When you are one of the oldest continually operating private practices of radiology in the United States, you really don’t want to sell the practice. You’d like to keep it going.
One would think that leading an organization with 115 years of history carries extra weight, but Ray Beauchamp, MD, president of Radiology Associates of Richmond (RAR), dismisses that notion: “Everybody has the same pressures of adapting to the changing world and keeping your practice at the forefront and solvent.”
“I will say our history did one thing,” he continues. “It made it much easier to resist the temptation to sell. When you are one of the oldest continually operating private practices of radiology in the United States, you really don’t want to sell the practice. You’d like to keep it going.”
Out of a sense of responsibility to the practice shareholders, now numbering almost 60 radiologists, the leader of Strategic Radiology’s newest member group acknowledged exploring opportunities to sell. “But going into it from the beginning, we approached it with some real doubts, and part of that was because of our history,” he shared.
Two factors have influenced the practice’s culture since Dr. Beauchamp joined straight out of a body imaging fellowship at the Medical College of Virginia in Richmond in 1988—a flattening of the hierarchy and the rise of subspecialization. “At the time, Richmond and Radiology Associates were parochial, old-style kinds of places,” he recalls. “Our practice was very hierarchical, there were senior partners and then there was everybody else. If you weren’t a senior partner, you took virtually all of the call, and there was very little subspecialization.”
Today, salary differences are much flatter and the practice is highly subspecialized, including body, cardio-thoracic, pediatric, MSK, neuroradiology, breast imaging, nuclear medicine, neuro-interventional and a large section of interventional-vascular radiologists. “Everything else has stayed pretty much the same,” he shares. “We’ve always been quality-focused, we were interested in high-quality service from the beginning.”
115 Years in a Nutshell and the First Subspecialist
It’s not easy to sum up 115 years of history in 10 minutes, but Dr. Beauchamp provided a quick review that mirrors the history of the specialty. RAR was founded in 1905 by a prescient physician who purchased an x-ray machine for $200 and installed it in an office. The practice remained essentially the same into the 1950s, when fluoroscopy was added; angiography was added in 1972; CT and the ability to do angioplasty arrived in 1977; and, in 1983, RAR was the first group practice to request a certificate of need for MRI in Virginia.
By the time Dr. Beauchamp arrived in 1988, RAR was reading from multiple CT scanners, doing angiography at most of its hospitals, and had MRI and nuclear medicine in several locations.
What happened next precipitated one of two milestones that have driven practice growth since his arrival: subspecialization. “With the advent of thrombolysis, we were using urokinase and not everybody was comfortable doing that, so two things happened,” he shares. “One, we started doing a more advanced level of interventional radiology, but two, we had to start specializing.”
When thrombolysis arrived in 1990, neuroradiologist Efstathios Spinos, MD, started doing that whenever he was available—which was almost all of the time—in addition to his regular call duties. By 1993, the need for thrombolysis had grown enough to warrant hiring a second radiologist just to do interventional procedures, and that was the beginning of RAR’s interventional service. “We had for the first time a subspecialty service—two doctors who only did interventional,” he recalls. “They did all of the IR call, and the rest of us quit being on call for interventional, and that was a big change.”
The next, transformative change was the introduction of PACS, of which RAR was an early adopter. “In 2000, we were the beta test site for GE’s Centricity PACS, the first PACS GE created to cover multiple hospital sites,” he notes. “That allowed us to read from any hospital, no matter where you were sitting. Those two things—the development of the IR service and the PACS—led to an explosion in subspecialization. Everyone we’ve hired in the last 15 years or so has a fellowship, but everybody also does general radiology, particularly ER work.”
Dr Beauchamp recalls visiting Eliot Siegel, MD, and his practice at the University of Maryland, the first filmless practice in the country. “It seemed odd that there would be a radiology practice with no x-ray film, but today you’d never find one,” he notes. “Things change so quickly that sometimes you forget it was ever the other way.”
