Procedural evolution: unveiling changes in OBL, PAD, and the ever-advancing world of interventional medicine

Recorded live from the Cook booth at SIR and featuring leading experts in the field of interventional radiology discussing a wide range of IR-related topics, this is the Cook@ SIR podcast series.

Hey everyone, welcome. We have what we hope to be an exciting podcast lined up for you today. Live from SIR in Cook’s beautiful podcast booth in the exhibition floor. I’m your host, Dr. Mike Watts, and I’m here with my esteemed guest and good friend, Dr. Don Garbett. So we’re planning on talking about the kind of changing OBL environment and the changes that we need to make and what we need to do in the future to advance our clinical practices. So we’re going to just kind of talk a little bit about our practices, our experience, what we’ve gone through to get to where we are, and then we’ll go into what we think we need to do in the future and people who are looking to start an OBL or people who are early in their OBL evolution, things that they should be thinking about, things they may need to do. But let’s start off with introductions. So Don, if you don’t mind, tell the audience a little bit about your practice.

Yeah, thanks, Mike. I’m Don Garbett. I’m a interventionalist in Eugene, Oregon. But briefly, I started med school in the University of Illinois, and I was a Midwest guy. So I went to Milwaukee for residency and fellowship in Indiana. Came out and kind of didn’t know what I wanted to do in IR. I knew I wanted to do IR, but where you’re going to go is a question mark I think when you come out of training.

Yeah, for everybody.

And the market was not great. So, I found a job in Texas, and I wanted to go to Texas at the time. So, went to Texas, and where I trained, we did a lot of oncology, we did a little bit of PAD, and we were just getting into DVT and PE, but not a lot of the other stuff. And I think the MSK and all these other things were pretty infantile at the time. So went to Texas and they were still doing AAAs and they were still doing the PAD. So I kind of grew into that and I got trained in stuff that I wasn’t really doing in training, which was helpful to help me grow.

Yeah, it’s a great way to start a practice, start your career at least.

Yeah, but it was still, it was an IR-DR group, and I spent a lot of my time, really probably the majority of my time doing DR. So I was getting a little bit, exactly, I was getting a little bit of what we want to do and a little bit of taste of learning new stuff. And I was trying to grow it and I was doing good growing it. But the basic things, a clinic didn’t have a clinic, there’s no way to follow up a patient. So I was running into these roadblocks and I was working on trying to get a clinic going, and at the same time we were thinking about moving, my wife and I, and we happened to talk to this group in Eugene, Oregon, and they already had a really highly functioning clinic, very busy practice. And it just so happened at the same time, a very good friend of mine moved to Eugene and his friend is married to my wife. So we followed them out to Eugene and joined this practice that was, in my mind, was world ahead of where I was. So they had a clinic, they didn’t have an OBL or anything like that. So we made the move, joined this group in Eugene, and it was sort of a leap forward for me to have a clinical practice set up. And then within six months, I was already making my OBL plans. I think at that point,

Just to sidetrack a little bit there, so when I was at Penn and I was the fellowship director and I was kind of creating the IR residency, and that first iteration of IR residency, to get people to have a clinic because we needed a real clinical direction of IR where we all are now or hopefully, or moving towards really should be by now. But to take an IR-DR group who’s functioning well and making money and saying, “Okay, we’re going to have two different doctors. One is going to sit and read CAT scans and MRIs all day and bring in hundreds of RVUs. And the other one is going to spend 15, 20, 25 minutes with a patient to talk about their veins. And that may or may not turn into a 10 RVU procedure, or it may not.” Just financially from the diagnostic radiology perspective, as you’ve seen, that doesn’t work, you need a really progressive group that understands what the clinical practice is and how it does benefit downstream. So I think hearing multiple stories like yours leaving that group and going to one that there already was an established practice that was a huge jump, like you say, a huge leap for it. But then you started making OBL plans six months later. What was kind of the impetus for that?

I was seeing where the landscape was going. I was seeing other people with OBLs, and I’ve talked to folks like Jerry Niedzwiecki and Bill Julien or just heard what they’ve said about how they’ve developed a practice. And the more you’re pulled in different directions, the more you’re pulled like “I have to read. I got six hours of scans to read.” It’s hard to have a clinical practice when you know, okay, I have eight hours of clinical work and then I’m going to have six hours of diagnostic work in addition to that. So it’s like, how do I divide the time? And I mean, that’s kind of how it started. So how do I divide that time? Well, if I can bring the revenue from the actual procedure work back, then maybe I don’t need to do that other piece. Maybe I can justify my time. It’s really about justifying your time doing stuff you want to do.

100%. Yeah. Yeah.

So that’s where it went. As far as where we’re going to move. As far as the, do you want to hear more about that stretch from development to open?

Well, I think we’ll get there. Okay. So let me kind of just be a little bit of a foil to that. So I was at University of Pennsylvania for fellowship and like you said, getting that first job is really stressful and knowing what you’re looking for and knowing where you want to go and geographically where you’re going to be happy, your family’s going to be happy, what your procedure mix is. So I basically chickened out and I said, I spent my fellowship here. I love these interventional radiologists. I’m comfortable here. I know that I can continue to build the practice that I’m already trained to do. So I stayed there for another four years, just really kind of more or less consolidating my skills. One of the things that was afforded to me specifically is when I signed on for the job, I was the director of IR for the Philadelphia VA.

So I was at Penn, but I was also at the VA and spending most of my clinical time at the VA, I was able to really develop a peripheral arterial disease practice and a real passion. And after a while because of certain limitations inherent to the VA, and I love the VA and I have nothing but great things to say about them, but my practice building kind of got halted. I was unable to continue to do more of what I was doing. And I kind of alluded earlier that I was the fellowship director and as the fellowship became a residency to become a residency director was going to take away more of my clinical time.

Roadblock.

Roadblock. So that’s exactly right. So I think as you’re looking at your career, there are things that, roadblock is a great term. So there are things that you do that don’t advance your goals and don’t speak to why you are doing the job that you’re doing. And I think that was part of it. So there were many roadblocks, but I kind of changed gears very quickly and left and joined a practice where, at that point there was just two of us IRs, and we wereww covering three OBLs over a pretty wide geographic area in Pennsylvania. And it was just constant PAD procedures. The procedures were great. I mean these patients were sick, these patients had terrible wounds. And because we were covering hundreds of square miles, I mean I could do, I dunno, 20, 30 maybe more procedures in a week. And it was great for me. I mean, I was young, fresh, energetic, didn’t have the same aches and pains that I had now, but it was true OBL only independent IR lifestyle that if I had to work from 6:00 AM to 8:00 PM I would do it and get the patients taken care of.

So sounds like you hit the perfect jackpot. Yeah, you make it sound perfect.

