Introduction

An office-based laboratory, more colloquially known as an OBL, refers to an outpatient office where evaluation and management in addition to diagnostic and therapeutic interventions, can be performed. The growth of OBLs began in 2008 when the Centers for Medicare and Medicaid Services (CMS) revised the fee schedule to support vascular office-based interventions. Endovascular interventions, in particular, have shifted from the inpatient setting to the OBL with safety data supporting this transition. The United States OBL market in 2022 was valued at 10.3 billion dollars with an estimated 7.3% annual growth rate over the next decade. Despite OBL market growth, only 12% of IRs practice in an OBL setting. Within the continued transition of care to lower-cost outpatient settings, as up to a third of hospital revenue has shifted to outpatient service sites in 2022, IR is primed for significant growth in the OBL space. The goal of this article is to highlight the unique role IR can have in the OBL setting and the critical role the OBL can have for IR.

The unique and diverse IR skill set helps OBL practices improve patient access to critical IR services and thereby positively impact population health. Relative to other endovascular specialists, IRs have the greatest reach in terms of the ability to treat patients across a wide variety of demographics. For example, IRs can offer unique outpatient-based therapies for patients with peripheral arterial disease, chronic venous insufficiency, benign prostatic hyperplasia, and uterine fibroids, which have a collective prevalence of over 50,000,000 in the United States. IR can address many other common pathologies with promising outpatient procedures in the pipeline, such as musculoskeletal and pain management interventions. Currently, most IRs are hospital-based, practicing a mix of interventional and diagnostic radiology. Hospital-based interventional care is typically episodic rather than longitudinal. This distinction is reflected by common practice patterns whereby IRs lack clinic infrastructure. The OBL facilitates longitudinal care and improves access to critical services, which may not be feasible in high-volume within hospital-based outpatient settings, given the demands of episodic hospital care with a growing volume of IR procedures. Furthermore, patients prefer the convenience and simplicity of care in physician offices instead of hospitals.

From a patient care standpoint, IRs can enhance multidisciplinary care teams, particularly within OBL settings. Services like oncological care, vascular care, men’s health, women’s health, and musculoskeletal service lines can be supported by an interventional radiologist. The unique training, which brings to the table a high level of technical expertise in conjunction with unrivaled knowledge of imaging anatomy, has the potential to not only support other specialists in their care of patients but also improve patient access to novel minimally invasive treatments interventional radiologists are trained to perform. From a patient perspective, the presence of an IR within a multidisciplinary setting has the potential to support patient autonomy by having IR play an essential role in the non-procedural management of patients and to present possible treatment options that may have the potential to be overlooked in the absence of multidisciplinary care. Ultimately, when patients are given a choice of treatment options presented to them by the physicians best suited to provide those treatments, we have the potential to improve both patient outcomes and experience.

From a financial standpoint, the presence of IRs in an OBL improves its ability to remain profitable in an ever-changing healthcare landscape. The diversification of procedures afforded by IRs is a strength unrivaled by other endovascular specialties. Inherent in the concept of diversification is the fact that IR training, which encompasses rigorous image guidance technical and clinical mastery in areas other endovascular specialists of cardiology, surgical, or nephrology backgrounds don’t receive exposure to in typical training pathways, including men’s health intervention, women’s health interventions, musculoskeletal interventions, and interventional oncology. With increasing scrutiny of peripheral arterial interventions and decreased reimbursement for these services, the primary revenue driver for most endovascular OBLs, the addition of IR services provides a high-revenue mechanism to stay competitive in a changing healthcare landscape.

Challenges IRs may experience in the outpatient space often stem from their ability to drive referrals to a given center. While there are many novel treatments for common conditions that an IR can perform, frequently, these treatments may be in direct competition with competing specialists who traditionally dominate the referral pattern as specialists rooted within a particular organ system. Furthermore, an overall limited understanding of interventional radiology by both other healthcare providers and patients may limit the potential for practice growth in the absence of proactive marketing and outreach strategies.

Possible mechanisms to aid in driving patient volume to a center centering around potential investor relationships with referring physicians or by multidisciplinary group practice with other specialists can be potential pitfalls. Anecdotally, multidisciplinary group practices with an OBL as a primary site of service have become more prevalent in the last several years. While this trend may be attributed to the clinical and financial strengths afforded by a multidisciplinary care model, there are several critical pitfalls related to IRs within multidisciplinary group practices. The primary legal pitfall is the potential for a multidisciplinary group practice to offer a legal mechanism to circumvent the Stark Law and Anti-Kickback Statute. In recent years, OBL practices with referring physicians as investors have been scrutinized due to allegations of Stark Law and Safe Harbor violations. By billing under a single tax ID, multidisciplinary group practices in-name-only may violate the spirit of Safe Harbor violations as the in-office ancillary services provision of Stark permits group practices to order Designated Health Services, including imaging studies or interventions from the group practice. Related to this concept is the potential to utilize an interventional radiologist, often without a pre-existing patient panel, as would be typical for a cardiologist, surgeon, or nephrologist as a proceduralist to drive revenue for a group practice owned by what would otherwise be a potential referring subspecialty group. The group practice model could relegate IRs to technicians performing a high volume of procedures, with clinical decision-making being driven by other specialists. IRs must maintain ethical practice patterns by engaging in comprehensive longitudinal management of patients regardless of practice type or financial arrangement.

While IRs have much to offer OBLs, OBLs can improve IR career longevity by promoting autonomy. OBLs have the potential to promote a favorable work-life balance by virtue of restricted hours typical for ambulatory settings as unpredictable work hours in hospital settings have been shown to be a significant factor leading to burnout. Furthermore, office-based care places autonomy in the hands of physicians who have the potential to direct care with fewer administrative hurdles than in a hospital setting. Critical operational decisions can be directed by physicians more readily than in hospitals. Ultimately, by reducing the layers of bloat that exist between physicians and patients, the OBL has the potential to reinvigorate an IR workforce that has been stretched to its limits in a post-pandemic world mired by staffing shortages, given the reduced presence of diagnostic radiologists in hospitals with a shift to teleradiology and increasing patient procedure volumes in hospitals.

The OBL is currently an underutilized site of service among IRs, and many existing OBLs would benefit from the presence of an IR on staff. Given the diversity of conditions IRs can safely treat on an outpatient basis in conjunction with a healthcare system that is seeing a shift in specialty care from fee-for-service to fee-for-value reimbursement models, interventional radiology is primed to thrive in the office setting. A failure to globally embrace this crucial site of service will have significant negative implications for interventional radiology physicians and the general public, who stand to benefit from our innovative minimally invasive solutions for many common disease states.