Many turf battles have been lost throughout the years by interventional radiology to other fields of medicine. And many more will be lost in the future unless interventional radiologists can successfully identify, cultivate, and permanently build upon opportunities to provide complete patient care, as advocated and demonstrated by Robert J. Min, MD, MBA.

Robert J. Min, MD, MBA, performs clinical evaluation on a patient using ultrasound to assess veins.

Min, an associate professor and vice chairman of radiology at Cornell University’s Weill Medical College in New York City, launched in 2000 an interventional radiology practice dedicated initially to treatment of venous insufficiency and today encompassing care for uterine fibroid conditions as well as peripheral and renal arterial disease. Min’s practice, Weill Cornell Vascular, is viable enough to occupy him and two other interventional radiologists.

Decisions in Axis Imaging News spoke with Min to learn more about Cornell Vascular and how he conceived it, faced down the challenges met along the way, and plans to avoid the fate of earlier interventional practices similarly created, only to be muscled out in the end.

IMAGING ECONOMICS: What led you to conclude that a venous insufficiency service could form the basis of a self-sustaining, stand-alone interventional radiology practice?

MIN: For starters, it is hard to find a medical condition more common than veins. Tens of millions of people in the United States alone suffer from symptomatic varicose veins. So there was clearly a market for my service. A huge one. Important, too, these patients are generally very healthy with few co-morbid conditions, which meant that providing complete care would be possible by a radiologist. Perhaps most significantly, I was in possession of a treatment methodology superior to anything else available for dealing with vein problems.

In most cases of clinically significant venous insufficiency, the underlying cause is a problem with the saphenous vein. Traditional treatment entailed ligation and strippinga very invasive procedure requiring extensive anesthesia and a long recovery. The procedure frequently yielded less-than-outstanding results and tended to have high rates of recurrence. For obvious reasons, this was a treatment option not well received by patients. Surgeons were not particularly fond of it either.

In 1997, my colleagues and I explored intraluminal uses of laser for treatment of venous disease. The combination of laser technology with transcatheter techniques performed under image guidance led to the development of endovenous laser ablation (EVLTTM). This involves sealing the faulty saphenous vein by first inserting the laser fiber into it through a tiny nick in the skin. This in-office procedure is performed under local anesthetics only. Patients can resume normal daily activities immediately. It represented a huge advance in terms of risk and cost reduction, and in speed of recovery. More so, however, the results have been far superior to those of traditional surgical treatment.

IMAGING ECONOMICS: You are also performing the initial diagnosis, not just the intervention, correct?

MIN: That’s right. We use ultrasound for that purpose. Often, the determinant of a good treatment outcome is how good a diagnosis you make; the key to that here is proper ultrasound evaluation of the veins. In the past, physicians relied solely on clinical diagnostic skills to determine treatment. Over the past decade, ultrasound imaging technology has improved and the cost of machines with color and pulsed waved Doppler has dramatically decreased, making quality ultrasound equipment affordable outside the hospital setting. This has allowed practitioners to directly visualize and accurately map out all of the underlying sources of venous reflux responsible for a patient’s varicose veins, rather than relying on a clinical guess. Armed with this information, we can now more thoroughly treat all of the abnormal veins and, just as important, we can preserve the veins that are normal.

IMAGING ECONOMICS: What were the circumstances that inspired you to explore development of endovenous laser ablation?

MIN: Well, this was a disease I knew a lot about. Fifteen years ago, before starting my radiology residency, I trained in surgery at Cornell. I was fortunate to work with a surgeon who was a leader at the time in treating varicose veins. Until then, I had always assumed it was merely a cosmetic nuisance. But I soon learned that venous disease can be the cause of a lot of other medical symptoms and, if left untreated, can produce significant morbidity including skin ulcerations. I also learned of the need for improved treatment.

From there, I entered my radiology residency and then, at Stanford University, completed an interventional radiology fellowship. At the same time, I continued some of my work dealing with veins. In the course of things, it occurred to me that interventional radiology was a natural fit with vein treatment.

IMAGING ECONOMICS: After you had developed the procedure, what kind of investment did it take to get your venous insufficiency service up and running?

MIN: One source of start-up expense was going to be the facility. To minimize the cost of that, I identified and requested space that was available in an existing, off-site imaging center owned by Cornell. The space in question was an entire floor, greatly underutilized. As a result of this choice, the only construction costs incurred came from build-out of the existing space. Then there were the costs of additional staff, office systems—computers and phones—plus equipment unique to my practice. This included a $30,000 laser, and a couple of ultrasound units. Adding up all these expenses, we spent no more than $300,000 to launch the vein service.

IMAGING ECONOMICS: How did you justify the outlay?

MIN: This type of service offers good income potential. Medicare, for instance, now pays a global fee of more than $2,000 for endovenous laser performed in-office. Beyond that, we have the ability to charge for a consultation, for initial ultrasound examination, for adjunctive treatments such as phlebectomy or sclerotherapy, and for follow-up visits. Although many people may seek treatment for symptomatic varicose veins, others are looking purely for improvement in the appearance of their legs. These cosmetic interventions are 100% cash-based business.