Yeah. So looking at one side of it, it kind of is, but the problem is when you are devoting all of your time and all of your energy to actually doing the procedures, you lose a lot of the clinical workup, the clinical follow-up, and we were just traveling from OBL to OBL, and we didn’t have any hospital affiliations. It’s very tough, as everyone listening to this podcast knows, to get an IR into a hospital when they’re not part of the group. So I think there were some real lapses in our ability to provide the care that we wanted to by not having that opportunity.

So were you lacking clinical time? Is that what happened there?

So yeah, that really was kind of the issue, one of many issues, but we did have a nurse practitioner who would be setting patients up and seeing them in follow up and doing the ultrasound follow ups. But I was just doing the procedures, which is great for developing your skills, but probably not overall in the best interest of the patients. So I got, I don’t want to say “rescued” because I was kind of thriving, maybe a little bit of error statement, but I was doing very well there. But I was asked to join the group that I’m in now to start a new fresh OBL inside the umbrella of this group in New Jersey from kind of the ground up. So my partner Nick Petruzzi, some of you probably know, started two OBLs under the umbrella of an IR-DR group and then wanted me to help him start the third.

So I jumped at the chance. He was a good friend of mine, he was a former fellow of mine at Penn. And so I knew that this group was different in that there were hospital affiliations. The OBLs were backed up by us as a group of IRs. We both cover the hospital and the OBLs. We had a very robust clinical staff in more of a corporate setting. With the DR component of the group, we had a lot of revenue coming in so we could use very high-end materials. And that’s kind of where we are now with the only kind of evolution over the past five or six years since I’ve been involved in that group is now we have vascular surgeons who cover multiple hospitals, who are my partners, who we send patients back and forth. So I think when you look at what the OBL situation is, it’s a vast array of possibilities.

So it could be just your one OBL and you go there and you build your business and you do your work and you go home and you go in the same place the next day. It can be part of a bigger group, all IRs or IR-DR or IR-DR-vascular surgery. So I’ve kind of run that gamut and we’ll talk a little bit about that and how that evolved. But as far as what you’ve been able to build, where do you kind of fit in with that and what’s your experience with what you’ve been able to achieve after moving to Oregon and starting your practice?

I think so, yeah, it’s good hearing the perspective from where you’ve gone now with the group, with the bigger group, and it’s sort of, I think a lot of people think of it as the unicorn situation where you’ve been able to do that. So I’m also in an IR-DR group and we were able to get the OBL open. And having a pre-established patient base of a lot of oncology and PAD, we sort of built an ASC. It’s an OBL, but it’s really built as an ASC. There’s locker rooms, the whole deal. It would take just paperwork to make it an ASC. But we have the ability to do cone beam. And we have two rooms. We have a big room, basically a station or fixed unit that does cone beam and we have a C-arm room, and we sort of built to grow. So we really only use the one room, but we have both. And so we are doing a lot of oncology. We haven’t moved the Y 90 over from the hospital, but that’s the intent. We’re doing–

What are the barriers to that? So I know that there are a handful of groups who are doing Y 90 outpatient, and I know that there are corporate partners who will be very helpful in helping you to do that. But it seems like I’ve talked to a lot of people who are doing a high volume embo and some really good embo work. And we can talk about that a little bit too as we talk about the reimbursement outlook as far as vascular stuff versus embo stuff. But Y 90, we’re talking about highly regulated materials, and it’s very easy in the hospital to say, all right, we have people in the hospital to deal with this. We have RSOs, we have disposal people, we have nuclear medicine techs. It just magically happens in the hospital. When you are in control of your own office, what are the barriers to that? How do you kind of overcome that? Because I think there are a lot of people who could benefit because we’re IRs, anybody who’s come to SIR in the past 15 years has just seen oncology after oncology after oncology after oncology talks and innovations. And I think everybody who’s listening to this has some oncology background and may be able to benefit from that. So what are you running into?

Yeah, I’ve listened to a lot of talks about, “Oh, we just did it. We did it. We brought it over and the people did it for us.” I think a lot of those, they’re part of a hospital employed or JV, a joint venture, and it is done for them. So we don’t have that. And so it’s been a little complicated but not hard honestly. There’s kind of three things. There’s insurance coverage, which recently the national coverage determination was changed, meaning that you don’t need an insurance carve out, which is a big deal. So before you’d have to get a special arrangement with each payer. That’s gone. There may be a couple straggler payers that you’d have to have a special arrangement, but it’s covered now by all the major payers and Medicare, so that’s no longer necessary. So that roadblock’s out of the way.

The second thing is a RAM license. So a radioactive materials license, not hard to do. What we did was we paid one of the nuke med techs at the hospital who wrote our RAM license in the first place. So she already knew how to do it. She wrote it, we edited it and then submitted it to the state and we just waited for it to come back. So we were able to just pay somebody to do that. And the third thing is what are you going to do with a hot lab? So reach out to like-minded folks. I reached out to, now I’m blanking on names I reached out to–

They’ll come back.

Some Northwestern guys–

They’re not important.

Some Northwestern guys–

They’re very important.

They were very, very important, who have done it already. And they lacked, they had the corporate folks from their institution doing the part that I spoke about. But the hot lab stuff, basically for Y 90, it’s beta radiation. You just need a wooden cabinet. The folks in my group are a little more litigious, so we got a huge steel safe to decay the materials

And to hold your guns.

You could put guns in there. So that’s kind of the three roadblocks. You do need a space. It doesn’t have to be big. It’s essentially a small closet that you could walk in, like a walk-in closet with a desk and a safe. And that being said, there’s some materials you have to buy. It’s about $20K worth of sensors and nuclear med items that you need to have. And then processes. So you have to write nuclear med materials handling processes. You can tag a nuke med tech, pay them as a consultant to write that stuff for you, or you go to Chat GPT and write it yourself.

I love that. That’s amazing. So tedious but doable.

Very doable. I think the big thing you have to think about though is if you’ve got a really big Y 90 practice already in the hospital, and you intend to bring it over, remember there’s that delay in payment. So if you bring over 10 cases in one month, it’s $20K per dose, you’re going to have a big upfront cost.

Yeah, you’re going to be in the hole.

You’re going to be in the hole for three months.

Gotcha. That’s super, super important.

Bring it slow. Do like one, make sure you’re getting paid.

This is masterclass stuff. But as I kind of go to these OBL meetings and OEIS and the meetings here, I think everyone’s looking for what they can do in the OBL because traditionally, and I think stereotypically, there’s a lot of, alright, PAD, you got in OBL, you got to do PAD. And now when we’re talking about 10 or 15 years ago, that was absolutely true, right? As kind of dirty of a word is to say, when the atherectomy code came into the outpatient world, all of a sudden you’re now able to treat patients to a point where the payment was able for you to keep your lab open, for you to pay your nurses, to pay your techs, to actually leave your hospital-based practice and create this whole OBL IR thing. Unfortunately, as we’ve all seen, the training in IR PAD has lagged behind that consistently.

