons.4, 5 For these reasons, the Women in Otolaryngology Section has determined that childcare is a key issue for practicing otolaryngologists. One option is childcare provided by a family member, but this is not always possible. Often, the decision boils down to daycare vs. a nanny. Each choice has advantages and disadvantages, and there are avid advocates of each. I will address advantages and disadvantages of daycare, and then nanny care. Not all daycare is the same. Facilities range from large corporate-run entities with multiple classrooms and children separated by age, to smaller family-run daycare centers with only one provider within the home. Advantages and disadvantages of daycare differ significantly based on these factors. One advantage of all types of daycare is that your children will be raised in the presence of other unrelated children. Thus from an early age, your child will learn how to interact with peers. A second advantage is that daycare providers do not live in your house, so you don’t have to supply a vehicle for your daycare provider, as you might for a full-time nanny. Also, state-directed mandates require daycare workers to have additional educational degrees and training that nannies may not have. Daycare is frequently less expensive than a full-time nanny. If you have work-subsidized daycare, your savings may be greater. Daycare facilities will often provide discounts of 10 percent to 25 percent for siblings. Costs differ based on geographic location and the age of your child. Typically, full-time daycare costs $100 to $400 Monday through Friday, with an additional $25 to $100 per month for children under 2 years old. Costs include tuition during vacations when your children are not present at daycare and backup care during daycare holidays. Additional costs can include supplies and diaper, laundry, and activity fees.  Most daycares provide snacks, and sometimes even lunch. Larger daycare facilities benefit from a larger workforce. As a consequence, centers do not close if one provider is absent, unlike family-run daycare (and nannies). There are multiple “eyes” on your child, minimizing the impact of interpersonal conflicts and negligent caregivers. Often larger facilities will have a planned curriculum of activities. Finally, larger centers are more likely to meet state-mandated standards. However, they can be less personal, and may shuffle daycare providers throughout the facility on a day-to-day basis. They also may not cater to dietary restrictions, unlike smaller daycare settings. In contrast, family-run daycare can have many of the advantages of a nanny, such as a more personal quality. Unfortunately, smaller centers also face some of the disadvantages of nanny care, including cancellations due to vacations or illness of the caregiver. Common disadvantages of daycare include multiple infections that your children will contract after contact with other children. This can lead to costs for backup care for your child and/or lost income when you or your children are ill. A second disadvantage is that your children may be sent home when they appear to facility personnel to be sick. A note from your child’s pediatrician may be required prior to return to daycare, necessitating lost work time.  Long waiting lists for daycare enrollment are another potential downside. Daycare drop-off and pick-up times are firm and will not accommodate occasional emergency calls or late cases. Full-time daycare typically will not extend through a full surgical-length workday, and daycare is not open on weekends and holidays. Finally, unlike a nanny, daycare workers will not take your child to pediatric or dental appointments or to extracurricular activities. There are as many permutations to nanny care as to daycare. Nannies come with a variety of experience levels, from untrained babysitters to individuals with master’s degrees. Nannies can live in your home part-time, full-time, or not at all. Benefits and salary are negotiable in the contract, as are work hours and expectations regarding activities and schedules for your children. For a full-time otolaryngologist, the scheduling flexibility that a nanny can offer may be the only workable solution to covering a long workday or last-minute cases and delays. This type of flexibility must be discussed thoroughly in advance with the nanny applicant to avoid gaps in childcare coverage. Overtime pay must be discussed and agreed upon prior to entering the nanny contract. For residents, live-in nannies, who are typically the most flexible for providing last-minute childcare, may be the best choice. One exception is that au pairs can work only up to 45 hours per week, and so will not be able to provide adequate childcare coverage for a surgeon. Another advantage of nanny care is the convenience of having a childcare provider in your home, thus avoiding the time and difficulty involved in preparing and transporting your children to another site. Your children will be raised in a familiar environment. Light chores may be negotiated into the nanny contract. You can determine how your child is disciplined, when nap and meal times occur, and what food and activities are offered. With a nanny, your child can have one-on-one attention.  A nanny will take care of your children even if they are sick, and your children may develop a strong bond with their nanny that lasts for years. Nanny care can be more expensive than daycare, especially if you have only one child and have negotiated an hourly rate, rather than a fixed salary. Rates run from $20,000 to $50,000 per year for full-time nannies or $10 to $19 by hour. Wages vary by education, experience, and geographic location. Salaries are lower for live-in nannies. For larger families, rates for nanny care may be less expensive than those for daycare. Taxes, including FICA, should be calculated into the costs of having a nanny. There are disadvantages to nanny care. The greatest is that there is no built-in backup for your nanny if she is unable to take care of your children. If she becomes sick, you have to find alternative care. Similarly, if she quits, you may be interviewing nannies over the phone late at night before a long day in the OR.  Another disadvantage is that nanny care is extremely variable. Some nannies are wonderful, others are dreadful. Finding one whom you trust can be difficult, and many families use nanny-cams to ensure that proper care is being given. Unlike daycare, where baseline education levels and additional training (CPR) are governed by state mandates, nannies may be uneducated. Background searches on credentials and letters of recommendation are a must when hiring a nanny.  Socialization may be lacking for children left in nannies’ care. Playdates and extracurricular activities need to be planned in advance to provide crucial peer interactions. You may need to supply a car, gas, and other benefits to the nanny. Since a nanny works in your home, privacy can be an issue, so limits must be set from the beginning. Regardless of the option chosen, backup care provisions must be available with very short notice to avoid compromising patient care. Backup care can range from drop-off daycare to backup nanny care through an emergency service. Either option tends to be expensive ($18 or more per hour). You must register for these services ahead of time. During times of high demand, you will need to contact backup care providers well in advance to secure their services. References Alsop R. “The ‘Trophy Kids’ Go To Work,” Wall Street Journal, October 21, 2008, D1. United States Department of Labor, “Employment Characteristics of Families Summary,” released 5/27/2010 (http://www.bls.gov/news.release/famee.nr0.htm). Association of American Medical Colleges, “FACTS: Applicants, Matriculants, Enrollment, Graduates, MD/PhD and Residency Applicants Data,” last accessed 12/29/2010 (https://www.aamc.org/data/facts/). Krueger AB, Mueller A. “Job Search and Unemployment Insurance: New Evidence from Time Use Data,” J Public Economics 2010;94:298-307. Troppmann KM et al, “Women Surgeons in the New Millennium,” Arch Surg 2009;144:635-642.

daycarePamela C. Roehm, MD, PhD
Assistant Professor
Department of Otolaryngology
NYU School of Medicine

Working parents face the dilemma: Who will take care of their children? For otolaryngologists, this issue is complicated by long hours and variable schedules. When otolaryngologists have children, they frequently have them during residency or early years of practice, when hours are long and dollars are few. In the new millennium, the concept of work before family no longer holds precedence for men or women, and more women work outside the home.1, 2 Thus otolaryngologists, male or female, must consider childcare issues. These become more pertinent to the ENT community as more women enter otolaryngology; in 2010, more than half of otolaryngology residency applicants were female.3 Even when women are primary breadwinners, they tend to be primary caregivers for children; this relationship holds true for female surgeons.4, 5 For these reasons, the Women in Otolaryngology Section has determined that childcare is a key issue for practicing otolaryngologists.

One option is childcare provided by a family member, but this is not always possible. Often, the decision boils down to daycare vs. a nanny. Each choice has advantages and disadvantages, and there are avid advocates of each. I will address advantages and disadvantages of daycare, and then nanny care.

Not all daycare is the same. Facilities range from large corporate-run entities with multiple classrooms and children separated by age, to smaller family-run daycare centers with only one provider within the home. Advantages and disadvantages of daycare differ significantly based on these factors.

One advantage of all types of daycare is that your children will be raised in the presence of other unrelated children. Thus from an early age, your child will learn how to interact with peers. A second advantage is that daycare providers do not live in your house, so you don’t have to supply a vehicle for your daycare provider, as you might for a full-time nanny. Also, state-directed mandates require daycare workers to have additional educational degrees and training that nannies may not have.

Daycare is frequently less expensive than a full-time nanny. If you have work-subsidized daycare, your savings may be greater. Daycare facilities will often provide discounts of 10 percent to 25 percent for siblings. Costs differ based on geographic location and the age of your child. Typically, full-time daycare costs $100 to $400 Monday through Friday, with an additional $25 to $100 per month for children under 2 years old. Costs include tuition during vacations when your children are not present at daycare and backup care during daycare holidays. Additional costs can include supplies and diaper, laundry, and activity fees.  Most daycares provide snacks, and sometimes even lunch.

