The Lure and the Legend of Office-based Interventional Radiology
By the nature of their subspecialty, interventional radiologists are enamored of innovations that engender emerging minimally invasive therapies, and the 2011 annual meeting of the Society of Interventional Radiology (SIR) in Chicago, Illinois, did not disappoint. Interventional-radiology researchers reported promising outcomes from clinical trials for stroke therapy, multiple-sclerosis treatment, and catheter-based treatments for hypertension. “New emerging therapies will define interventional radiology,” Timothy P. Murphy, MD, FSIR, told attendees of “Freestanding IR: Economics, Politics, and Business of IR: A Mini MBA,” on March 26. Murphy is the newly inducted president of SIR, medical director of the Vascular Disease Research Center of Rhode Island Hospital in Providence, and a professor at Brown Medical School. Traditionally, interventional radiologists have delivered their services in hospital settings, often unbeknown to patients with stroke, gastrointestinal bleeding, gunshot wounds, and obstetric emergencies. A growing number of interventional radiologists, however, seek the autonomy to control their own destinies—outside the confines of the hospital—in freestanding clinics. During a half-day business-development session that described the pros and cons of freestanding interventional-radiology clinics, no clear model emerged, and many caveats were voiced. Business strategists, for instance, caution interventional radiologists (and their diagnostic-radiology partners) to remember that the hospital is a very important customer, much as the referring physician is. Murphy notes that the hospital delivery model is not absolutely essential, though it is very important. A market is emerging, nonetheless, for the outpatient delivery of interventional services as discriminating patients want to know how minimally invasive treatment alternatives compare (in price and outcomes) with surgery or medication. These patients often have debilitating or life-threatening diseases that have not improved in response to other therapies. An Independent Streak According to the 17 presenters of the half-day symposium, interventional radiologists gravitating to the freestanding setting prefer the flexibility to schedule patients, to define their case mixes, and work from central offices. Many minimally invasive procedures, however, still require inpatient admission, so whether they work as independent practitioners or in hospital–radiologist joint ventures, more and more interventional radiologists seek the opportunity to meet patients and counsel them about treatment options before their procedures and to follow them throughout their therapy regimens. The greatest challenge for a freestanding interventional-radiology clinic, Murphy says, is to break even—which might be as simple as adding a new procedure that will take the operation into the black. The first challenge, however, will be to overcome the interventionalist’s reputation as a therapeutic technician and win the confidence of referrers and patients for evaluation/management expertise. If the interventional radiologist isn’t ready to go solo, another option is a joint venture with the hospital. “Everyone benefits,” Murphy says. “Currently, patients with ambulatory conditions go to the hospital, but hospitals are designed for acute care. Parking isn’t good. In contrast, an interventional-radiology office should be designed for convenient access and patient comfort, and should have a well-trained office staff.” In those scenarios in which an interventional radiologist is employed by the hospital, the hospital typically designates the interventional-radiology budget as a subcost and manages downward, Murphy notes. In this case, interventional radiology is considered an ancillary service, is often operating under capacity, and is most likely to need resources. When a progressive hospital executive sees interventional radiology as a growth area and collaborates with the interventional radiologist in the development of new services, however, investment can follow—and a joint venture can evolve. In the end, hospitals might not recognize the subsequent procedures that stem from interventional-radiology services, nor might they be tracking those data. Murphy explains that SIR is actively working to document the return on investment of interventional-radiology services. Moving forward with a freestanding interventional-radiology center or a joint-venture outpatient clinic requires interventional radiologists to document how the investment will generate downstream procedures. The Patient-safety Mandate Bret Wiechmann, MD, is a member of Vascular & Interventional Physicians (Gainesville, Florida), a subgroup of five interventional radiologists within the 21-radiologist Doctors Imaging Group. He addressed the safety spectrum associated with interventional-radiology procedures. His group is affiliated with two hospitals, and it has an outpatient interventional-radiology clinic and a solely owned imaging center. “Freestanding interventional radiology is a portable concept,” Wiechmann explains. “With that comes a self-awareness that safety is on the frontline—should we be doing these procedures in an outpatient center, and is this safe and effective? For the most part, yes: We have protocols that arrange for patients to be transferred, if needed.” Because of the safety issues, the scheduling process in the freestanding center is critical. “We can’t overcommit,” Wiechmann