Quite a few radiology groups over the years have tried but failed to make interventional radiology a core competency. An exception is Inland Imaging Associates of Spokane, WA, which, in partnership with that city’s major hospital, Sacred Heart Medical Center, successfully transitioned from a support service to a full-fledged care provider, and did so in a way that largely preserved the goodwill of other specialties, such as cardiology and vascular surgery, that are themselves attempting to capture interventional market share.

With 35 member radiologists, Inland Imaging Associates is the leading radiology group in Spokane, a city of about 400,000 people 300 miles east of Seattle. Inland’s actual market area extends into Seattle, south to Portland, OR, and east to the Montana border, affording it a demographic pool of roughly 1.2 million prospective patients.

Locally, in addition to Sacred Heart Medical Center, there are five other hospitals, and Inland Imaging Associates provides imaging services to all but two. However, it is at Sacred Heart that Inland delivers a growing roster of interventional services.

The most utilized of these interventions include both diagnostics and therapeutics of the peripheral, renal, and cerebral vasculatures, according to Rodney Raabe, MD, medical director of the Sacred Heart Department of Radiology and a board member with Inland Imaging Associates.

“Our involvement has become particularly significant of late in cerebral vasculature service, especially as it relates to stroke therapy, both preventive and the performance of angioplasty as well as in the treatment of acute stroke and thrombolysis,” Raabe says. “We also are involved interventionally in uterine artery embolization for treatment of fibroid, in insertion of dialysis catheters, and in working on dialysis grafts when they fail or are near failing. Moreover, we are in the early stages of developing interventional capabilities for oncology cases.”


Steve Duvoisin, the chief executive officer of Inland Imaging Associates, lists four objectives his group aims to achieve by offering interventional radiology. First, he says, is to provide a higher level of care for patients in the market area. Second is to produce for radiologists in the group a greater degree of professional challenge and, consequently, job satisfaction. Third is to increase Inland’s referral volume appropriately. Fourth is to retain market share.

Inland’s embrace of interventional radiology began about a decade ago with the development of technologies and techniques to permit radiology to advance beyond a purely diagnostic role.

“Interventional radiology held out the potential to let us play a much more prominent role in achieving better outcomes at lower costs,” Duvoisin says. “There was also the appeal of attaining enhanced revenues resulting from the ability to perform more procedures.”

The group started small by utilizing basic MR machines, CT scanners, and whatever other diagnostic equipment it had on hand that could be pressed into service as interventional tools. Following exhaustive training, the radiologists began to offer a limited variety of vascular intervention procedures.

“In addition to acquiring the technical and clinical competency necessary, we also had to gain skill at educating referring physicians to accept us as an appropriate alternative to sending patients to other specialists, such as vascular surgeons and cardiologists,” Raabe says.

At about the same time that Inland was developing its interventional services, competitive forces in the Spokane marketplace conspired to drive specialists of all kinds to enter the interventional arena.

“It was not merely the cardiologists and vascular surgeons who were jumping on this bandwagon,” Raabe says. “Seemingly everyone from urologists to nephrologists had some sort of interventional service in the works.”

The advent of health maintenance organizations (which even today amount to no more than 25% of the Spokane market) had little to do with the trend. Rather, it was a response to declining reimbursement rates led by a boom in discounted fee-for-service managed care contracting, Raabe explains. “Everyone was looking for a competitive advantage,” he says.

Although Inland Imaging Associates got off to a good start with its modest interventional radiology service, efforts to subsequently build upon that early roster did not progress unfettered.

“One of our weaknesses as radiologists had always been that we never had to spend time talking to patients, getting to know them,” Raabe confesses. “By contrast, vascular surgeons and cardiologists always excelled at patient relations, and the same was even more true of their relationships with referring physicians. That placed us at a disadvantage because, when patients entered the system, we tended to be the second or third level down on the referral chain. Unless we could develop solid patient and referring physician relationship skills, success would elude us. I was convinced that the viability of our interventional services depended on persuading primary care physicians to send their patients directly to us rather than to cardiology or vascular surgery.”


Inland Imaging Associates recognized it could take interventional radiology only so far on its own. It needed sophisticated equipment, which it would have trouble capitalizing without external backing. And it needed a well-positioned friend to influence the decisions of referral sources as well as help facilitate cordial relations with specialists in other fields who might be alarmed by Inland’s incursions on their turf.