And we’ve tried to improve that through societies and through the actual IR residency, and hopefully that will continue to improve. But there are a lot of people who may say, look, “I want to be in the OBL. I think that’s the right life for me. I want to have that. I’m the patient’s doctor and they’re my patient and I see them and have ownership of them, but I don’t have the skillset right now to do A PAD and I don’t feel comfortable just starting it.” So my practice has always been very, very high-volume PAD and very high-complexity PAD. So in my office, I’m doing two or three lower extremity arteriograms every day. So because my practice is so mature, both clinically and financially, I’m able to do anything and everything in my office. And I would much rather do everything in my office than the hospital, meaning I have all the wires and all the catheters and all of the balloons, specialty balloons, drug-coated balloons, the stents that I want to use, the drug-eluting stents, the interwoven nitinol stents, the tibial stents, every atherectomy device, every thrombectomy device.

I can do that in my lab. And a lot of people can’t, and financially it doesn’t work for them. And so they may feel that they’re providing a lower-level service. And we certainly see people who treat peripheral arterial disease in their outpatient setting and they’re using stents that were FDA approved for the biliary system in 1994 and for the SFA in 2001. And we’re seeing them all over the place.

For cost containment purposes.

For cost containment purposes. So that’s a huge buzzword in OBLs, but it needs to be not the detriment of the patient. And I could talk for an hour about things that are detrimental to patients that are done in the OBL, but that’s kind of part and parcel of what we’re doing here. But don’t do that, by the way.

And now with my hospital association too, I mean we’re doing deep venous arterializations, we’re doing detours, we’re doing all these things because we have that part of our practice. We’re doing hybrid endarterectomy or we’re doing AAAs for these patients because we can, but not everybody can. So as we kind of step back away from PAD and look into other things, your Y 90 example was perfect, we need to have a good mix of procedures. And that hits my practice too. So as we’ve seen year over year over year, we’re losing PAD reimbursement in the outpatient lab, 9%, 4%, 8%, 9%, and it just continues to get hit. And at the point, whether that’s driving people A) out of business or B) to use higher-margin materials, meaning less advanced or less appropriate materials, that becomes a concern. And so there does need to be this additional procedures.

Maybe we’re talking about embos or we’re talking about venous work. And I’ll talk about venous a little bit and then I’ll let you kind of get into embos. I know that you’re kind of really pushing the envelope there in such a great way. But superficial veins for patients with venous ulcers, people with venous skin changes, is actually very, very rewarding. And it is financially very feasible. So another part of my practice, which I think is really valuable and may not be possible based on your time commitments, but I do wound care every other week I spend a day in a wound care center. And where my offices are located, I’m the main vascular provider for about five wound care centers. As long as I’m a vascular guy who’s associated with wound care centers, all the wounds get sent to me. And you’d like to think, “Well, I’m going to get a bunch of critical limb ischemia.” And if I see 12 patients in a day, all new, I may see one or two that are critical limb ischemia.

I may see a couple that are neuropathic, and I may see six or eight that are venous ulcers. So you can make a really good practice with these, especially doing ablations. Everybody’s been doing ablations forever. There’s a decent margin on those if you’re high volume, but some of the foam sclerosis, whether it’s a glue, so Varithena, VenaSeal, these procedures literally take about three minutes, half hour of room time. They reimburse well, patients do very well. So that’s something that you can definitely do.

Well, you brought up an interesting thing. You go to the wound care center and you do some of that.

Yeah. So I’ll show up on a Wednesday afternoon, “Sarah?” “You got 12 patients today.” And so they may be patients that I’ve seen before. I see them on two week intervals or whatever. They may be new patients. And I’m an interventional radiologist. I’m not a podiatrist, I’m not a general surgeon, and I specialize in vascular.

So you would think, “Okay, well that’s great. You’re going and you’re seeing necrotic toe wounds and you’re seeing non-healing lateral malleolar ulcerations.” No, I’m seeing ass wounds. I’m seeing non-healing chest wounds from sternotomies. I’m seeing dog bites. I’m seeing venous wounds. I’m seeing everything. So you get a really good sense of all of it, not just arterial wounds. So I know there are a few scattered places around the country where some IRs are doing wound care, and it is I think a very valuable addition. One, just because not only the patients I see, but there are eight other docs I think who are doing wound care there on different days. And I’m now the vascular guy in that wound care center. So they’re like, oh, just send to Watts, send them to Watts. So it does build a practice, but it’s also kind of increasing your case mix and diversifying a little bit.

So that I have found to be rewarding. I think that everybody in the industry is going to tell you that treating deep veins in the OBL is a gold mine. And iliac vein stents take no time at all. And there’s this huge unmet need of treating patient who have iliac vein compression. I’ve talked to every one of these companies and they’re all pretty mad at me, but I think you need to be really careful in doing that, putting stents that are highly reimbursed and take you very little time, in people who may not necessarily need them, and especially young women who have non-thrombotic ileal, caval venous lesions, is really, I think ethically, morally, and potentially legally an issue. So you can do it, and I may do two or three a year as opposed to someone down the street from me who’s doing two or three a week.

It really depends on your patient base and where you are. But like I said, PAD is a great way to have a clinic have downstream income in that you’re going to have ultrasounds, you’re going to have CAT scans, CTAs, you’re going to re-treat these patients. They’re your patients forever. And so it’s a great patient base and it’s really satisfying for you and the patients. Venous work I think is very similar. I do a little bit in embo, but nothing like you. So I think that’s maybe one area we can look in the future. And if you can get into a little bit the horizons for embo coming up, I think that’d be very helpful.

Well, to address some of the things you said, the PAD patients and the venous patients, they’re pretty much your patients for life because it’s a chronic disease. And so when you look at the spectrum of all the things we can do, there’s not that much that’s patient for life. There’s a lot of one and done. We fixed the problem and you probably don’t need our help again.

That’s been the IR mantra for 30, 40 years. Right? I put a PICC line in and I drained an abscess. I saved this GI bleed, I coiled this GI bleed, I did this TIPS. That’s it. We high five, never meet the patient. Patient doesn’t know who I am. They go home, their life is saved. And then the surgeon who referred you to IR gets a bottle of bourbon sent to them, and then their whole family learns about what a great surgeon was who referred you to IR.

Well, I guess taking that, you were talking about embolization as another venture that you can use in the OBL or that you can do in the OBL, take out of the hospital. In my practice, we’re kind of stretching the envelope a bit. We already talked about Y 90 and that’s liver-directed therapy. Or you could think of TACE and liver ablations as well.

