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Moving Y90 from the Hospital to the OBL: A Quickstart Guide for Physicians

Author Gabrielle Gard covers Moving Y90 from the Hospital to the OBL: A Quickstart Guide for Physicians on BackTable VI

Gabrielle Gard • Dec 8, 2022 • 86 hits

Dr. Jayson Brower describes how to successfully set up Y90 in an office-based lab (OBL), and the benefits of transitioning Y90 cases from the hospital to his outpatient practice. After gaining the consensus of both the radiology group and the hospital, it is necessary to make sure all financials are in order, from reimbursements to equipment to staffing costs. Finally, having a vendor, a Radiation Safety Officer (RSO), and a director can be helpful when navigating licensure and regulation.

This article features excerpts from the BackTable VI Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable Brief

• To secure consensus within the radiology group, Dr. Brower recommends emphasizing the benefits of a controlled work environment and the ability to treat “off-label” cases.

• The hospital may be concerned about revenue loss, but any loss can be mitigated with the increased freeing of hospital time and resources for emergencies and the newfound ability to tap into a new patient base.

• The group needs to ensure that all payers commit to cover procedures in the OBL setting, and the group must spend thorough time accounting for each financial piece of the setup.

• Finding a vendor with experience in setting up OBLs can be an invaluable resource; Dr. Brower’s group had help from Sirtex Medical for RAM license, DOH application, and the hot lab setup.

Moving Y90 from the Hospital to the OBL: A Quickstart Guide for Physicians

Table of Contents

(1) Step 1: Consensus is Key

(2) Step 2: Getting Your Financials in Order

(3) Step 3: Finishing the Setup with RAM, DOH & the Hot Lab

Step 1: Consensus is Key

While moving interventional radiology procedures from the hospital to the OBL may seem like a “foreign” practice, it is becoming increasingly prevalent in the field due to increased physician and patient satisfaction in an OBL. While Dr. Brower’s group was quick to move to a unanimous favor of Y90 in the OBL, he encourages citing benefits, such as as increased ability to control the work environment and treat “off-label” cases, in order to help cultivate group-wide consensus. Convincing hospitals is another matter as there is the concern of reducing hospital revenue by moving Y90 cases to the OBL. That said, there are hospital benefits, including the freeing of hospital time and resources for both emergency cases and procedures that require the hospital setting, and tapping into a new patient base of individuals that may not be willing to seek treatment in a hospital setting.

[Dr. Aparna Baheti]
Okay. Now you've made the decision, you're going to move your cases from the hospital to the OBL, what were the initial steps that you took when you were first deciding to start moving things out?

[Dr. Jayson Brower]
Step one, build consensus within the group. I had been beating the OBL drum for probably a good three to five years before anybody else in the group really took it seriously, and it's not that we were afraid to do it, it was just so foreign to anything that the group had ever done. We've been doing outpatient diagnostic imaging for years but transitioning from imaging to intervention really was a big leap forward.

[Dr. Aparna Baheti]
Did you have consensus within your IR section first before you took it to the big group? Or was it kind of just a present to everyone?

[Dr. Jayson Brower]
100% consensus within the IR group. I think everybody loved the concept of being able to control our work environment, so no concerns on the IR side. Frankly, even when we took it to the group, it was a complete non-issue. It was sort of along the lines of, "If you guys think you can do it, then let's go for it." I realized that's an anomaly.

[Dr. Aparna Baheti]
Wow. That's so progressive. That's amazing. You had to get consensus, then what?

[Dr. Jayson Brower]
Consensus number one, then we started putting together, I would say, parallel pathways, looking at proformas including volumes and reimbursements, and then trying to get our hospital partners up to speed and get them bought into the concept of putting an OBL in and moving cases out of the hospital.

[Dr. Aparna Baheti]
I can imagine there's probably quite a bit of pushback from the hospital when you made this decision because their revenue drops when they move stuff to the OBL. What did you use in your favor to combat this?

[Dr. Jayson Brower]
Well, it was about a year and a half process that we went through ultimately to secure the approval from our hospital partner to move this into the joint venture. I think part of it was just being honest and acknowledging the elephant in the room. We were going to be taking outpatient cases out of the hospital. It would have an impact, but what we tried to do is package it with what we thought the benefits to the hospital would be.

