Early Career OBL: Finding The Right Opportunity

I spend a fair amount of time each week talking with young interventional radiologists and trainees about the OBL world. There is a lot of talk in our field about the OBL space. Whether you see people like me on Twitter talking about it, or you see jobs posted on the job boards, or you’re hearing about it from various webinars on SIR, the whole OBL concept is very hot right now. 

The truth of the matter is the OBL space is not new, but it is becoming increasingly popular, particularly within interventional radiology. Much of this has to do with the fact that our training and focus is changing resulting in a very slow culture change towards the concept of independent radiology practices without the need for diagnostic radiology subsidization. Being the broken record that I’ve been for the last 3.5 years, the OBL provides a viable financial pathway for those of us interested in a 100% IR practice independent of the baggage that comes with hospitals and/or diagnostic radiology groups. 

From a business standpoint, the OBL is largely the wild west of medicine where the interventionalist now has the potential to become a practice owner. Of course, keeping with the general theme of medicine, these opportunities are becoming harder to come by given various factors, but mostly due to long standing trends of healthcare consolidation which have accelerated in the last 10 years. 

So, let’s say you’re a young interventional radiologist, or perhaps a very clinically aggressive and motivated trainee looking to enter this space. How do you go about finding your right opportunity? This path is very different for each interventionalist and likely requires some degree of coaching and introspection to make the right decision. The goal of this post is to give you a framework to make the right decision for you.  Then in typical Line Monkey MD fashion, I’m going to give you very unsolicited advice based on my own biases and experiences.

First, here are some two myths that I’d like to debunk:

1. Outpatient jobs are easier than inpatient jobs. 

In general, when you need to do high-end interventions quickly and efficiently to keep the OBL engine running, the demands placed on the interventionalist in my mind are actually greater in the OBL than in the hospital. In particular, your patients in the OBL are outpatients presenting with elective or in the worst case, urgent clinical scenarios where clinical failure or complications are generally less accepted than they are in the hospital where patients are sicker, there is more clinical support and efficiency is not necessarily as important.  In the OBL you are clearly the patient’s doctor. The buck stops with you.

2. Outpatient jobs pay more than inpatient jobs.

An OBL job has the potential to make more than a typical hospital-based IR job, but only if you have significant equity ownership opportunity. Otherwise, salaries will be similar, or in many cases, less than what you could make being either directly employed by a healthcare system or by an IR/DR group.

With that out of the way, here are some valid reasons for entering the outpatient world:

1. You want to focus on treating mostly elective outpatient conditions. 
2. You don’t want to be dependent on diagnostic radiology to make a living. 
3. You don’t enjoy hospital-based interventional radiology.
4. You want to be a business owner and have direct control over your economic destiny.

So how do you go about finding the right opportunity for you? Take some time to reflect on these questions:

1. Are you looking for a job, or are you trying to create your own opportunity?

This first question is by far the most important question you need to answer for yourself. Simply put, are you looking to be an employee, or are you looking to build a business? There are pros and cons to each pathway, but even though I’m posing this is an either/or type of question, the truth of the matter is the distinction between employee and entrepreneur is more opaque than it may seem. 

In order to add value to any given outpatient organization, you need to find a way to meet an unmet need. Here are some of those potential unmet needs:

1. Ability to take care of patients referred to the practice who cannot be treated by existing physicians in a time-efficient manner. 
2. Ability to bring new patients to a practice.
3. Ability to offer new service lines not currently offered by a given practice. 

The first point is pretty straightforward. The practice simply has more referrals than it can currently handle, so it is naturally looking to hire an interventionalist to meet the unmet demand.   

Two is an interesting unmet need. By bringing in new patients to the practice, in some sense the IR joining the practice is already somewhat entrepreneurial by finding their own source of patients. This certainly requires a lot more work than just showing up and taking care of existing referrals in point 1. 

Three is also an interesting unmet need. In this scenario you are helping a practice diversify its existing service line offering. Depending on the organization, this potential role would also likely involve significant more work than work than option 1 and 2. You need to either bring in your own patients, or help the practice generate referrals for this new service line offering in addition to working with the lab to develop protocols for taking care of these patients. This also requires some degree of entrepreneurial vision.

You can see, the idea of an “OBL job” will vary considerably depending on the role. As you could imagine, your pay structure and economic incentives should theoretically vary as well depending on the role, but as you’ll soon find out, that can also vary considerably depending on who you are dealing with.

2. Are you looking for professional support or training?

This is particularly important if you’re early career or fresh out of training. Ideally, you’d want a situation where there is a senior physician who can mentor you and provide you with some degree of training/back-up. Do understand, that this will likely come at a financial cost. Expect to be paid less in general. 

