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Strength in Numbers

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When the partners at Kentucky Ear, Nose and Throat (KY ENT) began considering association with a larger medical system in early 2012, they found an eager and capable partner in Lexington Clinic. Almost two years later, the symbiotic relationship has produced positive results for all parties: Lexington Clinic’s ENT department has gained five accomplished colleagues; KY ENT’s seasoned physicians have seen the administrative side of their workload decrease considerably; and the patients of both practices have access to expertise in all aspects of the specialty on a shared EHR system.

For Lexington Clinic’s Wayne Colin, DMD, MD, “The net result has been very positive. We are able to see a broader range of patients working together than would be possible separately.” KY ENT founder Keith Alexander, MD, is equally appreciative: “With such rapid changes in the delivery of healthcare in the last two to three years, a partnership like that with the Lexington Clinic empowers us. It’s very hard for a small group practice to have the expertise that the Clinic has when it comes to contract negotiations, HR, and IT.”

KY ENT, founded in 1989, has five physicians, a nurse practitioner, and five audiologists. Alexander is joined by partners Alberto Laureano, MD, Gregory V. Osetinsky, MD, FACS, K.V. “Tad” Hughes, III, MD, FACS, and Ray M. Van Metre, MD. Lexington Clinic’s ENT department is comprised of two physicians, Wayne Colin, DMD, MD, and Michael Cecil, MD, as well as one audiologist.

Both practices agree that the variety of otolaryngology is what attracted them to the field, both in body systems covered and patient population served. Alexander calls it a “specialty that is not so narrow,” and while each of the seven practitioners is trained in all aspects of the profession, each also has developed specific areas of expertise. Though the association of the two practices is not a daily presence in the lives of the physicians, their resource sharing is an anchor for all in this complex and multifaceted field.

The Players

Colin has been a fixture at Lexington Clinic for over 12 years. His adult-only practice focuses on obstructive sleep disorders; head, neck, and skin cancer treatment; and reconstructive surgery for head and neck cancer patients. Trained as a dentist at Harvard School for Dental Medicine, he did his first residency in oral and maxillofacial surgery (OMFS) and a second residency in ENT when head and neck cancer piqued his interest. The OMFS training is a rare attribute among ENT physicians and serves the two associated practices well. Colin’s most notable contribution, however, has been his work on sleep apnea, and the KY ENT physicians send their patients with obstructive apnea directly to him.

Sleep apnea affects two to four percent of the general population, but Colin says there is a dearth diagnosis, with “only about 20 percent of the cases” being detected. This means that many people are feeling the effects of sleep apnea without receiving treatment. Those effects, says Colin, are fundamental and potentially profound: “Each obstructive event interferes with our brain wave pattern. This results in psychological and physiological stress.” He continues, “Nighttime sleep disruption is a prime risk factor for hypertension, cardiovascular disease, congestive heart failure, and diabetes.” Colin is active in trying to convey this connection to other physicians. “Sleep is intrinsic to our well-being. If it is being perturbed, it’s going to affect all aspects of our well being,” he says.

Cecil handles adult and pediatric ENT cases that come to Lexington Clinic. He was drawn to the field because he “enjoyed the complex anatomy of the head, neck, and ear.” Cecil trained at UK and was recruited to Lexington Clinic after a few years in Pikeville as they sought another physician to join Colin. Cecil developed a particular interest in sinus issues in residency and has focused on non-invasive surgeries the last few years. He particularly values this aspect of his practice, noting, “It’s very gratifying to be able to treat patients surgically without the disfiguring effects we might have seen years ago.” Looking to the future, Cecil currently is working with balloon sinuplasty. While it is only appropriate for about five percent of patients he sees with sinus issues, he is actively following whether it emerges as financially feasible.

Cecil also performs tonsillectomies. The reasons for these have changed, however. “Most tonsil and adenoid removal these days are done because kids are having more sleep disorders, and tonsil and adenoid removal can help this,” he says. His pediatric work has been bolstered by the association with KY ENT, as this brings him valuable collegial input. “If I have a difficult case, someone in the group has likely had this case before. Sharing of information has been the biggest advantage of this large group,” he says.

Having evolved as a stand-alone practice, Kentucky Ear, Nose and Throat seeks to serve all ENT needs for the general population. In addition to physician appointments – hearing aids, allergy shots, and hearing tests are some of the services available in their Lexington, Richmond, and Frankfort offices. The practice has gradually grown, adding physicians and audiologists steadily. The latter is a key to the practice. Each has six years of training and an AuD degree. Alexander says, “We really rely on our audiologists a lot. It’s a team effort here with them.”

The KY ENT physicians are all trained to do the full-range of ENT, but each has developed some areas of interest and focus. Alexander was drawn to the specialty because he liked the combinations of surgery and primary care, adult and pediatric. “It has a great variety of things to treat, including the sensory elements of hearing and olfactory,” he notes. He treats allergy and sinus patients of all ages and specializes in functional and cosmetic nasal surgery, including rhinoplasty.

