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

[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.

[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.

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[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.