Facility expansions. Equipment trials. Budget constraints. Natural disasters. Patient backlogs. Unlikely members of a club, for sure. But they do have one thing in common: Each is a reason for the surge in popularity of temporary imaging solutions.

The new scanner that was ordered has not arrived? A tornado flattened the imaging wing? Too many patients, not enough systems? Never fear—rentals and mobile units are here.

Even if there is no emergency, temporary equipment may be a good solution for health care providers who are apprehensive about purchasing expensive technologies one year only to have them be obsolete the next. Perhaps a facility wants to “test-drive” the latest technology before buying it or demonstrate that it will be a profitable investment. With a lease, both are possible.

For these and many other reasons, interim imaging solutions are having a major impact on the health care services industry. A report by business analysts Frost & Sullivan (San Jose, Calif) says revenue for the North American mobile imaging market was $686 million in 2002 and could climb to $1.2 billion in 2008.

According to the report, Growth Opportunities in North American Mobile Imaging Markets, big hospitals are not the only ones leasing. Because mobile solutions can move on a daily basis, they enable smaller hospitals in a network or in the same area to share critical resources. The author of the study, Frost & Sullivan analyst Antonio Garcia, says, “The combination of low or sporadic procedure throughput, dispersed populations, and small medical imaging budgets has made shared mobile imaging services the ideal solution for many small to medium-sized imaging operations.”

As a result of the growing rentals market, mobile services, including trailer and coach outfitters, transportation companies, and mobile service personnel are expanding; and modality vendors are hurrying to form strategic alliances with them, says Garcia. In 1997, for instance, Prime Medical Services Inc, a leading lithotripsy provider based in Austin, Tex, bought a 75% interest in AK Specialty Vehicles (AKSV in Harvey, Ill). AKSV subsequently acquired Calumet Coach Co (Calumet City, Ill) in 2001 and then bought SMIT Mobile Equipment (Oud-Beijerland, the Netherlands) in 2002. AKSV says that now makes it the world’s largest mobile medical manufacturer. The company designs and builds magnetic resonance imaging, positron emissions tomography, computed tomography, cardiac catheter laboratory, electron-beam CT, and mammography mobile units.

Garcia says, “Although to date, all of the major mobile medical imaging companies such as Alliance Imaging [Anaheim, Calif] and InSight Health Corp [Newport Beach, Calif] essentially remain independent, major modality vendors such as GE Medical [GEMS of Waukesha, Wis] have been investing time and resources in closer relationships with mobile medical outfitter companies. Notable examples are AKSV and Medical Coaches [Oneonta, NY].” Both have partnerships with GEMS, as well as with Siemens Medical Solutions (Malvern, Pa), Philips Medical Systems (Bothell, Wash), CTI Molecular Imaging (Knoxville, Tenn), Karl Storz (Tuttlingen, Germany), and Medstone International (Aliso Viejo, Calif).

Who Rents What?
Modality acquisition at many health care facilities is, for many reasons, most easily achieved through renting equipment or by sharing mobile services with other facilities. According to IMV Medical Information Division (Des Plaines, Ill), 81% of hospitals with fewer than 400 beds were using mobile MRI as of mid-2002.

The solution a facility chooses ultimately depends on its needs and pocketbook. Whatever the requirement, there is a supplier out there that can tailor a solution to fit. Whether one wants mobile or modular, for a day or for months, the answer to the problem is only a phone call (or sometimes a mouse click) away.

Some providers offer an assortment of equipment, with menus that include everything from basic roentgenography to nuclear medicine. Others specialize in a single modality. For instance, NuWay Medical Inc (Laguna Hills, Calif) rents 3-D ultrasound, and Catalina Imaging Inc (Loomis, Calif) specializes in CT. Whether they offer one or multiple modalities, most providers tend to specialize in either interim solutions, which last until they are not needed anymore, or mobile solutions, which can serve indefinitely. Some providers, though, offer both types.

A number of vendors can provide variety both in modality types and service options. Alliance Imaging is one. It deals in mobile and interim MRI, single photon emission computed tomography, CT, and PET, and also provides technologists, maintenance, marketing assistance, and insurance. The company operates 425 systems in 42 states, serving more than 1,300 health care sites. Shared Medical Equipment Group (Madison, Wis) offers CT, MRI, PET, and bone densitometry on both mobile and rental bases. InSight Health also offers a variety of modalities and services.

