Mountain Kidney Associates

Situation

In the past, using diagnostic ultrasound to look at the renal arteries and track and monitor renal artery disease could not be done easily because of archaic technology. Prior to the evolution of Doppler, there was no sound, non invasive technique. And while medical literature would suggest that a nuclear scan provided a sound, non invasive option, according to Dr. Manley, doctors found it unreliable. And, of course, MRAs and MRIs are accurate, but very expensive.

"It was new and certainly not the norm," said Dr. Manley, referring to the early use of ultrasound to diagnose kidney failure. "And the quality of equipment then – we used an echo ultrasound machine – isn't what it is now."

So while Dr. Manley studied under experts in the field, he knew that improved technology would come and that would mean improved diagnosis. "I recognized there was a need and an opportunity to better and more regularly monitor these patients and ultrasound was the way to do it," he said.

Soon into his medical career, Dr. Manley discovered there were, indeed, vascular practices successfully pursuing diagnostic ultrasound. Dr. Manley then attended a vascular conference in Virginia and met Marcia Neumyer, a pioneer in the area of renal artery ultrasound. She is the head vascular tech at Penn State and an expert at interpreting renal artery ultrasounds.

Dr. Manley later coordinated a personal training session with Marcia Neumyer and then brought her to Mountain Kidney Associates to consult. After that, Dr. Manley was sold on the value of using ultrasound in his practice, and he developed a proposal outlining the financial implications of adding a renal ultrasound business to the practice.

According to Dr. Manley's conservative proposal, the practice needed to book 30 ultrasounds a month to break even and cover the cost of the equipment and the technician. In 2002, Dr. Manley bought an ATL ultrasound machine direct from the OEM and launched this business unit.

GMI Helps Support The Practice

This new practice area was off and running. And in 2004, GMI's Jeff Volpp approached Mountain Kidney Associates to discuss the value of leasing refurbished ultrasound equipment."

His proposal cut our costs by half and GMI provided us an iron-clad service agreement," Dr. Manley commented. He went back to the group to discuss the proposal – changing from an OEM was new and different.

The result? Mountain Kidney Associates agreed to trade in its current ATL machine and lease two upgraded ATL machines from GMI, along with the service agreement.

"GMI's leasing agreement works for Dr. Manley and his practice because the life of an ultrasound machine is so predetermined, so they are not paying on an outdated machine when they need to move on to another." Volpp said. And of course, savings in the leasing and service agreement means more revenues to the practice. "Using GMI, Mountain Kidney Associates has cut costs and increased revenues by 33 percent."

Today, Dr. Manley's practice sees approximately 1,000 consults annually and among that patient population, 20 to 25 percent have been identified as having renal vascular disease."With our new ultrasound practice, we've been able to rescue people from end-stage renal failure," said Dr. Manley."This investment has been more than worth it."

Looking Forward

If this is so beneficial to patients and doctors, why aren't more practices doing it?

GMI's Jeff Volpp thinks nephrology practices are not aware of the financial benefits of leasing refurbished ultrasound equipment for use in kidney, bladder, renal artery, vein and abdominal diagnostics.

"There is an incredible value opportunity for these practices to lease quality ultrasound equipment," says Volpp. "The key is securing a service arrangement that allows doctors to do what they do best – treat patients; and allows GMI to do what we do best – provide reliable equipment, value-added service agreements and experienced service technicians."

According to Dr. Manley, some nephrologists have never been trained in renal ultrasound and some don't realize they can do it. Well-trained vascular techs can get images and well-trained doctors can get really accurate interpretations. "Only three doctors in Mountain Kidney Association interpret ultrasound, but everyone in the practice utilizes the procedure," commented Dr. Manley. "It has increased my value to the practice and hence, my salary - by 25 percent."

And Dr. Manley also stresses accreditation by ICAVL, the International Commission for the Accreditation of Vascular Laboratories, is important.

But having proven and reliable equipment, along with consultative and knowledgeable service is also the key question. "There's no doubt having the latest ultrasound equipment and unmatched service of that equipment is critical to the success of this practice. GMI is a partner in that success." he said.

The Results

Since then, Mountain Kidney Associates has conducted about 2,000 duplex renal artery ultrasounds.

Today, Mountain Kidney Associates employs a full-time in its main office and a part-time vascular tech in a satellite office with plans for expansion.
The practice books approximately 5-7 ultrasounds daily on each of the two machines.
Approximate charge per ultrasound is $600 - $700, with a $350 reimbursement from Medicaid.
Ultrasound revenues in 2005 were over $400,000, with profits around $200,000. Dr. Manley expects revenue to increase by $300,000 in the next year.

"This has been a huge success financially, but more important it has been critical to our ability to serially monitor our patients with chronic kidney disease," said Dr. Manley.

Clinical Examples

Manley Case Study #1

Mountain Kidney Associates first saw Mrs. Jones*, an 80-year-old African-American, in October 2000. She was diagnosed with chronic renal failure (with a creatinine of 1.6) – etiology secondary to hypertension, plus or minus nonsteroidal anti-inflammatory nephropathy, plus or minus a component of renovascular disease. The nephrologists concluded Mrs. Jones could have possible renovascular disease, but felt the risks of angioplasty outweighed the benefits of correcting a possible renal artery stenosis.

In October 2003, after her first ultrasound at the Mountain Kidney Associates vascular lab, Mrs. Jones' renal function had worsened and she was found to have bilateral renal artery stenosis of >60% and her creatinine level was 6. The next day she had an arteriogram which revealed 80 percent proximal stenoses in the renal arteries bilaterally. Intravascular stent placement was performed and her renal function improved (creatinine of 1.8) and remained stable for six months.

In April 2004, blood work and lab work showed Mrs. Jones' creatinine had elevated to 4, showing marked renal function deterioration. An ultrasound study in May 2004 revealed restenosis of the stents bilaterally. A few days later Mrs. Jones underwent angioplasty of both stents and once again, her renal function improved. Since then, her stents have remained patent and her renal function has remained stable (in the 1.5 – 1.7 range). She is seen in the vascular lab approximately every six months to assess the patency of the stents. Thus far, Mrs. Jones has not required dialysis.

Manley Case Study #2

Mr. Reed* is a 67-year-old Caucasian first seen in the Mountain Kidney Associates office in March 2003.She was referred for evaluation of acute renal failure. Her labs showed her creatinine had jumped from 1.1 (in 2000) to 3.2. She was immediately scheduled for a renal artery ultrasound in the practice's vascular lab.

The ultrasound exam in April showed bilateral renal artery stenosis of >60%. This was confirmed by arteriography and bilateral stents were placed in the renal arteries in May 2003. Mrs. Reed's renal function has been clinically stable since that procedure and her most recent creatinine was measured at 1.5. She has been evaluated on a regular basis at the vascular lab and her stents have remained patent. Thus far, she has not required dialysis.

Manley Case Study #3

Mr. Brown* is a 43-year-old Caucasian with severe hypertension. He was referred to Mountain Kidney Associates' vascular lab by a cardiologist who, after performing on the patient a heart catheterization for coronary artery disease, suspected he had renal artery stenosis. The right renal artery was not well visualized during the procedure and as such, the cardiologist wanted a second opinion. A renal artery ultrasound revealed a bilateral renal artery stenosis of >60%.

This study is an example of a complete renal artery ultrasound performed in the vascular lab for ICAVL accreditation.

* Actual names were not used.