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Radiology Technology and Technologists “The physicians determine nearly all of a hospital’s costs through their individual utilization patterns. This is the physician trump card in the endgame with hospitals. Enlightened hospitals know this; enlightened physicians know how to play it.” Bleeding Edge: the business of healthcare in the new century, 1998 Radiology Imaging Modalities Diagnostic and Interventional Angiography Ultrasound X-ray and Fluoroscopy CT MRI Nuclear Medicine, including PET Mammography Diagnostic and Interventional Angiography X-ray (Special Procedures) Systems that are designed to provide applications for both diagnostic and interventional (Angiographic) applications. Single Plane Angiography Lab ($1,500,000) Dedicated special procedure (Angiographic) systems that are configured with one imaging positioner. These systems provide complete head-to-toe coverage; No Hearts (Cardiac Cath). Bi-Plane Angiography Lab ($2,300,000) Dedicated special procedure (Angiography) systems that are configured with two imaging positioners. These are typically dedicated neuro vascular (Angiography) suites that can also be configured for peripheral coverage. Ultrasound (General, OB, Vascular, Urology, Surgery) Premium Level ($200,000 - $300,000) Premium ultrasound systems have the highest performance characteristics available. Typically such systems are used in high volume, research facilities. Premium systems may be cost prohibitive for some facilities. High Level ($150,000) The High level is for performance and applications required by the high volume, sophisticated facility. Mid Level ($100,000) This segment includes price sensitive characteristics for the imaging center, clinic or can function as a secondary or dedicated unit in the hospital. Low Level ($40,000 - $50,000) This segment has a lower cost and limited applications. Typically the low system is found in the clinic or office market. Niche market, mobile systems may be found here. Point-of-Care ($20,000 - $50,000) This tier includes hand-carried, highly portable, high-performance systems used primarily at point-of-care. X-ray and Fluoroscopy Full Field Digital Radiographic System ($650,000) High end Radiographic Units ($100,000 - $150,000) Radiography systems typically recommended for hospitals and clinics with a need for a heavy duty system and a medium volume of patients. Low end Radiographic Units ($60,000 - $80,000) Radiography systems upgradeable to a digital system. These units are typically used in large hospitals with high throughput. Mid range Radiographic Units ($80,000 - $120,000) Radiography system using digital technology. These units are typically used in large hospitals with high throughput. Radiography systems typically recommended to <100 bed hospitals and clinics. Mobile Radiographic Units ($45,000 - $55,000) X-ray and Fluoroscopy Conventional R/F Systems ($300,000 - $500,000) Conventional R/F systems include a fluoroscopy unit mounted over the patient table. Staff are required at the table to operate the fluoroscopy function. Digital Spot R/F Systems Non-Digital Spot film R/F Systems A digital fluoroscopy system is often purchased with an R/F unit and is a computerized method of image storage and playback from a variety of X-ray based systems. A spot film device is used to take hard copy radiographs during the fluoroscopy procedure. These radiographic images can be taken using regular radiographic cassettes or a spot film camera. Remote R/F Systems ($600,000 - $650,000) Remote control R/F systems feature a fluoroscopy assembly below the patient table by which fluoroscopy is operated from a remote console. Computed Tomography (CT) Multi-Slice CT Scanners Premium Helical CT Scanners ($895,000) Multi-slice CT scanners have 2 or more rows of detectors for spiral imaging acquisitions. It is designed for high volume imaging facilities and/or specialized imaging applications. Dual-Slice ($900,000 - $950,000) Dual Slice CT scanners have the Capability to provide 2-Slices per 360degree X-ray Tube Rotation. Quad-Slice ($1,300,000 -$1,500,000) Quad-Slice CT scanners have the Capability to provide 4-Slices per 360degree X-ray Tube Rotation. Eight- Slice ($1,900,000) Eight-Slice CT scanners