d02a.jpg (10581 bytes)When Tropical Storm Allison pummeled the southeast coast of Texas in early June — a mere five days into the 2001 Atlantic hurricane season — numerous Houston-area hospitals, clinics and imaging centers were hit hard, suffering severe damage to their medical imaging equipment.

Calling the insurance company set long-term relief into motion. But who or what rushed in — stat! — to ensure little or no interruption of imaging services?

Businesses whose business it is to keep imaging facilities in business sped to the rescue, providing equipment rentals and interim set-ups that enabled a return to daily scanning operations as quickly and conveniently as possible, given the circumstances. With their fleets of mobile and modular solutions poised for daylong rentals or months-long contracts, these companies offer provisional options in medical imaging — not just when disaster strikes, but for almost any ad hoc imaging situation.

Pick from a pack of providers
While Houston’s recent SOS highlighted the capabilities and flexibility of companies furnishing imaging products and services on a temporary, even emergency, basis, calls for disaster recovery action are few and far in between (which is a good thing, when you think about it). More commonly, their business is more likely the result of hospitals’ budgetary realities, burgeoning backlogs, physical constraints, construction periods to relieve those constraints, or exploration of market potential for a particular imaging modality.

At one end of the spectrum are businesses specializing in a single modality and one delivery mode, such as mobile MRI provider Diagnostic Radiology Systems Inc. (Lexington, Ky.) and Mobile P.E.T. Systems Inc. (San Diego), whose name states its mission. Remedy Medical Systems Inc. (Atlanta) and Interim Solutions & Sales Inc. (Ramsey, Minn.), owned and operated by brothers Steve and Jeff Axelrod, respectively, cover the middle ground: Both offer MRI and CT and can do so in either a mobile or a modular format. Then there are those businesses whose fleets contain several modalities, available in both mobile and modular configurations. MedAssets Exchange Inc. (Wood Dale, Ill.), for example, offers MRI, CT, cardiac cath and angiography, as does Mobile Radiology Inc. (St. Petersburg, Fla.), and Alliance Imaging Inc. (Anaheim, Calif.) weighs in with MRI, CT, PET (positron emission tomography), SPECT (single photon emission computed tomography), ultrasound and lithotripsy.

Mobile route providers do just what their designation implies — move, from location to location as night falls after scanning all day. Their trailers show up at a particular site every Tuesday for three years, for instance. Generally, they are fee-for-service businesses whose packages include the unit in a trailer, a licensed technologist to perform the exam, any maintenance the unit may require and the finished product, the exam results, for the contracting entity. In most cases, they need no special accommodations. The exception is easy access to fluorodeoxyglucose (FDG) isotopes for mobile PET services. Jill Janik, director of education and marketing for Mobile P.E.T. Systems, says that hospitals in metropolitan areas are usually close to cyclotrons and can arrange for several FDG deliveries during the day.

Despite the transient nature of the business, scans by mobile route providers are no less professional than those performed inside the hospital proper. And for smaller rural facilities where money is always an object or larger urban hospitals with budgets and physical locations that preclude a multimillion-dollar investment in new equipment, construction and real estate, mobile makes sense for an indefinite interval.

“Before we go to a hospital, we get information on their procedures so that when we are there, we are them,” says Maryanne Inman, Diagnostic Radiology Systems’ CEO. “In our contract, the hospital will provide a physician who will determine the protocols and procedures. Our technologists do what that physician wants and requires. We follow their emergency procedures, we follow their conscious-sedation procedures, we follow their competency credentialing requirements. We are under the direction of the radiologist at that facility.”

But even niche industries have their hierarchies. Companies that deal in interim resources draw a differentiating line between themselves and mobile service providers.

“Our interim business focuses more on taking a unit and placing it somewhere for an extended period of time — extended being three to 24 months — where the hospital provides the staffing, and they are using that unit for a couple of reasons,” explains MedAssets President Chip Halverson. “One would be they might be in a construction program where they are moving the cardiac part of the hospital from one wing to another and they don’t want to be without cardiac cath service. So we provide them with a mobile cath lab or perhaps even one in a modular building, to provide bridge service during construction.

“We have some units that go out to your suburban hospital, for instance,” he continues. “The cardiologists have been doing their caths in the big downtown hospital and they say they want to do them in the suburban hospital and it is $1.5 million to build out a new permanent facility and the hospital administrator says, ‘I’m not sure the volume is there.’ So they come to us and rent [a cath lab] for six months at $30,000 a month and then they can prove the demand before they make the investment.”

“There are a lot of hospitals that don’t have any intent of owning high-tech equipment that is known for its obsolescence,” declares Jay Mericle, executive vice president, operations group, Alliance Imaging. “They don’t want to take a risk with their capital. They are already having a hard enough time staffing their radiology department with X-ray or ultrasound or nuclear medicine technologists and then having to procure new equipment, spending capital dollars and all the stuff that goes with it — they would rather contract with an imaging service provider like us.”

