From left, Marcia Flaherty, CEO, Mark Alfonso, MD, group president, and J. Kevin McGraw, MD, partner, Riverside Radiology Associates, Columbus, Ohio.

A betting man might have wagered that Riverside Radiology Associates in Columbus, Ohio, was making a fatal mistake back in 1998 by setting up a hospital-based interventional radiology clinic with admitting privileges. After all, the launch of such a facility surely would be seen by cardiologists, vascular surgeons, gynecologists, and other nonradiology specialists as an attempt to purloin their patients. In no time at all, the interventional clinicwith its noninvasive inpatient treatments and follow-ups for conditions ranging from aneurysm and stroke to vertebral body compression fractures and varicose veinswould be the subject of a devastating embargo on referrals by the medical community.

Of course, had this hypothetical gambler laid down money on that basis, he would have lost his shirt. Nothing even remotely resembling such a scenario has been directed at Riverside Radiology since the clinic opened. Quite the opposite. The 40-member subspecialized group has, by and large, received only praise for the facility, much of it emanating from the very physicians most likely to view the clinic as a competitive threat.

"We've not encountered much in the way of animosity because we've mainly been providing procedures that haven't been offered by anybody else in this market," says Mark Alfonso, MD, group president of Riverside Radiology.

"These other physicians refer to us routinely and without hesitation because they see us merely as providing more options for their patients. They welcome that," insists Marcia Flaherty, the group's chief executive officer.

"The referring physicians appreciate being able to send a patient to us, knowing that we're going to provide full, comprehensive care of that patient and do all the pre-, inter- and post-procedure work," adds J. Kevin McGraw, MD, a Riverside Radiology Associates partner and the codirector of interventional radiology at Columbus' Riverside Methodist Hospital, where the interventional clinic is located. "We're relieving those physicians of some of their burden."

ECONOMIC WINNER

Those cardiologists and other potential competitors might have felt somewhat differently toward Riverside Radiology were it not for the pains taken right from the beginning to reassure them that the clinic was not a ploy to spirit away their patients.

"Our interventionalists have been extremely cognizant of and sensitive to the physician-patient relationships of the referral physicians," says Alfonso. "In all their interactions with the other physicians, our team emphasized that we're here to assist them in the care of their patients."

It also has helped that the medical staff at Riverside Methodist Hospital is exceptionally collegial, Flaherty says.

(Riverside Methodist Hospital is the flagship facility in the OhioHealth system, a not-for-profit consortium of eight acute care and four community hospitals plus numerous outpatient health care and surgery centers, rehabilitation and long-term skilled-nursing operations, and home-health services providing coverage to 46 Ohio counties. With a medical staff of more than 1,200 physicians, Riverside Methodist is especially noted for its heart, orthopedic, and maternity services.)

"Our interventionalists are very visible in the hospital," says Flaherty. "They round on the floors, they visit the patients. The medical staff has welcomed our presence."

So has the hospital itself. According to Alfonso, inpatient admissions are up at Riverside Methodist, partially attributable to the interventionalists.

"The ability to admit patients has made our group a far more valuable player to the hospital," he says. "And to the community as wellwe're the only radiology group in town performing this type of service. As a result, there's a perception out there that we're on the cutting edge."

Financially, the interventional clinic and admitting privileges represent a winning combination for Riverside Radiology Associates.

"Actually, the clinic breaks even from the revenues generated by evaluation and management charges," says McGraw. "But what represents tremendous growth for our group is the additional procedures we perform and all the ancillary imaging we order."

Over one recent 4-week period, for example, the interventionalists saw 138 patients, 81 of whom were new (the remainder were follow-ups). Reports McGraw, the 138 encounters led to orders for 42 MRI studies, 11 CT scans, 7 bone scans, and 58 ultrasound examinations (or a total of 118 ancillary imaging studies). In turn, these resulted in 31 angiograms, 9 angioplasty/stent procedures, 25 venograms, 31 spine intervention procedures (which included vertebroplasty, epidural steroid injections, and discography), 41 embolization procedures (which included fibroid embolization and treatment of varicose veins), 3 transjugular intrahepatic portosystemic shunt (TIPS) procedures, and 8 venous sclerotherapies.

ON TO THE NEXT LEVEL

The realization that waves of competition from other radiology providers were threatening to swamp Riverside Radiology prompted the group in 1996 to contemplate setting up a clinic to take its existing but limited interventional program to the next level.