Larger daycare facilities benefit from a larger workforce. As a consequence, centers do not close if one provider is absent, unlike family-run daycare (and nannies). There are multiple “eyes” on your child, minimizing the impact of interpersonal conflicts and negligent caregivers. Often larger facilities will have a planned curriculum of activities. Finally, larger centers are more likely to meet state-mandated standards. However, they can be less personal, and may shuffle daycare providers throughout the facility on a day-to-day basis. They also may not cater to dietary restrictions, unlike smaller daycare settings.

In contrast, family-run daycare can have many of the advantages of a nanny, such as a more personal quality. Unfortunately, smaller centers also face some of the disadvantages of nanny care, including cancellations due to vacations or illness of the caregiver.

Common disadvantages of daycare include multiple infections that your children will contract after contact with other children. This can lead to costs for backup care for your child and/or lost income when you or your children are ill. A second disadvantage is that your children may be sent home when they appear to facility personnel to be sick. A note from your child’s pediatrician may be required prior to return to daycare, necessitating lost work time.  Long waiting lists for daycare enrollment are another potential downside.

Daycare drop-off and pick-up times are firm and will not accommodate occasional emergency calls or late cases. Full-time daycare typically will not extend through a full surgical-length workday, and daycare is not open on weekends and holidays. Finally, unlike a nanny, daycare workers will not take your child to pediatric or dental appointments or to extracurricular activities.

There are as many permutations to nanny care as to daycare. Nannies come with a variety of experience levels, from untrained babysitters to individuals with master’s degrees. Nannies can live in your home part-time, full-time, or not at all. Benefits and salary are negotiable in the contract, as are work hours and expectations regarding activities and schedules for your children.

For a full-time otolaryngologist, the scheduling flexibility that a nanny can offer may be the only workable solution to covering a long workday or last-minute cases and delays. This type of flexibility must be discussed thoroughly in advance with the nanny applicant to avoid gaps in childcare coverage. Overtime pay must be discussed and agreed upon prior to entering the nanny contract. For residents, live-in nannies, who are typically the most flexible for providing last-minute childcare, may be the best choice. One exception is that au pairs can work only up to 45 hours per week, and so will not be able to provide adequate childcare coverage for a surgeon.

Another advantage of nanny care is the convenience of having a childcare provider in your home, thus avoiding the time and difficulty involved in preparing and transporting your children to another site. Your children will be raised in a familiar environment. Light chores may be negotiated into the nanny contract. You can determine how your child is disciplined, when nap and meal times occur, and what food and activities are offered. With a nanny, your child can have one-on-one attention.  A nanny will take care of your children even if they are sick, and your children may develop a strong bond with their nanny that lasts for years.

Nanny care can be more expensive than daycare, especially if you have only one child and have negotiated an hourly rate, rather than a fixed salary. Rates run from $20,000 to $50,000 per year for full-time nannies or $10 to $19 by hour. Wages vary by education, experience, and geographic location. Salaries are lower for live-in nannies. For larger families, rates for nanny care may be less expensive than those for daycare. Taxes, including FICA, should be calculated into the costs of having a nanny.

There are disadvantages to nanny care. The greatest is that there is no built-in backup for your nanny if she is unable to take care of your children. If she becomes sick, you have to find alternative care. Similarly, if she quits, you may be interviewing nannies over the phone late at night before a long day in the OR.  Another disadvantage is that nanny care is extremely variable. Some nannies are wonderful, others are dreadful. Finding one whom you trust can be difficult, and many families use nanny-cams to ensure that proper care is being given. Unlike daycare, where baseline education levels and additional training (CPR) are governed by state mandates, nannies may be uneducated. Background searches on credentials and letters of recommendation are a must when hiring a nanny.  Socialization may be lacking for children left in nannies’ care. Playdates and extracurricular activities need to be planned in advance to provide crucial peer interactions. You may need to supply a car, gas, and other benefits to the nanny. Since a nanny works in your home, privacy can be an issue, so limits must be set from the beginning.

Regardless of the option chosen, backup care provisions must be available with very short notice to avoid compromising patient care. Backup care can range from drop-off daycare to backup nanny care through an emergency service. Either option tends to be expensive ($18 or more per hour). You must register for these services ahead of time. During times of high demand, you will need to contact backup care providers well in advance to secure their services.

