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March 13, 2006

Suite of Dreams
By Jim Knaub
Radiology Today
Vol. 7 No. 5 P. 14

There were no mystical voices or cornfields, but good planning, strong service orientation, and sound marketing certainly brought the patients to Paoli Hospital’s new interventional radiology department.

If you build it (and market effectively), they will come.

He didn’t use those words, but Atul Gupta, MD, was confident that effective marketing was key to successfully launching an interventional radiology (IR) suite at Paoli Hospital. Gupta is the front man for the radiology group and hospital team that launched the dedicated IR suite at the suburban Philadelphia hospital last year. He believed that demand was out there and the project would succeed if the team offered quality care and marketed it sensibly.

Gupta came to Paoli to launch a dedicated interventional suite. Paoli Hospital, a hospital whose service area focuses on fast-growing and prosperous eastern Chester County, is the western outpost of the three hospitals in the Main Line Health System. Main Line Health’s other two hospitals—Bryn Mawr and Lankenau—already operated dedicated interventional suites and provided some IR service via Paoli’s cardiac catheterization lab. Vikram Dravid, MD, and Eric J. Stein, MD, are based at Bryn Mawr and John F. Schilling, MD, works at Lankenau. And in the next few months, Joseph Bonn, MD, and Stefan V. Franciosa, DO, MBA, will be joining the radiology group, both coming from
Philadelphia's Thomas Jefferson University Hospital.

Home Base
“Prior to my arrival, Paoli did not have a dedicated interventional radiology department,” Gupta explains. “Our practice [Radiology Associates of the Main Line] covered three hospitals on the Main Line—Bryn Mawr Hospital, Lankenau Hospital, and Paoli Hospital—but Paoli didn’t have an interventional radiology presence. What would happen is … interventional radiologists would come out to Paoli on an as-needed basis and do what needed to be done in the cardiac catheterization lab. It wasn’t ideal because the cath lab was built to work on the heart and nothing else. Paoli [administration] and our radiology group saw the need for a dedicated interventional radiology practice prior to my arrival. Much of what we do has now reached the lay press and people know about it.”

But first everyone involved needed to get past what Gupta described as a “chicken and egg” phenomenon: The hospital was leery about building an interventional suite without an interventional radiologist on board to fill it, while Main Line Radiology Associates was worried about its ability to recruit an interventionalist without a dedicated place for him or her to work.

Ultimately, Gupta was recruited from St. Agnes Medical Center in south Philadelphia. He had been closely involved in setting up the facility’s IR suite, so the plan included Gupta serving as the radiology group’s point man to work with Paoli’s radiology department director, Dolores Nawrocki, and her staff to set up the suite Gupta would work from upon its completion.

“There were a number of facilities around that already had an interventional suite and Paoli didn’t want to be left behind,” Gupta says. They set a goal of ultimately providing the full range of interventional procedures to patients so every patient who comes to Paoli for interventional care would be treated at Paoli.

Full-Service Shop
“Everything that a university hospital interventional radiology department does, we should do,” Gupta says. “We’ve done that at Main Line Health with our physicians.” Gupta explains that Main Line Health’s interventional radiologists are based in their respective hospitals but cover call and certain procedures at other hospitals in the system.

Gupta’s objective certainly aligns with patient expectations in the 21st century. Many suburban Philadelphia hospitals have evolved beyond the basic community hospital that handles routine work and hands off secondary and tertiary care to the large metropolitan hospitals in relatively nearby Philadelphia. While big-name Philadelphia university and specialty hospitals still draw many suburban patients, more and more care is handled locally by suburban hospitals. Patients want to be treated close to home whenever possible; hospitals providing that care can prosper.

Reaching the Demand
With a growing, prosperous, and educated patient base in place, Paoli’s key tasks were to reach that group and project how much work it would provide the facility to support the investment. Gupta quickly notes that marketing and financial questions were paramount because IR’s medical value to patients and the system had already been accepted by Main Line Health. It’s one reason they sought someone like him. That the hospital should provide interventional services and that patient demand already existed were settled issues. “Interventional radiology is standard of care,” Gupta says.

The three major components of the job were sound financial projections, preparing the clinical space, and marketing the service—to turn the demand everyone believed was out there into patients and dollars that support those financial projections. Gupta worked closely with Nawrocki on both the financial projections and physically setting up the clinic.

“The board of trustees wants to know what the return will be on the investment,” Gupta says. “We had to come up with projected revenue and costs and see how quickly we could pay for this piece of equipment, the room, and the staff we needed.”

Aside from the direct revenue from the interventional services, there is another component to anticipating the return on investment (ROI). Gupta notes there is a rollover effect from IR patients that should lead to other work for the hospital.

“A lot of the patients have other imaging and procedures that need to be done,” he explains. “Patients are admitted to the hospital for other procedures. So the hospital benefits from the work that I do, but my patients also have other things done at the hospital. They take that into account when they look at ROI.”

