Mobile imaging continues to keep pace with advances in medical technology and patient demand for more convenient service. Imaging systems began hitting the road a generation ago. Initially, there were only two types of mobile radiography scannersmammography and CT. Both were invariably fixed in place in semitrailers or vans the size of motor homes.
CT systems are now so reasonably priced that even the smallest hospital or clinic can afford one and does not have to share a mobile unit. Breaking even on mammography has become so difficult that many providers have bailed out, while others have shifted to deploying portable units in panel trucks and minivans.
The market for mobile MRI to supplement fixed-base systems and serve suburban outpatient clinics continues to be robust, and mobile positron emission tomography (PET) appears on many hospital wish lists.
PET, a scanner that looks at cell metabolism rather than anatomy, is the current darling of nuclear medicine departments and the oncology community. A decade ago it was found only in a handful of research and teaching institutions. At $2 million per machine, buying a PET would be a major gamble for most hospitals for several reasons: it represents an unexplored territory for most radiology professionals, only a smallalbeit growingnumber of PET studies have been approved for reimbursement by Medicare and Medicaid, and the learning curve for referring physicians to get comfortable with new technology often can be as long as 5 to 10 years
However, mobile PET offers a way “to build the service without having to incur the tremendous up-front cost,” says James Smith, director of radiology for the 103-bed JC Blair Memorial Hospital in Huntingdon, Pa, a community of about 7,000 that is a 2-hour drive west of Harrisburg. “We never could have afforded the hardware, let alone the cost of creating a facility for it and staffing up to operate it,” Smith notes. “But doing a mobile service gave us the opportunity to grow with the system, and offer it to the community. Our patients no longer have to drive a couple of hours to be imaged.”
JC Blair contracted in October 2001 for 1-day-a-week mobile PET service. At that time the nearest PET installations were in Pittsburgh and Philadelphia, both a 3-to-4 hour drive.
The PET provider staffs the hardware while JC Blair schedules patients, supplies the radiopharmaceuticals, and has its independent radiology group read the scans.? “We pay the PET supplier on a per-scan basis,” Smith explains.
“Our contract calls for 12 scans a month. Some weeks we do five scans and others only one. We have had weeks where there were no requests for PET. When that happens, we call the vendor and tell him to bypass us. After 7 months, JC Blair was at the breakeven point, but its contract enables it to cut back to 1 day every 2 weeks if its patient volume declines.
“We are making a little bit of money,” Smith says. “But it has been very slow.? With a new modality like PET you have to establish a referral base, and with PET the referrals are primarily coming from oncologists. Even though it has been around for a long time, unless you are an oncologist just coming out of your residency program, you’ve heard about it, but you really are just not attuned to it. It is going to take some time for the learning curve to kick in and for PET to take off. But it will, just as CT and MRI did.”
Smith notes that JC Blair introduced MRI with a mobile unit in 1988. “It took us until 1997 before we were doing 85 to 100 scans a month and went to 2 days a week. But volume continued to grow and in July 2001, the hospital went to 5-day-a-week service. “We are doing 155-160 scans a month,” Smith reports. “With MRI it took almost 10 years for the learning curve to kick in with physicians in our conservative rural area and for them to feel comfortable with the hardware and the results they were getting.”
When JC Blair signed on for PET, attempts were made to get other area hospitals to work with it in scheduling PET patients. “We found it hard to convince our neighboring hospitals to share their patients with us, even though we made it clear we only wanted to do the PET studies and would not poach their patients. However, it has just become another competitive issue and each hospital wants to offer its own PET service.”
Since Blair started offering PET, nearby Altoona General has also added mobile PET service, as has Hershey Medical Center. Two other hospitals in the area have signed contracts with mobile PET firms. As a? result, and even though reimbursement for PET breast scans is scheduled to begin this October, Smith does not expect PET income to pick up in the immediate future.? “It will stay pretty much flat line,” he believes. “The key is what additional examinations Medicare will agree to pay for.”
Boost From Breast Cancer
However, Medicare reimbursement for breast scans is expected to result in big patient volume at St Francis Hospital and Medical Center in Hartford, Conn, a 600-bed plus cancer center, which began 2-day-a-week mobile PET service in January. It is averaging 9-10 patients a day, is booked 2 weeks in advance, and is already trying to negotiate getting the PET system for a third day a week even though Hartford Hospital, across the street, also has two-day-a-week PET service.
St Francis has had no problem introducing PET service because it had already been doing multi-coincidence detector (MCD) PET in its nuclear medicine department for the past 3 years, and its radiology group had three partners who could read PET scans, says Len Quartarato, director? of radiology. MCD scans were being done with a retrofitted dual-headed gamma camera converted for coincidence imaging.
The mobile PET, says Quartarato, provides greater image resolution. Another factor in the decision to go with PET, Quartarato says, is that “we also have a very active nuclear medicine physician who has great rapport with clinicians. We did a mailing when we first went on-line with PET, and we can market that more if we feel the need.” Also facilitating PET service at St Francis was the fact that the hospital had a pad at an outpatient facility across the street, which it had installed for its 7-day-a-week mobile MRI. The PET van is parked on the pad when the MRI is on the road at the three rural outpatient clinics it also serves. “PET is going to be the gold standard in oncology very shortly,” states Nancy Nelligon, St Francis’ director of imaging services. “Oncologists are not going to want to treat any cancer patients without PET staging.”
