“Collaboration” vs Collaboration: Multidisciplinary Care in the OBL

Big congratulations to all the recently matched MS4s who are diagnostic and interventional radiology bound. I’m particularly proud of the several students I have worked with. I remember opening my match envelope 10 years ago. It truly is a life changing moment and I’m excited to welcome a new batch of highly motivated, intelligent and diverse voices to our growing community in interventional radiology. 

While I do believe the interventional radiologist of the future is better educated about the realities of a career in interventional radiology than my contemporaries or I were a decade ago, make no doubt about it that there are significant barriers which make a satisfying career practicing independent of diagnostic radiology difficult to accomplish. I have highlighted many of these challenges on this blog. For those who may be reading this for the first time please check out some of my earlier blog posts including this one, this one, and more recently a look at the realty of the current market status quo of interventional radiology in the context of a diagnostic radiology practice. 

Some of these early blog posts were particularly dark. I have developed somewhat of a reputation for having a negative voice in our field, but I actually look at it through a different lens. My voice needs to exist so those who are coming up do so with clear eyes so they can avoid many of the hardships I and those before me have endured trying to function in a capacity where we seek to practice interventional radiology outside of a diagnostic radiology setting. Perhaps some of these blogs may encourage you to seek a different path. Honestly, as much as I want the best and brightest to join us, sometimes keeping it real can go wrong with respect to recruiting. And I’m ok with that. I don’t want to be reading poorly written blog posts by some disgruntled early career interventional radiologist 10 years from now.  We need all of our future colleagues to know what they’re getting into. While this is a great career, it’s not all roses. 

I strongly believe that as a field, we will be better off if interventional radiologists have the freedom to choose how they would like to practice. Some will want to seek an academic practice, others will be very happy utilizing their skills in a traditional IR/DR hospital group setting and a growing number of individuals may want to follow in my footsteps and seek to develop independent IR practices focused on alternative sites of services such as OBLs and ASCs where I personally believe our growth potential is the greatest. As interventional radiologists, we are humans first with very diverse backgrounds and beliefs, motivations, needs and interests. There will be no one size fits all strategy for one’s career in interventional radiology. 

The problem is currently interventional radiologists are structurally pushed into practicing in traditional private practice hospital based settings, generally within the context of a radiology infrastructure.  While not true of all settings, in the vast majority of settings there are both cultural and financial barriers which preclude a clinically focused practice. This entire blog and my whole shift towards speaking and educating was born as a result of being incredibly burned out trying to change a culture in a traditional private practice that I couldn’t. My efforts lead to me joining a cardiologist to create an OBL, subsequently leaving that partnership after learning more than I ever wanted to about the business of medicine, MSOs and partnerships ultimately leading to locums work with the goal of developing my own IR practice in the near future.

So like many of us who have felt total dissatisfaction with traditional IR/DR practice, we seek alternative practice models where we can accomplish our goals. Some of us are ok with the limitations of academic practices and go back to that model. Some of us will try to find “good groups” to work for. Then there are others like me who go deep into the world of practice development. 

Healthcare business development is no joke. It comes with significant challenges that go above and beyond being an excellent interventional radiologist. And particular to interventional radiology, it requires jumping through some seemingly impossible hoops that are unique to us as board certified radiologists. 

An exciting opportunity for interventional radiologists to practice outside of a traditional hospital setting is to join other specialties by forming multidisciplinary group practices. When it comes to optimal outcomes, patients are generally better served when care is coordinated with key specialists involved in their care. For example, women’s health is best when interventional radiologists are coordinating care with gynecologists. For mens health, outcomes are optimized when urologists collaborate with interventional radiologists. For vascular disease, several fields should work closely together, with the more obvious pairing being podiatry and vascular specialists.

