This report originally appeared in the December 2009 issue of DOTmed Business News

If you build it, they don't have to come. That's the great thing about medical equipment trailers that bring mobile diagnostic imaging and other medical services directly to patients.

"Temporary space is a much more cost-effective way of providing health care services than building brick and mortar structures. Then, if demographics change after a new facility is built you can move a mobile trailer," said Tony Ellis, vice president and general manager, Oshkosh Specialty Vehicles, Calumet City, Ill. "If you are really looking for cost-effectiveness and how to utilize the machines best, there is no more efficient delivery model than the mobile. Ease of transfer to emerging technology is easier since you are not locked into a physical structure."

But despite the benefit of a flexible and cost-effective medical service delivery method, sales of new trailers are down since 2007, the trailer manufacturers told DOTmed Business News. As an imaging-dominated industry sector, mobile trailers have suffered along with fixed systems, experiencing double digit declines in the last two years due in part to reimbursement cuts.

"The market is down for all the primary mobile medical uses - MRI, PET, and PET/CT - and across the board whether mobile or fixed equipment," reported Geoffrey A. Smith, president, Medical Coaches, Oneonta, NY. "Add to that the uncertainty over health care; even the people trying to pass [health care reform laws] are uncertain."

"Our market is slow now because it's driven by OEM sales which are slow. Once that picks up, the interim rentals will pick up and so will our business," said Bill King, president, King Equipment Services, Inc., a mobile trailer refurbisher in Waukegan, Ill.

Customers for mobile trailer makers include OEMs, mobile health service providers, brokers and hospitals. Mobile trailers are mainly used to deploy diagnostic imaging services either to improve patient access such as in rural areas, or to provide interim services while hospitals and facilities upgrade or handle patient overflow. Since the diagnostic imaging market has declined after the Deficit Reduction Act became law, the overall sector has suffered. Yet, several trailer market segments should be examined separately since the mobile business is so diverse.




"Every market sector is different," observed Smith. "Hospitals are facing a real challenge; buying capital equipment is treated differently on their balance statement and income sheet. They can buy things from an operational budget so they are leaning more toward purchasing shared services than buying equipment. It does open up opportunities but some hospitals aren't making any decisions and are staying with the equipment they have.

"On an operator side," Smith added, "we deal with entrepreneurs for example, that might buy an MRI, put it in a trailer and find hospitals to contract with to make money. But unfortunately, the level of reimbursement is reduced to a point where it's very difficult to break even; it all depends on throughput."

Outfitting the Trailer

Medical trailers enjoy a distinct advantage over the fixed technology business model since many types of medical modalities can be installed €- not just scanners for diagnostic imaging.

"Four years ago, we were only doing PET/CT and MRIs. Because of the economy, we now build mobile OR or mammography units," said Michael Hardesty, sales manager, Calutech Mobile Solutions, Hammond, Ind. "Because of our experience, we can do non-traditional applications."

The company is providing a mobile OR for a health care organization that is undergoing construction. "As they remodel the hospital, a trailer will pull up with an OR and up to three recovery rooms, all self-contained with medical gases, and [Joint Commission] approved."




As another example of non-traditional uses for trailers, Oshkosh Specialty Vehicles is providing a mobile primary care treatment facility for GE at the upcoming 2010 Vancouver Olympic Games. The multi-purpose unit also includes surgery and recovery. (For more information about GE's mobile medical services at the games, go to DOTmed.com and enter DM 10501 into any search box. You can also read about TomoTherapy's new mobile radiation therapy unit online at DM 10579.)

Another successful application for mobile medical trailers is to transport lithotripters used to blast kidney stones.

"Lithotripters can be bounced between hospitals and it makes sense economically to share that equipment," said Chaz Beadling, owner of American X-Ray Equipment Sales & Service, Cumberland, Md.

Call a Specialist

A new trailer to house a medical application can cost $300,000 to $400,000 -and that's without the imaging scanner or medical equipment loaded into it.

"These are sophisticated machines going into the mobile units whether it is PET/CT, CT or MRI, or mammography. They are very sensitive in terms of vibration dampening, shock absorption, temperature control, humidity, power control and other factors," said Ellis. "We manufacture the trailer from the ground up, starting with a twin I-beam chassis. The MRI trailers are unique, highly specialized, purpose-built (not conversion units), and sensitive. Whether it's rainy or sunny, cloudy or windy - all of that affects image quality. You can have ghosting or poor image quality if the MRI system is not isolated properly with magnetic and radio-tight RF shielding as well as adherence to proper site protocol."

"The MRI trailer is the most complex because you have chillers to keep the jacket of the MRI at a certain temperature," Smith said. "RFI shielding is very difficult to install and maintain. Then you have the metallic, steel shielding to contain the gauss field - all technical challenges that require tremendous expertise."

When PET is matched with CT, other design obstacles present themselves because the patient table cannot move without disturbing registration between the two modalities. So the trailer must be designed and built to prevent twists or turns when being set up onsite. (Read about Medical Coaches' PET/CT auto-leveling technology at DM 10014.)




