There are 700 hospitals in Texas,” says one imaging industry analyst, “that’s 10% of the 7,000 in the country. But Texas has only 2% of the total number of beds. They want imaging services in all those rural hospitals.”
Jeff Johnson, RRT, is director of radiology at one of those rural hospitals, the 35-bed Falls Community Hospital and Clinic in Marlin, Tex, a town with a population of about 6,600 located 20 miles south of Waco.
One day each week for the past 3 years, a mobile truck with an MRI unit on board has been pulling up at Falls Community Hospital to provide MRI scans to the eight to 10 patients who show up for diagnosis.
Johnson says there simply is not the demand at his hospital to justify the installation of an MR scanner permanently on-site. Using the 1-day-per-week mobile covers demand and allows the hospital to retain patients, he says.
“We were sending a lot of patients to Waco, and we were looking to keep them local,” he says. “The mobile MRI has helped our bottom line. That’s probably 40 patients each month who don’t need to travel. And for us it means $300 to $400 for each of those patients. The mobile company has a marketing person who contacts all the doctors in our area of service, and we get referrals from other doctors who know we have the MRI.”
Falls Community Hospital fits a profile for hundreds, possibly thousands, of small hospitals around the country who turn to mobile imaging vendors to provide modalities the hospitals are too small to capitalize.
MRI is not the only modality being hauled around on a truck. CT, PET, and increasingly PET/CT trucks are journeying between hospitals too. Sometimes they carry bone densitometers and stereotactic breast biopsy equipment as well.
Proponents of this 1-, 2-, 3-, and sometimes even 4-day-per-week mobile imaging point out that it is good for patients. Patients get service close to home, with doctors and nurses they know. Some hospitals using mobile modalities say they do not make much money, but all of them who continue the services at least reach the break-even point. Local doctors like the services too. Patients stay close and radiology reports come from the local facility they routinely deal with.
But there is often much more to this short-term mobile imaging vendors call it shared servicesthan having a truck with a crew of technologists pull up to a site. Hospitals and clinics that use these services need to get their regulatory ducks in a row before they can ever bring the modalities in. They have to have some place to park the units and to run power to them, and doctors must be on hand to oversee some procedures. Scheduling is required; sometimes it is critical that patients show up. The hospitals have to make sure that the mobile technologists are properly licensed and that the provider/vendor is insured, and they may want the reassurance of having the vendor accredited too.
When the mobile modalities change from one type to another, the requirements for them and the patient-care landscapes around them change too. So a hospital with a mobile MRI would face a different situation, perhaps, with a mobile PET unit.
Back in the days when CT scanners were just coming on the market, the demand for them gave a big boost to mobile imaging companies, and the mobile companies gave a big boost to the popularity of the CT scan. Now CT scanners have become so affordable and the demand for the scans has increased so much that even small hospitals usually have a CT in house. The demand for CT on the shared services model, where the modality truck follows a route from hospital to clinic to hospital to provide routine weekly service, is not nearly as robust as it once was.
The main call for shared service CT these days comes from facilities that are just on the cusp in patient volume where the in-house CT capacity has been maxed out, but the added demand does not yet justify the installation of a second or third CT unit.
At Providence Holy Cross Hospital, a 250-bed trauma center in Mission Hills, Calif, that was the scenario when a mobile CT was called in 3 days per week during a span in 2003.
“We had a pretty bad backup in scheduling,” says Providence director of radiology Harry Keleshian, RT. “We were 4 or 5 days behind.”
The hospital had one CT in-house that was doing about 15,000 procedures per year, Keleshian says. “Our volume had been about 10,000 and we went up. If the machine was down, we had a lot of delays.”
Providence ran the mobile for several months, but eventually added a second in-house CT and ended the mobile service. Unlike most shared service users, Providence paid for the truck and modality use only and provided its own staff for the mobile. “For the most part, we sent the outpatients to the mobile site in the parking lot,” Keleshian says. “It might have been better if we’d had it for more than 3 days; the limited coverage was a problem.”
At Fletcher Allen Healthcare, a teaching hospital of about 450 beds in Burlington, Vt, a mobile CT is now coming in 3 days per week, while a new scanner is being installed.
“It’s all about the backlog,” says imaging manager Paula Gonyea, RT(R), CT. “If we didn’t have it, we’d have patients waiting for weeks. We would have a difficult time upgrading because the downtime would be unacceptable.”
Gonyea notes that the mobile CT could tie electronically right into the hospital’s PACS and laser printers. “It was seamless to the radiologists, and we could print film for our referring providers.”
Before it leased its mobile CT, Fletcher Allen Healthcare had made similar use of a mobile MR during an install. “We were averaging about 1,000 MR procedures per month, more than we could do with our two MRIs, so we leased a mobile until we could get a new magnet approved,” says Gonyea.
The MRI also came 3 days per week, but unlike the CT, the vendor staffed the MRI. “That worked out great. Their techs did a great job,” Gonyea says.