Do TACE patients or liver ablation patients need to be admitted ever? So I mean, I’ve done a lot of oncology in the hospital, but I think some of the fear is, all right, we’ve done a TACE, we’ve done embolization to the liver, and this patient’s going to have post-embolization syndrome in the holding area. They’re going to be cramping and febrile. Does that really happen? Is there a way– are you using certain embolics that make that less or is there some thought to that? I’m just not familiar.

That’s a good question. Yeah. So I think I had the same thing in training too. Would embolize, they stay in the hospital, PCA pump, whatever we’re going to do. I think when I first went to Eugene, we were still doing that, and some papers came out and I wish I could reference them, I don’t remember. But people were toying around with, okay, if we’re doing selective embolization, do we really need to admit? And we started kind of experimenting with it and we ended up, okay, the selective TACEs where we’re not doing a lobar, let’s send them home and see how they do. And they did fine. And then we started expanding that. So we started taking even the lobar Y 90s, I think we were always sending them home, but we were sending lobar Y 90s home. And we said, well, let’s see if we can get a lobar TACE home.

And it didn’t always work, but for the most part, folks who were like Child-Pugh A, they would tend to be fine. Or if they’re functional status, if they’re like an ECOG zero or a one, they would do okay going home. And certainly the folks who are not in as good shape would have to stay in the hospital. So I think on the clinic side, when we see them, you kind of know you don’t always know their status, but if they come in a wheelchair, that’s a hospital case. And if they come in, walk in, and they’re pretty spry and they’re just like, I want to kill this cancer, then that’s your patient, from a broad stroke, that’s your patient who’s probably going to be okay going with some pain meds. And you give them the whole deal, like, “Look, you’re going to feel crappy for a good week, but the meds will get you through it. This is how it goes.” And they do okay. But then coming back from liver, we had, I think a little bit fortuitously the renal folks. We do about a hundred renal tumors a year (RCCs).

And when COVID happened, we had a real press. The hospital was not letting surgeons operate, and they were not letting us use anesthesia. We tried kind of backpedaling, okay, we’ll do the renal ablations with moderate sedation.

Cryos.

Cryos, yes. And the nurses, the sedation nurses fought back. They’re like, “We don’t want to sedate these patients.” So we would schedule them and they would come in and then the nurses would say, “We’re not going to sedate.” Anesthesia would say “We’re not available.” So then we ran into a roadblock.

Roadblock.

Roadblock. So I’d read some papers by AJ Gunn and some other folks.

Newly FSIR, Andrew Gunn. Congratulations.

Yes, congrats. So of pre-op embo and then ablation. And so at our OBL, we have cone beam. And so I said, well, let’s see if we just do this in the OBL. We had patients waiting eight months at that point from diagnosis, and they’re freaking out.

Tumors grow, right?

Tumors grow. We’re getting repeat CTs and they’re getting bigger and everyone’s getting frustrated. The urologist that referred the patient is like, “Hey, I just saw him back six months, what’s going on?” And I’m like, “We’re trying to figure it out. We’re trying to deal with the hospital.” So we started pre-op embolizing, even smaller ones because the smaller ones we can’t see. We couldn’t see them on ultrasound.

Use lipiodol?

So yeah, we’d use lipiodol, embolize, and you could see them, even the hypovascular ones, you could see them like a Christmas tree. And so initially we would do it all same day, embolize turn them over, and then you could see it on fluoro.

Now instead of trying to target it with ultrasound or trying to target with CT, it’s like me poking a stone. So I aim, we do a cone beam, I can see where the bowel is or where anything is, just avoid that. Plan a trajectory and just poke into the tumor. And, think about it, without looking at a live fluoro, remember they’re breathing. So even if you’re doing a cone beam or you’re doing a CT, which we don’t have regular CT, you have a moving target. And now with live fluoro and the lipiodol stain, I can target a moving target.

That’s the same reason we biopsy under ultrasound, right?

Yes, moving target.

Moving target.

So it was incredible. We were able to, once we demonstrated that it worked effectively, anything less than three centimeters, which is the majority of them, probably 70 of the hundred we do a year. We just teed them all up. They’re all going to get embolized, as long as insurance proves, and we’re going to ablate. And we started separating them by day because it became a little bit hectic to try and do both things same day. So we said, okay, within 10 days we’re going to do the embo and the ablation. That’s worked out really well.

That’s actually probably very few people are doing that. But again, given the setup and given the referral base, I think that’s amazing. And to add on my experience, so one of the things about the VA and VA patients are a different animal, but the VA hospital is very strict in that patients can’t have sedation if they don’t have a ride home, and they couldn’t be admitted for a lot of things. You can’t just admit someone. And they had something called the “hoptel,” which is really cute. It was like a room, a couple of rooms on the seventh floor that you could basically board someone in overnight. But that was a whole different beast. It never really worked out. So we had a lot of RCCs, and what ended up happening very commonly and with the support of the rep who I was working with at the time, he’s like, “Look, let’s be honest here, cryo doesn’t hurt.”

I mean, putting the needle in can be uncomfortable, but it’s like doing a biopsy with a big needle. And if you can get in as soon as you’re hitting that button and that probe is going to negative hundred and however many degrees Celsius like instantaneously, basically everything freezes, the nerves freeze. They don’t hurt. And we had just come off publishing a paper at Penn 2012, 2013, or something. It was pain medication requirements for renal heat-based ablation versus cryoablation. And it was a massive difference. So that was when you have the kind of nurses pushing back or someone pushing back saying, “Hey, we’re not going to sedate this patient for a cryo,” chances are they don’t need much. They don’t really need much. And I think if that’s a limitation that you have, you don’t need anesthesia for these patients. So there are different ways to do this, and I think for a lot of people as we look to who’s starting their OBL or what their situation is, cone beam may not be a reality right now.

So that’s one. You don’t want to poke through bowel, you don’t want to poke through something you don’t understand. But sometimes even understanding what the anatomy is on a recent CT, and if you’re coming posteriorly and you know what your angle is and you’re using live fluoro for a previously lipiodol embolized tumor, that may not be an issue. And by the way, lipiodol is expensive, but it is not prohibitively expensive. We see the same things for outpatient fistula grams. If someone has a vein graft anastomotic stenosis in their dialysis fistula, data very clearly says, use a stent graft. So a stent graft may cost me three to five times what a bare metal stent is. And so you’re like, “Well, I can’t use that.” Well, that’s not true. You just have to take a little bit lower margin and understand you’re doing the right thing for the patient and you’re still making money on the procedure. So I do AMLs, I do AMLs in my office, so that’s lipiodol and ethanol and treat those and embolize those. And I get pushback from people saying, “Hey, lipiodol is really expensive.” I’m like, I get it, but I’m doing the case here. We’re actually getting the revenue from this and it does end up paying more than it costs. And so we do make money. So you kind of have to look at it like that. So a high volume of these patients using lipiodol is not out of the question.