Gupta says he, Nawrocki, and the Paoli financial staff worked for approximately four months on the financial projections, from both the radiologists’ professional fees side and the facility fees side. He says that even planning with conservative revenue projections, the choice to move forward was clear.

Setup and Staffing
“After all this was done, the hospital looked at the numbers and thought this was a no-brainer,” Gupta says. “They realized that interventional radiology is here—in fact, it has been here for some time—and they must move forward.”

Moving forward meant staffing and suite setup. They started out with what Gupta called a fairly large IR suite and a control area that was staffed with a nurse and two technologists.

The centerpiece equipment for the suite was Philips Medical System’s Allura Xper FD20, a digital flat-panel C-arm system for interventional and diagnostic radiology and cardiovascular applications. Gupta has a research relationship with Philips, and Paoli is one of four preliminary research sites for Philips’ new Xper CT, which creates 3-D CT images by rotating the flat-panel detector around the patient.

Gupta believes it is important and valuable on several levels to use a company’s top-shelf equipment. Purchasing the latest equipment helps a facility stay more current through the equipment’s five- to seven-year life span. The latest equipment can also help facilities differentiate themselves from other providers in competitive marketplaces such as Philadelphia. “It all lets Paoli market itself to patients and physicians about the high technology we have,” Gupta says.

But pro forma budgets and quality equipment don’t guarantee patients and dollars. To convert those financial projections to actual revenue, Paoli built a marketing program tied to its women’s health center.

“We planned to bridge a lot of the marketing with a new women’s health center being created at Paoli,” Gupta says. “We decided to focus on several women’s procedures. The procedures we initially targeted were uterine fibroid embolization [UFE], a varicose vein radio frequency ablation procedure, vertebroplasty, and peripheral vascular disease.”

Uterine fibroids obviously only afflict women, but varicose vein treatments and vertebroplasty are predominantly performed on women, Gupta notes. The marketing department created the four brochures and set up interviews for Gupta with local and regional newspapers, magazines, and television stations. The procedures were also covered in the women’s health center’s lecture series.

Although it offers a broader range of interventional procedures, focusing marketing on the four procedures also helped Paoli avoid overpromising. “We didn’t want to advertise that we could do everything unless we had the infrastructure in place,” Gupta says. “You never want to promise that you can do something and then have patients never be able to get scheduled or have them call and no one ever answers the phone. It’s better not to offer a service at all unless you’re really able to do it. One upset patient can be a big negative and push you back several steps.”

Marketing Early
Nawrocki says marketing efforts were underway before construction, including interviews and speaking engagements in front of patients and referring physicians. Gupta stresses that both are important. “It’s very interesting how practice patterns have changed from three to five years ago where a physician would refer a patient to another doctor,” Gupta says. “Now patients are taking their care into their own hands, reading articles online or in magazines and coming to us directly. I’m very proud that our marketing department was able to extend this Web presence and marketing presence to help us reach those people.”

With the facility ready and patients and referrers aware of Paoli’s interventional services, finally Paoli put out the shingle (and the cybershingle) and opened the doors to patients. Their projections proving less than accurate proved to be good news.

“We were pretty conservative with our ROI numbers before we opened,” Gupta says. “We were shocked at how far we were off from our projections, but it wasn’t in a negative way. It was quite the opposite. We were far busier than we thought we were going to be.

“We had immense growth in UFE after Condoleeza Rice had the procedure performed,” Gupta added. “That really bumped up that procedure faster than I thought it would grow.”

He says the VNUS Closure procedure for painful varicose veins also took off faster than expected. Replacing the vein stripping procedure that put the patient out of commission for a week to 10 days proved a powerful draw. “A lot of women had no interest in having that [vein stripping] done because they remembered their mothers or friends having that procedure,” Gupta says.

Tripling Projections
While Gupta expected to exceed projections somewhat because they budgeted conservatively, he says tripling the projections was startling. Nawrocki provided the numbers: Six months into offering IR services in the new suite, Paoli overshot their volume and revenue projections by 200%. Nawrocki says the unit performed 77 procedures in its first month when it opened in February 2005. That number grew to 245 procedures this past January.

Six months after opening, the interventional team also went back to the capital committee seeking funding for space and staff to meet the growing demand. “Our budgets are done on a yearly basis,” Gupta explains. “We didn’t have approval to add staff and had to reapproach the committee and request an additional scheduler, additional nursing help for call cases, and a swing technologist to cover the demand.”

Tripling your volume and revenue projections engenders confidence when approaching the capital committee. The interventional team has since grown with a full-time scheduler an additional swing technologist (shared by all three Main Line Health hospitals) and cross-trained call nurses who can be shifted from other areas of the hospital as needed (see box at left). The interventional suite’s footprint has grown a few sizes, adding a patient exam room, scheduler’s office, physician office, nurse/technologists office, and staff lounge.

