Preview
Exhibit 6
Re: Simple Business Model for Vascular Setup
Subje e: Simple Business Model for Vascular Setup
From: "Andrew E. Gomes, ID"
Date: 3/10/2015, 2:39 PM
To: Sam Alam
Email from Donna Looser who works with me (very smart) below about your idea. There could be some synergy b/c some Vascular IR
procedures do in fact need XR/US/CT imaging either before and/or after the procedures. Furthermore, if we did this the IR doc we
have staffing the IR Suite could easily read all of their XR/US/CT studies for FINAL reports. This is good brainstorming
Donna Looser 2:32 PM (6 minutes ago)
te
tome
[3]
IF he is considering First Choice ER as the target entity, they do have a lot of centers - over 60, mostly in TX, and some in CO. They offer CT XR and US now, and prelim reports w/i
30m. | wonder who does their prelims. Also - they do NOT accept Medicare or Medicaid, but do accept uninsured, self-pay, and all other carriers. Interesting,
On Tue, Mar 10, 2015 at 2:33 PM, Andrew E. Gomes, MD wrote:
: Interesting idea Sam. | have some questions/comments:
1. Where are the cases coming from? See the big procedures that IR centers like the one you are proposing do here. Of these,
the Big 3 are dialysis fistula declot, arterial revascularization, and varicose veins. What would the referral sources be?
2. See major players in the IR OBL space here. They all utilize specifically constructed |R Suites -- like an OR but built for IR
procedures -- with 600K fixed C-arm, 50K portable US, and around another SOK misc equipment and materials. in the model
you propose, would there be an IR suite build out? Because a lead-lined room that is built to certain specifications, with the
right equipment, would be needed i.e. Vascular IR procedures cannot simply be done in any spare room with a mobile C-arm
Perhaps | am not understanding correctly?
| would like to bring in a very good friend and IR colleague of mine into this conversation ~ Dr. Aiay Choudhri. But | won't do so
without your okay. If you want him to sign an NDA with you | am certain he would do so. Ajay has the clinical insight into IR
that I lack, and will be able to comment intelligently on this model -- strengths and possible weaknesses that would need to be
addressed.
" like a lot of elements of the model -- turnkey, low cost, rapid expansion. Call me please to discuss, thanks Sam
Andrew
On Tue, Mar 10, 2015 at 12:35 PM, Sam Alam wrote:
Andrew:
Consistent with my email this morning and your request | disclose the business model here is the gist of it
" | think, to get you up and running “soon” and yet make it scale able (into many centers and many cities) you will find our model contemporary and
unique.
Preface: Urgent Care Centers and 24 Hour ER's business is inconsistent — especially during the day time (fixed cost and loss of
productivity). ASC’s slow down after 1pm. They want to enhance their business (bottom line). What is the solution?
" Model: 1. We set up Vascular Centers inside the Urgent Care, 24 Hour ER or ASC’s
2 We contract with the Center in which we provide the equipment and personnel to qualify for technical fees
3. We “rent” from them the space, equipment and some personnel. Buy few pieces of equipment
4. Start with a company that has many ASC’s UCC and 24 Hour ER; and seek the provision of exclusivity
5 One successful testimonial and we earn the right establish Vascular Centers in “all” their centers
Benefit to UCC et.al, windfall profits, stay busy, and get ancillary revenues for other tests and procedures
18-months and you will have a dozen centers - nationwide.
AG000348
lof4 12/20/2019, 5:51
Re: Embedded IR Lab - Summary
Subject: Re: Embedded IR Lab - Summary
From: "Andrew E. Gomes, MD"
Date: 3/12/2015, 5:07 PM
To: Donna Looser
CC: Sam Alam , Rebecca - Becky - Zwakenberg ,
Tuan Nguyen , Ajay Choudhri
All, this is a work in progress, and it is Sam's brainchild; | take responsibility for any inaccuracies, Sam
can correct these tomorrow. Looking forward to a good meeting of the minds,
Andrew
On Thu, Mar 12, 2015 at 1:20 PM, Donna Looser wrote:
All.
This Link will allow you to view a document summarizing the Embedded IR Lab concept, which we
will be discussing in detail tomorrow. Please review before the meeting.
Note: this is a live, cloud based document containing hyperlinks in blue text, and is fully functional
when viewed on your laptop or PC. Just click on the blue links within the document to view
additional, key information. Printing the document is not advisable.
\'ll be dialed in to the call tomorrow, and available anytime to field questions.
Looking forward to it,
Donna
-
Donna Looser
VP of Business Development
Casper Radiology
dlooser @casperradiology.com
www.CasperRadiology.com
914-623-8156 - office
914-407-4765 - cell
314-754-9476 - efax
DISCLAIMER: This email and any files transmitted with it are privileged and confidential information
and intended solely for the use of the individual or entity to which they are addressed. This
transmission may contain protected health information as defined by the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). If you are not the intended recipient, please
notify the sender by e-mail and delete the original message. Further, you are not to copy, disclose,
or distribute this e-mail or its contents to any other person and any such actions are unlawful. This
e-mail may contain viruses. CASPER RADIOLOGY has taken every reasonable precaution to minimize
this risk, but is not liable for any damage you may sustain as a result of any virus in this e-mail. The
AG000374
1 of 2 12/20/2019, 5:49 PM
Subject: Re: appendix a
From: Donna Looser
Date: 5/14/2015, 5:02 PM
To: Sam Alam
CC: "Andrew E. Gomes, MD"
All 136 IR (these include Light IR) and 35 Diagnostic CPT codes are applicable to the UCC OBLs.
