The Benefits of Outpatient Solutions

On this week's ADVENTing, Dr. Madan Kandula and Dr. Ethan Handler discuss the fact that 99% of ENT patients don't need a hospital
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Published on
March 16, 2020
Updated on
March 16, 2020

On this episode of ADVENTing, Dr. Madan Kandula and Dr. Handler talk about ENT patients and why hospital visits are, most times, unnecessary.

Dr. Kandula:
All right. I got something for you. Right? Okay. Yep. So would you agree or disagree? 99% of ENT patients don't need a hospital for their care. Does that sound about right?Dr. Handler:
Okay. That sounds about rightDr. Kandula:
98, whatever. 97, somewhere in that,Dr. Handler:
Let's call it like inpatient where they have to stay the night or multiple days or something my way. Yeah.Dr. Kandula:
Or a hospital as part of their care. Let's just say that period. And yet, so we're here in Milwaukee and Milwaukee, uh, 99% of the ENTS are employed by hospitals and hospital systems. How do you jive those two things? Does that make sense?Dr. Handler:
It does not make sense.Dr. Kandula:
It is. Okay. How can that, how can our current reality not make sense in the healthcare world? How is that possible?Dr. Handler:
You know, I mean I think a lot of power was given to hospitals to grow and expand and therefore gobbled up independent practices.Dr. Kandula:
Why?Dr. Handler:
Because they can consolidate all of the care and charge hospital rates.Dr, Kandula:
How does that help anybody?Dr. Handler:
It doesn't help. It does not help. It does not help patients.Dr. Kandula:
So I guess all I can, so speaking for our little piece of the world or ear, nose and throat part of the world. What we just said is hospitals add pretty much zero value to the care university, but with certain exceptions there are exceptions, but certainly if you are going to have your septum repaired, you could, well, let me go this way. If you're going to have your septum repaired, the septum is the thing to divide your nose. The two, uh, sides, you know, left and right, you could have that done in, you could take your pick here, you could have it done in a hospital, a hospital outpatient department, that ambulatory surgery center, potentially an office. So that that's an option nowadays sometimes. So why would you choose any of those options over one over the other what value added, why would you, you're going to have your septum done. Why would you possibly have your septum done, your septum surgery done in a hospital?Dr. Handler:
I would say if you're going to have anesthesia and you have a lot of other health issues, right? So that really is the only way to justify it. If there's some concern for a complication with anesthesia. Okay. A hospital might be a safer place to do it, but you could say the majority of patients don't have those situations. And even if they do have, you know, high blood pressure, other things, you can still do those safely in a non hospital setting.Dr. Kandula:
Yeah. I hear you.Dr. Handler:
Well when you say the majority of patients, I'd say if for folks who are concerned enough about their septum that they are thinking about getting it taken care of, um, they're probably not, you know, um, clasping their chest in the midst of a heart attack. Right. If you're having a heart attack, you're probably not so concerned about your septum.Dr.Handler:
I wouldn't be correctDr. Kandula:
cause I would say most people are going to have to get their septums taken care of are pretty much, you know, not necessarily the, the sickest of the sick. But I would give you that. I think if you're, if there's a good medical reason to have your septum done in the hospital, then do that. Uh, but, uh, I'd go back to that 99% in the easy number and I'd say 99% of the time, that's not the case. And that's probably even higher. I'd say it's probably higher than the 99% of the time we're, it's just no value added. And yet in Milwaukee, uh, if you're going to have your septum done, the most likely place you're going to have that done is in a hospital. [inaudible] and that's, we talk about insane from a medical billing standpoint. That's insane. That doesn't make any sense at all.

Speaker 2: Well, and why is that?