have the Capability to provide 8-Slices per 360degree X-ray Tube Rotation. Premium Helical Single-Slice CT scanners have a single row of detectors for spiral imaging acquisitions. The systems are configured with advanced imaging capabilities for high volume caseloads. Cardiac CT ($1,000,000 - $1,600,000) Premium Helical Single-Slice and Multi-Slice CT scanners that are configured with advanced imaging capabilities for Cardiac Scoring (Coronary Artery Disease). Computed Tomography (CT) Mid-Range Helical CT Scanner ($715,000 - $870,000) Entry Level Helical CT Scanner ($385,000 - $465,000) Axial CT scanners have a single row of detectors for imaging acquisitions. Designed for low volume or low budget facilities, the scanner is incapable of spiral or helical acquisitions. Oncology Specific CT Scanners ($570,000 - $1,000,000) Entry Level Helical CT scanners have a single row of detectors for spiral imaging acquisitions. It is designed for low volume caseload or facilities with a limited budget. Axial Single Slice CT Scanners (?) Mid-range Helical Single-Slice CT scanners have a single row of detectors for spiral imaging acquisitions and are configured for moderate volume caseloads. Oncology specific CT scanners are base CT systems configured with Visualization and/or Dosimetric software and workstations (Virtual Simulation package for RTP). The base CT system is determined by the anticipated volume of the facility. Specialty CT Scanners (?) Specialty CT scanners are niche market systems utilizing CT technology for specific applications. These systems include mobile (moves within the facility) CT configurations. Magnetic Resonance Imager (MRI) 3.0T High Field Strength ($2,500,000) 1.5T High Field Strength ($2,500,000) Short bore, mid-field magnetic strength typically designed for moderate to high volume clinical settings or those requiring advanced imaging options. Open Mid-Field Strength ($2,000,000) Short bore, high magnetic field strength typically designed for high volume of cardiac applications or those requiring advanced imaging options. 1.0T Mid-Field Strength ($2,200,000) Short bore, high magnetic field strength typically designed for high volume clinical settings or those requiring advanced imaging options. 1.5T Cardiac MRI ($3,000,000) High magnetic field strength typically designed for research and large facilities for advanced imaging applications such as functional imaging and spectroscopy. Open designed mid-field strength superconductive MRI systems utilized for whole body applications. .5T Low-Field Strength ($1,300,000) Short bore, low field magnetic strength designed for whole body imaging for low volume clinical settings. Magnetic Resonance Imager (MRI) Intraoperative MRI ($2,500,000) Open Designed Low Field Strength ($900,000 - $1,300,000) Intraoperative MRI offering capabilities for surgical planning in the operating room. Open designed low field strength (generally permanent magnets) designed for whole body imaging for outpatient clinics or backup to high-end magnet. Other MR Systems This includes low field MRI systems such as dedicated breast and dedicated orthopedic MR systems. Nuclear Medicine Single-Head Gamma Camera ($290,000 - $480,000) Single-head imaging detector gamma camera that provides applications for whole body and SPECT imaging. Single-Head Circular Detector Single-head gamma camera with circular imaging detector that provides applications for whole body and SPECT imaging. Single-Head Rectangular Detector Single-head gamma camera with rectangular imaging detector that provides applications for whole body and SPECT imaging. Single-Head Square Detector Single-head gamma camera with square imaging detector that provides applications for whole body and SPECT imaging. Nuclear Medicine Dual-Head Gamma Camera (Dual-head imaging detector gamma camera that provides applications for whole body and SPECT imaging.) ($440,000 - $1,200,000) 90-Degree Fixed 180-Degree Fixed Gamma Camera Variable angle, dual-head imaging detector gamma camera that provides applications for whole body and SPECT imaging. Configured with coincidence imaging and attenuation correction packages. Variable Angle w/ CT & AC Variable angle, dual-head imaging detector gamma camera that provides applications for