This article is part of a series describing the variety of settings in which IRs treat their patients. If you are interested in profiling your IR practice, contact the society at irq@sirweb.org.
About 10 years ago, I took a leap of faith and left a solid position as a staff interventionalist at a large, respected hospital and opened my first freestanding outpatient interventional center in the greater Washington, D.C., area. Along the way, I made mistakes and learned some important lessons that continue to shape the way I run my practice.
Background
Freestanding outpatient settings include ambulatory surgery centers (ASCs) and physician offices. In recent years, the concept of a dedicated outpatient interventional ASC (irASC) has come into discussion,1 fueled in large part by the increasing emphasis by government and private payers to drive procedures to the outpatient ASC setting due to the substantial cost savings2. Currently my practice setting is classified as a physician office, but that may change in the future depending on reimbursement trends and regulatory issues.
Establishment
I originally named my business “Center for Interventional Medicine.” Recently I rebranded it as simply “VascularCare,” because I wanted a name that patients could more easily understand and remember. I chose the name to emphasize the words “vascular” and “patient care.”
I opened my first outpatient center in 2009 with the assistance of a medical practice consultant, who provided advice on potential geographic locations. Since then, I have learned about optimizing locations to be closer to target populations and referring physicians. I opened a second office in 2012, and I am in planning stages to open a third office in 2020.
All office locations are optimized to be convenient to target populations (based primarily on where people live, as opposed to where they may work) as well as close to communities of potential referring physicians. When possible (such as may be the case with the upcoming third office), we establish relationships with health systems to be their preferred choice for outpatient interventional services.
Operations
In general, our offices are run in a very cost-efficient manner. We aggressively negotiate pricing with vendors and regularly shop around for better pricing. Each staff member has a primary role but is cross-trained to fulfill other roles when necessary.
Like Southwest Airlines’ exclusive use of the Boeing 737, we prefer to use the same equipment (such as ultrasound and c-arm) in all offices to allow simplicity in staff training and reduce costs of service contracts and maintenance.
Our offices tend to have a small footprint—probably smaller than average outpatient interventional centers. This may be a result of being in a large city (with relatively expensive rents) but it applies to future locations as well. A “rule of thumb” metric that I use is revenue per square foot (commonly used in the retail industry). While not a perfect metric (because various uncontrollable factors can affect revenue in a particular geography), in general revenue per square foot is the metric we seek to maximize.
Philosophy
A fundamental paradigm of our practice is that we are patient-centric. Nearly everything we do focuses on providing the patient with the best experience, including clinical outcomes, making sure that patients and designated family members are comfortable with the treatment plan, and frequent follow-ups as needed.
Our practice is based in consultation. The initial consultation visit is central to building the relationship with our patient. We see virtually all patients initially during a consultation visit, with the possible exceptions of very simple procedures such as thyroid nodule biopsies or PICC line placements—but, even then, a mini-consult is carried out at the time of the procedure.
During the consultation, we provide a detailed explanation of the underlying medical condition and treatment alternatives (including noninterventional treatments if appropriate). We use pictures, diagrams and charts to help the patient understand the proposed procedure. We make sure all questions are answered and, if helpful to the patient, we offer to have another discussion with a family member by phone (this option is popular with senior citizens who may want us to speak with their daughter or son as well).
During this consultation visit, we will perform a focused clinical examination if applicable and perform a diagnostic ultrasound exam (e.g., if it is a vascular issue). During the ultrasound exam, we spend a fair amount of time explaining the ultrasound findings to the patient. We prefer to perform the ultrasound at the time of the consult (as opposed to on a different day) so that, when the patient leaves our office, they have a very good understanding of the condition and treatment plan. We provide the patient with a written summary of the ultrasound findings and the treatment plan.
Consistently and repeatedly, we receive excellent feedback from patients and family members about the quality of our consultations. We also send a detailed letter to the referring physician as well as the patient’s primary care physician (with the patient’s permission and if the PCP is not the same as the referring physician), to keep those providers in the loop, and also call them to discuss in detail if necessary.
Furthermore, during a complex procedure that involves a prolonged recovery period, we may avoid seeing any other patient that day so that the entire office can focus on that one patient to provide them a totally customized experience. A good example of when that approach is used is for uterine fibroid embolization. We certainly do not use the “assembly line” approach of multiple patients being rapidly shuttled through, which may be seen in large facilities.
In keeping with the patient-centric philosophy, I prefer vascular access via the radial artery when possible, so that the patient can immediately ambulate and lie in a comfortable position on the recovery bed. The radial approach has worked well for UFE cases.
Scope
Based on location, demographics and other factors, each office has a slightly different procedural focus. Our business model allows rapid adaptability to different markets. For example, some markets have more patients with venous reflux disease, other markets have more patients with fibroids and PAD, and others may have a strong demand for dialysis access procedures.
In general, we do a large amount of vascular work, including venous reflux disease and PAD. We also do a good amount of women’s health, in particular UFE. We offer other procedures such as ultrasound-guided biopsies and central venous access as well that, while not generating significant revenue, draw in referred patients and help keep our name in the minds of referring physicians.
Challenges
Consistent branding is our single biggest and never-ending challenge. Branding is a broad term and, as it applies to our business, includes reputation management, referral patterns, patient reviews, word of mouth and other means. Warren Buffett once said, “It takes 20 years to build a reputation and 5 minutes to ruin it.” Branding, which is about who we are and what we do, is a direct reflection of the quality of our care and the patient experience. Training all staff in providing high-quality patient care is necessary and requires repetition. Maintaining excellent working relationships with referring physicians requires consistent attention, including making sure they receive accurate and informative reports on time and promptly. We employ a physician liaison to manage those channels of communication. With strong branding, our competition becomes irrelevant.
Summary
In summary, building our practice has taken time, expense and learning by the seat of the pants. A patient-centric approach is key to our philosophy. As the outpatient setting becomes more emphasized over the hospital setting for certain procedures, we see exciting growth opportunities in different markets and with upcoming new procedures.
References
- Weiss M, Kronawitter C. Explosive growth in ASC codes fuels opportunity. Radiology Business, April 2018. Available at radiologybusiness.com/topics/reimbursement/explosive-growth-asc-codes-fuels-opportunity.
- Abrams K, et al. Growth in outpatient care. Deloitte Insights, August 2018. Available at deloitte.com/insights/us/en/industry/health-care/outpatient-hospital-services-medicare-incentives-value-quality.html.
