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Which C-Arm Should I Buy?

Today you can be faced with many choices when deciding to purchase a mobile c-arm. Although most are appropriate for the majority of procedures, some may be particular good for the procedures you perform. Of course, the first consideration must be financial. You certainly can't purchase a $150,000 unit if your budget is maximized at $50,000. Let's look at some of the choices.

If you have decided that you will only consider a new c-arm, the field is limited to the major manufactures such as GE-OEC, Philips, Siemens and Ziehm, all who produce excellent products. Also, secondary manufactures including companies such as Genoray and Comed, both Korean organizations with US presence who offer excellent products. Although you may not be as comfortable considering one of these products, millions of Americans now drive Hyundai's and Kia's – the reason is, they have a good product at a more competitive price that performs similar to its US and Japanese competitors.

These new full sized mobile c-arms range in price from $70,000 to $275,000. Your choices of features range from units that provide basic fluoroscopy for pain management procedures to units designed to accommodate cardio-vascular and/or neuro-vascular procedures. The new high end units are now equipped with flat panel digital detectors in place of traditional image intensifiers. View fields range from 9” to as large as 15”. Image monitors are also high resolution flat screens used in conjunction with high performance software. Obviously, as the features become more robust, so does pricing, therefore it is important to determine exactly what is required and how much you can spend prior to begin looking.

Models you may want to consider are the GE-OEC 9900 series, the Philips Veradis Neo, BV Pulsera and the BV Endura, the Siemens Arcadis line and the Compact L and the Ziehm Vision line and the Solo. The Genoray line includes the ZEN-2090 Pro and the ZEN-7000. Comed offers the KMC-950.

If you have decided that you do not want to make a substantial investment in a new system, you may want to consider a fully refurbished pre-owned unit. The truth is, not much has really changed with the c-arm fluoroscopy technology. You can purchase units produced in 1990 for a little as $12,000 or late model units built in 2008 for $90,000 and up depending on features and software. The only difference between these units is they may have CRT monitors, images may not be a crisp as a new unit but certainly adequate to handle most procedures. They either produce Dicom information or can be retrofitted with devices that enable both extended storage and distribution of both patient information and images.

There are many units to choose from. The most popular include the OEC 9800, OEC 9600, OEC 9400, OEC 9000, OEC 7700/Compact. The Philips BV Pulsera, BV Endura, BV 300, BV Libra, BV 29, BV 25. The Siemens Arcadis, Siremobil Compact L, Siremobil Iso-C, Siremobil Compact, Siremobil 2000. The Ziehm Quantum, Vista, Exposcop 7000, Exposcop CB7-D.

Choosing a supplier for a refurbished system may be almost as important as choosing the correct unit. Important issues include receiving a detailed proposal with specifications, having a tech set up the unit and provide training on how to operate it. Make sure system manuals are included, estimate for inside delivery charges and warranty information. Service contracts generally range from $8,000-$15,000 per year substantiating the value of the warranty coverage. Make sure the supplier provides a FDA 2579 form showing the system information to be provided for US, state and local regulatory agencies.

An imaging table may also be required if purchasing a c-arm for a facility that has not used a c-arm in the past. There are many different to choose from ranging from 4-leg economy tables to multi movement with diving board (cantilever) style top tables. These c-arm tables range in price from $2,500 to upwards of $35,000.

Lastly, it would be wise to choose a member of the International Association of Medical Equipment Resellers and Servicers (IAMERS) to provide your equipment. Members of this organization subscribe to providing quality products, honest representations while upholding the highest level of ethics and customer service. If you are considering a supplier whom is not a member, you just may wonder why they don't or can't participate? Not everyone can qualify and there are about 150 members worldwide.

Contact us for additional information.

Med Imaging System Sales       www.missales.com

NCD Medical Company             www.ncdmedical.com

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DR Digital X-Ray Prices Finally Low Enough To Compete With CR

Direct Digital Radiography (DR) traditionally have been priced so high that only large medical facilities could afford to install them. The alternative for digital x-ray output has been Computer Radiography (CR). Typically a new X-ray system equipped with two fixed DR detectors (one for the table bucky and one for the wall bucky) were priced in the $250K - $300K range. If you wanted to retrofit an existing system, you were faced with a expenditure of around $90K per DR detector. The logical alternative was CR. You could purchase a CR system for $30K- $90K and it could accommodate multiple buckys or even multiple systems.

Of course, when offered a less expensive solution, there generally are several downsides, and CR is no exception. The first and most obvious down side is throughput time. Whereas DR can produce an image in less than 10 seconds, CR needs to be manually manipulated which takes time. First the CR cassette/plate needs to be inserted into the bucky. After the exposure is completed, it needs to be removed, walked over to the CR reader and inserted in the reader . Within 30-60 seconds the reader will produce an image, then it will erase the image from the plate and then needs to be returned to the bucky for the next exposure. This process can take anywhere from 3-5 minutes, a far cry from the 10 second DR time. The second downside is that the CR plates have a limited life and after 1000-2000 exposures will need to be replaced at a cost of about $1000 each. The last and maybe most concerning downside is the dose requirements of CR. DR and even film require less exposure than CR, this could become a problem as x-ray exposure is continually being scrutinized by the FDA and ACR.