Andrew and Ajay reviewed these codes, and provided us with these conservative volumes. | can use
this as a baseline to add 3 tabs (for 2016, 2017, 2018) if you and Andrew decide that we need that.
For reference, | have attached a spreadsheet | created from data Mentor prepared for us, showing the
volume that a Houston OBL did in 2014. Note - this does not include light IR procedures, or diagnostic
studies. You will see that it correlates very closely to our estimates.
! included the raw data too, in case you need it. That sheet is password protected - use ctdh559 to
open it.
thanks,
On Thu, May 14, 2015 at 3:59 PM, Sam Alam wrote:
Donna: | have this spreadsheet b/c | remember sending it for you to tweak. Can you asterick the procedures that
will be done at the OP center or do you think all 136 are applicable to the OBL? Thanks, Sam
= sai
From: Donna Looser [mailto: dlooser @casperradiology.com]
Sent: Thursday, May 14, 2015 3:01 PM
To: Sam Alam
Subject: appendix a
will this work?
a
Donna Looser
Vice President, Business Development
Casper Radiology
dlooser@casperradiology.com
www.CasperRadiology.com
914-623-8156 - office
914-407-4765 - cell
314-754-9476 - efax
DISCLAIMER: This email and any files transmitted with it are privileged and confidential information
AG001504
RE: Dr, Agraharkar
Subject: RE: Dr. Agraharkar
From: "Sam Alam"
ae *
Date: 3/23/2015, 1:19 PM
To: "Donna Looser"
CC: "Andrew E. Gomes, MD"
Donna: I AGREE. | thought she was a Psychiatrist. Yes, pain manage
ment also makes sense. Sam
ssc ut -
From: Donna Looser [mailto id looser @casperradiology .co mi].
Sent: Monday, March 23, 2015 1:00 PM
To: Sam Alam
Ce: Andrew E. Gomes, MD
Subject: Dr. Agraharkar
Sam,
I prepared a Dossier on Dr. Agraharkar in anticipation of your dinner
meeting tonight. I wonder if his wife's
practice would be another potential referral source. Geriatric IMs refer
a lot of Pain procedures and
Vertebro/Kyphoplasties. V/K are very high reimbursement. typical
Kypho net is ~$5,500 ($9K for procedure,
$3500 supply cost). If we average only I/week, that's significant bottom line
impact.
Related: I think adding pain mgt is important -- adds to the USP and
supports a broader referral profile. CPT
codes are added to the spreadsheet. Ajay is going to give us data
for times and frequency. Will forward to
you when complete. Primary utilization will be Ortho/Spine, PCPs,
and nursing homes.
a
Call anytime to discuss. Cell is best.
Thanks,
Donna
-
Donna Looser
VP of Business Development
Casper Radiology
d 1(@caspe: di COM
www.CasperRadiology.com
914-623-8156 - office
914-407-4765 - cell
314-754-9476 - efax
DISCLAIMER: This email and any files transmitted with it are privileg
ed and confidential information and
intended solely for the use of the individual or entity to which they
are addressed. This transmission may
contain protected health information as defined by the Health Insurance
Portabili ity and Accountability Act of
1996 (HIPAA). If you are not the intended recipient, please noti: ify
the sender by e-mail and delete the original
message. Further, you are not to copy, disclose, or distribute this
e-mail or its contents to any other person
and any such actions are unlawful. This e-mail may contain viruses.
CASPER RADIOLOGY has taken every
reasonable precaution to minimize this risk, but is not liable for
any damage you may sustain as a result of
any virus in this e-mail. The recipient should check this email and any attachm
ents for the presence of
AG001837
lof2
12/20/2019. 4-20 P
Subject: Re: confidential info
From: "Andrew E. Gomes, MD"
Date: 3/10/2015, 10:16 PM
To: Ajay Choudhri
Good shit. | forwarded to Sam. Let's doa call with him, and maybe Becky, later this week and have a
meeting of the minds on this. When are good days and times for you?
Thing is, Sam has the local connections to make something like
this happen if we want
On Tue, Mar 10, 2015 at 8:13 PM, Ajay Choudhri < ajay.choudhri@g
mail.com> wrote:
Andrew,
Next week was wide open until | booked it solid 2 weeks ago. | can't
make it next week. | have time
on monday the week of 3/30. | can take that monday off and fly
in on sunday night. I'd have to lock
that down pretty quick before someone grabs that day
| like the idea of a box within a box.
RE: UCC ‘
You can lead-line a room for cheap. What you need however is holding area for
pre-post patients
and also a waiting room/exam. I'm not sure the UCC provides any synergy
to adding patients. You
would need a fair amount of space during the 8-5 hours. Most MD's
(no matter what specialty -
endovasc) only want to work M-F 8-5. The flip-side is possibly offer
vascular testing and screening
to all those who roll through the UCC (that | can see would benefit the vascular
care center)
I'm not in favor of compressing the technical margin by sharing for
little gain, when finding space is
not that difficult. The model does allow for risk-sharing. If you did the procedu
res in an ASC, the
ASC would bill for the procedure because you are doing the procedure on
their real estate under
their certificate. As soon as they bill, the revenue goes to their "shared profit"
scheme.
