Lyssa Ochoa, MD, is used to the assumptions. One: ”What a nice program you have.” Another: “It must be so nice that you can give away all of this charity care.”
Ochoa is the founding vascular surgeon behind the SAVE Clinic in San Antonio, geared in its entirety towards targeting the Texas city’s most socially and economically disadvantaged areas against the backdrop of some of the state’s most eye-watering rates of diabetes-related amputation.
Her answers to these types of questions are to point out that she is not operating a program.
Rather, her work in these communities is her entire practice. SAVE—which stands for San Antonio Vascular and Endovascular—is a comprehensive private practice. As for that other assumption? “I don’t do charity care,” Ochoa says sharply.
Ochoa, a native of the Rio Grande Valley in the borderlands of south Texas where she grew up seeing the same kind of health disparities which she now helps tackle in the city, is turning heads in the vascular community lately for her work in underserved communities. Recently, she has given revealing presentations on aspects of how she goes about her practice. At both the Houston Aortic Symposium (March 16–18) and the Society for Clinical Vascular Surgery (SCVS) Annual Symposium (March 25–29) in Miami, the themes of Ochoa’s talks—respectively “pioneering equitable vascular care” and “the path less traveled in private practice”—spurred those kinds of assumptions and questions. Many of those puzzled by it settle on the ultimate question of: “How does she manage to pull this off?”
Making the numbers work
She is, to be sure, a private-practice surgeon. The numbers still have to work—a bottom line marshaled by both Ochoa and her husband, also the SAVE Clinic business administrator. Which means she must fulfill a certain volume of work. But that isn’t to say Ochoa is not on a vascular mission.
The need she describes is great: “We are in the most economically segregated city in the nation. Literally you can draw a line across the middle of San Antonio, and lifespan can vary up to 20 years. It is a very clear line.”
Ochoa started out in private practice in the city as part of a large single-specialty group of vascular surgeons. Fairly quickly, Ochoa realized the practice culture was not a good fit for her goals as a surgeon. Yet it was here that she first struck on what would become the object of her future work. While there, Ochoa was assigned to the south side of the city, and what she saw, and the realizations her experiences spawned, helped fuel a career-defining move.
“I had already established a practice in those areas, mainly because none of the other surgeons wanted to go there, and they were happy to let me go there myself,” she explains. “It was when I began to see that disparate care … I would see over and over again how the patients—depending on which hospitals they were at—they got treated differently.
“Of course, when the patients came in on the south side, they were definitely sicker. They were younger. I was seeing patients in their early 30s who suffer from complications of type-2 diabetes, of amputation, being blind, on dialysis, heart attacks, strokes. It was just so profound for me when I experienced that—even different than when I trained in Houston in the county system. I knew that something was wrong and couldn’t figure out why.”
Then she started to learn about the particular history of San Antonio. Of its manifestations of segregation. Red-lining. Non-investment in areas populated by minorities.
“If you look at a red-line map of San Antonio, it is the same healthcare outcomes for COVID deaths, for diabetic amputations and all the other social determinants of health,” Ochoa says. “I now understood. It was that light-bulb moment for me of why we have such horrible outcomes and things are not changing. It’s because these whole neighborhoods, these whole communities, have a lack of investment in education, healthcare literacy, in food deserts, safe places to walk and play, access to the internet. They just don’t have that.”
It is one thing to identify a problem and to begin to understand it, but quite another to devote an entire practice to its remedy. The decision to do so was fraught. At first, Ochoa wasn’t sure if she would be capable of pulling off all of the mechanics and finer points of starting a private practice from the ground up. Especially as she would be entering a vascular surgical practice environment dominated by the group she was leaving behind. That’s where the business acumen of her husband came into its own. A business plan. A business loan. The business nitty gritty.
Ultimately, for Ochoa, it boiled down to the volume question. “How many patients do I have to see? How many surgeries do I have to do? How many endovascular procedures do I have to do?” she recalls saying. “I need to know I’m going to be financially viable and I’m not just going out there blind, hoping and praying that it is going to work. I also told him that I wanted to make sure that when we calculate what that was, that I am practicing evidence-based vascular surgery.”
Conservative estimates eventually gave way to a confidence in Ochoa that she was on a viable track. “When I got that number, I had been doing that easily already,” she relates. “I knew that if I could get just as busy as I was in the other group that we would be fine.”
In the interim, business planning went into full flow. An existing space was acquired for the practice in the south side of San Antonio. And Ochoa went on a fact-finding mission across the country to hoover up private-practice wisdom from other solo practitioners who broke out on their own.
Today, the SAVE Clinic is buttressed by a main center and eight satellite clinics. The satellites operate on a time-share basis, made possible by a 15-passenger bus that is loaded with imaging equipment, techs, medical students, and even front desk staff, in order to meet vascular patients confronting the on-the-ground realities of social determinants of health where they are.