References

  1. Alsop R. “The ‘Trophy Kids’ Go To Work,” Wall Street Journal, October 21, 2008, D1.
  2. United States Department of Labor, “Employment Characteristics of Families Summary,” released 5/27/2010 (http://www.bls.gov/news.release/famee.nr0.htm).
  3. Association of American Medical Colleges, “FACTS: Applicants, Matriculants, Enrollment, Graduates, MD/PhD and Residency Applicants Data,” last accessed 12/29/2010 (https://www.aamc.org/data/facts/).
  4. Krueger AB, Mueller A. “Job Search and Unemployment Insurance: New Evidence from Time Use Data,” J Public Economics 2010;94:298-307. Troppmann KM et al, “Women Surgeons in the New Millennium,” Arch Surg 2009;144:635-642.
More from March 2011 - Vol. 30 No. 03
Samantha Caccamo, Nobel Laureate Professor Yunus, and Michael D. Seidman, MD, at Yunus Center.
Bangladesh: Tackling Health Issues and Implementing Social Business
Michael D. Seidman, MD Chair, Board of Governors In June 2010, the Coalition for Global Hearing Health meeting was held at Academy headquarters, organized by James E. Saunders, MD, and Jackie Clark, PhD. During the meeting, 27 countries that have significant healthcare concerns were represented. Samantha Caccamo, founder of Social Business Earth (SBE), presented issues about Bangladesh. She planned to go there for two weeks, and solicited my participation. Our visit to this incredible country in November 2010 was too short, but productive. The country is roughly the size of Iowa with more than 160 million inhabitants and an infrastructure that cannot support the population. We met with members of the health department; Professor Pran Gopal Datta, an otolaryngologist who is vice chancellor of Bangladesh’s only medical university; Professor M. Nurul Amin, who started the Society for Assistance to Hearing Impaired Children (SAHIC), the only ear hospital in the city; and Professor Muhammad Yunus, Nobel Peace Laureate, founder of the Grameen Bank, and originator of the concept of Social Business (SB). SBs are organizations designed to solve a pressing need such as poverty, agriculture, technology, or health. Each organization must be financially self-sustaining and is allowed to make a profit, with the caveat that the profit is re-invested to expand the reach of the SB. The only profit a founder or investor may reap — perhaps the most important — is the profit gained by the heart, knowing that you are involved in selfless pursuits. Several SBs are already in place, such as the Grameen Eye Hospital, which serves the rural poor and provides inexpensive cataract surgery, and Grameen Danone, where the CEO of Dannon Yogurt and Professor Yunus collectively serve the poor and malnourished. They produce Shokti Doi, a yogurt fortified with iron, calcium, and other nutrients, which sells for seven “taka,” or about 10 cents. If children consume two servings a week for eight months, the nutrients mitigate malnutrition. The hearing issues are staggering — more than 11 million people in Bangladesh are deaf. The World Health Organization (WHO) suggests that 80 percent is acquired and 50 percent is preventable through proper immunizations, education, and early intervention. Preventing these problems would save billions in lost productivity, not to mention the huge emotional and psychological toll this situation has on the affected person and their families. Most with sensorineural hearing loss (SNHL) receive no education, are relegated to their homes, and become ostracized and the target of abuse, further perpetuating the stigma associated with SNHL. Professor Amin started a hospital for hearing issues. He now has 16 surgeons, audiologists, nurses, and technicians. They are eager for surgeons to come for two weeks at a time to share surgical and diagnostic expertise. He also started a school for the deaf and teaches 220 children ages 3-6 with the intent to mainstream them. We worked with Professor Datta at the Medical University of Bangladesh, where he was appointed by the Prime Minister to be the vice chancellor. He notes the most pressing problem is population control, and would like to see birth control as the primary concept to be disseminated. We spoke of vaccination issues and he thinks he could run a program through the university. We then worked with Professor Yunus and his team at the Grameen Bank (GB), including the managing director, Imamus Sultan, who oversees the two eye hospitals and 51 primary care clinics across the country, and Lamiya Morshed, executive director of the Yunus Centre. The GB has agreed to distribute vaccines to patients at all 51 centers if we are able to start the program and lower the cost of the vaccine. We were in awe and fully inspired with the important work being done by the GB, and we had the opportunity to evaluate areas of need. Specifically, we will address the following: reduce SNHL with immunizations and education; set the stage for the creation of the Grameen Ear Hospital; train professionals and provide care to patients using telemedicine; employ simulation centers to fill the void created by the legalities of allowing visiting physicians “hands on training” while in the U.S.; describe the need for rehabilitation of those already affected by SNHL; proactively address the issues of rickets (fully preventable); and address the issue of population control. Ms. Caccamo stayed on to visit the traumatic brothels where 11- and 12-year-old girls are forced to take Oradexon, a dangerous cow steroid to enhance their physical appearance and look more appealing to their clients. She visited Chakaria and the Cox’s Bazaar area, where rickets is rampant and largely preventable, and she worked with the Minister of Health. I am convinced that when you have the support of the GB, the Minister of Health, the vice chancellor of the Medical University, and  hard-working, generous people in humanitarian efforts, change will happen. With the enormous needs of these people and the lack of resources, the SB concept created by Professor Yunus is a model of success, and the time to act is now. Our plan is to open an Ear Hospital with GB. We will need 15 audiologists and otolaryngologists from Europe and the U.S. who are willing to go to Bangladesh in rotation for a period of two weeks at a time to train the local ENT doctors and assistants. Travel and other expenses are the volunteer’s responsibility. If you wish to share your expertise at the Ear Hospital, please contact me (Mseidma1@hfhs.org) or Samantha Caccamo (samantha@socialbusinessearth.org). We are still at the early stages of our planning but we’d like to hear from you!
survey
Get Ready to Participate in the 2011 Socioeconomic Survey
Planning for the Academy’s 2011 socioeconomic survey is under way. The results of this survey provide an invaluable tool for otolaryngologist—head and neck surgeons to compare their practices’ productivity, revenue, operations and other patterns. The Academy has used the same outside vendor for each survey, the Townsend Group, which disseminated the survey in mid-February 2011, and will work with the Academy to analyze the results. The survey was sent via email to all members (excluding military, retirees, and those in training). If you received the survey, please complete it! As you know, a high survey response rate will provide more robust data, which will help provide AAO-HNS members with benchmarking tools for your practices. We plan to display the results and analysis of the survey at our 2011 annual convention in San Francisco.  AAO-HNS members may access previous socioeconomic surveys on our website (log-in required) at http://www.entnet.org/Practice/members/socioeconomic.cfm. If you have questions, please contact Healthpolicy@entnet.org.
interview
Rules of Recruitment: the Interview
Benedict Ferro, International Medical Placement, Ltd., and Gene Corbett, Physician Finders This is the first in a series of Bulletin articles related to the recruitment process. The companies named above provide physician recruiting and consulting services to Academy members at a discounted price, and will return a portion of the proceeds to support AAO-HNS programs and services.  This month’s question: Preparing for a physician candidate interview — what should an employer do to ensure a successful interview?  Background Information  Ben: Request and check references from the candidate before scheduling the visit and making travel arrangements. This allows you to confirm a potential fit with each prospective candidate before making a time and cost commitment to that person. Provide the candidate with all promotional literature and corresponding websites about your practice/community/hospitals. Those give the candidate an introductory view of who you are and allow them to assess the overall compatibility they believe they will have with your practice. Gene: When checking references, the program coordinator [at the candidate’s current institution] is typically accessible, while the program director can be difficult to reach. You can get a good feel for a candidate by speaking with staff personnel. If physician candidates treat the staff well and are well-liked, then they will do the same in your practice. If they don’t treat the staff well, you might be taking on a personality that may not work well in your office. Go to the source when conducting a reference check. Call some of the faculty whom the candidate may not have on the reference list. Itinerary Ben: Besides travel and accommodation arrangements, the employer should have a schedule of all events that occur during a candidate visit. This includes meeting staff, community and real estate tour, meals, and entertainment. Consider whether you want them to shadow you in surgery and/or during patient visits. Candidates’ spouses should always be included in a site visit whenever possible. Determining which events they will attend and keeping them engaged in the process is vital to the overall success of the visit. Gene: It is imperative to include the spouse in all itinerary planning. When planning a site visit, make sure that you understand what the spouse desires to see during their visit. The spouse may want to look at potential employment opportunities and perhaps you may be able to network and help set up an interview. The spouse may be interested in schools, recreational opportunities, housing, or other items. Perhaps there is some common thread the spouse may have with another member or spouse in your practice that can be exploited and used to your advantage. Don’t let the spouse have idle time and become bored. Use the assistance of a competent real estate agent. Typically, agents are well versed in their communities and can provide great tours supplying a multitude of information. Employment Agreement Ben: While most employers may not make a formal offer during an initial candidate visit, you will still want to have the ability to provide at least a sample contract to those candidates in whom you are interested before they return home. If that sample does not include specific compensation, you should share with the candidate both the salary and overall compensation potential of your opportunity. You want a candidate that you feel is a good fit for your practice to know both your interest level and the specifics of what you can offer before they leave. One of the biggest mistakes employers make is not having an employment offer in place before an interview occurs, and then after meeting a candidate they like and want to hire, lose valuable time while waiting for attorneys/accountants to create an offer. This leaves you vulnerable to losing the candidate to another employer and sends a message to the candidate that you are not really sure what you can offer. Gene: I agree with Ben wholeheartedly with this point. I can’t tell you how many times a candidate chooses another opportunity while waiting for a written contract from a different employer. The recruitment process starts with a written contract. If you don’t have a contract prepared, you are not ready to recruit. The conveying of a written contract is the confirmation of the offer. An oral offer is acceptable to discuss, but the written offer states “We want you to join us; here is proof of our intent.” The candidate is able to take that offer, read it over, have it reviewed, and ultimately make a decision to accept or reject based upon what is stated in the written offer. An employment agreement should be written in a manner that is balanced to both sides. An imbalanced agreement may lead to an imbalanced relationship, and ultimately, poor retention.
