Sunday, 30 December 2007

MRI scan price war.

Private imaging cowboys shoot it out

A couple of years ago it was quite common-place for patients to be charged £600 for a single area MRI scan. The atmosphere surrounding private medicine was very much like I imagine it is when buying a Saville Row suit: "if Sir needs to ask the price then Sir cannot afford it".
As MRI scanners became more widely available and patients began to shop around, or even go abroad, for their scans MRI providers began to compete on price.
I think the first to break ranks was the Cobalt Appeal in Cheltenham, who suddenly found themselves with vast overcapacity for their mobile service as hospitals in the West Midlands installed their own fixed scanners. As a registered charity they have financial advantages over purely commercial organisations and could also rely on charitable donations to provide working capital, rather than have to borrow money at commercial rates.
With little competition and clever marketing to potential referrers and directly to the public they established themselves fairly firmly as a low cost quality provider and drew patients from throughout the UK.
Last year Vistadiagnostics in London entered the market with a variable charging structure depending on the time of day but as low as £250 for one area and actually cheaper than the Cobalt Appeal for multiple areas and for contrast enhanced scans. Their business is based on the EasyJet model and relies on using the scanner 7 days a week for 13 hours each day with aggressive promotion of their service. I think this was quite a risk because rents and radiographers still have to be paid if the scanner is idle and costs in London are high. With such narrow margins they could only survive if they ran the scanner at full capacity.
They had the lucrative London market to themselves for about a year but just before this Christmas, Med-Tel, another private scanning centre in the City, announced a "special deal" matching Vista's prices for MRI. Not to be outdone Vista has taken the classic poker player's route and upped its stake and cut its headline price to £200.
Both companies are haemorrhaging money with Google pay-per-click advertising campaigns and, unlike the Cobalt Appeal, can't rattle tins at village fetes and shopping centres to restore their cash flow. It looks like the town ain't big enough for both of them and I foresee the one who blinks first will be eating dust before the new year is out.
Meanwhile, our private scanning enterprise, UK Radiology, which still offers scans cheaper than all of them, sailed serenely on, gradually taking business off the commercial scanning centres and Cobalt Appeal while spending virtually nothing on advertising. Irritatingly though, after my self-contented last post on this blog, it has disappeared off the first page of Google again for the search term "private MRI scan". I think getting a high Google ranking is a bit like sailing a tanker. Where you are now depends on actions taken weeks or months before and I now realise I had become complacent over the year and took my foot off the throttle (sorry about the mixed metaphor - do tankers have a throttle?). Out of interest I looked into the cost of pay-per-click. To put a company's link in the first four places for the search term "private MRI scan" costs 0.43p every time someone clicks on the link. Google accounts for around 75% of my visitors and if I were in the first four places it would be many more. Based on the number of click-throughs I get from Google, Met-Tel, Vistadiagnostics and Cobalt Appeal must each be spending hundreds of pounds every month on Google. At the margins they are working to now and with unused capacity that must be hurting.

A happy and prosperous New Year to all my fellow bloggers and readers. (Especially Dr Crippen - I hope you decide to come back next year- even if its just the occasional blog).

Wednesday, 19 December 2007

More good news

My cup brimmeth over.

When I wrote my article last week I meant to mention one other development which had cheered me up but I forgot at the time and, when I remembered, the moment had passed. What I was going to add was that the CT screening companies, the prostitutes of modern healthcare, were coming under critical examination.
Many people in the profession, and in particular Radiologists, have been alarmed by the lack of regulation of these companies and their direct marketing of CT scans to the worried well for purely profit motives.
The screening business had flourished for a time in the USA but, as the public became better educated and began to realise the lack of evidence for the claims the companies were making, there has been a tail off in demand. In the UK we are still on the upward slope of the curve with the worried well believing the claims that the scans can find your cancer and thereby allow you to be cured by timely surgery.
Considering the close regulation of industries which expose people to ionising radiation I have always been puzzled by the way these companies are allowed to irradiate the public with no proven evidence of benefit. The irradiation of someone without informed consent is technically assault. In hospitals we generally assume consent for irradiation but each investigation has to be justified such that we are satisfied that the benefits outweigh the risks. The benefits of screening CT are largely anecdotal so, by definition, the benefit/risk ratio is unknown and I cannot see how someone can give informed consent. I presume they ask the punters to sign a disclaimer rather than a consent form.
Anyway, last week there was a Jeremy Laurance article in The Independent that raised the issue of the dubious claims made for these "medical MOTs" and the risks to the unsuspecting public. This week calls for regulation have been made by COMARE, a government advisory panel on radiation. Even Liam Donaldson stuck the boot in.
Now, like many other bloggers - most notably DK, the news that an unelected, pressure group want to inflict more regulation and restrict the individuals choice does not generally cheer me up but in this case the public really does need to be protected. The very same public who worry about living close to a power line or having a mobile phone mast near their childrens' school are quite happy to part with anything up to £1300 to be subjected to radiation doses similar to those which caused excess cancers following the use of nuclear weapons in Japan.
Dr John Giles, a radiologist who runs Lifescan, one of the more aggressive and successful "radiation-for-reward" companies put a brave face on it today, claiming that he welcomes the report and, bizzarely, that Lifescan don't do screening scans but target individual organs. This might wash with the gullible public Lifescan usually deals with but as a radiologist he knows that CT scanning doesn't target individual organs; everything in the region scanned is irradiated. If he "targets" just the lungs and bowel that is a screening scan of the whole torso. Notwithstanding Dr Giles' welcoming of the report, COMARE states "...we have strongly recommended that services offering whole body CT scanning of asymptomatic individuals should discontinue to do so."
In fact its probably a distraction to focus too much on the radiation risk, which is unquantified for small doses. The main problem with the "scans-for-spondulis" companies is that they make unsupported claims of benefit, expose patients to the anxiety and physical risk of further investigations, and cost the taxpayer a large amount of money.
The scientific evidence in favour of screening is notoriously difficult to prove. There are still eminent scientists arguing whether breast screening is effective. CT screening for cancers is much less studied. Some cancers will not be reliably detected, others will be detected too late to alter outcome and others will be detected that would not have shortened the patient's life anyway. The best example of a cancer that is worth finding and is often picked up by chance is a renal tumour. You will find this mentioned in all the testimonials ( an indication of quackery) on the scanning company websites. The other abnormality worth finding is an aortic aneurysm. Both are easily picked up on a £50 ultrasound.
The anxiety, physical risk and cost to the taxpayer stem from the large number of false positive scans. These are scans that either show something which looks abnormal but isn't present or something that looks serious but is harmless. The scanning companies don't reveal how many "patients" have false positive scans but, in my experience, the majority of patients will have either a cyst or haemangioma in the liver, a cyst in the kidney or a solitary lung nodule. These patients would need a further investigation such as ultrasound, a repeat CT with contrast, a repeat CT after an interval or even a biopsy. Many of these would look to the NHS for these further investigations and some patients will suffer as a result of unnecessary biopsies.
Patients often contact me for screening scans and I find it difficult to explain why we don't offer them at UK-Radiology. The first time I was asked I wrote a long thesis on the scientific arguments; there just isn't a quick way to explain it. Now I say we don't consider it ethical and send a copy of my reasoning. I have been thanked a few times. If I were a quack I could use the comments on my testimonials page!