Right? Totally. You got to look at the whole frame of what you’re using for the procedure and the reimbursement and then do the subtraction. It’s not that complicated. For a basic embo, an AML embo, for example, you need a sheath, a base catheter, a microcatheter, and an embolic.

And 15 minutes.

And it’s not long. Exactly. So you’re doing okay on that procedure. If it takes you four hours, then maybe that’s not the right thing. But on that same note, the ablations, so ablation does not, cryoablation does not reimburse a ton, and the probes are not cheap. So we’ve made that three centimeter distinction because if we need to go to a bigger tumor, you need two probes and two probes exceeds the cost of the reimbursement.

Sure. These are the important things you need to know.

And we have eaten it though.

Oh, of course.

I’ve been on cases where I’m like, “I need two probes. We’re going to eat it on this.”

We do it all the time. I mean PAD cases, if I do 10 and I make money on seven, I break even on two and I eat some cost on one because the patient really needs a balloon-expandable stent graft in the iliac or whatever we do it. Let’s keep going down the embo line, I think, because as we get into other procedures people can do, I think embos is a really exciting topic. And then we can kind of get into a few more things about maybe what we can do in maybe an ASC situation versus an OBL situation. But someone who has an OBL and is looking for building a business and getting more referrals, what else are we embolizing? What’s coming down the line? What are things that you are experimenting with that other people may not be?

Yeah, so I think this is where it gets interesting.

It’s about freaking time.

Right? We’re finally here. So there’s the basics that everybody kind of knows UFE and prostate. I’m going to leave prostate alone because I think it’s been talked about a lot.

Do you need a cone beam for it?

Don’t need a cone beam for it. I think we can talk about that very briefly. Learning prostate, if you’re learning it, you probably need cone beam. So if you’re coming, I think the new trainees probably, I’m assuming, I’m hoping that they’re learning it in training. They’re learning with cone beam. It’s not Y 90. You’re not trying to hit a tumor. It’s usually a big organ in the pelvis. You can triangulate pretty easily. You do an oblique, you do an AP, and you shoot that vessel and you’re like, that’s the rectum peristalsing wrong one. And so you should be able to figure it out. But ideally you’re getting that training in training or you’re doing workshops and you’re not learning on your patients.

Yeah, we’re doing prostates in the office without cone beam and I don’t think we’ve had an issue. Yeah, I don’t think, no, we haven’t had an issue. I know just because you just kind of threw prostates and UAEs out there kind of as low hanging fruit, which I think it is. But I just want to hit on that for a second. You need to talk to OBGYNs in your area because when they trained, they’re telling their patients this is what they’re telling their patients. So we can do an fibroid embolization. You’re going to be in the hospital overnight, you’re going to have two groin sticks. You’re going to be at a PCA pump, you’re going to be throwing up all night. It is really,

I didn’t even know that.

Oh yeah. Ask an OBGYN, who doesn’t refer to you and say, what are you expecting from a UAE? I’ve had this conversation with dozens. Dozens. They’re like, “Oh my God. The patients have sandbags on their groins and they’re in the hospital overnight with PCA pumps crying and it’s just miserable. “I’m like, “Okay, well, I do it in my outpatient office.” “How do you do that?” “I don’t know.”

Wow.

I come from the wrist, I put a little band on the wrist, they’re with me for two hours. I give them massive amounts of anti-inflammatories. I give them massive amounts of, not massive, I give them reasonable amounts of narcotics, DEA, reasonable amounts, no massive amounts for me. And then I give them a sublingual Zofran, and then I tell the patients beforehand, I’m like, “Hey, you may be miserable and there’s a real chance, it’s not likely, but there’s a real chance that you’re going to go home and over the next day or two, you’re going to feel so trashed that you’re going to want to go to the hospital for hydration. I don’t expect that to happen. It’s not out of the ordinary, but you really don’t need to be in the hospital and we’re going to do this through the wrist. You’re going to end up with just a bandaid and you’re not going to need multiple groin sticks and all this.”

And they’re like, “Oh my God, this is amazing. If I knew this five years ago, I would’ve had it done.” And they’re like, “Well, my gynecologist told me a completely different story.” So educate your potential referrers about what you do, because just like you said with the TACE patients, you know, you have some idea with your experience, how they’re going to react, and if that can be done in an outpatient setting or if it shouldn’t be. And you don’t always know that with UAEs, but you do know just the preponderance of evidence is that they’re going to be okay. So that’s my kind of spiel on UAE. It’s a procedure that I love and I wish I did it more, but I’m kind of PAD busy. So there are other people who do it, but we’re really going to get into more embos, I promise.

So yeah, that’s really interesting. I didn’t know the education lack on the OBGYN side. That’s valuable for me too.

You’re welcome.

Before we get into the, basically I’m going to talk about MSK embolization at this point. I think we have to say an ode to Okuno, to Yuji Okuno, first because he really blazed a trail for us. And there’s some folks in the US who have kind of been helping to blaze that trail. Oz, Dr. Oz.

Dr. Oz.

He’s published some cool stuff and there’s a bunch of people publishing stuff now about MSK embolization. But so what we’ve done is we’ve really kind of started talking to orthopedics. And I think that’s the important thing about this. It’s not necessarily a necessity, but for the most part, people have joint pain. They go to their primary care and they’re going to get sent to ortho. It’s going to be a hard press to have a patient sent from primary care to interventional radiology for anything. Number one. It doesn’t mean that we’re not doing that. I’m still going out and talking to PCPs and making relationships and telling them about joint pain. But what we’ve really done and what the real headway has been is talking to orthopedics. And we didn’t realize, I don’t think we realized initially how many patients orthopedics sees that. They’re like, “Wow, I got nothing for you.”

But if you think about that, not in the patient side, but you think about your auntie or your uncle or your grandpa or your mom at this point, you’re like, well, orthopedics said that my knee is effed, but they can’t do anything now. They need to wait five years or 10 years before they replace it. So if you think about it in your own personal life, it makes sense. But when you think about it as a doctor and you’re like, well, these patients are coming to ortho, why aren’t they fixing them? And then you think all the experience you’ve had of people just saying, I wish my hip didn’t hurt, but they won’t replace it yet. So you got to think just to people in your personal life, they’re going to the orthopedics. These orthopedic doctors really are treating these patients very conservatively. So there is at least intuitively, if you think about it from big picture, there’s got to be a large amount of patients who they would rather say, “Hey, go to my colleague who may be able to help you and come back to me in six months and then we’ll see where you are and see if you’re ready for that joint replacement yet.”

So I guess just thinking about it now, I hadn’t thought about this before, but now just you explaining that there is, got to be, a great opportunity.

