Bradley A. Blackburn, MD, knows he has climbed far out on a limb by opening the first freestanding outpatient diagnostic imaging center in northeastern Ohio to feature interventional procedures among its retinue of services. Yet Blackburn projects only confidence that the 4-year-old venture will grow up to be a full-blown success story, one that could very well serve as a model for other interventional radiologists tired of feeling overlooked by colleagues from other fields and eager to escape the hamstringing effects of health-system politics.

(Left to right) Sandy Blackburn, controller, Chuck Morrell, building manager, Kristine Conrad, front office manager Denise Parrish, nurse, Tom Grimes, sales director, MSN Imaging, Cleveland.

But that day remains in the offing. For the moment, MSN Imaging is operating at only about 35% of its potential interventional capacity, 65% counting all modalities combined.

“We do expect to see growth of about 50% across the board in the next year,” Blackburn asserts. “Most encouraging is the fact that our interventional service in this past year has emerged as the strongest growing facet of our enterprise.”

Favoring MSN Imaging in its efforts to thrive is an ability to see patients far sooner than can many other imaging-capable providers in the area, within 2 to 3 days for routine procedures and stat cases usually can be accommodated the same day with precertification. “The timeliness factor is a solid point of differentiation for us,” says sales director Thomas Grimes. “Some of the hospital systems in this area might have a 2- or 3-week wait to get in for various studies and procedures. Patients, when they need to be seen, do not want to wait that long. If the patient comes to us, we can usually get them right in.”

MSN Imaging also offers extended hours of service for greater patient convenience.

“We even work some Saturdays if there are patients with special needs,” says chief operating officer Joyce Scott, RT. “For example, sedation. There are a lot of places in this market where you can get an MRI, but not all can accommodate patients in need of sedation because they don’t have a radiologist on-site as required by law. We, on the other hand, can accommodate such patients because we have the on-site radiologist who can oversee administration of the necessary narcotics.”

And then there is the attractiveness of having interventional procedures performed in an outpatient setting. At MSN Imaging, these include angiography, angioplasty/stents, venous access (CVP, PICC, dialysis catheters, ports), percutaneous biliary intervention, percutaneous renal intervention, invasive spine procedures, embolizations, TIPS, and image-guided biopsies and drainages.

“No one else in this market or in the entire state of Ohio offers these procedures in an unaffiliated outpatient facility,” says Blackburn.


Even with its advantages, MSN Imaging nevertheless faces several daunting challenges. First is payor relations. “Insurance is a major barrier to our success,” says Scott. “A problem for us is there are some procedures we would like to perform and are readily able to perform but can’t because we can’t get reimbursement. Even when we get reimbursed for procedures, there is no mechanism to be compensated for the extremely expensive supplies and/or implantables utilized in some procedures.” Those procedures include stent placements, vertebroplasty, and some port placements.

Moreover, because MSN Imaging’s interventional activities customarily take place in the outpatient setting, payors routinely demand prior approval, which they scrutinize on a case-by-case basis.

“Precertification is the word around here,” says Scott. “If we perform an examination that’s going to cost the facility $5,000 to $8,000, we have to be certain we’re going to get paid for it-and that means precertified.”

Convincing physicians to refer patients in the first place represents one more challenge for MSN Imaging. “Doctors are in the habit of referring to hospitals, and they’re encouraged to keep referring to hospitals because that may be part of what it takes to gain and keep hospital privileges,” says Scott. “Besides, doctors are well acquainted with and comfortable around the medical staff who provide or assist in the delivery of the procedures at those same hospitals.”

Part of the problem seems to be that referring physicians possess an uneven sophistication in their understanding of interventional radiology, Blackburn believes.

“They also have varying degrees of prejudice with regard to what interventionalists should and should not do, especially in the outpatient setting,” he adds. “That’s significant, because we are a completely referral-based service. One of the main challenges in building business is to convince people that we can treat people just as safely here in our outpatient facility as can be done at the hospital.

“But I look at it this way: when surgeons first decided to open ambulatory surgery centers, they had exactly the same problem of convincing their peers of procedure safety and quality. Now look at where ambulatory surgery centers are. They’re everywhere because they’ve become so thoroughly accepted.”

National health-system policies play a role too in dampening MSN Imaging’s fortunes. Non-radiology practices that have become invested in MRI, CT, and ultrasound as a way to add value in the eyes of patients worry that referring interventional work to Blackburn will lead to patients demanding being seen at MSN Imaging for noninterventional imaging services, suggests Blackburn. Also, physicians affiliated with various hospitals fear they might jeopardize their privileges by referring cases to MSN Imaging rather than to those hospitals.

“It’s unfortunate, but you enter the interventional business and you step into a very political arena,” Blackburn laments.


Problematic though politics are, they sometimes spark positive developments. The gaining of one’s independence, for instance: it was the politics of medicine, says Blackburn, that prompted him to launch MSN Imaging. Or, more correctly, it was his adverse reaction to the politics of medicine that got the ball rolling.

