Interventional Radiology Service Line Business and Practice Building Focus: Arterial Disease

1. Interventional Radiology Service Line Business and Practice BuildingFocus: Arterial Disease Raj P. Shah MD, MBA http://www.streamlinemd.com/Data/Sites/58/assets/ir_image.png

2. Objectives -Gain an understanding of the business environment in which interventional radiologists practice. -Learn about various market forces, and different entities that contribute to delivery of interventional radiology services. -Learn about the important aspects of a practice, and factors one must consider when developing a strategic business plan. -Develop a marketing strategy for your future practice. -Learn about resources/initiatives to effectively manage change. -Learn how to ‘create value’, and structure one’s practice to compete and succeed in this dynamic environment.

3. Business Environment - Increasing Competition/Diminishing Reimbursements  Disruption of traditional referral practices, as physicians have felt compelled to acquire minimally invasive skills/procedures that they once referred  ‘Turf Wars’ - IR has felt this competition at multiple levels, due to the coverage of procedures across many specialties

4. How to Prepare for the Future? - Create/implement a strategic business planthat defines your practice’s core purpose, outlines the principles that it gives importance to, and focuses on specific objectives/goals. - Strategy integrates vision, policies, and action sequences into an organized plan.

5. Components to Develop Strategy for a Successful IR Service Line - Goals – Mission and Vision - Basic Market Analysis - Service Lines Operations Analysis - Marketing Overview - Tools for Success - Financial Overview

6. Organizational Structure Mission Statement: Defines the overriding purpose of the organization; it provides a framework for implementing specific objectives. They are generally culture/business dependent. Vision Statement: Outlines the core values of the organization; it helps define the characteristics of the organization and its people. It represents an image of what the organization wishes to become, as they accomplish their mission.

7. Service Line Market Analysis -Is there a need for this product/device or service? -Who will be a customer? (Considering the wide variety of customers is helpful, eg - patients, referring physicians, hospital organizations, insurance companies) -What value does the practice bring to its product/service? -What competitive forces are in play?

8. The 5 C’s of Market Analysis

9. The 5 C’s of Market Analysis Customers .Patients .Referring Physicians .Hospitals .Insurance Companies Competencies eg- Arterial disease service line- carotid artery disease, aortic dissection, peripheral artery disease, aortic/peripheral aneurysms, renal artery disease, mesenteric artery disease, vasculitis, medical management of comorbidities.

10. The 5 C’s of Market Analysis Competitors .Vascular surgeons, Interventional Cardiologists Changing Context .Turf wars .Decreasing reimbursements .Change in payment model, from fee-for-service to flat-fee (based on admitting diagnoses/comorbidities)

11. The SWOT analysis aims to identify the key internal and external factors seen as important to achieving an objective

12. Customer Value Proposition -The way we propose to help customers treat a condition, including the benefits we claim they will receive and the costs we ask them to pay. -How we plan to address their ‘clinical need’, and do better than our competitors (in terms of achieving goals of treatment, long-term clinical outcomes, providing reliable follow-up care, staying up-to-date with the latest techniques and therapies) at a comparable cost.

13. Positioning- Targeted Value Proposition For (our target segment), our (product/procedure/therapy/treatment) is (single most differentiating element of value proposition) among all (competing ways of solving targeted problem) because (single most important “supporting evidence”)

14. Service Line Operations -What is required to operate? -Are there specific infrastructure or milestone requirements that must exist to introduce the product/service? -How will the quality be controlled and value assessed?

15. Value Analysis -Do we provide value beyond ‘catheter skills’? .Patient outcome? .Patient satisfaction? .Referral satisfaction? .Institutional satisfaction? A value analysis is important for all IR practitioners; in most circumstances, results will directly relate to financial performance of service line.

16. Marketing

17. Marketing -Product – Procedures relevant to a particular service line. What gives you a competitive advantage? .Is it a shorter, less invasive procedure? .Does it involve a shorter stay at the hospital? .Is it less painful than other techniques to treat the same condition? .Is it your breadth of experience which such cases/therapies? .Does your technique result in better long-term clinical outcomes? .Is it your reputation for exceptional follow-up care?

18. Marketing -Promotion – (Acknowledgement: Dr. Mark Lessne of JHU) . “Brand Yourself” – Distinguish your services in hospital records; eg – title-specific notes/consults . Follow-up with EVERYONE– Keep referring providers in the loop; keep yourself “visible”. -Pre-procedure Plan (eg – medical management) -Post-procedure Plan (eg – follow-up plan)

19. Marketing . Speak with Provider Organizations (eg – Connecticut Podiatric Medical Association, Connecticut Academy of Family Physicians) – Explain capabilities, services: What happens when you refer a patient? Provider identifies patient who needs vascular service referral At my VIR clinic, non-invasive testing and procedures are performed (if indicated) Patient returns to your care, with recommendations for disease management. A complete report of findings and procedures performed is generated.

