How to purchase Ultrasound
Purchasing ultrasound is an expensive and difficult task for the first time buyer. My goal is to help the person who has a desire to purchase ultrasound and help them make the right decision. With 15 years in the ultrasound industry I will share how, if I was a Pain Physician, I would go about selecting a product and company.
Economics of Ultrasound
Would ultrasound make a good business decision for you? You first have to identify the types of procedures you want to use it on. Any peripheral nerve, SI Joint, knee, shoulder, hip, trigger points (thoracic area), facet’s, piriformis, stellate ganglion, caudal epidurals, pump refills, and many more procedures are clinically validated area’s in which ultrasound is as good or better than fluoro. Also, these are areas where you will be reimbursed.
Let’s assume your cost is $35k and you finance with a monthly payment of $700. You evaluate your uses at approximately 15 uses per week and would get an average of $200 per use.
Gross Revenue = $12,000/mo or $144,000 annually
Purchase Cost = $700/mo
Net Revenue = $11,300/mo or $135,600 annually
Breakeven = approx. 3 injections/mo
The economics of ultrasound are pretty fantastic, now let’s get to the real important items to make sure the numbers you sketch out on paper, actually end up in your bank account. How and what you purchase will directly impact how successful ultrasound will be in your practice. So let’s get down to the business of purchasing ultrasound.
Common Pitfalls
The first place to start is realizing how others have made mistakes and not to repeat them yourself. Purchasing mistakes happen from people who are afraid to make a mistake and are scared, so let me ease your mind a little if you are one of those people. At this point you are not the first person in Pain Management to buy ultrasound, in fact you are probably surrounded by others successfully using it. If you’re not, you have a great marketing opportunity. In addition, many of the leaders in Pain Management will tell you “ultrasound is here to stay, so you are either going to get it now before the reimbursement starts getting cut, or later when it’s not as profitable”.
So let’s looked at the two most common failed notions in how to purchase:
I need to learn it before I buy it.
Ultrasound is a hands-on tool that when used routinely with expert instruction, can be easily picked up and learned. The person that buys into this notion of learning before buying, often times spends thousands of dollars on wasted courses, invests days on using sales reps to “demo” the machine for multiple trials, only to walk away thinking they aren’t ready to buy because they still don’t understand what they see or how to visualize the needle. If they don’t come to the realization that they just need to buy it in order to learn it, they will continue on this path for years. You may laugh, but I see it happen everyday to people who want to dip their toe into the water and not commit. The waters warm, jump on in!
I want to buy the cheapest thing I can find to get started.
In today’s environment this is a dangerous notion to sell yourself on. Medicare states “upon audit, documentation must prove clinical relevance”. Of course we all want to spend nothing and make a lot of money. The reality is that if you go with a cheap system, you get what you pay for. And 95% of the time you get a system where even an expert like me cannot make out what it is I’m looking at on those types of ultrasound machines. If you can’t see your target, then ultrasound is nothing more than a gimmick, if you practice “gimmick” ultrasound on your patients, then upon audit the insurance companies will most likely require their money back.
You don’t need the $200k system the Radiologist is buying, nor should you be buying the $20k and under system.
Selecting the system
Now that we have that out of the way you are positioned to start your shopping off on the right foot. If you’ve never used ultrasound before in a chronic pain setting then there are 2 that are critical in order for you to implement it successfully:
Diagnostic quality system
Progressive on-site training from experts
CME off-site courses for on-going training
Choosing a diagnostic quality system can be difficult because there is no “spec” you can look for or evaluate in a system to decipher how good it is. You simply need to see the system and the quality for yourself. But if you can’t tell a bad image from a good, then stick with well known companies and don’t try to make that decision. In order to do this go with the big 3. There are many other companies, but in general if you are new and you want to make the least risky purchase without surprises after the sale or make a mistake on buying something that won’t work, then it’s safer to stay within the box and not try to be the expert and go with an unknown. The 3 main companies that are involved in this space are:
Advisor Medical
GE
Sonosite
Unless you intend on doing heavy spinal procedures right off the bat, I would stick with a probe configuration that includes one probe. The best broadband probe to go with is a linear that has selectable frequencies between 5-10 MHz. It offers both resolution for superficial structures, and penetration for deeper structures. In the future you may decide to purchase a convex probe with lower frequencies between 2-5 MHz, but you can always purchase it later so I don’t see a big need to spend $10,000 additional right up front. The best way to structure your purchase is to have the company guarantee you a price on that extra probe for a term of 6 months after you purchase. That way you lock in your price and can delay the decision until you have further information on whether or not you are limited by not having it.