There’s a ton. There really is. And so being part of the diagnostic and interventional group, my MSK radiologist basically sent me an email. They’re like, “Hey, ortho’s doing a journal club next month. Do you want to go and present some stuff?” And so we’ve gone a couple times and there’s a few papers. There’s obviously all the Yujg Okuno stuff, but there’s also papers about post-arthroplasty pain. And if you ask any ortho, “Do your patients that had a joint replacement have pain?” And they’re like, “Never.” But then there’s the reality, and there’s actually plenty of patients who have pain after a joint replacement.

Post-arthroplasty, recurrent hemarthrosis, right?

Yeah, and you don’t know as the interventionalist how many that is, but they know. They know. And a lot of them, we know that that’s an option, but a lot of them don’t realize that’s an option. Some of them do. They’ll Google it and be like, “Oh, I’m going to send you to IR to embolize it.” But until you make that relationship and become someone in their mind, you know? You do that with the oncologists. They know all the stuff you can do in general, maybe they don’t, but often they do. The orthos don’t. And so that’s a connection that has to be made.

It’s a whole new connection.

It’s a whole new connection. So we’ve done that, and what we’ve done is now we’re doing knee pain for folks. Where does it fit? Where’s the niche? So folks who are too heavy to have a joint replacement, folks who’ve had a joint replacement and they have pain or they have hemarthrosis, people who are too old to have a joint replacement, but they’re still really vital and they’re just limited because they can’t go up and down stairs. There’s people who have had a knee joint revision and they still have pain. Pretty much all of them still have pain after revision. And then there’s just people who are too young for their replacement. So there’s a ton of people.

Lot of categories

With knee pain, and you obviously have to evaluate them. If you see them in the clinic and they’ve got an anterior drawer, don’t analyze that. Get an MRI.

There’s clinical medicine folks.

Yeah, that’s basics. Be able to do basics. And that’s the knee. And then there’s a whole bunch of other stuff now. So there’s adhesive capsulitis on the shoulder. We’ve done a lot of it at this point. And ortho is, it’s something that they don’t have good treatments for. And if they’re telling you they do, they’re probably lying.

Mine’s getting better after three years I didn’t have it embolized, but it’s finally better. It’s finally getting better.

It’ll heal. And I have that conversation with patients. It’s going to heal itself probably, but we could do something to hasten that.

God, I’m old.

Same. So yeah, we’ve been taking care of that. The procedure’s not hard. There’s an anatomy to learn, obviously, it’s like anything else, but it works exceedingly well. It’s not a hundred percent, nothing is. So I’d say about 80% of the people we treat shoulder, they’re immensely happy. And they’ll come into the office and just swing their shoulder around and smile, and then there’s about 10% of them, 10–20% of them who are like, “It didn’t make a difference.” And so I’ll go down the road of nerve blocks and nerve ablations with those folks then. So we kept going with it. We’ve done hand embolization. So this sounds scary to everybody.

Ehich I think is amazing. I think this is absolutely amazing.

It’s pretty amazing. I was very reluctant, but one of my partners is very go-getter. And so we started seeing folks and it’s interesting. So there’s straight old osteoarthritis with Heberden’s nodules and Bouchard’s nodules, and then there’s people who just have hand joint pain, CMC arthritis. And a lot of them are either mechanics who’ve been using their hands like hammers, and then there’s people that play the piano. There’s musicians who can’t play an instrument anymore. And we didn’t know until we started seeing them and started noticing all these pianists coming in to the clinic, and we have something to offer. So what I’ll usually initially do is just, the orthos don’t want to inject a joint in the hand in general. So we’ll do a little fluoroscopic steroid injection and then I’ll see them back in a month. “How you doing?” Half of them are like, “I’m great.” “See you back in a year.” And then the other half of them were like, “That didn’t do anything.” So we’ll embolize it, and we haven’t had one yet that didn’t get pain relief. It was pretty incredible. So that’s knee, shoulder, hand. Insurance coverage is a whole other ballgame.

Yeah, I don’t know that we’re going to get into all of that.

Yeah, I don’t think we need to talk about that.

There’s a lot of things as we kind of thought about this podcast, and one of the things that it comes down to: is anybody can come up to us and ask us questions about local politics or local. So insurance coverage, referrals. We can talk about referrals, but I want to finish up with embo and kind of continue on with a little bit more of these kind of musculoskeletal neuropathic things. But I think the other kind of low-hanging fruit, I guess, when it comes to embo, this is really cool, evolving, specialized stuff. But don’t forget about varicoceles. Don’t forget about pelvic congestion and don’t forget about hemorrhoids, right? So hemorrhoids is kind of this new horizon where the data is looking really good, the patients do very well, and the procedure, again, is very easy on a flat panel detector in the outpatient setting.

And the surgeons, the colorectal surgeons aren’t in love with this right now because they do a lot of hemorrhoid surgery. But the GIs are in love with this. So again, politics are going to be politics, but if you can convince a GI that you can take one of these patients who otherwise either doesn’t want a surgery or recovery is an issue or some issue with age, but whatever it is, there are a lot of patients who can benefit from hemorrhoid embo. And we’re starting to do that and we’re starting to really see the flood gates open. In fact, once one of my newer partners started doing it and he started making it very clear that this is something that he’s interested in and started getting out there talking about it, one of our employees said, “Hey,” and this is a woman in her thirties. She’s like, “Hey, I really need this.”

And he said, “Well, tell me.” He’s like, “Oh yeah, you definitely need it.” So it’s like these are people that you wouldn’t otherwise expect who have these issues. And then the gynecologists, again, they love to know there’s something to do with pelvic congestion syndrome, and then there’s setting expectations. This is multifactorial. However, we can address this in three different ways. We can look at the gonadal vein, we can look at the iliac vein. We can look for nutcracker. There are things that we understand about the physiology and about the venous drainage of the pelvis that most other people don’t. And with setting expectations, there are a lot of procedures we can do to help with this. Anyway, that’s kind of embo where we can go and just maybe a light bulb is going off, somebody says, “Hey, I work with the orthos,” or “I work with GIs and we can do some of these procedures.”

I think as we talked about, decreasing reimbursement in the OBLs. And one of, if you think about this continuing on and kind of reaching the asymptote and basically no longer being profitable in the OBL as some people are concerned about, and the ASC possibility really starts to become attractive. So my cynical view of this is that so much business has left the hospital to go to the OBL, that the lobbying forces have continued to increase ASC reimbursement reimbursements for the reason that it’s almost impossible in multiple states, many states to be an ASC. If you don’t have hospital buy-in, if you’re not a joint venture with the hospital or if you’re not hospital owned. So it’s kind of a way to increase reimbursement for these procedures for the hospital to have a piece of. But in many states, you can have an ASC, or sometimes depending on your relationship with local hospital and list something that we’ve been successful with and a couple times, there are ways to financially make a joint venture work for an ASC with a hospital. The politics can be difficult to navigate, but I think the benefits are huge.