While the use of the two modalities was similar in Fletcher Allen’s case, the use of mobile MRIs generally presents a far different picture than the use of mobile CTs. For one thing, MRIs are out of the price range of many rural hospitals, particularly when demand levels do not justify purchasing. For that reason alone, mobile MRIs are in demand, and vendors are eager to create routes to satisfy their rural customers. One big vendor runs about 70 shared service mobile MRIs throughout several states but primarily in a broad corridor going right down the middle of the country, stopping in one small town on one day and another the next.
Marketing the shared services is also intense. The same vendor that plies the center of the country employs a sales force of about 20 to call on hospitals and clinics. The company is also conscious of value-added services like consultation on billing, patient education, and local marketing. An irony of the mobile MRI business, says a representative for the company, is that creating mobile MRI patient bases eventually gives the hospital or clinic enough demand that an install is economically feasible. “If we do a good enough job, we eventually work ourselves out of that customer,” the representative says. The two or three big shared service vendors are “for the most part swapping customers,” he adds.
At St Alexius Medical Center, a 300-bed hospital in Bismarck, ND, an in-house MRI was installed 2 years ago, but demand has already outstripped its capacity.
“We were really getting the sense that one magnet would not be sufficient, so we have contracted to have a mobile on-site 2 days a week,” says radiology director Amy Hofmann. “We are moving into the 390 to 400 examinations per month range, of which roughly 25% are now being done with the mobile. It comes on Mondays and Thursdays, the peak days for us.”
Hofmann says the hospital is careful to make sure that the mobile technologists are properly licensed and credentialed. The radiology department is responsible for overseeing the quality of the mobile unit’s imaging. “If it needed calibration, the radiologist would talk to me, and we would make sure the quality control was done on service and the technical staff. The technicians out there also have QC reports that they run. We had them change some scanning parameters by radiologist’s preference, but there haven’t been any quality problems.”
At Dartmouth-Hitchcock Medical Center, a 400-bed teaching hospital in Lebanon, NH, there are three fixed MRIs on-site. They stay open until 11 pm, but even that is not late enough to meet patient demand.
“At night people do research on the MRIs,” says the Department of Radiology’s administrative director Monte Clinton, CRA, “so we can’t bring in patients from midnight to 6 am.”
To meet its demand, Dartmouth-Hitchcock has joined a consortium of New Hampshire hospitals that contract with a mobile vendor to bring services in. The mobile MRI truck comes to Dartmouth-Hitchcock 4 days per week.
“We can do contrast down there, but generally we don’t. Contrast monitoring is not a good use of the physician’s time. The mobile unit takes about 5 minutes to walk to,” Clinton says. For the same reason, most patients taken to the mobile are ambulatory. “We do the reception in the radiology department, enter the patient in the RIS (radiology information system), and then the vendor has two technicians, one to do the examinations and one to bring the patients back and forth.
“The mobile vendor has its own liability coverage. We do the interpretations so that the malpractice is covered under our hospital. The contract goes through our purchasing and risk management department,” Clinton adds.
The ways in which shared service mobile units are deployed are not limited to contracting with the big vendors. At Intermountain Healthcare (IHC), a 22-hospital system with hospitals and clinics in Utah and Idaho, several variations on the shared service model are employed.
IHC owns two mobile MRI units outright that it dispatches to its many rural sites. But it also rents or leases vendor-owned mobile MRIs depending on demand. Oddly, while IHC has purchased two mobile MRIs, it contracts with a mobile vending company to staff them.
“They supply the technician, the driver, the insurance. All we have to do is own the unit and see it at our site,” says IHC’s administrative director of imaging services, Deanna Welch. She says IHC bought the mobiles because it was cheaper to own them. She estimates there is about a 15% saving through ownership over leasing. But a second reason was flexibility. “We probably have six or seven hospitals that are too small to have their own MRIs,” Welch explains. “At other sites the mobiles are needed to control backlogs. The other place we are going to start using them is in our physician division at outpatient sites,” Welch says.
She says by contracting with a vendor to supply the staff for the mobiles, IHC avoided a lot of time-consuming searches for technicians and other management duties. “Now we have the best of both worlds,” she says.
Many hospitals that use mobile MRI also use mobile PET services. In-house PET units are expensive and reimbursement for PET scans can still be a struggle so that even big institutions call in mobile PET vans. One factor makes PET mobile use much different than either MRI or CT. The key word is radiopharmaceuticals. Radiopharmaceuticals can be used with other scanners, but with PET they are a routine part of the procedure. This has a big impact for hospitals on the regulatory side.
John Montville is a strong proponent of PET. He is administrator for two cancer treatment centers in northern New York. He is also director of services for North County PET Imaging. North County is an entity organized by three hospitalsthe Alice Hyde Medical Center, the Canton-Potsdam Hospital, and Massena Memorial Hospitalto allow them to economically and efficiently offer mobile PET scans. The three hospitals are within a roughly 50-mile circle; all are licensed for about 100 beds.
Each Friday the PET unit goes to one of the three hospitals; on the fourth Friday of the month it goes “where the need is,” Montville says. “The mobile PET works much better for us than having a fixed unit.” The same vendor serves all of the hospitals under the direction of the North County entity. “The three hospitals agreed to work together and to try to draw patients from their own markets and not compete on the PET,” says Montville. “There is no contract between them. It’s informal, but a solid relationship.” All three hospitals contract with the same vendor but each contract is separate, Montville adds.
