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1,400 Clinics And 300,000 Lives: How One Texas Radiologist Built A Coast-To-Coast Patient-Centered Imaging Network With Transparent Prices


Guest: Dr. Cristin Dickerson

Narrator (00:00):
Welcome to 360 degrees of healthcare with Dr. Stan an in depth. Look at our industry from our very own chief medical officer who will talk with other medical and industry professionals on the changing and evolving landscape of the healthcare system from the inside, and now live from zero studios, our very own infectious disease expert, Dr. Stan Schwartz,

Stan (00:29):
Welcome to 360 degrees of healthcare. My name is Dr. Stan Schwartz. I’m an internal medicine and infectious diseases physician, my lifetime roles as med student, resident, physician, practicing physician clinic, administrator, and now consultant. And co-founder of zero digital health enterprise has given me a 360 degree view of medicine that I hope to share with you. And trust me, getting older also teaches you a lot about healthcare. My guest today is Dr. Cristin Dickerson. She’s the and CEO of green imaging, which is a unique coast to coast network of imaging centers. And I think we’re gonna have a really interesting conversation today. If you’re listening live, please use the Q and A button at the bottom of your screen. And we’ll try, try to get to any questions that you may have. I need to start with the disclosure zero works with green imaging, but we’re not here to talk about that. We’re here to talk about the, a remarkable journey by a remarkable individual who made her national aspirations come true and how she overcame obstacles in her way. Sometimes obstacles that may have been intentionally placed that in her way. So Dr. Dickerson, and thanks for joining us today, let’s start at the beginning. You worked as a diagnostic radiologist for 13 years in a group setting in which you also had some administrative responsibilities. What happened during those 13 years to spur you to build an independent national network?

Cristin (02:00):
Well, I went to diagnostic clinic of Houston straight out of, of residency because I never wanted to deal with the business of healthcare. I just wanted to practice radiology and the great irony there is that within about six years I was president of the clinic. Um, what had happened is we found a box of the tickets that we used to charge for our hospital care. That the, the time that I was a away from my family nights and weekends, that the hospital wasn’t providing us the demographics for. So we couldn’t bill for it. And that changed my tune on the business of healthcare.

Stan (02:38):
When did you get the notion to start to branch out on your own and, and go independent?

Cristin (02:43):
Well, I built the, the digital, I, I, I created a digital department for the, you know, the, the digital technologies were coming out for imaging, such that, um, we were able to do voice transcription rather than have traditional transcribers. Um, we were able to put in PAC systems, we were no longer on film and suddenly our six radiologists seven radiologists were too many. And so I started actually a radiology group at that point in time. And then when the clinic decided to go with a hospital system, uh, we went a different direction and started our own radiology group. We stayed in that multi specialty, um, setting, um, mostly, but, you know, we, we did, um, move across and I, I did really start my own practice at that point in time.

Stan (03:28):
So how long did it take you to go from zero to 1400 clinics in your head imaging centers in your network?

Cristin (03:35):
Um, you know, I founded green imaging to almost 10 years ago. It’ll be 10 years ago and two months. And, um, it was really as a self-pay network. What the problem I saw in our community was that we had 21% uninsured and there were no affordable cash pay rates. The cash pay rates were set for the international visitors to the Texas medical center and all of the outpatient imaging centers that were in that, or were purchased, gobbled up by hospital systems. And we were left with these out of network imaging centers, uh, that had, you know, that, that were basically taking huge sums of money for imaging. Um, and so I was going to open my own imaging center, but by the time I looked at a proforma, I wasn’t gonna be able to do it any less expensively. So I got the idea Travelocity and some other models like that were evolving. And so I got the idea to tap into the unused time at the existing imaging centers. Uh, radiologists can do lease arrangements, lease that, um, that unused time and pass the savings along to, um, patients. And so it took us, it’s really taken us 10 years to get to this number.

Stan (04:41):
Do you own the clinics that you, the imaging centers?

Cristin (04:46):
No, I did up until three months ago, I did own an MRI center. Um, but we, and we were offering a $250 MRI, but the cost of healthcare have gone up so dramatically during the pandemic that we found that to really continue to operate, that we were gonna have to go up to the same pricing as the centers that, you know, we are contracted with in the area. And so we decided to put our focus more onto our national network and we let that facility go.

