October 01, 2016
Mobile Health Care: A Private Practice Niche
Onsite imaging services make swallow studies easier for some patients, but starting up a mobile business takes research and a financial commitment.
The ASHA Leader, October 2016, Vol. 21, 40-41. doi:10.1044/leader.IPP.21102016.40
For a person with dementia, a modified barium swallow study (MBSS) is anything but routine.
Mrs. N, for example, lives in a skilled nursing facility, where dining staff alerted the speech-language pathologist to Mrs. N’s new symptom of extensive coughing during meals. Concerned that Mrs. N was having difficulty swallowing, the SLP arranged for her to have an MBSS at a nearby hospital.
Mrs. N arrived at the hospital disoriented, tired from the private ambulance transport, and frightened in the unfamiliar surroundings. Her lunch and usual medication times came and went as she waited more than an hour for her study.
Under these conditions, how reliable are the study results?
A mobile solution
There’s an alternative to this scenario: a mobile service that brings imaging studies to skilled nursing facilities, rehab hospitals, patients’ homes or wherever the patient is located. Mobile diagnostic services expand accessibility of advanced technological procedures, reduce ambulance or other outside transportation costs, and increase efficiencies, such as time and staff resources, without sacrificing quality.
Mobile MBSS provides a trained technician, licensed physician (as required by Medicare) and trained SLP to conduct a full, comprehensive dysphagia examination. The MBSS—performed inside the mobile clinic parked outside the facility or home—uses a C-arm. This device allows the study to be performed while patients are sitting in wheelchairs, geriatric chairs and bariatric chairs, which cannot be accommodated in a hospital fluoroscopy suite.
Private practitioners may be interested in establishing a mobile service. Here are some important considerations.
And, most important, the results of the test are more representative of a patient’s swallowing function, because the issues of fatigue, disorientation, and testing delays can be greatly decreased.
Medicare recognizes two categories of mobile health care units.
- Mobile medical clinic—physician-owned and operated, requiring its own national provider identifier (NPI), its own Medicare number, and physicians with their own NPIs.
- Independent diagnostic testing facility (IDTF), required by Medicare to meet 17 detailed, extensive performance standards to obtain and maintain billing privileges. These standards, in their entirety, can be found at your local intermediary website.
Inside the clinic, providers can conduct a full evaluation of a patient’s swallow function by the lateral view as well as the anterior-posterior view, which is not usually completed in the hospital setting due to positioning restrictions. The specialized fluoroscopic system designed for the mobile MBSS exposes the patient to less radiation than in most hospital settings, which typically use two to three times as much radiation.
The physician operates the radiological equipment while the technician documents the total fluoroscopy time and archives the videotape with footage markers for the permanent medical record. Real-time DVD recorders capture a full dynamic range of high-quality images of all three phases (oral, pharyngeal and esophageal) of the swallow function, and also capture the audio explanations. The study is displayed on two real-time viewing monitors for the SLP to evaluate and the providers to observe.
The mobile clinic provides the facility and its SLP with a DVD of the evaluation to use for review or education. Written and verbal results, recommendations, and the physician’s and SLP’s detailed evaluation reports are immediate.
The total time to complete an evaluation, from the time the mobile unit arrives at the facility until it leaves, averages 30 to 45 minutes.
The mobile units/buses can cost up to $250,000. Fluoroscopy equipment can cost up to $100,000. The onboard fluoroscopy equipment is subject to all state radiological health department regulations and requires inspections by the state every one to three years and annual physicist inspections. A new IDTF that is ready to operate must have an initial inspection before it sees any patients.
In most states, Medicare rules require a physician to be present for an MBSS on the mobile clinic. A physician must always be present under Medicare regulations when any contrast is used. Additional costs include basic business expenses such as salaries for staff (clinical and billing) and supplies (including barium, for which costs have increased dramatically over the past several years). Other expenses include regular maintenance to the mobile clinics, maintenance of portable generators, fuel and insurance on vehicles, medical equipment, and health care employees.
The requirement of an electronic medical record (EMR) system has been a new and costly expense for any small company that bills physician codes. Even after the initial installation expense, there are other issues to consider, including collecting and reporting data required by Medicare.
The key to a successful mobile practice is a coverage area with a large population of long-term-care and other medical facilities.
Billing and reimbursement
The key to a successful mobile practice is a coverage area with a large population of long-term care and other medical facilities. Reimbursement for SLPs’ fluoroscopic evaluation of swallowing function, as well as physician codes, has dropped significantly over the past several years. This fee change, as well as other reimbursement changes—such as bundled payments—affect all outpatient locations and have dramatically reduced income and profits for mobile diagnostic services.
And, under longstanding Medicare regulations, mobile units and IDTFs are not considered portable X-ray providers, and cannot charge a travel fee.
These reimbursement considerations may create obstacles to starting a new mobile company; the handful of existing mobile clinics, some of which have been in business for more than 13 years, were established in a health care and reimbursement climate that was more amenable to sustaining a start-up. Nevertheless, the difference in the quality and accessibility of the swallowing studies makes mobile imaging the cost-effective choice of many facilities.
- Ronda Polansky, MS, CCC-SLP, is the owner and managing partner of DiagnosTEX, LLC, which provides mobile MBSS in Dallas-Fort Worth and the surrounding areas. email@example.com
- Joan Kelly Arsenault, MA, CCC-SLP, BCS-S, is the CEO and managing owner of MassTex Imaging, LLC, which provides mobile MBSS studies and dysphagia consultations in the New England area. firstname.lastname@example.org
- © 2016 American Speech-Language-Hearing Association