The MRI Sweet Spot: 1.5T
 Chest scan using the GE Healthcare Signa 1.5 Tesla HDX system.

Several factors are impacting the MRI market. On one hand, providers are seeing an upswing in some studies. Breast MRI, for example, has demonstrated its utility in women with a high risk of developing breast cancer with many facilities reporting a doubling of studies since a year ago, and other scans like prostate MRI are expected to follow a similar pattern.

On the other hand, the Deficit Reduction Act of 2005 (DRA) and more stringent private insurers pre-authorization requirements are pinching MRI providers. Volume is dropping at some sites, while costs are rising at nearly all. But smart centers are deploying a variety of strategies to thrive in the current market, including:

  • An emphasis on high-quality service and sub-specialty interpretations
  • Carefully focused marketing to referring physicians and patients
  • Focused business cost analyses 
  • Judicious use of staff and software

Many successful programs center on the current sweet spot in MRI scanning: 1.5 Tesla systems. These systems, many with large bores for easy patient access, offer the power of a high-field magnet with high resolution, sensitivity and established protocols to meet the clinical and financial needs of many providers. This month, Health Imaging & IT visits some successful operations to learn more about their strategies and plans for the future.

The universal magnet

MRI at Belfair in Bluffton, S.C., is a single-modality imaging center equipped with the GE Healthcare Signa HDX 1.5T Twinspeed scanner. The system is a perfect fit for the center’s needs, says President and Medical Director Joseph Borelli, MD. “There are drawbacks to 3T, particularly for single-magnet facilities,” continues Borelli. 3T can be prone to artifacts, and some scans cannot be performed on 3T systems. Cardiac imaging, scanning patients with large abdomens and breast studies can be very challenging on 3T systems because of issues like signal dropoff. 1.5T systems, on the other hand, aren’t associated with such drawbacks, says Borelli. In fact, current-generation 1.5T systems hit the sweet spot, and allow sites to offer an array of high-quality scans.

Take for example Suburban Imaging, a seven-site radiology practice in suburban Minneapolis. The group has transitioned to 1.5T magnets throughout its centers and uses nine Siemens Medical Solutions Magnetom systems, including one Magnetom Espree open scanner.

The practice reserves the open system for large or claustrophobic patients, but because it is a high-field magnet, the Espree is suitable for most studies. “The sophistication, sensitivity and resolution of 1.5T MRI meets our needs,” confirms Aaron Binstock, MD, body imaging radiologist.

The center offers a wide array of MRI studies; it has seen an increase in breast MRI volume since the March 2007 American Cancer Society recommendation that certain high-risk women receive annual breast MRI scans in addition to mammograms. Plus, MRI is helpful in patients with known breast cancer, says Nihar Shah, MD, body imaging radiologist. In addition, radiologists use MRI to characterize indeterminate findings on CT scans. It can prevent unnecessary biopsies or interventions, says Binstock.

What’s more, clinical applications continue to evolve. Functional MRI, particularly breast and prostate MRI, is poised for a clinical breakthrough. “Dynamic contrast enhanced MRI could revolutionize the diagnosis and staging of prostate cancer,” Borelli says. Recent studies point to 95 percent prostate cancer staging accuracy via dynamic contrast vs. 70 to 80 percent with MR spectroscopy. And body imaging continues to grow especially with mounting concerns about radiation exposure.

Dealing with DRA

Health Scan Imaging (HIS) in Palm Desert, Calif., operates a network of eight imaging centers in southern California. Four sites are outfitted with Toshiba America Medical Systems Vantage 1.5T MRI scanners. Like others across the nation, the practice is attempting to cope with DRA.

“It’s driven down MRI referrals and added an administrative burden on top of the 25 percent cut in Medicare payments,” sums Medical Director William Kelly, MD. In the last year, HSI has added an additional FTE at each site to handle the additional hour of pre-authorization paperwork needed for every case. That’s because referring practices need assistance to secure pre-authorization. The breakeven point on MRI went from seven to eight studies per day on a scanner to 12 or 13, says Kelly. 

Similarly, many sites have seen a global drop in high-tech imaging volume with more stringent pre-authorization requirements instituted in November 2006. Suburban Imaging deployed Commissure RadPort Suite software, an integrated and payor-approved decision support tool for appropriate exam ordering, to help manage the requirements. Most MRI studies meet payors’ criteria. Radiologists get involved when an ordered exam gets flagged as not meeting the appropriate criteria. They work with the ordering physician to determine what exam would best address the clinical question.

Despite the recent challenges, it is possible for savvy centers to survive and thrive in the current environment. HSI embraces a multi-pronged approach to cut costs and maintain its billing as a top-quality provider.

“We’ve made very careful choices with our 1.5T systems. It is important to establish and maintain a reputation for excellence,” explains Kelly. The practice offers a number of non-routine studies including breast MRI, MR arthograms and diffusion tensor imaging. These offerings capture the attention of specialists and, in some cases, persuade them to refer their entire book of MRI business to HSI.

The business also focused on service and staff costs. It cut service costs from nearly $1 million annually by internalizing its service agreements and hiring a staff engineer. At the same time, it negotiated a phase II training agreement with a local college to offer MRI tech training. After a few weeks of intensive training, each student functions as a technologist assistant, effectively extending tech staffing.

Like most practices, HSI employs multiple tactics to keep physicians and patients satisfied. At the physician level, Kelly stresses focused reading by the most appropriate staff. For example, joint studies are read by the radiologist with training in sports medicine. At the patient level, the practice emphasizes comfort and high-quality service. Toshiba systems facilitate the approach in two ways, says Kelly. The Pianissimo noise reduction system results in a quieter patient experience, and the wide bore magnet expands patients’ comfort level.

The final piece of the puzzle is marketing. HSI espouses a comprehensive approach that focuses on procedural advantages facilitated by state-of-the-art hardware and software. MRI at Belfair advocates a no-cost-different approach to marketing. “Our marketing budget is zero,” admits Borelli. Despite a competitive local market, the center does very well based on its reputation and word-of-mouth recommendations.

Bracing for the future

DRA will continue to squeeze MRI providers. In addition, referral patterns are coming under greater scrutiny from Centers for Medicare and Medicaid Services, private payors and radiology benefits management companies. There will be winners and losers.

“Reimbursement could drop as much as an additional 20 percent in the next five years. We’ll see a 20 to 40 percent reduction in the number of MRI facilities, but high quality/high volume facilities with modern equipment could see unexpected success,” predicts Borelli. Practices can boost their odds of survival by:

  • Maintaining an updated 1.5T system that delivers high-quality scans
  • Developing protocols to ensure adequate volume, and implementing 1.5T sequences to optimize throughput and patient comfort
  • Focusing on timely report turnaround
  • Providing sub-specialty interpretations
  • Obtaining American College of Radiology (ACR) accreditation in all sub-specialty modules after it becomes available in 2008.

Averting Adverse Reactions
Another recent challenge in the MRI world is nephrogenic systemic fibrosis, which is a potentially fatal reaction to gadolinium-based contrast. Centers are turning to different mechanisms to ensure patient safety.

Toshiba America Medical Systems MRI techniques, specifically Fresh Blood Imaging (FBI) and Contrast Free Image-enhanced Angiography (CIA), enable non-contrast MRI and MRA, a key consideration in patients vulnerable to systemic reactions to gadolinium. Suburban Imaging in Minneapolis handles the nephrogenic systemic fibrosis issue by screening all patients for renal disease and assessing the risks and benefits of the scan.