There’s no shortage of resources that offer advice on starting a vein practice (including this magazine). From books to lectures, practice management companies to marketing companies and more, part of the hurdle to starting a vein practice may very well be deciding on which path(s) of support to choose. But this article isn’t about that.

We spoke to two doctors with successful practices, one with a single office practice and one with a multi-location practice, and asked them for their insights on some of the major topics associated with starting a successful vein practice. Mark Isaacs, MD, has a successful single location practice, Vein Specialists of Northern California, in Walnut Creek, CA. Dr. Isaacs has specialized in phlebology since 1990, and among his many credentials he is a fellow of the ACP and AAFP, has served on the faculty of the ACP and IUP, has taught the course for the ACP’s phlebology boards, was among the first doctors to take and pass the ABPh Board Certification and was asked to join in the original FDA study of endovenous laser treatment for venous disease treatment. He is also an ABPh diplomate and has been a clinical faculty member at both the University of California San Francisco and University of Minnesota.

Ariel Soffer, MD, FACC, is the founder of Soffer Health Institute and has four office locations in south Florida. Dr. Soffer was board certified in internal medicine in 1995 and cardiovascular disease in 1998, and was recertified in 2008. He served as Chief of Cardiology for Jackson North Medical Center and maintains teaching relationships with Florida International University and Nova Southeastern University’s medical school. Dr. Soffer has authored multiple peer-reviewed articles on cardiovascular disease and has multiple phlebology patents registered with the U.S. patent office. He has been training physicians in phlebology since 2005 for multiple companies and his practice is an AngioDynamics Endovenous Laser “Center of Excellence.” He is member of the ACP and is Chair the Venous Session for the New CardioVascular Horizons Symposia.

We asked both about their practices, what they felt made them successful, and how they got to where they are. We asked for staffing advice, choosing a location, equipment, strategic alliances, the legal aspect, billing/payment strategies and the minimum training a doctor should have if he or she endeavors to start a vein practice. Here’s what they had
to say:

Make the Commitment

Both doctors treat veins as a full-time practice, and neither started as a part-time practice that grew to full time. Dr. Isaacs’ background provided a great perspective as to why it’s important to make the full commitment to starting a full-time phlebology practice: “I was recruited in 1990 from my primary care practice by a larger, nationally based group that wanted to open a phlebology practice in my area. At the time I couldn’t see why I shouldn’t be able to integrate phlebology into my existing practice, but the larger group was adamant that the new practice had to be a full-time specialty commitment. With the perspective of time, it became obvious that they were right. Phlebology is not just a set of procedures; it’s an entire field of knowledge that requires serious dedication, the right equipment and extensive supplies. Since then I’ve seen a couple of primary care offices in my area try to offer vein treatment without success. Patients seeking vein treatment generally want to see a specialist.”

Dr. Soffer integrated phlebology into his cardiology practice but likewise made a full-time commitment to treating venous disease within his practice: “At Soffer Health we have both full a full-time cardiology division and concurrently a full-time vein division. We felt that cardiology and the practice of cardiovascular disease (the way our ABIM board certification classifies all cardiologists), goes hand in hand with phlebology. Thus, we were able to incorporate (treating veins) easily into our full-time cardiology practices about a decade ago. We had extensive training in ultrasonography, catheter-based techniques and peripheral vascular anatomy. We then received further training with experienced phlebologists in many of the traditional and emerging techniques.”

Singularity or Multiplicity?

Whether your ambition is to have multiple locations or work steadfastly growing one location, both doctors offer advice on their chosen paths.

Dr. Soffer’s intent was always to open multiple locations. “We ensured our success by documenting all of our best practices from our first office and bringing it to our satellites. Our first location was built as our flagship and our group was cautious to make sure that the customer experience was superior. From the experiences gained in our first office, we realized that a vein practice is different from the typical cardiology practices of yesterday. Thus, I made all of our staff read a book called If Disney Ran Your Hospital: 9½ Things You Would Do Differently, written by Fred Lee, a former Disney employee turned healthcare executive. Building a practice oriented toward an exceeded expectation is invaluable.”