IMAGING ECONOMICS: Are people willing to pay fully out of pocket for those elective cosmetic procedures?

MIN: Absolutely.

Patient Demographics and Delivery

Endovenous laser ablation-the interventional radiology procedure developed by Robert J. Min, MD, MBA-has become quite popular among patients. In large part, that popularity stems from the quality of results made possible by the minimally invasive and easily performed treatment. However, extensive media attention has fanned the interest.

“It’s been written about on several occasions in the New York Times; it’s been shown on national television—Good Morning America, The Early Show, Today,—and has appeared on many network news programs,” says Min. “When a procedure receives that much attention from those kinds of prestige media outlets, people pay attention and the demand builds swiftly from there.”

Min, the Cornell University associate professor and vice chairman of radiology who devised the endovenous laser ablation procedure, adds that he did not pursue the media’s gaze, but benefited from media attention following presentations at scientific meetings. “My contribution to this was simply to make myself available for interviews with the print media and for guest appearances on the broadcast programs,” he notes.

In the early days of his venous insufficiency service, Min did not rely solely on free publicity to prime the patient-referral pump. He also advertised. Radio, he says, offered the biggest bang for the buck.

“Stations you advertise on must be chosen with care—you’re looking for stations that deliver audiences made up of listeners whose demographics match those of the people most likely to need your interventional service,” Min advises. “Contrary to what might be expected, patients tend to be young and healthy.” However, the demographics of a vein practice in Upper East Side Manhattan will be somewhat different from those in Anytown, USA. Min says the typical patient is female, 30 to 50 years old, who has given birth to at least two children and has noticed her varicose veins worsen with each successive pregnancy. About 15% of the patients a practice attracts will be male, also in the 30-to-50 age range. They seldom seek treatment for aesthetic improvement: “When they come in, it will be for relief of symptoms,” Min explains. Venous insufficiency is not race-specific, although for treatment of spider veins, Min tends to see more Caucasians than any other group. “Spider veins usually are more apparent in someone with light or fair skin.”

Consumers most inclined to seek treatment for venous insufficiency are those at least in the higher middle-income brackets, which means they likely have a post-high school education (thus a higher level of sophistication in a great many matters).

“My experience has been that the more educated the person is, the more aggressive he or she will be about using the Internet or attending lectures and health fairs to gain knowledge about medical services and providers,” Min notes.

“When I used radio, I wrote my own ads and the station read them over the air [see sidebar “Cornell…”]. It was less expensive to do it that way, compared to having the ads produced by a professional company.”

In contrast, advertising in newspapers and magazines has more permanence than commercials consisting of the spoken word alone, but costs a lot more.

“No matter how the interventional service is advertised, the message needs to reflect the sophistication of the consumer,” Min says. “Thanks to today’s media and greatly expanded use of the Internet, patients are now incredibly savvy about medical procedures, risks, and likely outcomes.”

Regarding the Internet, Min says an online presence is essential in order to successfully market a vein practice. “There probably isn’t a patient who has come to me who didn’t first conduct an online search of my name to try to learn everything there is to know about me and my practice,” he says.

Beyond advertising, getting onto the lecture circuit and talking directly to the public about the vein service also proved helpful for Min.

“Health fairs and wellness seminars are great venues for outreach,” he says. “Be forewarned, though. When you lecture, expect to be inundated with questions from those in the audience—the reason is you’re offering information that leads to hope with regard to a common disease for which, up until only relatively recently, treatment has been less than satisfactory.”

—R. Smith

IMAGING ECONOMICS: What kind of patient volume were you looking for?

MIN: Up to 75 patients a week on a Monday-through-Friday schedule. I felt that was a realistic expectation based on factors such as the existing marketplace need, the efficacy of the treatment, my reputation in veins, and the fact that this was the only place people could go for this particular treatment. And, indeed, my patient-volume goals were met very soon after starting the practice, to the point that there was a 3- to 4-month wait to get in to be seen by me, then another 3- to 4-month wait for an appointment to have the endovenous laser ablation treatment done.

The backlog of cases was large enough that I was able to bring aboard a second interventionalist and then, later, a third—Neil Khilnani [MD] and Thomas Sos [MD], respectively. Today, I’m currently seeing about 30 patients a day; that’s about as many as I can comfortably handle right now, given my other responsibilities.

IMAGING ECONOMICS: What are your primary sources of referral?

MIN: Although referrals from other physicians are a source of patients, most patients come directly to us.

IMAGING ECONOMICS: You are in an outpatient setting, as you’ve mentioned. Putting aside for this discussion the matter of your build-out costs, would you have been better off in the long run establishing Cornell Vascular in an inpatient environment?

MIN: No. In general, aside from having vein-related problems, our patients are healthy. People who see themselves as healthy are reluctant to go to a hospital for simple procedures like endovenous laser ablation. You don’t encounter that reluctance when you offer to take care of their veins in an office or outpatient clinic, especially one that is designed to look very upscale and inviting as is ours.