For those reasons, Inland Imaging Associates began searching for a partner and found one in Sacred Heart Medical Center, a 600-bed tertiary care facility that was, like most institutions during the mid-1990s, being sorely tested by the new economic realities of the health care marketplace.

“We had become challenged by the new competitiveness in and around Spokane, which is why we were intrigued by Inland Imaging’s overtures to us about teaming up to do an advanced radiology interventional service,” says Skip Davis, CEO of Sacred Heart Medical Center and of Providence Services Eastern Washington (a five-hospital regional network of which Sacred Heart is a member). “We liked the idea that Inland was proposing. We saw interventional radiology as something complementary to what we do at Sacred Heart, and essential to keeping us at the forefront of medicine in this part of the country.”

Raabe says: “The incentives of Inland and Sacred Heart were wholly aligned around the concept of partnering in interventional radiology. It made perfect sense for us to team up.”

Initially, this partnered approach to interventional services was marketed by meeting with prospective referral sources individually and in groups to create awareness.

“With Sacred Heart providing entree for those meetings, the technique worked well,” Duvoisin notes. “We also worked extremely hard to deliver on our promises to the referring physicians. For example, we never delayed performance of a requested interventional service. A referring physician could send us a nonemergency patient after hours and know the service would be provided promptly. We thought that if we had instead told referring physicians to contact us in the morning when our office was open to schedule an appointment for the patient, we would have lost that business. We were determined not to give those referring physicians an opportunity to rethink overnight their decision to send the patient to us. We believed that if any rethinking were to occur, the referring physician might well make a choice other than to utilize our service. By providing the service promptly, even after hours, we eliminated the possibility of physicians changing their mind.”

Inland Imaging Associates and Sacred Heart looked for other ways to make their interventional program generally indispensable. One such way was via an Internet web site for patients and referring physicians alike to learn about interventional vascular services. By mid-2000, Raabe expects that enhancements to the web site will enable patients and physicians to use their home or office computer to schedule studies.

Inland Imaging Associates and Sacred Heart today treat an estimated 300 patients a month with interventional radiologic services. Six of the 35 radiologists at Inland Imaging perform interventional procedures, generating 20% of the group’s volume. Yet, perhaps most remarkable has been the preservation of goodwill among other specialists.

“We did not trigger any turf wars with the radiology interventional service because we were very aggressive in efforts to be inclusive right from the beginning,” Davis says. “Our position was and is that there is plenty of room for everyone at this table, that no one provider should squeeze out any of the others.”

Raabe agrees: “We insisted that other players be at the table. Their presence was considered essential. We believed there was no room for turf battles over interventional radiology services, especially when we are looking at the treatment of problems such as stroke. Because, to efficaciously treat a stroke patient, we have to work as a cohesive team with vascular surgeons, neurologists and neurosurgeons, and cardiologists.”

It took some time and considerable flexibility, but the hospital and the radiology group were able — with the participation of other specialists — to formulate credentialing procedures for performing interventional radiology at Sacred Heart.

“It was a very delicate process that had to be done with a keen awareness of the sensitivities of the other physicians gathered around the table,” Duvoisin says. “Turf battles never occurred because we took pains to demonstrate to the specialists that our interventional service was actually going to benefit them and their patients.”


The inclusive approach has resulted in wins and losses for the group in its quest to expand interventional radiology services with the help of partner Sacred Heart.

For every advance Inland Imaging Associates makes into previously off-limits domains with its interventional services, the group loses at least some turf to other specialties that are making inroads of their own into areas previously the exclusive or near-exclusive realm of radiology, Raabe notes.

“We perform routine biliary cases, urologic cases, such as drainages for cancer and gallstones,” he says. “But in fact, those are areas where the urologists and gastroenterologists have really taken over what we used to do. The urologists have developed the procedures in such a way that they now offer a better and less expensive service for the patients than what we can provide. But I am not complaining. I think that is good because it is a benefit to the patients in this community.”

As a provider of interventional services, the group encounters other challenges as well. “Offering interventional radiology has imposed increased demands on radiologists’ time, on staff time, and on our ability to maintain throughput in accustomed ways because now, instead of merely doing procedures, we are more involved in the clinical care aspects,” Raabe indicates.