scan
Private Payer Advocacy: Humana’s Coverage for Mini-CT Scans
Several years ago, we learned from a member about Humana’s problematic medical coverage policy for mini-CT. Although the Food and Drug Administration (FDA) had approved mini-CT scans, Humana was not willing to cover them. Initially, its policy on mini-CT scans stated: “Humana members may not be eligible under the Plan for mini-CT scan. This technology is considered experimental/investigational as it is not identified as widely used…” Therefore, we began following the issue and worked with several practices to advocate for coverage of mini-CT scans and other cone-beam, limited-use CT imaging modalities for sinonasal CT imaging procedures. In November 2009, the AAO-HNS’ Health Policy staff and some members including Gavin Setzen, MD, chair of the new Imaging Committee, as well as representatives of  the Association of Otolaryngology Administrators, American Medical Association, Kentucky Medical Association, Greater Louisville Medical Society, Intersocietal Commission for the Accreditation of Computed Tomography Laboratories (ICACTL), and Xoran Technologies,  held a conference call with a number of Humana leaders to discuss the policy and argue for appropriate coverage for mini-CT scans. Consequently, the insurer expanded coverage for the mini-CT to “diagnosis uncertain AND suspected acute frontal or sphenoidal sinusitis.” Unfortunately, the revised policy at that time was limited in its coverage for mini-CT because it did not cover mini-CT scans for “immunodeficient patients (at high risk for invasive fungal sinusitis) OR orbital complications and/or neurologic deficit; OR recurrent acute or chronic rhinosinusitis; OR sinonasal obstruction; OR sinonasal polyposis.” Building on our momentum from this advocacy effort, in August 2010, AAO-HNS and other representatives on the 2009 conference call held another follow-up conference call with Humana. The call was well-received and Humana Medical Directors indicated that support from the Academy for use of mini-CT for sinonasal CT imaging procedures based on medical necessity would likely result in reversal of the policy. In an October 2010 Academy comment letter to Humana, we provided rationale based on evidence-based literature (including our recently approved policy statement, Point of Care Imaging in Otolaryngology at http://www.entnet.org/Practice/policyReimburseImagingStudies.cfm) supporting safety, reduced costs, and convenience to patients that the device presented. Specifically, we reiterated that since the FDA had already approved mini-CT devices, Humana should not deem them as experimental or investigational. The AAO-HNS also specifically requested that Humana cover mini-CT scans for the conditions (listed above) for which Humana previously excluded coverage. Our efforts paid off. In November 2010, we received a positive response from Humana stating it would reverse its coverage position for mini-CT scans. In this letter, Humana agreed to cover immunodeficient patients (at high risk for invasive fungal sinusitis), orbital complications and/or neurologic deficit, recurrent acute or chronic rhinosinusitis, sinonasal obstruction, and sinonasal polyposis. This major win would not have been possible without the help of all our member volunteers who rigorously and diligently had open dialogue with Humana representatives.  This experience again echoes how each member can be his or her own advocate by taking advantage of the private payer advocacy resources on our website and using the following steps when you encounter coverage issues: Determine whether the insurer denied the claim because of billing errors. (Please contact the Academy’s coding hotline at 800-584-7773; this is a FREE service for members.) Determine whether you submitted the appropriate supporting medical documentation. After you have determined there was no billing or documentation error, please appeal the denial, using the Academy’s resources (http://www.entnet.org/Practice/Private-Payer-Resources.cfm). Report the issue to your state medical or otolaryngology society after you determine the issue is state-wide. If you determine that the coverage issue is nationwide, contact the Academy’s Health Policy department at Healthpolicy@entnet.org which will forward the issue on to the Physician Payment Policy (3P) workgroup for review and determining next steps to pursue. To learn more about the Academy’s latest private payer advocacy efforts, check our weekly e-newsletter, the News, the website (http://www.entnet.org/Practice/News-and-Updates-from-Private-Payers.cfm) and the Bulletin or contact Healthpolicy@entnet.org.
3pgroup
Update from the Physician Payment Policy (3P) Workgroup
Richard Waguespack, MD, Coordinator for Socioeconomic Affairs, and Michael Setzen, MD, Coordinator for Practice Affairs, Co-Chairs of 3P with Jenna Kappel, Director, Health Policy; Tricia Bardon, Assistant Director, Health Policy; Udo Kaja, Program Manager, Payer Advocacy The Physician Payment Policy Workgroup (3P), co-chaired by Richard Waguespack, MD, and Michael Setzen, MD, is the senior advisory body to Academy leadership and staff on issues related to socioeconomic advocacy, regulatory activity, coding or reimbursement, and practice services or management. 3P and the Health Policy staff have been busy in 2011 with a continued high level of activity, constant e-mails and monthly calls, working diligently and tirelessly on behalf of all members. Below, we have highlighted some advocacy efforts. (For the latest health policy updates, visit the “what’s new” page at http://www.entnet.org/Practice/CMS-News.cfm on our website.) Continued Advocacy Effort with United Healthcare (UHC) The Academy continues to advocate for its members regarding UHC’s guideline on Rhinoplasty, Septoplasty and Turbinate resection (http://www.entnet.org/Practice/CMS-News.cfm#ADV). The revised policy now includes repair of vestibular stenosis. Based on a conference call led by Setzen on January 18, 2011, with UHC representatives, AAO-HNS, and other society leaders, we are hopeful that many outstanding concerns will be revised by UHC soon. We will continue to keep members apprised of the latest updates. For more information, contact healthpolicy@entnet.org. Updated Coding Guidance Available for New/Revised CPT Codes: Stereotactic Computer-Assisted Navigation (SCAN) and Balloon Sinus Dilation • SCAN CPT code 61795 deleted; now 61781, 61782, and 61783. The Academy and 3P leaders were very involved in the review and revision of Stereotactic Computer-Assisted Navigation (SCAN) because the CPT code, 61795, over the course of several AMA CPT and Specialty Society/Relative Value Scale Update Committee (RUC) meetings. CPT code 61795 was identified for review through a screen of the fastest-growing procedures in 2008 so the societies involved in performing the procedures were required to review the code. (The code also had not been surveyed since the original Harvard data was collected.)  Neurosurgeons and otolaryngologists were the two highest users of 61795. Therefore the societies collaborated and determined that moving forward with a RUC survey for the code with the combined anatomy code descriptor would not provide the appropriate work value. Different levels of work are involved for the code related to performing the procedure in different anatomical sites. The societies then worked together to break up the code into three separate codes (61781, 61782, and 61783) with three distinct code descriptors for procedures relating to cranial intradural, cranial extradural, and spinal procedures and submitted CPT code proposals to the AMA CPT Editorial Panel, which were then approved. The codes were then surveyed and presented to the RUC at the February 2010 meeting. CMS approved the RUC submitted values for the codes and were published in the final Medicare physician fee schedule to be effective January 1, 2011. In order to provide guidance to members, in December 2010, 3P revised the CPT for ENT for SCAN  (http://www.entnet.org/Practice/Coding-for-Stereotactic-Computer-Assisted-Navigatione.cfm) Generally, otolaryngologist—head and neck surgeons would use the second code, +61782 cranial, extradural (list separately in addition to code for primary procedure) in addition to the appropriate FESS code. • New CPT codes for Balloon Sinus Dilation: 31295, 31296, 31297. In late 2010, 3P also revised the Academy’s coding consensus opinion for balloon sinus dilation (http://www.entnet.org/Practice/Coding-for-Balloon-Sinus-Dilation-2010.cfm) because of the new 2011 CPT codes that were accepted by CMS for balloon sinus dilation. Please review both coding guidance to become familiar with these changes. Academy Members Advocating for You at the RUC Meeting 3P continues to ensure that the coding and reimbursement positions of otolaryngology—head and neck surgery are heard during AMA CPT and AMA/Specialty Society Relative Value Update Committee (RUC) meetings. On February 3-5, 2011, Wayne Koch, MD; Charles Koopmann, MD, MHSA; and Jane Dillon, MD, represented the Academy at the AMA/Specialty Society Relative Value Update Committee (RUC). The next weekend, Dr. Waguespack represented you at the AMA CPT Editorial Panel meeting. The CPT and RUC meetings are held three times a year and are high-intensity meetings, with numerous opportunities to meet and discuss the most pressing and controversial coding and policy issues that members are currently facing. Please take the time to thank these 3P members for advocating tirelessly throughout the year on your behalf. For additional information or questions, please contact the Health Policy staff: HealthPolicy@entnet.org.
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Quality and Volume – Are They Related?
