3 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
4 Radiology Imaging Modalities Diagnostic and Interventional Angiography Ultrasound X-ray and Fluoroscopy CT MRI Nuclear Medicine, including PET Mammography
5 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.
6 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.
7 X-ray and Fluoroscopy Full Field Digital Radiographic System ($650,000) Radiography system using digital technology. These units are typically used in large hospitals with high throughput. High end Radiographic Units ($100,000 - $150,000) 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 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 typically recommended to <100 bed hospitals and clinics. Mobile Radiographic Units ($45,000 - $55,000)
8 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 f function. Digital Spot 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 X based systems. Non-Digital Spot film R/F Systems A spot film device is used to take hard copy radiographs during the fluoroscopy procedure. These radiographic images can be taken using u 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.
9 Computed Tomography (CT) Multi-Slice CT Scanners 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 360- degree X-ray Tube Rotation. Quad-Slice ($1,300,000 -$1,500,000) Quad-Slice CT scanners have the Capability to provide 4-Slices per 360- degree X-ray Tube Rotation. Eight- Slice ($1,900,000) Eight-Slice CT scanners have the Capability to provide 8-Slices per 360- degree X-ray Tube Rotation. Premium Helical CT Scanners ($895,000) 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).
10 Computed Tomography (CT) Mid-Range Helical CT Scanner ($715,000 - $870,000) Mid-range Helical Single-Slice CT scanners have a single row of detectors for spiral imaging acquisitions and are configured for moderate volume caseloads. Entry Level Helical CT Scanner ($385,000 - $465,000) 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 (?) 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) 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.
11 Magnetic Resonance Imager (MRI) 3.0T High Field Strength ($2,500,000) High magnetic field strength typically designed for research and large facilities for advanced imaging applications such as functional imaging and spectroscopy. 1.5T High Field Strength ($2,500,000) 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) 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, 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) 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.
12 Magnetic Resonance Imager (MRI) Intraoperative MRI ($2,500,000) Intraoperative MRI offering capabilities for surgical planning in the operating room. Open Designed Low Field Strength ($900,000 - $1,300,000) 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.
13 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.
14 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 90-degree fixed dual-head imaging detector gamma camera that provides applications for whole body and SPECT imaging. 180-Degree Fixed Gamma Camera 180-degree fixed dual-head imaging detector gamma camera that provides applications for whole body and SPECT imaging. Variable Angle Gamma Camera Variable angle, dual-head imaging detector gamma camera that provides applications for whole body and SPECT imaging. Variable Angle 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. 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. 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 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.
15 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 imaging detector gamma camera that provides SPECT applications for whole body, cardiac and brain imaging. 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 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.
16 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).
17 Nuclear Medicine (PET) Low End ($1,000,000 - $1,400,000) Low End or Entry Level PET scanner utilized for clinical applications. Mid End ($1,500,000 - $2,100,000) Mid Range PET scanner utilized for research and clinical applications. High End ($2,200,000 - $3,600,000) High End PET scanner utilized for both research and clinical applications. PET / CT Scanners ($3,400,000 - $4,300,000) 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.).
18 Mammography Full Field Digital Mammography Unit ($500,000) Full field digital mammography to provide full field breast imaging. This technology is most appropriate for large teaching facilities. Diagnostic Mammography System 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
19 Retail is for suckers Kramer
20 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
21 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
22 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 (!!)
23 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
24 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 (!!!)
25 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
26 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
27 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
30 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
31 Speaking Hospital Administratorese Contribution Margin Incremental Revenue Bond Rating Cost per Adjusted Discharge (Cost per Case) FTE Reductions Clinical Need?
32 What about the technologists?
33 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
34 Hypothesis # 2 The wisdom of the world can be found in the lyrics of country music songs
35 Since my phone still ain t ringin I ll assume it still ain t you
36 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
40 If you ve got the money, honey, I ve got the time
41 Radiography Nuclear Medicine Ultrasound Mammography CT MRI Vascular/Interventional System Administrator Technical Trainer Hardware Technician Hardware Analyst PC Support Web Designer Average Wages by Job Class (Radiology vs. Computer Technology) $70,000 $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 $-
42 What can you get for $400 per month? 4-year, $16,000 car 7% per year Full- time daycare for a 6-year old 12 rounds of golf at Utah public courses $184,816 if 6% over 20 years
43 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
44 After losing money on operations in 1999, the not- for-profit sector managed to eke out a 0.6% operating margin in 2000 Modern Healthcare,
45 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
46 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
48 Runnin over the cat again only makes it flatter, it don t make it more dead
49 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.
50 What is being done? Media Campaign Recruitment Video Work Force survey Research Scholarships
51 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.
52 Non Radiologists Sub Task Force on Human Resources The ASRT is developing a research project to find ways of improving productivity and job satisfaction.
53 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.
54 Other areas to be Investigated Non Radiologists Sub Task Force on Human Resources 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
55 Little things I should have said and done, I just never took the time
56 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.
57 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
58 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
59 Special Thanks to: Dwight Yoakam Willie Nelson Bruce Springsteen Charles Williams, MD
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SANFORD HEALTH RADIOLOGY PROGRAM Sanford Health Radiology Program of Sanford Health, North Dakota, offers a 24-month program in radiology, affiliating with NDSU and University of Jamestown for fulfillment
Radiologic Technology Degree This associate degree brings the student into the area of high technology in the field of medicine. You will experience all the applications of diagnostic imaging, including
Getting to Know Avreo Avreo develops complete Radiology Workflow Solutions (RWS) that manage every aspect of your workflow from order entry to report distribution within a single application/single database