"The major limitation in our interventional service at that time was a follow-up role," Alfonso recalls. "We'd do the procedures but then tended to lose track of the patients. Our interventionalists felt it was imperative that we be involved in the pre- and post-procedural management of the patients, particularly with the follow-ups to make sure they were doing well. Our motivation was to provide a coordinated clinical setting for the evaluation and management of the patients. Ultimately, we were looking to provide excellent quality of care and convenience for patients who were presenting to the radiology department for interventional services."

The idea to undertake an interventional clinic with admitting privileges was sparked by the group's observation of national trends in interventional services. Alfonso says it was evident the future of interventional radiology lay in that direction.

"Ours has always been a very progressive group," he tells. "We're continually looking at new technologies and forms of practicestarting an interventional clinic with admitting privileges fell right in line with that."

Initially, some of the radiologists on the diagnostic side of the practice were not in favor of the idea. One of their objections centered around the question of whether the interventionalists were really up to the task of managing patients and providing 24/7 on-call care. The concerned diagnosticians worried that the entire group's reputation would suffer if this endeavor faltered due to an inability to deliver an appropriate level of patient management and care.

"Most of us who do interventional radiology have a strong clinical background to begin with, so we felt confident that a clinic with admitting privileges was something we could do well," says McGraw. "Our confidence helped convince the doubters to give their assent. We also were able to reassure them that, in the event we ran into a medical situation about which we weren't sure, we could always obtain a consult with the appropriate physicians right there in the hospital, and since we were based in the hospital, we knew we could obtain those needed consults very quickly."

In answer to the concern about being on call, the interventionalists pledged to do whatever was necessary to make it work.

"They really stepped up to the plate on this," says Alfonso. "Providing the service initially took an exceptional amount of on-call duty until we were able to hire additional interventionalists and a nurse-practitioner to spread around the load. After that, the call situation became very tolerable."

SETUP COSTS

Over the course of the 5 years since the clinic debuted, Riverside Radiology has spent roughly $1 million to support the interventional practice, or about 10% of the revenues generated by it to date. That sum includes the costs of office space, clerical staff, nursing staff, and equipment. It does not include physician salaries.

In getting that enterprise up and running, the first thing Riverside Radiology did was hire a business manager. Filling that role was a cardiac research nurse who helped with the coordination of patients and the development of an operations plan for the interventional office.

"She put in place policies and procedures for how the office would be runeverything right down to the protocols we would later use for clinical trials," says Flaherty.

A short time afterward, the group hired an additional nurse (who happened to also be a registered radiology technologist) to serve as office manager. Flaherty was brought aboard to assume the post of practice CEO.

"Along with Marcia, we hired a clinical nurse practitioner, followed by a scheduler, receptionist, precertification

specialist, and marketing representative," says Alfonso. "This is the complement of staff we currently have. We also brought aboard additional interventional radiologists, bringing the total today to seven physicians, two of whom are neurointerventionalists."

Soon after nailing down the organizational particulars, the group went shopping for a place to house the clinic.

"We at first sublet about 750 square feet of a primary care physician's office here in the hospital," says Flaherty. "We did this because we wanted to increase our level of comfort with the clinic before signing a long-term lease. We realized that there would be a risk in starting this venture and we didn't want to be stuck with the cost of an office lease in the event the interventional service didn't work according to our plans and had to be shut down. We felt that with a sublease we could get in and out of the deal quickly and with the least financial pain should that route become necessary."

Another factor leading to the decision to sublet: there was a waiting list for office space on the hospital campus.

"At the time, there wasn't anything immediately available other than a space that was far larger than what we needed," says Flaherty.

Throughout its existence, the clinic (which now occupies somewhat larger quarters) has been essentially a physician office with examination rooms.

"There wasn't any specialized equipment that we put in this clinical setting," she explains. "With just a couple of exceptions, all the procedures took place in our interventional lab within the hospital's radiology department."

True enough, says Alfonso: "At first, our clinic space was meant to be just an area for meeting patients, discussing with them the procedure contemplated, collecting history and physical examination information prior to scheduling them for an interventional procedure at the lab. So, all we had were examination tables, blood pressure cuffs, very basic items. We obtained a lot of that equipment from the hospital, which sold the items to us at very reasonable prices."