I would break those down into a couple of different categories. One would be freeing up time within the hospital for true emergencies and for other patients that their procedures couldn't be performed in anything other than a hospital-based setting. Now, I realize that's a bit of greenfield when you're saying, "I think we can do this," but you don't necessarily have the data to back you up. That was one piece of it.

I think another piece was a potential independent outpatient center that-- I realize I'm talking out of both sides of my mouth a little bit because we are partnered with our hospital system, but the OBL is branded under our Inland Imaging name. It does create a Switzerland of sorts where patients or refers that might not want to go to the hospital for a procedure would be willing to come to an independent third party to have a procedure done.

What we proposed was there's a certain number of patients like that out there that we think that we could capture that wouldn't get treated within our "collective system" as it stands. That was a secondary benefit as well that we proposed to the hospital.

[Dr. Aparna Baheti]
Interesting. That's a theoretical pool of patients?

[Dr. Jayson Brower]
Correct.

Listen to the Full Podcast

Y90 in the OBL with Dr. Jayson Brower on the BackTable VI Podcast)
Ep 245 Y90 in the OBL with Dr. Jayson Brower
00:00 / 01:04

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Step 2: Getting Your Financials in Order

Early in the process, it is essential to ensure that all payers on board can provide coverage for a specific set of procedure codes in the OBL setting. After calculating reimbursements based on the fee schedule and contracts, Dr. Brower’s group moved on to the “in-depth cost accounting analysis” to determine which procedures could be realistically and safely moved into the OBL. Considering the costs of the room itself, the type of the room, equipment costs, and staffing is necessary to construct an accurate financial model.

[Dr. Aparna Baheti]
Well, walk me through the process from conception of this idea to its implementation. This is going to be a long discussion.

[Dr. Jayson Brower]
Yes and, interrupt me as we go with other questions. I literally remember like it was yesterday. We did our first case in September of 2019. For about a year and a half prior to that, once we had the group on board, we had been talking with the hospital, lots of meetings about developing the proformas, looking at volumes, the nuts and bolts that really go into making it work. I would say we broke it down into a couple of different categories, and we can skip through all of the consensus building and just say we got to the point where everybody was on board.

[Dr. Aparna Baheti]
Sure.

[Dr. Jayson Brower]
I think one of the things that we did well early on, and this is my advice to anybody who is looking at going down this pathway, you want to get your payers on board as soon as you can. We have a fantastic chief revenue officer. What he did was reached out to all of our payers, excluding Medicare, they have their way that they do things, but all the private, the commercial insurers out there, we drafted a letter. We put down all of the codes that we proposed that we would like to treat and we sent this to them, and we secured their written agreement that they would provide coverage for these codes, these procedures within the OBL setting.

[Dr. Aparna Baheti]
Wow, that's really, really interesting. You are the first person I've talked to who's been proactive about that, in reaching out to the insurers before starting their OBL, at least that’s talked to me about this. Did they give you reimbursement information or just that they would cover it?

[Dr. Jayson Brower]
Well, they covered it. What they did was they said that they would cover it and, based on the fee schedule and the contracts that we had in place, we knew that once they agreed to cover it and they would cover it in the outpatient setting, we knew what that reimbursement would be.

[Dr. Aparna Baheti]
That's interesting. What was the next step?

[Dr. Jayson Brower]
Once we had the reimbursement information, we spent a lot of time going through proformas, parsing out the entire book of our interventional radiology business, looking at what we thought we could realistically move out of the hospital that would be safe to do in this type of a setting, and then going into a very in-depth cost accounting analysis of what it would cost to put the room in, what type of room would we put in, looking at equipment, staffing discussions. That took us quite a bit of time to try to get to the point where we had at least a clear idea of what we thought we can do from a financial aspect.

Step 3: Finishing the Setup with RAM, DOH & the Hot Lab

For Dr. Brower’s group, vendors were invaluable resources in their OBL setup. For instance, Sirtex Medical was instrumental in providing resources for amending their RAM license, applying to the DOH, and setting up the hot lab. While the full hot lab setup is not necessary in the OBL, state regulations (which can vary) must still be followed, something which vendors can help with. Additionally, Dr. Brower’s group utilized a Radiation Safety Officer (RSO) and an overarching director to help with regulation and documentation of procedures/protocols.

