by Jean Grillo

This article is from in the March 2008 issue of DOTmed Business News. A list of registered users that provide sales & service can be found at the end.

Normally, three's a crowd. But the trifecta of OEMs, refurbishers and broker/dealers is the engine that's driving the medical trailer business.

Among the fundamental economic conditions which the three have to cope with:

- Increasingly stringent installation and service demands by the OEMs manufacturing the imaging devices

- The pressure of DRA cuts on independent imaging centers

- Evolving imaging technology requiring highly specialized mobile transportation

- The hospital communities need to provide sophisticated and expensive technology in a cost effective manner, which often means sharing equipment with neighboring facilities on a rotating basis

- Export considerations

Trailers range in size from 53 feet, suite sized ones with slide outs and in some cases even hot labs and ready to receive a machine to those no bigger than a small camper. Fully equipped, brand new trailers set to house certified OEM MRIs or CTs can sell for as much as $450,000; smaller rv types for mammography and ultrasound, for example, are in the $100,000 plus category, with client specifications determining the final tab.

Such lofty prices have generated a growing specialty field of medical trailer refurbishing, creating a subset of companies, large and small, dedicated to rebuilding entire trailers or providing spot service, maintenance and repairing of individual components. Medical trailer refurbishers often rebuild trailers to house MRI, CT or mammography equipment, usually at one-third the cost of a brand new piece.

The new and refurbished mobile medical business is a bright growth area in an industry that's seen the equipment manufacturers sales slump over the past couple of years.

And despite economic pressures which force thousands of manufacturing jobs overseas, producing and refurbishing medical trailers is still mostly an American industry. The top four medical manufacturers, along with the fully certified trailer refurbishing companies, are US based, all in sprawling facilities housing their own welding, painting and air conditioning bays.




Oshkosh Specialty Vehicles, based in Harvey, IL, is acknowledged as the market share leader among manufacturers, with Medical Coaches, Inc., Oneonta, NY (the first and oldest), Ellis & Watts International, Batavia, OH and Calutech Medical Solutions, Hammond, IN the other major players.

Medical trailers aren't simply four-walled trucks with equipment inside. Technology's cutting-edge demands require interiors able to include onboard generators, water-cooling and air conditioning systems, fully contained lighting heating, computer workstations and storage. Because these mobile units, once parked, have to serve as stand-alone medical operations, steel and aluminum chassis must be first rate. Specialized shielding requirements based on the modality housed are another huge consideration wiring as is ensuring an area both visually attractive and medically efficient.

In addition, mobile trailer manufacturers must then pass muster with the top equipment OEMs who then certify, or not, the manufacturers ability to install MRI, PET/CT, mammography or other sensitive systems.

While several metrics exist for measuring medical trailer manufacturers such as volume of trailers made, plant size, numbers of employees, the key marker is OEM certification by GE, Philips, Siemens, Toshiba among others.

Getting certified is costly and demanding and means not only meeting all OEM requirements, but getting the OEM to agree that your facility is capable of doing the job. Each OEM has separate divisions that select which companies they want to handle installation and refurbishing.

Profiling the Trailer OEMs

Oshkosh Specialty Vehicles of Harvey, IL, a $140 million operation, was established in 1991 as AK Associates before merging with Calumet and Oshkosh. It is, the company says, the only trailer manufacturer certified to install all GE, Siemens and Philips MRI, CT, and PET/CT medical equipment in all their modalities. Over the years the company has developed an innovative water
chiller/air-conditioning system was the first to mobilize digital mammography vehicles, and is often the first manufacturer selected to install new equipment from a brace of the OEMs.

GE, in particular, has signaled that Oshkosh is their preferred installer for all of its mobile scanning equipment. According to Mike Bamrick, national sales manager, Oshkosh's certification track record causes some to believe GE only allows Oshkosh to install its equipment in trailers, even though that's not true. "However, because we are the only ones certified for every system, most people prefer us when having GE equipment installed." And he said, "We stand behind our product with the largest customer service and support team in the industry."




Oshkosh turns out 125 new coaches a year, 90 percent of travel to hospitals and medical centers in the U.S. Within its 110,000 square foot plant, 20 to 25 medical trailers are assembled at one time from the wheels up in about two months time, though special situations can also mean as quickly as two weeks. Oshkosh has its own welding team, electrical team, flooring experts, chassis and super-structure experts, painting bay and signage team.

