Given that today imaging services are considered crucial for diagnosing neurological disorders and creating a detailed neurosurgical plan, it is surprising that more neurosurgeons have not instituted an imaging center within their practices. Other specialists such as dentists and obstetricians routinely offer their patients X-ray and ultrasound services in their offices, saving their patients travel to an off-site radiology department where they endure yet another registration process, obtain the needed imaging studies and return to the office for interpretation of the studies and recommendation of a treatment plan.
The ability to provide pertinent imaging for patients in an office setting significantly improves the quality and efficiency of care delivered to patients. Further, it gives the physician a competitive edge in the community and markedly improves patient satisfaction. This not only is my opinion, it is my experience. In 2003, our three-physician group implemented an imaging center that included an X-ray machine and an MRI scanner. In 2006 we added a 64-slice CT scanner, C-arm fluoroscopy, and full pain clinic injection services, and it has turned out to be the best strategic decision possible to the benefit of our patients, the community, and our practice. Based on our experience, this article offers an overview of implementing an imaging center in a neurosurgical practice. While the financial information estimates presented are fictitious and only for a hypothetical imaging center, they represent realistic figures rooted in our recent experience.
Benefits of Owning an Imaging Center
Even if an imaging center were entirely revenue neutral (which it is not),
the benefits to a neurosurgical practice and its patients far outweigh the
time commitment for the initial start-up of the center. An imaging center within
a neurosurgical practice allows the neurosurgeon to control all of the factors
relating to patient imaging and to tailor the imaging studies to meet the specific
needs of the patient. This allows the neurosurgeon to make a precise diagnosis
and to formulate an accurate treatment plan that most benefits the patient.
The neurosurgeon-owned imaging center also can help keep imaging costs down
by offering competition to hospital-based imaging centers.
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A neurosurgeon-owned imaging center can offer flexible hours of operation in response to the needs of the patients. Because of work and child care issues, some patients are best served if they can obtain imaging studies outside of conventional business hours, either very early or very late in the day and on weekends.
With a neurosurgeon-owned imaging center, the neurosurgeons also have control over the timing and the quality of the radiological interpretation. If image interpretation is of poor quality or if radiological reports are consistently difficult to obtain in a timely manner, images can be easily routed to a radiology group that will work collegially with the neurosurgical practice.
In our center, all images are captured digitally and sent by secure Internet transmission to be read and interpreted by a large radiology group in another state with 24-hour coverage. Within 24 hours of the time the image was taken, the radiology group faxes a report to the neurosurgeon. The quality of the interpretation is superlative and the timely return of radiology reports makes the imaging service we offer our patients outstanding. It also has been very easy to find quality radiology groups that interpret images for our imaging center at a reasonable price.
Factors such as the ability to tailor the imaging studies to meet the specific needs of the patient, lowered cost, flexible hours for imaging, and timeliness and quality of image interpretation are only a few of the clear advantages of operating an imaging center within a neurosurgical practice.
Impediments to Implementing an Imaging Center
Reasons neurosurgeons have been reluctant to pursue imaging centers within
their practices undoubtedly are related to fear of retribution, lack of knowledge
in this area, and a reluctance to invest a significant amount of time and financial
resources for an uncertain return.
Fear of retribution or scorn by other imaging centers, physicians, or hospitals in the practice region are realistic concerns. In our experience, it is usually the entities which are directly and significantly profiting from an existing imaging center that are most vocally opposed to another center opening. One possible way to ameliorate potential animosity is to structure the imaging center as a joint venture or partnership with a hospital or radiology group. If this is not possible, then the neurosurgical practice should be prepared for distain and criticism from a small segment of the medical community, possibly including a hospital’s administration. The reasons often cited by those opposing a neurosurgical imaging center typically are false and self-serving and have little or nothing to do with the general welfare of the community. It is through tempered competition that costs are kept low, physicians have a choice in imaging, and patient and physician satisfaction are truly valued.
Initially our practice’s imaging center was to be a 50-50 venture with the local hospital. At the eleventh hour, after money had been invested, the hospital decided not to participate for reasons which were unclear and perhaps related to pressure from a competing imaging center owned and managed by a single radiology group. Our practice considered the financial options and decided to pursue an imaging center without any other partners, a decision that has proven fruitful for our patients, our practice and our community.
Another serious consideration to keep in mind when adding an imaging center to a neurosurgical practice is the understanding of and strict adherence to state and federal laws and guidelines with regard to physician ownership of ancillary services and the related issue of self-referral. Our group consulted a qualified attorney to ensure correct interpretation of all applicable laws, and we recommend that those considering opening a similar ancillary service do the same.
Financial Considerations
In the past, the biggest challenge for physicians wishing to open an imaging
center was financial. Today, however, most imaging equipment companies will
work with physicians under leasing arrangements, making imaging centers very
affordable.
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Cost estimates for development and initial operation of a hypothetical neurosurgeon-owned imaging center are shown in tables 1–4. It is important to view these tables with the following caveats in mind: The dollar amounts presented are hypothetical, and costs with respect to employees, supplies, and possibly reimbursement will vary significantly by geographical region.
Table 1 illustrates the basic operating assumptions associated with the initial purchase and operation of an MRI scanner and a digital plain radiograph machine. In table 2, estimated average monthly costs of implementing, owning, and managing an imaging center in a neurosurgical office setting are shown. Revenue growth for the first and twelfth months of imaging service implementation is shown in table 3. For obvious reasons, it is wise to underestimate the number of studies and revenue generated; in our projection, 90 percent capacity is never exceeded. With reasonable estimates in hand, a cost-benefit analysis then can be formulated. Table 4 shows the theoretical expenses and probable revenue associated with medical imaging over a four-year period. In this exercise, the average annual net income is more than $1 million after the first year.
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In summary, the increasing costs of operating a neurosurgical practice, escalating malpractice insurance premiums, and lack of realistic increase in reimbursements for surgical procedures create an increasingly difficult practice environment. To continue to practice neurosurgery in this environment, it makes sense for some practices to capture a portion of the ancillary imaging revenue. The addition of an imaging center to a neurosurgical practice can offer the neurosurgeons much more authority over the quality of imaging studies, and the neurosurgeons that render the care to the patients can have the ultimate influence on charity and unreimbursed care by controlling another facet of the global cost of patient care.
Thomas A. Kopitnik, MD, is a neurosurgeon with Central Wyoming
Neurosurgery in
Casper, Wyo.
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Note: Dollar amounts in tables 1–4 are hypothetical, and costs with respect to employees, supplies, and possibly reimbursement will vary significantly by geographical region.