Putting A Face On CIRA

From left, H. Bob Smouse, MD; James Swischuk, MD; and Greg Q. Hill, JD, pictured in the Central Illinois Radiological Associates clinic.

Like many imaging groups in the 1990s, Central Illinois Radiological Associates (CIRA) watched in dismay as formerly genial referral sources transmogrified into heel-nipping competitors. Competition from other specialties, however, has failed to stymie the steady growth of this dynamic, Peoria-based practice of 40 radiologists. In part, its success can be attributed to the interventional section, which now is responsible for pulling in nearly 30% of the practice’s total annual revenues.

Key to the success of CIRA’s resilience—despite the challenges posed by a market brimming with imaging-modality-equipped cardiologists, orthopedists, and others—was a decision by the interventional section to give itself a very public face.

“We’ve sought to help our community recognize that CIRA is more than just a name on a bill the patient receives, that we’re a place where people come to be evaluated, treated, and followed,” says interventional radiologist H. Bob Smouse, MD.

Changing the public’s perceptions of what interventional radiology is these days was achieved to a degree through aggressive marketing efforts. But, more substantively, it came about as a result of the opening of a dedicated outpatient office.

Known as the CIRA Interventional Vascular Clinic, the outpatient office consists of three examination rooms and a noninvasive imaging laboratory. It is located on the third floor of the medical office building adjacent to 700-bed OSF-St. Francis Hospital, largest of Peoria’s three major health care institutions.

“We perform only some of our venous disease procedures in this office,” says Smouse, explaining that the big-ticket interventional work still takes place in hospital settings. “Mainly, this clinic is where we conduct screenings and follow-ups of patients for peripheral vascular disease and abdominal aortic aneurysms.”

RESPONSE TO CHANGE

Clearly, for radiology practices that want to flourish these days, the name of the game is patient control and the development of a robust patient base—and in that regard, “our interventional outpatient clinic has been a very good addition,” says Gregory Q. Hill, JD, corporate counsel and chief operations officer for CIRA. “The clinic allows us to introduce the interventional practice to referring physicians and, equally important, provide follow-up with patients. If you just have an interventional radiology practice in a hospital, sure, you can follow up with the patients, but it’s a lot easier and better for everyone if it’s in an outpatient setting. Because, in the hospital, follow-up is of necessity limited largely to emergency situations.”

Hill—who is also a University of Illinois at Peoria College of Medicine adjunct assistant professor of medicine—was not even born when CIRA started. The year was 1938, and back then the group went by the appellation of Peoria Radiology Associates, which changed to CIRA in 2000 following its merger with the city’s second-largest radiology practice—Methodist Radiology Group, based at 500-bed Methodist Hospital. (CIRA also is linked to nearby Proctor Hospital, where that 150-bed facility’s radiology group invited CIRA to manage the interventional radiology service they had launched but were having difficulty piloting.)

CIRA today is noted for its 24/7 consult and on-call services, as well as its close academic affiliation with the University of Illinois through CIRA-administered residency and fellowship programs. The relationship with the university extends into the realm of scientific research—the practice currently is engaged in beta testing and clinical trials of numerous technologies and protocols, Hill reports.

CIRA made its initial foray into interventional radiology in the mid 1960s when a radiologist by the name of Robert Wright, MD, performed Peoria’s first angioplasty. However, it took nearly 30 years for CIRA to realize that interventional radiology would be so essential to the practice’s survival and long-term success.

“In the 1990s, the landscape for radiology began to change,” says Smouse. “Cardiology suites and endovascular suites that hospitals had established were opened up to noncardiologists and noninterventional radiologists in order to generate more revenue. We were awakened to the fact that, if we were going to compete on a somewhat level playing field, we would have to become more clinically oriented and have more of a surgical practice model. By that I mean we had to have an outpatient office where we could see patients, an office that would serve as a portal through which we could reach out to the practitioners who could really benefit by referring to us—primary care physicians, internists, and others not able to perform image-guided interventional procedures themselves.”

Smouse credits most of the hard work to Jim Swischuk, MD, one of his interventional partners.

RUNNING IN THE BLACK

The office initially occupied by the CIRA Interventional Vascular Clinic was a humble affair—basically, an underutilized ultrasound room.

“During the months that it was located in the ultrasound room, our outpatient office was open just 1 day a week,” says Smouse. “Before long, volume had increased to the point that we felt confident about moving into a larger space and being open more days of the week.”

The clinic relocated to the office of an internal medicine physician at OSF-St. Francis Hospital. “We rented space from her,” says Smouse. “For about $600 a month, we had access to an examination room for 2 half-days a week. It wasn’t long before we outgrew this space, so we moved again.”

