Mobile homes can sit for years in parks designed for them. Some never move, but they are still called mobiles because their structural features are different than conventional houses. If the mobile units have to be moved, they can be.
In the fixed mobile imaging world, the situation can be remarkably the same. Some mobile imaging units stay in one spot for years; other fixed mobile units are on site only for a short time, often while a modality is being replaced at a hospital or clinic.
A distinguishing feature with fixed mobiles, as compared to those that travel a route, is that the fixed mobile is normally staffed by the institution hiring the imaging van, not by the mobile vendor, but that is not a hard and fast rule. Mobile vendors do staff fixed mobiles at times, but it is rare.
One of the more interesting permutations in the fixed mobile world is that of entrepreneurs who spot opportunities for imaging volumes and rent or even buy a truckable modality, deploy it, and leave it in place as long as business stays lucrative.
Shin MRI in Los Angeles’ Koreatown is one of these ventures that depend on finding an overlooked niche. Koreatown is an enclave of mini-malls, off-brand banks, and specialty shops in the flats that spread beneath the Hollywood Hills. But Koreatown is economically robust. Its residents number in the tens of thousands. Street signs are in Korean, as are any number of directories, including phone books. For the partners in Shin MRI, bringing a fixed mobile unit to Koreatown was an opportunity that could not be overlooked.
“I had been in the business of consulting to and organizing MRI groups for almost 30 years,” says Lon Gillette, vice president of Shin. “We knew the market from that standpoint. Even so, we spent 6 months interviewing doctors and making sure that the opportunity was a viable one.”
Gillette’s partners include a Korean-American MRI technician who operates the machine and a Chinese-speaking physician who is retired except for handling duties like contrast injections for the MRI patients. The images are interpreted by an independent radiologist who reads on contract. The images are printed on film in the trailer that houses the MRI machine.
To get started, the three Shin partners rented a mobile unit on a long-term contract and placed it in a rented parking lot space next to a medical office building. Shin has a small office in the building where patients arrive and are registered. From there, the patients are taken across the parking lot to the trailer for the actual imaging.
Gillette says the MRI is put through a quality control check daily to make sure it is functioning correctly. Beyond that, the vendor conducts monthly and quarterly reviews, he says. He says all applicable operational and billing regulations are being met. “We take classes when we need to,” he adds.
Gillette says Shin gets its patients through a pool of about 80 physicians who refer to it. “We see about 200 patients a month,” he adds. The MRI operates from 9 am to 6 pm six days per week.
What makes Shin a successful business, says Gillette, is that it knows how to serve the Korean community. “One, we know the language, and we understand the culture and how to greet people. Koreans are very intense, and they can be very impatient. You have to respond quickly. You have to schedule quickly. They are also cash based, so you have to deal with that.”
Gillette says 90% of Shin’s patients are Korean, a few are Chinese. He says serving an ethnic subpopulation has clinical ramifications as well as cultural ones.
“Normally, if outpatients are sick or if there are exotic cases, those people go to the hospital. But that’s not the case where we are,” he says. “We get some very sick people. They often wait before they seek medical help. There is a lot of reliance on herbal remedies and acupuncture. The patients often prefer us to an impersonal academic setting.”
Walk-in patients are common. They are referred to doctors if needed. “We would like to have a doctor in the loop,” Gillette says. “Otherwise, we become the provider.” He says Shin tries to help indigent patients as part of its mission. These patients are referred to doctors at free clinics, he says.
Gillette says Shin has no plans to add other modalities at its site. “MR is what we’re familiar with; there are complications to doing multiple modalities.” He also thinks it is pipedreaming to suggest that Shin should expand its model into other ethnic enclaves.
“There have been many groups that have tried to consolidate the MRI market, and most of them have failed,” he says. “Each business appears to be very different in what is needed to make it successful. We evaluate our business plan every day. Who knows what the future is?”
Rayville, La, is a town of about 4,300 people just off Interstate 20 about 30 miles east of Monroe. Rayville is a rural hub where another fixed mobile MRI has been deployed.
Dick Todd is managing member and part owner of MRI of Northeast Louisiana, LLC, the partnership that installed the fixed mobile in Rayville. Todd says the machine serves a population of about 30,000 in Rayville and several nearby small towns. “We average between 150 and 175 patients per month,” he says.