As you pointed out. The deciding factor is going to be referrals. Doing a
doc-in-a-doc-in-a-box
means choosing the right synergistic partner. That is going to be inside or next
to a dialysis center.
That model is already being rolled out by Lifeline and Fresenius.
If you can get one center cash flow positive in a short time, the next
two are easier. - rinse and
repeat. The whole thing is predicated on patients. patients. patients.
You have patients (like Indian Reservations! WT
!!!!!), you win... that is it. Syndicates / Cartels /
"Arrangements" / Patient Sources are the key to your success, everything else is easy!!!
Ajay
AG002185
FAS PE.ER
www.CasperRadiology.com
OG
Diagnostic and Interventional Radiology Center
Conditions We Treat
Peripheral Arterial Disease (PAD.
Chronic Venous Insufficiency
Osteoporotic Compression Fracture:
Chronic Pain
Uterine Fibroids
Pelvi C. i dro!
Vascular Procedures
Dialysis Access Maintenance (Fistulograms, Thrombectomy, Vein Mapping, Complete
HD catheter services)
Limb Revascularization (Angiography, Angioplasty, Stent Placement, and Atherectomy)
Varicose and Spider Vein Treatment (Venous Ablation, Sclerotherapy, Phlebectomy,
Embolizati Pelvic Varic
Uterine Fibroid Embolization
PICC Line and Access Port Placement
Vertebroplasty/Kyphoplasty
DRISONLINE2440
General Interventional Radiology Procedures
image-guided biopsy
image-quided drainage (Paracentesis, Thoracentesis)
Lumbar Puncture
Myeiogram
Arthrogram
Pain Management (Facet and Joint injections)
Diagnostic Radiology
US includi Di ler
CT
Coming soon to the Champions Forest area
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Contact: Rebecca “Becky” Zwakenberg, BSRS, RT (R) (CV) (BD)
Vice President, Clinical Services
Physician Liaison
rzwakenberg@casperradiology.com, 832-457-6995
DRISONLINE2441
piers Group 000763 Spiers Group 000763
4
ADIOLOG
Executive Summary
Interventional Radiology Office-based Labs
FM1960/Champions Forest and Pasadena, TX
Preface
Operating an Interventional Radiology (IR) Office-based Lab (OBL) in physician's office or an ambulatory center is on the rise.
Changes in the healthcare landscape are shifting more medical care from the costly hospital setting to the less expensive
outpatient setting, and from open surgical procedures requiring long recovery times to minimally-invasive IR procedures
which can be performed safely and easily in the OBL. In fact, for venous procedures, the office has become the main site for
treatment. Almost all dialysis access-related procedures including angioplasty, stents, atherectomy, and thrombectomy can
be performed in the office setting, and an increasing number of patients with chronic lower extremity ischemia will also
undergo minimally-invasive treatment in this setting as well. The operators for these procedures are Interventional
Radiologists, and they too have a strong preference to perform these procedures in OBL’s vs. in the hospital setting, as in the
IR OBL they exercise far more control over staffing, operations, and overall throughput and profitability.
Similar benefits are derived from Diagnostic Radiology studies and “Light” Interventional Radiology procedures such as
image-guided biopsies, catheter placements, and lumbar punctures. These too can easily be performed in the IR OBL, at cost
savings to payers, while also meeting unmet demands of referring physicians. Both Diagnostic and Interventional Radiology
are highly amenable to Lean process improvement and standardization, which results in better results, faster delivery, at
lower cost and better financial performance.
Medicare and many insurance payers reimburse procedures performed in the physician office setting at a different, higher rate
called the global fee -- Place of Service Code 11 -- which in effect combines payments for both professional and technical
services provided by the IR OBL’s. The global fee is typically 10 times higher than professional fees. This higher fee is, in part,
to reimburse the physicians for the technical component of the service provided by the physician office, such as staffing,
equipment, supplies, and other overheads. Thus, the Interventional Radiology Office-based Lab presents a tremendous
opportunity to capture a very significant source of new revenue when compared to procedures performed in the hospital
setting.
With regard to the physical structure, co-locating into existing designated medical space, such as urgent care centers and
dialysis facilities supports a shorter “ramp-up” period as opposed to a free-standing center. In addition, the expected
conversion costs, including build out, represents a significantly lower cost per square foot cost as compared to new
construction,
While there is a surplus of 24 hour Emergency Rooms, Urgent Care Centers, and Vein Centers in large cities in the State of
Texas, there is a relative paucity of comprehensive outpatient IR Labs, particularly ones which also offer Diagnostic Imaging.
In the current climate of downward pressure on reimbursements, the Interventional Radiology Office-based Lab offers one of
the most attractive options for profitability and rapid growth in the outpatient healthcare space. It is entirely in keeping with
the directives of the Affordable Care Act.
