Todd Clyde
Analyst · Silk Investment Advisers
Yes, it certainly has an impact on both sides of the business, and I can kind of describe some of the general dynamics. If you look at the Affordable Care Act and the implementation of that act, there are required modifications in terms of reimbursement, there are standards of quality care that drive different perspectives in terms of how imaging is utilized going forward. That's a trend that's been going on for quite some time. But when we look at it from a high level, we would expect there to be continued downward pressures, both on kind of study volumes as well as reimbursements. And the reason that happens is just because, overall, as the baby booming population ages out and you have more people hitting these modalities, there's got to be a way to drive the kind of per-unit cost down. That doesn’t mean that you shouldn’t see some offset based on there being higher volumes. So that kind of happens in one scenario. Many physician practices have made decisions to kind of sell-out and align with hospitals. So there's many, many ownership modifications that are going on, either formally or some that are a little less formal. That can be in terms of true ownership, or it can also be accountable care organizations. That's a classic example of something that's inside of the Accountable Care Act, where you have hospitals and physicians kind of combining and grouping. And then, based on the population of patients that they serve, they then have kind of economic benefit and discounts that come back from, essentially, Medicare. So when you have all these relationship changes, like with large -- let's say a large cardiology practice, during those negotiating periods they're not buying assets and swapping in and out. And ultimately then the hospitals have ownership structures where they own not only imaging equipment in their own facilities, but they now own facilities that are usually within about a 35-mile drive radius of that main campus. And so they have now a larger group of assets that they’re trying to manage. So when you think about kind of a normal replacement cycle, it gets depressed, and it also ends up getting stretched because of these economic changes and general concerns in the healthcare market. And I think that's why you've seen a dramatic reduction over the last 5 years in the number of nuclear cameras that are sold into the general market. Where some folks are actually purchasing, like in a hospital setting they're buying a multipurpose spec CT camera versus necessarily a dedicated device. And that's because when they think about the uncertainty, they kind of say, I’m going to buy a more general-purpose device, whereas my cardiac volumes have come down a little bit or perhaps they're flat. I believe that, over time, that will kind of settle out and you'll get back to a replacement cycle that's a little bit normal that should be a higher level of purchasing than you see today. But that's going to take certainly a few years. I also remind you, Marc, that when a hospital purchases a facility, or a hospital -- or a physician practice that is within a certain drive radius, they're able to now shift the billing from the physician fee schedule in the outpatient setting to the hospital HOPS billing, which actually is a higher reimbursement rate. So that's another economic driver of why some of those combinations happen. And ultimately hospitals, if you think about their economics, by 2014, 2015, kind of in that range, they start to get hit much harder in terms of reimbursement with the implementation of the Affordable Care Act. And therefore, today, many hospitals are doing a lot of things to try to improve utilization, which is why they're buying practices, as well as kind of manage and reduce their cost infrastructure. And that ends up linking back their Capex budgets. And so, you have -- like in our -- in the case of our ergo, we have very little problem creating excitement and demand for the product, but when it goes into the budgeting cycle, as dollars get compressed down sometimes those dedicated unique devices end up getting trumped for that more general-purpose device. So there's lots of dynamics there and you kind of feel how it impacts the product side of the business. On the DIS side of the business, it's kind of interesting. We've had an increase in new business this year compared to the last couple of years. We've been able to help drive production activity on a per-day basis so that the economics are little more favorable for the physician. Sure, ASPs are absolutely down based on that severe cut back in 2010. But as a large practice gets bought out, if it's a 20-man practice, sometimes 2 to 3 physicians splinter out the back and form another small practice. And those end up being kind of natural consumers of a DIS services model. So that won’t last forever, but currently we're able to take advantage of that. So that's actually a positive. In the DIS business, the sustainable growth rate of the doc fix is still looming. That's for all physician fee schedules. Today it'd be about a 27% cut on all Medicare codes. That is scheduled to go back into effect on 01-01-2013. So of course it's been delayed for multiple years, but it still is out there. It's looming. Could you see, when you talk about like a new administration coming in and either trying to repeal Obamacare, there has to be something to replace that. Will there be trade-offs? You know, don’t know. But what we do see in that business is the ASPs are lower than they were certainly a handful of years ago. We work really hard to kind of drive and maintain the margin dollars. We've seen definitely some positive improvement this year. And we see modest growth in new accounts. We've been able to hold on to some accounts. But that business always has lots of business activities too. We know of a fairly large customer that will take some of the imaging in-house. This is actually a hospital in one of our areas. Like in the fourth quarter, right? So those things happen. So you work hard and you kind of replace. And you wonder why when you talk positively, why don’t you always have this massive growth? Well, sometimes there's changes where different groups decide to pull the imaging in-house or stop. So those are kind of the general overviews as I think about not only the -- kind of the Obamacare implementation, but there's also impacts of just kind of the economy in general, how patients interact and how they go in and to get healthcare today.