There is a clear business argument to be made for multidisciplinary practices involving interventional radiologists and other specialists.  In the OBL world, the majority of outpatient practices are currently staffed by vascular surgeons, followed closely by interventional cardiologists with interventional radiologists lagging in third place (see this report). This likely has to do with both structural considerations like I’ve mentioned and the culture in our field where we are hospital focused. This data also clearly suggests that the greatest growth potential in the OBL space is with interventional radiologists. Furthermore, particularly in light of reimbursement cuts for lucrative peripheral arterial disease procedures, case diversification makes having an interventional radiologist on staff in an OBL a very attractive option. 

With respect to other fields such as wound care specialists/podiatrists, gynecologist and urologists, working with interventional radiologists in a group practice can significantly increase practice revenue due to the simple nature that our procedures are reimbursed favorably in the office based setting.

More than anything, collaboration has become somewhat of a buzz-word in the endovascular community, particularly with respect to critical limb ischemia. And in many ways it’s good that we are discussing collaboration because it is essential for many of our vascular patients. I learned quickly that I can’t do my job effectively without having dedicated colleagues in wound care, podiatric surgery, primary care, nephrology, endocrinology, cardiology and vascular surgery who are on the same team as me. Likewise, collaboration has also become an incredibly popular buzz-word with respect to the care of fibroid patients and BPH patients and their respective gynecologists and urologists. 

I used to think, like many naive physicians either in training or early in their careers, that collaboration meant working closely with other specialties focused on maximizing patient outcomes. I soon learned that there is collaboration, and then there is “collaboration.” “Collaboration,” is patient care where there are aligned financial incentives. Financial incentives can be good for business, but there are many legal and ethical questions that arise from these relationships. I’m not here to paint a black or white picture, but I do want to bring this issue to light because financial relationships are a common theme in American healthcare and interventional radiologists must be aware of the relevant relationships which can impact their practice. I will devote a separate post about some of the legal implications, particularly related to the Anti-Kickback Statute and relevant Safe Harbor provisions.

I want to take a minute to tell you about two stories in my own professional life where financial relationships came into play. Well first and foremost, I joined an interventional cardiologist as a minority partner as part of a group practice. His success was my success and vice versa, though at very different proportions which I have discussed previously. I’ll get into relationships with other vascular specialists in a second, but I want to start with a bit about my relationships with urologists. 

When I was a fresh graduate in the local IR/DR group, I was hellbent on starting a PAE practice. I didn’t come into fellowship training particularly interested in PAE, but I soon learned about the tremendous impact this procedure can have on men having been fortunate enough to train with an awesome IR who is a true expert in this procedure. I also became intrigued because the procedure is so damn difficult. I’ve been naturally drawn to difficult procedures. Up until this point in my fellowship program, no graduate has really gone on to practice PAE in a high volume practice. There was a negative connotation with this procedure among nurses and techs (argh Room 9 is going to be down for a good 3 hours!) as well as some trainees. Well, one of the reasons those procedures were long is because this was an academic environment where trainees like myself would get a legitimate crack at trying to get through one of these cases. I struggled so much trying to do PAE. While I got better towards the end of the year, these are tough and I can remember feeling so defeated not being able to catheterize type 1 origins. I would struggle mightily while my attending would whisper to me these are the skills that will pay the bills. He wasn’t joking. 

I worked very hard that year trying to get in on these cases. I’d try to go to the clinic when I could to get as much exposure to the non-procedural management of these patients. I struggled and kept struggling, but left fellowship having a decent base of experience. One of the reasons I was drawn to my initial private practice was the ability to grow this service line, particularly being within a healthcare system that didn’t do this procedure in high volume. When I got to my first job, I worked hard developing great relationships with the local urologists and got my chance to grow with them over two years. Those first 10 cases were adventures, but the majority turned out well and things grew from there. In due time I developed procedural efficiency and comfort with PAE. 

