Interventional radiology became a primary medical specialty 13 years ago. Since then, more and more IRs have embraced clinician identities, increasing their focus on longitudinal patient management, building patient relationships and caring for patients over the years.
It’s only natural then that the next evolution in IR expansion is the office-based laboratory, also called the office interventional suite. While IR OBLs first came onto the scene 20 years ago, interest has expanded recently among IRs seeking more autonomy.
“There’s been a big explosion of OBLs, and I think that’s because doctors are burnt out and tired of being handcuffed by administration and corporate medicine,” said Mary Costantino, MD, FSIR, owner and medical director of Advanced Vascular Centers in Portland, Oregon. “To go out on your own takes a leap of faith and investment in yourself, but I think there’s enough of us that are willing to do that because we love what we do, and we want to deliver the best care to people.”
The growth of the OBL model
For William H. Julien, MD, president of South Florida Vascular Associates, the motivation to open an OBL two decades ago was simply to have an additional location to perform procedures, since there was limited IR suite availability at his small community hospital.
“All the radiology groups in the city were blocking my hospital privileges. So, in desperation, I opened an OBL to offload the easy procedures,” Dr. Julien said. “Little did I know what a great idea it was. Before long, I was performing 90% of my cases in the OBL, especially the complex ones.”
Michael J. Cumming, MD, MBA, founded an OBL, Vascular & Interventional Experts, in Minneapolis in 2020. He had already been working partly outside the hospital system, first opening a vein center through the group practice he worked for and later opening an outpatient vascular center with private equity support. But he yearned for more independence.
Dr. Cumming learned about the OBL model after meeting Dr. Julien at a vascular conference and learning what true independent IR practice could look like. Twenty years ago, unbeknownst to each other, Dr. Julien and Gerald A. Niedzwiecki, MD, FSIR, both launched the first comprehensive endovascular and IR-focused OBLs, both in Florida. As pioneers in the space, they became friends and founded the Outpatient Endovascular and Interventional Society, a multidisciplinary group of IRs, vascular surgeons and interventional cardiologists.
But Dr. Cumming wasn’t convinced he could replicate the Florida model in Minnesota where healthcare was more consolidated and the “turf had already been carved up.” He also wasn’t sure how he would generate referrals or fit into the marketplace. But then he observed that his competitors were large practices offering a lot of procedures but not necessarily serving patients well. He knew he could home in on patient care and procedural excellence, so he decided to start by building an OBL that specialized in critical limb ischemia care.
“There is room for an independent physician, even in a crowded marketplace, as long as you do really good work and you take good care of people and treat them well,” Dr. Cumming said.
Patients appreciate OBLs because of the smooth, streamlined care under one roof and the personalized, comprehensive support patients receive, Dr. Cumming said. “We have everything under one roof in our OBL; we have ultrasound, a CT scanner, our C-arm. Patients can come in and, on most visits, get things done in one visit.”
He also joked that patients like the free parking—but, in all seriousness, that’s part of the convenience and access. “You’re usually parking 50 feet from the front door,” he explained. “You know where you’re going—you’re not in a maze of a hospital.”
Overall, an OBL is a much more patient-centered approach than a hospital, he said. “We are usually a smaller group of people, so we all know the patients, and we are all invested in them doing well.”
Dr. Cumming and his staff can spend ample time with each patient, making sure they comprehend their diagnosis, procedure and options. “One of our goals in our clinic is to make sure we understand why the patient is coming and try and allocate the resources we need to take care of them so they can walk away from their visit understanding what the problem is and what we can do to help them,” he said.
Benefits and challenges
The primary benefit of owning an OBL is also one of its biggest challenges: autonomy. IR owners are the final decision-makers, but that means they also must succeed at hiring and managing staff, buying and setting up equipment, marketing and building a referral base, and ensuring the lights stay on.
IR OBL owners must be strong, patient-focused clinicians and entrepreneurs, these owners said. It’s not for everyone.
“You’ve got to be willing to work through the obstacles that you’re inevitably going to run into,” Dr. Cumming said. “And there’s always another obstacle. I never look down the road and see a straight line to where we’re going.” But that’s what being a business owner is all about, he said. “The people who are successful understand that the obstacle is the pathway forward.”
Two specific challenges are hospital privileges and financial investment. Some, but not all, states require hospital privileges or a transfer agreement for OBLs. Even without a requirement, privileges can be important to allow IRs to care for or follow up with their patients in the hospital when necessary. However, in some areas it can be difficult to obtain hospital privileges because of a local diagnostic radiology practice’s exclusive contract with the hospital.
“It’s regrettable that independent IRs are the only procedural specialty unable to easily obtain hospital privileges in the United States,” Dr. Julien said.
This is one of the reasons why it’s critical for an IR to evaluate the market in a specific area before opening an OBL. Is there a better area or state with more need and less competition where hospital privileges would be granted? Areas with limited healthcare access, like rural or frontier areas, may offer a better business opportunity, while also improving access in that community, Dr. Niedzwiecki said.
Independent IRs should use caution, as many procedures do not reimburse in the outpatient setting. Additionally, at first glance it may appear that Medicare and other payers reimburse OBLs at higher “nonfacility” or “global” rates compared to hospital-performed procedures, but Dr. Costantino said this is oversimplified.
The technical expense to the patient and insurance companies is much higher in the hospital setting. The hospital charges “piecemeal” for the technical and professional services, medical devices, sedation, etc., she explained. The fee that the OBL receives covers the technical and professional fees and all expenses related to the procedure. However, physician fees have faced several cuts in recent years, while costs for equipment and staff continue to rise. Patients and payers will hopefully start to recognize the enormous cost savings of OBL care, she said.
Opening an OBL
Opening an OBL is a hefty financial investment, much like launching a start-up company, Dr. Costantino continued. It can take a couple of years before the owner breaks even or begins to receive a salary. That makes it even more critical to have a solid business plan, select an ideal location and seek advice from other OBL owners. Interested IRs can find resources through SIR and the Outpatient Endovascular and Interventional Society. In addition, the SIR Business Institute is a 1-day entrepreneurial symposium offered each year that focuses on the business side of IR.
Despite the challenges, OBLs continue to hold appeal for many IRs and can offer a more efficient, less expensive healthcare model to patients. “This isn’t for everybody, and there’s no right or wrong way to practice interventional radiology,” Dr. Costantino said. “It’s about being happy in your job and practicing great medicine, because we’ve all earned that right.”