Gupta believes one key to Paoli’s success is maintaining a full-service relationship with referring physicians, an area he believes too many groups don’t handle very well.

“What referring doctors really hate,” Gupta warns, “is when they have to do all the legwork—all the precertifications, write all the orders, write all the blood work, admit the patients under their own service, and set up admissions to the short procedures unit. They do all the thousand pieces of paperwork they have to do because insurance companies require it, and then we do the procedure.” Gupta contrasted that to a referring physician, who makes one call to a surgeon and the surgeon’s staff takes care of everything. Which call is a referrer more tempted to make: one that generates a pile of paperwork or one where the specialist handles all the details?

First-Rate Service
“That’s why it was important to have the scheduler to take [care] of that paperwork and to handle precertification with me,” Gupta says. “We want to make it as much of a seamless, one-stop shopping experience as possible. Our interventional radiologists have admitting privileges at all three of our hospitals. We take care of the patient from admission to discharge.” The group has hired a physician assistant to help with inpatient and outpatient consults and clinic visits and one of its IR technologists is currently training to become a radiology practitioner assistant..

While there weren’t any mysterious voices emanating from a cornfield, financial planning, good service, and well-planned marketing have made IR at Paoli Hospital a thriving success—for both patients and finances.

“What’s not to like?” Gupta asks, ready to offer his own answer. “We perform procedures on an outpatient basis or as next-day discharge. Hospitals are looking for ways to get patients home quicker. Insurance companies like IR because it’s cheaper to have them treated by us than a surgery, or to not treat them at all and face the consequences later. People like interventional radiology and hospitals make money from it.”

— Jim Knaub is editor of Radiology Today.

Watch Out for These Obstacles
While opening an interventional radiology (IR) suite proved to be a huge success, there were a few obstacles that the team at Paoli had to overcome. Atul Gupta, MD, discussed three likely challenges radiology groups and/or hospitals may face when adding or expanding interventional services.

1. Nursing staff. IR changes the nature of nursing care needed in radiology. Inpatients don’t just need monitoring for a noninvasive diagnostic procedure before being sent home or back to their rooms; they need care before, during, and after an invasive procedure. As Paoli’s patient volume grew, demand for differently trained nurses became apparent—especially for overnight emergency cases.

“When emergency cases came in at night we would have to scramble and bring in ICU [intensive care unit] nurses or pull nurses off the floors,” Gupta says. That, of course, caused a ripple effect in other areas. The solution came in what he calls their “SWAT team” nurses.

The hospital trained a team of nurses in cardiac life support, creating a pool of ICU-level swing nurses who prepared to move between the emergency department, ICU, and the IR suite. The nurses were trained to handle each role, limiting the scrambling to the busiest nights, which will happen occasionally in any hospital situation. The SWAT team helps maintain both the continuity and quality of care around the clock, something Gupta says is essential to building an interventional practice.

2. Turf issues. Many procedures interventional radiologists perform are also done by other specialists, creating real potential for turf disputes. How many disputes manifest depends on the mix of competitive specialists in any given service area and how the doctors handle it. In general, Gupta admits the turf issues have been modest in Paoli’s start-up.

“A larger turf battle that IR departments have is peripheral vascular disease and who does it,” Gupta says. “Is it cardiology, is it vascular surgery, or is it interventional radiology who sees these patients?” At Paoli, Gupta says the cardiologists aren’t doing peripheral vascular work and the relationship is a strong one.

“I have a very good relationship with the referring cardiologists,” he says. “They are very happy and very good at working on the heart. They are very happy doing what they do well and having me do what I do well and refer those patients to us.”

But Gupta adds that there are some surgeons performing peripheral artery interventions in Paoli’s cardiac catheterization lab. “My feeling is that PAD [peripheral artery disease] remains an underdiagnosed disease in the United States,” Gupta says. “There’s more than enough business—if you want to look at it this way—to go around.… My role as an interventional radiologist shouldn’t be to fight over the existing patients but to go and find the undiagnosed patients, of which there are a lot of them out there.”

3. Winning over diagnostic radiology colleagues. Because his group had already served interventional suites at Main Line Health’s Bryn Mawr and Lankenau locations, Gupta didn’t struggle when convincing his colleagues of their value. But he pointed out that it can be a big issue if a traditional diagnostic radiology group—especially one with few or no subspecialists—is investigating adding an interventional service. Gupta says it can be difficult to convince diagnostic colleagues that a radiologist’s time can be well spent outside the procedure room or the reading room. Seeing patients in the hospital is part of an interventionalist’s job, but alien (or at least forgotten since training) to many diagnostic radiologists. While the interventional radiologist isn’t always earning professional fees in the reading room, the service certainly opens a new revenue stream for the group.

— JK

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