Originally from New York City, Blackburn arrived in Cleveland in the mid 1980s to join one of the region’s largest independent radiology groups as an interventional radiologist.

“Interventional radiology was just coming onto the radar screen back then,” he recounts, “and the group I signed up with was in the process of introducing interventional radiology to its service lines.”

Blackburn possessed the right background to help get this addition off the ground. He came certified by the American Board of Radiology and was a diplomate of the National Board of Medical Examiners; he was trained in both vascular medicine and radiology by Mount Sinai School of Medicine and Mount Sinai Hospital in New York City, Blackburn also completed a fellowship in peripheral vascular and interventional radiology at Yale New Haven Medical Center in Connecticut.

“I started my career in medicine as a surgeon—a surgeon with an interest in vascular work in particular,” he explains. “Looking ahead to what might be out on the horizon in this field, I saw that minimally invasive procedures were going to be commonplace within a decade or so. At the time, the field that was offering the training in minimally invasive procedures was radiology. So I established myself in that field.”

The Cleveland radiology group to which Blackburn belonged was an independent outfit, albeit predominantly a hospital-based service provider under contract to a number of area hospitals unaffiliated with either of the two major health systems commanding the lion’s share of the Cleveland market. As a part of this group, Blackburn expected to be able to develop for himself a strong clinical presence in those unaffiliated hospitals. It did not work out that way.

“The hospitals offered me no office space to see patients, and there was no mechanism or understanding that I wanted to be viewed as a consultant rather than as a technician,” he says.

His radiology group was not much more accommodating.

“They were themselves very tradition-bound as to how things were done,” he recalls. “It reached the point where I just couldn’t see myself being able to break out of the mold within that environment.’

In Blackburn’s thinking, the only workable solution would be to strike off on his own. But taking that course of action  was not something to be attempted lightly. Becoming master of his own destiny would take much planning and preparation. Blackburn understood that. Accordingly, he spent more than 18 months gearing up for the launch of MSN Imaging.

“I wasn’t a natural-born entrepreneur, just a person who knew how to work hard to get ahead in life,” he says. “So, the first thing I did was talk to a lot of very savvy people about the steps involved in building a business.”

He fielded some pretty good advice along the way. Even so, he remained hesitant to take the plunge. Until, that is, he was subjected to a breach of common courtesy.

“I was working at one hospital more than any of the others,” Blackburn begins. “One day, the hospital’s administration sent out a memo announcing they had secured for the hospital a better deal on the purchase of various products, including contrast agents. This meant we would be switching to a different vendor of contrast. The hospital’s motivation was not bad. But I was absolutely put off by the fact that they did not at all run this past the physicians to first determine if the alternate contrast agents would be adequate from the standpoint of quality of care.

“The administration should have asked themselves, OK, how much of this contrast is being used and by whom? Had they done that, they would have recognized that as much as 75% of consumption could be tied to just one doctor—me.

“It sounds trivial, but it was nevertheless upsetting. I didn’t know all that much about the alternative agents. I wanted to first learn more about the alternative agents, but was given no opportunity to do so before the decision to switch was made. I was afforded no opportunity to comment on the switch when it was still just being proposed. I felt this was wrong. It was the last straw. The time had come to go for broke with my MSN Imaging idea.”


The Staff

Of the 20 individuals employed by MSN Imaging, Cleveland, six are technologists (a few of whom double in senior administrative and other capacities), four are clerical in the front office, one is clerical in the back office, four are clinical aides (one of whom is a nurse), and the remainder are administrators.

“The salaried personnel include our interventional room’s nurse, the marketing people, and the managers of every department. The hourly employees are the clinical and front-office staff,” says Sandra Blackburn, controller of MSN Imaging and wife of founder and sole practitioner Bradley A. Blackburn, MD.

Benefits packages vary in content, depending on whether the employee is full- or part-time and on the nature of the individual’s job description. Included for all full-timers are comprehensive health coverage and life insurance programs. There also is a 401(k) retirement plan to which employees can contribute.

It cost approximately $5 million to get MSN Imaging up and running. The bulk of that expense covered equipment acquisitions: MRI, CT, ultrasound, mammography, computed radiography, an angiography suite, PACS, and RIS, all of it state-of-the-art.

“We elected to buy rather than lease our equipment, although the purchase price was met with the help of a traditional loan package obtained through

a bank,” says Sandra Blackburn, MSN Imaging’s controller. “We went this route of buying because there weren’t a lot of companies willing to risk leasing to a start-up company.”

The interventional piece doubtless figured into that unwillingness.

“Nobody in the world of banking understands interventional radiology,” Bradley Blackburn says. “They understand imaging a little. But when I told them I was a radiologist who would be sticking balloons and things in patients, it really threw them.”