says. “We need to schedule time to review the biopsy results and necessary images.” There is no official accreditation process for outpatient interventional-radiology facilities, but Wiechmann’s group has quarterly safety and quality-assurance meetings. “Limitations are defined by CMS and insurance reimbursements, as well as case complexity,” Wiechmann notes. “Patient selection becomes key in the outpatient facility. To have an optimum interventional-radiology service, safety demands a strong quality-assurance system.” Wiechmann continues, “If the interventional radiologist is hospital based, he or she may feel like an interventional radiologist in a box. The hospital assigns the interventional radiologist the procedure based on the procedure, not the patient. In this scenario, the interventional radiologist becomes more of a procedure technician than a consultant, and that is unlikely to change.” Three steps are critical to the freestanding-clinic model, he says. First, since the interventional radiologist can treat so many organs, he or she has to communicate with all physician specialty groups. Second, the larger radiology group must establishing the legitimacy of its relationship with the freestanding interventional-radiology clinic, requiring buy-in from diagnostic partners. Third, it takes one-on-one meetings with the patient to demonstrate that the interventional radiologist is not just a technician. Taking the Plunge While the best-laid plans are, after all, just plans, Jeremy Friese, MD, MBA, of the Mayo Clinic (Rochester, Minnesota) impressed on attendees that development is not a static process; interventional radiologists must be willing to make adjustments and respond to changes in the market as their businesses develop. Case mix and insurance adjustments are unpredictable factors in the road to revenue generation, and the best products and services still need to be enhanced by customer-service excellence. Ted Chambers, MD, started his own freestanding interventional-radiology center in White Plains, New York (American Access Vascular & Interventional–Westchester), after initially practicing in a highly specialized radiology practice in the Washington, DC, area. He interviewed various partners and later affiliated with a nationwide company that provides operational support and economies of scale. He weighed the pros and cons of starting a freestanding interventional-radiology center; he says that he is challenged on a daily basis, but feels that this model brings satisfaction because he can do better work and still have autonomy. “When I give a clinical report on a patient to the referring physician, the physician is surprised, asking, ‘Excuse me, what is your specialty?’” Chambers notes. “Physicians are not used to having an interventional radiologist speak so clinically.” He adds that many physicians appear to see interventional radiologists merely as the people who place peripherally inserted central lines. Chambers advises those following in his entrepreneurial footsteps to take a case-mix inventory often and to communicate continuously with their customers (including hospital executives, radiology-group colleagues, referring physicians, and patients). “This venture is not for the faint-hearted,” he says. “Once you move to a freestanding center, competitors will be watching.” Chambers continues, “Young interventional radiologists need the experience that comes from being part of a dynamic hospital setting and a radiology group. Some of us are well suited for the hospital environment, some have more leadership potential, and some are fiercely independent. For me, it was about growing; for others, it’s more about preservation. Do you have control over your schedule? Do you like the cases you are doing?” When William H. Julien, MD, founded South Florida Vascular Associates in 2001, he was one of the first interventional radiologists to establish an office-based clinical practice in the United States. By 2005, his group had opened the only office-based endovascular suite in the South Florida area. In 2010, the group opened a new 8,000–square-foot facility, in Coconut Creek, with multiple endovascular suites; 95% of the practice’s interventional-radiology procedures are now done at this freestanding center. While there are 74 interventional radiologists practicing in the South Florida region, those in Julien’s group operate in what continues to be the only freestanding clinic in the region that provides a broad spectrum of services. As consolidation sweeps health care and hospitals gain greater clout, Julien warns interventional radiologists against overspecialization and relying too heavily on any one referrer. If interventional radiologists provide only a small range of procedures, they are more vulnerable to market forces. For example, Julien is known for his expertise in treating gangrene. “Don’t rely on the vascular surgeon to feed you,” he says. “Being too limited—or too gifted—may number the days of the interventional-radiology practice.” A Hybrid Model Paramjit (Romi) Chopra, MD, described a hybrid outpatient interventional-radiology model that he has established at the Midwest Institute for Minimally Invasive Therapies (Melrose Park, Illinois). This metropolitan Chicago physician works hard at serving patients through the community hospital system while maintaining an office-based clinical practice. Chopra’s multispecialty group includes interventional radiologists and vascular surgeons who provide the full spectrum of consulting, procedural, and