David: 0:01

Could smarter imaging strategies be the hidden superpower benefits advisors need to win more clients? We'll find out on this episode of Shift Shapers.

Announcer: 0:12

This is the Shift Shapers Podcast. Connecting benefits advisors with thought leaders and entrepreneurs who are shaping the shifts in the industry. And now, here's your host, David Saltzman.

David: 0:25

And to help us answer that question, we have invited back one of our favorite people, Dr. Cristin Dickerson, who's founder, managing member, and CEO of Green Imaging. Good morning, Cristin.

Cristin: 0:37

Good morning. Excited to be here.

David: 0:39

Well, thank you. Thank you. The last time we had you on was March 15, 2021. So a lot of stuff I'm sure has changed. And yeah, I know, time goes by. But let's let's start at that jumping off point. So since that last conversation that we had back in March of 2021, how has the independent imaging market evolved? And let's look at it in maybe three phases: patient demand, pricing transparency, and competition from hospital-loan facilities.

Cristin: 1:08

You know, uh it's changed dramatically. And uh the first is patients from just a patient standpoint. From a patient standpoint, access is a problem. There are a couple of things going on. Number one, you may go to an imaging center and you may expect to pay what you paid three years ago. And that imaging center still has the same name, but it's been acquired not as likely by a hospital system now, but by private equity. And meanwhile, the price has tripled overnight. The contracted rates have tripled overnight because they're aggregating contracts. And it's likely that they're split billing with a radiology group as well, because the radiology groups are also private equity-owned and want to control their own money. So you may have a surprise bill coming as well. So that's the likelihood from a patient. Also, it's harder to access imaging. 2021 was a tough year because of COVID as it was, but really prior to COVID to now, access to imaging is very difficult.

David: 2:12

So it's gotten worse?

Cristin: 2:13

It's gotten worse. It has gotten less. Getting contrast or getting a procedure done that requires a radiologist on site is very, very limited and difficult. Number two, there's a radiologist shortage nationally, just like every other kind of doctor, but particularly radiologists, because we had a brilliant um Nobel Prize winner who uh 10 years ago said that radiologists would be um, you know, obsolete by now, and radiologists' residents stopped going into radiology. And they thought AI was going to be replacing radiology, and he has retracted that now, but it's not without doing tremendous damage to the field.

David: 2:57

What about pricing transparency? Has there been any improvement there?

Cristin: 3:01

I can usually find one or two facilities in a metropolitan area that have some pricing transparency. It's terrible with hospitals because you would have to know all of the CPT codes. You know, typically it's not just one CPT code that is built with an exam. Often there's a contrast code or some other supplies. And frequently it's also going to be an outside radiology bird that reads the study. So when you get a good faith estimate from a hospital, you're getting typically one CPT code, the main CPT code, and there's going to be a footnote that says other codes may apply. And also that this does not include professional services. So you're really getting a tiny fraction of what you might expect to pay.

David: 3:43

Oh, fun and games, fun and games. Well, you alluded to COVID a little while ago. So during the pandemic, you know, imaging volumes dropped, I'm sure, significantly. How did you guys rebound and what lasting changes do you see in either patient behavior or referral patterns as a result?

Cristin: 3:58

Um, I think, you know, things, yes, especially in Texas and Florida, which are our best, I would say, you know, most populous states for covered lives, um, that we were limited to what was called essential imaging, only uh imaging that, you know, couldn't be uh avoided. Screening was out. So we were at about 50% capacity as a company. We took that as a challenge to become stronger. We did not lay anybody off. We put everybody on special projects trying to, you know, build out the network because at that time there were challenges with somebody's tech would go out sick or their kid would be sick, and you know, we wouldn't have CT scans at the site for a month. So we really built out a much more redundant network and we just built out a lot of projects that helped automate things in the back office. I never want the front office to be automated. That's real people taking care of people. But we built out a lot of um back office automation that I think has really made our company um much, much, much more frictionless.