Stan (05:13):
So you mentioned that you initially started out being a resource for people that couldn’t afford traditional care because they didn’t have have insurance. I know now you work with a lot of employers. When did that shift take place and why?

Cristin (05:27):
I had always seen the potential because when I was president of diagnostic clinic, I was running a self-funded healthcare plan and we incentivized our employees to use our own services. We pulled everything we could out of the blue cross blue shield plan to hold down our premium. And so I always saw the potential for it to be a, um, you know, a preferred imaging network for employers, but it really couldn’t get anybody’s attention until maybe five years ago. We started getting some TPAs interest. I think when people started becoming functionally uninsured, they ha they’re paying so much for a healthcare plan, um, that has such a high deductible that they can’t afford care. I think that’s when the tide really turned. And, um, the, the, both the employers and TPAs and cost containment companies started reaching out to us.

Stan (06:17):
Are you, do you participate in many of the, you know, the big Buka plans, blue cross Aetna and so forth? None. No, no

Cristin (06:25):

Stan (06:25):
No more. Do you take any insurance?

Cristin (06:28):
We deal with, you know, self-funded healthcare plans. Um, we do deal with some non-traditional insurance companies, uh, some defined benefit plans, some DPC based, um, insurance plans. You know, we, we’re always looking for innovation and new ways to, to try to make it better.

Stan (06:47):
So DPC for our audience that may not know the lingo is direct primary care. So do you see many people who just come to even pay cash cuz they can’t afford their deductibles and out of pockets?

Cristin (07:01):
Well, I see a lot of there is more and more consumerism and I see a lot of people finding that the con it it’s like the good RX card. A lot of times, if you have a traditional insurance plan, you can still do better. Then your copay by paying the good, good RX price. We’re the same way we have at the $325 MRI in Houston. There are very few imaging centers where you can get your contracted rate, be below that. And so people, if they’re not going to reach their deductible or don’t plan, you know, don’t think they will reach their deductible. They’re basically self pay patients.

Stan (07:35):
So tell our audience, how do you provide a $325 MRI scan? And let me couch that in saying, you know, I did a bunch of analyses for a company today and we saw MRI scans from 3000 to $6,000 for things that are just a few hundred dollars at your place. How do you do that

Cristin (07:58):
Number for way we did, it was as radiologists, typically an imaging center will contract with a radiologist to provide an interpretation for a flat fee. The imaging center pays me for the interpretation and bills globally. We flip that upside down. We buy the scan from the imaging center. We in at a discount, we interpret it and we build globally. And so I’m making my money, you know, by interpreting the exam. That’s, you know, that, and that’s the model that radiologists have used for years where it’s not possible geographically for us to get that arrangement either we don’t have enough cover lives in a region or it’s, you know, their radiology groups with exclusive contracts. We serve more as a traditional network, but we really love the, the model where we’re looking at those imaging. We’re making sure the right radiologist reads the study and we’re in total control where we don’t have that. We still, because we’re radiologists, we have peer review access to the images and reports. So if there’s ever a question of quality we can get in there and make sure that things were good.

Stan (09:05):
You mentioned in a past conversation that we had, that you really help employers fulfill what you call their fiduciary responsibilities that their Alliance have to their covered members. Can you tell us what you meant by that?

Cristin (09:19):
Sure. I have, I have a great case study. That’s actually validation Institute validated about school district of Oola county, um, just south of Orlando. And, um, that school district in Casem, um, had 10,000 members in the health plan and they had a three, $3,000 deductible, $6,000 out-of-pocket maximum, which meant that once they hit that deductible, they were still having to pay. I think it was 30% of the care, um, all the way up to that $6,000. So these people were paying 20% of their income for this policy. It just didn’t, they weren’t able to afford care. They were functionally classically function, Leon uninsured, and the teacher’s union went to the school board and said, you gotta do your fiduciary duty. You have, you should be overseeing this plan. This is these teachers money. And you have a duty just like you do to their 401k to make sure that, you know, they have affordable options and quality options for healthcare. So the school district put the Rosen health center, um, in place at zero out of pocket as the near site clinic and put green imaging in at zero out of pocket, the school district and the, um, the employees themselves save 1.5 million in 2020. And this year we’re on target for 2.2 million in savings.