Medical Coaches, which opened its doors in 1949 was built on the back is one of a large order to the Cuban government. Today, says it's the one of the top four offering a two-year warranty.

"My grandfather was a minister who helped people secure medical treatment," Geoffrey Smith, president, explains. "And my dad, Ian Smith, always wondered why someone didn't just put their medical offices on wheels. Medical Coaches, which he created, full-filled this life-long dream."

Medical Coaches has 200,000 square feet of manufacturing space at two facilities, 100,000 at its 95-acre Oneonta site, another 100,000 in Albany, OR. It is certified for Siemens MRI, PET/CT and CT, on GE's PET/CT (although not GE MRIs). It is capable of working on 10 MRI or PET/CT installations at any one time, according to Smith, who adds, "We also build a variety of other special purpose vehicles that are in production." Medical Coaches says it can turn-around a trailer in 30 days.

While Oshkosh is justifiably proud of its close ties with GE, Medical Coaches touts its history and custom design.

"What makes us different is our attitude toward our product," Smith says. "We began as a company that built its mobile trailers as medical trailers from the start. We don't (rework) over-the-road trailers."

Medical Coaches works closely with Siemens, GE and Philips. Smith says, "all mobile vendors must have certification to build specific products to receive support from the OEMs," since, "they've decided their equipment can only operate in a properly designed and tested mobile environment that is under their control."

Medical Coaches, like other manufacturers, does the entire installation of all OEM equipment, involving placing the modality unit in the trailer, bolting it down, running the cable required, and making the electrical connections. The individual OEM does the final calibration, turning on the equipment and calibrating and adjusting it so it works properly.

The company is rightly proud, Smith says, that it was the first trailer OEM to be certified through Lloyd's Register Quality Assurance Its resultant ISO 9001 certification, he says, is an internationally-recognized standard "that levels the playing field for smaller companies like ours to deal with the industry giants of the world." In that vein, Medical Coaches, which does not rent or lease its trailers, has scored sales in 110 countries.

Ellis & Watts Mobile Medical, located in Batavia, Ohio, installs MRI, CT, PET/CT, and mammography systems into trailers. E&W also builds and sells trailers for disaster recovery services, military and other equipment and other applications. E&W, in its 180,000 square feet of manufacturing space, also builds water chillers for use with medical equipment. In an eight-week period, E&W can build four trailers that carry some certification for selected modalities from the OEMs.

"We work with leasing companies, particularly those of the medical equipment manufacturers, to provide our customers with attractive acquisition solutions," says E&W's Bob Freudenberger. The company specializes in custom add-ons, including sinks, fire suppression systems, additional storage cabinets, different door configurations, and so on. E&W says its trailers set themselves apart from the competition as a result of attention to better environmental control.

Other E&W features: sliding doors that allow more interior space in the operator's room, lower compartment doors that last longer due to one-piece aluminum construction and durability because it uses more fasteners in construction. "When refurbishing E&W products, we also provide manuals, diagrams, and use genuine replacement parts," Freudenberger says.

While only about 10 percent of E&W trailers make it oversees, it's quite a different picture at Calutech Solutions, the newest of the mobile trailer manufacturers, which opened its doors having started in 2001 in Hammond, Indiana. More than half the company's sales are overseas. Particularly the Middle East and Europe.

"In 2005, we sold one mammography trailer to Saudi Arabia," says sales manager Michael Hardesty. "Since then, we've sold a CT to Russia and the UAE and have about 15 other leads overseas."

In fact, Hardesty's just back from Dubai, where Calutech delivered a mammography trailer at the Arab Health Show, attended by 50,000 visitors. Calutech also offers a two-year warranty,

Calutech can handle nine trailers in production at any one time, with five more in the wings outside at its 47,000 square foot facility. While Hardesty says the trailer company is number three in units shipped, "We are number one in mammography trailer sales." Calutech is certified to install some Siemens, Philips and Hologic equipment but is still working to attain certification in certain GE systems. "The key issue for all medical trailer manufacturers," Hardesty says, "is that the OEMs certify your installation." GE, for example, only provides warranties on mobile trailers it certifies.

DRA's Impact Affects OEMS, Refurbishers

All four trailer manufacturers note some impact from the Deficit Reduction Act of 2005, which took effect January 1, 2007. It mandates reductions in Medicare reimbursement for imaging at freestanding facilities and doctors offices, aiding the refurbishing end of the business by stimulating demand by hospitals left to absorb patients who once turned to independent facilities that have now closed.