Dr. Isaacs, on the other hand, admits that his personality is suited toward having a single location and offers a consideration for those who want to grow quickly, “In 1994, I separated off from the larger group that originally recruited me, and although I probably have had the opportunity to open multiple offices over the course of time, that wasn’t a goal that appealed to me. I’ve been content to concentrate on offering quality care at one centrally located office. In my case, at least,this was probably more a decision based on personality and ambition than opportunity. I would give a word of caution to anyone expecting to expand to multiple locations quickly, however. This kind of business plan often means taking on a great deal of debt, and an unexpected economic downturn is all it takes to put that kind of practice out of business.

The Ultrasound Tech — Your Most Valuable Staff Resource

Both doctors noted that having an ultrasound technician who is skillful in evaluating the superficial venous system is critical. Dr. Isaacs offers experiential advice and a terrific visual analogy regarding working with his ultrasound tech: “I believe that the toughest part of staffing is finding a good ultrasound tech. When I started there was no such thing as a protocol for studying the superficial vein system, and even now finding a tech who is proficient in this kind of evaluation is difficult. Even if you do your own initial screening examinations you will almost certainly need a tech to guide you with endovenous ablations and to help with difficult evaluations. I’ve been fortunate enough to have worked with my tech, Mike Gardner, for the full 23 years of my practice. I often joke that when we work together we are so familiar with each other’s thinking that it’s like having one brain with four arms.”

Dr. Soffer adds, “We cross-trained all of our staff, particularly our ultrasound technicians. The most important person in the beginning was the ultrasound tech, as proper initial patient selection was crucial. A common mistake is to not update your ultrasonagraphy staff in superficial anatomy disease detection and documentation. Through experience we learned to make sure that only experienced phlebology trained ultrasonographers were involved in opening up an area.”

Dr. Isaacs also addressed the topic of nonphysicians performing treatments for consideration. “If you want to have nonphysicians helping with procedures (an RN doing sclerotherapy, for example), you’ll need to look carefully at the laws and restrictions that govern the use of these personnel in your state.”

The Three Rules of Real Estate

While location will play a vital role, as Dr. Isaacs pointed out, consideration should be given to more than just the bricks and mortar. “Since a significant portion of your business likely will be out of pocket for treatment that is not medically necessary, a careful study of local demographics is mandatory, and this is where a consultant can be very helpful. Starting a practice in an area where most of the population is in a closed-panel HMO, for instance, obviously is doomed to failure. Beyond that, being accessible by car and public transportation is highly desirable. Local geography can be a factor, as well. In the San Francisco Bay Area where I am located, people perceive bridges as obstacles, a problem for drawing patients from across the Bay.

“When I started my practice there was virtually no competition, but times have changed. If you are considering opening a practice in an area where there is established competition you should be confident that there is the patient population to support more than one practice and that you have the referral base in place to support your office. Simply having training, skill, an office and a winning smile is no longer enough.”

Tools of the Trade

When asked what equipment is necessary to get started and how best to manage payment, both doctors answered respective to their personal experiences of starting up, but both agree that a radiofrequency generator or laser is integral. Dr. Soffer commented, “The only real equipment early on was the thermal energy generators. Now the companies make trial programs very cost effective. Often, working with either a consultant or one of the thermal energy generator companies can help pave the way. I suggest investing the least amount that you can at first as most of the equipment is already in your office, but never skimp on quality.”

Dr. Isaacs offered the following considerations: “I feel strongly that anyone who is serious about phlebology as a specialty needs to learn how to do a venous ultrasound study and should have a decent, quality duplex ultrasound available in the office. There are many times referring patients to a vascular lab is not feasible and will not give you the information you need. Also, patients are impressed when you can show them on the ultrasound screen the reflux that you will be treating.

Decisions regarding sclerosants and suppliers should be made well in advance, and all supporting supplies, including compression hose, should be in stock. Assuming endovenous heat catheter ablation will be a part of your practice, either a radiofrequency generator or laser equipment needs to be obtained and a relationship with a reliable rep should be established. For a new practice, leasing equipment is probably more cost effective than purchasing, but this is a question that should be directed to an accountant.”