[Dr. Jayson Brower]
The two vendors we work with, Sirtex Medical, and frankly we use their product exclusively and that could be a whole other podcast right there. This was now in 2019, that the idea of doing outpatient-based Y90 was really in its infancy. They had just hired a gentleman who lives on the East Coast and he was their key point for helping to build this outpatient Y90 practice.

He helped us with amending our RAM license, with our application to the DOH, with thinking through what the setup for our hot lab had to look like and just all of the nuts and bolts that we don't really think about because, in the hospital, it's already there.

[Dr. Aparna Baheti]
Okay. I have some follow-up questions from some of our contributors and audience members about those things specifically. Are there space requirements for a hot lab?

[Dr. Jayson Brower]
There's not technically-- here's the caveat. Every state is a little bit different, and this is where these folks, whether you're using one brand or the other brand, they have people there that can help you with that. They know the state regulations and they can help walk you through it.

In Washington State, which is where we are, you have to have somewhere where you can receive the dose, and then you have to be able to dispose of the dose. A hot lab, I think, will have different meanings for different people if you're actually drawing the dose and that's what you need to do with Sirtex and SIR-Spheres. You have to receive the dose, you have to draw it up, you do need to have a hot lab of sorts, but you don't have to have a full-blown hot lab that you would think of in the hospital. You need a well counter, you need to be able to handle the dose securely, and then you need a lead-lined cabinet in order to degrade your byproducts.

[Dr. Aparna Baheti]
But you don't need the full setup?

[Dr. Jayson Brower]
You don't need the full setup.

[Dr. Aparna Baheti]
Then the RAM license, is that also a state-to-state difference, or is that a national thing that's uniform?

[Dr. Jayson Brower]
I believe it's a state-to-state difference, but either your radiation safety officer or whoever you choose to work with, they can help you navigate those different hurdles.

[Dr. Aparna Baheti]
This was actually a question from multiple people, and I'm very curious too, who is your radiation safety officer? Is it somebody from the hospital? Is it one of the physicians in your group? Is it an administrator?

[Dr. Jayson Brower]
It's one of the physicians in our group. All five of us that do Y90, we're all authorized users. One of our partners were lucky enough, before he went into interventional radiology, he did a nuclear medicine fellowship.





[Dr. Aparna Baheti]
How in-depth is that process to become an RSO? Is it like months, years? Do you have to take a test?

[Dr. Jayson Brower]
No, you basically have to either volunteer or be volunteered to do it.



[Dr. Jayson Brower]
He became our RSO, and really between him, we do outpatient nuclear medicine within our imaging center company, so the head of our nuclear medicine department also, extremely bright, diligent, detail-oriented guy, the two of them really have taken on the lion's share of making sure from a regulatory standpoint that we're doing everything that we need to.

[Dr. Aparna Baheti]
Did you have to hire any additional administrative staff just to be on top of all the regulatory stuff, or were you able to absorb that within your existing structure?

[Dr. Jayson Brower]
We were able to absorb it within our structure, but it was a bit of an evolution. When we first opened up our OBL, we did not have an overarching director, and we tried to cobble it together. Over the course of about a year or so, we hired a director, and then she went back and really with a fine-tooth comb, made sure that all of our policies and protocols and procedures were documented, that they met all of the standards.

It's not that we were haphazard, but it's one of those things that you learn as you go, and when you look back in retrospect and identify that there are ways to do it better and make sure that you're maybe a little more compliant. That's what she was able to bring to the table, and she's done a phenomenal job.

[Dr. Aparna Baheti]
She's an all-star, man. We talked about the RSO, the RAM license. Your vendor was able to help with that. Was the hospital system involved at all in that part?

[Dr. Jayson Brower]
They were not. No, we did this all independently.

Podcast Contributors

Dr. Jayson Brower discusses Y90 in the OBL on the BackTable 245 Podcast

Dr. Jayson Brower

Dr. Jayson Brower is an interventional radiologist and interventional oncologist with Inland Imaging in Spokane, Washington.

Dr. Aparna Baheti discusses Y90 in the OBL on the BackTable 245 Podcast

Dr. Aparna Baheti

Dr. Aparna Baheti is a practicing Interventional Radiologist in Tacoma, Washington.

Cite This Podcast

BackTable, LLC (Producer). (2022, September 23). Ep. 245 – Y90 in the OBL [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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