David: 4:58

You know, we're having that same conversation with some of our clients. You know, that everybody's AI this and AI that. You know, you can buy an AI toaster and an AI blender. And, you know, I try to tell folks, you know, we won't ever do that on our front end because we prefer to use the other AI, which is adult intelligence. So you get, you know, actual human beings. It's always, you know, it's always it's great that we've got AI, but you ever notice that all of the satellites and whatnot that are looking for intelligent life are pointed away from the earth? Just an observation, but you know, so you you took it as a go ahead.

Cristin: 5:28

When Brene Brown brought this up at a conference last week. Um, you know, it's humanity now that's gonna be the differentiator. And we've taken humanity out of our lives a lot, especially the business place. And so really restoring humanity and trust, I think, to the healthcare equation is essential.

David: 5:45

You know, it's interesting because all of the folks who are building AI are of the opinion, at least for the next five, 10 years, that the best use of it is going to be AI alongside human beings. Right.

Cristin: 5:56

And I for for radiology reporting, same thing, and that that was ultimately the uh the conclusion there is that you know, it radiologists are not going to go away, they're just gonna be better.

David: 6:09

And nothing wrong with that. So you again, something else that you touched on in one of your earlier answers. The federal price transparency rules for hospitals went into effect in 2021. So from from where you sit, have those rules made any meaningful changes in patient choices or employer strategies around imaging?

Cristin: 6:28

I think there are, you know, I never want to throw everybody in one bucket. I am working with a number of hospitals, especially in Texas, who see the opportunity to work with us as an opportunity to provide transparent pricing. And we, you know, we are gonna offer a bundled price for their services and we're gonna read the, you know, we're gonna have our radiologists read it. Um we get around the exclusivity with the radiology groups because we do a lease arrangement with that hospital. So there's no, and and they're right, you know, typically their radiology groups will not give them cash rates. Um, you know, they're not compliant with that. And so we really give them the opportunity to do that. So I don't want to throw the baby out with a bat moderator, but nationally, not only are is there a lack of transparency, you know, there's this good faith estimate that's a tiny fraction of what people are going to pay. Um, it's hard to get those. They make it as difficult as possible. And they're not honoring those if the patient has insurance. So even if the patient is coming, you know, through us with, you know, the employer is going to pay for this on their behalf, which is under the HIPAA omniscience law, that's completely legal. They are illegally going into the patient's record. This they use scrubbers, which are is a software that goes in and looks for that kind of information. They find the patient has insurance and then they won't honor that price. And we fight that, our our legal team fights that almost on a daily basis.

David: 7:53

Uh and that's the subject of a whole other conversation. And maybe we'll have that one day soon. So, to the advisor side of it, um, have you seen advisors and even employers being more proactive about steering members towards um more independent centers for cost and quality reasons?

Cristin: 8:12

You know, I really have. I've seen even um brokers with the traditional brokerage houses are they're coming our way or their employers are coming our way despite them. And so, you know, I would say the biggest change I've seen David since 2021 is the size of our groups. I would say 2021, it was 50 to 200 was probably the average growth. Um, two years ago, it was probably 500 to 2000. And now we're probably on average at 5,000 or more.

David: 8:48

Interesting. Do you do you attribute that predominantly to cost differentials, or is there also a patient satisfaction metric that figures in there?

Cristin: 8:57

You know, it the city of Plano in Texas, um, that they have a wonderful um lead for their health plan. And she's an ex-CFO, which if that gives you some perspective. What she said was at the Houston Business Coalition on Health panel that we were both on. She said, we brought green imaging in to solve a cost problem that we knew we had. We ended up solving an access problem that we did not know we had. And so I think it's more with these larger companies, it's as much about access as it is about cost. And when you know you look at these national coalitions, they're quoting their employers as saying they're mem, they're spending as much on their members being away from work, trying to navigate the broken health system as they are on the healthcare itself. And so I think when we can correct that by providing these people access, getting their appointments scheduled for them. They're not hanging on the tub for two hours. They're not going through the traditional authentic process that may take a week. When we're getting them the care they need when they need it, that's a game changer.