The good news is high performance DR is now available at prices which compete with mid range CR systems. As the price of DR contiues to come down and CR remains relatively the same, competion is becoming real. However, it's not just the price of DR that has reduced, but the application has become different. Instead of using two fixed DR panels in a system, many facilities are opting for one portable DR detector. The least expensive is the tethered detector which has a cable attached that can allow it to me moved from bucky to bucky without plugging in or unplugging the cable, it simply stays with the panel. Starting at $55,000, this solution is much faster than CR, is less expensive than a high end CR and about the same price as mid range CR. The alternative choice is a portable DR with a wireless detector. This solution is similar to the tethered DR detector but with no cable. It can be moved from bucky to bucky without moving a cable with it. The wireless DR subsytem begins at about $69,000 again competing with hgh end CR.

DR systems - fixed, tethered and wireless - have pretty much the same compoents - DR detector(s), PC console worksation, acquisition/manipulation/viewing software with full Dicom capability as well as full workflow interface capability, including PACS, RIS, HIS and EHR.

The good news doesn't stop with fixed x-ray systems. Portable DR is the main component of portable digital x-ray. The pricing to retrofit a portable x-ray unit with a tethered or wireless DR system is pretty much the same as for a fixed system. A portable x-ray unit can be upgraded to Tethered DR for about $55,000 and to wireless DR for about $69,000.

The question is will CR go the route of Beta video tape and DR become the VHS of the digital diagnostic imaging world or will they both remain viable in their particular applications?

Contact us for additional information.

Med Imaging System Sales       www.missales.com

NCD Medical Company             www.ncdmedical.com

For More Information About Digital X-ray Imaging go to   www.digitalx-ray.info

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Demand For Diagnostic Imaging Systems Growing Rapidly In Africa, The Middle East And Eastern Europe - Will The Systems Be Purchased?

The demand for medical facilities and related diagnostic imaging systems is growing at a tremendous rate. There is a strong need for x-ray and fluoroscopic systems as well as CT, MRI and ultrasound systems. There is an adequate supply of used and/or refurbished systems world wide to meet the demand, however there are two major problems – available budgets and distribution sources. Although it appears funding is becoming more available, little can be done to improve funds availability.

The real problem lies with the growing number of potential suppliers in these areas. Many inexperienced players in Africa, the Middle East and Eastern Europe also have recognized the potential of this growing market and are attempting to jump in and become suppliers. Unfortunately very few understand the systems, the market or the concept of sales. They believe a sale can occur if they identify a general need, inquire as to what general equipment is available inexpensively and then present this inexpensive solution regardless if it accommodates the buyer's specific need. Generally, what then occurs is that the buyer lets the sales representative know what he has offered is too expensive and doesn't meet requirements that were not discussed previously in detail.

The reason the system and application were not discussed in detail initially is that the sales representative is not familiar with the application or system and therefore cannot discuss the details associated with the requirement. We get many inquiries from representatives from these areas. Their initial request is usually so general, we cannot offer a response. For example, a request will be “Please send price for an x-ray system CIF Nigeria”. This is like writing, “Please send price for a car CIF Nigeria”. Without make, model, year, features, condition and available budget, we have no idea of what is required and unfortunately neither does the requesting sales representative. He simply spoke with a physician at a medical facility and the physician indicated they needed an x-ray system and they had funds. The sales representative immediately runs out and begins emailing resellers around the world, hoping to identify a system he can purchase inexpensively, inflate the price drastically and then sell to the medical facility. He cannot discuss the details of the x-ray system because he knows nothing about x-ray systems. He believes if enough resellers provide him systems to offer, he will present them and his prospect will purchase one allowing him to make a handsome profit. He is hoping, like a novice car salesman, if you put enough cars in front of someone they may buy one eventually.

As diagnostic imaging system resellers, we continually receive these inquiries from international agents attempting to sell equipment. But as soon as we respond back and ask for specifications, application details and/or available budget, most disappear. Solving the problem isn't that difficult. First and foremost these representative need to learn and understand basic sales. The key to working with a legitimate prospect is communication. If the representative is able to engage in a dialogue where his prospect will discuss details of the acquisition, then the chances of making a sale increase significantly. The most important questions are: When does the system need to be delivered? Is the funding available now? How much is being budgeted for this purchase? If the prospect won't or can't answer these questions, then he won't or can't make a decision to purchase. A lot of time will be wasted and most suppliers like ourselves will not respond with an offering because we are also convinced a sale will not occur. There is no reason to get into a discussion about system specs or applications, if the prospect won't discuss basic purchasing information.