Todd describes himself as a former commercial banker who gravitated into health care ventures. Prior to starting the MRI clinic, he had helped a physician group install a CT in a modular building. Doctors suggested he do the same thing with MRI.
“The reason we went with the MRI is because the [rural] clinics couldn’t wait for a [rotating] mobile to come to each town,” he says. “They didn’t have the volume, and they would have had to wait a whole week for the MRI to get done. We can schedule in a day or so typically, and the patients don’t have to wait more than 15 minutes to get scanned. In an hour they’re out of there. It has worked out real well.”
To get going, Todd formed an investor’s group that included local doctors. As rural providers, the doctors are exempt from self-referral regulations, Todd says. “It had to be structured just right, and we got an attorney who is very conservative. We are not in any way tied to self-referrals.”
Todd says he put up about $50,000 of his own capital and negotiated a bank loan to make a time purchase on the MRI. “We found an old parking lot that was vacant. We bought a [modular] office building, moved in the machine, and set up a covered drive between them. It took a couple of weeks from vacant lot to doing scans.”
Todd’s MRI has been running for about two and a half years. Electronic images are sent to radiologists in Monroe who read them on monitors. “To staff it, I put an ad in a local paper and found someone,” he says. “I’ve got an office assistant, and it’s just the two employees and myself. I contracted out the billing.”
Todd says he had to get approval to take Medicare patients. A supervising physician with an office nearby oversees patients during contrast procedures, he adds.
Todd says he will keep going just like he is until the machine is paid for. Even when he upgrades, he says, he will keep the mobile format. “A fixed site is very expensive.”
Having found one successful niche, Todd is looking for new opportunities, “possibly in the Atlanta area,” he says.
TRACKING THE OEMS
Permanent “mobile” scanners are but one variation on the long-term mobile imaging landscape. But vendors who rent or lease the long-term imaging vans have a problem they do not face when running short-term mobiles over routes. How to market the long-term units?
The big mobile companies have sales forces continually marketing their once-a-week vans to small hospitals and clinics. But it is hard to know when a potential client for a fixed mobile unit is going to actually need one. One method mobile vendors use to try to solve this problem is to rely on tips from friendly OEM sales reps about where new modalities are going in, and who may be needing a fixed mobile as a substitute during the install.
The vice president of sales for an Amarillo, Tex-based company that mainly provides service for CT scanners, but also has four mobile CTs and three mobile MRIs that it rents for both short-term and long-term use, says the mobile business is highly cyclical. Lately, he has seen a slowdown in demand for CT and an uptick in demand for MR, he says. “Sometimes, the OEM will call us and say, We’re doing an install, have you got something?’ I followed one salesman around for 8 months.”
Long-term mobile vendors particularly follow the OEMs from which they buy imaging equipment. They also watch trade magazines and go to trade shows to find customers. “Marketing to [OEM] sales reps is part of our effort,” says a senior executive of one of the giant mobile companies. “We rely a lot on our vendor partners to provide solutions.”
Sometimes long-term mobile units can be brought in as an effective way to get around CON (certificate of need) regulations. “In New York, for instance, you have to have a CON certificate [to bring in a mobile unit] unless you’re a radiology group and then you don’t need one, so they [the radiology group] might bring the mobile on site and rent the space from the hospital,” says one mobile executive.
When long-term mobiles are brought in during an install, which may take 90 days, the end users typically want a modality like either the one they are replacing or the new one they are installing, the same executive says.
“If you have an old CT and I can deliver that same model to you for $40,000 per month, then that hospital saves money and the techs never have to leave the system they had,” he says. “But there is also the mirror image of that. You can bring in the latest and greatest and you’ll pay $65,000 to 75,000 per month, but the advantage is you can train your techs on the new equipment.”
CT, MR, PET, OR PET/CT
Demand for different mobile scanners, even for fixed site use, tends to follow price and technology curves. If hospitals are replacing units, then demand reflects what is being replaced, but sometimes the latest multislice CTs will be brought in to see how well they perform. With PET scanners particularly, because they are expensive, hospitals will choose mobile deployment to test and build markets before making a purchasing commitment. But demand for PET is not on fire.