I was able to maintain those urology relationships when I left to start the OBL. I was actually able to leverage one of those relationships to develop a new relationship with a senior urologist in the local large urology group in the immediate geographic area of the OBL. This particular urologist ended up becoming one of my highest volume sources of referrals. In due time I generated referrals from primary care physicians, my cardiology partner and self-referrals as well. Many of these patients I ended up sending to this particular urologist for evaluation. Together, we had a very nice thing going on where we were taking good care of patients, chatting multiple times a week, providing a great service for our local community. It was incredibly satisfying.

For this urologist, it was so satisfying, that he told his partners about this independent IR who is doing some good stuff for his patients. On a random Saturday, I remember getting a call from one of his partners who was the president of the group at the time. He had never referred a patient to me before, and while I heard about him, I didn’t really know this particular urologist well at all. He wanted to meet with my cardiology partner and I to talk about a “partnership” between our practice to optimize care for their patients. 

So one evening, three senior urologists ended up coming to our OBL and met with my former cardiology partner and I to talk about a proposal to financially align our practices. The proposal was to have the urology practice block lease space from the OBL and to hire me as an independent contractor to perform PAE for their patients. The urology group would of course control the billing. The initial proposal was one day a week, but with plans to grow from there. 

The deal was a particularly bad one for my former partner as majority OBL owner, but was a tremendous financial opportunity for me. My former partner has a very high volume peripheral practice and could likely keep the lab busy every day of the week. To him, it didn’t make a lot of sense, financially speaking, to collect rent from a urology group which would be far less than what he alone could generate doing cases, or what he could generate from me doing a lower volume of those cases without such a financial arrangement. I after all still had a good volume of self-referrals, primary care referrals and referrals from the other urology group across town.

For me, I now had the opportunity to be incredibly busy doing an incredibly high volume of PAE. I was initially very excited about this opportunity. This would potentially position me as one of the highest volume operators in the Southeast and potentially launch me on a trajectory that could define my career. Despite this, something didn’t feel right in my gut about this relationship. All of a sudden, I’d be getting referrals from over 10 different urologists who never sent me patients to begin with. What has changed? The fact that they now would control the billing and basically make money from me doing PAE. 

The financial implications for me were staggering. I would derive significantly more income from professional fees doing a high volume of PAE cases where the urology group would control the billing, than I would as a minority OBL owner doing a lower volume of PAE cases without this arrangement but making more revenue the lab. With this arrangement I was looking at the prospect of easily making another 300-400k a year from PAE alone allowing me to approach a seven figure take home within a year or two at my current growth. That’s a crap ton of money.

Financial incentives also provide a certain level of security because as long as my outcomes aren’t terrible and the urology group is making money, I have a source of referrals. Furthermore, the urology group was in discussions pursuing financial arrangements with the local radiology group across the street and the group my PAE mentor from training ended up joining (touch awkward when your mentor is about to be your competition) as alternatives, but told me they were more interested in joining me. Not sure if that’s really true or if they were just gassing me up. While I do believe my skills are good, I think the urology group wanting to align with me had more to to do with the fact that there were fewer strings attached with me as an independent IR partner as opposed to a multi-state prostate practice or with a large radiology group that has close hospital ties. Maybe I was willing to work for less? Who really knows.

For what it’s worth, despite the fact that it wasn’t in his best interest, my former partner saw the importance of this potential partnership and was willing to make it work. I now had a decision to make. Do I solidify my immediate financial future and lock this deal down? And believe, me that financial pressure is real when you really think about what’s at stake. Or do I keep grinding without partaking in a “collaborative” endeavor?

Around this time, there were other issues regarding my OBL partnership, mostly pertaining to incredibly high employee turnover/low-morale, significant understaffing putting a strain on my remote clinics where I derive PAD referrals and particular business decisions made by my partner which really made me question my future working with him given our very misaligned financial incentives. When I raised my concerns, he made it very clear to me that he doesn’t care what I think and I should be grateful for the opportunity to exist in the OBL. My former partner truly believed that my ability to even develop a potential business relationship with urology group was because of him, an interventional cardiologist. Really? Enough was enough. Between the partnership with the cardiologist and this possible partnership with the urology group I just felt empty and legitimately questioned if it’s even worth practicing medicine anymore.