Stan (10:32):
Is that the same Rosen as in the Rosen hotels?

Cristin (10:35):
It is. And there are client as well.

Stan (10:37):
Wow. I mean, he is legendary in the world of business coalitions as setting a standard for what employers should do to provide healthcare to their employees.

Cristin (10:48):
It, I, two weeks ago I was there at the Rosen health center and it was so exciting to see what they’re doing down to the fact when they, when they dis they dis they have their own pharmacy. When they give their employees, their medicines, they’re in a pill container laid out day by day, hour by hour, whatever it is, um, nursing mothers, they, they, they own breast pumps and they provide those to the nursing mothers. It’s just an amazing place. They, uh, they do everything they can to, to be innovative and provide better care for their employees.

Stan (11:22):
You know, I, I, when the object is to provide better care and not to provide the lowest cost care, it really makes a difference in the way employers think

Cristin (11:30):
It’s a paradigm shift.

Stan (11:32):
So, you know, as we, we go around and we talk with employers, the one thing that they hear from the incumbent, so to speak is that, you know, these imaging centers, they really can’t compete with the health systems. A couple reasons. Number one is they don’t have to specialize radiologists. You know, they talk about, they have the neuro radiologist, the orthopedic radiologist, the Euro urology radiologist, and that the small imaging shops don’t have them. And the second thing they say is that the small imaging centers just use hand down equipment that comes when the, when the big hospitals replace their MRI with one that’s more capable and they sell off the old one. It’s the small shops that buy those. What are your comments about that

Cristin (12:21):
Couple of different things? Number one, it’s usually the same radiology group that’s reading for the hospital systems and the outpatient imaging centers. You know, we have in-house radiology, um, cuz we’re radiologists owned and operated and we have all the subspecialties we’re all the four full-time radiologists are also all MD Anderson, trained, um, radiologists. So we have the same background as those hospital radiologists. Um, as far as the equipment, it does vary and we’re, we are, I would say one of my great hopes for I is we actually beta tested subtle Mr. Um, soft AI software. That turns a 1.5 Tesla magnet. It, it actually improves the image quality, but the bigger thing is it decreases the scan time because it’s the computing power. That’s actually, uh, the difference in the old or, and newer, um, some of the software, but they get software upgrades, but the computing power is usually a limiting factor.

Cristin (13:20):
And so these new, a I’m so hopeful that we can hold down the cost of imaging dramatically over the next couple of decades with AI software, why do we have to replace a super conducting magnet? You know, that, that makes no sense. Um, it should be that we change out the software and upgrade the software and you know, don’t have to re you know, even the, the machine may cost 1.5 million, but then you gotta rebuild the room for another half, a million million, you know, the, the, the mathematics, the economics of that don’t make sense anymore.

Stan (13:50):
So AI artificial intelligence, what does that mean in interpreting an MRI scan? Does it mean you guys don’t have to read ’em anymore?

Cristin (14:01):
No. Um, there are, there are, you know, very interesting emerging technologies. Like I said, I I’m most hopeful about the equipment, but they’re great things that are happening. Um, at the interpretation level. Some of them are very relative to triage and in a hospital system where you’ve got trauma patients. And so it can pick up a pneumothorax, it can pick up a bad pneumonia, it can pick up something that looks suspicious for tuberculosis or air freer in the abdomen. You know, there are specific, um, software that are, can pick up those things and get those to the top of the radiologist list. And that’s, what’s really, I think, um, being most utilized right now, I saw a great, um, piece of software recently that I’m contemplating rolling out to my employers because they’re looking at the long term health of their employees, not just the short term, that’s just takes a non-contrast chest CT and looks at the lung per it looks at, you know, grades, fibrosis, and emphysema and, you know, scarring, um, especially post COVID.