Spiers Group 000763 Spiers Group 000763
00047
‘Spiers Group 000764 Spiers Group 000764
Rationale
In today’s reimbursement market, a co-located IR OBL offering a combination of Office-based Diagnostic Radiology studies
and Interventional Radiology procedures, focusing on higher reimbursement services, can be profitable when performing as
few as 3 procedures per day.
Evolution and Timeline
= Name. [Start Date [End Date lage [May [oon [oot Thug [Sep [Oct Tov [Dee [Jan [Feb [mar
Markel Research, Scale loarterie
Leto stage - Due Diligence paniane. loarsoris.
[Secure funding Daisris joasans
fees ntinved market analyst and outreach
[Forrralize project limetine and rBestones
[Execute equiomroni and supply contracts for Caner
bares,
oasis,
7 lowisvt5
loarans
foarsons.
Joarsors
(Center 4 loaning. lorraine.
[Buikd-out, renovation, design of Carter 7 [o501715 lorrsins
Regulatory, toensing, end socreditation papetwork psig lorrsis
[Loan operatorsand anes! 8 planning lssro17as, lo7rsiis
luorviow. select, enage, and tain appropriate stat SOs lorisias.
(Center 1 oemtrG OSTA
Fine-tune operations eos hosts
[Schct feedback from roleriing phykians oes. Osis
[Grow volume and revere. oamins. hos
Center 2 fowii6, hasan.
Execute Equipment and Supply contracts for Center foams: h2sins
Buis-out. renovation, design of Certert HOS ais
Reguiatory, foensing, end accreditation popenwork hooiis iarsias
[Goan Operstons and Clinical process planning Foon naaws
interview, select enege, and wen appropriale staf OOS ISIS
Centor2 omar lasraore
[Fine-tune operations lovouy fosrsori6:
[Sobek feedback irom rofe orransn loarsorie.
jvolume and revenue louie learsori6.
Services
“Heavy” and Vascular IR Procedures
° Dialysis Access Maintenance (Fistulograms, Thrombectomy, Vein Mapping, Complete HD catheter services)
° Limb Revascularization (Angiography, Angioplasty, Stent Placement, Atherectomy)
. Varicose and Spider Vein Treatment (Venous Ablation, Sclerot herapy, Phlebectomy, Embolization of Pelvic Varices)
Uterine Fibroid Embolization
PICC Line and Access Port Placement
Vertebroplasty / Kyphoplasty
Pain Management (Facet and Joint injections)
“Light” IR Procedures
° Image-guided biopsy
° Image-guided drainage (Paracentesis, Thoracentesis)
° Lumbar Puncture
° Myelogram
° Arthrogram
Diagnostic Radiology
° US including Doppler
° cT
Resources
Each OBL will be developed by an experienced project management and deployment team, led by Dr. Andrew Gomes, Dr
Gomes is a Lean Six Sigma-Certified Black Belt, whose vehement approach to productivity and operational excellence through
Spiers Group 000764 Spiers Group 000764
00048
Spiers Group 000765 Spiers Group 000765
standardization, systemization, and scale will drive the OBL’s from concept to reality quickly and efficiently. Staffing for each
location will include an onsite Interventional Radiol logist Physician Champion,
who in addition performing all procedures
and interpreting all diagnostic studies performed in the Lab, will also establish relationships withto local referring physicians
and provide ongoing community outreach to retain and build volume. § specialized Radiologic Technologist s, Critical Care
Registered Nurses, and Administrative Staff will also be required.
Diagnostic imaging equipment, including CT scanner and two US scanners will be utilized in each OBL. The fully equipped
Interventional Radiology Suite will contain an adjustable procedure table, Mobile C-Arm,, and Venous Ablation equipment, as
well as medical monitoring equipment, and 1 mergency medical equipment including
medical supplies, pharmaceuticals, and disposables will be needed, as well holding aandcrashrecoverycart, Standard and specialty
stretchers. Each OBL will include patient holding and recovery areas, and a asreading room for the
beds, wheelchairs, and
Radiologist to interpret
studies and dictate reports. Patient waiting rooms as well as staff break areas will be
share id with the co-located entity.
Cost
The estimated cost to open both Centers is estimated at $2.5M, based on the following assumptions:
Locat in EM 1960 Pasadena
Commission Date Aug-15 Jan-16 Cumulative
CONSTRUCTION COST/TI $123,309 $73,986 $197,295 Build out/Leasehold improvement;
Signage
EQUIPMENT FF&E COST $350,000 $465,500 $815,500 Medical Equipment, Furniture and
Fixtures
WORKING CAPITAL $676,575 $405,945 $1,082,520 Three months of expenses
PRE-DEVELOPMENT COST $191,365 $76,546 $267,911 PPM, Partnership Agreement, Feasibility
Study
COMMISSIONING COST $94,000 $37,600 $131,600 Administrative Project Management
TOTAL $1,435,249 $1,059,577 $2,494,826
Revenue
Based on conservative estimates of anticipated utilization, benchmarked against
current national average Medicare
reimbursement data, as well as utilization data from an established existing center,
it is anticipated that both OBL’ 's will have
positive cash flow by the end of the first fiscal year. Estimated cumulative 4-year EBITDA
earnings are $4.01M for the FM 1960
location at 27.9% of net revenue, and $4.5M for the Pasadena location at 29.5%
of net revenue.