whole body and SPECT imaging. Configuration includes coincidence imaging package. Coincidence w/Attenuation Correction Variable angle, dual-head imaging detector gamma camera that provides applications for whole body and SPECT imaging. Configuration includes attenuation correction. Variable Angle w/Coincidence Detection Variable angle, dual-head imaging detector gamma camera that provides applications for whole body and SPECT imaging. Variable Angle w/Attenuation Correction 180-degree fixed dual-head imaging detector gamma camera that provides applications for whole body and SPECT imaging. Variable Angle Gamma Camera 90-degree fixed dual-head imaging detector gamma camera that provides applications for whole body and SPECT imaging. Variable angle, dual-head imaging detector gamma camera that provides applications for whole body SPECT & Computed Tomography (CT) imaging. Configured with CT and attenuation correction packages. Variable Angle w/ CT, CoDe & AC Variable angle, dual-head imaging detector gamma camera that provides applications for whole body SPECT/PET/CT imaging & Computed Tomography (CT). Configured with CT, Coincidence Detection & attenuation correction packages. Nuclear Medicine Triple-Head Gamma Camera ($600,000 - $1,200,000) Triple-head imaging detector gamma camera that provides applications for whole body, cardiac and brain imaging. General Purpose Triple-Head Gamma Camera Triple Head w/Attenuation Correction Triple-head imaging detector gamma camera with the attenuation correction option that provides applications for whole body, cardiac and brain imaging. Triple-Head w/Coincidence Detection Triple-head imaging detector gamma camera that provides SPECT applications for whole body, cardiac and brain imaging. Triple-head imaging detector gamma camera that provides applications for whole body and SPECT imaging. Configuration includes coincidence imaging package. Coincidence & Attenuation Correction Triple-head imaging detector gamma camera that provides applications for whole body and SPECT imaging. Configured with coincidence imaging and attenuation correction packages. Nuclear Medicine Other (Specialty) Gamma Camera Gamma cameras that include mobile cameras for bedside exams and dedicated cardiac cameras. Dedicated Cardiac Nuclear medicine gamma cameras that are dedicated cardiac systems. Mobile Camera Nuclear medicine gamma cameras that are designed to perform the exam at bedside (mobile environment). Nuclear Medicine (PET) Low End ($1,000,000 - $1,400,000) Mid End ($1,500,000 - $2,100,000) High End PET scanner utilized for both research and clinical applications. PET / CT Scanners ($3,400,000 - $4,300,000) Mid Range PET scanner utilized for research and clinical applications. High End ($2,200,000 - $3,600,000) Low End or Entry Level PET scanner utilized for clinical applications. Combination of PET and CT scanners that provides two exams: CT for anatomy and PET for physiological imaging. Cyclotron ($1,100,000 - $2,000,000) Used for Production of Positron-Emitting Elements, or Radioisotopes (oxygen, carbon, nitrogen, fluorine, etc.). Mammography Full Field Digital Mammography Unit ($500,000) Diagnostic Mammography System Full field digital mammography to provide full field breast imaging. This technology is most appropriate for large teaching facilities. A diagnostic mammography unit is a radiographic device that is designed to perform X-rays of the breast. A fully diagnostic mammography system must include the capacity to perform biopsy and magnification studies. Digital Capable ($95,000) A diagnostic mammography unit that has been retrofitted for easy upgrade to full field digital when it becomes available. Conventional Diagnostic Units ($95,000) A diagnostic unit that can perform magnification views and can be fitted with an add-on device that attaches to the system. These units are capable of diagnostic exams but are not retrofitted for full field digital when it becomes available. Screening Mammography System ($71,000) Screening units are basic systems that do not feature magnification or biopsy capabilities and are typically placed in outpatient imaging centers, mobile coaches or in hospitals as a second mammography “Retail is for suckers” Kramer How is a purchase price determined? List