Keep it Simple Stupid (KISS). You probably don’t want to be an ultrasound tech who pushes a million buttons while they’re scanning in order to optimize the image. Look for procedure presets that you can customize into the system so that you can walk in, put the probe down, do the procedure and move on to the next patient. Pushing buttons and having to run the system will slow you down and steepen your learning curve.
Training...you do intend on actually using it right?
Pay attention closely to this section, because not all training is created equal. The best training for you to really learn ultrasound fast, is on real patients with an expert at your side helping you learn how to angle, position, needle entry point, and a whole host of other key’s in making ultrasound simple. And then repeating the next day on your own, and the next day after that until it becomes as second nature as fluoro guided procedures. This is the fast-track to learning quickly. Then after 30-45 days, go to a course where you can learn on live models and/or cadaver’s to further your skills from faculty that have been doing it for years and can teach you more difficult to do procedures. Since the on-site training is the first and most important step, you need to make sure the company is willing and capable of the following:
Teach you how to run the system (patient name, save image, etc)
Teach you how to perform ultrasound-guided procedures!
Buyer beware: Most companies provide ‘on-site’ training by an ultrasound tech. Ultrasound tech’s come from traditional ultrasound environment’s which include scanning breast, vascular, abdominal, cardiac and other non-MSK or chronic pain related areas. What this means is that they can teach you how to run the ultrasound system but cannot show you anything about procedural ultrasound in chronic pain simply because they, like you, don’t know the sono-anatomy of the surrounding structures, the target, or where to best insert the needle. In addition, many companies are run by lawyers and make it a policy to “not show the Dr how to perform procedures, but simply run and optimize the system”. This means that learning procedural ultrasound will be on your shoulders. Now all of a sudden you are stuck, you are not comfortable using the system you bought on patients and it sits there as a very expensive dust collector. In addition, that ROI you performed while deciding to purchase becomes irrelevant.
The only way to get the numbers off of the paper and into your bank account is to be using it. Be absolutely clear on this point and get it in writing from the sales person if possible.
Now that you have your on-site honed-in and have a clear path laid out for how you will get started, take it to the next step. What CME courses will you be going to in the future to ensure you are adding to your expertise as well as using the ultrasound system to it’s fullest potential in your practice? I recommend AAPMU (American Association of Pain Management in Ultrasound, www.aapmu.org), it runs 3 levels of courses depending on experience, and in 2014 will be offering the first and only Procedural Ultrasound Certification. It can be possible to negotiate with your vendor to have them reimburse you for tuition for those courses.
Price Range & Financing
I get a lot of questions on the price range to try to stay in, the answer is simple and shared by most other experts, it’s $30-60k. If you are just doing basic ultrasound injections, then stick with a premium portable unit with a target of around $30-40k. If you intend on utilizing it in spine and/or heavy diagnostic uses, then you should consider looking for more horse-power that a cart based unit gives you. This also means you may be having to spend more on the hi-end of $50-60k.
Why not finance? Financing is a great option to help with cash flow, consider the following when having your sales person putting the quote together:
3-9 month deferral on payments
No pre-payment penalty
60 month Dollar Buyout Loan (qualifies for IRS Section 179 tax deduction)
This allows you time to get reimbursements in before the unit starts costing you money. Then if you have made enough in a couple months you can just payoff the loan without penalties and own it outright. What you structured is a way to have the ultrasound completely pay itself off without impacting your cash flow at all.
About Paul Kapenga
Paul Kapenga has been involved in the ultrasound industry for over 15 years. He founded Advisor Medical on the notion that big companies were focused on just selling ultrasound equipment to Dr’s who didn’t know how to use it. So he built an infrastructure on training to help Dr’s successfully implement ultrasound into their practice and then partnered up with the manufacturers to sell their equipment with proper training at no additional cost to the Dr. Today Advisor Medical is one of the biggest MSK & Procedural Ultrasound sales companies in the industry. He currently sits on the Board of AAPMU and has taught procedural ultrasound to various other Pain & Orthopedic Associations.
For questions or comments please contact Paul Kapenga directly at paulk@advisormedical.com or call 866.263.4219 x700.