Dartmouth-Hitchcock Medical Center in Hanover, NH, expects to have a mobile PET on site 2 days a week sometime this summer. “We expect we will use up those 2 days pretty quickly and then we will have to try to expand to another day,” says Director of Radiology Monte Clinton. Like JC Blair and St Francis, Dartmouth-Hitchcock expects its PET patients will be 80% oncology referrals? Dartmouth-Hitchcock had planned to be doing PET scans months ago, but had trouble getting approval from the New Hampshire Bureau of Radiological Health, which was not familiar with the technology. Because the equipment is portable, the bureau also required a certificate of need (CON).
Although he has two fixed MRls at the medical center, Clinton also has contracted since last summer for the services of an identical MRI in a mobile van 4 days a week. The mobile is used 10 hours a day for ambulatory patients. It supplements the owned units, which scan patients 16-17 hours a day, 7 days a week, and are used for research protocols during the remaining 7 hours. The mobile vendor provides technologists for the system; the hospital’s radiologists read the images and the hospital administration does the billing.
Mobile CT, which was popular when states were stringent in their CON regulations, has become a rarity ever since the price of new units began dropping dramatically, according to Clinton. He notes that he recently was looking for a spiral CT in a van to accommodate overflow, but could not find anyone who could help him out.
Radiography On The Move
Transporting mobile radiography equipment on call to bedridden patients in nursing homes can be more cost-effective and less traumatizing than transporting them to and from a clinic or hospital by ambulance. This is a business that has a lot of potential, believes Paul Woelkers, director, Lackawanna Mobile X-Ray Inc, Dunmore, Pa.
The firm has 43 employees and 15 vans to transport radiography units. It does about 5,000 total examinations a year. Included are mammograms and ECGs. “We image nursing home patients in their beds,” Woelkers says. “If a patient is at home, we go there and, if necessary, take the equipment up two or three flights of stairs. In addition to contracts to provide on-site service to more than 100 nursing homes in a 180-mile radius of Scranton, Pa, Lackawanna Mobile also contracts to serve rural hospitals, small medical centers, prisons, and Department of Veterans Affairs facilities.
Response time is usually within 4 hours. Ninety percent of its patients are on Medicare. Lackawanna bills for the technical component and works with a local radiological group that reads the films.
As of November 2001, there were 337 mobile mammography systems accredited by the American College of Radiology in the United States, according to the Food and Drug Administration web site. Of these, it is estimated that perhaps one half are permanently installed in vans, and the balance are transportable units on wheels. Some of these mobile mammography providers are nonprofits targeting? rural and remote areas, while others are hospital-subsidized outreach programs with a sizeable base of corporate clients who provide third-party reimbursement. Regardless of the payee mix or how the service is delivered, all agree that without grants and donations they would be unable to exist, and that breaking even is the annual goal.
Health Systems, Stamford, Conn, now 12 years old, has been doing 6,000 mammograms a year but is cutting back this year to about 3,500. About two thirds of its clients are working women in large corporations who are covered by health insurance. The balance are uninsured.
“We target Latinas and African American women,” explains program director Christine McGuire. It does about 1,000 free mammograms annually, which its radiology group, Stamford Radiology Associates, reads at a greatly discounted fee.
McGuire raised $225,000 for the program this year, and Stamford Hospital normally subsidizes it with $60,000 to $90,000 in salaries and services. “But even with those donations, our program will be running close to breakeven,” she says. “Without the grants, we could not exist.”
The Stamford program has two portable mammography units that it transports to community centers and corporate sites in vans.
Another mobile program screening some 6,000 women a year-half of them free-is Mobile Health Outreach (MHO), based in Charlotte, NC. Founded by CEO Jean Griswold as a for-profit company (Metrolina Outreach Mammography) in 1991, it became a not-for-profit in 1995.
The firm operates a single van with a fixed unit, but is trying to raise $330,000 for a second one. MHO serves more than 150 company and community locations, primarily in the rural and remote areas of 60 North Carolina counties-including 15 where there are no mammography facilities-as well as about one half of the states of Virginia and South Carolina.
While mammography is the main service, it has recently diversified to offer prostate examinations for men as well as ergocycle stress testing, lipid profiles, and cardiopulmonary testing. The annual operating budget is $750,000. It receives 30% to 40% of this figure from insurance, including Medicare and Medicaid, and 50% to 60% from grants and donations.
“We have a tremendous number of individual donors, plus several larger funders,” Griswold says. She credits the passion of the organization for its ability to solicit contributions from major corporations. To break even on mammography, Mobile Health Outreach needs to bill or raise $570,000, an average of $95 per examination. It does global billing for most of the mammography, contracting with Southeastern Radiology of Greensboro, NC, for film interpretation on a fixed price per scan.
Salaries are a major expense item. The firm has 23 employees, most of them dedicated to the mammography service. There are two full-time technologists, who are each paid $42,000 per year, and three part-timers. In addition, the firm has a full-time fund raiser, an insurance clerk, a bookkeeper, case managers, and office and data entry personnel.
Griswold sold the radiography equipment for the very first mobile mammography van in the United States in 1985. She is a sought-after consultant among health care providers seeking guidance in setting up mammography programs. “It is really easy to do mammograms,” she says. “The hard part is taking care of the women. That’s what we have focused on.”
Richard B. Elsberry is a contributing writer for Decisions in Axis Imaging News.