Likewise, finding a compensation formula for interventional that was acceptable to all group members was critical to the successful integration of interventional into a traditional radiology group practice.

“Each of six radiologists is scheduled an equal amount of time during regular business hours in what we call an interventional slot or position,” Duvoisin explains. “Everybody rotates through the same position. While in a slot, the radiologist does whatever comes in: it may be busy one week, light the next. Averaged over a year, everyone ends up carrying the same workload.

“However, after 7 pm, there is an incentive to do additional work. The interventional radiologists get half of the revenue the group collects on work that is generated after 7 pm. That is the magic formula.”


Indeed, by all accounts, the interventional radiology service has been a boon to both Inland Imaging Associates and Sacred Heart, and in more ways than one. For example, it helped persuade the city’s largest neurosurgery group to abandon plans to relocate and instead remain based at Sacred Heart.

“The neurosurgeons were considering moving their offices to one of the other hospitals where they provide coverage,” Raabe says. “While they would have continued to cover at Sacred Heart after the move, the fact that they would no longer be based at Sacred Heart would have reduced our business at the hospital. So we and the hospital asked the neurosurgeons what they needed in the way of interventional support and then went about acquiring the technologies and capabilities necessary to convince them that they would be able to better serve their patients by staying at Sacred Heart, which they chose to do.”

The partnership also has enabled both the radiology group and the hospital to be on the leading edge of technology.

“We now have an even higher level of credibility and associated prestige to more readily access new techniques and technologies being developed by vendors and major academic centers,” Duvoisin says. “For example, we are serving as a show site for a major vendor of radiologic and medical technology. In exchange for our willingness to let this vendor’s customer prospects tour our installation, we are supplied with equipment that represents the latest technology, thereby greatly aiding us in our efforts to further develop the interventional service.”

Beyond these specific positives, the partnership has worked wonders for the general relationship between Inland Imaging Associates and Sacred Heart.

“With our incentives aligned both professionally and financially, we are talking with each other all the time now, whereas before we seldom did because we had scant reason to do so,” Raabe says. “As a result, the hospital no longer is compelled to compete against us and we against them either for business or merely in the sense of clinicians-vs-administrators.”

The conviviality of the relationship between Inland Imaging Associates and Sacred Heart, cemented by the success of the interventional radiology service, has prompted the partners to explore other ventures together. Currently, for instance, the radiology group and the hospital are co-owners of a small string of outpatient imaging centers.

“Together, we share ownership of the outpatient centers’ MR machines, CT scanners, the physical plant, everything,” Raabe explains.

This joint ownership is expressed through an entity known as Inland Imaging LLC, controlled equally by Inland Imaging Associates and Sacred Heart Medical Center.

In establishing Inland Imaging LLC, the two parties avoided problems by deciding at the very onset of talks that there would be ground rules to govern the venture set-up process and that those rules would be scrupulously honored.

“The first rule was that the business plan we produced for this venture would have to make sense for both parties,” Davis says. “The second rule was that assets, be they equipment, real estate, or what have you, would have to undergo valuation by a third party, a respected professional in the valuation business to prevent endless disputes over their worth down to the last nickel and dime, with one side claiming its assets were worth more and the other arguing they were worth a lot less.

“Also, it was agreed that every decision made on the road to forming the joint venture and thereafter would not be reached with the idea that one facet of the deal would be good just for Sacred Heart but maybe not so good for Inland Imaging, or vice versa. Every decision had to be made with what was good for both parties clearly in view at all times.”

Davis says the process was helped as well by setting definitive time lines for achieving stated objectives.

“Once the time lines were drawn up, we did everything in our joint power to adhere to them,” Davis says. “This enabled us to maintain the momentum and the enthusiasm.”

Another example of joint-venturing between Inland Imaging Associates and Sacred Heart is a heart institute at which research programs are conducted to allow the introduction of the newest technology and procedures even before they were approved by the federal Food and Drug Administration. The partners also are cooperating with the neurology and neurosurgery groups to develop an outpatient neuroscience center. And, later this year, an outpatient angiography suite operated by Inland Imaging Associates and Sacred Heart will open on the Sacred Heart campus.

“We have been so willing to partner with Inland on this and other ventures because of the synergy that has emerged from our relationship,” Davis explains. “This is one of the most enjoyable and mutually rewarding business partnerships I have ever had the pleasure of being a party to.”


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