Palo Pinto General is a hospital in the grassy plains of Mineral Wells, Texas, located over an hour west of the Fort Worth-Dallas area. Radiologist Dr. Charles Myers has worked there for almost 12 years but does not know the nearest supplier of radiopharmaceuticals.

“Either it’s too expensive or takes too long for us to get those radiopharmaceuticals,” Myers told HCB News. “When we have a need for PET imaging or other nuclear medicine tests, such as tagged white blood cells studies to look for infections, we need to refer that case out to either Weatherford or Fort Worth, closer to the suppliers where patients can get those exams done.”

As a result, many patients experience delays in care as financial and logistical hurdles prevent them from making the trip to the urban care centers.

Providing PET imaging is not feasible for Palo Pinto due to the expenses that come with it and the distance and time in obtaining radioisotopes, according to Myers, but mobile MR and CT units have been successfully deployed whenever in-house scanners are down or require maintenance.

The rural provider, which serves a population of 20 to 30 thousand residents, is not unique in its struggle to deliver excellent care with limited resources. In fact, it’s a common problem throughout the country.

Making the most of what’s available
In rural areas where physically laborious work like farming and lumber are more prevalent and healthcare facilities are farther away, the rate of unintentional injury deaths is 50 percent higher, according to research published by the Centers for Disease Control and Prevention in 2017.

The problem highlighted in those staggering statistics applies to access to advanced imaging too, meaning that sometimes patients simply can’t get access to urgent diagnostic scans when they need them.

“If it’s an emergent injury and we don’t have the modality they need that day, then we have to have an ambulance transport the patient,” said Jon Linnell, CEO of North Valley Health Center and CEO and executive director of the North Region Health Alliance in Minnesota. His hospital works with DMS Health, a Digirad company and a member of the OpenMarkets Community.

“If it’s a modality that we use very infrequently, say like three times a month, we will send those patients out to our tertiary facility or our referral hospitals for those modalities because, often, a patient can’t wait weeks,” he said. “They may be able to wait a couple of days but not weeks.”

For patients who require PET or PET/CT scans, the situation is even more complex, requiring facilities to have timely access to radiopharmaceuticals due to their short half-lives. In addition, regulatory requirements for handling isotopes must be adhered to and patients need to be educated about special scan instructions.

Despite the hurdles involved, some mobile imaging providers, like Insight Imaging and Shared Imaging, are successfully deploying mobile PET/CT units to providers.

“With PET/CT, the whole scheduling process involves calling the patient the night before, giving them instructions, such as not to eat after this time frame or to be here this early,” said Steve Richter, senior vice president and general manager of Insight Imaging’s mobile division. “It’s a lot different from an MR because there’s an injection involved; there’s a time and weight for the uptake of the pharmaceutical into the anatomy and the scan itself; and there’s a lot more coordination required between our schedulers, pharmacies, and our clinical nursing staff.”

Breast MR is also a challenge for rural providers, requiring specific software updates and hardware. The cost of this equipment is often too much for hospitals in rural areas to afford.

Even mobile coaches for these exams require specific coils and breast software to ensure high quality images are produced, meaning the hospital cannot perform the procedure if there is no mobile provider in the area equipped with these coaches or parts.

“A lot of accounts typically don’t do a lot with women’s health but some that we go to have a very large women’s health population so they need breast software and breast coils,” said Richter. “It’s the same with prostate. They’re going to want some specialized software and coils for that to accommodate their patients.”

Getting squeezed by the bigger compliance and reimbursement picture
Compliance is also an issue for mobile CTs depending on how long a facility uses one. Those that are long-term must, at minimum, hold XR-29 compliance, which requires scanners to be equipped with DICOM Structured Reporting to log a patient’s dose history in records; built-in adult and pediatric protocols; a MITA dose check function to notify when dose thresholds have been exceeded; and automatic exposure control for real-time radiation dosage.

“You can’t have a CT for three years on a three year lease and have it be exempt from XR-29 compliance,” said Steve Pennington, sales manager of Oxford Instruments Healthcare. “That is considered essentially a part of the hospital, as opposed to a unit that’s only there for something like a period of construction. In those situations, you may not have to have the same level of compliance.”

For rural providers, though, access to any modality comes down to scheduling, with some able to afford services such as MR five days a week and others only a few times a month. Itineraries for these services depend on the needs of residents, many of whom are older, with conditions such as chronic vascular disease or diabetes, and are prone to infections and complications of conditions.

The challenges of rural access are further compounded by bigger financial trends, according to Larry Siebs, president of Shared Imaging, such as the rising price of mobile imaging and ongoing reductions in reimbursement.

“The type of technology within the modality is not going to be looked at for the reimbursement decision,” said Siebs, whose company specializes in CT, MR, PET/CT and DR systems. “The question that rural hospitals struggle with for reimbursement is that, just like every other healthcare provider, they’re seeing declining reimbursement both from the government and from commercial payors. That’s part of the struggle they have when it comes to providing these services.”

In addition to reimbursements and cost, the number of underinsured and uninsured patients is higher in rural areas, preventing providers from funding these services and investing in lifesaving technologies.

“As the underinsured and uninsured grow, they put stress on the organization to be able to fund investments in new technologies or to maintain current ones,” said Brach Slabach, senior vice president of the National Rural Health Association.

Though Medicare can assist partially, the rest of the expense falls on the patient, with providers like Myers at Palo Pinto trying to find ways to help them pay off what they owe.

“Every cost they incur is going to come out of their pocket or at least partially out of their pocket,” he said. “We have to find cheaper ways to try and make medically relevant diagnoses so these patients can get proper treatment.”

Moving down the road
While professionals in others areas of the imaging landscape are buzzing about the potential capabilities of artificial intelligence to improve image interpretation, mobile imaging companies remain focused on ensuring the scans can be performed in the first place.

“The mobile imaging is still the acquiring tool,” said Richter. “It’s in contact with the patient and acquires all the digital data. A lot of the technology that’s being developed whether it’s AI, software or even the cloud, that’s after the fact.”

The cost of technology and mobile transportation combined with funding deficiencies among rural hospitals must be addressed, to bring these innovations to fruition.

“Some of the DOT regulations, such as cost of fuel, put more cost on the system,” said Richter. “We’re going to have to find a way, particularly in the mobile environment, of being much more efficient with our dollars and how we’re spending them. It’s very expensive to drive a coach around multiple miles apart, so we have to be more efficient. We have to find customers on a closer route or some different economic models, or work closer with healthcare organizations to provide them with an in-house system.”

Myers suggests that rural providers consider entering partnerships with enterprises that can help offset costs. He is also employed by Eagle Radiology, a division of Radiology Partners which interprets the hospital’s scans while RP supplies it with hardware, software and IT support.

In addition, he advocates that hospitals educate themselves on what their limitations are and get creative with the resources at their disposal.

“When there are cheaper and more available means to reach the same diagnosis and find out the same information that we could get otherwise with more advanced imaging, we take advantage of those,” he said.

Slabach stresses that the most important thing a rural practice can do is strategize and collaborate with different parties throughout its facilities.

“Engage in robust strategic planning that includes all stakeholders of the organization. The acquisition planned for new technology, including in radiology, should be an important part of the plan, as well as an existing schedule for replacing equipment to make sure that community needs are being assessed and met.”