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The Invasion of the Body Scanners
By Richard B. Elsberry
They are coming soon to a neighborhood near you: storefront scanning centers offering whole-body imaging, coronary calcium scoring, and virtual colonoscopy to asymptomatic, health-conscious individuals seeking the peace of mind that comes from knowing they are not about to be ambushed by arterial plaque or unsuspected tumors.
No referral from a primary care physician is needed. These are elective screening services not reimbursed by Medicare or health insurers. And they are not cheap.
The overnight proliferation of full-body screening centers is a trend that appears ready to assume epic proportions. Currently, there are less than 100 such centers in operation or ready for their grand opening.
But medical professionals and entrepreneurs are predicting that 5 years from now, there could be as many as 4,000 such facilities in the United States, most located in nontraditional medical settings such as health spas, mini malls, and shopping centers.
What is behind the race to be among the first to establish retail imaging boutiques where individuals can indulge their desire for a clean bill of health by selecting from a price-fixed menu of imaging tests that will detect medical problems before any symptoms appear?
One part of the equation is technology. The rollout over the past 12 months of ultrafast, $1.2-million, subsecond, submillimeter helical CT scanners now makes it possible to do a neck-to-pelvis body scan and a simultaneous virtual colonoscopy in 15 minutes or less. Previously, the only systems considered fast enough for high volume screening were electron beam tomography (EBT) imagers. While EBT scanners are capable of imaging a 6-mm slice in just 100 milliseconds, they cost nearly $2 million and until recently were perceived as best suited for doing coronary calcium assessments.
The major reason, however, that whole-body scanning is as hot as a Finnish sauna is because Americans are fed up with the nation's health care system and are willing to dig deep into their wallet to get answers to questions that they believe they cannot get from an HMO gatekeeper or a PPO internist.
"People are dissatisfied with the health care system and are looking for ways to bypass it or to work out of it," says George Berk, MD, a cardiologist for the past 26 years who in March opened Imaging for Life LLC, a whole-body scanning center in White Plains, NY, as a sideline to his full-time cardiology practice. "This kind of technology appeals to that sort of thinking."
Over the first 6 months of operation, his Westchester County center scanned 700 clients, including some who drove there from Boston and North Carolina. His clients have turned out to be a cross section of American demographics. "They do not fit any specific profile," says Berk. "They run the gamut. Initially, we thought our market would be wealthy yuppies with lots of money to burn. But it hasn't turned out that way. Because we are in a relatively affluent area, we get our share of that. But we also get our share of cops and firemen-all sorts of people you would not think would want to invest that kind of money." Berk charges $850 for a whole-body scan on his EBT system. The scans are read by two radiologists on retainer.
Berk currently plans to open two more scanning centers in Manhattan-one in mid-November on East 38th Street, and another next spring on the West Side. Both will be equipped with helical CT. The scans will be read by radiologists at Mt Sinai Hospital. In addition to whole-body scans, both Imaging for Life centers will also offer virtual colonoscopy for $995, as well as a special heart, torso, and colon package for $1,495.
"I think the driving force behind whole-body scanning is a combination of technology-the multislice CT scanner-and the public's reaction to the existing state of medicine," says Richard Penfil, MD, a long- time radiologist and CEO of CT Screening International (CTSI), Newport Beach, Calif. "We have a lot of HMO patients who are uncomfortable with the type of medicine they are getting, so they really want an actual examination, not a virtual examination.
"Historically, you go to your internist once a year and he thumps on your chest, takes out his stethoscope, draws some blood to send to a laboratory, sends you for a chest x-ray, and asks how your golf game is doing," says Penfil. "That, to me, is the virtual examination. The actual examination is where you take a look at what is going on inside your body. But to do this you need quality physicians, quality technology, and a quality delivery system. If you are not interested in helping patients and society in general, you should not be doing whole-body scanning. People who are looking at this as a moneymaker are looking at the wrong end of it. The right end of it is what you can do for patients.
A Medical Venture
"CTSI is not a commercial venture, but a medical venture," says Penfil. It began operations in January 2001, and now has four centers in Southern California, one in the San Francisco Bay area, two in New Jersey-Paramus and West Orange-and an eighth center on the Upper West Side of Manhattan, between 73rd and 74th Streets, which opened in early November. CTSI plans other Manhattan centers at 88th and Park Avenue and 53rd and Madison, plus centers in Scarsdale, NY, and West Los Angeles and two in Northern California. Longer range, it has its sights set on Boston, Washington, DC, Florida, and Texas. While CTSI does predominantly whole-body scanning, it also offers virtual colonoscopy as an add-on. It charges $800 for a whole-body scan in California, and plans to charge $850 in the New York metropolitan area. Californians pay $475 for a virtual colonoscopy; the price for that examination in the New York area had not been determined at the time this article was being written.
While virtual colonoscopy as a stand-alone examination generally ranges from $900 to $1,000 at most scanning centers, Medicare reimbursement for colonoscopy is pegged at $380 and for flexible sigmoidoscopy at $98.
Standard procedure with most whole-body scanning centers is to provide "clients" with a CD-ROM of the examination (which they can view on a home personal computer or use to get a second opinion) and a written report. Most also have a radiologist or other physician personally go through the scan with the customer and answer questions. Some, like Berk, call clients at home in the evening to review their coronary calcium scores.
AmeriScan, with three centers in the Phoenix area and one in Northern California, also gives clients a password that enables them to access their images worldwide from a secure Web-based server.