Cristin (15:02):
That’s gonna be important. It looks at cardiac chamber size, coronary artery, calcium. Um, it looks at aortic all the major vessels in their size is it looks at, uh, breast density. It looks at bone density. It assesses so much of health risk. You know, it’s kind of the chest is kind of the, the conduit to the rest of the body. And it, it just assesses so many risk factors that I’m really interested in seeing if that can’t benefit our health plans. I try to read a CT that way. Anyway, when I’m reading for the Rosen center or school district Ola county center, I’m always looking at those, you know, if there’s a little bit of wedging of a thoracic vertebra, I’ll report that and say, you know, if this patient hasn’t had a recent bone density exam, let’s get that in place. Just, I, I read differently for these and, and I, I try to do that across the board, but I know these people are looking for those items that need, you know, that really impact long term care.

Stan (15:57):
You mentioned, uh, CT scans and lungs. You know, one of the things I’ve been reading in the medical reports is that, you know, emergency rooms are using CT scans to rapidly assess whether a patient is likely to have COVID or not sometimes even before laboratory work had come back. Can you tell us about that?

Cristin (16:16):
You know, it’s been very interesting because when we start, I started seeing the reemergence of abnormal chest x-rays actually, you can do it with a chest x-ray as well. The CT is, is, is more sensitive, but I can’t tell you how many COVID cases we’ve caught just with a screening chest x-ray, um, and definitely there’s a diagnostic appearance, um, on, on a chest CT. So, you know, and then the other issue is you can pick up, you know, if you do it properly with the right technique, you can also pick up the pulmonary Oli that have been so debilitating for these patients.

Stan (16:48):
Yeah. Blood, blood clots in the lungs, and these folks that get excessive blood cloting are around the body. So in the short period of time that you’ve gone from zero to 1400 clinics, you must have made ruffled a few feathers along the way, and displeased a few people. What landmines have people left for you? What torpedoes of people launched against you since you started and have any of those been related to your being a female entrepreneur?

Cristin (17:20):
You know, I think I am of a female of the age where that has not been a factor. The females 10 years older than me in the practice at diagnostic clinic definitely, uh, were impacted, uh, by prejudice. I have found it probably to be an asset. Um, I think I’m, I’m not very threatening to people hopefully. And, um, you know, I really try to go in, um, and address pain points, uh, with my imaging centers. I say, look, I’m gonna bring you no patient bad debt. I’m gonna pay you fast and I’m gonna give you clean orders. And I try to address pain points. You know, the hospital systems, um, expressed a lot of, um, displeasure and know kind of, um, threats that we, we weren’t gonna have the quality. We weren’t gonna be able to, to serve people as well as they did. Well, let me tell you, we have a net promoter score of 85.6, which, and we’re doing that while we’re changing the way people are practicing healthcare, we’re disrupt, we’re disrupting their typical, you know, healthcare highway.

Cristin (18:29):
And yet we have that net promoter score. So I think we’re proving that we can do this. I think we’re proving that we can provide it with good quality. And so, as that happens, you know, the most beautiful thing that happened in Orlando was suddenly we were the best referral source in the region for em, for the outpatient imaging centers. And they, they opened into their doors on Saturday and Sunday for, um, imaging for our patients. It just, you know, and we have this, you know, they’re like, what else do we need to add other modalities? We have another big chain of imaging centers that said, okay, where else do you need centers? So, you know, once you get that flywheel turning, it’s amazing, the momentum you can pick up and to the energy you can pick up along the way and the enthusiasm, you know, I think we try not to, we, we try to, to build bridges and we try to bring out the patients, the employers, the community, you know, the community healthcare providers.

Cristin (19:23):
I try to be really great if it’s not ordered from the Rosen center, but by a specialist. And there’s something abnormal. I’m gonna pick up the phone and call doctor. I wanna prove that we’re providing great care and I, and I wanna provide great care more importantly, but we really try to go that extra mile because if, if we don’t, you know, there’s a long history of one call in us imaging and P you know, networks that tried to do this. And, you know, one call turned into 10 calls and, you know, us imaging only offer CTS MSS and pet CTS, which is, you know, a small fraction of the exams done, um, in a health plan. So we’re really trying to do it better and do it right. So there’s not that criticism of quality or any question of that,

Stan (20:07):
Where are you not currently located? And where do you think you’ll be expanding? And a second question on that is, are all the imaging centers you work with? Are they branded as green imaging?