According to Joe Denninger, InSight’s vice president of asset management, most of the company’s mobile rentals are MR, PET, and litho, but, he adds, “We also do fixed-site, complete multimodality centers with MR, PET, mammo, ultrasound, x-ray, and nuke med.”
InSight’s typical mobile customers include smaller hospitals that cannot afford to own those modalities outright or do not have enough volume to justify such a purchase but want access to it just the same. Other customers are hospitals undergoing construction or upgrading their own equipment, and they want to continue service while their imaging wing is closed.

Then there is a third flavor of customer, says Denninger. “They have their own system, but the daily volume is outstripping the capacity of their in-house system, so they have some overflow volume they need to address.

Among the usual suspects are hospitals in the South. Every winter, Denninger notes, “they get their influx of snowbirds” who would overwhelm a hospital’s imaging capacity without a seasonal backup.

Overflow is a common reason why many hospitals decide to buy or rent additional modalities. IMV notes that the threshold volume for acquiring a second gamma camera, for instance, is 1,000 patients per year.

PET Rocks
It used to be that PET sites of any kind were few and far between. It is, after all, a costly modality, and the availability of fluorodeoxyglucose (FDG), the glucose-based radiopharmaceutical used in PET imaging, was limited. But PET mobile services are flourishing now. IMV reports that mobile PET sites in the United States were averaging 190 procedures per site in 2001 and that the total number of PET procedures that year increased 7% from the previous year.

The change is due primarily to increased reimbursement for PET, new applications for the technology, and better and more widespread availability of FDG. The few cyclotrons that produced FDG in the beginning were located primarily in major metropolitan areas, limiting the use of PET systems to those cities. That is no longer the case.

“You can get FDG pretty much anywhere now. There are a lot of providers,” says Dean Hobson, San Diego regional route manager for Mobile PET Systems, Inc (San Diego), the largest provider of PET imaging in the United States. Hobson says his customers include facilities of all sizes in a wide range of locations, including 100-bed hospitals in rural locales.
One of the main issues with PET availability (which, to be fair, becomes less and less an issue as time goes by) remains the race to deliver the tracer in time. The commonly used fluorine-18 FDG, for example, has a physical half-life of only 109.7 minutes. “If you need 10 millicuries to do a dose and it’s going to take 2 hours to get it,” says Hobson, “the pharmaceutical company needs to send out 40 millicuries. For some of my sites here in Southern California, I have FDG driven 2.5 hours to get it there. The cost of the FDG is all bundled into how far away you are [from the source] and how the pharmaceutical company is going to provide the service.”

Whenever a potential customer approaches Mobile PET about service, Hobson says his company advises them to talk to FDG providers first to determine the logistics and costs. “The cyclotrons are run such that the FDG is produced at 2:00 am or 3:00 am, and then they provide the transportation service.”

Depending on the cyclotron’s proximity to a given PET site, the FDG production schedule will determine that facility’s daily PET services schedule. “We have a rural hospital on the very outskirts of Oklahoma City,” says Hobson. “The FDG can’t get there before 10 am, so they don’t start scanning patients until 10. We start our PET service to them later and let them go later into the evening.”

Fee Structures
There are a number of ways that vendors charge for rentals and interim solutions. Blue Ridge Medical Imaging (BRMI in Salem, Va) is a cath, angio and R&F provider that specializes in mobile solutions. Carl Hoffman, BRMI’s president, says, “When people are replacing cath labs, that’s when we get called in. Or they’re thinking about expanding, and they want to make sure they can justify the cost and the customer base will be there. They’ll bring in a mobile for a couple of months to see how things work out. Some places, we’ve had mobiles out there going on 3 years.”

BRMI charges by the month. The fee includes delivery, setup, and application training for facilities using their own staff. Some mobile providers charge on a fee-for-service basis that includes a trailer with the modality, a technologist to run it, the examinations that are conducted, and any equipment maintenance required. Some charge on a longer-term basis. For instance, MedCath Corp., a cath and angio provider in Charlotte, NC, leases mobile laboratories operated by its own medical technicians and nurses and also modular systems with technical training and maintenance included in the contracts.

Some companies offer several different payment options, depending on the customer’s particular situation. For example, Insight’s Denninger says, “We maintain a number of MR systems that are available for short-term rentals of 1 week to 6 months.”