“The majority of the work out there is equipment replacements, when changeovers occur,” states Dennis Giuzio, president, Mobile Radiology. “You never know how long. I have had a unit at the University of Miami for a year because there is a changeover of equipment.”

Tales from the trenches
Medical Center Hospital (Odessa, Texas) signed with Interim Solutions & Sales for a fixed-site mobile MRI approximately 18 months ago for two reasons: to alleviate a patient backlog and to rationalize the purchase of a second MRI scanner. The 350-bed hospital has since ordered its second MRI from the manufacturer and was anticipating its delivery last month.

“We wanted to justify to administration on paper, with hopes that the problem would not go away. Fortunately, it didn’t,” says Joe Salmon, lead MRI technologist who also has supervisory responsibilities. “We exceeded our number to administration and we have since exceeded that, and we still have a two-and-a-half-week backlog.”

Medical Center Hospital conducts 30 to 55 scheduled and nonscheduled scans a day on two MRIs: its own, a Siemens Medical Systems Inc. (Iselin, N.J.) 1.5 unit, and a Siemens 1.0 from Interim. The “loaner” sits about 12 feet from the hospital doors and is run by Medical’s own staff five days a week, 15 hours a day, from 6 a.m. to 9 p.m.

Salmon, who was involved in choosing Interim Solutions, said he and his immediate supervisor selected the company independent of each other as they investigated several firms’ prices, options and the like. And while he calls Interim’s pricing “competitive,” its flexibility is what Medical Center Hospital prizes most.

“We have been very happy with Interim Solutions; in fact, delivery dates on MRI systems change, and they have been very lenient with us as far as the contract goes,” Salmon testifies. “We have asked for extensions and they have never given us any problem. If there is any problem, we call his office directly and within that day he has something working to get it solved, whatever it might be. And,” he adds, “we have had no downtime because of Interim.”

Flexibility, availability, contract length, pricing, service — healthcare facilities considering a stopgap solution should ask innumerable questions. At least that is the advice of Jerry Gruhlke, materials manager at Jefferson Memorial Hospital in Crystal City, Mo., just south of St. Louis. Jefferson Memorial contracted with MedAssets last year for a GE Medical Systems (GEMS of Waukesha, Wis.) cath lab, in current use at the hospital.

“We have one [cardiac cath lab] in service but with the needs and the volumes that the doctors had expressed to us we felt that an additional cath lab was what we needed,” begins Gruhlke. “The whole idea is to get a good feel for how many you are going to do in addition. Our forecast is we do need another cath lab; this allows us to do some of that growth.

“This was a new thing for us; it is one of those things that when you go into it, of course, you’re looking for something to go wrong and it really didn’t,” he elaborates. “We went into this whole program with just oodles of questions: Does this cover this? Does this cover that? And they just pretty much walked us through. You actually have more questions than if you are buying your own because you want to know who is going to do what. For example, Who handles the building if I develop a leak or something? There were a ton of questions I wasn’t used to dealing with.”

imageMedAssets Exchange Inc. offers MRI, CT, cardiac cath and angiography.

Jefferson Memorial prepared for its modular cath lab by installing footings and making minor adjustments to the side of the hospital that would lead to the attached cath lab. MedAssets managed everything else, Gruhlke recalls. It trucked in the building and set all pieces in place. It provides the technologist, handles the insurance on the structure and maintains the installation with OEM service. Gruhlke appreciates that MedAssets allowed Jefferson doctors to modify the installation to their liking. He also appreciates that patients entering the cath lab do not realize they are leaving the hospital’s bricks-and-mortar architecture for a modular configuration.

“The patient doesn’t even know he is going out of the building; he has the feeling he is still within the institution when he goes into that cath lab,” Gruhlke relates. “Patients are already tenuous when they walk in there, and this allows things to look like this is part of the hospital. It is really important that you give that effect. I think it is a comfort factor.”

Customer comfort, in the form of a smooth-running installation, is what John P. Eastman, special projects coordinator with SDI Diagnostic Imaging (Tampa, Fla.) experienced with the fixed-site mobile MRI scanner SDI leased from Remedy Medical earlier this year.

A radiology group serving area hospitals and referring physicians, SDI offers MRI and mammography imaging services in outpatient centers in Tampa and Oldsmar, Fla. It also reads images for the Tampa Bay Buccaneers. When staff realized that MRI services were going to be interrupted at the Tampa site, SDI rented a 0.5 MRI unit from Remedy to keep scanning on track.

“To be honest, the MRI went pretty smoothly,” remembers Eastman. “What was nice was that the [neighboring] hospital we serve had had a mobile MRI there in the past so there already was an electrical hook-up.

“To Steve’s credit, he was very, very helpful in the actual set up and installation,” Eastman maintains. “When you put in a mobile, you want to have some kind of barrier around it; you don’t want people getting too close to the magnet and you don’t want cars parking too close to it and throwing it off. Steve came down himself and helped build a [concrete and construction fencing] barrier. He was very good about keeping in touch with me to make sure things were working smoothly, checking up from time to time. If there were questions or concerns, he was on the ball as far as getting back to us.”