Drawn to surgery in medical school, Laureano’s mentors showed him the appeal of ENT. He too enjoys the variety of patients and systems he engages with every day. He sees patients of all ages, for all maladies, and only sends out the most complicated head and neck cancer cases. In addition, Laureano treats thyroid and salivary gland disorders and places ear tubes. He also has interest in hearing problems/hearing aids and cosmetic rhinoplasty.

Many people come to ENT with a complaint about sinus problems or with nasal, sinus, or ear congestion, but Alexander notes, “It could be any number of things causing their complaint – allergies, obstruction – so we must dissect the problem in order to determine which factors are causing the underlying symptoms.” KY ENT sees patients from all over central Kentucky, so allergy treatment is an integral part of their services.

The three other physicians also have areas of focus: Osetinsky has a special interest in head and neck cancer; Hughes is their voice specialist; and Van Metre focuses on pediatric care. KY ENT considered adding a neuro-otologist at one point, however, given the practice’s excellent working relationship with UK’s neuro-otologists, there was no need to add such a subspecialist.

Advances in the Field

Endoscopic sinus surgery was innovated in the early 1990s as standard practice. “It really was one of the first minimally invasive surgical techniques,” notes Laureano. External incisions and drilling through bone are no longer necessary. This is all done intra-nasally with small telescopes and special instruments with no external bruising or swelling. Digital image-guided sinus scans that allow ENTs to “peel back the layers” are now a standard tool also. As balloon sinuplasty increases in popularity, time will tell if it is good business. It is not paid for by many health plans, as it is still considered experimental.

Non-surgical advancements are being developed also. Utilization of culture-specific antimicrobials applied through irrigation to treat sinus infections is increasingly accepted. They are covered by insurance more so than they were even a few years ago. Treatment of nasal polyps through bio-film removal is increasingly employed. These biofilms are a protein matrix that bacteria secrete to protect themselves from the outside, making them antibiotic resistant. Scrubbing this with an irrigation of a simple soap makes the bacteria vulnerable again. Immunotherapy to treat allergies – essentially a slow vaccine – is helping many patients. Long-lasting allergy shots are on the horizon also. “These are cheaper and easier treatment that maximize efficacy and minimize costs,” Laureano says. Self-administered sub-lingual drops, long popular in Europe, are gaining ground here too.

Misconceptions abound about ENT. Alexander finds that many referring physicians do not realize that otolaryngologists are trained extensively in allergy as part of their overall ENT training and are well versed to treat allergy symptoms. “It’s very hard to practice our specialty well without doing good allergy work,” he says. “Its part of the ENT training.” Allergies often obscure a bigger problem that only an ENT can properly diagnose. Colin wants GPs to consider gastroesophogeal reflux before referring some patients on to ENTs. “I have patients each week who are alarmed about throat issues – hoarseness, for example – only to learn they have reflux, and this is what is causing their discomfort,” says Colin. Cecil is concerned that some GPs may assume that ENTs are inclined toward surgery and may steer patients away. “The sentiment is that they need to ‘protect them from the surgeon,’” Cecil says. “Surgery is not our primary mode of treatment: we try to treat medically first and use surgery as a last resort.”

The Association Advantage

When KY ENT began considering association in 2012, Lexington Clinic seized the opportunity as it fit a larger vision of theirs. Lexington Clinic has been bringing associate practices into their fold for a few years, with a total of eight practices currently. According to Lexington Clinic, affiliation creates opportunities that will help each organization remain competitive in patient care and technology as health care continues to undergo massive changes. Lexington Clinic seeks practices with which they share similar values, philosophies, and goals and that will allow them to “provide better patient care through expanded locations and services, an increased number of physicians, and better continuity of care.” The Clinic is not buying up practices. They help manage them; handle negotiations with insurance, technology, and equipment providers; and facilitate use of a system-wide EHR. The only evidence of the association at KY ENT’s Lexington office is a small addition to their insignia.

By all accounts, Lexington Clinic’s association with KY ENT has been a win-win for patients. Lexington Clinic patients have more pediatric ENTs and audiologists, and Colin and Cecil have more colleagues with whom to confer. KY ENT patients have access to Colin’s sleep apnea expertise and, as Laureano says, the EHR that enables “a seamless transition to send him all patients who might benefit from his care.” Most notably, the physicians at KY ENT can devote more of their daily energy to patients. For Alexander, association with Lexington Clinic, “Relieves a big burden regarding non-medical headaches; the stress of the practice was running the business side of it.” Laureano concludes, “Changes in healthcare make it sensible to align with bigger entities. We are proud of our association with the Clinic.”

With over 120 years of practice amongst them, the ENTs of Lexington Clinic and Kentucky Ear, Nose and Throat provide a strong service to the patients of central Kentucky. The Clinic’s association model is allowing physicians to do what they do best, and while that association may not be visible to patients, they are certainly the beneficiaries of it.