Montville, who headed the effort to initiate the PET service, says it was a regulatory nightmare that took a year. A separate certificate of need application (CON) had to be filed by each hospital and approved by the state. He says the vendor was extremely helpful in meeting regulations, including the use of the radioisotope. The vendor staffs the van and provides the radioisotope. The service got under way in October with no capital equipment outlay for any of the hospitals.
Montville says the PET units have been heavily marketed. Despite that, he says, “volumes tend to wax and wane. We’re looking at five to 10 scans per visit of the PET, which is solvency. It’s definitely a moneymaker.”
The expenses of PET are considerable. The machines are expensive to maintain, and the radiopharmaceuticals are $300 to $400 per dose. The modalities themselves cost more than $1 million.
“We couldn’t do what we’re doing in this small rural area without the mobile,” says Montville. “It would be too much of a capital expense. With the mobile you are given equipment that’s state of the art, and there’s no real disadvantage.”
Handling radiopharmaceuticals like fluorine 18-labeled deoxyglucose (FDG) directly is something that most hospitals leave up to the mobile vendors. Both vendor and hospital or clinic must be licensed to administer the drug. Typically, the vendor will contract with a cyclotron operator for the FDG, which will often be delivered to the mobile site twice per day, necessary because the half-life of the FDG is just under 2 hours. Beyond that, it is medically useless, but must be carefully disposed of. Hospitals use radiopharmaceuticals for other scans, however, and they usually have disposal methods in place. But in most cases the FDG is kept in a lead-lined vault in the mobile PET van and not carried between the hospital and the mobile unit. The cyclotron representative usually picks up the old syringes with the decayed residues when new materials are delivered. Lead-lined cartridge boxes are used for pickup and delivery.
Hospitals and the mobile operators too must be scrupulous that patients have signed physician orders to receive an injection of FDG. They must meet regulations to have a radiologist on- site at the hospital when the injections are given.
At the Dixie Regional Medical Center in St George, Utah, MRI manager Gregg Stout oversees the mobile PET unit that comes once a week. Dixie Regional shares the PET with a Salt Lake City hospital and that hospital supplies the nuclear medicine technologist who comes with the van.
“The radionuclides are delivered right to the scanner,” Stout says. “We’ve got cameras that have to be trained on the scanner at all times. They don’t want any terrorists getting radioactive materials. Even the person who brings them in is bonded.”
But the hospitals’ real fear regarding FDG is simpler. If the patients do not show, they are held responsible for the cost of the radiopharmaceutical.
“We have to be careful with our scheduling,” Stout says. “We’ve only had one instance where a patient didn’t show up. We can charge them for the radionuclide, unless the hospital was at fault or the ordering physician was negligent in informing the patient. We always get preauthorization.”
One major vendor operates 11 mobile PET vans but only one PET/CT. PET/CT is in its extreme infancy. However, nearly all those who now use PET say that PET/CT will be the way of the future.
At Dartmouth-Hitchcock Medical Center, Clinton is bringing in a mobile PET/CT unit 3 days a week to build demand prior to the hospital installing a fixed PET/CT. “We are building an expansion to our radiology department, and it will have a fixed PET/CT and shell space for a second PET/CT,” he says.
In the meantime, the hospital is now booking 10 hours of examinations per day on its PET/CT mobile. “We are going to be doing 860 PET/CT scans per year in 3 days, and that’s fully booked,” Clinton says. “We have to be up to 1,220 examinations per year before we can get a CON for a fixed unit.”
Some states, according to one mobile vendor, are requiring that PET/CT units be declared as one type of modality or the other but not both.
When the wrinkles are worked out and when physicians become more familiar with the abilities of the scanners, look for more mobile PET/CT trucks to be out on the highways.
George Wiley is a contributing writer for Decisions in Axis Imaging News.
When It’s Cold Outside
John Roberts is majority partner in Integral Mobile Services, which supplies per-day PET mobile scanners to hospitals and clinics, mostly in the Northeast. He tells a story that highlights another side of the mobile imaging trade. The trucks are operating in all kinds of weather.
“It was minus 26 degrees in Malone, NY, which we service,” he recalls. “We had to move on that night. A generator went down. Without a generator, the temperature in the coach will drop below freezing in 3 hours. This would ruin the crystal in the PET scanner.
“The driver called me wanting to know what to do. I told him to go to Wal-Mart and get a bunch of down quilts and several packs of hand warmers. I said, I want you to load those in the gantry and wrap the scanner in swaddling cloths.’ When we got to Malone 8 hours later the temperature in the scanner was 67 degrees. That kept the crystal from freezing. You have to be inventive in this business.”
Now with changes in ICC (Interstate Commerce Commission) regulations comes another driver-related headache, Roberts says. “The driver can’t go more than 11 hours on the road without a 10-hour rest, so that will mean tag-team driving or route constructions that will play a large role in how we allocate resources.”
Roberts says he considers himself “in the large tool rental” business. He also is in the hauling business.