price minus Discounts associated with being part of a Global Purchasing Organization (GPO) Volume discounts for buying multiple units or a basket of goodies Discounts for being a “research site” Discounts for being a “show site” Old fashioned Negotiation How much does this stuff cost to operate? Contribution Margin Total collected dollars minus Variable cost per Procedure Technologists Consumables (Film, Contrast, Supplies) Total Fixed Costs Equipment Depreciation or Lease (5 Years) Service/Maintenance/Contract Let’s try to buy an MRI scanner!! Income (Collected Dollars) Average Reimbursement per procedure ($650) Projected number of procedures/year (4200) 350/month 16/day 2/hour Total Collected Dollars over 5 years $650 x 4200 x 5 = $13,650,000 (!!) Let’s try to buy an MRI scanner!! Expenses Fixed Costs Purchase Price = $2,000,000 Service Contract = $120,000 x 4 years = $480,000 Variable Costs Technologist: $50/procedure $50 x 4200 x 5 = $1,050,000 Consumables: $40/procedure $40 x 4200 x 5 = $840,000 Let’s try to buy an MRI scanner!! 5-Year Contribution Margin $13.65M (Income) - $2.0M (Cost of Equipment) - $480K (Service Contract) - $1.05M (Technologists) - $840K (Consumables) = $9,280,000 (!!!) Let’s try to buy a Mammography Unit Income (Collected Dollars) Average Reimbursement per procedure ($60) Projected number of procedures/year (3600) 300 per month 14-15/day 1.75/hour Total Collected Dollars over 5 years $60 x 3600 x 5 = $1,080,000 Let’s try to buy a Mammography Unit!! Expenses Fixed Costs Purchase Price = $80,000 Service Contract = $4500 x 4 years = $18,000 Variable Costs Technologist: $30/procedure $30 x 3600 x 5 = $540,000 Consumables: $16/procedure $16 x 3600 x 5 = $288,000 Let’s try to buy a Mammography Unit!! 5-Year Contribution Margin $1.08M (Income) - $80K (Cost of Equipment) - $18K (Service Contract) - $540K (Technologists)- $288K (Consumables) = $154,000 Contribution Margin Comparison MRI: $9,280,000 Mammography: $154,000 Real Analysis Start Up YEAR 1 MRI INCOME Gross Billings Estimated Contractual Adjustments Estimated Collections TOTAL MRI INCOME EXPENSES Technologist Salaries $50/exam Supplies (film, contrast, etc) $40/exam Repairs/Maintenance Data/Computer Admin (FDA, MQSA, ACR, tech credentials, etc) Depreciation/Amortization MRI 1.5 Tesla purchase price $ 2,000,000 TOTAL EXPENSES $ Contribution Margin Modality MRI Average Charge Average Reimbursement 1,500 650 YEAR 3 YEAR 4 YEAR 5 $ $ $ $ 6,300,000 (2,709,000) 3,591,000 3,591,000 $ $ $ $ 6,615,000 (2,844,450) 3,770,550 3,770,550 $ $ $ $ 6,945,750 (2,986,673) 3,959,078 3,959,078 $ $ $ $ 7,293,038 (3,136,006) 4,157,031 4,157,031 $ $ $ $ 7,657,689 (3,292,806) 4,364,883 4,364,883 $ $ $ $ $ $ 210,000 168,000 10,000 5,000 400,000 $ $ $ $ $ $ 229,320 185,220 120,000 10,500 5,000 400,000 $ $ $ $ $ $ 240,786 194,481 120,000 11,025 5,000 400,000 $ $ $ $ $ $ 252,825 204,205 120,000 11,576 5,000 400,000 $ $ $ $ $ $ 265,467 214,415 120,000 12,155 5,000 400,000 $ 793,000 $ 950,040 $ 971,292 $ 993,607 $ 1,017,037 $ 2,798,000 $ 2,820,510 $ 2,987,786 $ 3,163,425 $ 3,347,846 Exam Volume 4200 $ $ YEAR 2 Exam Volume 4410 Exam Volume 4631 Exam Volume 4862 Exam Volume 5105 Radiology Imaging Modalities (Contribution Margins) Diagnostic and Interventional Angiography ($1.5M) Ultrasound ($380K) X-ray and Fluoroscopy (-$1.0M) CT ($3.6M) MRI ($4.7M) Nuclear Medicine, including PET ($1.1M) Mammography (-$200K) TOTAL: $10.08M Speaking Hospital Administratorese Contribution Margin Incremental Revenue Bond Rating Cost per Adjusted Discharge (Cost per Case) FTE Reductions Clinical Need? What about the technologists? Hypothesis #1 The availability of qualified technologists in radiology is at a crisis stage and will continue to have a significant impact on health system’s ability to deliver imaging services Hypothesis # 2 “The wisdom of the world can be found in the lyrics of country music songs” “Since my phone still ain’t ringin’ I’ll assume it still ain’t you” Sobering Statistics Since 1994, the number of first-time candidates taking the RT exam has declined by 32% Since 1995, the number of radiography programs has declined by 14% (677 to 584) 75% of radiology managers report they are understaffed in budgeted positions Radiology Management, May/June 2001 