The easier—and perhaps less risky—way to go might have been to acquire initially only those few pieces of equipment deemed most critical for a rollout of the center, then add to the asset inventory later on as revenues grew and profitability permitted. However, Blackburn felt that only a full-service offering would attract enough case volume to quickly put MSN Imaging in the pink of fiscal health.

Over and above the equipment acquisitions, Blackburn’s enterprise acquired the building that MSN Imaging occupies, a two-story, 30,000-square-foot property near a major interstate highway (which makes for convenient access from all points of the compass). The lower floor had to be gutted to make room for MSN Imaging’s operations.

“The downstairs build-out included the features envisioned in our business plan,” says Sandra Blackburn. “Among those was an operating room for the interventional procedures.”

MSN Imaging needed only about a third of the total area on the lower floor,  roughly 6,000 square feet in all. The remaining 12,000 was leased to MetroHealth, a company with no relationship to MSN Imaging that turned the square footage there into an ambulatory surgery center.

No alterations were contemplated for the upper floor. That part of the building was occupied by a group of primary care physicians (unconnected to MSN Imaging other than as rent-paying tenants, but part of the reason Blackburn decided to purchase this particular address).

“In the pro forma that was developed in conjunction with the purchase, we assumed the upstairs physicians would become strong referrers to MSN Imaging, but in actuality this did not happen,” says Blackburn. “We miscalculated how they would respond to our presence in the building. They did not support us with the level of utilization we predicted because of health-system politics.”

After realizing the upstairs doctors could not be counted on, MSN Imaging unleashed a campaignstill activeto market the center’s services to physicians elsewhere in Cleveland. Response for the most part has been encouraging.

“We have a sales force that we send out to make in-person visits to physician offices,” says sales director Grimes. “The sales force answers clinical questions the doctors have about our services and especially about the interventional services. We also talk to the ancillary office staff, since those are the people who most times send out referrals from that office.”

The sales force of which Grimes speaks consists of himself, marketing manager Valerie Smith, and a handful of independently contracted field representatives. They make return visits to the physician offices every so often following their initial contacts.

“It’s an ongoing cycle because we’re trying to encourage consistent referrals,” he says. “Once physicians and their staffs become well acquainted with us and see that we achieve good results with their patients and bend over backward to provide excellent service, they develop trust in us and become far more prone to reutilizing us.”

Effort is made as well to educate patients. “Consumers typically have no concept of interventional radiology,” says Blackburn. “It’s only those patients who have recurring medical servicessuch as kidney dialysiswho come to have a relationship with an interventional radiologist.”

Grimes finds marketing to consumers a greater challenge than marketing to physicians, simply because of the highly clinical nature of interventional radiology. The remedy has been to supply physicians with cogent, yet easily understood educational materials that can be passed along to patients.

“A good example is the literature we’ve developed on uterine fibroid,” he says. “Sometimes this condition is treated with a referral to an OB-GYN for a hysterectomy. But there are alternatives to that, one of them being uterine fibroid embolization, a procedure we perform here. So, the educational materials perform double-duty: one is to educate the patient, the other is to inform the physician who likely knows about the interventional radiologic procedure but not necessarily that MSN Imaging is capable of performing it.”


Although MSN Imaging’s location affords good access to physician offices and patients on Cleveland’s westside region, it is a bit off the beaten path for those in the eastern portion of the city. To rectify that, Blackburn intends by the end of fiscal 2004 to open a full-service satellite somewhere in the market’s opposite half.

“Having a location to serve the eastside will help boost our appeal to insurance companies and HMOs that need to sell convenience to their policyholders and members,” says Blackburn. “Being able to give the insurance companies what they need makes good business sense. But at the same time, opening a satellite will stretch our resources thin.”

That is actually an issue already, with the main thinly stretched resource being none other than Blackburn himself.

“I’m a solo practitioner and we’re right at the point where growth has made it a real challenge for me to continue much longer doing by myself what is required clinically on a daily basis,” he says. “I currently have to work until 8:30 or 9 at night to get done all the work that requires radiologist expertise.”

Blackburn presently performs two to three interventional procedures  and reads more than 50 studies daily, including studies done at MSN Imaging as well as some outside work. Blackburn sends out the nonvascular MRI studies done at the facility.

Blackburn hopes to take on at least one partner. However, “based on current service volume and revenues, we could afford only at present about a .5 or .75 FTE interventionalist in addition to me. I want to wait until we reach the point where we could sustain a full FTE before recruiting a partner, economics being what they are.”

The wait might well be a short one. “MSN Imaging is well positioned for growth generally, and in interventional radiology in particular,” Blackburn believes. “We’ve made enormous inroads in this market, although it hasn’t been easy. Sure, we’ve made our share of mistakes, but each time we learned from those mistakes and never repeated the same one twice. I think that our ability to learn quickly and not repeat mistakes is one reason we’ve been able to grow the way we have.

“This is, after all, a pioneering venture. I liken it to the early settlers out on the plains back in the 1800s who created towns and cities using little more than sheer determination. If anything, we here have sheer determination.”

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