In terms of business trends, medical trailer companies are consolidating. For example, in 2001, AK Associates bought Calumet Coach to form AK Specialty Vehicles. Oshkosh then acquired them in 2006.

Few players remain that have the expertise to compete in this sector.

"It's a fairly controlled field of competition because the trailers that house MRI and PET/CT are extremely sophisticated with special suspensions to make sure the equipment is not affected by shock and vibration," Smith said, noting also the interior climate control and complexity of maintaining the MRI magnet. "The OEMs have very detailed programs of evaluating potential manufacturers. And once the manufacturer is approved as a potential supplier, they have to build a unit and go through extensive tests. The cost of entry in out-of-pocket and engineering time makes it difficult for anyone to come in. The market is not growing; it is shrinking, so it makes the investment impossible to recover."

Refurbished Resurgence

Nobody knows where health care reform will settle, but given today's economy and health care debate, all trends increase pricing pressure for OEMs, mobile service providers and health care institutions looking for competitive alternatives.

As a result, another bright spot for the industry is the refurbished market, which is an economical alternative. While sales of new trailers are down, the refurbishers are generally reporting steady business.

"People haven't been able to upgrade, so they have put dollars into their current fleet or equipment because of the state of the economy," said Paul Zahn, director of sales and marketing, Shared Medical Equipment Group, LLC, Cottage Grove, Wis.

"The competitive dollars for reimbursement per scan dictated doing things more affordably. Five years ago, customers would have just bought a new trailer with a new system," explained Calutech's Hardesty. While new manufacturing is the company's primary business, Calutech is also a big refurbisher of medical trailers, a business that has picked up recently.

"Business is steady, but a lot of business moved toward refurbishing of customers' trailers as opposed to them selling the old one and buying a new one," Hardesty said.

As in new trailer production, refitting and refurbishing is technically complex.

"A lot goes into putting medical equipment into trailers," said Cliff Hess, president, Texas Medical Mobile Services, Waxahachie, Texas. "Things like shielding are obvious. But what people don't think about when you put a used piece of equipment into a used trailer, is that the trailer may have been built to house something different. It takes quite a bit of research and coordination with the trailer manufacturers to make sure the frame can support the new system, that shielding is adequate and even making sure it's the proper type of metal used in the axels and frames. It can get pretty complicated."

"We start off with a premium refurbished CT scanner installed on steel plates welded to the trailer frame and trimmed out to look better than new," said Greg Kramer, president, C&G Technologies, Inc., Jeffersonville, Ind. "Then, we like to incorporate certain design elements into the interior to break up the monotony of the trailer environment. Our engineering crew will spend many hours burning in the new installation, including road test and setup to check stability of our work and the unit. This whole process is a little more expensive, but you get what you pay for."

Some models of fixed imaging equipment cannot be put into a trailer; however the durable mobile scanners generally can be repositioned into fixed sites to take on another purpose.

"When the life of the mobile is old and they want to pull the equipment out, it may find a home in a small town in a fixed site," Smith said. "However there are times when you cannot take something out of a fixed site and put in a mobile because it doesn't have the accessories."

The international market is another active area for medical trailer companies and refurbishers.

"I feel that you will see trailers going to Eastern Europe and South America that have outlived their usefulness in the U.S.," said Beadling, who recently exported a PET system to Mexico.

But that's a whole new road to travel.

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DOTmed Registered Medical Trailer Sales & Service Companies
Names in boldface are Premium Listings.

Domestic
Carl Frank, DBRS Medical Systems, Inc., CA
DOTmed Certified
Leah Purnell, Eclipse Medical Imaging, CA
Gene Miller, MobileMed Support Services, CT
Dennis Giuzio, Mobile Radiology, Inc., FL
Frank Pontillo, Engineering & Network Systems, FL
Larry Brewer, Oshkosh Specialty Vehicles, IL
William King, KING Equipment Services, Inc., IL
DOTmed Certified
Ronald Moore, R & D Imaging, Inc., IN
Michael Hardesty, Calutech Mobile Solutions, IN
Greg Kramer, C&G Technologies, Inc., IN
DOTmed Certified/100
Chaz Beadling, American Xray Equipment Sales & Service, MD
Jeff Rogers, Medical Imaging Resources, Inc., MI
DOTmed 100
Megan Laterra, Matthews Specialty Vehicles, Inc., NC
Geoffrey Smith, Medical Coaches, NY
Fran Ambrose, Ambrose Rigging, PA
Gary Casey, A.C.M.I., TN
Ken Walker, Molecular Imaging Solutions, TN
Michael Webster, Legacy Medical Imaging, TX
Robert Graham, Polaris Medical Imaging, TX
Rich Greb, Sunrise Medical Technology, Inc., TX
DOTmed Certified
Cliff Hess, Texas Medical Mobile Services, TX
Jon DeRoost, Beacon International, WA
Paul Zahn, Shared Medical Equipment Group, LLC, WI
DOTmed Certified/100

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