Mobile imaging technology is making inroads as a major provider of imaging services throughout the country. The companies who lease these mobile wonders are not just driven by growing demand and rapidly advancing technology. In many cases, the companies themselves are driving up patient demand by ensuring its availability to an increasing number of hospitals and providers who couldnt otherwise afford to offer such diagnostic capabilities in their communities.
But dont expect to see a CT trailer cruising your neighborhood. These impressive units resemble large tractor trailers and, as a rule, travel infrequently. With shared routes, the trailers travel between two or three provider locations throughout the week. Usually, however, mobile imaging units are looked upon as interim solutions, leased for periods ranging from a few weeks to several years and remaining parked in a single location.
If these trailers become hospital fixtures, what are the benefits to providers of em-ploying mobile imaging units?
Taking the Show on the Road
We target three markets, says Dean Tangalakis, president of Medical Imaging Resources Inc (Ann Arbor, Mich). The company leases mobile MRI, CT, PET, and full digital cardiac and vascular labs to health care providers throughout the United States.
First are the facilities looking to take care of a backlog of patients on a temporary basis. They can use the numbers to justify additional [or permanent] facilities, whether thats MRI, CT, PET, or another technology, he explains. Second is everything from major research hospitals to small community hospitals that use the equipment while they upgrade existing facilities. We come in as a plug-and-play solution during the upgrade process. And third are smaller hospitals starting up an imaging service for the first time.
Such hospitals take advantage of the lesser financial commitment of mobile to learn whether the demographics of their community will support their service offering in the long term.
Hospitals that lack the financial resources to build imaging centers of their own can lease the same equipment in a mobile unit. The arrangement allows providers to pay as they go, and earn as they go, Tangalakis says, without a multimillion-dollar expenditure.
A 1.5T magnet with all the bells and whistles could cost $1.5 million to $2 million by the time you do the build-out, says Mark Casner, president and COO of DMS Imaging (Osseo, Minn).
With such a hefty price tag, smaller hospitals are turning to interim mobile services. The majority of our installations are rural, right down the middle of the country, Casner says. Were in 40 states now. About 90% of our business is small hospitals. Because of its small-hospital niche, DMS Imaging also includes some of the lower-end technologies in its mobile fleet, including mammography, DEXA scans, and ultrasound.
Alliance Imaging (Anaheim, Calif), the largest provider of imaging services in the country, provides both interim and shared-route mobile services, but the company focuses on the high-end technologies only.
We started focusing on the CT business when a lot of hospitals couldnt afford CTs, says Paul Viviano, president and CEO of Alliance Imaging. Our business evolved to MRs in the 80s as the technology evolved. Now we have about 450 mobile systems and about 1,300 customers across the country.
Hospitals without the community demand or the resources to pay for an interim trailer on a full-time basis opt for a shared route.
We have units that are at a hospital three days a week, and then we move the unit to another hospital within reasonable driving distance for the next three days of the week, Viviano explains.
These contracts leave hospitals free to allocate capital for other needsmore expansion, more service, new programswhile still allowing them access to an MRI or another technology. The average contract, he says, is for three years and includes such services as scheduling, marketing assistance, equipment support, and complete staffing.
This turnkey environment is typical of the mobile and interim imaging companies, and costs vary widely because of the extensive menu of add-on services. DMS Imaging also offers fee-for-scan payment arrangementstypically anywhere from $300 to $800 per MRIbut most customers opt for leasing at a fixed rate.
Cannon Falls Community Hospital in Minnesota began leasing a shared-route MRA unit from Alliance on weekends in December 2002. The 24-bed hospital caters to a pop-ulation of about 7,000 people halfway between Minneapolis/St. Paul and Rochester, each of which is about an hours drive.
When a physician asked [patients] to go to another city to have the exam done, they didnt want to go, says Quentin Garlets, director of radiology and cardiology at the hospital. And sometimes with these large medical centers, the backlog could be a number of days. That creates some difficulties in certain situations. If the MRI is postponed, then the surgery is also postponed.
But the health care provider was hesitant to trust mobile imaging. Unreliable service with a mobile CT they had leased nearly 10 years ago had created image problems for the community hospital. The CT trailer frequent-ly arrived too late to accommodate scheduled patients, who likely blamed such hassles on the hospital, not the mobile provider.
DMS Imaging provides, among other services, open MRI capabilities in one of its mobile imaging units.
However, the hospitals commitment to providing MR services in the community encouraged another try, this time with open eyes and a plan to interview an array of mobile providers before signing a lease.
Alliance assured us that reliability was as important to them as it was to us, Garlets remembers. A year later, Dr. Charles Nicolosi, a radiologist at Cannon Falls Community Hospital, agrees that the exam quality is excellent, and the service has been outstand-ing and reliable.