Networking for Referrals — Do It

Given the multitude of marketing options available (which could consume an entire article unto itself), we asked the doctors how important developing doctor and patient referrals was to the success of their practice. Both doctors felt strongly that these areas are critical for success. Dr. Isaacs commented, “A referral base is critical to the long-term success of a practice. Making yourself known to primary care offices in the area and educating them regarding appropriate referrals is essential. Ultimately, the quality of care you deliver to your patients and the feedback they give to their doctors will determine the success of your practice. There’s no substitute for positive word of mouth.”

Dr. Soffer stated, “Podiatrists, internists and even OB/ GYNs were our best referring mechanisms. Also, nurses in the hospital helped spread the word particularly after good personal results. Although patient referrals take a bit of time to happen, once they do, they are the best.”

The 'L' Word

When it comes to legal considerations, both doctors noted that proper malpractice insurance is an important consideration. Dr. Soffer added that since he was expanding from an existing cardiology practice, “Minor adjustments to our patient consent forms were about all that was legally necessary.”

Dr. Isaacs added, “Since phlebologists currently come from a variety of specialty backgrounds, it’s important to make sure your new practice is within the scope of your training. You should check with your malpractice carrier to make sure you have adequate coverage and that they have no restrictions on your new practice. You may also need to check with the medical board in your state to make sure you are aware of any legally mandated guidelines. I believe that being a diplomate of the American Board of Venous and Lymphatic Medicine (formerly the American Board of Phlebology) adds credibility to your practice.”

Services Rendered

When asked for advice on billing, both doctors gave insightful perspectives. Dr. Soffer noted that for insurance purposes, staff education is very important in order to make sure notes are complete and meet the insurance criteria. “Often this requires staff education, so things like vessel size, reflux time, compression stocking usage, etc., are adequately addressed prior to the authorization request. Also, proper and consistent clinical photography is absolutely crucial for documentation and is quickly becoming a gold standard for phlebology practices since smartphone technology has made it so easy to accomplish, particularly with satellite offices. Proper documentation, coding and billing is possibly the most important piece to get right, and we strongly recommend ongoing training for this part of your staff. This can be done formally with a consultancy or lots of information is available on peer-to-peer websites. Also, patient financing for cash paying patients for cosmetic procedures through companies such as CareCredit can be a useful additional strategy.”

Dr. Isaacs noted that in addition to proper coding, it is also critical to thoroughly communicate the extent of coverage with the patient. “I now contract with most of the major carriers and am a Medicare provider. This requires that my staff be updated constantly on the ever-changing criteria for medical necessity, but I see no way around that. We are careful to give patients estimates at the time of their initial consultations regarding what portions of their treatment will be covered by a third-party payer and what will be out of pocket. We make sure to get all necessary authorization in advance. Out-of-pocket payment is made at the time of service. We do all our own billing, but outsourcing this function is an alternative.”

Essential Training

Both doctors agreed that training with a specialist is an important element when starting a phlebology practice in order to ensure best outcomes and patient satisfaction. Dr. Soffer said, “If the doctor has a vascular, cardiovascular, or radiological background and understanding of ultrasonography of peripheral vasculature, a course in phlebology and endovenous ablation is usually sufficient to begin helping their patients. If hands-on experience is needed, Dr. Almeida’s course in the Dominican Republic can be very useful. Dr. Ron Bush also is a wonderful phlebology teacher and will often fly into practices around the country training enthusiastic physicians.”

Dr. Isaacs noted that due to current lack of phlebology in medical school curriculum, the few fellowships offered across the country, and the fact that while some vascular surgeons receive training on vein disease in their curriculum it is rudimentary at best, there are challenges for the emerging physician looking to enter into phlebology. To this end, he offers the following suggestions: “The American College of Phlebology and the American Venous Forum offer many lecture programs and workshops that serve as an introduction to the specialty, and the ACP offers preceptorships through approved private offices. Beyond that, finding a mentor is probably the best way to go. No one should fool themselves into thinking that a few workshops or a day of training with an equipment rep is adequate to start a phlebology practice. A full fund of knowledge and familiarity with a variety of treatment options that will cover the full range of vein disease is essential.”