The other bit of good news this week is UK-radiology's return to first page of Google for the search term "private MRI scan". My colleagues simply don't appreciate how difficult and labour intensive it is to do this. Some have even criticised my methods (i.e. this blog - they haven't found out about my other methods yet). The easy way would have been to copy our competitors, charge the patients an extra £50 each and buy a pay-per-click campaign. That would have left me my last month's evenings and weekends free for me to enjoy away from my PC. Then again, we run an ethical company.

Thursday, 13 December 2007

Happy Days

Dr Ray (In my dreams!)

Apologies for neglecting my blog for the last couple of weeks.
Blogging for some of us is born out of turmoil and strife. It is a cry for help and attention. I hope I am not tempting fate by saying things have been going pretty well recently and my need for blogging has correspondingly decreased.
I started blogging in the closing months of Blair and Hewitt. Contracts were being signed with the private sector to put me and my colleagues out of work and the medical profession were generally getting a good kicking and were too timid to resist.
Now Blair and Hewitt have gone. Mercury Healthcare and a few other private sector "providers" have been told to sling their hook and, even though the medical profession has not become militant, the government is being brought to account by the police over the way they reneged on independently recommended wage rises (as they have done for doctors over many years).
Add to this the total shambles that passes for Gordon Brown's premiership and I am beginning to think the government may lose its appetite for meddling too much more with the NHS for ideological reasons.
The cherry on the cake came yesterday while watching Gerry Robinson on "saving the NHS" (or Rotherham General Hospital to be precise).
Sir Gerry wasn't very complimentary of the consultants when he did his first program last year, blaming them for the hospital's problems and failing to see the bigger picture and understand the reason for their lack of enthusiasm for the changes being foisted on them by managers. A year later he recognised that Rotherham General was just a pawn in the great game the government was playing with the NHS. Even though the Hospital was working flat out and providing a service which was obviously in demand a £12m Polyclinic was being built within walking distance which would make the General Hospital non-viable. And what sort of work would the Polyclinic do? Sir Gerry asked the CEO of the primary care trust. The Polyclinic would be a nurse-run walk in centre for people with bumps and bruises or for people who felt a bit "iffy" while at work. Sir Gerry pressed him on this but that is as specific as he could be. That is the level of planning that has gone into Polyclinics. They are going to target people who are well enough to go to work but feel a bit "iffy". In return the District General Hospital in Rotherham, which serves 250,000 people will probably end up closing. Why does this make me happy? It's because I already knew this was happening but was having trouble explaining it to anyone else. Sir Gerry has exposed the sham of Polyclinics to a much wider audience than I could ever hope for and made Lord Darzi look like a fool. I hope they repeat the program. It's a good thing Sir Gerry already has his knighthood because I don't think Gordon Brown would honour him now, not even for money.

The other reason I haven't blogged is more mundane. A couple of weeks ago I noticed that UK-Radiology, our private radiology set up in Hereford County Hospital, had dropped off the first page of Google for the search term "private MRI scan". It was still on the first page for all the other relevant search terms I could think of but the demotion riled me and I have spent all my free time trying to get back links by doing articles and "press-releases" to post on the web, going on to medical websites and forums and submitting my URL to directories. It takes some time to influence google ranking and I still have a bit more to do but I hope this all works.
My little enterprise with UK-radiology is one year old this week and despite the google set-back is continuing to grow and attract patients from throughout the UK. It has enabled our NHS department to recruit more staff while the rest of the hospital is making redundancies, we run the scanners for longer, offer open access for GPs and our department is in financial surplus. Isn't it amazing what NHS consultants can achieve if they are properly incentivised.