Cristin (20:21):
No, they are not branded as green imaging. So it, it would be similar to Travelocity in that model and, but a patient. So the patient, the younger patients, the patients are tech savvy actually can take a snapshot of their imaging order and their benefits card, text it to our main number. And then within a couple of answering a few screening questions, they’ve got a voucher for their, um, exam. They have the, you know, the address of the facility. They have the name of the facility, they know where they’re going, time and data, the exam, any prep for that exam. And so they’re well prepared. We, we really try to prepare them for the fact that it’s not gonna be this sign. It’s not gonna say green imaging. Now there’s usually a green imaging sign at the desk at the imaging centers with our phone numbers.

Cristin (21:03):
So if there’s any confusion or problem they can call us. Um, and as far as our distribution, um, we are picking up some groups in Alaska. So that’s soon going to be on, on our list. Um, the Northwest it, where the there’s not as a great population. Density is really where we have a dearth of centers, a few Midwestern states, but mostly the Northwest. And we have a large number of health sharing ministry patients coming in from those areas that we will soon have on our heat map and be able to, we no longer build out our network until we have covered lives, cuz we’re just not able to leverage good pricing. So we just shop for care for patients in those areas.

Stan (21:43):
What do you do for people who are, whose tech savviness, uh, includes thinking a fax machine is modern,

Cristin (21:51):
Right? Um, we have a warm person on the phone ready to go so we can accept. You know, the other thing is that the is the fax machine. And so many orders are faxed from a doctor’s office from their EMR. We accept those, we reach out to the patient directly. Um, but it, I would say 80% of our patient and use the texting feature along the way.

Stan (22:12):
Do you get many calls from radiologists who wanna work for you?

Cristin (22:15):
We do occasionally. Um, it is definitely a different model. I think that’s as, and as we get into this era of private equity backed radiology, super groups, I think that is going to be, you know, I think there may be an opportu. I, I never thought I wanted to grow the radiologist business again, but I think there may be a huge opportunity for reform there because I think what we’ve seen is in the claims data used to be about 22% of the global imaging spend was at the professional fee. I just got a set of blue cross blue shield, large set of blue cross blue shield claims data. And it was 45%. So these private equity groups are looking at all those old contracts and billing under the quote unquote best old contract. And so the cost of outpatient imaging, you know, for it, it has long been cheaper than hospital based imaging, but as these groups split bill and, you know, start working with these outpatient imaging centers, it’s, it’s driving up the cost of care.

Stan (23:12):
Will that work in your favor going forward?

Cristin (23:16):
I think it probably will. Um, I, I, I believe that we, you know, we do have long term contracts. We ask for long term contracts from our imaging centers. And so they are in, at these, you know, competitive what are gonna be more and more competitive rates. So I do think it will, will help us. I always, I also wanna pay them fairly, you know, if they need more, I mean, I can tell you, you know, from experience it’s more expensive to provide care. Labor is expensive, we’ve got more turnaround in our workforces and all of those things drive up the cost. So I don’t want to be a hard liner either and them not want my patients. We wanna be the best referral source.

Stan (23:55):
What’s been the, what tectonic shifts in healthcare. Do you see as, as having the greatest influence on green and in the next five or 10 years, and how does that affect what the future holds for you?

Cristin (24:11):
I think the reform based, um, benefits advisors, um, for example, health, Rosetta, ascend, um, benefits pro to a degree, you know, some of these big groups of benefits that are trying to put solutions in place and really change self-funded healthcare, um, plans for the better and make them look long term and look for solutions that better serve their employers. I see that as the saving grace of American healthcare, and I’m actually going to an event this weekend in DC, kind of a think tank to discuss how start to get, you know, to get this more widespread. Cuz if that happens, we can then change government healthcare plans. They can follow these same models. Then we get down the cost of care and then we really can provide everybody catastrophic coverage at some level who needs it.

Stan (25:03):
So two last questions I have for you. What’s been the was gratifying, a satisfying part of this jury.

