Doing Wheelies: Moving into Mobile Imaging

In 1999, when experts discussed trends in MR imaging, their viewpoints were divided on many topics, including mobile MRI. In fact, many believed that thanks to low-bore open MRI scanners, the mobile MRI unit was likely to disappear.

Not only hasn’t the mobile MRI disappeared, it?and mobile imaging units in general?apparently will keep increasing. One Frost & Sullivan study¹ concluded, “The market for mobile imaging services in North America should see further growth from its current levels of $686 million (US) to $1.2 billion by 2008.” A 2003 PET study² indicated that 890 medical facilities out of 1,400 surveyed were already using a mobile service to provide PET or PET/CT service

Is mobile imaging right for your facility? Read on to find out.

Know Your Market

The general consensus for instituting a mobile imaging service is to know your market. Tina Reese, VP of marketing for Alliance Imaging Inc (Anaheim, Calif), says, “Know what exams you’re already doing and what trends you’re seeing. There could be exams that you’re missing or that might be going to a competing facility.”

John Vartanian is VP of Medical Imaging Resources Inc (Ann Arbor, Mich), which provides imaging services, including mobile, in every state except Alaska and Hawaii. “Find out how many patients you’re referring out. Someone’s turning 50 every seven seconds in America,” he says, adding that this information is important because aging bodies require more imaging services. Vartanian points to the following scenario: “The hospital has two MRIs going nonstop, and the administrator says, ‘We’re losing patients. We have to put in another unit.’ But the facility’s manager says, ‘We don’t have the room.’ The answer is a mobile unit.”

Avoiding business loss is a main reason why Radiologix (Dallas), which owns and operates 76 diagnostic imaging centers in 10 states, turns to mobile units. John Ellis, a VP of operations for Radiologix, talks about the company’s business in Maryland: “We currently have two mobile MRIs in our practice. Both were instituted because we’ve maxed out our capacity in those centers to handle the MR demand from 8 am to 5 pm.”

Ellis admits that this was a surprising phenomenon; however, rather than sit and analyze the issue, Radiologix hurried to cope with it. Ellis adds, “There have been a lot of new MRs in the past two years that are not as busy as ours. We call them ’boutique providers,’ “?in other words, they offer MR only as opposed to a full suite of imaging services. With its MR patients having their choice of providers, Radiologix turned to mobile imaging as the solution for maintaining its share of that daytime business.

Filling Upgrade Needs

Even if a potential imaging buyer has the money?and space?to install a new unit, there’s still downtime during the construction period. “Last year, we swapped out four 16-slice CT scanners and had one mobile traveling to our four offices,” Ellis says. “There’s about a 100-mile radius between the northern- and southern-most facilities.” The mobile CT stayed on-site 3 months at one center and then moved on to the next.

Sometimes the mobile unit is even more mobile than expected. “The national average for PET scans is about three to four per day,” says nuclear medicine technologist Lisa Kohlhorst, CNMT, RT, (R)(M), VP of business development for Shared PET Imaging (Canton, Ohio). The company’s mobile units do more than that because the hospital schedules the unit for one or two visits per week, depending on referral patterns. As mobile PET/CT replaces both in-house and mobile PET, the company will be able to do even more procedures daily, as PET/CT scans take about 15?20 minutes as opposed to PET’s 45 minutes. The bottom line: A mobile unit like one of Shared PET’s could visit several different facilities in any given week.

Once a facility has accommodated one type of mobile unit during an upgrade, it can accommodate another. “In the majority of cases,” says Shared PET CEO Randy W. Skiles, “a hospital already has a parking area or a [weight] pad, plus the [necessary] 480 three-phase power hookup, available because it’s had CT, MR, or some other mobile unit in place during an upgrade.” The only difference is that PET/CT could take a longer coach?from 48 to 52 feet instead of 44?48.

Testing the Waters

“Try before you buy” is the motto that Mark Casner offers potential customers. Casner is president and CEO of DMS Imaging (Minneapolis), which has been a mobile vendor for about 20 years and now services 40 states. Casner notes that an in-house PET/CT system could cost a hospital at least $2.5 million. Skiles concurs, adding, “If you’re doing only eight scans per week, that’s hard to justify.”

Vartanian points out that a single-slice CT can cost a facility $75,000 just for the scanner itself. By the time it’s loaded into the trailer, the cost is more like $225,000?and that’s assuming that single-slice is still adequate for a facility’s needs. “A 4-slice can cost $425,000 total, 16-slice $700,000 to $750,000, and about $1 million for 64-slice,” he says.