Many agree huge savings can be achieved by buying refurbished trailers. But, Hardest cautions, "if you are a large image
scanning company, you probably would not want a fleet of used equipment because the downtime for repairs is greater."

However, as Medical Coach's Smith notes, "Good deals and good equipment are a profitable match that funnel funds to a seller for new upgrades and can offer high tech diagnostics for under-served areas of the country." On the other hand, Smith says, "Bad deals and bad equipment are a disaster because uncontrolled and uncertified refurbishers are rarely qualified to perform extensive refurbs."
Which is why, Smith says, "The industry has to have some form of self-regulation and so the top vendors are all certified by the top brand OEMs."


Refurbishers, Broker/Dealers Play Increasingly Important Role

According to a number of top mobile trailer refurbishering companies and equipment brokers, DRA's impact is mixed, though all the incentives are in place to encourage the growth of the resale of previously owned Siemens, GE, Philips and Toshiba mobile units. A refurbished medical trailer generally costs one-third the price of a brand new medical trailer so clearly, the financial differential tilting towards a pre-owned is huge.

How a trailer is refurbished plays a key role in both cost and quality. Not everyone has the space, skill, and expertise to take a used trailer and retrofit and then get OEM certification. While the companies that build new trailers must be certified by the OEMs before they are allowed to install its equipment, refurbishing companies are not. What the refurbishers rely on is quality work and strong connections with the four major mobile trailer manufacturers who can oversee an installation, once a refurbishing is finished.

It's important to understand the different roles played by refurbishers, brokers, and assorted other specialty sub-contractors.

A broker/dealer has, in the past, been credited with being the lubricant that allows for all parts of the business to function smoothly. Some dealers buy then sell trailers while brokers simply work the phones in order to put available buyers and sellers together. It's always important to work with a broker/dealer who understands trailer technology as well each modality's special transit requirements.

The increasing importance of online as a part of the equipment business has, however, modified roles somewhat, attracting a number of brokers in other pieces of equipment to adding a range of other products to their portfolio.

A "gut" refurbisher, as they are sometimes called, needs a huge warehouse site with room for separate bays to work on previously-owned Oshkosh, Medical Coach, Ellis &Watts or Calutech trailer. Such an operation normally has several trailers in different stages of retrofitting and often is large enough to have its own crews doing the gutting and the replacing. Smaller refurbishers will sub-contract work out while brokers will buy, sell and move various parts and pieces within a mobile unit.

Genesis Medial Imaging is one of the largest independent MRI/CT service companies in the country, housed on 40,000 square feet in Huntley, IL. Although it has only three bays inside, its staff of mainly GE-trained engineers has the capacity to store 25 trailers outside. Turn-around time is about two weeks, depending on specific client needs.

"All of our work is done in house, including heating, welding and painting," notes company vice president Ron Ragan. "We're all ex-GE guys, so we are able to install GE units." While not "certified" per se, Ragan says Genesis will send a trailer with newly installed equipment down to Oshkosh or Calutech for RF testing of MRI units.

Genesis also does a great deal of work for Siemens and Philips, including being one of the few Siemens has approved to do do-installs (removing Siemens equipment which is then stored with an option to buy).

"We are also one of the few medical trailer refurbishers in the country capable of working on the new 102 inch wides," Ragan notes. "Most used trailers are still the old 8 foot wide variety, but most of the newest medical stuff require the larger 8 and a half width."

Medical Imaging Resources, Inc., based in a 35,000 square foot facility in Ann Arbor, MI, has a fleet of 40 mobile trailers on interim and long-term leases, according to Jeff Rogers, director of sales, offering "custom mobile turnkey solutions for all modalities" including MRI, CT, Cath/Angio and Nuclear Medical Systems.

"These leases can go from two weeks to five years," Rogers says. "We'll refurbish from A to Z, soup to nuts, or do something as specific as taking a mobile with one popout and adding two."

While acknowledging the mobile market has been down for some, he says his company has enjoyed "double-digit growth." Among the reasons for this upturn, he suggests, is Medical Imaging's having 10 to 15 empty trailers in storage at any one time, ready for refurbishing, while also ensuring two or three "fully-refurbished trailers also always good to go.

"All our trailers are under OEM service contracts,' he adds. "And, as far as I know, we are the only company in the world Siemens allows to put its Sensation CT into a mobile trailer."