David: 10:03

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Cristin: 11:38

It is because my background is with multi-specialty groups. I spent the first 13 years of my really the first 20 years of my career totally with multi-specialty groups. And I think that is a tremendous way to practice medicine. You know, the doctors would bring the patient down to the radiology department and say, she hurts right here. And it's amazing how much more you see when you know exactly what's going on. And there's no ICD 10 code that says she hurts here. There's just no way to do that. As many ICD-10 codes as there are. And so it was a great way to practice medicine. Um, I have tried to reproduce that in the digital world. Um, we have what we call a navigator portal now, where and it's mostly it's as many, you know, that we have these nurse navigators that are using it, and that's fantastic. We have a lot of DPCs, a lot of direct primary care doctors and other doctors for referring our way that have complete access to our team and to me and to anybody they need at Green Imaging via this portal. They can search by CBT code and price and find a study. They can submit the order, they can tell us in a narrative way what we need, and they've got my phone number. And so I strongly feel, as does my partner Craig Cook, who's also a radiologist, that our availability to clinicians, and that was one of the things that, you know, was not factored in in radiologists going away, and is that we're the doctor's doctor. We're the ones who help them figure out what's going on inside of their patient and tie things together. And, you know, it's our knowledge of kind of that crosses all specialties that really makes us different than a lot of other physicians. I think pathologists are somewhat in that uh realm as well. It's the same kind of thought process, but we're really diagnosticians. And so I really try to foster that digitally. I will say that telehealth has decreased. There's a good American College of Radiology study that shows that telehealth has decreased imaging orders and not in a good way. People are getting less, they're going on antibiotics without the chest x-ray to see if they have an amemia because telehealth, it's inconvenient for those doctors to receive an imaging report. They don't have management for that. I'm seeing more and more of them reach over our way to try to solve those problems. But it really created more of a problem than it did a solution initially.

David: 13:59

Interesting. We touched on AI earlier in our conversation with regard to radiology, both for diagnostics and we talked a little bit about workflow. What's hype? What's real, and how are you guys approaching it?

Cristin: 14:13

Um the hype is that you know, I actually had an MSK company say they were just gonna use AI to interpret their MSK exams. That's hype. That's not gonna happen anytime soon. If you're doing that, you're gonna move, you know, you're gonna miss the lung tumor that's over there next to the shoulder. And it's just never gonna happen because those solutions are built to solve one problem, not the all-encompassing patient and patient experience. Um, so I think you know that that's the hype, the good things that are happening. I'm using a tool that actually organizes my radiology report. So I don't have to take my eyes off of the images. I'm scrolling, I'm looking at the images, I'm saying what I'm seeing, and it organizes it. I don't have to go find those fields. Those fields are already there in my, you know, it's not like I know the order in which they go, but it puts them in the right place and I'm not scrambling my eyes back and forth from two different, you know, on two different screens. I think that's a wonderful thing. Um, you know, and I'm very careful to make sure it's working properly. Um, I think some I'm seeing reports that indicate that some radiologists are not, but you know, that's that's certainly my responsibility. And the other thing that I see is there are some technologies that are enabling us to take kind of a traditional exam and turn it into a population health exam. For example, we have um the opportunity to turn any CT, any body CT scan into a bone density exam, uh quantitative bone density, which is better than DEXA, which is kind of the gold standard right now. Um if it's a chest CT, I can also do a calcium score CT evaluation, which is the best predictor of cardiovascular risk for a human being. And then I can also do a cardiac chamber size, which is kind of an epicardiogram. It's not an equivalent, but it's a it's kind of a screening epicardiogram. And being able to get those three exams from like one screening chest CT is an amazing thing to me and a true game changer for population health.

David: 16:15

Interesting. Now, you know, every time you and I see each other at a meeting, there you're surrounded by a bunch of agents and brokers, and they they love what you do, and you guys make it very easy and very accessible. So I'm interested since that slowdown, you know, the COVID slowdown, what have you learned about working with benefits advisors and TPAs that help them build stronger value props with their employer clients?

