MY BEST IDEA: ESTABLISHING A STRATEGIC COMMERCIAL PARTNERSHIP FOR AN OUTPATIENT IMAGING CENTER

I was chairman of the Department of Radiology at Thomas Jefferson University Hospital from 1986 until I semiretired in 2002. Although the hospital’s capital budget process was reasonably generous to us over the years, by around 1998 I felt we were falling behind. We had substantial backlogs in MRI and CT, and a PET scanner wasn’t even on the horizon. When I pleaded with the hospital administration for additional equipment, they told me that the board of trustees couldn’t approve more dollars for radiology. After a year or two of this, I lost patience and told them I wanted to go outside and broker a deal to bring in private investment capital in a joint venture. Somewhat reluctantly, they agreed, probably to shut me up more than anything else.

I began speaking with imaging center companies and found considerable variability in what they would offer. Most proposals were quite unfavorable: we’d take most of the risk, and they’d own the majority share of the facility. This was certainly not very appealing, but I kept at it and eventually found one company in which I developed a sense of trust. The company had experience and was particularly interested in working with academic radiology departments. Its CEO struck me as someone who was knowledgeable, fair, and honest. After some not-too-difficult negotiations, we struck a deal to build a new imaging center one block away from the hospital as a joint venture owned by our department, the hospital, and the company. The company would manage the center, for which they would receive a fee, in addition to their share of any profits from ownership. It would be our department’s first experience owning any of its equipment. Almost all start up costs, including build-out and equipment purchase, were to be financed and therefore required only a small initial capital infusion from the venture partners.

Our department business manager had at first suggested that maybe we ought to do it in partnership just with the hospital, leaving the company out of it. I didn’t like that idea because neither he nor I (and certainly not the hospital) had the know how or time to do it right. For one thing, we weren’t absolutely sure the market was there for a venture like this. But the company knew how to do proper due diligence, and their subsequent willingness to participate as an equity partner and share risk with us convinced both the hospital administration and me that the plan was feasible. For another, there were dozens, if not hundreds, of little details to be attended to that were best taken care of by people who had the experience and had been through it before. Among these were having to rent space, complete architectural designs, get construction permits and licenses, draw up contracts and other legal documents, arrange for financing, work out reimbursement schedules with payers, hire personnel, and develop a marketing plan. And these were just the bigger things. Without the company’s taking over responsibility for all this, I’m convinced the project never would have gotten off the ground.

The center opened in late 2002, several months after I retired as chairman. It was a beautiful facility containing a 1.5-T MRI scanner, a multidetector CT scanner, a PET scanner, two ultrasound machines, a DEXA scanner, a general x-ray room with computed radiography, and abundant shell space to allow further expansion. The ensuing years have proven that this was indeed a good idea. My successor as radiology chair, Vijay Rao, MD, has provided outstanding leadership and, working together with the CEO and his associates at the company, has greatly expanded the venture. The original facility located a block from the hospital has more than doubled in size, with the addition of high-field open and extremity MRI units, as well as a PET/CT scanner. The joint venture has acquired 3 more freestanding MRI centers in the Philadelphia suburbs. And just this past summer, it opened a brand-new multimodality center in another suburb, and it is doing very well. All the venture’s centers are branded with the Jefferson name, and the hospital has benefited from the extension of its reach into the suburbs. That idea of more than a decade ago has proven to be a boon for the department’s practice and a healthy source of new revenue to support our research and teaching missions.

MY WORST IDEA: NOT STAYING ACTIVE CLINICALLY AS AN ACADEMIC DEPARTMENT CHAIR

I’ve had more than a few ideas that weren’t so great over the course of my career, but probably the worst of them was to give up clinical practice when I became a department chairman. Before coming to Jefferson as chairman in 1986, I had been at the Brigham and Women’s Hospital, where Don Harrington, MD, and I were codirectors of what was then called the cardiovascular and interventional radiology division. Don and I were good friends in addition to being colleagues, and the arrangement worked well because our division was jointly involved with cardiology in running the cardiac catheterization laboratories at Brigham and Women’s. Thus, we actually had two services: cardiac and vascular/interventional. I greatly enjoyed my clinical work on both those services for the 11 years I was there. Our department chairman was Herbert Abrams, MD, a giant in the field in those days and a man I had tremendous respect for. When he retired at the beginning of 1985, the hospital appointed me acting chairman, a role I assumed with some trepidation because I had never been very interested in administration and didn’t feel I knew much about it. I tried to model myself after Dr Abrams during the next year and a half while I learned the trade. He hadn’t done clinical work anymore, and although I continued to do some, I spent much more time worrying about how to run the department.

In July 1986, I left Brigham and Women’s and came to Jefferson as chairman. By then, I had learned the ropes and felt much more confident in my ability to be a chair. When I started at Jefferson, I toyed with the idea of continuing to do some interventional radiology but ultimately decided against it. I felt that running a multimillion dollar business with about 85 physicians and 300 other employees and that had major research and teaching responsibilities was more than enough to keep me busy. Moreover, the sophistication of interventional radiology was growing exponentially, and it would have been hard to justify trying to keep up with it on just a part-time basis. Another factor was that I got into the habit of making rounds in the department most days. I would go from one section to another and just pop in unannounced to see what was happening. It gave me a good feel for what faculty members were doing, and it let them know I was interested. It also gave them an opportunity to talk to me about whatever was on their minds. It was a rare day that I didn’t hear at least one gripe or interesting idea on those rounds. I felt it was a good management tool, but it took lots of time.

So I gave up clinical work, but I’ve always had regrets about it thereafter. After all, I had gone into medicine to be a physician, not a businessman. Maybe if I hadn’t been so obsessive-compulsive about doing my administrative job, I could have done both. Maybe I could have taken up something less technologically demanding than interventional radiology, such as reading chest films. Not being “in the trenches” distanced me somewhat from the daily routine in the department, and I feel it was a mistake.

Fortunately, in my semiretirement, I’ve gotten a second chance, and for that I owe thanks to my successor, Dr. Rao. Around 2004, the department began a coronary CT angiography program. As a result of the many years I had spent working in cardiac catheterization laboratories, I had a strong background in coronary artery disease and imaging of the coronary arteries. Back in 2004, no one else in the department knew much about those things. Working closely with Ethan Halpern, MD, an expert in body CT, we were able to get the program going, and it is still totally within the purview of radiology at our hospital. Like most other coronary CT angiography programs around the country, it has not grown rapidly, but it’s still been a real pleasure to once again feel like I can make some sort of contribution to patient care.

David C. Levin, MD

Disclosure:
After our outpatient imaging center opened in late 2002, I became a member of the board of directors of the company Outpatient Imaging Affiliates of Nashville, Tennessee.