Next Steps
Engage investment partners
Secure funding
Secure locations
Continue market research and outreach
Begin construction on Location 1
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Exhibit 6 Re: Simple Business Model for Vascular Setup Subje e: Simple Business Model for Vascular Setup From: "Andrew E. Gomes, ID" Date: 3/10/2015, 2:39 PM To: Sam Alam Email from Donna Looser who works with me (very smart) below about your idea. There could be some synergy b/c some Vascular IR procedures do in fact need XR/US/CT imaging either before and/or after the procedures. Furthermore, if we did this the IR doc we have staffing the IR Suite could easily read all of their XR/US/CT studies for FINAL reports. This is good brainstorming Donna Looser 2:32 PM (6 minutes ago) te tome [3] IF he is considering First Choice ER as the target entity, they do have a lot of centers - over 60, mostly in TX, and some in CO. They offer CT XR and US now, and prelim reports w/i 30m. | wonder who does their prelims. Also - they do NOT accept Medicare or Medicaid, but do accept uninsured, self-pay, and all other carriers. Interesting, On Tue, Mar 10, 2015 at 2:33 PM, Andrew E. Gomes, MD wrote: : Interesting idea Sam. | have some questions/comments: 1. Where are the cases coming from? See the big procedures that IR centers like the one you are proposing do here. Of these, the Big 3 are dialysis fistula declot, arterial revascularization, and varicose veins. What would the referral sources be? 2. See major players in the IR OBL space here. They all utilize specifically constructed |R Suites -- like an OR but built for IR procedures -- with 600K fixed C-arm, 50K portable US, and around another SOK misc equipment and materials. in the model you propose, would there be an IR suite build out? Because a lead-lined room that is built to certain specifications, with the right equipment, would be needed i.e. Vascular IR procedures cannot simply be done in any spare room with a mobile C-arm Perhaps | am not understanding correctly? | would like to bring in a very good friend and IR colleague of mine into this conversation ~ Dr. Aiay Choudhri. But | won't do so without your okay. If you want him to sign an NDA with you | am certain he would do so. Ajay has the clinical insight into IR that I lack, and will be able to comment intelligently on this model -- strengths and possible weaknesses that would need to be addressed. " like a lot of elements of the model -- turnkey, low cost, rapid expansion. Call me please to discuss, thanks Sam Andrew On Tue, Mar 10, 2015 at 12:35 PM, Sam Alam wrote: Andrew: Consistent with my email this morning and your request | disclose the business model here is the gist of it " | think, to get you up and running “soon” and yet make it scale able (into many centers and many cities) you will find our model contemporary and unique. Preface: Urgent Care Centers and 24 Hour ER's business is inconsistent — especially during the day time (fixed cost and loss of productivity). ASC’s slow down after 1pm. They want to enhance their business (bottom line). What is the solution? " Model: 1. We set up Vascular Centers inside the Urgent Care, 24 Hour ER or ASC’s 2 We contract with the Center in which we provide the equipment and personnel to qualify for technical fees 3. We “rent” from them the space, equipment and some personnel. Buy few pieces of equipment 4. Start with a company that has many ASC’s UCC and 24 Hour ER; and seek the provision of exclusivity 5 One successful testimonial and we earn the right establish Vascular Centers in “all” their centers Benefit to UCC et.al, windfall profits, stay busy, and get ancillary revenues for other tests and procedures 18-months and you will have a dozen centers - nationwide. AG000348 lof4 12/20/2019, 5:51 Re: Embedded IR Lab - Summary Subject: Re: Embedded IR Lab - Summary From: "Andrew E. Gomes, MD" Date: 3/12/2015, 5:07 PM To: Donna Looser CC: Sam Alam , Rebecca - Becky - Zwakenberg , Tuan Nguyen , Ajay Choudhri All, this is a work in progress, and it is Sam's brainchild; | take responsibility for any inaccuracies, Sam can correct these tomorrow. Looking forward to a good meeting of the minds, Andrew On Thu, Mar 12, 2015 at 1:20 PM, Donna Looser wrote: All. This Link will allow you to view a document summarizing the Embedded IR Lab concept, which we will be discussing in detail tomorrow. Please review before the meeting. Note: this is a live, cloud based document containing hyperlinks in blue text, and is fully functional when viewed on your laptop or PC. Just click on the blue links within the document to view additional, key information. Printing the document is not advisable. \'ll be dialed in to the call tomorrow, and available anytime to field questions. Looking forward to it, Donna - Donna Looser VP of Business Development Casper Radiology dlooser @casperradiology.com www.CasperRadiology.com 914-623-8156 - office 914-407-4765 - cell 314-754-9476 - efax DISCLAIMER: This email and any files transmitted with it are privileged and confidential information and intended solely for the use of the individual or entity to which they are addressed. This transmission may contain protected health information as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). If you are not the intended recipient, please notify the sender by e-mail and delete the original message. Further, you are not to copy, disclose, or distribute