3. What kind of cases are you interested in performing?

This one is pretty straightforward. If you hate dialysis work, you probably shouldn’t join a dialysis access clinic. If you don’t like PAD, you should probably avoid a vascular clinic. If you don’t want to treat fibroid patients, don’t join a practice focused on women’s health.

3. What is your growth potential and what will you require to remain professionally fulfilled in the long-run?

I think this is an important one that many young physicians don’t think about, including myself when I first got out of training. It’s hard to have a vision for your career when you don’t know what you don’t know. The issue is further complicated by the fact that our needs and wants change as we age and transition to different stages of life.  

4. How does the practice generate referrals?

This is one of the most important questions you will need to ask of any given practice who is looking to hire you. For many OBL employment opportunities, there is a high likelihood that you will be joining a practice that is already generating referrals. You should know where they are coming from and if there is some financial link between the practice and the referring offices that may be fueling the OBL engine.

Why should financial considerations pertaining to referrals matter? Please see my previous post titled “Competition and Collaboration.” You want to make sure that the practice you are joining has a solid business plan and is operating in an ethical and legal fashion. If you’re promised a high six-figure pay day performing a high volume of PAD cases, it is imperative that you figure out if there are some laws being broken to generate those referrals. The most important consideration is the Stark and Anti-Kickback laws. Just know that any given practice cannot derive more than 40% of their revenue from investor partners. 

Types of OBL Jobs

Forget about doing this on your own or with others establishing a new lab from scratch for a second. This is the part where I’m going to break down employment opportunities and tell you what’s what. Here are the most common existing opportunities:

• Dialysis Shop

• PAD Shop

• Vein Shop

• “Multidisciplinary” Subspecialty Practice

• Imaging Center/Radiology Group Collaboration

• Swimming With a Shark

Dialysis Shop

These focus primarily on the creation, maintenance and salvage of dialysis access. Think fistulograms, declots, declots, more declots and perhaps some endovascular AVF creation.  Look, dialysis access is important work, and not everyone does this well. These procedures are largely uncomplicated, though not always. They generally are fast, lower reimbursing procedures therefore high volume is what generates meaningful revenue. Creating a viable business involves having close alliances with dialysis centers and providing very timely service. These positions often are salary based with a production bonus and may involve the potential for a very nominal equity stake after a provisional period (generally 1-2 years and no more than 10% equity generally). If you find satisfaction in taking care of these patients, and really only these types of patients and prefer a generally fast-paced environment, these types of jobs aren’t necessarily bad. 

Here are the challenges. First, you have to understand that the market for dialysis access has undergone a significant change in the last 5 years due to two large factors:

1. Significant OBL reimbursement decrease in 2017
2. Proliferation of interventional nephrologists

In 2017, dialysis access codes were slashed in the office setting which has resulted in many offices closing and the movement of these types of procedures to the ambulatory surgical center where reimbursement for these procedures is still relatively favorable. If you are entertaining a job in an ASC doing dialysis cases, that’s all fine, but you need to think about how you’re going to justify your salary. These corporate owners aren’t idiots. They know that interventional nephrologists can do these procedures well and in general they command less salary than an IR with a broader endovascular skillset. As such, they’re going to want their IRs to either produce more than an interventional nephrologist or diversify their case mix by establishing high reimbursing service lines like PAD or embolizations. In order to maximize their revenue potential, many will have a mechanism for switching between an ASC and OBL location so they can bill accordingly. 

The problem with this strategy? You may be tasked with building a service line with limited equity upside and within an organization that really has no existing clinical infrastructure to establish these service lines. These are organizations which are not used to having robust clinics. Furthermore, they are going to want you mostly in cases creating revenue and not taking time to evaluate patients in clinic. In typical Line Monkey MD #clinicalIR #consultnotorder fashion, you know that you can’t generate meaningful procedural revenue unless you take the time to actually take care of patients!

I’m not saying that all dialysis clinics are like this, but many are. Just do your due diligence and reach out to me or others to get an honest assessment. 

PAD Shop

Come join our amazing practice with a starting salary of $600,000 and the potential to make 7 figures doing nothing but high-end PAD cases. Pedal loops for DAYS.

I’m sure you may have seen some of these advertisements on the SIR or ACR job boards. Just so this monkey doesn’t get sued, I won’t name names, but there are two very infamous organizations which also have a reputation for frank violation of Stark laws that you should probably know about. And that’s the inherent issue with PAD shops. 