This time the clinic landed in the offices of a surgery group on the campus of OSF-St. Francis Hospital, but not in the hospital proper. The arrangement gave CIRA daily access to two examination rooms and a procedure suite. Then, about 5 years ago, CIRA secured from the group an additional examination room.

Included in each rental agreement was a right to make use of designated clerical personnel for a specified number of hours each week. Right from the beginning, the small ranks of these helpers were enlarged by physician extenders CIRA itself hired.

Bringing aboard at an early juncture those physician extenders—nurse-practitioners, to be precise—proved a brilliant move. In addition to turbocharging patient throughput and greatly contributing to the dramatic growth of the office, the physician extenders were a big part of the reason the CIRA Interventional Vascular Clinic was able to break even and begin operating in the black within a matter of months after its debut

“Our physician extenders paid for themselves almost immediately,” says Smouse. “A few years ago, we crunched the numbers on the physician extenders to gauge their true impact on our bottom line. We calculated that, between wages and benefits, the physician extenders were costing at that time $400,000 a year. But we found that this outlay was offset by the $1 million in extension-and-management code billings they generated. The payors, of course, allowed less than that—so we had actual E&M revenues of just over $400,000. That meant the physician extenders were revenue neutral.”

Hill, the COO, suggests the revenue-neutral descriptor undervalues the actual worth of the physician extenders in this type of venture. “The first thing groups want to do when they decide to set up an interventional radiology clinic is go out and hire additional interventional radiologists,” he says. “But those radiologists are very expensive, whereas physician extenders are not. Physician extenders help with consultations, they can do H&Ps, they can round on patients, and do follow-up. They’re not a substitute for an interventional radiologist; they simply free up the ones you already have so that the interventionalists can concentrate on doing more of the better-paid and higher-margin work—procedures, in other words—without the need to bring in more interventional radiologists.”

There is no question that physician extenders contribute to increased quality of care and patient satisfaction in Smouse’s view. “When the interventional radiologists round on the patients, they may be able to spend only a brief couple of minutes with each one,” he says. “But, when the physician extenders round, they can devote 10, 15, 20 minutes with each patient. Here at CIRA, we interventional radiologists still round, but, now, when we do, thanks to the work of the physician extenders, the few minutes we have available to spend with each patient are much more productive.”

A MODEST PROPOSAL

Smouse and his fellow interventionalists needed authorization from the full practice before initiating the CIRA Interventional Vascular Clinic, a great departure from the practice pattern of most radiology practices. The request was well received.

“Our group realized we needed the clinic to help us stay competitive in the market,” says Smouse. “They understood that we needed a clinical presence.”

Smouse contends that the natural tendency of many interventional radiologists is to determine the need for an interventional radiology clinic and then put in a pitch for a sizable chunk of change to fund it. “They’ll go to their colleagues and urge them to put up $150,000 over 3 years—and then they’ll wonder why the idea is met with quite a few raised eyebrows,” he says. “In our situation, we felt the best way was to gradually sell our colleagues on the idea. We started with a very modest and inexpensive proposal that was easy to say yes to. As growth occurred, we were able to go back to our practice partners and show them our business plan, our business model, what we accomplished, what it had cost—and what it was not costing—and ask them for more support so that we could move into larger quarters and hire more physician extenders.”

Still, not every member of the practice was convinced the interventional radiology clinic could deliver the goods that Smouse and his section’s partners were promising. “It wasn’t so much objections as it was that they had questions about the return-on-investment (ROI), questions about expenditures, questions about what the group could expect to gain from this,” he recounts.

Skepticism vanished as the interventionalists rolled out the ROI numbers, which were small on conjecture due to reliance on established figures, projected forward. “Our forecasts proved reasonably accurate,” says Smouse.

Part of the reason the clinic concept was favorably received was that the interventional radiology section came to the table in possession of a well-burnished record as a profitable arm of the group. That is no less true today. If anything, it is more so. According to Hill, “Twenty-nine percent of our gross charges for the group as a whole are derived from the interventional radiology section. That’s more than a quarter but less than one third of all income—a significant contribution.”

The contribution of interventional radiology is particularly impressive in that of the nearly 600,000 imaging studies CIRA performs annually, only about 10,000 are interventional-related.

“We do an average of 25 cases a day at OSF-St. Francis Hospital, close to half of which are vascular-arterial work,” says Smouse. “Over at Methodist Hospital, we do about 12 cases a day. And at Proctor Hospital, an average day for us is five cases.”

In terms of technology assets, the CIRA interventional radiology section has at its disposal four fully equipped, state-of-the-art interventional suites, and next year will add a pair of endovascular suites. “We expect CT angiography to be a big part of our practice in the near future,” says Smouse, indicating that both OSF-St. Francis and Proctor hospitals recently installed 64-slice CT scanners (a 16-slice CT at Methodist is slated for upgrade to 64-slice).