Home Suite Home
Radiologists might be reluctant to set up shop in a trailer, but most are surprised at how easily they can make the transition. Once youre inside the unit, you wouldnt know youre not in a hospital suite, Tang-alakis says of the trailers. They vary slightly in size from 43 feet to 48 feet long and as wide as 19 feet, depending on the company you lease it from as well as the equipment on board.
The size of the imaging equipment is the same as that found in fixed-site imaging centers, although they often have pop-out sides to accommodate smaller quarters.
Due to the weight of the equipment, each trailer can house only one modality, with the exception of the new mobile PET/CT combination introduced last July, and mobile units are restricted to magnets of 1.5T or less because of shielding issues.
The equipments durability is put to the test when trailers are driven frequently or for long distances, but service contracts allow leaseholders to rest easyanother benefit of leasing rather than owning the expensive technology.
Leslie Steventon, a CVT at Oakwood Southshore Medical Center (Trenton, Mich), watched as a mobile cardiac cath lab arrived at her hospital in July 2002, leased from Mobile Imaging Resources.
The trailer had expansions on the side of the unit, Steventon remembers. There was an area for a scrub table, monitoring systems, and plenty of room to function. It looked like the back end of a big semi: clean, white, and streamlined. We knocked out part of a wall and had a canvas canopy with clear windows, which was installed to create a walkway from the unit into the hospital.
Once the Center decided to offer the services, staffers dove right in by leasing a mobile cath lab. The unit left Oakwood in the beginning of October 2003, when construction was completed on its fixed-site imaging center.
As the technology continues to advance, so does the demand, says Casner, whose company has enjoyed fairly consistent double-digit growth in the radiology market for a number of years. You wouldnt have done an MRI of the breast a couple years ago. Now its sometimes even better [than other diagnostic tools]. PET scans originally were intended for oncology only. Now you see them used for cardiac, neurological, and even Alzheimers patients.
The astounding technological leaps have made imaging more valuable to a growing number of health care professionals outside the traditional scope of radiology.
Cardiology, for example, is very big, Tangalakis says. Cardiologists bring a lot of dollars into the hospital. This is our sixth year offering nuclear medical diagnosis and interventional cardiology systems. The demand grew out of a need from smaller hospitals that dont have the services. Theyre sending patients to big city hospitals, and some of those patients are waiting as long as three or four months.
With mobile and interim services, these small hospitals can care for patients within their communities, sparing them countless miles of commuting and often interminable waits for appointments at overloaded facilities.
The biggest demand these days, Casner says, is with single-specialty practices: an orthopedic group that wants MRI, a cardiology group that wants super-fast multi-slice CT or angio, oncology practices that want PETs. That trend is going to continue for awhile. The driving force is revenue. As theyre getting squeezed, [practices] feel an increasing demand to create new revenue streams.
Open MRI and C-Arms are available on the go with Medical Imaging Resources.
Multispecialty practices, too, are after the imaging market. These medical mini-malls want to provide one-stop shopping within the confines of their clinical settings, and many believe that the continuity of care they can provide contributes to patients wellness.
The speed of the computers is allowing us to take heart images, says Tangalakis, whose company plans to acquire more multislice CT scanners to meet the growing demand. Technology is creating faster and more powerful magnets and imaging cap-abilities. There are more digital applications, including flat-panel imaging and DICOM connectivity. And its necessary for these systems to integrate with PACS systems. We send the information over the network so doctors can see the images right on their computer. We dont even need cameras anymore. Some hospitals use them, but only as backup.
Mike Hedges can attest to that. As director of diagnostic imaging at Amery Regional Medical Center (Amery, Wis), Hedges has witnessed technologys evolution since his hospital first began leasing a mobile MRI unit from DMS Imaging in 1994. Before DICOM connectivity, technicians at the 35-bed hospital had to FedEx scans to St. Paul, Minn, to be read. At best, that took a couple days. Often, though, it took another three days to have the scan read and two more days to get the film returned. With DICOM connectivity, patients results are completed in just a day.
Advances like 4- and 8-slice CT combined with PET have fueled the desire for imaging with physicians in a variety of specialties.
The PET/CT allows for radiologists or other providers to evaluate the presence of a cancerous tumor in a much more precise manner, Alliance Imagings Viviano says. A PET scanner can detect the metabolic presence of cancer before there are any other palpable tumors or evidence of cancer. Adding a CT to that will tell you not only if theres a presence of metabolic activity that will lead to a tumor, but it also can tell you precisely where it is, how big, and what the shape and scope of it is. Oncologists and oncological surgeons are most interested in this. But surgeons, neurosurgeons, and internists are interested in it as well. The technology is just phenomenal.
And as with other phenomenal technology, changes render less-sophisticated systems obsolete at a record pace. This shift, Casner points out, is another reason many hospitals and health care practices choose to forego exorbitant cash expenditures to purchase their own equipment. Instead, the responsibility for maintenance and upgrades lies with the companies who own the equipment. DMS Imaging upgrades its mobile fleet every year, retiring some units and replacing others, much as an airline updates its fleet.