IMAGING ECONOMICS: Did the establishment of Cornell Vascular increase your exposure to malpractice?

MIN: Again the answer is no. Treating veins is extraordinarily safe, much safer than the kinds of procedures interventional radiologists perform in a hospital.

IMAGING ECONOMICS: The majority of diagnosis and treatment in your practice deals with varicose veins. However, you are also offering consultation for uterine fibroid embolization along with evaluation of peripheral and renal arterial disease. How did you go from being just a vein service to this broader outpatient interventional practice?

MIN: The income generated by our work with veins was substantial enough to leverage those other services—all of which as interventional radiologists we wanted to offer but were not individually in sufficient demand to justify as self-contained practices. With the vein service in place, we had all the ingredients necessary to very easily incorporate the other services—and without incurring additional costs.

IMAGING ECONOMICS: There had to have been moments where your practice concept encountered opposition. What was the nature of that opposition?

MIN: Given that this was the province of vascular surgeons, dermatologists, and general surgeons, certainly there were some turf issues. The fact that I took for the service the name Cornell Vascular did not sit well with the vascular surgeons, and some were quite angry about that. In many ways, the biggest hurdle was making everyone comfortable with the notion of radiologists taking care of patients, scheduling consultations, performing clinical evaluations, precertifying procedures, delivering appropriate therapies, admitting patients to the hospital if necessary, and providing follow-up visits. It’s all part of being a doctor, but it was unheard of.

IMAGING ECONOMICS: How did you deal with those who did not want to see you succeed?

MIN: I refused to engage in any battles with them. I decided instead to focus on doing the best job I could do and, in so doing, deprive my opponents of the ability to discredit my practice or my clinical skills. But also, I had working in my favor the fact that vein disease is not easy to treat using traditional methods. I came along and was, in effect, helping the providers in those other fields by freeing them of a procedure they did not like to perform because of its complexity and high rate of patient dissatisfaction. Eventually, they realized my service was not competition but a help.

IMAGING ECONOMICS: Did those efforts pay off?

MIN: Yes. In fact, many of the vascular surgeons and dermatologists are now my patients, and so are many of their family members. Quite a few also send me their cases involving larger veins or cases that are exceptionally puzzling.

IMAGING ECONOMICS: So much for the opposition outside your world. How about opposition from within the radiology departmentdid you encounter any there?

MIN: I was fortunate to not run into internal resistance. I had—and still do have—as my radiology chairman Dirk Sostman [MD], a very forward-thinking and business-savvy individual. He was willing to listen to my ideas and, later, invest department dollars in them.

It required presentation of a cogent business plan that persuasively laid out the concept, set forth clear goals, and articulated a realistic ROI weighed against the expected, thoroughly researched costs.

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“Endovenous laser treatment has virtually eliminated the need for surgery in patients with varicose veins. The procedure is performed in less than one hour and requires no recovery time; patients can even come in for treatment during their lunch hour. Endovenous laser treatment of varicose veins was developed at Cornell Vascular and its physicians have the world’s largest experience with this breakthrough procedure.

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“Once again that’s CORNELL Vascular at (212) 752-7999.

“Get rid of those unsightly veins and get ready for summer!”

IMAGING ECONOMICS: Cornell Vascular occupies much of your time, but, as you alluded earlier, it is not your only clinical area of responsibility. What else do you do there?

MIN: Here in the same outpatient center with my practice is Cornell MRI, which operates a pair of 1.5 Tesla magnets. I oversee that enterprise. Also here is the Women’s Imaging Center. It has a CT scanner, three mammography machines, and several ultrasound units. I oversee it as well. In the near future, the medical school will be opening a state-of-the-art ambulatory care facility. Radiology will occupy a floor of this new building, and planned imaging modalities include: two 3T MRIs, one or two 64-slice CTs, multiple ultrasound units, nuclear medicine imaging and perhaps a PET/CT. In addition to overseeing these off-site facilities, much of my time is devoted to administrative responsibilities required of the vice chairman of operations for the department of radiology.

IMAGING ECONOMICS: The Society of Interventional Radiology informs us that there are fewer than 6,000 interventional radiologists in the United States, and of that number only a rare few are treating veins. Do you think more will follow your lead?

MIN: Until recently, I was the only interventional radiologist anywhere treating varicose veins. But one of the reasons I started this practice was to have an impact on interventional radiology. Historically, the strength of interventional radiologists has been as innovators. However, their weakness has been holding onto the innovations. I am certainly not the first to recognize that the one who controls patient referral is the one who will ultimately continue to perform the procedures, at least those procedures that are desirable. Dr Barry Katzen has been a champion of this for decades. Building a venous insufficiency service is a golden opportunity for radiologists to provide comprehensive care and control patient flow. As a caveat, though, no one should assume that interventional radiology thus invigorated is from here on going to win all the turf battles. It’s naive to think so. However, it’s fair to say that what I’ve accomplished is to show that there are indeed opportunities for us to secure interesting and satisfying practices wherein we’re able to provide complete care of the patient.

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