Why we did it
The Keystone Kidney Center is a freestanding, physician-owned for-profit kidney specialty center; we perform kidney stone lithotripsy and related procedures. Our JCAHO-accredited facility has a lithotripter suite, a cysto-x-ray suite and a five-bed PACU.
Even though many people get kidney stones, lithotripsy is traditionally a low-volume, high-cost procedure. That's because only about 10 percent of kidney stone patients need lithotripsy to break up the stones so they can be passed. At our peak, we see four to six cases a day; two to three cases is standard for most facilities. That is why lithotripsy is best suited to being a regionalized service.
When we decided to expand our services to provide mobile lithotripsy to patients and physicians at other facilities, we did so in order to respond to changes in the marketplace and increased competition. We felt the mobile unit would offer advantages for us and for the facilities we were planning to target. It would enable us to further tap into Keystone Kidney's local service area as well as create a wider service area network and reach doctors and patients located too far away to conveniently travel to us. Facilities that couldn't afford lithotripters (most can't-they cost about $1 million in the early 1990s and cost about $500,000 now) would benefit from being able to offer the service without having to make a major investment.
The mobile unit
The process of buying our first mobile lithotripsy unit-from research time to operation-took about a year. During that year, we visited facilities around the country that had mobile lithotripsy units, comparison-shopped for new and used units, and worked closely with equipment brokers. We eventually purchased a used mobile lithotripsy unit from a hospital in Texas. The lithotripter cost $700,000 and the vehicle cost more than $100,000.
We transported the unit to Florida, where a fabricating company reconditioned the vehicle's coach and engine (the lithotripter itself was in good condition). We then brought it to our facility and put it into service in the southeastern Pennsylvania region. In the late 1990s, we traded it in and got a new generation lithotripter and a new vehicle.
The interior of the unit is basically a procedure room. It contains the equipment needed for the procedure (the lithotripter, anesthesia machine, etc.) and enough room to bring a stretcher through. The patient changes clothes inside the facility, is brought outside to the mobile unit for treatment and is then taken back inside to the facility.
To host our mobile unit-or any type of mobile service-a facility must have an equipment pad. This is the biggest requirement for the service provider as well as the service receiver.
The mobile equipment pad must have several specific features. It must be large enough for a commercial truck to be able to dock there. It must be a level surface. There must be power lines hooked up for running electricity and telephone service to the mobile unit. There must also be a waterline. Finally, there must environmental seal protection for the patients as they exit the building (similar to the walkway up to an airplane). Once built, the equipment pad can host any sort of mobile unit-including refractive surgical units, mobile MRIs or CTs, mobile mammography, stereotactic breast biopsy units, mobile urology, etc.
Facilities that already have equipment pads must determine physician interest and patient caseloads before contracting to receive a specific mobile service. A much more difficult decision faces managers of facilities that do not have an equipment pad. After the necessary arrangements with building contractors, electricians, and plumbers are all factored in, the cost of building the pad typically runs about $80,000. For facilities that may be diverse enough to be able to utilize multiple mobile services, the cost of building a pad may eventually be made back in total case volume. But, in most cases, facilities that do not already have a mobile equipment pad have a hard time justifying the expense, given that the service may come just a few times a month.
Thus, from a service provider's perspective, there is very real danger of under-utilization. Our lithotripsy truck is in service three to four days a week, but it also ends up docked at our facility, not earning any revenue. Furthermore, we had to build our own pad at our site. Since we don't do our own lithotripsy cases in the truck, there was no need for the environmental seals from the building to the truck. But we still had to create a cement parking apron big enough to keep the truck and run power lines out to the equipment, which must remain on. Our facility's landing pad serves as the "home base" for the unit whenever it is not in service at another facility-it comes back here at the end of the day.
Some mobile service providers hire a professional driver to move the vehicle from site to site and the lithotripsy staff meets the truck at the facility. Because of our fairly concentrated service area, however, we decided to train our own staff team to be able to drive the truck themselves. This meant that the staff had to take driving classes and be licensed to drive a commercial truck; in our case, a commercial Class B (i.e., coach classification) vehicle. While this results in savings in terms of paying a driver, it does increase your staff costs by requiring them to be on duty for much longer periods of time. They're "on the clock" as they get the vehicle, take it on the road to the site, set it up, handle the cases, pack it up, and bring the unit back.
The host facility's staff never performs the procedure-it is the service provider's lithotripsy technologists and/or nurse who perform the procedure, along with the host-facility affiliated doctor who is handling the case. We usually send along two lithotripsy technologists or, occasionally, one technologist and a nurse. The techs are cross-trained radiology technologists.