“The PET market has taken a real flattening,” says one vendor. “It’s partly cost related and partly sizzle related.” Yet, this same vendor says that recent Medicare PET procedure approvals bode well for increased demand. “Do I believe in PET? That’s where all my focus is right now.” He says PET/CT units are still finding their place. “Payors don’t want to pay on the CT level for a PET when it is only an analog marker,” he says. “Insurance companies already are paying for only one exam on a PET/CT.”
Not all fixed site mobile scanners are rented or leased from vendors. Big health care systems will sometimes deploy their own mobile units to various sites. Some say they have saved in the double digits by buying the mobile vans.
Intermountain Healthcare (IHC), headquartered in Salt Lake City, operates 22 hospitals and dozens of clinics in Utah and Idaho. Deanna Welch, administrative director of imaging services, says the company bought a mobile PET and two mobile MRIs that can be deployed either short or long term. Unlike most end users, IHC contracts with a management company to staff and insure its mobiles. Welch estimates a 15% saving through mobile ownership. She says the units are not marketed. “Our purpose is to try to keep up with our patient needs. We own a health plan, and we’ve got to keep up with demand.”
Many hospitals turn to fixed mobiles to meet demand until they can install a unit in-house. Sometimes that takes longer than expected.
John Snader is director of ancillary services for the 125-bed Ephrata Hospital in Ephrata, Pa. Snader says a mobile MRI staffed by the hospital, which was meant to be temporary, has been parked on a hospital pad for months. “Space is at a premium; our radiology suite is filled.” He says the hospital plans a stationary MRI install within the next 18 months.
“If we have a malfunction, we call the vendor,” he says, “and we have had really good response. It was also a brand-new unit. We were looking at the mobile as a stepping stone, but the process has been longer than we intended.”
At Providence Holy Cross Hospital in Mission Hills, Calif, a similar situation developed. To meet MRI demand, the hospital kept a mobile on site for 16 months, says director of radiology Harry Keleshian, RT. The mobile was staffed by the hospital, and from a regulatory point of view, it was handled as a normal in-house MRI, Keleshian says, except for a requirement by state regulators to upgrade the pad on which the mobile was parked. “It had been parked in the doctor’s parking lot, which didn’t have the solid concrete foundation they looked for,” he says.
As long as hospitals need to meet demand more quickly than they can install new equipment, there will be a need for fixed mobile imaging units. The same goes for intervals when new in-house machines are being installed. But the fixed mobile world is a mysterious one that one vendor calls “opportunistic chasing down of whatever is there and making something work.”
“When a mobile unit reaches the end of its life, what do you do with it?” he asks. “I had a client call me for a dated CT system. It was an inner-city site, and they could only accommodate the older, narrower coach in their service bay door. I bought a machine for $65,000 that I financed over a year. My spread was $10,000 a month for that system. I had a service contract for 6 months. After that, I sold it for $50,000 to some guy in Kuwait and off it went.”
Seal of Approval: JCAHO
According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the larger companies that provide mobile imaging services are seeking to have their mobile units accredited now more than ever before.
“We are seeing an increasing interest in JCAHO accreditation on the part of the mobile companies,” says JCAHO’s Michael Kulczykcki, executive director of the commission’s ambulatory accreditation program. “The public sees patient safety as paramount.”
Kulczykcki says JCAHO treats mobile units the same way it treats freestanding outpatient imaging centers. “The sites may or may not be visited as part of the survey process,” he says. “We would visit the corporate offices to look at governance, human training, licensing, performance improvement. Then we would do a sampling of the mobile sites. We would look at patient care, physical plant layout, fire safety, and emergency procedures. We would check on the clinical staffing requirements, but not on the clinical procedure itself. We don’t examine the actual technology. The ACR (American College of Radiology) does that. We do look at their machine maintenance program, and we look at their performance improvement studies based on quality of images.”
Kulczykcki says having JCAHO accreditation reassures hospitals and clinics that use the mobile services that the mobiles meet industry standards. “If they use a nonaccredited provider, it creates a greater burden on the hospital for the oversight of that contract. If there are any licensed technologists with that service, they would have to check their ability to be practicing. Sometimes liability carriers will skip their auditing process if there is accreditation. Increasingly, JCAHO has been trying to treat accreditation as the gold seal of quality.”
George Wiley is a contributing writer for Decisions in Axis Imaging News.