PAD is now basically worth just as much in the ASC as the OBL, and that looks to continue to increase as the OBL may decrease. Fistula maintenance, dialysis work, is much better in the ASC. Biopsies are better in ASCs. There are a lot of things that pay significantly better in the ASC, but there are also procedures that you can do in the ASC that you can’t do in the OBL. And so one of the things that’s driving me towards this is I have a huge CLI population, and I’m really freaking good at fixing their arteries. And we can fix their arteries, we can save their legs, we can save their toes, we can save their foot, but we can’t fix that neuropathy. So one of the big things, and you’re giving shout outs to people, I’ll give a shout out to Doug Beall.

There are people, magical people, whose whole career is fixing pain and whether it’s kyphoplasty, which is great in the OBL, by the way, we haven’t even talked about that. Great procedure, reimburses very well, and patients generally have no other option. decreases. Basically, there’s a very small number of kyphoplasties you need to do to save a life. The number needed to treat for survival benefit is tiny.

And the immense patient satisfaction there. Like immediate.

Right, it’s activity, out of bed, decreased pain medications. Anyway, it’s a great procedure. We’ve been talking forever, but that’s something again, as you get into this ASC situation and you start talking about neuromodulation and spinal cord stimulators for patients with painful diabetic neuropathy, these new generations of spinal cord stimulators, the data is amazing and the patients have no other option. I have patients who are getting acupuncture for their neuropathy because the medications aren’t working.

They’re doing all these things, and I have patients saying, “Cut my legs off.” I am like, “Sir, your arteries are perfect. There’s nothing else I can do.” He’s like, “Well, I can’t function. I’m 60 years old. I can’t do anything. I’m in too much pain all the time.” So I think as you look into pain, like the traditional pain procedures, pain injections, facet injections, and nerve ablations and nerve blocks, these are all things that are really easy to do with a little bit of training in the ASC. But my goal for this is neuromodulation spinal cord stimulation, which I think a lot of people, IRs, have the ability to do. So it’s putting leads into the epidural space. It’s tunneling some leads basically to the lower back kind of the whatever lumbar triangle there, and implanting a large, basically a large port. And I’ve always been kind of against doing some of this stuff; I don’t want to do the wrong thing for the patient.

But what we’re doing now is we can do a temporary lead placement, which you can do actually in the OBL, you can do in the office or an ASC. You can basically spend 15 minutes putting temporary epidural leads in. And it’s not scary. I mean the needles you use are actually kind of blunt. You puncture into the epidural space, just loss of resistance technique, kind of like you have CRNAs and people giving epidurals to your pregnant wife or it’s the same thing. It’s a very safe procedure. And then over the course of seven days, they can work with a company and the patients can say yay or nay. And what was actually talking to Doug Beall about this, what he kind of said is the way you look at it is when you have a patient with painful diabetic neuropathy, you can, your job is to convince them to go through this temporary trial.

And after that temporary trial, everything comes out. It’s like you’ve never touched and then it is their job to convince you to put in the permanent implant. So there’s this whole different way of looking at it to say, “Hey look, I don’t know if this is going to help. I’m not going to go in and put a spinal cord stimulator in and then you’re going to have this big surgery and have this implant and it may not work.” Now it’s “I can do a very minimally invasive quick procedure and we can see if it’s going to work. And if it is, you need to prove to me that this is worth it for you. Now that you know the benefit,” which I think is a huge kind of game changer in my mind of making sure you’re doing the right thing for the right patient.

And we’re talking about ASCs, doing that in the ASC is probably the most lucrative thing you can do, with the exception of some of the deep venous arterialization stuff that’s kind of happening now. These are other things that are ASC approved and depending on your geography can be massively beneficial for you. But we’re talking about the ability to go from an OBL where we’re getting squeezed and OEIS continues to work on this and we continue to have advocacy at the government level and trying to fight to save these OBL reimbursements. There are major powers that be that continue to drive down the reimbursement of OBLs. And if that squeezes us into ASCs, there are some really, really good things that we can do. Not just the procedure we’re already doing, but new procedures that may actually make this work out better for us.

I think that’s kind of a hot topic at SIR this year, and I’ve talked to Beall about it as well. And basically if you can take someone and show them that here we have a solution that’s going to take care of the pain you’ve been dealing with for years, they’re going to bust down your door and tell you it worked on that trial period. They’re going to say, “How soon can I get it?” Or if it didn’t work, they’re just going to say “It didn’t work.”

Which is fine.

But makes it super easy. It’s very binary. They’re not going to say “Eh, kind of worked.” It either worked or it didn’t work. And so that’s great. And that fits in with how we like to practice. We like to do things that it’s like either the worked great or it didn’t work.

Not to continue to harp on it, but this is the antithesis of the deep vein stenting where someone says, “Well, my leg swells sometimes.” And if someone says, “Okay, well we’re going to put a 20 millimeter iliac vein stent that, you’re 25 years old, I don’t know what’s going to happen to it in 10 or 15 years, but we’re going to try. Let’s do it.” And then they come back a month later and “Did it help?” “I don’t know. I mean, I still kind of swell.” “Okay, well now you have this humongous piece of metal in your deep venous system, you’re only outflow out of your leg and good luck. You’re on blood thinners forever now.” That’s what this avoids and that’s what I really, really don’t think we should be doing for patients. We should be providing a benefit that is clear and obvious. And I think this is an opportunity to do that for patients who really otherwise have no other options. They’ve all been part of the requirements of doing this that they’ve been on Lyrica or they’ve been on Neurontin for six months at high levels without any pain benefit. And you’ve seen the patients, they all fit into that.

There’s a huge population. And what I think what’s very interesting about this is that the population of this is large. There’s a squeezing reimbursement on OBL. So you have a potential population that’s very large and you have a modus that, okay, it looks like we need to change to an ASC. So you have that population already there, you just need the ASC to do it. So I mean regarding that, and it’s not just that, so it’s the new horizon stuff that needs an ASC. It’s the stuff you’ve already been doing that CMS is saying, “You need to be in an ASC to do this.” So it certainly seems like a no-brainer at this point. And I know people are talking about “Can we stay in OBL? How do we keep the OBL afloat?” But it sure seems like there’s not going to be a choice very soon.

Right. Well actually that’s kind of an interesting point. There is not everyone who is able to do this. There’s certificate-needs states there, people who either have to be an OBL or have to go back to the hospital. And I think the goal, again, OEIS, OEIS, OEIS, I love them, they’re wonderful. Part of it is trying to guarantee quality in the OBL. So we, as OBL providers, we need to take the onus on ourselves to be in a registry, to prove our value, to show that we’re doing the right things, to be completely transparent. So when it comes to arguing for, at a government level, at a payer level, that what we’re doing in the OBL is appropriate and beneficial and cost effective, we need to be very forthcoming with our data and we need to be very diligent about tracking our data. So what we do, what we spend, and what that gets the patient as far as follow-up and clinical benefit, that all needs to be recorded. And OEIS has registries. And I think as we continue to argue that what we’re doing is beneficial and is efficient and is valuable, we need to prove that. So I think that’s coming down the line.