Cristin: 16:38

Um, I think I became an advisor through the Foundation Institute training as an advisor in the Health Resetta um program and really came to understand health benefits plans. And um, you know, I think that gives us a tremendous leg up. We know how to work with HSA plans, um, we know how stop loss works, we know um we have the institutional knowledge now that you know an a very advanced program direct contracting would have. And I think that has been a game changer. I can really help them problem solve. Um and also I think we offer wonderful tools for sales for advisors. If they can just get a de-identified census from an employer, we can show them, both on a histogram and a map, how close our imaging sitters are to their employees. If we can get the claims data, we can do a claims data assessment and actually show them, rebundle the prices in the claims data and show them the comparison of what the savings would be, even after the employer offers it at zero out of pocket. And finally, if they don't have access to claims data, which is more frequent than you would think, um we have reams of claims data from across the country, different networks, different industries, and we can typically provide a sample for them of what the savings would be.

David: 17:55

Are you seeing any new plan designs or employer contracting models emerging that have made it easier to integrate high quality, lower cost imaging into benefits packages?

Cristin: 18:06

I think these new health plans that are DPC-centric, especially that are advanced primary care centric, are a wonderful market entity because I think it looks more cohesive to a member to have a plan with this name, whether that's Curative Santa, whatever it is, um, to have a health plan, I think that makes a difference instead of 10 different stickers. I as much as you know, we love working with other best-in-class solutions and we work cohesively with it, it may not seem that way to a member who's getting this independent TPA benefits card with 10 different QR codes on it. So I really think these health plans that are, you know, working with best in class solutions are a great market addition.

David: 18:59

Looking ahead, what do you see as the biggest opportunities for independent imaging over the next three to five years, especially where employers and advisors are all facing renewed cost pressure? And frankly, the medical trend numbers that I'm hearing for this coming year are just breathtaking.

Cristin: 19:14

Right. I think the independent imaging centers and the office practices especially are locked in at terrible reimbursement rates. They are at reimbursement rates that are not sustainable. They are going to, if they don't make changes, they are going to be bought up by private equity. There is just, you know, I have a friend who sold out to private equity at wonderful imaging centers in Houston. He said his EBITDA tripled under their contracts compared to his. That's irresistible. How can you, you know, not change things and do that? So I think if they really want to stay independent, and I urge physicians across the country to stay independent, you know, this this change is not going to happen without that and without them. But the ones that want to stay independent need to get, you know, get aggregated. You can't do it alone. Get aggregated with people with green imaging and with everybody else that is, you know, looking for direct contracts for imaging and get better reimbursement. You can get it. The differential is so high between what's in the claims data and what you're getting paid. Let us pay you better and keep you independent. And that's that's really what needs to happen.

David: 20:25

So, one last question as we wrap up. If if we were to talk, let's fast forward five years from now, what do you hope to be able to say about how independent imaging has reshaped healthcare delivery in our country?

Cristin: 20:37

Um, I I want to see them succeed and have the um have the resources, you know, kind of no margin, no mission, the resources to employ these things that make a difference in population health. Not things like whole body MRI screening, which take us from, you know, we're down at the millimeter level now with with breast imaging, with traditional breast imaging and with colonoscopy. We're detecting things at the millimeter level. You go back to whole body MRI and you're at the centimeter level. That makes no sense. And so I really think it is giving them the margin to invest in the technology that makes them exceptional and maybe better than hospital systems. Um I think people are looking, individuals are looking. You know, so many people on health shares in this country, so many people uninsured in this country. And I think people are looking for good health care that they can rely on and that's going to give them information to be healthier people. And I think, you know, investing in these AI tools, you know, we bring those to all of our imaging centers. All of our imaging centers can launch these AI tools that I'm talking about through us. You know, I think really um taking the time to look at population health, what's emerging out there, what people want from their health care, and answering that question and giving yourself the margin to do that is super important. That will be success for independent imaging centers.

David: 21:59

If our listeners want to reach out to you to learn more about what you're doing or how they can interact or bring what you guys are offering to their clients, what's the best way to find information or to get in touch?

Cristin: 22:09

Best way to get in touch is through me. It's DRD, drd at greenimaging.net. Dot com will take you to Canada.net kiks you in Houston.

David: 22:19

Good to know. Kristen Dickerson, founder, managing member, CEO of Green Imaging. Doc, thanks so much for another great interview.

Cristin: 22:27

So fun, David. Good to see you.

Announcer: 22:32

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