this e-mail or its contents to any other person and any such actions are unlawful. This e-mail may contain viruses. CASPER RADIOLOGY has taken every reasonable precaution to minimize this risk, but is not liable for any damage you may sustain as a result of any virus in this e-mail. The AG000374 1 of 2 12/20/2019, 5:49 PM Subject: Re: appendix a From: Donna Looser Date: 5/14/2015, 5:02 PM To: Sam Alam CC: "Andrew E. Gomes, MD" All 136 IR (these include Light IR) and 35 Diagnostic CPT codes are applicable to the UCC OBLs. Andrew and Ajay reviewed these codes, and provided us with these conservative volumes. | can use this as a baseline to add 3 tabs (for 2016, 2017, 2018) if you and Andrew decide that we need that. For reference, | have attached a spreadsheet | created from data Mentor prepared for us, showing the volume that a Houston OBL did in 2014. Note - this does not include light IR procedures, or diagnostic studies. You will see that it correlates very closely to our estimates. ! included the raw data too, in case you need it. That sheet is password protected - use ctdh559 to open it. thanks, On Thu, May 14, 2015 at 3:59 PM, Sam Alam wrote: Donna: | have this spreadsheet b/c | remember sending it for you to tweak. Can you asterick the procedures that will be done at the OP center or do you think all 136 are applicable to the OBL? Thanks, Sam = sai From: Donna Looser [mailto: dlooser @casperradiology.com] Sent: Thursday, May 14, 2015 3:01 PM To: Sam Alam Subject: appendix a will this work? a Donna Looser Vice President, Business Development Casper Radiology dlooser@casperradiology.com www.CasperRadiology.com 914-623-8156 - office 914-407-4765 - cell 314-754-9476 - efax DISCLAIMER: This email and any files transmitted with it are privileged and confidential information AG001504 RE: Dr, Agraharkar Subject: RE: Dr. Agraharkar From: "Sam Alam" ae * Date: 3/23/2015, 1:19 PM To: "Donna Looser" CC: "Andrew E. Gomes, MD" Donna: I AGREE. | thought she was a Psychiatrist. Yes, pain manage ment also makes sense. Sam ssc ut - From: Donna Looser [mailto id looser @casperradiology .co mi]. Sent: Monday, March 23, 2015 1:00 PM To: Sam Alam Ce: Andrew E. Gomes, MD Subject: Dr. Agraharkar Sam, I prepared a Dossier on Dr. Agraharkar in anticipation of your dinner meeting tonight. I wonder if his wife's practice would be another potential referral source. Geriatric IMs refer a lot of Pain procedures and Vertebro/Kyphoplasties. V/K are very high reimbursement. typical Kypho net is ~$5,500 ($9K for procedure, $3500 supply cost). If we average only I/week, that's significant bottom line impact. Related: I think adding pain mgt is important -- adds to the USP and supports a broader referral profile. CPT codes are added to the spreadsheet. Ajay is going to give us data for times and frequency. Will forward to you when complete. Primary utilization will be Ortho/Spine, PCPs, and nursing homes. a Call anytime to discuss. Cell is best. Thanks, Donna - Donna Looser VP of Business Development Casper Radiology d 1(@caspe: di COM www.CasperRadiology.com 914-623-8156 - office 914-407-4765 - cell 314-754-9476 - efax DISCLAIMER: This email and any files transmitted with it are privileg ed and confidential information and intended solely for the use of the individual or entity to which they are addressed. This transmission may contain protected health information as defined by the Health Insurance Portabili ity and Accountability Act of 1996 (HIPAA). If you are not the intended recipient, please noti: ify the sender by e-mail and delete the original message. Further, you are not to copy, disclose, or distribute this e-mail or its contents to any other person and any such actions are unlawful. This e-mail may contain viruses. CASPER RADIOLOGY has taken every reasonable precaution to minimize this risk, but is not liable for any damage you may sustain as a result of any virus in this e-mail. The recipient should check this email and any attachm ents for the presence of AG001837 lof2 12/20/2019. 4-20 P Subject: Re: confidential info From: "Andrew E. Gomes, MD" Date: 3/10/2015, 10:16 PM To: Ajay Choudhri Good shit. | forwarded to Sam. Let's doa call with him, and maybe Becky, later this week and have a meeting of the minds on this. When are good days and times for you? Thing is, Sam has the local connections to make something like this happen if we want On Tue, Mar 10, 2015 at 8:13 PM, Ajay Choudhri < ajay.choudhri@g mail.com> wrote: Andrew, Next week was wide open until | booked it solid 2 weeks ago. | can't make it next week. | have time on monday the week of 3/30. | can take that monday off and fly in on sunday night. I'd have to lock that down pretty quick before someone grabs that day | like the idea of a box within a box. RE: UCC ‘ You can lead-line a room for cheap. What you need however is holding area for pre-post patients and also a waiting room/exam. I'm not sure the UCC provides any synergy to adding patients. You would need a fair amount of space during the 8-5 hours. Most MD's (no matter what specialty - endovasc) only want to work M-F 8-5. The flip-side is possibly offer vascular testing and screening to all those who roll through the UCC (that | can see would benefit the vascular care center) I'm not in favor of compressing the technical margin by sharing for little gain, when finding space is not that difficult. The model does allow for risk-sharing. If