Making the Leap to Outpatient Centers: An In-Depth Discussion at ISET

Hollywood, FL (January 22, 2020) -- With reimbursement pushing an increase in outpatient procedures, the topic of office-based labs, or OBLs, was a hot one at the International Symposium of Endovascular Therapy (ISET) 2020. In a focused session, four vascular specialists who made the OBL leap shared their experiences.

Jihad Mustapha, MD, Advanced Cardiac & Vascular Centers for Amputation Prevention in Grand Rapids, Michigan, started an outpatient CLI center because he simply couldn’t get his patients treated at the hospital in a timely fashion, in particular, urgent limb salvage cases and complex critical limb ischemia (CLI) cases that are lengthy and time-sensitive.

“Despite having a nationally recognized hospital-based program, there remained a true lack of understanding and we constantly had to explain to the hospital administrators that saving a limb is about saving the life, and the prevention of amputation drastically improves quality of life,” said Dr. Mustapha.

“So, I took the plunge and decided to do what I felt is the right thing. CLI work is my passion, so these patients are my responsibility and I felt there is no greater need with so many opportunities for therapy ahead of us,” said Mustapha.

He opened an OBL in February 2018 and hasn’t looked back, adding a second center in November 2018 and a second cath lab to the flagship center in January 2020. Dr. Mustapha is now able to treat all CLI patients that are not currently hospitalized for co-morbid conditions.

What advice can he offer others? “CLI patients are complex, cases are long. The days are not short — I’m still working 18 hours a day. There is no perfect EMR system, don’t understaff, running a business is difficult so hire someone for the business part. And don’t take the cheap way out, it’ll cost you in the long run.”

But in the end, “the buck stops with you. It’s really great to be able to provide proper care to my patients without them having to wait.”

One issue to consider before taking the plunge and opening an OBL is understanding your market — your patients and your competitors — but also deciding on your scope of practice, said Bret Wiechmann, MD, from Vascular & Interventional Physicians in Gainesville, Florida.

What services will you provide and what are you not willing to do in your outpatient interventional suite or OBL? Understand and manage your risk, he said.

“Doing quality work in the office is about safety and patient selection. You’ve got to know what your red flag is,” said Dr. Wiechmann.

“There is outcome data that shows that endovascular intervention can be done safely and effectively in an office-based environment,” he said. But the key to safety is not changing practice patterns or taking short cuts based on how you’d practice in a hospital setting.

“If you don't change your practice patterns, you can expect the same results,” he concluded.

Mark Garcia, MD, is nearing the one-year anniversary of opening the doors on his OBL in Wilmington, Delaware. His advice for those thinking of opening an OBL? Prepare. “It takes longer than you think and is more complex than anticipated,” he told ISET attendees.

“It’s imperative to develop a detailed business plan and to engage good legal counsel early, someone who knows and specializes in healthcare law and understands the model that you're going to build, whether it’s an OBL and ASC, or a combination — they need to know the regulations and laws.”

He went through a significant list of other “lessons learned” in starting an OBL, which included needing to understand the financing model you choose for your OBL, how to secure financing, how to staff and manage your OBL, and facility, EMR, and social media needs.

“Make sure you have enough cases when you look at whether this is going to be a viable decision, and the right case makes it a very big difference between arterial and venous interventions. But you need to know what's going to make up your case load,” said Dr. Garcia.

He concluded: “As far as utilization, I think this is very important and what can't be emphasized enough is that you have to have question to both overutilization as well as underutilization.”

“You don't want to skimp on your procedures to the point of affecting the quality and outcomes, but you also don't want to be excessive and bankrupted the practice every time you take out a wire. Every time you take out a catheter, every time you take out a device, it's coming from your margin, and over a period of time that can dwindle down that margin and that may put you in the red.”

In a similar vein, Dr. Sonia Noor, the Director of Endovascular Services at Gates Vascular Institute in Buffalo, New York, spoke to attendees about the need to understand your revenue stream.

“If you think about it, when you want to get work done in your house and you ask someone to come in for the roof or for plumbing, you’ve talked to them about the job and they give you an estimate. Most of us have very little clue about how much we actually get paid when we do a case.”

To illustrate, Dr. Noor walked the audience through how a physician might get paid in different hospital and OBL settings, and with different fee arrangements. “Whether you have a one-year contract or a three-year contract, you need to take a look at it once in a while.”

A key takeaway from Dr. Noor’s experience is that reimbursement is the sum of coding plus coverage, plus payment. “Clear dictation affords accurate coding, and accurate coding facilitates appropriate payment. It’s important to maintain open lines of communication with your coders and billers.” She added, “Answer their questions and train them, and you’ll do a lot better.”

There is more to know about OBLs and entire meetings are devoted just to this topic, but Dr. Garcia summed it up succinctly: “In the end, it’s about being smart and using common sense. The market is primed for these endeavors — patients want them, payers want them, and doctors want them.”