Reimbursements are a major factor to consider when deciding which mobile units a facility should use and when. “One client didn’t want to just run out and buy a PET/CT scanner without finding out three things: Is it effective? Will our physicians use it appropriately? Is it reimbursable?” Skiles explains, noting that the latter is the issue that gives facilities the most concerns.

Mobile mammography is often seen as a loss leader?more of a community outreach program. Pamela Anderson, RN, a breast health specialist at University Breast Health Center (Augusta, Ga), oversees her center’s unit, which services 25 counties in the central Savannah River area. “The mammogram itself costs about $105,” she says. “When you add in the radiologist’s fee, it easily can be a $185 procedure.” Yet less and less is being reimbursed by either managed care or Medicare.

MR, on the other hand, has become a cash cow for many hospitals. “If you follow the money, the national reimbursement average for a CT scan is $200 to $250, while an MR is $650,” Vartanian says. (Of course, all prices vary depending on the kind of scan, the facility’s competition in the area, and many other variables.)

Fitting PET/CT In

PET and PET/CT are still very much under scrutiny. A facility might be able to bill $2,500 on the diagnostic, but will it be paid? “About 14 or 15 cancers are approved for reimbursement,” Skiles notes, “and about an equal number aren’t.” That could change within the next year or two, though. “We’re about to enter a time when all cancers will be scanned, and all the information will be sent to Medicare for one year to evaluate how effective PET is in the management of cancer for all patients,” he says. Once that’s analyzed, PET/CT might start seeing an increase in mobile imaging.

Still, both large and small facilities are taking advantage of mobile PET/CT already. “We have a fixed PET unit at our Pomona site [in Baltimore], and we’re replacing it with a PET/CT,” Ellis says. “That’s about a three-month process?to decommission PET, deinstall it, reconfigure the room, and install the new unit. That’s why we put a mobile PET/CT scanner there for now. We won’t lose our current PET business, and we can start PET/CT procedures three months earlier.”

Alliance Imaging’s Reese says that PET/CT is a perfect example of how mobile services can help a facility increase its business. “Hospitals have invested a lot of dollars into their existing radiology service; by partnering with a mobile provider, they can offer this additional radiology service to their community without the capital outlay,” she notes.

Don’t assume that only major competitors like Radiologix or a university medical center are turning to mobile PET/CT services. According to Geri Heilman, radiology manager at Mercy Hospital (Coon Rapids, Minn), “I was hearing from our oncologists that PET/CT would be a really great piece of equipment. Otherwise, they’d have to go outside the community.”

At first glance, Mercy’s relatively small operation (271 beds) might not seem to make it a candidate for the highly specialized PET/CT business. The solution? Offer the service to referring oncologists (and patients) at both Mercy and a sister hospital in the Allina Health System?Unity Hospital, a 275-bed facility in nearby Fridley, Minn.

“I requested PET/CT ASAP and was able to get one of the first coaches upgraded,” Heilman explains. “It was really good for us. It was a way for Mercy to offer procedures for our patients without them having to drive to another location.” Oncologists at both Mercy and Unity use the PET/CT coach from DMS Imaging, which is stationed at Mercy.

Heilman notes a logistical issue that Mercy had to address in providing mobile PET/CT. It was transporting the patient, but that was relatively easy because Mercy was already configured for mobile units. The truck pulls up into a sort of “docking port”?the kind that smaller airports use to connect a plane with the terminal. This area provides a protective shield to guard the transported patient against the harsh realities of a Minnesota winter.

Also, Heilman is an aggressive marketer. She says that the hospital does various PET/CT education programs at Mercy for potential referring oncologists, thus increasing the chances of making a profit on the service.

