Running a successful balance center had always appeared to me to be among the most obvious and straightforward business decisions within audiology and otolaryngology practices. Yet, here we are in 2017, equipped with more tools to successfully diagnose and treat balance disorders than ever before, with a growing population of people with high incidences of balance disorders without enough practitioners to serve them.
The population of those 65 years and older is growing at 10,000 per day for the next 15 years. There seems, however, some reluctance—perhaps even an aversion—to implementing much-needed balance disorder services in these practices. At a time when otolaryngology and audiology practices are searching for opportunities to grow services and revenue—without the competition seen in the hearing aid space from alternative players, manufacturers, the internet, or big box competitors—why the hesitation? The most common responses heard as to why to avoid balance services are listed in Table 1. Does any of this sound familiar to you? Why be a naysayer when the sheer magnitude of an exploding demographic that needs these services is approaching and upon us like a tidal wave of patients? Some compelling reasons to consider providing balance services are listed in Table 2.
“Alright, I'm interested. Now what?” Here are seven principles that I have employed for over 25 years of creating and operating successful balance centers within various venues, including private practices; freestanding, physician-based, multi-specialty physician groups; and hospitals. These principles are valid for any and all situations. Before we review these, however, I suggest we do some preparatory work. Prior to purchasing or leasing equipment, hiring personnel, or moving or expanding into additional office space, have you taken the first necessary steps? These steps are critical to ensuring that the project is sound, financially viable, and sustainable.
FIRST 5 STEPS
1. Learn about the health insurance payers in your community or the area you are considering. What is the penetration of payers by type, especially Medicare Advantage Plans? Are you a provider for Medicare and the majority of insurance carriers in your area? If not, get to work and obtain your credentials. Without this, the venture is set on a poor foundation. Do this months before you sign a lease or buy any equipment.
2. Reach out to all potential referral sources and discuss the viability of your project. What is their belief system about “dizzy” patients? What are they doing for these patients now? This includes primary care and other specialists in cardiology, endocrinology, etc., other than ENT physicians and neurologists who will have a much better comprehension. Prepare yourself for the task of the “lift,” which means the time needed in educating the referral sources on the value of balance services.
3. Consider providing a contract service model to hospitals, multi-specialty physician groups, and ENT and neurology practices. This model offers many advantages, and it may also operate alongside them with a direct service model.
4. Decide what diagnostic services you will include, with the understanding that you need not have every test all at once. For example, if there are several facilities that perform VNG in your town but no rotary chair, vHIT, or VEMP, this suggests a possible strategy for you, which will create a competitive advantage. The idea that somehow your VNG will be superior to someone else's may be a hard sell to cause your referral sources to change their preferences. On the other hand, if there are no vestibular services being offered in your community, then introducing video-goggle may be brilliant. Figure 1 depicts a teenager being tested with a rotary chair post-concussion.
5. Accept the fact that sometime after you begin the service and gain momentum, someone else will follow. It is inevitable. So plan on developing as many friends and referral sources as quickly as possible and create a mid-long-term strategy, including what new services and programs you will bring forward and when. Do not become complacent, or your new competitors will catch up and may even surpass you.
THE 7 PRINCIPLES
By following these principles, you will create a high-quality business and practice niche that will survive the test of time and allow you to meet your personal, professional, and financial goals.
1. Become the “expert” in your community. Referring practitioners do not respect the degree nor the school you attended, but they respect the knowledge you have in the service of caring for their patients.
2. Identify mentors, including specialists, in your community with whom to consult. No one ever achieved anything great alone. There are physicians, therapists, and audiologists from whom you can gain invaluable wisdom on medical and psychiatric conditions, rehabilitation strategies, and patient management. Open yourself to these sources of new knowledge.
3. “Step away from the ear,” develop interdisciplinary interests and resources. Balance conditions may not be ear-related, and often are not. Consider all the physical and psychological manifestations of your patients’ conditions. Take nothing for granted.
4. Be a lifelong learner…read, read, read, then share your knowledge. New information is published every month in professional journals of various specialties. Do not assume that the only important articles or breakthroughs will be in ENT or audiology publications.
5. Recognize that human equilibrium is a “birth to earth” clinical science, providing your practice limitless opportunity. The human vestibular mechanism is fully developed en utero at 49 days of gestation. More than 500 known syndromes and mitochondrial disorders affect vestibular function. Consider that infants and children with or without hearing loss may present with balance dysfunction based on delayed maturational motor milestones. The aging process affects all aspects of the equilibrium, so remember that we walk on our legs, not our ears. Also consider the status of your patient's visual, neurological, biomechanical, and neuromuscular systems.
6. Create and promote an interdisciplinary continuum of care to serve all patients, pediatric to geriatric. Considering that the majority of patients other than those with BPPV, vestibular neuritis, or Meniere's will likely have non-otologic conditions, you will need collaborative relationships with specialists and physical and occupational therapists who will be essential to your patients’ progress through a continuum of care. These practitioners will also become sources of knowledge and great assistance in your own growth as a balance expert.
7. Build real and meaningful relationships with referral sources that are value based; become a colleague! To have a friend, you must be a friend. Your availability, accessibility, and willingness to go that extra mile for referring practitioners and their patients will pay dividends for years. Avoid being perceived as a “transactional” fellow professional. As we often say, “No one cares how much you know, until they know how much you care.”
The changing landscape for audiologists and otolaryngologists, as well as the growing patient population and the need for well-trained practitioners in the balance sciences, suggests there's no better time than now to consider including balance services into your practice. These principles will help you realize your goals, and provide your patients with solutions to conditions like dizziness, vertigo, and imbalance so they will no longer will be told to “just learn to live with it.”
Opportunities in the evaluation and management of balance disorders will be very strong for many years to come. With robust planning and execution of a good business plan, audiology and otolaryngology professionals who seek to fulfill this need will have great success. Ultimately, in the world of rehabilitation medicine, success is not driven by hope but by knowledge and strategy.