Once we had our refurbished unit, a home base for the truck, and our newly-trained staff, we were ready to put our unit into service. We contracted out our services to a handful of facilities in the region and by the mid-1990s we were completing approximately 50 cases a month at four facilities.
Here's how the unit hooks up to a facility. First, the tractor trailer pulls up and parks on the equipment pad and the staff places stabilizing jacks under the vehicle. The vehicle's walls slide out on either side of the vehicle to create a larger workspace inside.
The staff plugs in the 440 volt power source (the plug is a little bit bigger in diameter than a fire hydrant plug) into the power jack and hooks up the water lines and the phone lines. Next, the inflatable environmental protection seal, to allow patients to easily enter and exit the unit, goes up to seal the side and the top of the truck.
The staff then prepares the vehicle itself, unstrapping the lithotripter equipment, x-ray equipment, anesthesia machine, IV poles, and chairs, which are all secured for transport. Finally, they turn on and pre-flight the equipment. The whole process usually takes 30 to 45 minutes.
At the end of the day, the staff reverses the process, shutting off the power lines and stowing and strapping the equipment before raising the jacks and taking the vehicle back on the road.
Maintenance and other costs
The breakdown rate of mobile medical equipment, especially high-tech electronic equipment, is considerably higher than that of on-site equipment because it sustains wear and tear not only through normal use, but through constant transport. From operating our fixed-site lithotripter, we understood that if we had a problem that was not immediately repairable, we could lose a day's worth or more of cases. To keep our mobile unit in good shape, we purchased full-service maintenance contracts with the manufacturer of the lithotripter to service the main unit and the x-ray components of the lithotripter. Our contracts include four preventive maintenance cycles to minimize the ravages of wear-and-tear.
We also stockpile the parts from the manufacturer that are most prone to failure-electronic components, circuit boards, fuses, etc. The manufacturer has locally-based service engineers who can make same-day repairs on the unit in case something minor goes wrong. Even though maintaining a comprehensive equipment service contract is costly (up to $100,000 for maximum coverage), it's not as expensive as having to make major repairs or replace equipment because we were lax in maintenance. Despite our efforts, we still lose a service day once every few months-and that is an enviable down-time rate.
The vehicle maintenance costs are another major expense for us. The vehicle itself requires about five different types of service contracts, including a contract to service the hydraulic lift gate and hydraulic jacks; a separate contract to maintain the environmental systems, including the air conditioners and the heaters; and yet another contract to maintain the truck itself. We must also pay inspection and licensure costs for the vehicle. Then there are replacement costs for the parts. For example, we recently had to replace two front tires on the vehicle, at a cost of $600 per tire.
Besides maintenance costs, we have other ongoing expenses, unique to mobile facilities, that add up. Highway tolls, are one example; tolls for large trucks are considerably higher than those for regular passenger vehicles. The unit also has considerable overhead even when it's not being used, and electricity costs are ongoing, because the lithotripter must always stay plugged in. Additionally, we pay medical and equipment-related insurance, as well as insurance on the vehicle. We have to have two separate policies-one for the exterior of the truck and another for the contents.
The next step
Mobile lithotripsy has been a successful business for us. It enabled us to add to our case volume-in places we never could have serviced had we maintained only our fixed-site lithotripter.
Moreover, the community reaction has been very positive. Customer satisfaction is high. Doctors and patients alike appreciate the convenience of having the equipment and technical staff come to them. Even with less-than-maximum utilization, the economic bottom line has been positive for us. We have made a profit on our initial investment.
These desirable results have offset the primary disadvantages of adding the mobile lithotrispy service; namely, the additional headaches that mobile care presents relative to fixed-site care. Additionally, there is a limit to the number of places that we can take the mobile unit, due to the aforementioned problems with finding facilities that have the equipment pad necessary to host us.
Although we've had great success, we're ready to move on to the next level, which, for us, is selling our mobile unit and moving on to portable lithotripsy. We already have two portable lithotripsy units in service and we're looking to add a third. Portable lithotripters are smaller, lighter versions of traditional lithotripters that can be temporarily moved into a host OR or procedure room on the day of service and then packed up and moved out at the end of the day. Portable units eliminate environmental issues involved in taking the patient outside the building into a vehicle. Actually, they eliminate altogether the need for a special equipment pad.
We purchased transport vehicles for the portable lithotripter for about $80,000 each; these vehicles are roughly 18 feet in length, with special tie-downs to stabilize the equipment and environmental controls. We'll still need to purchase service contracts for this vehicle, and we've hired a driver to free up our staff.
We plan to service even more facilities and reduce our costs with our portable lithotripters, and we're sure that the future of lithotripsy is here. Although we have decided to sell off our mobile lithotripsy unit, we don't regret having invested in it-it was appropriate for its time and it was an invaluable way to learn the ins and outs of offering mobile medical services.