The Vendor’s Job

THE NICHE-MARKET MOBILE Jamie Willis, president of Mobile Coach Specialties (Oklahoma City), has a niche market. “We build smaller coaches, 24-foot and shorter,” she says. “They generally house mobile X-ray equipment that an independent operation uses to service clients.” Specifically, Willis says those clients tend to be nursing homes and prisons. The latter rely on mobile X-ray services to eliminate the worry in transporting criminals?and the extra manpower and logistics involved when doing so. Nursing homes have another reason. “Let’s say one of your residents has taken a fall,” she explains. “If you have to take her into a hospital just to find out her hip’s bruised, not broken, it’s extremely expensive. In Oklahoma, that will cost $500 for the ambulance ride, plus $300 for the ER visit.” The trip also can be very difficult for a senior patient, anything from just annoying to truly disorienting. With Willis’ coaches, the X-ray machine is rolled right off the truck and up to the patient’s bedside. That disorientation is avoided?and the total cost for the visit is $120. Not long ago, according to Willis, “People would buy a mobile X-ray unit and throw it in a truck. But the X-ray quality was terrible.” Besides, users couldn’t be sure that the equipment would withstand the trip. “We start with a base vehicle and convert the entire rear end into a mobile darkroom, putting in either teleradiography or?more and more now?computed radiography,” she explains. “We’ll put a lift in to move the X-ray in and out, and to make sure that it’s stably anchored.” And, of course, the company will decorate the truck with any graphics requested. Willis warns the mobile operator who’s thinking of working on the cheap of competition like Harold Watson, who runs the kind of quality service Willis describes. Based in Tennessee, Watson was a mobile X-ray technologist who went on his own in 1999. It wasn’t an easy decision to leave his staff job, especially since he had to borrow the money for his first unit from his 80-year-old father. Fortunately, he was able to pick up many clients when his former employer went into bankruptcy. Watson emphasizes that the job is usually 24/7?it’s not unusual for him to be paged away from dinner with his wife or out of bed at 2 am. Still, today he has 10 vans and expects to see $1 million in revenue this year. A 3/4-ton cargo van provides the most room for both the equipment and the technologist, Watson asserts. He still has the original that Mobile Coach built for him with 300,000 miles on it, but he doesn’t recommend starting with a used vehicle, given all the wear and tear that will be added. For those seeking to get into the mobile-service business, he offers three tips: “First, make sure the van has a lift. That mobile X-ray is 125 pounds. With a lift, you don’t have to worry about how strong your technologist is.” Second, X-ray experience alone won’t help. “You must be an independent worker,” he says. “You won’t have anyone holding your hand.” And most of all, “You have to love people, especially seniors. You have be creative about how you do the exam,” because you may have to adapt it to your patient’s physical limitations. ?WM

The ads spout specifications: “Most durable, widely used mobile on the market with 2.5 kW high-frequency system.” “Soft-touch control panel.” “Quick lift.” “Battery-operated ID printer.” And the list continues.

How is a facility supposed to plow through everything? Experts on both sides agree: Don’t try to do it alone. “Facilities should partner with a mobile provider for more than just a piece of equipment,” Reese recommends. “Part of the relationship is helping a facility identify what piece of equipment will best meet its needs and in what configuration. One size does not fit all.”

Casner adds that a good vendor will disabuse any unrealistic expectations. For example, a facility might want the newer 3T MRI, but it really doesn’t have the budget for it. “Some want the Cadillac,” he says, “but they really can only afford the Volkswagen Beetle.”

Among the questions to have answered:

• What’s the vendor’s expertise with a particular modality? Does it specialize or handle more?
• How many pieces of equipment does the vendor have in the area? What’s the average age of its mobile units? How often are quality checks done?
• How frequently is preventive maintenance performed, and who does it?the original equipment manufacturer or a third party?
• What value-added services are available?
• Does the vendor have technologists? How often are they trained? How frequently do they obtain additional education?
• What’s the mobile unit’s staffing numbers? (“We always have at least two technologists on board,” Kohlhorst notes, “and if a facility’s scheduling ten scans a day, we’ll add a third.” Such precautions make for better shift rotation and overall backup.)
• Does the organization have accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO of Oakbrook Terrace, Ill) or the American College of Radiology (ACR of Reston, Va)?
• What coil options are available? (Reese notes that with MRI, a facility might want to make sure that there’s a dedicated knee coil if, for example, it has an orthopedic surgeon who’s going to require lots of knee scans.)
• Does the vendor have a manufacturer preference?

Of course, the question that’s top on the list is, what will it cost? Heilman’s arrangement with DMS Imaging calls for a turnkey operation in which the vendor supplies both the coach and the technologist for a graduated fee system. Heilman says, “Our fee depends on how many scans we perform each day. The more scans, the less it costs us.” Casner says that although many clients prefer this fee-for-scan approach, others set up a daily or a monthly rate. “We try to be very flexible.”

Profit Potential

It should be noted that a range of services beyond CT, MRI, PET, and PET/CT are being offered in mobile coaches. These include small Mom-and-Pop mobile X-ray units (see “The Niche-Market Mobile” sidebar at right), lithoscopy, ultrasound, and so on.