All of the CT scanners and interventional suites are owned by the hospitals. “We haven’t had to acquire these ourselves—no capital outlay on our part at all,” says Smouse. “We advised the hospitals on equipment and systems we felt were necessary in light of where the market was going, but it was left to them to make the purchase decisions. It’s worked out really well for us.”

ANCILLARY SERVICES

For further evidence that the interventional radiology section’s strategy of putting a face on its practice has worked, consider that, a decade ago, nearly 75% of its vascular referrals originated with surgeons. Now, 75% comes from primary care physicians.

“The primary care physicians like sending their patients here to us because they know those patients will be followed up on a regular basis,” says Smouse.

Insurance companies too have been welcoming of the interventional radiology clinic. Says Hill, “There has been no instance of an insurance company denying our interventional radiology claims solely because the claim originated in the outpatient clinic.”

Buoyed by the acceptance of patients, providers, and payors, CIRA’s interventional radiology section has begun replicating the Interventional Vascular Clinic model. A short time ago, the section started a Thursdays-only carotid clinic to see patients for cerebral vascular diseases—specifically; atherosclerosis of the carotid artery. “These are patients endorsed by OSF-St. Francis Hospital and the Illinois Neurological Institute in Peoria,” says Smouse. “In this particular clinic, the brain child of Dr Kenneth Moresco [another CIRA partner], an interventional radiologist, a neurosurgeon, and a stroke neurologist together see the patient, discuss the case, and then refer the patient for either medical management, surgical management, or stenting of the carotid artery. It’s proving successful and is attracting more cases every week.”

Another newly established clinic focuses on abdominal aortic aneurysm (AAA). “We noticed that primary care physicians were not following their AAA-diagnosed patients in a uniform way, so we offered to take over that surveillance,” says Smouse. “Now, if they encounter a patient with an AAA, they refer right to us. Once the patient comes to our clinic, they’ll be seen initially by a physician and a nurse-practitioner, and then we’ll order the follow-up studies. When there has been a rapid expansion of the aneurysm or if it reaches a certain level, we’ll decide whether the patent will be best served with an endoluminal graft or an open procedure, then make the appropriate referrals.”

On the drawing board is a venous treatment clinic.

“We see these spin-off businesses as giving us a very visible position in the community,” Smouse explains. “They also allow us to develop niche markets and further incrementally increase our business. Now, no longer are we just a name on a bill the patient receives. We actually treat and manage the patents. Our noninterventional radiologist partners appreciate that, and we are all enjoying the fruits of it.”

Marketing the IR Clinic

If you build an interventional radiology outpatient clinic, the outpatients will come. Well, yes and no. A hospital-based interventional radiologist can always self-refer his inpatients for follow-up in the outpatient setting. However, attracting patients in sufficient numbers to really make a go of the clinic requires ambitiously developed and executed outreach. To spread the word about its own outpatient interventional clinic, Central Illinois Radiological Associates ran newspaper advertisements, set up electronic brochures on multiple Internet web sites, participated in community forums, and passed around promotional literature at mammography centers, family practice doctors’ offices, health spas, and pharmacies. “We even worked with our hospital’s public-relations department to generate free media coverage so that our story could be more widely told,” says interventional radiologist H. Bob Smouse, MD. Smouse says his team also prepared newsletters about the clinic and sent them to primary care physicians. “Additionally, we hosted local symposia for the doctors: in February, we did one for podiatrists on wound healing and limb salvage, and found opportunities in the course of that gathering to present information about our vascular services.” Other ways to communicate with referring physicians have included direct mailing, phone calls, and lunchtime meetings. “We’re soon going to begin sending our senior nurse-practitioner out on a regular basis to visit physicians’ offices and provide CME courses and in-services,” Smouse says. A next step will be to expand the clinic marketing to Central Illinois Radiological Associates as a whole. Says Smouse, “It would make sense for us to promote, for example, CT angiography in the context of the CT diagnostic services our noninterventional radiologists provide. Doing so would allow us to present a more complete picture of our practice in the face of growing nonradiology competition in the imaging arena.” Great marketing can go nowhere if improperly aimed. “You have to know who your target audience is,” Smouse explains. “We’ve defined them as primary care physicians, friendly specialists, administrators, and the lay public-in particular, women.” Smouse says CIRA sees women’s health as an untapped market, and a relatively inexpensive one to develop, since no unique or different technologies are needed. “It’s very unusual for radiology groups to pursue the women’s health market, except in mammography,” he notes. So, why do it? Because of the strong economic opportunity it embodies. “Women are huge purchasers of health care services,” says Smouse. “Nationally, they spend more than $300 billion out of the nearly $600 billion per year on health care. We’d like to do our part in encouraging a redirection of at least some of that toward us.”

—R. Smith

Rich Smith is a contributing writer for Decisions in Axis Imaging News.