Freestanding Vascular Centers
Vascular centers are here to stay.
One of the hottest trends in minimally invasive medicine is the development of freestanding outpatient centers. Interventionists (interventional radiologists, endovascular surgeons, interventional nephrologists, and/or interventional cardiologists) were traditionally restricted to hospital-based practices because of existing partnerships, hospital commitments or non-competes, or because of technology. While business solutions have trended toward resolution of hospital-related practice development issues, technological advancements have enabled quality outpatient care. During the dawn of endovascular abdominal aortic aneurysm repair, many physicians had their first exposure to the improved portable C-arms previously found only in the operating room. Fluoroscopic images and sophisticated vascular packages that provide high frame rate exposures, a large image intensifier surface area, digital subtraction imaging, and roadmapping or trace techniques are now available and have enabled physicians to perform more intricate therapeutic procedures. Several portable, high-tech C-arm systems are available, including the Philips Pulsera (Philips Medical Systems, Best, The Netherlands) and the GE OEC (GE Healthcare Technologies, Waukesha, WI). These cost-effective systems offer varying degrees of imaging platform rotation, filtration, and coning to ensure ease of use and minimal dosing to the users and patients.
With the new capabilities of the technology, physicians asked the next logical question: "Where else can we use the new C-arm?" Although the hospital was the traditional home for these machines and their floor- and/or ceiling-mounted counterparts, outpatient center development is driving this market. Interventionists including Perry Arnold, MD, Sandy Altman, MD, and others were among the first to break free of the hospital yoke and forge out on their own. Their initiative has led to a wave of outpatient center development across the country.
SETTING UP YOUR PRACTICE
Outpatient interventional centers have many advantages over a traditional hospital-based practice. The most important advantages are a warm and friendly staff in a relatively cozy but professional facility setting. The physician or physicians interested in staffing their own centers will gain a true private practice experience and its associated risks and benefits. Creating an outpatient center de novo is a challenge that requires several areas of expertise, including market analysis, site planning, space design and permitting, leasing/purchase, and construction and furnishings, staffing and center management, ordering equipment and supplies, thorough knowledge of the legal and accounting issues including federal and state statutes, information technology, and billing and collection for services performed.
The outpatient center practice provides physicians with the opportunity to develop their own practices tailored to their own skill sets. The array of procedures performed at the center will dictate its focus. Some centers, such as vein centers or dialysis access management centers, offer a more narrowed focus, whereas others offer the gamut of interventional procedures. Interventional centers with a more general procedural focus can also offer therapy for peripheral arterial disease, venous insufficiency, deep vein thrombosis, oncologic procedures, venous access, uterine fibroid embolization, pain management, and cosmetic therapies.
Patients entering a center should encounter a warm feel compared to their local hospital, as well as a friendly, helpful, and trained staff. Practice growth is enhanced through excellent care, a dedicated staff, focused marketing, appropriate follow-up, and good patient management regarding throughput and time to discharge from the facility. Conscious sedation is often used for minimally invasive procedures. and its judicious use is a critical factor in providing excellent patient care in conjunction with adherence to center policies and state guidelines. Achieving early ambulation after peripheral arterial interventions requires expertise in at least one arterial closure technique. Many types of arterial intervention procedures are being safely performed in outpatient laboratories, with the exception of endovascular abdominal aortic aneurysm repair, neurologic interventions, and carotid stenting.
Direct marketing and contact with referring physicians are also key ingredients to success. Although there are many hurdles to overcome before you treat your first patient, a mature practice can provide an added service to your patients and community, a sense of pride, and financial remuneration. The hours of operation, including evenings and weekends, will be dictated by your patients' needs and by the availability of the physicians and staff.
Although reimbursement protocol for outpatient procedures, accrediting standards, center certification, and state regulations are constantly shifting, minimally invasive outpatient interventional services are here to stay. The physician office extension center is a popular, dominant model today. The Health Care Financing Administration and Joint Commission on Accreditation of Health Organizations, however, may tether reimbursement to ambulatory surgical center standards. Partnering with a corporate entity may alleviate many of the risks and mistakes while helping to avoid delays when opening your center of excellence. Corporate partnering may also minimize at-risk personal capital, the need for personal guarantees for large-ticket leases and purchases, policy and procedure standards, and knowledge of federal and state statutes regarding physician ownership and referral.
Deciding to open a vascular center can be an arduous process for you and/or your partners. Once you have made the decision to open a center and you have the freedom to practice in an arena with minimal constraint and friendly surroundings, you will have little regret. You will wonder, "How would my practice have fared in a competitive environment if it were still hospital based?" In outpatient medicine, you should strive to be the best therapist in your field of interest and the first to market in a desired location, if possible. I recommend expediency through partnering to get your center open on time.
James F. McGuckin, MD, is Managing Partner and CEO of Vascular Access Centers, LP; Cofounder of Rex Medical in Conshohocken, Pennsylvania; and Medical Director of the Philadelphia Vascular Institute. He has disclosed that he receives money from Vascular Access Centers, Rex Medical, and Philadelphia Vascular Institute. Dr. McGuckin may be reached at (215) 382-3680; firstname.lastname@example.org.