Rahul K. Shah, MD George Washington University School of Medicine Children’s National Medical Center, Washington, DC Do surgeons who do more cases of one type have superior results than other surgeons? It is one of the most contentious questions about the case volume of surgeons and their outcomes. Intuitively, one would answer – of course! This, indeed, may be one of the historical justifications for specialization within medicine and why and how our healthcare provider system has evolved to hospitals of different triage abilities and physicians with such in-depth content expertise. A significant body of literature supports the claim that high-volume hospitals have superior outcomes compared to other hospitals. There is also data that for specific surgeons this relationship holds true for higher volume surgeons. It is worth noting an article1 from the Johns Hopkins Medical Institutions that explores the relationship of surgeon and hospital volume to the short-term outcomes in laryngeal cancer surgery care. This article is pertinent to discuss, as much of the literature regarding volume of surgeons and hospitals and their relationship to outcomes is not germane to otolaryngologists. As a surgical specialty with some of the most complex cases (head and neck reconstructions, skull base approaches, etc.) and with significant volume (approaching 40 percent at some major medical centers), it is imperative that the quality/outcome/volume relationship is explored for otolaryngology. The article’s authors, Gourin, et al., evaluate this relationship in short-term outcomes of laryngeal cancer care vis-à-vis surgeon and hospital volume. The article is an exceptional use of existing state databases, which provide macro-level data on surgical volume and hospital outcomes. The intent of the column this month is not to discuss whether patients should have laryngeal cancer care at high volume hospitals or not — this is well-addressed by the article we reference below. Rather, my aim is for otolaryngologists to begin contemplating where quality, outcomes, and volume intersect. This question has significant implications for our specialty in terms of physician workforce; reimbursement; expectations of the government in relation to quality outcomes; and for maintenance of certification. The power of aggregate data obtained via national datasets is the ability to identify trends that may be lost in smaller institutional series. The danger is that if we are not the ones mining the data, then others, with presumably less understanding of the disease process, will do it for us. The result will be attempts via reimbursement, pay for performance, or legislation to affect the scope of what we can practice. Gourin, et al., should be commended for objectively looking at outcomes for a complex disease process. With the availability of mega-data sets, which are easily obtained and accessed, healthcare professionals have the ability to ask profound questions similar to the one posed by Gourin, et al. Their study used a state-level database; it would be of interest to see if their findings are supported by a nationwide sampling and the further relationships that would be exposed by such a perspective. Where patient safety and quality improvement initiatives end up in otolaryngology is really up to us. With the myriad data that exist and the significant public pressure upon us, it is incumbent on us that we examine our outcomes in our institutions, and, on a macro-level, demonstrate that, indeed, we are providing the highest level of care. In the last five years, many major medical centers have begun publishing their outcomes in an attempt to be transparent and show how their results benchmark to others. The next iteration of this is to use the macro-level data as shown by Gourin, et al., to compare our own institution’s outcomes to the national benchmarks. The quality/volume/outcomes relationship continues to be contentious, however, we can expect that the availability of macro-level data will provide insight which was previously not available. Reference Gourin CG, Forastiere AA, Sanguineti G, Koch WM, Marur S, Bristow RE. Impact of surgeon and hospital volume on short-term outcomes and cost of laryngeal cancer surgical care. Laryngoscope. 2011 Jan;121(1):85-90. Dr. Shah serves the AAO-HNS/F as the Chair of the Patient Safety and Quality Improvement Committee. Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.
AAO-HNS Co-Hosts Fourth Annual JSAC, March 27-29
Join your colleagues from 17 other surgical societies in Washington, DC, and speak to Congress with a powerful, unified voice. The fourth annual Joint Surgical Advocacy Conference (JSAC), which is co-hosted by the AAO-HNS, will be held Sunday, March 27, through Tuesday, March 29, at the J.W. Marriott Hotel. The conference provides Academy members the unique opportunity to meet with Members of Congress and/or their staff, network with surgical colleagues, receive advocacy training, and learn about ENT PAC, the AAO-HNS political action committee.* Also, mark your calendar for the exclusive AAO-HNS members-only legislative briefing on Sunday, March 27, before the opening reception of JSAC 2011. Get the “insider’s update” on all the legislative issues impacting the specialty. This year’s conference program also includes a CME course on Accountable Care Organizations (ACOs), experience-based advocacy training sessions, and a new “role-playing” exercise to prepare members for their pre-scheduled Capitol Hill visits. The experience-based advocacy training will provide attendees two options: “Advocacy 101” for beginners (mandatory for first-time attendees) or “Advanced Advocacy.” In addition, specialized training will be available for our resident physicians. Online registration and additional details are available through the AAO-HNS JSAC website (http://www.entnet.org/jsac), or use the form behind this page. The conference registration fee is $299 ($75 for residents), and on-site registration will be available. With questions, please contact the AAO-HNS Government Affairs Team at govtaffairs@entnet.org. We look forward to seeing you in Washington, DC. * Contributions to ENT PAC are not deductible as charitable contributions for federal income tax purposes. Contributions are voluntary, and all members of the American Academy of Otolaryngology-Head and Neck Surgery have the right to refuse to contribute without reprisal. Federal law prohibits ENT PAC from accepting contributions from foreign nationals. By law, if your contributions are made using a personal check or credit card, ENT PAC may use your contribution only to support candidates in federal elections. All corporate contributions to ENT PAC will be used for educational and administrative fees of ENT PAC, and other activities permissible under federal law. Federal law requires ENT PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year. ENT PAC is a program of the AAO-HNS which is exempt from federal income tax under section 501 (c) (6) of the Internal Revenue Code.
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Special Annual Meeting Offer for Millennium Society Members
With every donation, Academy members continue to make a difference in the specialty. Through Millennium Society participation, the AAO-HNS/F is able to help meet the changing needs of our member physicians and empower them to deliver the best in patient care. One of the many ways we thank our Millennium Society donors for their generosity is by offering early housing and registration access for our annual meeting. Every year, members and vendors alike await the opportunity to participate in all that the Annual Meeting & OTO EXPO has to offer. This year’s meeting will take place September 11-14 in San Francisco. Coming off record-breaking attendance at our 2010 Boston meeting, we are excited to build upon that success in San Francisco. Early registration for Millennium Society members will open April 18, 2011. Society members will receive email communications with directions for how to log in and register for the meeting. We hope our donors will take advantage of this opportunity and enjoy having early access to the best possible hotels in San Francisco. In addition to advanced hotel registration, Millennium Society members will again enjoy the donor appreciation lounge in San Francisco’s Moscone Convention Center. The lounge offers complimentary concierge services including business center access, breakfast, lunch, and refreshments throughout the day. Every year since its inception, we have received incredible feedback from our donors on how much they value the use of this lounge. In addition to advanced registration and housing, and the donor lounge, Millennium Society Members receive: Recognition on the Donor Wall of Honor during the annual meeting; VIP seating at the annual meeting Opening Ceremony; and Year-round recognition and special acknowledgements in the Bulletin, AAO-HNS website, and other popular AAO-HNS/F publications. If you are not already a member, join the Millennium Society today – www.entnet.org/donate. For questions regarding the Millennium Society and advanced hotel registration, contact Rudy Anderson, Development Manager, at randerson@entnet.org or 703-535-3718. We look forward to seeing you in San Francisco!
Michael S. Benninger, MD, Ira Lee Sorkin, Esq., keynote speaker, and Michael Setzen, MD, at the Annual Clinic Day of the Nassau Surgical Society and Brooklyn & Long Island Chapter of the American College of Surgeons.
Local and State Society Meetings Advance Our Philanthropic Mission
Michael Setzen, MD Coordinator for Practice Management  Local and state society meetings have always been a great way to connect with local colleagues as well as stay abreast of new and improved treatment methods regarding our specialty. This past December, we had our Annual Clinic Day, which usually takes place the first Wednesday in December. This meeting is a combined meeting of our local society, the Nassau Surgical Society, and the Brooklyn & Long Island Chapter of the American College of Surgeons. The 2010 Annual Clinic Day brought together more than 500 surgeons of all surgical specialties. This gathering is one of the College of Surgeons’ largest meetings (excepting their annual meeting). The goal of the meeting is to create an epicenter for new ideas and ways to further advance the specialty in our community. It typically begins with a luncheon and keynote speaker, followed with each surgical specialty breaking out for their afternoon session. Speakers at the afternoon sessions are national and internationally renowned speakers. The otolaryngology speakers included Marvin P. Fried, MD, Robert C. Kern, MD, and Michael S. Benninger, MD. Sujana S. Chandrasekhar, MD, Chair-Elect of the Board of Governors (BOG) of the AAO-HNS, spoke on the importance of giving to the ENT PAC. Following this, Megan N. Schagrin, CAE, Senior Director of the AAO-HNSF Development Unit, made a brief presentation. Her presentation focused on the importance of supporting our Academy and Foundation by being a member, becoming a volunteer, and also by making a contribution to the Foundation through the Millennium Society. (The Millennium Society is a charitable program of the AAO-HNS Foundation that generously provides financial support to help us achieve our vital mission in the areas of education, research/quality, residents programs, humanitarian, and international efforts.) As she shared with the audience, a donation is equivalent to making an investment in the future of our Academy. At the end of the day, many members came over to Megan, Jay S. Youngerman, MD, BOG Development Taskforce Co-Chair, and me and asked how they can support the Academy and Millennium Society. The fact that members of the Academy wanted to give was very important to me. I am so pleased with the recent successes of the Millennium Society and am especially pleased with my New York colleagues. In 2010, more than $217,000 was donated by members from New York to the Millennium Society. Based on my experience at our Annual Clinic Day, I would encourage other local and state societies to invite the development team to participate in your meetings. It is an opportunity for you to highlight the work and philanthropic contributions of your members, as well as advance the specialty by raising awareness and building support for areas that are critical to our specialty’s growth. To request development staff attendance at your next local meeting, email development@entnet.org.
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The Hal Foster, MD, Endowment Campaign — Securing the Specialty’s Future