Dr. Kandula:
Why is that?Dr. Handler:
But it's cause it's going to cost exponentially more for no, no value add. Yeah.Dr. Kandula:
Well how could that be? How could something costs more with no added additional value? How is that possible?Dr. Handler:
It's because there's a lot more overhead to run a really fancy hospital than there is to run a surgery center or a clinic. Yeah. But there's a lot more administrators needed to get paid and everything else we could go, we could get really into the weeds here, but you know, as far as the value add to the patient there is there, there really isn't any, and then as a patient, I've been a patient myself, you know, and I've had surgeries done. I don't want to be in a hospital unless I have to be in office.Dr. Kandula:
Why? Hospitals are safe, man. They're the place you want to be.Dr. Handler:
Bbecause hospitals have sick people, right. You know, and if you're having an elective surgery and you're not sick, you don't want to be in a place where people are.Dr. Kandula:
So say if you're a healthy person, the last place you want to be is in a hospital.Dr. Handler:
Correct.Dr. Kandula:
If you're a healthy person wanting to take care of your nose, the last place you could possibly ever want to find yourself is in a hospital because that's where you get, that's, that's where sickness finds you.Dr. Handler:
Right.Dr. Kandula:
Let me go another direction. If you, if we're, we're, we're kind of going off topic here, but, um, you heard of the coronavirus.Dr. Handler:
What's that?Dr. Kandula:
The coronavirus, do you want the coronavirus?Dr. Handler:
absolutely do not want the coronavirus.Dr. Kandula:
You know how you get the coronavirus?Dr. Handler:
Go to a hospital.Dr. Kandula:
Go to, go to a cruise ship with somebody who has a coronavirus and hang out there.Dr. Handler:
Right?Dr. Kandula:
Because you know, when you look at that, the data there, you see China number one, the country number one on that, on the coronavirus viral list, virus list is China. And number two is the cruise ship that had the one person who had coronavirus I'd make an analogy to a hospital is not that they're, you know, if you have coronavirus please go to a hospital and get treated. So I'm not saying that right, but what I am saying is if you don't have those sorts of things, and that's just a, it's an a bit of an absurd example, but it's not because, you know, people, hospital acquired infections are real. And the, the part of those things that you can avoid or is the hospital part, it's, it's absolutely real. And yet the entire system is flipped, you know, completely on its head. Where the only way for folks to get access to many medical surfaces is, or it's through a hospital and the only way that their services are going to be provided is in a hospital. And, um, well how can that be, you know, well, you flip around what we said before, if, and this is actually a low stat, but if 99% of ENTs are, you know, are employed by a hospital system, um, then the only way to get access to those are in a hospital. And that sort of, I don't know what the technical definition of a monopoly is, but if that's not, not a monopoly, I don't know what is.Dr. Handler:
Right.Dr. Kandula:
And so what do you get there? You get a lot of people who are, um, sort of whose interests are aligned together, uh, against the interest of patients.Dr. Handler:
Well, yeah, and those surgeons, you know, they have no other place to operate because they're employed by the hospital system. So they say, here are your operating rooms.Dr. Kandula:
Right.Dr. Handler:
And they're not involved in billing or anything else. You know, that's all the administrative, and so that's where they operate because they have nowhere else to operate.Dr. Kandula:
Right.Dr. Handler:
You know, and we've had this discussion before that on the 99% I'd say the overwhelming majority of surgeries that are done in the United States operations that are done in United States are are elective. Then that's not cosmetic. Okay. They're elective, meaning that they're still covered by insurance, but then you don't necessarily have to have them done.Dr. Kandula:
RightDr. Handler:
Now out of the overwhelming elective surgeries or operations, most of them could be done where you don't have to say stay the night in the hospital or maybe you do, but it's less than 23 hours. Right. Or 24 hours. Absolutely. Right. And so therefore all of those shouldn't be done at a hospital, right? Or most of them.Dr. Kandula:
Absolutely. Yeah. I mean it's basically, you know, conceptually you're taking same surgeon. If, if this is a true surgery where somebody is asleep, same surgeon, same anesthesiologist, different facility, same outcomes, better outcomes because you don't have to worry about sort of...Dr. Handler:
Lower infection rate.Dr. Kandula:
All those sorts of things. It makes all the sense in the world, but the system isn't controlled by the little old patient. The system is controlled by the big, big boys, the big Goliath in the world, control things. And that doesn't work really well for, from their vantage point. And they'll talk and they'll say all they'll, they'll talk around the concept of, you know, here's what I'm saying is if you have a septum that needs to be straightened and you have the choice to do that, and in, in a setting other than a hospital do that. And the counter argument is about, well, all the value add that a hospital adds for the population in general. And, and yet if it's your septum, um, it really doesn't impact you in a, in a positive way at all. It doesn't mean that there shouldn't be hospitals, it just means hospitals should do what they do. And surgeons and surgery should be done in places where it makes the most sense without any questions.Dr. Handler:
And, and, and we shouldn't be wrapped up like the, you know, the rising cost of healthcare, which is massive in our country. You know, we don't need a a three star Michelin restaurant in our hospital, you know, or like five Starbucks, you know, those kinds of things that you know, that, that are shown as value add or are just not for patients, you know, and they just increased the cost of care. And that septum that's done at that outpatient surgery center, that costs half of what it costs in the hospital. It's no different. The procedure itself and the outcomes arguably could be worse than a hospital. Than a surgery center.Dr. Kandula:
Next level. Now I'm going to blow your mind here. I think you already had this blown, but if you take that septum that's bent that now you can, that you want straightened. Is that what you're saying to me? Are you saying I've got a septum that's bet that I, that I want straightened or are you on, are you saying I want to breathe through my nose and I want my nose and sinuses to work properly?Dr. Handler:
I want to breathe through my nose. Correct.Dr. Kandula:
So if you want to, if you want to breathe through your nose, lo and behold, a lot of times we can leave that bent septum alone and we can gain space around it in the office. Now that's, that's like next, next level thinking that nobody would ever dane to think that that's an option in 2020. No way. You know, that you could take something, somebody who's on a one way pathway towards surgery in a hospital, which is ridiculous, and save them from that. Bring them into an office, leave your septum alone. Uh, gain space around it. Get you what you want. What you're asking for is, I want to breathe through my nose and what we're going to do is we're going to let you breathe through your nose. We don't need to put you to sleep to do this. We can do this in a very, you know, relatively quick and elegant procedure and have you up on your way. And if you have that choice, and most people do have, well most people that choices there in the world for people, most people don't know they have that, that choice. And so when we talk with patients, we're talking and through, uh, it is with the recognition and acknowledgement of there's all sorts of versions of, of getting somebody moving forward. Um, there's sort of high intensity, you know, relatively high, low yield for what we put you through to low intensity, high yield. And most people are really looking for a problem that they want fixed. And my job is to fix it. And you know, the nice thing is, um, well I don't, I don't own a hospital. Do you own a hospital?Dr. Handler:
I do not own a hospital.Dr. Kandula:
So I don't really have a skin in the game as far as a hospital, you know, sort of, um, getting gets cut of whatever it is that it's supposed to get, get to get. I don't care. It doesn't matter to me.Dr. Handler:
Right.Dr. Kandula:
And so if you don't own a hospital, then your interests are more likely to be aligned with the patients that you're treating. If you do own a hospital then good God man, you've got a lot that you need to pay for. The hospitals are expensive and expensive. The things need, you know, it needs, it needs money to feed it. And so, you know, thank God we don't own a hospital. Thank God. I, you know, uh, that, that's not part of who we are. Um, that's a good thing. It sounds, it's sort of this, um, the end of the day for what we do on a day to day basis. Um, the nice thing is the tools and the set up that we have are completely tailored for the people that we're treating, not for the people that are, you know, sort of not for people that were not treating. I guess that's at the end of the day a hospital was built for pretty much if you have ENT issues, hospitals are built for everybody else other than you. If you have an ENT, ENT issue, uh, you don't need a hospital for the majority of the majority of patients.Dr. Handler:
Right. And let me question for you. How many patients who have their noses look in by, whether it's an ENT or somebody else that looks in there, how many of them will probably be told they have a deviated septum?Dr. Kandula:
Oh, quite a bit. Quite a bit. Although I'd say I would venture to say there are more people who are told that they have a deviated septum by somebody who actually wasn't able to look in their nose.Dr. Handler:
Sure.Dr. Kandula:
Does that make sense?Dr. Handler:
Yeah, absolutely.Dr. Kandula:
Cause it not to knock every other person in medicine, but it's a sort of an ENT looking in somebody's nose I don't necessarily trust the information I'm getting. If he's looking in there and they say, you've got a deviated septum, you probably do. And on that metric, I'd say the majority of people walking around in the world have some degree of a deviated septum.Dr. Handler:
Correct. Right. So, so yet it is always kind of talked about as, "Oh my gosh, I have a deviated septu," Like I know I have one around how many times the patients come in and said, "Hey, I know I've got a deviated septum. I don't breathe well." And in their minds, they're already connecting the dots about what they need to have done and what's causing their problem. Right. And so, and then we have to say, or I usually tell people, like everybody stepped into deviated. It's just a matter of how bad, right? So, so it kind of just reshift their mindset there.Dr. Kandula:
Yep. Yeah. Generally, although I'd say go back to what I was saying before, if somebody is pretty much, if somebody is having your nose looked at almost anywhere, it's because they have an issue going on there that they want, they want, they were wondering if, you know, can it be corrected? Can I do better? That's really, again, back to the question they're asking is that, and the answer that often is given is not the most effective way to treat right or answer the question. You know, the question is I want to read, read better. Uh, your septum may not be helping you, but there are likely other things that are helping you either. And it may very well be better to start with those other things that we can treat in a lower intensity manner. And likely save you from maybe even need to get that step and taken care of in the first place. So,Dr. Handler:
And having it done in a hospital.Dr. Kandula:
Right, which, and again, nothing back to now on the hospital front, I'd say I don't have anything necessarily against the hospital. I trained in hospitals,Dr. handler:
My wife works in a hospital.Dr. Kandula:
You know, hospitals are generally, they're good, but hospitals are for sick people and, and that's what they're built for. And you shouldn't take a healthy person and put them in a hospital, uh, because you're going to get, you basically, if you put a healthy person in a hospital, you're going to take that healthy person that you're more likely to make them sick, unhealthy.Dr. Handler:
Absolutely.Dr. Kandula:
That's not a game that anybody wants to, to, to play in. And if you have a choice, you would make that choice. Um, unfortunately most people don't have the choice. Most people, most people are told what to do. Most people would understand that they are actually in the driver's seats. If you're patient seeking care out, uh, you're in the driver's seat. We can tell you what to do or where to do it. Um, you can write, uh, state your case and you can make it sell. I, I think a lot of people don't even know to question or ask questions or question authority or just question. Questions are good. You know, answers. Questions are good, and the answers are good when they are matched up with the questions that are being asked. And I guess that's a simple thing. If you have an ENT issue, why in God's name do you do, do you need a hospital? And the answer is likely you don't.

First published by ADVENT on
March 16, 2020
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The Benefits of Outpatient Solutions