follow-up services, in both hospital and outpatient settings. “It’s a changing landscape for physicians,” Chopra says. “With national and state health-care reforms looming, physicians need to change to demonstrate that they can reduce the waste (if not literally, then figuratively) in our health-care system. Interventional radiologists respond with the SIR mantra (quicker, better, safer), but when negotiating with hospitals, interventional radiologists will need to validate how they can make these services faster, better, and cheaper.” Chopra likens the physician practice to a sports franchise moving from owner players to employee players. In these player negotiations, the interventional radiologist can demonstrate that in many cases, interventional radiologists are the biggest patient admitters to the hospital. If that sounds surprising, Chopra advises, track the case mix, share it with the hospital, and one of two things will happen: The hospital either will employ the interventional radiologist directly or will partner with the radiology group that employs interventional radiologists. “In either case, if interventional radiologists can bring their specialized care to a community hospital, the patients don’t need to be transferred.” Chopra says, noting that this is the key. “If the patient is transferred to a large tertiary center, he or she generally doesn’t come back,” he says. A hallmark of Chopra’s interventional-radiology practice is providing follow-up consultations for the 16,000 patients seen in hospital and clinic settings annually. “I try to be a physician’s physician, working closely with primary-care providers and letting them know that alternative treatments exist,” he says. “That effort puts us higher on the food chain. To have a successful interventional-radiology practice (whether freestanding, independent, or hybrid), be a physician first: Talk to and know your patient.” Barry Katzen, MD, FACR, FACC, FSIR, founder and medical director of the Baptist Cardiac & Vascular Institute (Miami, Florida), believes that office-based interventional-radiology practices can exit within (and benefit) radiology group practices, although many interventional radiologists believe that their patient-care contributions are not fully appreciated by diagnostic-radiologist colleagues, who are typically focused on throughput and productivity. To the patient, the interventional radiologist has intrinsic value, Katzen says. “We provide a less-invasive solution to a severe problem,” he adds. Aligning With the National View Katherine Krol, MD, of Indiana University Health Arnett Hospital (Lafayette, Indiana), represents SIR on CPT® and CMS matters. She believes that the trend favoring freestanding interventional radiology aligns well with the current health-care environment. “I feel better this year than in past years about the future of freestanding interventional-radiology centers,” she says. “When interventional radiologists started doing interventions, procedures were done for inpatients, but in the past 10 years, advances in minimally invasive medicine have safely enabled interventional radiologists to access sites in the body with much smaller incisions (using microcatheters and the like).” She adds, “Some of these procedures can safely be done on an outpatient basis, but safety is correlated with everything we can do. People want to know what happens if you have a code or a complication, and the patient has to be sent to the emergency department. For this reason, the SIR Foundation is actively collecting data to provide guidance about procedures that are best suited for freestanding centers.” The SIR Foundation is continuing to collect documentation and to review every CPT code for effective, safe performance in a freestanding interventional-radiology setting. In the beginning, if a radiology group had a freestanding facility, each facility typically contracted independently with non-Medicare insurance carriers. This laborious process deterred many from developing a successful freestanding model. Today, more and more interventional radiologists are clearing such hurdles by contracting through hospitals and radiology group practices. Documenting safe and effective care and managing the relevant data are essential, she adds. “Currently, there is no accreditation process for freestanding interventional-radiology centers, and there is no repository where physicians can provide information,” she notes, “but if the hospital has established the freestanding center, there should be an oversight process for the safety of the outpatient center—and an opportunity to collect data to support the CPT and CMS processes. CMS is asking very good questions that may evolve into CMS policy, but that policy doesn’t exist yet.” Carrier negotiations represent another hurdle for office-based interventional radiology. “There are a number of procedures we haven’t gotten payment for,” Krol says. “If we’re celebrating a 10-year anniversary, then certainly, interventional radiologists have made progress on all three fronts. The future of freestanding interventional radiology is in the hands of entrepreneurial interventional radiologists who are willing to navigate these hurdles, much as they navigate the vasculature, on a daily basis. It’s tough, but they persevere, knowing that the delivery of better, faster, safer medicine is possible.” Karen Roberts is a contributing writer for Radiology Business Journal. Additional Reading - Quantifying interventional radiology’s tangible Value