Sobering Statistics (cont.) Percent of Registrants Birth Decade of ARRT Registered Technologists 35% 30% 25% 20% 15% 10% 5% 0% 33% 32% 16% 15% 4% 1930's 1940's 1950's 1960's Decade of Birth 1970's “The last thing I needed the first thing this morning, was to have you walk out on me” Annual Turnover Rates General Radiology - 20% CT - 23% MRI - 24% Nuclear Medicine - 33% Ultrasound - 32% Angiography - 28% Radiology Management, May/June 2001 “If you’ve got the money, honey, I’ve got the time” Web Designer PC Support Hardware Analyst Hardware Technician Technical Trainer System Administrator Vascular/Interventional MRI CT Mammography Ultrasound Nuclear Medicine Radiography Average Wages by Job Class (Radiology vs. Computer Technology) $70,000 $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 $- What can you get for $400 per month? 4-year, $16,000 car loan @ 7% per year Full- time daycare for a 6-year old 12 rounds of golf at Utah public courses $184,816 if invested @ 6% over 20 years “I got a call from the folks over at Bell just to let me know my next phone call I could walk outside and yell” “After losing money on operations in 1999, the notfor-profit sector managed to eke out a 0.6% operating margin in 2000…” Modern Healthcare, 64-2001 Hypothetical Example 350 bed teaching hospital 2500 clinical employees $300M annual net patient revenues 0.6% operating margin = $1.8M profit Cost of raising each employee wage by one dollar per hour = $5.2M “Workin' in the fields Till you get your back burned Workin' 'neath the wheel Till you get your facts learned Baby I got my facts Learned real good right now” Technologist Productivity/Workload Exams per technologist FTE 3500 1992 AHRA 1995 AHRA 2000 AHRA 3000 2500 2000 1500 1000 500 0 DIAGNOSTIC RADIOLOGY (INCLUDES MAMMOGRAPHY) CT ULTRASOUND MRI NUC MED INTERVENTIONAL “Runnin’ over the cat again only makes it flatter, it don’t make it more dead ” ACR Resolution #52 Be It Resolved, that to address the medical workforce shortage that includes radiologists, radiation oncologists, imaging technologists, radiation therapists and medical physicists, the American College of Radiology and representatives from the major radiological societies form a task force to explore ways to increase the medical workforce. What is being done? Media Campaign Recruitment Video Work Force survey Research Scholarships Non Radiologists Sub Task Force on Human Resources The development and dissemination of a recruitment videotape to Junior High schools, High schools and Public Television stations. Non Radiologists Sub Task Force on Human Resources The ASRT is developing a research project to find ways of improving productivity and job satisfaction. Non Radiologists Sub Task Force on Human Resources The ASRT Education and Research Foundation has begun to develop minority scholarships to interest a significant population in the radiologic sciences as a career path. Non Radiologists Sub Task Force on Human Resources Other areas to be Investigated… Increasing the number of schools Increasing funding for existing schools Exploring the development of Technologist’s Assistants and Radiologists PA’s Development of web page on the ACR and RSNA web site describing careers for imaging technologists, radiation therapists, and medical physicists. Improving job satisfaction and job opportunities Increasing the number of students “Little things I should have said and done, I just never took the time” Non-monetary retention tools that radiologists can implement Very public reward and recognition programs Scholarships in exchange for years of service One-time “big splash” events (paegentry!!) Cover the cost of professional memberships, subscriptions, etc. Conclusions Radiology equipment is really expensive If managed well, owning and operating radiology equipment can be very profitable The price paid for equipment varies wildly and can be irrational Radiology is critical to the financial health of hospitals Conclusions Rad Tech staffing crisis exists!! Crisis impacts diagnostic radiology most (lowest wage area) Techs are working harder than they were 5 years ago ACR is exploring several options to solve the staffing problem Special Thanks to: Dwight Yoakam Willie Nelson Bruce Springsteen Charles Williams, MD