20. Marketing . Write articles in referring providers’ non-peer reviewed journals (educate providers and focus on patient care) . Patient Education – -Speak at public institutions (places of worship, YMCA, Rotary International, etc.) to educate potential patients on common medical conditions. -Screen patients at public places or events (malls, parks, fairs, concerts, sports games) -Provide information pamphlets, flyers, ‘email list’ option. -Follow-up with patients’ PCPs, and provide explanation of services.

21. Marketing .Use Existing Hospital Resources -give lectures (to other departments within the hospital), through multidisciplinary conferences – case presentations, medical management, follow-up care, relevant literature. -write an article in the hospital newspaper/magazine to distribute into the community (to providers + patients)

22. Marketing -Price – Competitive; negotiated to ensure that procedure reimbursement exceeds variable cost and contribute to overhead (concept of contribution margin). -Place – Diagnostic radiology office, referring providers’ offices, public places, television/radio/highway billboard advertisements, SOCIAL MEDIA (Facebook Pages)

23. Marketing Important: -Take ownership of your patients! -Understand the value that you provide! -Be able to articulate this to appropriate stakeholders, eg -non-interventional colleagues, the hospital, an academic institution, a private practice, the insurance companies, and the patients themselves!

24. Building A Service Line – Tools for Success Kaizen -Mindset of continuous improvement -Ownership of one’s role and focused effort on making the role better. -Kaizen ‘event’: Acollection of resources (dedicated people, money, and time resources) that are pulled with a targeted problem project in mind.

25. Kaizen – The 5 Elements 1. Teamwork 2. Personal Discipline 3. Improved Morale 4. Quality Circles 5. Suggestions for Improvement

26. Building A Service Line – Tools for Success Lean - A management philosophy focused on improving process speed and quality through reduction of process wastes. - Reduce activities that drive up cycle times or cost; make processes more efficient and more predictable.

27. Lean – Basic Principles to Implement a Lean Process RadioGraphics March-April 2012 Vol. 32 No. 2 573-587

28. Lean -Particularly relevant to radiology departments, which depend on a smooth flow of patients and uninterrupted equipment function for efficient operation -Vital to institute a gradual but continuous and comprehensive “lean transformation” of work philosophy and workplace culture

29. Six Sigma -Key pieces of Six Sigma are consistent output, stability, and accuracy. -Six Sigma aims to reduce output variation through the use of statistical analysis and root cause analysis.

30. Six Sigma Example- Nebraska Medical Center IR Department’s use of Six Sigma Problems: -Process inefficiencies were causing patient volumes to decline. -Dissatisfied referring physicians were sending patients to other hospitals. -Patients who remained were experiencing delays in their treatments

31. Six Sigma Solutions: -Collaborating with referring clinics, and strengthening relationships. -Improving job satisfaction amongst employees, by establishing clear expectations about each individual’s role. (eg – for the scheduler, this involved clarifying what type of lab testing was required prior to each procedure, obtaining timely clearance/approval from other providers, and knowing the precise time that had to be scheduled) -Improving communication between employees, to better understand what each individual required to perform his/her job better.

32. Six Sigma Results: - The Nebraska Medical Center interventional radiology department saw a 21% increase in patients from the previous fiscal year; it reflected improvements in patient and referring physician satisfaction as well as process efficiencies.

33. The Approach 1) When presented with an issue, transition to a Kaizenmindset and ask “What is the problem we are looking to solve?” 2) Lean principles are the first set of tools applicable to any scenario. Generally, we are addressing a problem in which there is a complete lack of process standardization and optimization. 3) Six Sigma is a strong methodology after processes are standardized and optimized. At that point, the process is looking for improved process outputs and consistent performance.

34. Financials Trends -A decrease in fee for service payments -An expansion of the ‘flat fee’ model (single payment based on admitting and comorbid diagnoses) The IR community should help the hospital by ensuring that indications for procedures are evidence-based and appropriate.

35. References Yousem, DM.,Beauchamp, NJ. Radiology Business Practice: How to Succeed. Philadelphia: Saunders Elsevier; 2008. Muroff, LR. Implementing an effective organization and governance structure for a radiology practice. J Am CollRadiol2004;1:26-32 Volland, J. Case Study: Now that’s Lean. Medical Imaging Magazing 2005 Kruskal, JB. Quality Initiatives:Lean Approach to Improving Performance and Efficiency in a Radiology Department. March 2012 Radiographics; 32; 573-587 Beheshti, MV. The interventional radiology business plan. J VascIntervRadiol 2012;23;1181-1186