Growth of the practice was quick, more than had been anticipated. Some of this owed to the fact that there were few alternative vascular surgery options in the market, Ochoa explains. For the SAVE Clinic, the result was one overstretched vascular surgeon. “My error in judgment would have been to start looking for another surgeon sooner,” she says chuckling. The hours, though, were no joke. She took 24/7 call for three and a half years.
It wasn’t easy, Ochoa concedes, but her mission is clear. She wants to do vascular surgery in these areas in a particular way— not by competing but by offering something completely different to the other practice option in town. “We may both do vascular surgery,” Ochoa says, “but I am really focusing on how I help address the social determinants of health with my patients and within the communities. And that means addressing transportation issues—I go to them. Wrapping them around with resources to help them get their medications. To help them get resources for mental health. To help them if they don’t have insurance.”
It is also multidisciplinary, looping in podiatry and primary care providers, for instance, to ensure care is a team sport. “We are here for more than just vascular surgery,” says Ochoa.
The SAVE Clinic has been around for around five years now, growing from just eight members of staff to a current workforce of 37, including one additional full-time and two part-time physicians. They also outgrew their original location, moving into a new 10,000-square-foot building— complete with two operating rooms—a year and a half ago.
This new space also plays into Ochoa’s team-sport vision for healthcare in these communities. “The reason we built the surgery center is not because I can do a lot of surgery on the south side—I usually need hospitals,” she points out. “But it now creates a space for other specialists to come in, to come to this area of town, to provide the care that [the people here] don’t have.”
Setting an example
The question then might be less about how this type of practice can be done, but rather why it should be. Ochoa makes clear she became a physician through luck and opportunity. So she takes a collaborative approach, working with stakeholders such as local politicians and academic medical centers. “I have been able to use my practice as a vehicle for advocacy for this area of town—for these populations,” she says. “People opened doors for me, and it is now my obligation to do the same. If I want future physicians and healthcare workers to do the work that we are doing, then I have to be a part of that training paradigm.”
That means working with everyone from high school students to medical students and beyond in order to “build the future healthcare force that is going to do this kind of work, and believes that it is possible we can do it the right way and benefit a community—and that it is a financially viable way to do things,” Ochoa says.
And that notion that, somehow, she must be carrying out charity care? It looms at the coalface of actually making sure patients get the treatment they need. “Part of the way it works is I’m where the need is,” Ochoa continues. “There are many, many patients that need help in this area. We are of the mindset that we will adjust and be flexible, and we will figure out how to make things work. An example: In my area of town, we have about 30% of unfunded [patients]. That’s what the numbers show. We still have a lot of Medicare and Medicaid, which pays just fine, but I will see my unfunded patients in the hospital, which is where they end up. And none of these hospital systems—we have just one 87-bed hospital to take care of over half a million people on the south side of San Antonio, by the way—pay me to take care of unfunded patients.”
Which is where the team effort kicks in once more—in order that not only is care delivered but the model remains financially viable. “I take care of them at that instant for that episode of care, and that I do for ‘free,’ so to say,” Ochoa explains. But what she also does is pair those patients with what she calls her “navigator,” whose deep-diving role involves finding a funded solution for them in the long term. “She knows the health insurance plans and the resources in San Antonio very well,” Ochoa elaborates. “She will sit with that patient, figure out what their finances are, what their needs are, and every single person I have sent to her has been able to find a marketplace plan or Medicare or Medicaid, or some of the non-profits to help get them care.”
Once an insurance provider is secured, the theory follows that Ochoa then has a reimbursement source going forward. “I don’t consider that charity care because I’m just putting in a little bit of effort in the beginning—which we all should—to help the patient get what they need, and then I’m reimbursed for their care,” she says. “And once a vascular patient, always a vascular patient, so they become lifelong patients of mine.”
Sometimes the how and the why questions of the SAVE Clinic and Ochoa’s efforts co-mingle. And, sometimes, the interlocutors can be closer to home. Much closer. “My father was once, like, ‘What are you doing? You’re just banging your head against a wall.’ I’ve had one of my mentors say, ‘Why are you doing this? This is going to kill you.’ I say, ‘No, actually, the opposite.’
“What does get frustrating for me as a physician is when I work and take care of these people, and the people who became physicians, who trained to take care of patients—they don’t do their job, and I have to fight them to take care of patients. That’s frustrating, because we are all physicians. That’s why we became doctors—to take care of those who are suffering and figure out a way to help them.”
The road ahead
What Ochoa founded in the SAVE Clinic was a way to pair her training and education with a passion for trying to make a difference. So, to that original assumption, hinting at the impossibility of it all, she has a question and an answer: “Is it really possible by doing it the right way? Yes.”
To those who may follow, she says this: Doing the right thing for patients for the right reasons, and practicing the specialty the way it was meant to be practiced, will ensure, in the end, things will work out. “I hope that, with what I am doing, I leave people behind me; that I’ve opened doors for them, laid a path for them, inspired them, educated them to come in and do the same. Even if I don’t move the number on diabetic amputations, I’m hoping that, through all those interactions, I leave some kind of legacy of hope—and that I’ve tried.”