What is an Interventional Oncology practice?

What is an Interventional Oncology practice? In my highly specialized university center, it’s embolizations and ablations (about 500 a year), palliative procedures for luminal access (GI, GU, biliary - over 400), fluid drainage (over 1000), and venous access (over 2000) -- but very few percutaneous biopsies, since most of them are done by the diagnostic radiologists. One or two of the IO faculty have office hours each day; every new IO consultation generates an average of $10,000 in professional revenue over the next 12 months.

At a community cancer center I recently audited, minor procedures outnumbered major ones by 10:1. There was enough work to keep two mid-level practitioners busy, but not enough for one doctor. Therein lies the rub for operating an IO practice in the United States: 90% of the work is minor procedures, which do not pay enough at Medicare rates to support a physician’s salary. 

What are the solutions to this conundrum? One is not to do the low-reimbursement procedures. Let the diagnostic radiologists do the biopsies, the endoscopists put in the gastrostomy tubes, the surgeons place the chest ports, the hepatologists do the paracenteses. Let them lose money.  If you can fill your schedule with enough high-end therapeutic procedures, this can work for you; but how may people can do this? 

Part of the reason that IO has picked up so many of these money-losing procedures is that no one else wants to do them. But another important reason is that we do them faster, better and cheaper than other specialists, and that is good for patients and good for the healthcare system. It doesn’t take medical oncologists long to figure out that asking IO to do chest ports means they get put in within days instead of weeks, with almost no complications, and that they are always in the right place. Doing it in a fluoro suite instead of an OR costs 40% less, so the hospital profits as well.  Similarly, we do percutaneous gastrostomies faster, safer and cheaper than PEGs, and obtain core biopsies where the weenie diagnostic radiologists will only do cytologic aspirates.

In addition to quality and cost effectiveness, there is another reason why doing loss leader procedures is important for an IO practice. Every biopsy, venous access, and fluid drainage procedure is a free IO consult. It is a point of contact with a patient and with the referring oncologist. Having reviewed the patient’s medical history and imaging, the IO can inform about and offer image-guided therapies that may be appropriate to the patient’s circumstance, either currently or in the future. Informational brochures and contact information can be handed out. The lesion being biopsied may be a good candidate for subsequent ablation. Increasingly frequent fluid drainage may trigger desire for a tunneled catheter or peritoneal-venous shunt. Poorly controlled pain may benefit from palliative neurolysis, embolization, or ablation. Chemo- or radioembolization may be offered as an adjunct to systemic therapy not previously considered by the patient’s oncologist.

Mitigating the low reimbursement for these procedures requires efficient allocation of resources. Mid-level practitioners are critical. A skilled nurse practitioner or physician assistant doing 5-10 procedures a day can turn what would otherwise be a loss leader into a profitable portion of the clinical practice, returning 2-4 times the cost of his/her salary and benefits. 

There are many models of IO practice, unique to each practice environment. Do you have a particular challenge or success story to share with the IO community? Post it on IO-Central.

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