Tonsillectomy Facts in the U.S.: From ENT Doctors

The American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS), representing 12,000 ear, nose, and throat surgeons, responded with significant concern to remarks by President Obama during a press briefing on July 22, 2009, as did many other physicians. During the briefing, the President suggested that physicians might be influenced to perform tonsillectomy surgeries based on reimbursement rates, in a situation where medical management might be equally efficacious. 

Obtaining the best possible healthcare for Americans is too important for the decisions to be based on poor information, as characterized during the press briefing. As physicians, we take the public trust placed in us very seriously. Although there can be variations in opinion in the management of any individual patient, the AAO-HNS is committed to the continued development of evidence-based treatment guidelines  produced from the best available current clinical research and data.

Facts on Tonsillectomy

• In the United States, the number of tonsillectomies has actually declined significantly and progressively since the 1970s. The frequency with which tonsillectomy is performed varies from region to region.  The variation appears to be related to differences in the medical practice of general practitioners, pediatricians, and otolaryngologists, in the management of recurrent tonsillitis and other conditions affecting the upper airway.
• 30 years ago, approximately 90% of tonsillectomies in children were done for recurrent infection; now it is about 20% for infection and 80% for obstructive sleep problems (OSA).
• The “gold standard” for the diagnosis and quantification of OSA is full-night polysomnography, or sleep study. However, polysomnography is expensive, time-consuming, and often unavailable. Consequently, most otolaryngologists will perform an adenotonsillectomy (T&A) based on a strong clinical history and parental observation in a child with chronically enlarged adenoids and tonsils.
• Extensive data shows the negative effects of OSA in children on behavior, school performance, and bed-wetting. Improvement for such behaviors following tonsillectomy is very well documented.
• Tonsillectomy for recurrent tonsillitis is effective at significantly reducing the number and severity of sore throats in children who are severely affected. There is also anecdotal evidence that some children’s quality of life is transformed by the surgery. This may be caused by a combination of factors that include the tendency of the frequency of recurrent sore throats to resolve over time and the elimination of a source of infection and of obstructive symptoms. These conclusions were published in “TO TREAT: Tonsillitis Outcomes – Toward Reaching Evidence in Adults and Tots,” a January 2008 supplement to the journal Otolaryngology-Head and Neck Surgery.
• Tonsillectomy alone is performed infrequently in children younger than 1 year old, whereas adenoidectomy alone is performed infrequently in individuals older than 14. The rate of adenoidectomy is about 1.5 times as high in boys as in girls, while the rate of tonsillectomy is almost twice as high in girls than in boys.
• On financial incentives favoring surgical intervention:  Tonsillectomy reimbursement ranges from approximately $180-$300 across all payers. For example:  Medicaid reimbursement to the surgeon for performing the procedure within the state of Virginia is currently $200, and this includes all the follow-up care for 90 days following the procedure.  Some payers base their fee schedules on a percentage of the Medicare payment. Out of this payment, the physician must pay significant malpractice insurance costs, as well as overhead costs for the practice,  including staff salaries and benefits, and utilities.

Our Activities for Quality Patient Care

The AAO-HNS is an approved collaborator of the National Institutes of Health (NIH) Roadmap for Medical Research, PROMIS (Patient-Reported Outcomes Measurement Information System), an  initiative to develop new ways to measure patient-reported outcomes (PROs). Such outcomes as pain, fatigue, physical functioning, emotional distress, and social role participation have a major impact on quality of life across a variety of chronic diseases. Clinical measures of health outcomes, such as x-rays and lab tests, may have minimal relevance to the day-to-day functioning of patients with chronic diseases. Often, the best way patients can judge the effectiveness of treatments is by changes in their symptoms. The goal of PROMIS is to improve the reporting and quantification of changes in PROs. (http://www.nihroadmap.nih.gov/about.asp)

Chronic conditions in otolaryngology require the same “whole patient” approach as noted in the NIH Roadmap. Conditions such as recurrent sore throat and infection, chronic sinusitis, sleep apnea, and recurrent ear infections, to name a few, have additional impacts on quality of life beyond clinically measured symptoms. The Academy supports an approach to physician-patient partnered decision-making that incorporates an evaluation of the patient’s overall health status, not just clinical measures, when making decisions on treatment. The Academy’s outcomes research network – BEST ENT – has published numerous studies related to quality of life for specific conditions. (http://www.entnet.org/educationandresearch/research.cfm)

Summary

Otolaryngology, like much of the surgery workforce, is facing significant manpower shortages in the coming years. We will deal with an expanding and aging population, younger physicians who value a manageable lifestyle with reasonable time commitments, and concern about the enormous debt that medical students incur.  Appropriate physician reimbursement, relief from indebtedness from the costs of medical education, and tort reform are required if we are to attract the best physicians to take care of the health needs of the country in the years ahead.

This information has been developed by the AAO-HNS with the American Society of Pediatric Otolaryngology (ASPO) to achieve quality patient care by actively participating in the healthcare reform process.  The decision to perform a tonsillectomy should be based on a physician-patient partnered approach and evaluation of the patient’s overall health status.

We clearly need a debate about healthcare reform, and to provide a clear and affordable model for healthcare in the years ahead.  However, it is critical that this debate revolves around appropriate understanding of the issues, accurate information on the reasons for rising healthcare costs, and a consensus about the level of healthcare funding, as well as public understanding of future expectations.

References:

1. The average Medicare payment for 2009 (Federal Register, Vol. 73, No 224, Wednesday, November 19, 2008/Rules and Regulations. The 2009 Physician Reimbursement Conversion Factor = $36.0666; Federal Register/page 697726) for Tonsillectomy & Adenoidectomy, under age 12 (Surgeon CPT Code = 42820) is $270 and also includes 90 days of postoperative follow-up. Reimbursement for Tonsillectomy alone, under age 12 (Surgeon CPT Code = 42825) is $242. In the commercial payer realm, the reimbursement varies, but is not markedly higher. With the pre-authorization requirements and 90-day all-included global periods typically associated with tonsillectomy, the procedure does not yield a much greater return for surgical versus medical management of a patient. The decision to perform a tonsillectomy should be based on a physician-patient partnered approach and evaluation of the patient’s overall health status.
2. Derkay, CS.  Pediatric otolaryngology procedures in the US: 1977-1987.  Int J Pediatr Otolaryngology 1993;25:1-12.
3. Ross, AT, Kazahaya, K, Tom, LW.  Revisiting outpatient tonsillectomy in young children. Otolaryngol Head Neck Surg 2003;128:326-31.
4. Bloor, MJ, Venters, GA, Samphier, ML. Geographical variation in the incidence of operations on the tonsils and adenoids: an epi demiological and sociological investigation. Part I. J Laryngol Otol 92:791, 1978.
5. Glover, JA. The incidence of tonsillectomy in school children. International J Edpidemiology 2008; 37 (1): 9-19.
6. McPherson, K, Wennberg, JE, Hovind, OB, et al. Small-area varia tions in the use of common surgical procedures: an international comparison of New England,
7. Clinical indicators tonsillectomy, adenoidectomy, adenotonsillectomy. Am Acad Otolaryngol Head Neck Surg. http://entnet.org/practice/products/indicators/tonsillectomy.html. Accessed August 17,2006.
8. TO TREAT (Tonsillitis Outcomes – Toward Reaching Evidence in Adults and Tots) Otolaryngol Head Neck Surg 2008; 138, S
9. Goldstein, N, Stewart, M, Hannley, M, et al. Quality of life after tonsillectomy in children with recurrent tonsillitis. Otolaryngol Head Neck Surg 2008; 138, S 9-S16

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