As with a personal computer, it seems that as soon as you buy it and take it home, its outdated, Casner says. The new ones are a heck of a lot faster. They do more, and they see more.
Thus, a large number of hospitals rely on companies like Casners to provide the brand-name technologies on an interim basis, aware that they can upgrade to the newest, fastest tools without writing off an investment in outmoded technology.
Sidetracked by Insurance Issues
The demand has increased for MR and CT about 10% to 12% a year for the past 10 years, Viviano explains. But insurance reimbursement for MRIs has declined on a national basis about 11/2% to 2% a year in the past five years. The same can generally be said for CT reimbursement. PET has been flat, but PETs will begin to grow now. Alliance plans to have 42 PET units by the end of the year, mostly mobile.
In the hospital setting, says Oakwoods Steventon, reimbursement for mobile imaging is not an issue. We bill for the procedure itself, she says, so the mobile location is irrelevant.
Reimbursement is always subject to the payers, Casner adds. Utilization levels are going up, so I think youll see some pushback from insurers. Therell be more tightening of the regulations.
One reason to anticipate scrutiny of the regulations, besides an overall increase in the number of scans, is the fact that imaging has grown to embrace more physicians outside traditional radiology practices.
Radiologists do not control the flow of patients, Casner points out, so their motives in requesting a scan arent questioned. When you take imaging out of that setting and put it anywhere else, he says, questioning the necessity of the scans is destined to follow.
Insurers might begin to take issue with physicians requiring scans for diagnoses where they werent considered necessary before, particularly when a growing number of those physicians are in a position to profit from the imaging services.
Hedges urges hospitals to look into reimbursement before signing a lease.
Reimbursements are different regional-ly, he says, which doesnt work well if we charge the patient X number of dollars and the mobile service charges more than that. With certain kinds of payers, it could turn out that you lose money per patient.
Bumps in the Road
Alliance Imaging (top) and DMS Imaging are just two companies helping health care facilities serve patients through mobile and interim imaging.
With new systems, problems will inevitably arise. The air conditioning actually froze over, Steventon says of the mobile cath lab at her hospital. [Medical Imaging Resources] was there within the day. They called us weekly, just to check. While Dean was here, one of our doctors said, I dont like having to carry my lead apron out there every day. Dean came out the next day and installed an apron rack. Subsequent glitches were similarly handled. Both Alliance Imaging and DMS Imaging offer comparable service options for their customers.
The trickier snags, though, come not from equipment difficulties but from the sur-prises of a new environment. The procedures you might follow inside a hospital can be-come obstacles in a mobile unit. Theres no room to rotate a gurney, host medical students, or accommodate visitors. But those hurdles, Steventon says, are simple to over-come with proper planning.
We did trial runs beforehand, she explains. We took ventilators out to make sure we could take a critical patient there with no problem. Getting patients gurneys into the hydraulic lift took some trial and error, but we learned how to do that.
Our biggest problem was turnover time. With 10 patients a day, we needed to keep 12 of everything in the unit. You dont have time to run inside for a different catheter 10 times a day. You have to shrink your standard product line, because theres little storage space.
Casner agrees, adding, Its not as efficient as a fixed site, for obvious reasons. With a fast enough CT or MRI, a facility can handle 25 patients a day. More typically, though, mobile units accommodate 10 to 12 patients per day. With PET and nuclear units, patient throughput is even slower. Seven to eight is a lot.
According to Steventon, Oakwood Southshore Medical Centers mobile cath lab completed roughly 100 cases its first quarter.
Cannon Falls Garlets adds, We see very little difference in patient throughput. MRI is not like X-ray or CT. You dont normally use it for trauma or acute care, so the patient can be scheduled a couple days later.
What Does the Future Hold?
The demand has grown, Garlets says. I guess it comes under the heading, Build it, and they will come. When something is available, it gets utilized.
Vivianos facility handles more than a million scans each year. Weve seen trends evolve, he says. The average size of the hospital were providing MR to is actually increasing. Alliance Imaging is leasing to hospitals with an average of 300 beds to supplement the equipment thats already there. MRI now has packages available that can do cardiac, vascular, and breast cancer work. The population needs more scans as they age and have more clinical problems. More health issues and more challenges are diagnosed. And as the technology has im-proved, the diagnostic capability has improved.
Tangalakis adds, Its part of the graying of Americaand part of our overweight society.
Patient demand will continue to build and might even gather steam as the technology forges ahead and new diagnostic capabilities continue to emerge. This continued flow of patients will ensure that interim and mobile imaging services continue to boom. Says Casner, There will always be a place for mobile.
Holly Celeste Fisk is a contributing writer for Medical Imaging.