Anderson of the University Breast Health Center says there are potential profits?at least long-term?for mobile mammography. She admits that the center’s initial expectations were to find the majority of those using the mobile unit to be impoverished, but that turned out not to be so. “About 55 percent of our cases are women over 40 who ‘don’t have time’ to get their mammograms,” she explains. “Despite all of the education we’re doing, most women feel they can take time out of their day or off work only to help their children or a parent, but not themselves.”

One way Anderson is working around that?and which she hopes will help in reaching her goal of 3,000 mobile mammograms per year (she made 2,400 last year)?is to partner with big business. “We took the van to Jockey International, the underwear company. They pay us a flat fee, make sure their female employees have the 15 minutes needed off from work, and they work very hard to coordinate with us their employees’ schedules through the van. We serviced more than 100 women last time.” Anderson is hoping to coordinate with supermarkets and other businesses where women are generally found during the day.

If you must think budget, then Anderson urges administrators to think of the mobile service’s long-term profit potential. “If we do find something, these women are likely to come to us for the ultrasound, biopsy, et cetera. Their husbands hear about us and come to University for their tests.”

Ultimately, that’s the overall benefit of mobile units: allowing a facility to provide much-needed medical care. “Our first day, we went to Washington County and found a woman with cancer,” Anderson remembers. “Her last mammogram had been three years before. We saved her life!”

Wendy J. Meyeroff is a contributing writer for Medical Imaging.

References

1. Frost & Sullivan. North American mobile imaging equipment markets (MRI – CT – PET). November 19, 2002.
2. IMV Medical Information Division. 2003 PET census market summary report. Available at: http://www.imvlimited.com/mid/pdf/1004/PET03%20TOC.pdf . Accessed May 24, 2005.

THE STARTING POINT: FROM WHERE DO MOBILE RADIOLOGY CENTERS ACTUALLY COME?

by Lori Sichtermann

By now, most imaging professionals either have worked firsthand on a mobile radiology unit, or at the very least, have seen one sturdily parked outside a medical facility. The whole concept of mobile imaging means that the system has no permanence, a concept that conjures up such questions as: Where did it come from? How did it get here? What ensures the equipment’s safety while en route? A plethora of information is available regarding the benefits of using a mobile radiology unit. However, the process and planning that goes into the development of each unit before it arrives at a medical facility is, for the most part, unknown. According to Chad Smith, marketing director of mobile MRI and PET CT systems for Medical Coaches Inc (Oneonta, NY), which manufactures mobile MRI and mobile PET CT units, as well as mobile surgical clinics and dental units, it takes anywhere from 30 to 60 days to construct one mobile MRI and mobile PET CT trailer. “Being a special-purpose mobile unit manufacturer, we have the ability to manufacture any type of mobile unit,” Smith says. “We build everything from the ground up, meaning our engineers design everything while working with the customer to understand what they need out of the system.” Working from the outside in, Medical Coaches uses aluminum c-section wall panels, which are 50% thicker and more lightweight than most trailer panels. The panels are specially bonded together instead of welded, which increases strength and flexibility, and makes them more resistant to rust and deterioration caused by vibrations. Once the framework is complete, customers?typically shared service providers and hospitals?provide Medical Coaches with equipment from an original equipment manufacturer (OEM). “[The customer] ships the system to us, and our trained technicians install and level the equipment onboard the trailer,” Smith says. “When the installation is complete, reps from the OEM come out and do the calibration. It’s a pretty smooth process.” Even after the equipment is installed and calibrated, the mobile unit’s development is not complete. Medical Coaches has an extensive training program in place to ensure that customers fully understand how to operate various aspects of the mobile unit. “We go through the coach, step-by-step, making sure our customers know exactly how the unit works,” Smith says. “Before the unit rolls off our lot, we make sure operators know how to operate the leveling systems and the lift gate; how to hook up the electrical and drainage systems; and how to perform basic service on the coach.” What’s more, units manufactured by Medical Coaches are designed with the generator and patient lift underneath the coach, which protects both from weather, road dirt, and debris, and quickens setup time. “That’s the whole point of the mobile business,” Smith adds. “You want to get the coach in there, get it set up quickly, and get patients onboard so you can start making money. Our coaches make that whole process possible from the beginning to the end.”

Lori Sichtermann is associate editor of Medical Imaging.