you did the procedu res in an ASC, the ASC would bill for the procedure because you are doing the procedure on their real estate under their certificate. As soon as they bill, the revenue goes to their "shared profit" scheme. As you pointed out. The deciding factor is going to be referrals. Doing a doc-in-a-doc-in-a-box means choosing the right synergistic partner. That is going to be inside or next to a dialysis center. That model is already being rolled out by Lifeline and Fresenius. If you can get one center cash flow positive in a short time, the next two are easier. - rinse and repeat. The whole thing is predicated on patients. patients. patients. You have patients (like Indian Reservations! WT !!!!!), you win... that is it. Syndicates / Cartels / "Arrangements" / Patient Sources are the key to your success, everything else is easy!!! Ajay AG002185 FAS PE.ER www.CasperRadiology.com OG Diagnostic and Interventional Radiology Center Conditions We Treat Peripheral Arterial Disease (PAD. Chronic Venous Insufficiency Osteoporotic Compression Fracture: Chronic Pain Uterine Fibroids Pelvi C. i dro! Vascular Procedures Dialysis Access Maintenance (Fistulograms, Thrombectomy, Vein Mapping, Complete HD catheter services) Limb Revascularization (Angiography, Angioplasty, Stent Placement, and Atherectomy) Varicose and Spider Vein Treatment (Venous Ablation, Sclerotherapy, Phlebectomy, Embolizati Pelvic Varic Uterine Fibroid Embolization PICC Line and Access Port Placement Vertebroplasty/Kyphoplasty DRISONLINE2440 General Interventional Radiology Procedures image-guided biopsy image-quided drainage (Paracentesis, Thoracentesis) Lumbar Puncture Myeiogram Arthrogram Pain Management (Facet and Joint injections) Diagnostic Radiology US includi Di ler CT Coming soon to the Champions Forest area oe % gy? ot oF % %,% ge % > wt ot eo ot Contact: Rebecca “Becky” Zwakenberg, BSRS, RT (R) (CV) (BD) Vice President, Clinical Services Physician Liaison rzwakenberg@casperradiology.com, 832-457-6995 DRISONLINE2441 piers Group 000763 Spiers Group 000763 4 ADIOLOG Executive Summary Interventional Radiology Office-based Labs FM1960/Champions Forest and Pasadena, TX Preface Operating an Interventional Radiology (IR) Office-based Lab (OBL) in physician's office or an ambulatory center is on the rise. Changes in the healthcare landscape are shifting more medical care from the costly hospital setting to the less expensive outpatient setting, and from open surgical procedures requiring long recovery times to minimally-invasive IR procedures which can be performed safely and easily in the OBL. In fact, for venous procedures, the office has become the main site for treatment. Almost all dialysis access-related procedures including angioplasty, stents, atherectomy, and thrombectomy can be performed in the office setting, and an increasing number of patients with chronic lower extremity ischemia will also undergo minimally-invasive treatment in this setting as well. The operators for these procedures are Interventional Radiologists, and they too have a strong preference to perform these procedures in OBL’s vs. in the hospital setting, as in the IR OBL they exercise far more control over staffing, operations, and overall throughput and profitability. Similar benefits are derived from Diagnostic Radiology studies and “Light” Interventional Radiology procedures such as image-guided biopsies, catheter placements, and lumbar punctures. These too can easily be performed in the IR OBL, at cost savings to payers, while also meeting unmet demands of referring physicians. Both Diagnostic and Interventional Radiology are highly amenable to Lean process improvement and standardization, which results in better results, faster delivery, at lower cost and better financial performance. Medicare and many insurance payers reimburse procedures performed in the physician office setting at a different, higher rate called the global fee -- Place of Service Code 11 -- which in effect combines payments for both professional and technical services provided by the IR OBL’s. The global fee is typically 10 times higher than professional fees. This higher fee is, in part, to reimburse the physicians for the technical component of the service provided by the physician office, such as staffing, equipment, supplies, and other overheads. Thus, the Interventional Radiology Office-based Lab presents a tremendous opportunity to capture a very significant source of new revenue when compared to procedures performed in the hospital setting. With regard to the physical structure, co-locating into existing designated medical space, such as urgent care centers and dialysis facilities supports a shorter “ramp-up” period as opposed to a free-standing center. In addition, the expected conversion costs, including build out, represents a significantly lower cost per square foot cost as compared to new construction, While there is a surplus of 24 hour Emergency Rooms, Urgent Care Centers, and Vein Centers in large cities in the State of Texas, there is a relative paucity of comprehensive outpatient IR Labs, particularly ones which also offer Diagnostic Imaging. In the current climate of downward pressure on reimbursements, the Interventional Radiology Office-based Lab offers one of the most attractive options for profitability and rapid growth in the outpatient healthcare space. It is entirely in keeping with the directives of