Details, details …
Having the president of the imaging service company help construct barriers is not a typical contract item. Certain other details are, however, and every option affects the bottom line — a monthly range of $20,000 to $90,000 and every number in between. What kind of equipment goes into these mobile and modular installations, for example? What services are included? Can you choose a unit with every bell and whistle or must you settle for utilitarian and basic?

imageThe cutaway view illustrates the layout of a trailer from manufacturer AK Specialty Vehicles (Harvey, Ill.). Interiors often provide processing and reception areas adjacent to the actual scanning rooms.

“The deal includes the system itself and any capabilities,” notes Steve Axelrod, Remedy’s barrier-building president. “It could be anything from a bread-and-butter system to state-of-the-art technology. It includes all service and maintenance on the system, and we generally use OEM service. It also can include a staff person; it depends on what type of solution they are looking for.”

“We will take care of the project from start to finish, from site planning — we make sure the system arrives, it will be properly placed and set up — all the way through applications training and handing the customer the key,” recites Interim’s Jeff Axelrod. “Networking is one thing, too, being able to take the imaging device that you have and network it either to their information systems within the hospital or to some sort of router or server network where they can look at images within the hospital or film in the hospital, so we take care of all those issues as well.”

“The typical deal would include: within the trailer you would have the actual device itself, and you would have all the other ancillary equipment: monitoring equipment, probably a film developing lab or a film processing station, or if it is digital you would have a laser printer,” offers MedAssets’ Halverson. “The assumption is some of these are going to go where they have never provided this service before.”

“You can rent one from us without any of our services that go along with it. You can rent just the physical asset itself,” Alliance’s Mericle remarks. “We can include service and cryogen contract coverage; we can include trailer maintenance coverage; we have insurance for the vehicles; if you want us to add technical staff, marketing support, scheduling, billing and training services — it is kind of like an a la carte menu. You can say, ‘I would like this, this and this,’ and we can keep adding more services to the program. Or, if you just want it strippo, you just want to rent a car without a driver, no radio, we can do that, too.”

imageAs with most mobile providers, Mobile P.E.T. Systems Inc.’s fee-for-service agreements include the unit in a trailer, a licensed technologist, equipment maintenance and exam results.

Most providers cultivate a mixed fleet, since the majority of customers want on a temporary basis what they are replacing or planning to acquire on a permanent basis. “In MRI, especially, everybody body seems to have some kind of an opinion when it comes to the manufacturer,” admits Mericle. “In the PET business, equipment preference does not seem to be a real high priority. About the fifth question on the list may be, ‘How about equipment?’ And no matter what you answer, nobody seems to say, ‘I won’t take that; I can’t have the blue one, I have to have the red one.’ In MRI, it is one of the first questions out of the hospital’s mouth.”

“The age of the equipment depends on the deal,” asserts Giuzio of Mobile Radiology. “It depends on what they prefer, what their budget is. We have equipment that is 10 years old to brand new. Some institutions just want to get by. But I have some institutions that want brand-new technology for a two-week or one month timeframe because they have such a high volume and they need this type of equipment. We have 1.0, 1.5, 0.5 [MRI field strengths]. The smaller systems are not as viable as they were a year ago. The big demand today is the 1.0 and the 1.5 shielded systems.”

“It does seem to make it easier if we can match up with the equipment they had in-house; of course, we can’t own every type of equipment, so we offer a couple of different options,” Steve Axelrod points out. “If it is a partnership with the facility where the system is going to be there for a couple of years, we will buy to order whatever system they want and place it in either modular or mobile; we will buy to suit. The other side of that is some systems — CT is the best example — are not capable of going into a mobile system because of size and manufacturer’s specifications, whereas every system could go into a modular.”

You were great! Did we mention we’re not renewing your contract?

Unfortunately for the imaging service provider, a sure sign of a job well done is the eventual loss of a customer’s business. For when a facility pronounces its interim measure a success, its decision to invest in its own system and take over the scanning is not far behind.

“One of the good things about this business and one of the unfortunate things about this business is, we will go into a facility that has no MRI and we will help them educate the physicians to the use of MRI, and when we work it up to the point where we are there three or four days a week, they decide, ‘we should be doing this ourselves,’” comments Diagnostics’ Inman. “So we build the business and then we work ourselves out of the business.”

“Typically what we find is that a long-term agreement leads to customers doing it themselves,” echoes Jeff Axelrod. “That is kind of our death wish.”

Brother Steve Axelrod, however, is of the opinion that “it is a necessary evil for the industry to be able to have the ability to do these rental systems and for other people it is a blessing. For the facility that does not want to use it but has to, we are there. For the facility that might have thought they might not have options available to them, we are there. And for the facilities that just need something for a short time or even a longer time, we bridge the gap from where they are to where they want or need to be.” end.gif (810 bytes)