Upon returning home from World War II, Ian Smith, a first generation Australian- American, partnered with Westinghouse (then an X-ray manufacturer) to bring medical care to Cuba’s United Sugar Workers Union. Upon fulfilling delivery of 36 multiphasic mobile health clinics in 1949 for $600,000, the mobile imaging marketplace was born.

Smith’s company, Medical Coaches, has remained in business ever since. In the ‘70s, when CT was emerging as a costly and desirable new modality, Medical Coaches was preoccupied with business in Iran, leaving room for new competition to enter the domestic mobile imaging market.

Ellis & Watts out of Ohio and Calumet Coaches out of Illinois were among the first big competitors to meet that need. “That really started the boom of the mobile high-end screening business,” says Geoff Smith, president of Medical Coaches and son of Ian Smith. Over the next decade or so, a handful of successful companies emerged and today most competitors in the mobile imaging market can trace their roots, in one way or another, to that bygone era when CT (and later MR) were new, and relatively exotic.

Shared Medical Services emerged out of northern Minnesota in 1980. Founder John Arington’s success followed a similar pathway of expansion, adding MR to CT, as well as bone densitometry. In 1983, Alliance HealthCare was founded as a mobile CT provider. Today it claims to be the largest provider of advanced outpatient diagnostic imaging services in the U.S. Medical Imaging Centers of America (MICA) was another highly successful company to rise up in this era. The company’s vice president and chief financial officer, Ray Stachowiak, used his knowledge and experience to start his own company, Shared Imaging, which has enjoyed over 20 years of success, and credits it largely to a footprint that allows it to provide flexible solutions to a diverse customer base.

In 1995, Jim Gallagher joined the company and remained for 13 years before setting out on his own with LG Medical, a mobile imaging company. In the early ‘90s PET started to gain ground as an imaging modality and was followed by PET/CT. It was around that time that Bob Bachman, formerly of Calumet Coaches, set out to start AK Specialty Vehicles with his business partner, Larry Sodomire, which they sold to OshKosh in 2006. After that, Bachman and Sodomire started Advanced Mobility.

John Vartanian had been a service engineer for a number of companies before starting Medical Imaging Resources (MIR) in 1992. All the while, Medical Coaches continued plugging away at its own mobile imaging business and it was relatively smooth sailing until the recession in 2008. The industry underwent drastic changes as revenue decreased, trailer manufacturing fell off and new legislation called for a restructuring of the business model.

Today, acquisitions are hinting at new signs of life. In May, MIR was acquired by Oxford Instruments Healthcare, and last year, Kentucky Trailer purchased Advanced Mobility, a move Bachman says gave his company the balance sheet and capacity to competitively leverage its knowledge of the industry.

In October, the newly formed Advanced Mobility by Kentucky Trailer acquired SMIT, a leading European provider of mobile medical trailers. What led to the sudden increase in market activity? Bachman calls that the million-dollar question.


Rural hospitals and the ACA
When advanced mobile imaging took off in the ‘70s and ‘80s, it was driven by the expense and scarcity of CT and MR. Today, an abundance of fixed installations and an evolved refurb market have eliminated a lot of those original market drivers. In rural areas, however, a shared system can still seem like a logical solution.

Dale Hockel, chief operations officer of Alliance HealthCare, says the lower patient volume in rural communities make them an ideal candidate for shared mobile service. “This is more viable than having the system sitting around not being utilized,” he says. “I would say there has been an increase in activity from shared service providers. A few have recently bought multiples from us,” says Smith, with Medical Coaches, referencing Cleveland Clinic as a hospital system that utilizes both fixed and mobile MR systems.

There are also significant capital expense benefits to not having fixed site installations, which bring their own unique demands for space and shielding. “As an alternative, I can buy [an MR] and plug it in and turn it on and be up and running,” says Vartanian. “That’s a lot easier than building the whole room, taking delivery of the system and rigging everything in.”

“The way health care is moving, rural hospitals are taking the hardest hit in many ways,” says Juan Rocha, vice president of field operations at Shared Imaging. The company was founded in the interest of serving rural areas, but currently finds the demand for trailers to be strongest in metropolitan business. “There is some growth simply because the population has increased, but most of that takes place in cities. People are leaving rural areas for work in city centers,” says Vartanian. He speculates that the business of mobile routes has no more room to expand for shared rural services.

For Oxford, the interim business is thriving. As for the fixed-state units, Vartanian says people are becoming familiar with the rules of the Affordable Care Act, and consequently entrepreneurial business is beginning to reemerge. “If you’re renting a building, you don’t want to invest $300,000 into a room you don’t even own, so you say, ‘You know what I’ll do? I’ll bring a mobile in.’”

Mobile MR leads the way
Most mobile imaging companies agree that MRs are the most highly sought units on the market. Meanwhile, hospitals with smaller budgets are still keeping mobile CT units active, and some more advanced hospitals are turning toward nuclear imaging with PET/ CT, or MCT.

For Oxford, Siemens and GE are the most highly sought MR system manufacturers. As for PET/CT, “We have three trailers and we are not building into that space because it doesn’t seem to be growing,” says Vartanian. There is some speculation that as PET/CT continues to expand its capabilities on the research front it will begin to gain greater ground among clinicians, but whether or not that shift has created any new market demand is a matter of some debate.

For Advanced Mobility, which works more directly with the OEMs than with the hospitals, the adoption of PET/CT has been apparent. “GE and Siemens both brought mobile PET/CT products to market last year and we have built several of each and have orders for several more,” says Bachman. “Philips has had a good run again this year with a 70 cm-bore MR product, [Ingenia] and hopefully the OEMs will continue to follow those paths of upgrading new systems with different modalities,” he added.