Cristin (25:11):
I would say the most gratifying, um, thing was going last week to the Rosen health center and real. And we stayed at Rosen shingle Creek and met the employees and saw what a difference we make, um, in their lives. And, and, and the people we work with, you know, during the pandemic, um, Kenneth Aldridge who runs the center and I worked to get all the women who had had abnormal screening mammograms, um, and didn’t come back for their diagnostics. We actually went in there, made phone calls, messaged them, got those employees back in. So that, to me, just that working and I come from multi-specialty background, I always loved that, you know, working with the clinicians and trying to provide the best care. That’s the fun part of this is that it’s getting back to my roots and multi-specialty care and making sure, you know, everybody’s working together for the better good of the patients, not these silos we’ve had going on in the past couple of decades.

Stan (26:05):
One thing you mentioned was mammograms. One thing thing I’ve seen is that a lot of independent, it seems like many independent radiology centers don’t provide mammograms cuz they don’t have the full buffet of breast services. How does that affect you?

Cristin (26:21):
It is it it’s a little more difficult. Um, it, it is very, very bureaucratic. It is. I, you know, having run some breast centers and, and that was really my niche. Um, in most of my practices, it, the CME we have, that’s required of that, the documentation, the, the monitors that are the specs for the monitors, you can go buy something at Costco that’s better than the medical grade monitors, but we’re still required to have these and have ’em tested. There’s a lot of bureaucracy and a lot of things that drive up cost of mamography. And so the average outpatient imaging center doesn’t wanna deal with that. Now I, there are a lot of them that are specialty centers and boutique centers, and I think that’s actually a nice atmosphere for women to, to get their imaging. And so we do work with those. Sometimes it is a challenge, but there are also OB gen practices that often screening mamography. So we’re frequently able to start there and then get them to a boutique practice. One of the interesting things though, is that, you know, it has been shown that although thought that 3d mamography was going to quote unquote, save money because fewer callbacks it’s actually driving up the cost of care, um, without, you know, a huge return on, um, impact on long term effects of breast cancer. So that’s gonna be an interesting, everybody has one now though. So we’re stuck. It’s kinda like the three T MRI.

Stan (27:47):
Yeah. One interesting question for you. So radiology used to be x-ray films, recycling, silver, and now it’s, it only involves electrons and photons and there’s only nothing to recycle. Why are you called green imaging? If there’s no recycling?

Cristin (28:08):
Exactly because we are we’re paper free. We are filmless and, but more importantly, we save money. So

Stan (28:18):
If someone were interested in or has an order, who’s listened to this podcast who has an order for an X or Ryan, they were interested in learning more, where would they go?

Cristin (28:28):
They can take a picture of their order and text it to 7 1 3 5, 2, 4 91 90. And they will be answered by one of our concierge staff and, uh, can have their questions answered and get pricing if, if we’re in their area.

Stan (28:44):
And do you have a play on that?

Cristin (28:47):
We do www.green imaging.net. So green imaging, all one word do net.

Stan (28:56):
What do you see yourself doing in 20 years?

Cristin (29:00):
Oh goodness. Um, probably this to some degree, um, you know, as Enoch entrepreneur does, I have to make myself, um, you know, make the business run so that I don’t have to be there. And I’m, I’ve hired a COO and I’m working on that, that duty to my business, but I love the creativity of doing this. And uh, to some degree I hope to, to always be involved. It’s a, it’s a family business and I have, I have a son I think someday could, could take it on. So

Stan (29:28):
Interesting. You still like what you do

Cristin (29:31):
Love what I do get my sister works with me as well, and we say we’re so blessed. We get up every day excited about what we do.

Stan (29:38):
Great green imaging, not net. If anybody is interested with that, we’re about run out of time here. Dr. Dickerson. Thank you so much for joining us today. I’d like to thank anybody who’s listening in for, uh, joining us. I’d like you to stay healthy and if you haven’t taken the COVID vaccine, please sit down with your physician or your healthcare provider and have a good conversion with that. We hope to hear from you next month. Thank you.

Narrator (30:05):
We hope you’ve enjoyed the time with our very own doctor Stan for 360 degrees of healthcare with Dr. Stan Schwartz, a part of zero studios tune in subscribe and review our podcast to keep current with the ins and outs of the medical and healthcare industry from the inside out.

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