Let's assume for a moment that the prospect has cooperated and provided delivery, funding availability and budget information. How do you now engage in a discussion about technology, applications and system nomenclatures of which you are totally unfamiliar? There are a number of general questions that can help you understand what is needed. Age – how old of a system will they consider purchasing? Used systems can range in age from 5-25 years old and most facilities have a threshold as to how old of a system they will consider. Features- what specific features are required? Often facilities want to have certain features that are important to them. High powered system, digital system, analog (film) system, etc. Preferred manufacture – like GE, Philips, Siemens or that's not important. Condition – as-is in good working condition or fully refurbished or new, each has its own price level. Shipping – air (fast and expensive) or sea (slow and less expensive), import clearance and destination ground transportation.

If the majority of this information is obtained, the chances of a reseller working with a international agent will increase significantly as will the chances of a successful sale occurring.

Contact us for additional information.

Med Imaging System Sales       www.missales.com

NCD Medical Company             www.ncdmedical.com

White Paper

INTERNATIONAL MEDICAL MARKETS

I recently received an email from a physician in India. He had been residing in the United Kingdom for several years and had returned to his home land. He contacted me because he was interested in developing a new business of selling and supporting pre-owned diagnostic imaging systems to facilities throughout India. His email included details of how he intended to develop this business in a rather lengthy dissertation and he wanted me to send him a catalog with pricing of the products we offer. Frankly I was amused at his misunderstanding of that market, the products and the competition. My point is that international markets are difficult to comprehend even if you reside in the market you are selling to when you are offering imported products. I introduced him to several Indian associates and provided some incite, but better yet, I developed a friendship with a person I have never met or have spoken with previously.

The world healthcare markets are developing rapidly and many systems are being imported from the United States, Australia, Europe and Japan by countries in the Middle East, Asia and Africa. Many developing countries in Africa are extremely interested in acquiring pre-owned x-ray, CT and MRI systems. Many of the organizations which require systems have very limited budgets and therefore rely on older systems from the US. Although they prefer to have newer systems, their budgets dictate 10 years old or older systems. Single slice CTs, low frequency x-ray systems and low strength MRIs are common.

There are many difficulties encountered when dealing with international transactions. The most obvious is communications. Although most buyers are able to communicate in English, often their English is rather difficult to understand clearly. This is not a criticism, it is just not their first language. The next hurdle to overcome is getting the prospect to communicate the required information. Often we get inquires requesting a price for a CT. This is like asking for a price of a car. Without knowing the preferred make, model, features, year and budget – it's impossible to provide pricing. The most important information is the budget, because regardless of what is preferred, only what is affordable can be considered. However, many international buyers believe that if they share what they are willing to pay, the price will be raised to match that amount and they will not be offered the lowest price available. They don't realize that weeks could be spent discussing details and availability of specific systems only to find out once everything has been agreed to that the system agreed upon is not within their budget. It is much easier to first establish the budget and then back into the most appropriate solution.

Like most buyers, international buyers are price sensitive. They believe that by identifying every available system reseller and pitting resellers against each other to achieve the very lowest price, that they will successfully purchase at bargain basement prices. Often they do, however more often, they purchase systems in very poor condition because there is a reason for the low price - poor condition. Although without question, price must be a prime factor in making the purchase, there also must be major consideration for the condition of the equipment. Of course cheap is good, but if the system is not functional or has limited features or requires extensive ongoing support – in the long run, it's not really cheap.

Once a sale has been consummated, other difficulties begin. First payment terms. Payments must be received in advance by electronic bank wire transfer. Credit cards, company checks, letters of credit are no longer safe means to obtain payment. Larger transactions will often be structured with a deposit payment with the order and the balance payment prior to the system shipping. Payment terms are relatively straight forward, shipping is another issue. The first step is to crate the equipment to provide maximum protection, being careful to have enough cushioning within the crate to prevent the objects from moving and/or being raddled around and creating damage. The equipment must be weighted and transportation arranged. The key to a smooth shipment is understanding the required documentation to export from the US and the correct documentation so the shipment will be allowed to be imported to the country of delivery. Generally, most shipments are allowed to leave the US if a commercial invoice and packing list is provided by the shipper. Import customs is usually not as easy. Documents of origin, engineering certificates, shipping declaration, safety documents and authentication certificates notarized by the country of import's Consulate in the US are just some of the documents that may be required.

International sales appears to be complicated and difficult, and many believe it's not worth the effort. However, as the US dollar continues to lose value, US products become more attractive to international buyers, creating demand for pre-owned diagnostic imaging systems and many other products. The world is an extremely large market and offering products to this market may have become one of the most important factors in increasing business and reducing the US trade deficit.