In addition to the primary modalities, Medical Coaches has recently delivered a few Hologic bone densitometry units and is also doing a fair amount of mammography units, according to Geoff Smith. Medical Coaches has also recently sold a few breast screening units that utilize CT. “There is a cup in the table where the breast goes in and CT will spin around it,” says Smith, adding that the image quality is extremely detailed, allowing for improved accuracy for biopsies.

The first mobile molecular breast imaging vehicle is currently traveling around Wisconsin between five Marshfield Clinic Health System hospitals. The imaging allows secondary screening for women with dense breasts for whom traditional mammography is not always conclusive. The mobile molecular breast imaging system is called the LumaGEM and is manufactured by Gamma Medica. Philip M. Croxford, the company’s president, says the system is small and light enough that installing it on a trailer was less complicated than it would be for more cumbersome modalities.

Getting the OEMs to play ball
“The fleets are aging, getting miles, rusting, hitting walls and getting damaged — a lot of stuff gets worn out and gets thrown away at some point,” says Vartanian. Oxford refurbishes some of those trailers back to their original specifications in order to get them back on the market with more modern technology.

Shared Imaging’s Rocha points out the engineering and regulatory hurdles that the manufacturers face in putting systems on wheels as a major deterrent, but if the market demand continues to grow, he speculates they may have to devote more energy to meeting it. “Around 2002 the whole market was putting out about 200 systems per year, but around 2009 that dropped to 10-12 units per year for the entire industry” says Bachman.

“If we can get 50 or 60 new-build units in the U.S. market next year, that would be a good year.” “The mobile industry has changed because it’s extremely expensive to get into the business,” says Geoff Smith. “Not only the cost of having the right people and developing the designs, but you also need certification and a lot of the vendors now just don’t do certifications anymore.”

Vartanian says the current output is a “trickle” compared to what it was nine or so years ago. The recession had everything to do with that, and as other countries have increasingly recognized the value of mobile imaging, the domestic fleet has further thinned.

For Philip Jacobus, the president of DOTmed.com and Owen Kane Holdings, as well as a board member of Diagnostic Treatment Centers in Russia, the international demand for mobile trailers represented a unique business opportunity. He says that between 2003 and 2014 he shipped over 100 mobile MR units to Russia. “If there was a mobile trailer out there for sale, we would buy it, refurbish it and reuse it in Russia,” says Jacobus. “However, as a result of the problems in Ukraine, the sanctions in Russia, and the lower price of oil, that market has dramatically dropped off.”

“Mobiles are being dispersed from our country, going out all over the world, and not being replaced by the manufacturers right now — which all adds up to more demand than supply,” says Vartanian. As the trailers in the U.S. grow older, they present new challenges. “In some cases you have to upgrade the trailer to meet new weight distributions or other different requirements,” says Rocha. “In a case like that you have to either go through the expense of refurbishing the unit or else buy a new trailer.”

If the trailer still meets Department of Transportation requirements and satisfies clinical needs, however, Shared Imaging has programs to get the vehicles back in top form and looking good, which is a legitimate consideration in the era of patient satisfaction ratings. “We do a lot of refurbishing of existing units, the fleets that are owned and maintained by Alliance HealthCare and Insight Imaging,” says Bachman of Advanced Mobility, adding that his company rarely ventures into the broker market, but will refurbish for a customer who chooses to go in that direction.

Advanced Mobility by Kentucky Trailer has just acquired an additional 75,000 square feet of manufacturing space, which is as clear an indication as any that they forecast a changing of the tide. “When OEMs receive orders from hospitals, we work behind the scenes to make sure we’re designing and building a product that supports their product most efficiently and works the way it’s supposed to,” he says.

Vartanian points out that their sales are based on volume, as evidence that the OEMs are unlikely to get back into mobilizing in earnest. “The old model of three hospitals buying in 100 percent for a five-year route — that business model is dying because the manufacturer still has to sell to an operator.”

A new era for mobile CT?
Geoff Smith contrasts the current regulatory atmosphere with that of years gone by. “The Odelca 70mm X-ray for chest imaging was around for probably 15-20 years because nobody was developing anything better,” he says.

While few hospitals can make the case for having the most advanced technology available, new dose monitoring legislation like XR-29 is raising the bar on minimum requirements. For facilities that don’t step up to the new standards, reimbursement gets cut. Rocha calls XR-29 a “driving force” in the mobile imaging field. He anticipates some hospitals will take this opportunity to re-evaluate the distribution of their assets and perhaps continue long term with shared or trailer-based systems originally intended as interim.

For Advanced Mobility, getting the mobile CT market rolling again has been a topic of serious consideration. “Right now most of the CT is going in refurb trailers and we’re trying to figure out how to bring a lower priced new CT trailer to market within the next several months,” says Bachman. The challenge is in making a mobile CT economically viable. “We can’t put a $400,000 CT scanner in a $400,000 trailer, so we’re working on a lower price new-build CT trailer,” he says. As hospitals look for ways to mitigate the cost impact of adhering to standards like XR-29, an affordable mobile solution could be a welcome alternative.

“It’s a factor you cannot ignore,” says Hockel. Ensuring that a facility is updated and compliant with dose standardization will increasingly impact not only the quality of equipment being utilized by providers, but the quality of the CTs being offered in the mobile market. “With health systems, the industry is continuing to create partners and solutions to provide the most patient-focused and economical model possible,” says Hockel. “There is an opportunity and a window that mobile solutions provide within that context, and it’s crucial to bring technological advancements into the mobile environment.”