“I’ve always felt, too, that we weren’t put on this earth just to be takers. We need to be givers. And for the success of our organization, I felt it was my responsibility to give back, because I’ve had so much given to me through the organization.” —Thomas B. Logan, MD To meet responsibilities to AAO-HNS members, further the mission, and encourage future physician leaders, AAO-HNSF relies on a broad base of support, including private philanthropy, corporate sponsorships, and foundation grants. From these sources, we have a strong foundation on which to build. But a living, thriving organization cannot grow in the long term on sponsorships and annual donations alone. We need reliable revenue – something that we can count on year in and year out – even when the economy fluctuates. In October 2009, the AAO-HNS/F Boards of Directors initiated the Hal Foster, MD, Endowment Campaign with a goal of raising $30 million to provide a sustained source of funding for the future. Since then, more than $4 million has been raised, much of it through significant commitments made by our leaders. During the 2010 Annual Meeting & OTO EXPO, we formally announced a 10-year campaign with a $15 million goal (one-half of the total campaign goal) by the conclusion. The endowment is named for Hal Lovelace Foster, MD, who in 1896 called the first meeting of what would become the AAO-HNS. Today, we ask you to become part of the continuing story of the AAO-HNS/F by considering a gift or pledge to the Hal Foster, MD, Endowment. Your participation will lay the groundwork for future leaders to equal – or exceed – the tremendous accomplishments of yesterday and today. Founding Donors Centurions   Ronald B. Kuppersmith, MD, MBA, and Nicole Kuppersmith Stewards   Neil Bhattacharyya, MD, and Anjini Bhattacharyya I. David Bough, Jr., MD Sujana S. Chandrasekhar, MD, and Krishnan Ramanathan Noel L. Cohen, MD, and Baukje Cohen Lee D. Eisenberg, MD, MPH, and Nancy Eisenberg Jonas T. Johnson, MD, and Janis Johnson David W. Kennedy, MD Thomas B. Logan, MD, and Jo Logan David R. Nielsen, MD, and Becky Nielsen Richard M. Rosenfeld, MD, MPH Harlene Ginsberg and Jerry Schreibstein, MD Gavin Setzen, MD, and Karen Setzen James Stankiewicz, MD J. Pablo Stolovitzky, MD, and Silvia P. Stolovitzky Sustainers   Kenneth W. Altman, MD, PhD, and Courtney Altman Seilesh Babu, MD, and Abbey Crooks-Babu, MD Raghuvir B. Gelot, MD, and Carolyn Gelot Helen F. Krause, MD Michael D. Seidman, MD, and Lynn Seidman Nancy L. Snyderman, MD As of February 2011   The impact of your gift “As I reflect upon my career in otolaryngology, the symmetry between AAO-HNS activity and my career track is very evident. I am delighted to have this opportunity to help ensure the continued support of otolaryngology everywhere through the AAO-HNS.” —Jonas T. Johnson, MD Advances have been made, improvements obtained, and the future of our specialty is promising because of the efforts of physicians like you. Your gift or pledge to the Hal Foster, MD, Endowment will not only profoundly impact otolaryngologist—head and neck surgeons and the patients they serve, but will also ensure the future viability of the specialty by investing in the next generation of educators and researchers. Giving to the Hal Foster, MD, Endowment of the AAO-HNSF will provide a tremendous source of funding that will significantly affect our ability to fulfill our mission. Regardless of the program area you choose to support, you will feel good knowing that your donation is being used to fulfill something that is important to you – your specialty’s advancement and your profession’s future. Through your gift, you can inspire great things by funding young investigators’ research, providing high-quality educational resources, promoting humanitarianism and international outreach, encouraging diversity, and facilitating leadership development. Becoming a Founding Donor Realizing this is a significant investment you will be making in the AAO-HNS/F, we want to work closely with you to tailor a commitment that is best for you individually and best matches your area of interest in our mission. There are many ways to provide your endowment gift or pledge. You can provide an unrestricted gift or pledge to the campaign that will provide much needed support for our existing programs and services. Or, you have the choice of restricting your gift or pledge to a specific area of our mission. The Hal Foster, MD, Endowment provides the perfect vehicle to create a permanent legacy at an organization that has provided you and your colleagues numerous opportunities to enhance the profession and improve patient care. Your gift can: Support targeted projects – such as research, education, humanitarian efforts, international outreach, leadership training, grants, and scholarships. Champion otolaryngology – head and neck surgery and its impact in the global community. Create a memorial in honor of a family member, friend, colleague, or physician leader. Inspire the next generation of Academy and Foundation leaders. Provide a steady income for quality and permanence to the profession. Each donor’s goals are unique. There are many different vehicles to provide a gift to the endowment. We encourage you to visit with an advisor about your intent in order to make sure the gift reflects your desires. The AAO-HNSF has relationships with several financial advisors who can work with you to identify your charitable goals and the best gift vehicles to support the endowment. Cash – Gifts of cash can immediately be invested in the endowment fund. Pledges – This option allows payments to be spread over three to five years to accommodate other obligations and increase the impact of your gift. Bequest. Life insurance – Life insurance policies may be donated to the Foundation and may provide many specific tax and financial benefits. Marketable securities – Publicly traded securities may be transferred to a brokerage account that the Foundation maintains in its own name, or endorsed stock certificates or certificates accompanied by signed stock powers may be physically delivered to the Foundation. Real estate. Tangible personal property – The Foundation will accept gifts of tangible personal property that it reasonably anticipates being able to liquidate for its charitable, educational, and scientific activities. Retirement plan assets – Name the Foundation as beneficiary or contingent beneficiary of your retirement plans and consider current gifts through tax-free rollovers in years when federal tax laws permit. Closely held securities – The Foundation will accept gifts of interest in non-publicly traded companies, S corporations, general or limited partnerships, limited liability companies, and other legal entities.   Recognizing your generosity  The Hal Foster, MD, Endowment Society is a special recognition status to be held only by donors to the endowment campaign. The prestigious status of Hal Foster, MD, Founding Donor will be held by all donors whose gifts are confirmed by December 31, 2011. The Hal Foster Endowment Society comprises four gift levels:  Sustainers, Stewards, Centurions, and Visionaries. All endowment donors will be honored through a special permanent commemorative display housed at the headquarters in Alexandria, VA. Additionally, donors will be honored in our communications, publicly at events, through special annual meeting donor recognition, and by the awarding of special medallions based on level of giving. Hal Foster, MD, donors also enjoy recognition as Life Members of the Millennium Society. Endowment donors giving through a planned gift are also recognized as members of the Legacy Circle. To learn more or to make a gift today Please contact Julie M. Wolfe, Senior Development Associate, at 703-535-3717 or jwolfe@entnet.org. If you have already made provisions for the Foundation in your estate and desire to be recognized as a Hal Foster, MD, Endowment Society Founding Donor, please call so we may begin to recognize you immediately for your generosity.
Denis C. Lafreniere, MD Professor and Chief, Division of Otolaryngology University of Connecticut Health Center Chair, BOG Socioeconomics and Grassroots Committee
Physicians Must Orchestrate Harmonious Care for Voice-Disordered Patients
April 16 has been set aside to recognize World Voice Day. This is a time to celebrate the gift of the human voice and is an opportunity for the AAO-HNS to highlight the efforts of clinicians, clinician scientists, and researchers who help to heal, improve, and protect the voices of our patients. Over the last three decades, laryngologists have developed a comprehensive approach to the treatment of voice- and swallowing-disordered patients. This approach has resulted in successful collaborations with our physician colleagues in specialties such as GI, pulmonary, and neurology, as well as with allied health professionals, such as speech pathologists. The evaluation and treatment of professional voice patients often requires that the physician work closely with vocal pedagogues, in both the private and university setting. Many times, patients with disorders of voice or swallowing will have tissue pathology that only a medical doctor is qualified to diagnose. At the same time, many patients will have functional voice or swallowing impairments that our speech pathology colleagues are trained to evaluate and treat. The orchestration of this complex symphony of vocal care is ultimately the responsibility of the otolaryngologist, who in essence is the conductor of care for our voice and swallowing patients. The various instruments in this orchestra are all vital to the care the patients deserve. The current world of healthcare reform will no doubt put additional pressure on the “maestros” of vocal care, but the need for continued direction from physicians is essential to ensure the best level of healthcare for our patients. The diagnosis of voice disorders must be performed by a physician. The Clinical Practice Guideline for Hoarseness (Dysphonia) published by the AAO-HNSF1 states that exams performed or reviewed by an otolaryngologist will ensure that diagnoses that are not treatable with voice therapy are managed appropriately. These conditions include squamous cell carcinoma or papilloma. The Guideline further states that a speech-language pathologist (SLP) trained in visual imaging may examine the larynx for the purpose of evaluating vocal function and planning appropriate therapy programs. In some practices that care for patients with voice disorders, such as ours at the University of Connecticut, the SLP works with an otolaryngologist and may perform a laryngeal exam that is reviewed by the otolaryngologist. These recommendations are consistent with the guidelines published by the American Speech-Language-Hearing Association. Our SLP colleagues are trained to evaluate and treat functional deficits in our patients with voice and swallowing disorders. In this role, they are invaluable to the care of these patients. However, the best patient care demands that a physician with the appropriate years of training in pathology, physiology, and medical and surgical care of this patient population be responsible for the diagnoses of these often complex cases. In their role as diagnosticians otolaryngologists can conduct the care of our voice patients, calling on the various instruments available for optimum patient care, to ultimately produce a symphony that results in consistently healthy voices. This is the goal desired by the entire voice community. The AAO-HNS, with the grassroots efforts of the Board of Governors, can provide the support the member societies need to guarantee we maintain our place on the “podium,” thus ensuring harmonious care of our patients with voice and swallowing disorders. Reference Clinical Practice Guideline: Hoarseness (Dysphonia). Otolaryngology Head and Neck Surgery (2009) 141: 3S2, S1-S31.
