Background
In 1987, Barry T. Katzen, MD, FSIR, founded our practice as the Miami Vascular Institute, with physicians including Michael D. Dake, MD, FSIR; Gary J. Becker, MD, FSIR; Gerald Zemel, MD, FSIR, RPVI; and James F. Benenati, MD, FSIR. In 2003, the Institute merged with a vascular surgery practice, which strengthened our core and allowed us to practice high-quality vascular medicine in a collaborative environment.
Structure
Today, Miami Cardiac & Vascular Institute is a larger multispecialty practice (including IR, DR and vascular surgery), with over 85 members. The practice’s clinical division includes nine IRs, six vascular surgeons, two neurointerventionalists, five fellows (soon to be residents) and five advanced practice practitioners (ARNP and PAs). The IR group provides in-house service at three hospitals and provides IR services at two additional hospitals.
Our collaboration with vascular surgery has been intellectually stimulating and is great for the patient, the hospital and the community.
James F. Benenati, MD, FSIR
The group was a private practice until it was acquired by MEDNAX, Inc. (a national health solutions company based in Sunrise, Florida), in August 2017. However, our practice still functions independently, governing itself. To date our relationship with MEDNAX has been very positive for the IR group because we have received support for our office, marketing and growth needs. We are in a better position to focus on finding innovative ways to provide effective, high-quality, efficient care in a rapidly changing and challenging health care environment. We can better scale areas of strength in our practice such as cardiac imaging. Consolidation allows for improved ability to negotiate more favorable reimbursement rates from payers. Like other private groups, we value autonomy and feared losing control when joining MEDNAX. When the relationship is structured correctly, however, we’ve found that it is possible to join a larger group without losing independence.
Scope
Although we cover all aspects of IR, our IO program has exploded in the last few years—especially with the opening of the new Miami Cancer Institute. The institute is one of the four members of the Memorial Sloan Kettering Cancer Alliance, a unique partnership dedicated to providing the latest and most effective cancer treatment care with a focus on a collaborative approach, expansion of clinical trials and personalized cancer care.
In addition, our scope includes complex venous interventions, minimally invasive therapies for pulmonary embolism, and embolization procedures like the treatment of uterine fibroids, pelvic congestion, varicoceles, visceral aneurysms, endoleaks and benign prostatic hyperplasia. We perform MSK interventions and all biopsies and drainages for the health system, as well as biliary, GI and GU interventions. The vascular practice includes all aspects of PAD, including peripheral occlusive disease for patients with claudication or CLI, aneurysms and carotid interventions.
To ensure we have a voice and a leadership role in the Cancer Institute, we have to be at the table when important decisions are being made. To this end, we’ve actively participated in its establishment, clinical research, its tumor site committees and disease management teams, as well as development of service lines and cancer treatment pathways.
Ripal Gandhi, MD, FSIR
The IR division reads vascular imaging including (CTA and MRAs) as well as noninvasive vascular laboratory testing, with yearly volumes of close to 10,000 studies that include carotid duplex, venous duplex, mesenteric and renal duplex, and arterial physiologic testing pulse volume recordings, doppler and segmental pressures.
We are completely integrated with vascular surgery, sharing procedures, patients and consultations. The collaboration between IR and vascular surgery allows for management of very complex vascular diseases, often with the development of innovative treatment options. Many procedures are performed in conjunction with vascular surgery and cardiac surgery in a hybrid vascular lab.
Practice management
The E&M service produces, on average, 15 new consults for inpatients daily and a large volume of follow-up visits. No IR procedure can be “ordered” in our hospital system; a full consultation is performed on every patient with a dedicated history and physical and with an assessment and plan appropriate to the disease condition. Although we take pride in our technical expertise, many consultations result in plans that involve no procedures.
The office/clinic functions five days a week with each physician having dedicated IR time. We’ve hired scribes to help with documentation in the office/clinic, relieving us of the EMR burden and significantly increasing productivity and patient volumes.
In addition to the patient care aspects of our practice, we are highly involved in many committees and conferences, including a vascular conference, multidisciplinary tumor boards, quality assurance meetings, operations committees, M&M conferences and marketing initiative meetings.
Training
Though technically a private practice, we are also academic. Because educating the next generation of interventionalists is one of our biggest goals, we have a longstanding fellowship (soon to be residency) program with medical students on rotation at any given time. We also participate in multiple training courses at the institute including those for peripheral vascular disease, aortic aneurysm management, radial access and radioembolization. We will soon have a training program for irreversible electroporation (IRE) as well.
“Our fellows learn not just how to open an iliac vessel or an SFA but also how to work up the patient, assess the noninvasive testing, look at the imaging and noninvasive tests to synthesize a plan with the patient, and then ultimately go on to treat the patient. We train them to be excellent clinical physicians as well as very good interventionists.”—Dr. Benenati
Every week, practicing physicians call us looking for additional experience in areas we cover. This demand has led to a one-week visiting fellowship that exposes practicing IR physicians to direct case observation, supplemented by didactic clinical conference sessions and informal discussions.
Challenges
Current challenges facing the practice include pressure for RVU production and a widening gap of understanding between the RVU-driven diagnostic division and the clinical division. Our clinical division may be growing in volume but it also has patient responsibilities, teaching components and academic obligations that may not be completely appreciated by nonclinical partners. In addition, the physicians in the clinical division are not only active participants but also leaders of multiple hospital committees. Decreasing reimbursement for some minimally invasive procedures has had
an impact.
Like many other IR practices, we are not immune to competition and face constant turf issues with cardiology, neurosurgery, and surgeons and interventionalists outside of our group in the outpatient setting.
Marketing
We market our practice in many ways:
- Local public TV (PBS) appearances on topics including PAD, CLI, fibroids, varicoceles, IO and spine interventions
- Dinners with referring physicians and trips to physician offices
- A regularly updated website
- Participation in health system–related committees, such as credentialing, QA, risk management, CME, PERT, CLI, clinical research, aneurysm, and various cancer center committees
- Marketing to administrators is a key component, especially since most other specialties offering vascular and endovascular services (cardiology, cardiac surgery) are employed by the health system.
Growth and future directions
Miami Cardiac & Vascular Institute has recently undergone a 120-million-dollar expansion. Walking into our interventional suites, one sees that all of our labs have large glass windows that are open to all. According to Dr. Katzen, “It was built as an architectural expression of the philosophy of the institute: transparency. The benefits to patient care are that all physicians involved in invasive therapy are working side by side. Literally. We don’t have barriers. If there is a problem with a patient, we have incredible human professional resources here to help solve the problem.”