These organizations generate massive revenue doing lots of atherectomy cases. And look, those of us serious about limb salvage know that atherectomy is very important for appropriate vessel prep in patients with chronic total occlusions of the infra-inguinal arteries. The problem is many of these organizations may pressure their IRs (largely financially) to do unnecessary atherectomies to generate revenue. Furthermore, in typical corporate OBL fashion, they don’t want you in clinic seeing patients. They want you doing as many PAD cases as possible. How do they get these cases? Largely by giving podiatry and wound care groups equity ownership and more or less paying them for referrals. Ultimately these PAD practices can be problematic on multiple levels. There are some really talented and well-intentioned IRs working for these types of practices. A lot of them do perform legitimate limb salvage work, but I fear that they are just cogs in a rather unethical and frankly illegal machine. 

Vein Shop

These practices are focused on the treatment of patients with chronic venous insufficiency and cosmetic vein concerns. Vein disease is largely misunderstood, poorly treated and there are tremendous opportunities in any market, no matter how saturated, to make a making a meaningful difference in the lives of patients with chronic venous insufficiency. These procedures pay well per unit time. Similar to dialysis work, they tend to be relatively less technically involved procedures so meaningful revenue is generated through a high volume. 

Challenges? Well, if you need to do X number of catheter ablations to justify your salary, you are more or less financially incentivized to NOT take care of the patients who need you the most (CEAP 4, 5 and 6 patients). Fun fact, I generated over $400,000 of annual revenue for my last OBL taking care of exclusively severe chronic venous insufficiency patients who have undergone prior ablations and were more or less abandoned by prior physicians because they no longer had “veins to ablate.” In fact, one of the most meaningful treatment options for patients with venous insufficiency who are no longer eligible for truncal ablation is ultrasound-guided foam sclerotherapy. I did a lot of that. The problem? These procedures can take longer than catheter ablation and the reimbursement is relatively terrible. The personal satisfaction achieved restoring quality of life and healing wounds? Huge. You’ll always have easier veins to ablate, but I tell you this story because you want to be in a situation where you can do the right thing for the patient regardless of the financial aspects. I do think there are some vein practices out there that hire IRs who are understanding of this concern, but I know that there are many who don’t care and would rather you keep crushing housewife veins. 

Multidisciplinary Subspecialty OBLs

This is a relatively new concept in the OBL world, but the premise is having an IR partner with a subspecialist physician to provide a single service line. Again, I’m not going to name names, but the most notable example right now is a practice focused on prostate artery embolization. 

The premise behind multidisciplinary OBLs is that care is enhanced when patients are treated in a multidisciplinary fashion. No one will argue with that because it’s the truth. So how do you get along with other physicians? Well there’s two ways. You either put aside your egos and do the right thing (which is what we all should be doing), or you make it such that financial incentives are completely aligned. Again, see my article titled “Competition and Collaboration” for more details.

These financial alignments need to be carefully examined to make sure they pass legal muster. The way you get around the Stark law, is to not have the collaborating subspecialist be an “investing” physician, but to rather create a single tax ID and call it a group practice. The group practice may or may not include equity ownership by the IR who is on the ground actually taking care of patients. And as you can imagine you can envision a situation in which the IR is an employee of the actual practice which is co-owned by a founding subspecialist physician and IR who create a managerial services organization and a local sub-specialist practice who will “send patients” to the IR on the ground. So, what you’ve essentially created is a model where the IR is an employee crushing a potentially endless stream of cases generated by the subspecialist physician owner which in theory can be a large group of subspecialized physicians who would otherwise be competing with IR for these procedures. It’s amazing how people want to play nice when they are being paid to do so.

So, the challenges? First, you have to be ok with being a strict employee with maybe a nominal equity ownership stake which is par for the course for any of these models I’m describing. Other challenge-well you have to be ok with basically offering a single service line. You’ll likely receive significant training and support from whoever the founding IR is.  From a business standpoint, the group will somewhat limit themselves to referrals from the financially affiliated subspecialist physicians as competing subspecialists in a given market will not want to send patients to you. It’s an interesting concept for sure. I get the feeling this type of model will become more popular in due time, but make no mistake about it: the fundamental premise is a legal mechanism to pay your referral source.

Imaging Center/Radiology Group Collaboration

There are some radiology groups out there who actually have their own outpatient IR practices. These practices may be part of existing outpatient imaging centers, or could in theory be free-standing. These types of set-ups are relatively rare for radiology groups since the presence of a free-standing interventional facility can pose as a financial threat/concern to the hospital system the group contracts with. Nevertheless, these set-ups do exist in certain markets and they usually relate to either lack of hospital system leverage at the time of office creation and/or just a savvy group of radiologists ahead of their time. 