Our Envisioned Future
As springtime approaches, Academy leaders, Boards, and staff are completing the final draft of our 2011-2012 operational plan. The approaching spring coincides with the renewal that takes place each year as we update and improve our efforts to achieve our goals. The current round began last fall with a long-term view of what we wish to see — our attempt at a “vivid description” of our envisioned future. Your Boards of Directors and senior staff met in December to look beyond the near future to the next 10 to 30 years at what we think, or hope, will occur. Some of the exciting ideas and futuristic comments we discussed were “industry” or overall professional dreams: finding a way to cure or eliminate sensory-neural hearing loss; expanding our knowledge of the human genome to eliminate allergies and infectious diseases; and implementing robotic surgery techniques. Although these goals are not specifically achievable for the Academy, nor do we alone have the resources to address them, the collective efforts of our members, along with valued colleagues in related disciplines, will undoubtedly achieve goals once thought unimaginable. Fifty years ago, any descriptions of routine surgical laser use, robotic surgery of the head and neck and airway, cochlear implants, and a host of other developments were hardly believable. I think all of us would agree that as technology advances, we practice medicine in ways we did not learn in residency. Although being strategic and effective requires that we create and achieve measurable goals within a specified time frame, we must also stay relevant by ensuring that our processes, programs, and activities are moving us toward the best that we can envision for the long-term future. We continue to improve our stated aspirations, which are laudable but need to be converted into measurable and achievable goals. Some of them are affirmative statements, such as: We improve the health of all people by preventing, treating, or curing otolaryngic diseases. Our members, partners, and the public know and value what we do. We have diverse leadership and staff who work together in integrated teams. We collaborate with specialty societies and strategic partners who share our vision and values. We provide the knowledge base that supports physician and patient education for the specialty. We have an optimal level of evidence to demonstrate and measure the quality of care our members provide. We believe in a long-term, continually growing, philanthropic endowment, supported by members and friends. We convene the world’s best otolaryngology meeting. These objectives, along with associated operational specifics and actions, are constantly modified and improved on. While qualitative and admittedly aspirational, they can lead to more specific descriptors of our envisioned future, such as: AAO-HNS will provide educational resources: For specific learners (medical students, residents, allied health professionals, otolaryngologists, other physicians, and the public); That are integrally linked to point-of-care access and systems; That are accessible and affordable. We will assist in the development of tools and systems that address gaps in healthcare and improve patient outcomes. We will continue to foster unity by collaborating internally and externally to continually adapt to change. We will ensure that partners (members and collaborators) are satisfied, through education, advocacy, effective communication, and extending our vision to encompass all providers of otolaryngic care, not just our members. (We will be the one-stop shop for all resources related to ENT care). We will effectively link all stakeholders for collaborative efforts to positively affect our patients (research, acquisition, and sharing of knowledge, technology implementation, and improving access to quality care). We will have a continuously growing endowment to ensure financial stability. Such statements are general, but they lead to specific actions and strategies that must be employed to be successful. Using them as a guide, we can evaluate the best of what we do — the Annual Meeting & OTO EXPO; our journal, Otolaryngology-Head and Neck Surgery and the Bulletin; AcademyU, Home Study Course, online and other educational offerings; CORE and research support; guidelines development; Specialty Society Advisory Council (SSAC); Joint Surgical Advocacy Conference (JSAC); ENT PAC; and many others. This will allow us to see if they are leading us to our envisioned future, and what else we can do to increase our relevance to our members. In addition, for a few years we have been building an endowment to help underwrite these efforts and ensure that we remain strong. In the next few months, as required by our bylaws, you will be notified of the proposed annual budget. In the fall, you will receive updates at the Annual Meeting & OTO EXPO. Please take the time to discuss them with your elected leaders to ensure that we continue to move toward the best that we can envision, for our future and the future health of our patients.
J. Regan Thomas, MD, AAO-HNS/F President
March Meetings Offer Debate, Advocacy
There are a multitude of reasons to be a member of the Academy, especially now. Two important examples are the meetings that will be held in Washington, DC, later this month: the Board of Governors (BOG) Spring Meeting and the Fourth Annual Joint Surgical Advocacy Conference (JSAC). BOG The Board of Governors (BOG) Spring Meeting begins Saturday morning, March 26, and continues through noon on Sunday, March 27.  Saturday will feature BOG committee meetings and information from a variety of dynamic speakers. The committee meetings offer BOG representatives from across the country an opportunity to gather and debate important national, state, and local issues that otolaryngologists encounter in today’s rapidly changing healthcare environment. Sunday’s keynote speaker will be Gail L. Warden, MHA, president emeritus of Henry Ford Health System in Detroit, where he was president and CEO from 1988 to 2003. Then, the BOG General Assembly will feature a virtual Candidates’ Forum of the Academy candidates for President-Elect. I expect that the issues of reimbursement, specialty unity, health system reform, and the shrinking otolaryngology workforce will all figure prominently. In addition, each BOG committee will present reports about their activities since last fall’s annual meeting in Boston. For more information or to register, visithttp://www.entnet.org/ConferencesAndEvents/BOG-Spring-Meeting.cfm. JSAC Following the BOG meeting, from Sunday afternoon through Tuesday, March 29, the action moves to the Fourth Annual Joint Surgical Advocacy Conference (JSAC), of which the Academy is a co-host. Headquartered at the flagship J. W. Marriott Hotel on Pennsylvania Avenue in the middle of the nation’s capital, the conference opens Sunday with an exclusive Academy members-only legislative briefing. The evening concludes with a reception including 17 participating surgical societies. It’s a great chance to network with your surgical colleagues and discuss the legislative issues that affect us all. Monday offers a CME course, at no additional cost, on Accountable Care Organizations (ACOs), as well as advocacy sessions based on your level of experience. In those, you will have role-playing exercises and training for your scheduled Capitol Hill meetings on Tuesday with Members of Congress and their staff. The afternoon’s legislative program will make sure we’re all up to date on the latest developments in the healthcare discussions, and Monday concludes with a reception for the Joint PAC fundraiser. (On-site contributors to the Academy’s ENT PAC will be included.) To make sure you’re well-prepared for Tuesday’s Congressional visits, the day begins with breakfast and a question-and-answer session on healthcare issues. Afterward, lunch will include a debriefing on how the visits went and next steps. To be sure you’re a part of this exciting meeting, register at http://www.entnet.org/jsac. Membership Benefits Meetings and advocacy, both legislative and regulatory, are only part of what your membership in the Academy offers you. The peer-reviewed journal Otolaryngology—Head and Neck Surgery has a new publisher, allowing you wider search opportunities on HighWire. Along with the exciting new look, the online version is enhanced by monthly podcasts where authors discuss new research. The monthly news magazine, the Bulletin, brings you the latest news of the Academy and our cooperating societies, as well as regular segments on specialty-specific coding and reimbursement tips, committee updates, announcements of new CME offerings, and employment ads. The “Find an ENT” service on our updated website makes your name and practice available to the public and referring physicians. The weekly email, The News, keeps you abreast of the latest happenings in the specialty. CORE grants, in which other specialty societies participate as well, encourage research. Information on the latest coding resources comes to you with guidance on how they affect otolaryngology. You can log on at any time to AcademyU for CME education, and much more is available through the Home Study Course, Online Study Guide, and of course, the annual meeting, to keep you up to date on the latest in the specialty. The 2011 Annual Meeting & OTO EXPO, set for September 11-14 in San Francisco, is probably the most popular member benefit. Registration opens on May 2. But don’t wait until September to let your voice be heard. Join us this month in Washington. We look forward to seeing you.
World Voice Day: We Share a Voice
Ramon A. Franco, Jr., MD Director, Division of Laryngology Harvard Medical School Massachusetts Eye and Ear Infirmary It can be kind or cruel, forceful or weak. It has the power to start wars and lead to destruction, but can also encourage, uplift, and effect the most positive of social changes. In the communications-centric society we live in, the human voice is indispensable. Each April 16, we celebrate World Voice Day (WVD) to promote awareness of disorders affecting the voice and celebrate the important role voice has in human society. In the United States, the theme for this year’s celebration is “We Share a Voice.”  World Voice Day is an outgrowth of Brazilian Voice Day, which was founded in 1999. In keeping with this year’s slogan, we seek to unify the world efforts to share a central theme while allowing each country or region the freedom to infuse its own local flavor into the celebration. These celebrations include informative lectures to explain how the human voice works and disorders that affect the voice; musical concerts featuring singing acts; and radio, TV, Internet, and print advertisements to encourage participation in local World Voice Day activities. As the International Steering Committee liaison for the global World Voice Day efforts, I work closely with the Academy’s Voice Committee chair, Clark A. Rosen, MD, to coordinate the WVD events. We have identified a core group of prominent members from various regions of the world who are committed to unifying the WVD celebrations. We are actively seeking new members to collaborate with as we expand our international efforts. Our group of collaborators includes Mario Andrea, MD, PhD, of Portugal (working closely with the European Laryngological Society), Norman D. Hogikyan, MD, of the U.S., Carla Carcamo, MD, of Honduras, Hector E. Ruiz, MD, of Argentina, and Ferhan Oz, MD, of Turkey. The efforts this year will concentrate mainly on the United States, Central and South America, Turkey, and Europe. We hope to include Australia, the Middle East, Russia, China, India, and the Southeast Asian countries in the next year. The lessons learned this year will be applied to next year’s efforts, while inviting more countries to work with us until we truly “share a voice” each April 16.
