The conventional wisdom is that mobile screening mammography is a money pit for hospitals and makes sense only as a means of showing a willingness to reach out to the uninsured in the community.

But not every mobile mammography provider is awash in a sea of red ink. Imaging Associates Inc, a Seattle-based for-profit established in 1989 by radiologist Ken Heilbrunn, MD, has evolved a business plan that enables it to more than break even despite the minimal reimbursements authorized by Medicare and Medicaid for half of its patients.

Imaging Associates generates 85% of its revenue from mammography and the balance from other off-site servicesultrasound examinations (8%), plain radiographic films (5%), and osteoporosis screening (2%), a service it recently initiated. It serves on a weekly or monthly basis some 40  remote, low-income, and Native American clinics throughout Washington, but primarily in the western part of the state. Only 1% of its volume comes from on-site service to corporate clients.

Its three portable mammography units, two ultrasound systems, and a pencil x-ray beam osteoporosis scanner are transported in full-size vans or minivans and set up in clinic examining rooms, which it rents. Chief technologist Sharon Haworth, who has been with the firm almost since its inception, works with four part-time technologists, a full-time sonographer, three part-time sonographers, and five office workers who handle billing, transcription, film processing, and customer coordination.

Last year, Imaging Associates did 7,887 on-site mammograms, which were primarily read by Heilbrunn. In addition, assisted by three locum tenens radiologists,  Heilbrunn read and billed for another 6,000-plus mammograms done at other facilities and sent to Imaging Associates by courier or UPS.

Only one half of the mammograms done by Imaging Associates are covered by commercial health insurance. The other half are reimbursed under Medicare or Medicaid, or qualify for the National Breast and Cervical Cancer Early Detection Program or a grant by the Susan G. Komen Breast Cancer Foundation under its outreach program. Patients who do not qualify for federal or grant programs are treated free or billed at a reduced rate.

To avoid red ink, Imaging Associates needs to average $75 to $80 per examination. When he started the business Heilbrunn hoped to provide examinations for $55, but soon had to adjust his sights. Third-party insurers are now billed a global fee of $120, "but we usually don't see the full amount," Haworth says. However, the higher fees paid by commercial insurers help offset the skimpy technical and professional payments from federal sources.

There are two keys to profitability, and both involve achieving high volume and high productivity. "One is building a relationship with the clinic people who are doing your scheduling, so you are booked tightly," Haworth says. "Our technologists need to see four patients an hour if we are to break even.

"Some remote and low-income clinics tend to have a high no-show rate. The sites that we work with know what is normal for their practice and if they typically have a 50% no-show rate overall, then they will double-book appointments." Imaging Associates technologists, who are paid $27-$28/hour portal-to-portal, do not process the film. "We use our support staff for that," Haworth notes.

The second key to profitability is optimizing film interpretation. "We provide an environment for optimal visual perception and have someone hanging films for the radiologist," Haworth says. "Reports are prepared using a computer-assisted mammography reporting system where all the radiologist has to do is check boxes; he does not have to dictate every report. When a film is not routine, we fax the report to the clinic or referring physician. If a patient is a self-referral without a provider, Heilbrunn assumes responsibility for getting her referred to a specialist.

The result of these procedures and Heilbrunn's experiencehis annual database of more than 150,000 examinations ranks among the five largest in the country for a single radiologisthas produced a recall rate of only 3% and a proportion of Stage 0-1 cancers of 80%, he says.

Imaging Associates' administrative and professional efficiencies allow proportionately lower per case professional compensation. That, Heilbrunn says, is an essential factor in its financial viability.