The issues with these kinds of set-ups is you still have to deal with radiologists. The same physicians who may not necessarily understand your economic potential, or if they do, tend to not understand the fact that you do don’t go from 0 to 100 RVU overnight. The whole patient care thing can be hard to explain and reconcile since an interventional procedure should not be treated like a commodity such as a non-contrast head CT. These centers have a pure profit/high-volume mentality. Even if the radiology group knows in theory what they’re doing, they may not understand that the IR’s time is best spent seeing patients in clinic to generate high revenue procedures and not simple bread and butter garbage which barely generates any revenue like biopsies and drains. This group will require a visionary IR who will spend significant time creating systems to help craft the OBL. Yet this same IR will have no financial incentive for doing so, other than just being a valued member of a typical group which splits profits equally. 

Despite my skepticism and critiques of this set-up, there are some groups out there that do it well. Unfortunately, I think I can count the number of these groups on one hand. 

Swimming With A Shark

The final job opportunity you may see presented, most likely via word-of-mouth, will be a senior established IR in an OBL who is looking to bring on a junior partner. There can be some significant positives and some very real negatives when it comes to this type of arrangement.

Positives include teaming up with a winner. You will have someone who can support your development, teach you new skills and really show you the ropes. It can really be a true apprenticeship in many ways. Another plus is joining an existing infrastructure which is physician owned and directed so the experience in theory for patients should be superior to corporate models. You’ll have valuable connections into the local community and can really get a huge leg up on establishing your presence. Finally, it’s nice having a partner and not being on an island by yourself. 

So what are the negatives? Well, money mostly. Money though is really a reflection of mentality and the key that any young IR needs to know is when you join an experienced IR who has done it on their own, you are joining somebody who really doesn’t need you. Or if they think they need you, the chances are your financial incentives won’t be clearly aligned and it may be very difficult to reconcile them. 

Senior partners are sharks. And this is not a negative statement. In today’s cutthroat world of healthcare you have to be a shark, or at least have some critical shark like tendencies in order to survive. Put yourselves in this IR’s shoes. They have established their own presence in a market and have built a profitable business. This has likely taken them many years, potentially decades and they likely had a significant opportunity cost in the nearly guaranteed generous salaries they could have made being in the local IR/DR group. They will undoubtedly have the mentality that a junior person’s existence in the market will be very difficult without their support and infrastructure. As such, they may value your presence very differently than you value your own. They may expect you to bring in your own patients and prove your value to their organization. This is all fine, because that’s what you were going to have to do if you wanted to do this on your own. The real issue is, after you do that and increase the value of this business, what’s in it for you as the junior IR? Well, in theory your benefit should be some meaningful equity stake. 

And therein lies the critical problem. By now, this OBL should be worth millions if not tens of millions of dollars. How are you supposed to buy into this practice without either significant sweat equity or serious upfront capital? You may be so soured by the potential of doing so. Chances are if you get the kind of capital it takes to have meaningful equity stake and if you’re successful as to even be offered the potential, you’ll go do it on your own.

And this is what happens all the time. No one really talks about it, but if you talk with other IRs on the low, this is what they’ll tell you. Most successful IRs who have founded OBLs have had junior partners, and it has not worked out. Usually it is because “they were a bad fit” or they “were not interested in bringing in new business.” And there’s probably some element of truth to that. But part of me wonders if the arrangements were just flawed from the get-go because there was no real growth potential for those IRs. They’re taking a lot of risk themselves going renegade and joining an independent practice, signing a non-compete, then realizing they probably did poor due diligence then move on into oblivion. I know how this feels, because I’ve been there, though with some key differences which I have talked about before.

Conclusion

So if you’re trying to get into the OBL game, what should you do?

Number one, get experience in your current practice if you’re out of training. Build a practice, even if you cannot scale. You need experience and you need a reputation. Don’t even think about getting into the OBL game without maximizing your current situation first. The experience will pay dividends later. 

Second, decide if you’re going to do this on your own, or if you don’t, then accept the limitations I’ve discussed with respect to joining an existing practice and find the best setting for you. I think the most ideal situation, short of doing it yourself, is the last one where you swim with a shark. Just know what you are getting into and talk to people like me before taking the plunge.

If you are fresh out of training, find a place where you and your family would like to set roots and go there. Take a job with a traditional IR/DR group if you can. Aggressively work on negotiating your non-compete. Build a reputation for a few years then make the leap, either on your own or with an existing practice. 

Personally, I feel the benefits of direct practice ownership in a meaningful fashion is worth it. I think more of us IRs should take that road.  I think more of us should work together doing so. We have so much potential in the OBL space and I sincerely believe the future of IR will be the migration of most practices to an outpatient setting. Hospitals won’t go anywhere and we still will need awesome IRs working in those settings, but I think in due time there will be a greater distribution of IRs across practice settings instead of significant hospital concentration like there currently is. 

As always, reach out with comments/questions/concerns. My goal here is education and to build a community where we can help each other out. If you’re a shark or an MSO founder reading this, sorry if you’re bothered by my viewpoint. Just have to tell it like it is. You know you’d want to hear the same when you were younger.