State Recognition of World Voice Day
On April 16, promote your specialty by attaining public recognition of World Voice Day. In recent years, legislatures in Alabama and Michigan celebrated voice services provided by otolaryngologist—head and neck surgeons by adopting resolutions naming April 16 as World Voice Day in their states. Resolutions are non-binding measures that express the view or will of a legislative body, and can be relatively simple to attain. The following, House Resolution 249, was adopted by the Michigan House of Representatives in 2010. A resolution to declare April 16, 2010, as World Voice Day in the state of Michigan. Whereas, It is estimated that nearly seven million Americans suffer from some form of voice disorder; and Whereas, Voice disorders can impact the everyday lives of those affected by inhibiting their ability to effectively express themselves; and Whereas, There are many ways in which people can conserve their voice and prevent the development of voice disorders, including keeping hydrated, minimizing activities causing vocal strain such as yelling, warming up before heavy vocal use, using appropriate breath support, using amplification, and paying attention to voice cues; and Whereas, It is important to draw state, national, and international awareness to the existence of voice disorders and the availability of services provided by otolaryngologists—head and neck surgeons — the only medical doctor specifically trained to treat the ear, nose, throat, head and neck — as well as other specialized providers for the amelioration of these disorders; and Whereas, Every year on April 16, otolaryngologists, who are head and neck surgeons, and other voice health professionals worldwide join together to recognize World Voice Day, an international celebration of the human voice established to help raise public and professional awareness about voice disorders; and Whereas, World Voice Day, sponsored in the U.S. by the American Academy of Otolaryngology—Head and Neck Surgery, encourages men and women, young and old, to assess their vocal health and take action to improve or maintain good voice habits; now, therefore, be it  Resolved by the House of Representatives, That the members of this legislative body declare April 16, 2010, as World Voice Day in the state of Michigan; and be it further  Resolved, That we encourage all citizens to practice techniques that may help prevent the onset of a voice disorder or to visit an otolaryngologist if they are suffering from a voice disorder. The AAO-HNS encourages its members to spread the word about World Voice Day 2011 by contacting their legislators today to ask them to sponsor a resolution. A sample resolution, letter, and press release are available for your use through the “World Voice Day Resources” page (member login required) on the State Advocacy portion of the AAO-HNS website (www.entnet.org/advocacy). With questions, contact legstate@entnet.org or 703-535-3794.
voiceday
Heed the Call of World Voice Day April 16, 2011
M. Steele Brown, special to the Bulletin Although the voice is humanity’s chief means of one-to-one communication, issues surrounding vocal health make very little noise on the national healthcare scene. On one hand, you cannot turn around without seeing a pink ribbon or a yellow wristband reminding you about breast health and testicular cancer. On the other hand, there’s astonishingly little clamor for people to take care of their vocal cords. “People do very little to take care of their voices,” said Michael M. Johns III, MD, associate professor in the department of Otolaryngology—Head and Neck Surgery at Emory University School of Medicine and the director of the Emory Voice Center in Atlanta. “Everywhere you go, people are screaming over the crowd at the bar, talking way too loudly into their mobile phone in a crowded area or while they’re driving down the road, or yelling at their kids. That list goes on and on. “What that means is that people are not recognizing that there are limits to what their voices can do and that there is damage they can do to their vocal cords if they don’t take care,” he said. “And those behaviors overlap in a sort of ‘Venn diagram’ way with many voice disorders.” For this reason the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) urges otolaryngologist—head and neck surgeons and other voice health professionals around the world to join together to sound the call and spread the word about World Voice Day, which takes place every year on April 16. World Voice Day encourages men and women, young and old, to assess their vocal health and take action to improve or maintain good voice habits. The Academy has sponsored the observance of World Voice Day in the U.S. since its inception in 2002. “I think that World Voice Day has two main missions,” Dr. Johns said. “The first is awareness of vocal health and vocal disorders, because this is something that so many people take for granted. The second is the celebration aspect.” Dr. Johns, who is also a member of the Academy’s Voice and Laryngology committees, said most people don’t respect the vocal cords as an instrument that must be tuned and taken care of like a piano or a guitar. “After you get out of the segment of the population that uses their voice professionally — singers, professional speakers, and the like — I’d tell you that most people probably respect the guitarist’s ability more than that of the lead singer,” he said. “You take someone like Jennifer Nettles (lead singer of headlining country music act Sugarland). People think she can just sing like that because she was born with it, while the guy playing the guitar had to practice to develop his abilities. “But what people don’t realize,” Dr. Johns continued, “is that you have to work to sing like she does. No matter who you are, if you’re interested in singing, dynamic speaking, or whatever, you can train yourself to get to those higher levels of performance. That is an important message that people need to hear.” Dr. Johns said it is even more important for otolaryngologist—head and neck surgeons and other voice health professionals to make the public aware of the hidden dangers that exist from over-working one’s voice. “Just like an early-stage cancer, you’re typically not going to feel pain when you’re developing a vocal disorder,” he said. “When you’re running and you strain something and you feel a sharp pain, that’s your first warning sign that there’s a problem, but the same isn’t true in the larynx. Pain in the larynx is pain of a different type, so people continue to use their voice when they crop up with, for example, viral laryngitis. They just figure, ‘I’ll power through it,’ and they end up scarring their vocal cords.” Dr. Johns said it is imperative that otolaryngologist—head and neck surgeons and other voice health professionals let their patients know that hoarseness lasting longer than two weeks needs to be examined. “They need to have their throats looked at by an otolaryngologist to check for cancerous nodes,” he said. “Unfortunately, too many of our patients are unaware that it could be serious, saying to themselves, ‘If I just wait long enough, it will get better.’ Then, of course, cancers grow larger and the rate of survival drops to nothing.” World Voice Day began in Brazil in 1999, when a group of voice care professionals decided to celebrate the voice by establishing Brazilian Voice Day. The theme for World Voice Day 2011—”We share a voice”—calls attention to the important role otolaryngologists play in stemming the tide of vocal disorders. Robert T. Sataloff, MD, DMA, the editor-in-chief of the journal Ear, Nose & Throat, has written extensively on this issue, saying that too many communities in the United States and elsewhere still do not actively celebrate World Voice Day. “This event provides an opportunity for all of us to collaborate with colleagues in speech-language pathology, singing, acting, public speaking, education, the media, and other endeavors,” he said. “Vocal health is critical to our communication-oriented society, but the voice does not receive the public recognition and appreciation it deserves. World Voice Day provides us a perfect forum through which to refamiliarize ourselves with the latest advances in laryngology and voice care, and to educate our colleagues, patients, and communities via lectures, free voice screenings, community outreach programs, and other offerings.” Dr. Sataloff is chair of the department of Otolaryngology—Head and Neck Surgery and the senior associate dean for Clinical Academic Specialties at Drexel University College of Medicine in Philadelphia. He pointed out that the past few decades have seen remarkable advances in voice diagnosis and treatment that have raised the standard of care for all voice patients.  Also a professional singer and teacher who holds an undergraduate degree in music theory and composition, and a doctorate in voice performance, Dr. Sataloff said that World Voice Day provides a perfect platform on which to highlight these advances and to educate the media about the state-of-the-art in voice care. Dr. Johns echoed this sentiment and encouraged otolaryngologists to reach out to other groups in spreading the word. “The fun part about World Voice Day is that it provides an opportunity to recognize multiple specialties, such as otolaryngology—head and neck surgery, speech pathology, singing teachers, voice coaches, all of whom have a kind of vested interest in the voice,” he said. “It is so important for us to take advantage of these folks and foster collaboration between the different voice care specialties. “World Voice Day provides an opportunity for otolaryngologists to get involved in their communities and share information that’s not always obvious to people around them. It is also a good opportunity to drive patients to your practice.” Dr. Johns said the Emory Voice Center usually puts on an event for the Atlanta community to raise awareness on a local level. “Last year, we put on a conference on disability in the voice,” he said. “There really is very little literature about this issue out there. “People with voice problems are disabled, but classifications are based on whether or not you can use your limbs or the quality of your eyesight, not whether or not you can use your voice. We had international speakers come to raise awareness about the issue and we had a pretty good turnout — maybe 150 people from a host of different segments of the population.” Dr. Johns said that Emory is reaching out to the singing voice community in 2011. “We are going to offer free vocal cord screenings for anyone who wants them,” he said. “That’s nothing novel or earth-shattering, but we haven’t done that yet, so it seemed like a good idea.” Dr. Johns said he believes it always makes sense to get a baseline exam and tells the physicians at Emory to encourage their patients to do so. “If you’re a singer or broadcast journalist or someone who uses his or her voice professionally, it is important to get a baseline exam of your instrument. The key is the video record, because once you’ve had a baseline video stroboscopy, you’ve got a baseline in case you get sick.”