If you have concerns or questions about any of the issues discussed, don't hesitate contacting me, as we are involved with these projects continually.

White Paper

How To Safely Buy Pre-Owned Medical Systems

Very often there is a need to acquire additional capability in our health care facilities but there isn't always the funds to purchase a new, full functioned, state of the art, diagnostic imaging system. Therefore, a decision must be made to determine if the additional services can be shifted to another facility or if it is critical or at least necessary to remain at your facility. The decision usually comes back that it needs to remain and options to accommodate it must be considered.

The first activity is to investigate potential solutions starting with new systems that deliver latest technology and extended functionality. Inviting manufacturer's sales representatives in usually begins the ball rolling. Generally, long meetings full of important facts about the capabilities of their systems help make you familiar with what's available and what it costs. Once the sticker shock subsides, you must now determine which of the features and functions discussed are absolutely necessary to carry out the application testing you need to accommodate. You probably will determine, in most cases, that basic functionality will be very appropriate to accommodate your requirement. For example, after investigating a 256 slice CT scanner's additional functionality and its cost, you may determine that a 16 slice unit would work quite well. But you also know that 16 slice technology has been available for some time and your budget is quite conservative (small). Therefore, you make the decision to investigate both new systems and pre-owned systems.

The first step is to re-contact the manufacturer's sales representatives and determine what the cost is for a new unit of older technology or if it is even still available. Now the sales people will be concerned you made this choice to move down to this older technology and probably won't offer any encouraging incentives unless you re-consider a more recent vintage, or they will claim these systems are no longer available and they will only be able to provide a price on a 32 or 64 slice system. It is at this point you decide that you will need to consider a pre-owned system, but how do you begin? You have heard horror stories of shady brokers who have run off with facilities money, delivered something totally inferior to what was ordered, or delivered systems missing components and requiring tens of thousands of additional dollars to complete the project. So where do you start?

The first thing you might consider doing is visiting the International Association of Medical Equipment Resellers and Servicers (IAMERS) web site. The organization was formed in the early 90's with the task of establishing a membership of companies committed to providing exceptional medical equipment, that maintained the highest ethical standards, and were willing to commit to being evaluated and monitored by its governing membership. Additionally, the organization is in continual contact with the FDA establishing important rules and operating procedures consistent with government policy. If you are considering acquiring pre-owned medical equipment, a quick visit to the IAMERS web site will provide you a list of companies that will provide a broad choice of available systems. Go to: www.iamers.org.

Choose several potential providers and give them your choice of system to be acquired. It is important to share with them as much information as possible to save time and money during the selection process. They should be aware of the preferred manufacturer (ie. GE, Siemens, Philips, etc), the model, the basic system functions, any options, required delivery date, and most importantly the amount budgeted for the system. Many organizations are hesitant to share available budget on concerns the supplier will move his sale price up to match the budgeted amount. This is silly. You will have multiple suppliers quoting and all interested in obtaining the business. They will be very aggressive to win your business, which means big-time competition. Also, why have a supplier spend the time to locate and offer you a $400K solution when you only have $250K to spend? As soon as you share with him your budget, he will undoubtedly share with you whether you are in the ball park for what you want or if you need to rethink what you are able to afford.

Once you have identified a supplier that can provide the preferred system, make sure you have considered all costs associated with the project, such as the cost of removing an existing system. Many times you will be able to have the system removed at no charge in trade for the system, or sometimes it may be a negotiated trade-in value, and other times it may be an out-right sale to the supplier or another third party. Room remodeling may be sometimes as simple as a new coat of paint or as involved as installing, shielding, changing power, installing new cable troughs, changing HVAC, lighting, flooring and/or the control room. The system supplier should provide detailed drawings indicating system location and required resources to successfully install the system. You need to consider access paths for the removal of old equipment and delivery of replacement equipment. Narrow hallways, tight corners, steps, ceiling heights, elevator capacities, door openings and truck docks (or the lack of) all need to be considered. Timing is usually critical. If you are removing an older system before installing the replacement, you are going to be without a system for as long as it takes to remove the old system and remodel the room. Schedule all activity and be sure the building contractors selected can meet the desired schedule. The supplier should provide in-service and/or application on-site training of the operation of the system. Lastly, you should identify a local service support group (it could be the manufacturer's service group or a third party group) who will offer an on-site system service contract once the suppliers warranty has expired.

Although the project may sound complicated, your organization will probably realize a savings of 50% or more and will have substantially increased capabilities. Most of the project activity is required whether you purchase new or pre-owned, so be prepared and tackle most of the things I addressed regardless of what you purchase. Although you can do more than one project at a time, you may want to limit yourself to one at a time unless you have a qualified staff to take on some of the tasks.

If you have concerns or questions about any of the issues discussed, don't hesitate contacting me, as we are involved with these projects continually.