It was actually one of my self-referred PAE patients I got to know well who gave me the encouragement to double down on my skills and to find a way to create my future on my own terms. It was those meaningful relationships I developed with patients, free of all the financial garbage that pushed me to make a bold decision and forgo a lucrative, but troubling path. I needed to do things my way.

I left the OBL and kindly told the urology group that I won’t be able to work with them. I loved collaborating with my urology friends, but something didn’t feel right about “collaborating” and magically opening the floodgates for PAE referrals from urologists who never really believed in referring patients for PAE to begin with. Perhaps I’m really stupid, and/or really naive, but I believe that we can do the right things for our patients without being financially incentivized to do so. And I’m not here to say that those IRs who partake in legal financial arrangements that happen to promote revenue generation are morally bankrupt, but what I am saying is that I think it’s unfortunate that we need to even get to that point to do the right thing for our patients. 

With respect to my cardiology partner, the entire financial premise of our partnership was flawed from the beginning. While I was a partner, my minority stake was such that I derived a far greater proportion of my income from production as opposed to profit sharing which more or less rendered me as an employee generating significant profits for my partner. In fact, I originally agreed to join him coming in as a pure contractor with no equity stake, but I’m pretty confident the contracting MSO actually encouraged him to bring me in at a minority stake as a means to ensure I have some skin in the game and to promote a meaningful partnership.

They say that when it comes to partnerships the output should be far greater than the sum of the individual components. They also say that it is important to not just look at what you are giving up, but to focus on what you are gaining in any partnership arrangement. In my case, I came in knowing that I would be gaining critical limb ischemia experience and support from a truly excellent physician. I also came in knowing that this experience would teach me a tremendous amount about the OBL space in a short period of time. We were after all building a new OBL from ground-up. It would potentially open doors for new opportunities and career growth. For me in this market, my immediate alternative was working in an IR/DR group which I frankly viewed as a dead end job.

What I didn’t account for was the fact that my inherent value to this practice was not performing a procedure that my partner could already do very well in very high volume, but was diversifying our lab by performing procedures which he could not perform as a cardiologist. While this is fine, it’s unacceptable to me in the context of not being able to leverage my partner’s experience to do a high volume of PAD work which for me justified the partnership to begin with. This is what I worry about when I think about other interventional radiologists joining other vascular specialists in an outpatient setting. When our value is not in doing peripheral arterial or venous work, but embolizations, why would we even consider joining other vascular specialists?  It particularly bothers me that in many markets we tend to have very little leverage because pseudoexclusive contracts make the only reasonable alternative a hospital based existence. As such, we can envision arrangements where we are non-equity or nominal-equity partners building a practice generating significant profits for non-IR OBL owners from the work we do not just doing the case, but implementing systems and generating referrals that are unique to IR. The fact that we need to simply count our lucky stars that we can exist in the outpatient setting as justification for these types of arrangements just bothers me to no end. 

I’m not saying that partnerships with vascular surgeons or cardiologists can’t be meaningful. There are some good examples of interventional radiologists co-existing and thriving in these multidisciplinary practices, but it takes compromise on both sides such as embracing collaborative vascular care models and truly aligning financial incentives through appropriate equity splits or professional services agreements. Of course the whole issue of Stark Law comes into play which I’ve discussed before. 

At the end of the day, I want every interventional radiologist going down this path to carefully analyze any collaborative or “collaborative” opportunity. In many cases, you simply need to follow the money to get a better understanding of the truth. So will we be seeing more multidisciplinary practices in the future? I sure do, but I hope it’s for the sake of good patient care and not revenue generation though the financial nature of these relationships may suggest otherwise. I still think it’s imperative that we continue to advance pathways for IRs to be independent, so at the very least they are not put in weak positions where they feel the need to partake in unfavorable partnership arrangements to practice independent of diagnostic radiology. I truly believe that there can be collaboration without “collaboration.”