That’s a good counterpoint as well.

But I think anybody who was coming into the space, you can no longer come into the space like you did 15 years ago and say, “I’m just going to operate basically out of my garage and do what I want, and it’s completely opaque and no one is going to know my results. No one’s going to know my complications. No one’s going to know if what I’m doing has any benefit. We’re just going to just keep it very internal.” You can’t do that. You just can’t do that. That’s not the right thing for the patient. That’s not the right thing for medicine in general. And it’s not the right thing for other people who are trying to prove their value in OBL. So I think that’s coming down the line to show our benefit that we all know we have. I mean, the payments are, it is just unbelievable what it costs to the healthcare system. It’s fractions for us to treat something that the hospital would treat for multiple more times. So I think we’re kind of winding, we’re kind of winding down. I think we’ve covered a lot. I’ve definitely learned some things, but is there anything that we didn’t touch on, anything we didn’t hit on or anything that words of wisdom you kind of want to leave here? Kind of on a parting note.

I was trying to avoid pelvic congestion, but thank you for taking us there.

I try to avoid it all the time, but it is something that, I mean, there are literally times that I’ll spend 45 minutes in a room with a woman explaining exactly what’s going on and they have a CAT scan and they have an MRI or they have an ultrasound and I can draw the plumbing and they always take my little drawings, which are god awful. And I think they take it home and put it on their fridge, but we talk about what the plumbing should be and what the plumbing is and set expectations. And sometimes they turn into procedures and sometimes they don’t and I don’t really care, but nobody else will offer them a fix.

Yeah, I’ve had that just as an aside, I’ve had that conversation with women about what’s actually going on, why they have pain, and then they’re just happy because they understand it now.

And they know they’re not crazy.

And they know they’re not crazy and they know they’re not going to die from it. And they’re like, “Well, thank you for teaching me everything. I don’t think I need a procedure, but thank you so much.” And then I get a five-star Google review because they’re just like, somebody finally taught me what’s going on.

Yeah, everybody told me I’m crazy. Everybody told I’m crazy. So yeah, that’s rewarding in its own right.

So.

Yeah, I guess if there’s anything you want to leave them with or anybody who’s looking to go into an OBL, anybody who’s in an OBL now and looking to expand their practice or just looking into the future, what are you thinking? What’s something now someone can do to benefit their practice?

Yes, I think if you’re thinking about it or you’re already in the OBL world, either way, really important that you link up with like-minded folks. There’s organizations like the OEIS, the Outpatient Endovascular and Interventional Society that has an annual meeting with a whole bunch of people that have same concerns as you or they’re getting into it and you can learn all that stuff.

A lot of legal stuff there too. There’s a whole session with lawyers and advocates and government-level people who fight for this every day. And the things you can learn from them about policies and procedures and what’s being done for you on a government level that you don’t know about. There’s a lot to pick up, not just about the procedural stuff, stuff you can’t get elsewhere.

Right. It’s the business of it and the work of it. So you get business and how to do it and how to do it better. There’s also Mary and Allan. Mary Costantino and Allan Hoffman have started the Business Institute at SIR, which I think is also very valuable. It’s only one day as of now, but it’s also, they cover finance and they cover business and they cover a little bit procedure wise, but mostly the finance and business and the legal and all that stuff. But there’s great resources out there and I think it’s very important that either way that you get involved in these things, even if you’re already in it.

I think that’s perfect. And reaching out, and we’ve actually dropped names of people that we’ve reached out to and that we’ve talked to, and I think that’s really important. People have done this, they’ve been through it. You don’t need to reinvent the wheel. You need to be talking with people who are at the same level that you are as far as advancing to where you hope to be and people who’ve done it before. And my thought being at least a kind of erstwhile amateur consultant for this, people come to me all the time and ask about my experience and they’re looking to start an OBL. The goal is, as far as I’m concerned, start actually doing something. Have some action items, meaning meet with a lawyer, meet with a planner, get a pro forma, understand the business, run the numbers. That’s kind of either you’re going to do it, you’re going to make the jump, or you’re going to kind of get off the pot kind of thing.

You need to know what you’re looking at. And when you start that, then you can start continuing down the path. But I was mentioning to Don before we started this that there was a group who came to me six years ago and said, “We’re looking to start an OBL with our group.” And now six years, I still see the same people. They’re that same group. They’re still going to these OBL, they’re going to these sessions saying, “Yeah, we’re looking to start our obl, we think, we don’t know.” And I’m like, “Man, if you started it six years ago, or at least started making steps, you’d be into it. Now you’re still a couple years down the line.” And as reimbursement’s shrinking now, it just is causing more stress. Are we going to do it? I don’t know, are we? I don’t know. So just start making concrete steps.

And again, there are a lot of people you can talk to about what those steps are, people you can talk to, get recommendations from people who will help you with that. And it’s just, I think the first actual concrete step into doing this rather than just thinking about it, be proactive and start planning the business. And if you hit a roadblock, you hit a wall and say, you know what? This is not going to work for me then, but this kind of nebulous, we’re thinking about starting an OBL and eight years later, you still haven’t, is the death knell for this. You need to actually be able to actually do it.

I think the key is proactive of what you said. And did you just remind me of quote?

Oh, quotes?

A quote. All right.

Cicero?

Yes, probably if you want to go, want to go fast, go alone. And if you want to go far, travel together.

Oh, that’s sweet. That’s super sweet.

But I think there’s a sweet spot in there of if you need to get somewhere, you just got to do it and you got to be proactive and then you can gather the right folks around you, I think to go farther at that point. But yeah, I thought it’d be.

I think we covered pretty much everything we were hoping to. I’m super excited to see you at OEIS now that this is an OEIS commercial. I’m just kidding. But thank you so much for Cook, for having us do this. This is an amazing kind of forum for this and it’s been a lot of fun. Hopefully it’s been useful, helpful for people kind of in this situation to talk about what the kind of evolving horizons and the future of OBLs look like and maybe some food for thought. And I know you’re bailing today, but I’m around the meeting for the rest of the week. If anybody wants to come, just pick my brain. Just buy me a beer.

Please bother Mike. Keep him inebriated.

Yeah, that’s when I talk the most, and I drop no F-bombs in this, but that will change if you get me a beer. Alright, well thanks again, Don. Appreciate you having me here. And again, thanks again to Cook.

Yeah, thank you Cook. Alright, thanks for, this is awesome.

This is fun, right?

Alright.