Mobile PET’s Hobson says that while his company is oriented toward 2- to 5-year contracts, “we’ll provide the service for however many days someone needs it. We’ve had imaging centers call us and say, ‘Our PET scanner’s going to be down for a week. Can you provide service to help us do our patients?’ Then we charge them a fee per service. We’ve also done short-term contracts for 3 to 6 months.”

Can I Get a Latte With That?
Rivalry among interim service providers is so lively nowadays, it is fueling a competition to offer more than just basic facilities. And the winner, of course, is the customer.

Vendors aim to deliver whatever their customers need and in any way they can dream it up. One can order a single modality or multimodality solution that lives inside the facility or inside a provider’s trailer. It can be basic digs or fancy, filling one mobile or modular room or a multiroom compound. It is the customer’s choice, and it is all doable.

Some mobile unit trailers, in fact, are more luxurious than an average big-city apartment, with all-digital amenities, remote controls, video and intercom systems, stereo sound systems, and nice kitchens. Some feature custom cabinetry, central air, and onboard generators. Why go home?

That is all very nice, one might say, but way too small. What if what is needed is a whole hospital? AKSV can set up a 10- to 22-unit field facility that includes operating and recovery rooms, infirmaries, intensive care units, laboratories, x-ray, MRI, CT, PET, pharmacies, administration, restrooms, staff sleeping quarters, kitchens, and dining rooms. One of the company’s customers—not surprisingly—is the military.

For some rental and interim vendors, no request is too difficult or too weird. BRMI’s Hoffman, for example, says his company’s first contract was a dilly.

“When we put our first unit together, the customer called on delivery day and said, ‘By the way, can you lift your trailer with cranes?’ And I said, ‘Excuse me?’” recalls Hoffman, laughing. “It turned out they’d dug a 4-foot-deep hole in the ground for it. They didn’t want to use a lift. It was going to be there for 6 months, and they just wanted to build a deck right up to it so they could roll the patients straight out.”

Ron Wright, chief executive officer of Catalina Imaging, says his typical customer is “a hospital that’s getting a new CT, and they’re going through a short-term construction-and-installation phase for which they need coverage.” There are exceptions, of course, as when Wright rented a CT to a bunch of lawyers. “They were doing a class-action suit for asbestos damage and wanted a unit for about 2 months to scan several hundred patients. They were looking for evidence of asbestos-related lung damage.”

On the other end of the “exceptions” spectrum are customers who order a temporary solution without any sort of realistic concept of what that entails. “That’s why I do a site inspection beforehand,” says Gary Heeseman, vice president of leasing at MedCath. “We cover the entire [United States]. We see everything. People often want to put a mobile in a place where it won’t fit.” That includes, he says, “underneath a canopy that’s 12 feet high and the trailer’s 13'6” high, and in the middle of a smokers’ patio in a courtyard.”

Disaster Recovery
Sometimes, facilities just do not care about luxury amenities or ultrapersonalized attention or smorgasbord contracts. They just need imaging equipment, and they need it fast.
“Last spring, San Antonio had a lot of rain,” says InSight’s Denninger. “A hospital down there had their radiology department below ground level, and it just got flooded out. They needed MR service, and we provided it to them a couple of different ways: shared service, where we just showed up one day a week and provided the techs, and full-time parts service where we brought in a unit and left it there.”

Another tricky time for Texas was the summer of 2001, when Tropical Storm Allison caused record amounts of rainfall that resulted in severe flooding in the Houston metropolitan area. Memorial Hermann Hospital, the main teaching hospital of the University of Houston, had five brand-new cath laboratoriess in its basement that had cost $15 million. All five labs were lost to flooding. The hospital called up MedCath.

“They needed a mobile quickly,” says Heeseman. “When I arrived, there were people everywhere, mostly contractors, scurrying around. There were portable generators roaring. There were news helicopters above.” Even the Army Corps of Engineers was there, installing the type of transformers usually found in military base camps. Add the overwhelming odor of mold emanating from the soggy hospital, says Heeseman, and “it was like a war zone.”

MedCath brought in a mobile cath laboratory for 6 months while Memorial Hermann rebuilt what the hurricane had ruined, but Heeseman says a hospital does not need a natural disaster to have an emergency. “Every day, there’s a chance for there to be problems. At some point, each hospital is going to experience an upgrade, a replacement, and, unfortunately, inoperable equipment. All hospitals should have a mobile pad site attached to them, because there are so many mobile services offered. Mobiles are great.”

Sydney Schuster is a contributing writer for 24x7.