While most scan centers request the name of a primary care physician to whom they can send a copy of the report, "many patients ask that we not send a copy of the report to their doctor," reports Laurie Higgins of HeartScan in Walnut Creek, Calif, which has been doing cardiac and whole-body scans, as well as virtual colonoscopy, since January 2001. "If they want the doctor to know, they will give it to him." HeartScan, part of the Technology Imaging Group, also has company-owned centers in Houston, Las Vegas, San Francisco, and Washington, DC, with subsidiaries in Minneapolis and New York City.
In those cases where a client has an abnormal study, the client is referred to his or her primary care physician, or asked to name an internist to whom the report can be sent. "We don't want to interrupt the usual chain of referral," says Berk. "We are not in the business of taking patients, or having people become our patients."
"One of the things we feel extremely strongly about is the need to have a knowledgeable person-either a radiologist or a cardiologist-spend time reviewing every single detail of the exam with the patient," says Penfil. "I know there are a number of other organizations that either are using general practitioners to talk to patients, or are not having patients see a physician at all. That's not the way we think it should be delivered."
Looking for Answers
People signing up for nonreimbursed whole-body scans in Southern California often tell radiologist Robert Wilson, MD, they are doing so because "I can't get any kind of an answer out of my HMO doctor."
They like scanning centers, he says, "because they get to sit and talk directly with a specialist and ask questions. They don't get that anywhere else. They really enjoy the experience of talking to a doctor who is willing to take the time to communicate with them about their health problems."
Wilson reads scans for several screening centers and is trying to raise capital to open his own whole-body imaging center. Providing normal, healthy people with peace of mind is one of the keys to the initial success, and the anticipated future profitability, of whole-body screening centers. "When you get a study of this sort and it says you don't have that much plaque, you sleep a lot better at night," says Berk. "The nagging uncertainty goes away. And if you have a problem, this is the early warning system. We've had three or four stent procedures and at least three bypass surgeries as a result of scans of totally asymptomatic people. The radiologists also have picked up some small cancers and a multiple myeloma."
Penfil believes that whole-body scanning not only can provide peace of mind but will buy some people extended life by finding cancers early, when they are treatable. "Lung cancer is the major cancer killer of both men and women in the United States. The 5-year survival rate is about 14%, and it hasn't changed in the last 50 years. If you screen chests, you will pick these [tumors] up so early that the survival rate could be 80%." Other physicians believe early detection of colon cancer, which currently causes about 60,000 deaths annually, can increase the survival rate from 35% to 90%.
But not everyone in the medical imaging community agrees with Berk and Penfil. The American College of Radiology issued a statement last year stating that "there is no evidence that total-body CT scanning is cost-effective or is effective in prolonging life."
Penfil, however, states that "22% of the patients we have scanned have significant abnormalities, not counting coronary calcifications. Granted, about 80% of the time you do not find any lesions. That is the good news. But when you do find one, you've done a very big service for the patient. Of course, there are instances when you find far advanced diseases that it is too late to do anything about, but their number is very small."
While whole-body scanning, covering the heart, lungs, abdomen, and pelvis, has been the primary attraction thus far, many scan center operators believe virtual colonoscopy is going to be a real blockbuster. "There are not very many units doing it yet, but it is a very good screening test, and people want it," Berk notes. What people do not want, Berk says, is the discomfort and anesthesia associated with colonoscopy. "This is a nice option," he notes. "A pleasant room, a nice office, some people talking to them, and no hospital and no invasion."
The combination of a whole-body scan and virtual colonoscopy is currently being offered by some facilities in packages that range in price from around $1,400 to $1,750.
Most centers using EBT technology, such as HeartScan, offer the option of a separate heart scan. It costs $495. AmeriScan, which has centers equipped with helical CT in Scottsdale, Chandler, and Glendale, Ariz, as well as San Jose, Calif, charges $450 for a heart scan. AmeriScan also offers a lung scan for $295, and began offering a head scan late in the fall for $200. HealthScreen america, which opened in January in Jacksonville, FL, has a different spin on screening. It does not do whole-body imaging, but offers heart and lung scans at $350 each, and virtual colonoscopy at $995, employing multislice CT technology.
HelathScreen also offers several comprehensive packages; the Bronze package of a dozen blood tests for persons under 35 years of age costs $189, while the diamond package for persons over 35 years of age comprises 29 tests, including a carotid artery ultrasound scan, for $1299. With an add-on virtual colonoscopy, the price is $2914, and the procedure take 2.5 hours.
HealthScreen is the brainchild of two Florida entrepreneurs, Frederick Fey and his brother Chris. they hope to open 50 corporate owned and franchised HealthScreen storefronts over the next 5 years; the first of those is set for Atlanta. AmeriScan was founded by Craig Bittner, MD, a former interventional radiologist in california, who has plans for future scanning centers in Seattle, Las Vegas, Denver, los Angeles, Chicago, San Francisco, and Kansa City.
Other entrepreneurs also are moving quickly to set up shop. Nitin Doshi, MD, who owns and operates seven diagnostic imaging centers in the New York area, has a helical CT on order, but has not decided where to site it. In Salt lake City, Mike Huish, a recent college graduate, expects to have his Accuscan center open in early January. It will be the first in Utah. Huish decided to go into business after visiting AmeriScan in Scottsdale with a group of local businessmen. "I saw a need for this service in Salt Lake," he explains. He has arranged venture capital funding to buy the helical CT.
Richard B. Elsberry is a contributing writer for Decisions in Imaging Economics.