the Affordable Care Act. Spiers Group 000763 Spiers Group 000763 00047 ‘Spiers Group 000764 Spiers Group 000764 Rationale In today’s reimbursement market, a co-located IR OBL offering a combination of Office-based Diagnostic Radiology studies and Interventional Radiology procedures, focusing on higher reimbursement services, can be profitable when performing as few as 3 procedures per day. Evolution and Timeline = Name. [Start Date [End Date lage [May [oon [oot Thug [Sep [Oct Tov [Dee [Jan [Feb [mar Markel Research, Scale loarterie Leto stage - Due Diligence paniane. loarsoris. [Secure funding Daisris joasans fees ntinved market analyst and outreach [Forrralize project limetine and rBestones [Execute equiomroni and supply contracts for Caner bares, oasis, 7 lowisvt5 loarans foarsons. Joarsors (Center 4 loaning. lorraine. [Buikd-out, renovation, design of Carter 7 [o501715 lorrsins Regulatory, toensing, end socreditation papetwork psig lorrsis [Loan operatorsand anes! 8 planning lssro17as, lo7rsiis luorviow. select, enage, and tain appropriate stat SOs lorisias. (Center 1 oemtrG OSTA Fine-tune operations eos hosts [Schct feedback from roleriing phykians oes. Osis [Grow volume and revere. oamins. hos Center 2 fowii6, hasan. Execute Equipment and Supply contracts for Center foams: h2sins Buis-out. renovation, design of Certert HOS ais Reguiatory, foensing, end accreditation popenwork hooiis iarsias [Goan Operstons and Clinical process planning Foon naaws interview, select enege, and wen appropriale staf OOS ISIS Centor2 omar lasraore [Fine-tune operations lovouy fosrsori6: [Sobek feedback irom rofe orransn loarsorie. jvolume and revenue louie learsori6. Services “Heavy” and Vascular IR Procedures ° Dialysis Access Maintenance (Fistulograms, Thrombectomy, Vein Mapping, Complete HD catheter services) ° Limb Revascularization (Angiography, Angioplasty, Stent Placement, Atherectomy) . Varicose and Spider Vein Treatment (Venous Ablation, Sclerot herapy, Phlebectomy, Embolization of Pelvic Varices) Uterine Fibroid Embolization PICC Line and Access Port Placement Vertebroplasty / Kyphoplasty Pain Management (Facet and Joint injections) “Light” IR Procedures ° Image-guided biopsy ° Image-guided drainage (Paracentesis, Thoracentesis) ° Lumbar Puncture ° Myelogram ° Arthrogram Diagnostic Radiology ° US including Doppler ° cT Resources Each OBL will be developed by an experienced project management and deployment team, led by Dr. Andrew Gomes, Dr Gomes is a Lean Six Sigma-Certified Black Belt, whose vehement approach to productivity and operational excellence through Spiers Group 000764 Spiers Group 000764 00048 Spiers Group 000765 Spiers Group 000765 standardization, systemization, and scale will drive the OBL’s from concept to reality quickly and efficiently. Staffing for each location will include an onsite Interventional Radiol logist Physician Champion, who in addition performing all procedures and interpreting all diagnostic studies performed in the Lab, will also establish relationships withto local referring physicians and provide ongoing community outreach to retain and build volume. § specialized Radiologic Technologist s, Critical Care Registered Nurses, and Administrative Staff will also be required. Diagnostic imaging equipment, including CT scanner and two US scanners will be utilized in each OBL. The fully equipped Interventional Radiology Suite will contain an adjustable procedure table, Mobile C-Arm,, and Venous Ablation equipment, as well as medical monitoring equipment, and 1 mergency medical equipment including medical supplies, pharmaceuticals, and disposables will be needed, as well holding aandcrashrecoverycart, Standard and specialty stretchers. Each OBL will include patient holding and recovery areas, and a asreading room for the beds, wheelchairs, and Radiologist to interpret studies and dictate reports. Patient waiting rooms as well as staff break areas will be share id with the co-located entity. Cost The estimated cost to open both Centers is estimated at $2.5M, based on the following assumptions: Locat in EM 1960 Pasadena Commission Date Aug-15 Jan-16 Cumulative CONSTRUCTION COST/TI $123,309 $73,986 $197,295 Build out/Leasehold improvement; Signage EQUIPMENT FF&E COST $350,000 $465,500 $815,500 Medical Equipment, Furniture and Fixtures WORKING CAPITAL $676,575 $405,945 $1,082,520 Three months of expenses PRE-DEVELOPMENT COST $191,365 $76,546 $267,911 PPM, Partnership Agreement, Feasibility Study COMMISSIONING COST $94,000 $37,600 $131,600 Administrative Project Management TOTAL $1,435,249 $1,059,577 $2,494,826 Revenue Based on conservative estimates of anticipated utilization, benchmarked against current national average Medicare reimbursement data, as well as utilization data from an established existing center, it is anticipated that both OBL’ 's will have positive cash flow by the end of the first fiscal year. Estimated cumulative 4-year EBITDA earnings are $4.01M for the FM 1960 location at 27.9% of net revenue, and $4.5M for the Pasadena location at 29.5% of net revenue. Next Steps Engage investment partners Secure funding Secure locations Continue market research and outreach Begin construction on Location 1 Spiers Group 000765 Spiers Group 000765 00049 png o wail = a a a % += | ee s 23 Qe on % oe. a 6 scares 2 2 = ane cu = = = s 3 = a= _ 8 22 cre c= aT a i co =F a2 BE iLO ~~= 2S =o 2> ee PE @E 20 oe a £O Fx tt zs _ = s,