IRQ Articles

Practice models 

07-11-2019 14:56

Desert Regional Medical Center, Palm Springs, Calif.

By Barbara Hamilton, MD  Summer 2019

Practice models

Background

About 8 years ago, the local interventional radiology practice at Desert Regional Medical Center in Palm Springs, California, was largely limited to venous access and biopsies. The service grew into a full-blown IR service under the leadership of Ralph Ho, MD, a colleague who introduced many of these services to the community for the first time. One of the major milestones was offering trauma embolization, a key procedure at our level II trauma center. He then began offering tumor and variceal embolization, gradually expanding the various service lines to including gastrointestinal and genitourinary procedures. He brought me on board about five years ago, following my fellowship at the University of California, Los Angeles. Now, as current chief of the section, I’ve continued to develop the breadth and quality of service alongside my fellow IRs.

Structure

Practice models 2 The local practice, a combined interventional and diagnostic radiology service, holds the exclusive contract with Desert Care Network, the local health system managed by Tenet Corporation. Radiologists are either employed by or contracted to work with Aris. This structure allows us to work collaboratively with administration, without being hospital employees. Aris staffs hospitals around the country. Because of the geographic separation, our local practice has a small private practice feel, while maintaining the infrastructure of a much larger group.

Desert Regional Medical Center is a 380-bed level II trauma center, with a dedicated IR on call at all times—a 100% procedural and clinical role. We do not have a dedicated clinic space yet but see patients in our offices, where we can go over images and counsel them prior to and following outpatient procedures. We provide a consultative service for inpatients as well. We do not bill separately for consults or evaluation and management (E&M) at this time due to lack of support from the previous group administrators. The previous leadership did not see the E&M component as a worthwhile investment of time and resources to bill and collect for it. With a new leadership team in place, I plan to raise this issue again, so that we can
bill for all of the clinical work we are already doing.

Both IRs and DRs in the group are involved in various tumor boards and hospital committees throughout the week.

Interventionalists also staff some of the smaller hospitals within our health system, one in Joshua Tree (general radiology with limited procedures performed) and one in Indio (full complement of IR procedures offered but predominantly dialysis work at this time). Since we cover multiple small hospitals, the doctor at that hospital is solely responsible for the procedures and challenges that arise.

Scope

The IR division provides all aspects of body IR to the exclusion of aortic endograft placement and neurointervention, which is provided by a dedicated service. A significant component of the practice is acute trauma, so we are available for angiography and embolization around the clock and arrive within 30 minutes of a call. We also assist in various aspects of the trauma patient’s ongoing care, including vena cava filtration, abscess drainage, thoracentesis, and the like. We have a cirrhotic population requiring the gamut of procedures from tunneled abdominal catheter placement to TIPS and BRTO. We perform venous and arterial work, including plenty of dialysis intervention. We are growing and developing our interventional oncology service line, with the introduction of a percutaneous ablation program in the past two years.

Training

Practice models 3We do not have radiology residents, but the hospital supports multiple DO residency programs, including internal medicine, family medicine, emergency medicine, neurosurgery and neurology. Our daily interface with these trainees provides a great way for these specialties to learn what we do and how best to work with us. Some of the residents are interested in getting experience in basic ultrasound-guided procedures and LPs, so they can gain confidence in doing them at the bedside.

Patient population

We serve a large community of retirees, many in their eighth and ninth decades. We serve patients from rural parts of the state, who live on ranches and rarely seek medical care, and some who have frequently crossed our southern border. A large proportion of our patients are Spanish-speaking, so our ability to speak medical Spanish is an asset to patient care. We have a large LGBTQ population, and local health care and advocacy is supported in good part by the Desert AIDS Project.

Because we have many music and architecture festivals, golf and tennis tournaments, and gay pride events, the local population fluctuates wildly, with many visitors from the coastal cities and from around the country. The summer here is very quiet as many exit the area to avoid the extreme temperatures, which can reach over 120 F.

Unfortunately, we see the effects of widespread methamphetamine abuse in Southern California, particularly in our trauma population.

Practice marketing

Marketing is performed on a grassroots basis. Referrals are based in relationships, which we work to foster. We garner trust by offering consistency, collegiality and communication. I was able to infiltrate our cancer center’s advertising campaign, so I’m included in some of their marketing materials.

One of the key ways in which we make our best referrers happy is to accept all comers. Taking all kinds of insurance coverage has taken stress off many referrers, who struggle with Medi-Cal patients who may not be accepted elsewhere. In addition, we take the challenging cases that may be rejected by other practices in the community, such as high-risk lung biopsies.

Pros and cons

Challenges include turf battles, which can be silent and covert. Referral patterns are entrenched and not always easily negotiated. We have had a challenging relationship with one of our major urology groups, who has tried to push us to do suprapubic tubes emergently without seeing the patient first. Perhaps because we have pushed back in this area, we don’t get referrals for renal ablation from them. We have attempted to collaborate with them on guidelines for appropriate patient care in this area of contention.

The biggest challenges we face include stagnant referral patterns for certain service lines, which are somewhat opaque and often require new physicians entering the community to change. Another significant challenge has been the limited role in choosing and managing hospital staff and workflow, since they are not our employees. In the past, we were subject to crippling nursing turnover and very slow patient turn-around, due to factors we could not control.

The biggest advantage of our practice model is being at the ready to serve the community in their time of extreme stress, trauma, cancer or other crisis—something I have found extremely fulfilling.

Growth areas

We are excited about improving the breadth and quality of the practice from year to year. We are seeing increased referrals for locoregional therapy over time. There is increased peripheral arterial work, allowing us to hone our critical limb ischemia program.

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