Ask the Experts

Arthur Lee, MD

North Florida Regional Medical Center
Gainesville, Florida
He has disclosed that he is a consultant to CSI and Covidien, and an investor in Sapheon.

The evolution of endovascular diagnostic and interventional technologies over the past decade has been remarkable. These technologies have introduced greater flexibility into our diagnostic and interventional work with significantly reduced complication rates. These innovations, coupled with the reimbursement silos created by governmental and private sector payers, have stimulated a significant proliferation of outpatient angiographic suites offering our patients the advantages of these improved efficiencies, resulting in unprecedented access and higher levels of patient satisfaction.

We have operated a physician-directed laboratory for more than a decade that provides diagnostic cardiology and vascular procedures. We made the decision to dramatically expand the scope of our services through the addition of peripheral vascular interventions in 2011. This has been a rewarding and challenging experience. We have learned through this process and have greatly grown in our respect for the accreditation processes of the joint commission as a method to enforce operational uniformity. In addition, we expanded our services at a time when health care reform was a concept without form and with little expectation of universal implementation. Obviously, a lot has changed between then and now.

From our experience, I would recommend any new venture to start by assessing the government's intention to migrate the reimbursement system from fee-for-service to some form of pay-for-performance. This evolution and the envisioned clinical integration it will engender will require us to look at our outpatient laboratories as separate clinical and business entities with dedicated clinical and business leadership. This is extremely important to ensure the development of the necessary clinical documentation and business infrastructure to adapt to the ever-changing reimbursement landscape.

I would also recommend a commitment to investing in infrastructure, specifically the development of the laboratory in a way to easily transform its operations into an ambulatory surgical center. Structuring laboratories in such a manner should include the acquisition of quality imaging equipment and highly qualified personnel. In addition, there is strong evidence that the evolution of outpatient, physician-directed laboratories into this structure is also one of the goals of governmental reform. The establishment of our laboratories as ambulatory surgical centers will ensure the maintenance of accreditation that is on par with hospital systems and will place our practices in a position to compete in the marketplace based on quality and price.

I am convinced that the utility of outpatient laboratories will remain a key component to physician practices in the future. However, it is essential that we adapt our clinical practice to be responsive to the documentation, quality, and outcome reporting systems that will drive the system in the foreseeable future. The creation of effective and efficient business systems will optimize outcomes of the clinical and business data necessary to ensure continued success.

Carlo A. Dall'Olmo, MD

Michigan Vascular Center
Flint, Michigan
He has disclosed that he has no related financial interests.

With Michigan Vascular Center's organizational culture of innovation, cost-effective resource utilization, and outstanding patient service, the advent of our office-based vascular procedural center was but another important step in the evolution of the care for the vascular patient. As our practice grew, we recognized that our approach to meeting the needs of three diverse patient groups (ie, the venous patient, the angiographic access patient, and the patient with chronic vascular issues) was antiquated and inefficient. Each group had its own special needs and time lines for treatment—some immediate, some urgent, and some elective—but our treatment response and timeliness was stifled because we lacked control over the scheduling process and immediate access to treatment facilities at outside institutions. Furthermore, we did not see these problems being resolved by others in the future.

Creating the full-service office-based vascular procedural center with its own staff and inventory of material was a logical solution to these problems. It was in keeping with the recognition that technological advances were leading to less-invasive methods of caring for the vascular patient. We recognized that this also represented a significant financial risk because we did not control the referral patterns. We believed that the quality and timeliness of the service would attract referrals and lead to success.

In assessing the risks and benefits, we concluded that such a center, a “one-stop shop,” would provide us numerous benefits in terms of control of our schedule, instant access to treatment rooms, efficient manpower deployment, and control of the entire patient experience from entrance to exit. It would also allow us to separate the patients into true service lines (venous, dialysis/angiographic access, and vascular) and result in better patient awareness and service line identity. All this has come to pass, and we have become more productive and cost effective while providing service in a more timely and personalized manner. The fact that patients overwhelming select our office-based vascular centers over any other facility speaks positively about their experience. In a cost-conscious environment, these centers are models of efficiency and need to be acknowledged as such with a premium reimbursement reward by the insurance companies for their timeliness of service and documented cost-effective care.

We were also acutely aware of the need to establish the safest and highest standards of quality. To that end, we decided to have our centers subjected to the rigorous certifying process of the Accreditation Association for Ambulatory Health Care. The accreditation process is an arduous 2-day affair in which every aspect of the center is scrutinized and standards must be met. The result is an ongoing 360-day safety and awareness process in which every effort is made to ensure patient safety. We are proud to announce that all of our centers have been certified. This is an important step because it assures the patient and community that every effort is made to comply with all safety standards for the benefit of the patient.

We now have four free-standing office-based vascular procedural centers—two in our community and two in adjoining communities. Had we the space, we would have located the two centers in our community on our main campus, but that was not possible. Of these two centers, one treats only venous problems (Vein Solutions), whereas the other (Michigan Vascular Access Center) treats dialysis/angiographic access issues and is also utilized for diagnostic and endovascular procedures. A third center (Michigan Vascular Center Clarkston Campus) is in an adjoining community where a local hospital plans to erect a new hospital. It is divided into a venous section and an angiographic access/vascular diagnostic center. Our fourth Center (Michigan Vascular Access Center Sagninaw Campus) treats dialysis/angiographic access issues and is in yet another community in which nephrologists extended an invitation because of the service we provided. All centers have an Intersocietal Accreditation Commission–approved vascular lab.

A group's first office-based vascular procedural center always involves several critical issues in determining the level of financial risk and the services to be offered. A careful analysis of projected costs and income must be made, along with a thorough survey of referral patterns. Expect to have financial resources negatively impacted for the first 6 to 18 months. Such a project requires a physician champion/communicator, and commitment from all group members is mandatory because all will share in the positive or negative outcome. Members must be involved in the process or willingly delegate responsibility to another member. The process is time consuming, involving drawing up plans, room arrangements, inventory selection, and selecting management with a caring staff. With regard to establishing a dialysis/angiographic access center, one must be aware of existing, competing nephrology-run access centers. There is no substitute for building relationships with all dialysis personnel. Meeting with nephrologists to explain the benefits of such a center for their patients and gaining their support is invaluable. It is also helpful to meet with the nurses in dialysis centers to inform them of the services and the benefits of an angiographic access–related center, a process no different from building a practice.

Providing great service is not enough in today's world in which a patient's choice of treatment facilities is limited and often determined by prearranged, managed referral patterns. One lesson we learned vindicates an old saying of Tip O'Neil, former Speaker of the House of Representatives, “All politics is local.” Take that to heart when considering whether to proceed with an office-based vascular procedural center.