King Equipment Service, Waukegan, IL, is, as its name implies, one of the largest refurbishers in the business, according to Bill King, its president. King Equipment has a large facility with seven separate bays, and a full 15-foot painting booth. The company usually has five trailers undergoing refurbishment at any one time during the winter months, with six to seven in the summer, when
weather is not a factor.

"We have the capability to do virtually anything a trailer needs, including completely gutting trailers down to the bare walls and rebuilding them. We also reconfigure trailers for other purposes, an area where our company really stands apart. We have the ability (and frequently do) convert a MRI trailer for a CT, or a PET trailer for a CT. We install our own engineered slide outs in trailers, which facilitate cutting holes in the trailer sides, fabricating slide outs and installing them and making them work. We then do wallpapering, flooring, cabinets, and everything else required to make the interior new." All interior work is in house using 11 employees, all of whom are certified in every facet of repair and maintenance.

"We do our own fabricating, welding, air conditioning and electrical. We make our own cabinets, have a certified mechanic to overhaul engines, do brake jobs, repair generators, in short every task to make a trailer look new.

Ron Moore, owner of R&D Imaging, Inc. of Evansville, IL, has a smaller, more specialized operation.

His warehouse is 10,000 square feet and can presently refurbish about four mobile medical trailers a year.

Moore installs new carpet, new tile floors, new ceiling tiles and checks all the AC/heaters to make sure they work. He'll check the slides for water leaks and replace air bags and tires as needed. He'll check the hydraulic pumps and values to make sure patient lifts and leveling jacks work well. The entire process make take a few weeks to a month. While most of this servicing work is done in-house, Moore subcontracts out all the AC work and about half of the painting (interior and exterior). Generally, his company works with medical trailers housing CT scanners and MRIs.

Another important refurbisher, Mobile MedTech has two sites: 44,000 square feet in Cottage Grove, WI, and 15,000 square feet in Council Bluffs, IA. It employs about 20 specialists, working on two or three at a time. The company does its own welding, HVAC work, and some of the painting.

According to Paul Zahn, director of sales and marketing, Mobile MedTech, the company does both custom work for clients or refurbishes entire medical trailers for sale. With many former Ellis & Watts on staff, Mobile Med Tech specializes in MRI, CT and PET/CT installation in its refurbished trailers, which it also rents, and leases.

"The pros of buying refurbished equipment from Mobile MedTech is the quality of the work and the price," Zahn says who admits to no cons about buying refurbished trailers from his company."

In the end, it's nearly impossible to view the mobile trailer business without understanding how the three parts of it-OEMs, refurbishers and broker/dealers-are all interconnected, not to mention relying on each other to fulfill vitally important roles.

As healthcare rules and guidelines continue to evolve, most believe trailers will gain in stature as a key component in making imaging more readily accessible to the public.

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DOTmed Registered Medical Trailers Sales and Service Companies
Names in boldface are Premium Listings.

Domestic
Gus Antus, Ampro International, Ltd, AZ
DOTmed Certified
Hisham Showli, Philips, AZ
David Denholtz, Integrity Medical Systems, Inc., FL
DOTmed Certified/100
Dennis Giuzio, Mobile Radiology, Inc., FL
Dave Johnson, Genesis Mobile Partners, IL
Ron Ragan, Genesis Medical Imaging, IL
DOTmed 100
Charles Gauthier, Imaging Services, IL
William King, KING Equipment Services, Inc., IL
Ronald Moore, R & D Imaging, Inc., IN
Mike Hardesty, Calutech Medical Solutions, IN
Greg Kramer, C&G Technologies, Inc., IN
DOTmed Certified/100
Jeff Rogers, Medical Imaging Resources, Inc., MI
DOTmed 100
Todd Palmer, SVSR, Inc., NC
Geoffrey A. Smith, Medical Coaches, Inc., NY
Michael Dobbins, Mobile Conversions, Inc., OH
Fred Jackson, Custom Trailerwerks.com, OR
Peter Chen, Global Medical Equipment, PA
DOTmed Certified/100
KC Spurlock, Spurlock Vehicles, TN
Marshall Shannon, Image Technology Consulting, LLC, TX
DOTmed Certified/100
Glen Henderson, Mobile Specialty Vehicles, Inc., TX
Paul Zahn, Mobile MedTech, WI
DOTmed Certified

International
Mohmed Aljundi, Alnile Medical & Trading, Egypt
Harrison D'Souza, Hospper Tkp International, India
Anatoli Baulin, Russia
Gerard van der Loo, X-Way B.V., Netherlands

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