New Service Lines, New Ventures
The practice continued to grow throughout the first decades of its second century. RAR opened an outpatient imaging center in 2000, sold it to its primary hospital partner, HCA, then entered into a joint venture with the system on three more imaging centers. The same radiologist who spearheaded thrombolysis started a neurointerventional service in 2010. The group shared that for a while with a neurosurgery practice but currently does 100% of the neuro-interventional work. RAR also operates the Richmond Vascular Center in cooperation with a different surgical group, where it does peripheral arterial disease procedures and interventions, uterine artery embolizations, kyphoplasties, and hemodialysis fistula evaluation and repair.
The vascular center has weathered its share of adversity since it was founded in 2010, most recently a significant drop in reimbursement for evaluation and treatment of malfunctioning hemodialysis fistulae. But Dr. Beauchamp is hopeful that the center’s fortunes are on the upswing, offering a sterling example of the resilience and innovation exemplary of interventional radiology. RAR interventional radiologist Jeffrey Hull, MD, invented the Ellipsys Device, a percutaneous device that creates hemodialysis arterial venous fistulae without the need for surgery.
“Ellipsys was approved by the FDA earlier this year,” Dr. Beauchamp reports. “The procedure produces a high-quality standardized AV fistula. We have not seen aneurysmal dilatation as can happen with surgically created fistulas because of the reliable size of the vascular connection. It’s quick and relatively easy, interventional radiologists and interventional nephrologists are doing them and certainly surgeons can learn.”
Navigating Covid-19, Planning for the Future
While RAR experienced the same dramatic Covid-19 volume declines as other radiology practices, Dr. Beauchamp suggests, “It could have been a lot worse.” Federal funds through various relief programs buoyed the practice through the brief “very slow times.” Volumes have rebounded to 90% of pre-Covid-19 volumes, although ER volume remains down 20%. He quips: “If I had to pick one thing to be slow, I’d pick ER because it’s the most inconvenient: it’s all night, all day, all Saturday, and all Sunday.”
He gives high marks to RAR’s hospital partners for managing the crisis. “We are very fortunate in that our hospital partners do a very good job of managing our hospitals, and they also do the job of managing our imaging centers,” he reports. “There were some difficult decisions about what to shut down, what to leave open, how to continue to provide services with social distancing and during the shut-down periods. They did a very good job. We had a little input, but, basically, they took care of it, and we went along for the ride.”
Keeping nine hospitals and multiple outpatient locations happy is all about providing quality service. “Quality reporting, timely reporting, talking to your referring physicians, it is all about quality,” he said. “But thinking ahead, you need to have the resources to be able to do that. Some of that is infrastructure, but the majority of it is staffing, making sure you have enough people and the right people.”
Looking ahead, Dr. Beauchamp sees continued growing demand for medical imaging, but he cautions that radiologists will need to be scrupulous about quality and service if they want to hold onto the specialty. He notes, “The challenge for radiologists is providing very high-quality medicine with very high-quality service to the patient, referring physicians, and hospital clients. We must also pay attention to payers to make sure we are doing it at a reasonable price. If we don’t do a great job, other people will do it for us.”
Keeping up with market changes and the advent of the corporate practice of medicine are Dr. Beauchamp’s greatest concerns. “They have a lot of money, a lot of size, and breadth, and they can pay for infrastructure,” he notes. “They can come in and offer services that we can’t provide by ourselves. That was an impetus in joining Strategic Radiology.”
The affiliation with Strategic Radiology relieves a lot of that pressure, he says, pointing to the ability to share ideas, best practices, and quality data with other radiology groups, as well as SR’s cloud-based clinical data exchange infrastructure project. “With SR Connect, we should be able to cross cover as needed,” he says. “If you have to have a neuroradiologist on 24/7, that is hard to do unless you are the size of Radiology Associates of North Texas. All of those things allow you to defend yourself against the people who would like to eat your lunch.”
Hub is the monthly newsletter published for the membership of Strategic Radiology practices. It includes coalition and practice news as well as news and commentary of interest to radiology professionals.
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