DEVELOPING A PATIENT BASE

Generating businessgetting patients in through the front doorwas the next step.

"We set up two outreach tracks to promote the clinic," says Flaherty. "One directed communications toward referring physicians. The other toward consumers."

On the physician track, the interventionalists and key administrators of the clinic devoted themselves to visiting prospective referring physicians' offices and the emergency department where they explained the service, the clinic, and the options awaiting their patients.

"We also provided educational seminars and grand rounds in conjunction with the hospital on things such as peripheral vascular disease," says Flaherty. "Our interventionalists do a tremendous number of educational sessions, whether it's with residentsthe hospital has a number of residency programsor CME at other OhioHealth hospitals."

Then there was the outreach to the public. Alfonso says it consisted at one level of participation in health seminars for community groups and women's organizations.

"We talked a lot to women about uterine artery embolization as an alternative to hysterectomy," he says. "They listened with great interest."

There also was a traditional marketing component that involved display advertising and use of the Internet. A newsletter was published. Articles about the clinic  appeared in local newspapers.

"A lot of awareness was built for the clinic, but the main focus of the outreach was on the procedures as minimally invasive options to various customary types of surgeries," says Alfonso. "This approach resulted in referring physicians receiving a lot of inquiries from their patients. As those inquiries came in, the referring physicians turned to us for information about the procedures. This, in turn, often led to us getting the referral."

AN APPRECIATIVE HOSPITAL

About 90% of the patients seen in the clinic go on to have an interventional procedure performed, says McGraw. Of those, as many as 20% are admitted to the hospital for a stay of at least 1 night. Most likely to be admitted are patients slated for uterine fibroid embolization, renal artery angioplasty, iliac angioplasty, and, on occasion, vertebroplasty.

"It's rare that a patient comes into our clinic and is immediately admitted to the hospital," McGraw explains. "Usually, most of the procedures we schedule for patients seen in our clinic are elective. In these instances, the patient comes in during the morning, we perform a physical examination, write the admitting order, perform the procedure, round on the patient after the procedure, round again the next morning, and, if we determine the patient is stable enough to go home, we write the discharge order and summary."

Those were responsibilities formerly belonging to the hospital.

"Most of the legwork on admissions, rounding, and discharge is performed by a single staffer, our nurse-practitioner," says Flaherty. "We've taken on some responsibilities that in the past were the hospital's. Some of that has to do with scheduling and pre-certifying We took those on because our staff had a better knowledge of how to handle them. This offloading of responsibilities from the hospital just sort of evolved. It was a practical matter. Taking on the responsibilities made our physicians more efficient. And it was easier for our patients to get the procedures done if we were involved with the scheduling and precertification than if they were going through the hospital channels."

The hospital greatly appreciated having Riverside take on those responsibilitiesand it is an appreciation that has only intensified over time, with the growth of interventional patient volume.

"The interventional portion of the practice experienced a 17% increase in 2002 and is on pace slightly above that rate for 2003," says Flaherty.

Alfonso attributes the growth not just to the outreach efforts but also to the fact that the group is offering a wider range of interventional procedures.

"We expanded our scope of services in interventional to include pain management, women's servicessuch as uterine artery embolization, ultrasound-guided vein therapy for varicose veinsand a neurointerventional practice that included treatment of aneurysm and stroke," he says. "We also added radio-frequency ablationa tremendous service to oncologists; it's another option in terms of pain management.

"Our interventionalists are constantly learning new techniques. So, we're going to continue to evolve and that means we're also going to continue to expand. That's our goal, certainly."

Riverside Radiology is in the process of developing an outpatient imaging center that will include medical offices andin addition to multi-modality MRI, CT, ultrasound, radiographicswill feature an outpatient angiography suite.

"This angiography suite would not have happened were it not for the success of our interventional service as currently constituted," says Alfonso. "Instead, the imaging center would consist strictly of diagnostic services, resulting in a diminished potential for achieving extraordinary success. It would have ended up being just another imaging center and with little to distinguish it from all the rest."

McGraw suggests the group might well be less prosperous today without the interventional clinic and admitting privileges.

"In order for our specialty to survive, we have to be able to manage and care for our patients instead of just doing procedures and then handing over their care to someone else," he says. "This is allowing us to maintain market share against growing competition and erosion."

Rich Smith is a contributing writer for Decisions in Imaging Economics.