In this episode of Healthcare Americana, Christopher Habig is joined by Dr. Cristin Dickerson, founder of Green Imaging, to discuss the innovative world of direct care and its intersection with transparent, affordable medical imaging. Dr. Dickerson explains how Green Imaging was founded to solve the problem of unaffordable imaging in her community and how it has expanded to provide savings and improved quality in employer health plans. Dr. Dickerson also highlights the importance of transparency and quality in healthcare and the impact of Green Imaging on the direct care movement. She discusses recent legislation in Texas that allows for more flexibility in healthcare plans and shares her insights on future challenges and opportunities in the industry.

Takeaways

• Green Imaging was founded to solve the problem of unaffordable imaging in the community by using untapped resources and offering savings through per click lease arrangements.
• Green Imaging has expanded to provide savings and improved quality in employer health plans by customizing solutions based on the specific needs of each employer.
• Transparency and quality are key factors in transforming the healthcare industry, and Green Imaging is leading the way by providing affordable imaging services with high quality.
• Recent legislation in Texas, such as House Bills 711 and 2002, has allowed for more flexibility in healthcare plans and has sparked interest from other states.

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[INTRODUCTION]

Announcer

[EPISODE]

Christopher Habig

Hello and welcome to Healthcare Americana, where we explore the frontiers of healthcare, bringing you insights from the leaders and innovators reshaping the industry.

I'm Christopher Habig, CEO of Freedom Healthworks and the host of Healthcare Americana. And in today's episode, we're diving into the innovative world of direct care, as always, and how it intersects with transparent, affordable medical imaging and how we bring in employer benefit plans into a larger industry. Joining us is Dr. Cristin Dickerson, founder of Green Imaging and a very active member of the Free Market Medical Association out of the Houston chapter.

Dr. Dickerson, welcome to the show. It's a pleasure to be speaking to you again.

Dr. Cristin Dickerson

Thanks so much. Excited to be here again and catch up. Lots happened over the last few years.

Christopher Habig

A lot has happened the last few years. I always get a chance to run into you at LikeMinded conferences. And I can't believe it's already been nearly two years since you're on the show. Last just for the audience's benefit. It's we had a great episode really diving into Green Imaging and really the nuances of your business model and really your motivations for starting that I do want to give today's listeners just a quick synopsis of what your day job is on the Green Imaging side. So give us

that quick elevator pitch and well maybe not that quick but very long elevator ride of Green Imaging just to bring us up to speed.

Dr. Cristin Dickerson

Sure. Well, I founded Green Imaging 13 years ago to solve a problem in my community, which was there wasn't affordable imaging. The hospital systems had bought up the imaging centers that were operating in network. The handful of imaging centers that I was reading for as an outpatient radiologist, I was running a radiology group, were operating out of network. And so patient...

responsibilities were super high if they went there, if they went to the hospital, they were paying several thousand for an MRI. And so decided to solve the problem, went out and did a proforma to open an imaging center, and I was gonna have to charge what everybody else did. And so, Travelocity and a lot of...

models that were using untapped resources and to offer savings were emerging. And it turns out that radiologists are allowed to do some things with imaging centers that other physicians cannot because we're not referring physicians. We are considered consultants, we are reading physicians, and we're not, you know, an order has to come from some other doctor for me to read an exam. And so we're able to do per click lease arrangements.

And so I was able to use the network of facilities we were actually reading for as radiologists by extra time on the table at a discount, flip imaging on its head where the imaging center typically bought the interpretation from the radiologists and build globally. We bought the scan from the imaging center and built globally. And we were able to really provide savings. But it turns out that it's not a problem unique to Houston. And...

I really had run a self-funded healthcare plan as president of a big multi-specialty group in the Texas Medical Center. I knew that direct contracting could do what we're seeing in our ecosystem now, where we're not just providing care to individual patients at a savings and improve quality, we're actually offering it in employer health plans. And so seven, eight years ago, we started contracting with TPAs and with employers.

Dr. Cristin Dickerson

And as we did that, it really became clear that we needed to be national. And as of beginning of last year, about 15 months ago, we are in 50 states. We...

Christopher Habig

All 50, all 50, got them checked off. I hope you had a big party about that because it's somebody that's hard to do. Not not a lot of companies actually want to do business in all 50 states.

Dr. Cristin Dickerson

Right. There are a couple of them we would almost rather not. Now, we only employ people in Texas, I will say that, but we do provide imaging in 50 states. And actually the malpractice coverage for that was astronomical. That was one of the big barriers. The other big barrier has been really cybersecurity. We're aggregating data, you know, employers' data in a way that a traditional network doesn't. You know, they are not aggregating the images and reports and everything else.

So that's the other big thing that has been a big expense for us is actually doing the SOC 2, type 2 audit and making sure we're totally compliant there. That doesn't protect anybody as we know from recent news.

Christopher Habig

At the time of this recording, yeah, exactly. OptumRx got hit pretty hard with some malware hackers. I'm not even sure what's going on there. So that's when you, as soon as you said that, my eyes kind of went big. I'm like, oh, all right. Even the biggest pharmacy in the country, one of the biggest pharmacy providers in the country just got hit and breached.

Dr. Cristin Dickerson

Right, and to change healthcare, which is actually providing the entrance verification for some Optum users

Christopher Habig

Optum's got their hands in everything these days. But what I love about Green Imaging is, you know, from our standpoint, from a national direct care network and community of physicians, imaging has always been something that's been very localized, or even I'll say, like a kind of a regional type of service where we got to do a lot of homework and go out there. But being able to look at Green Imaging and be like, oh, look at this. All 50 states. It's it really changed the landscape of the imaging industry,

and originally from my standpoint, took it out of the hands of the hospitals and then really took it out of the hands of these regional players. But you're still playing very nicely with those hospitals and with the regional players. These aren't, you know, just to cut to what you said, these aren't Green Imaging standalone centers that you're building. So when you when you talked about capacity and untapped capacity, I think that's the big revelation that I want to make sure listeners understand.

Dr. Cristin Dickerson

Yeah, and you know, actually the hospitals, we actually provide a great solution for hospitals right now. Number one, their radiology groups are not wanting to play nicely with bundled pricing. They're private equity backed largely and they're wanting to split bill where the patient gets a surprise bill at the end of the year. And also they have a problem with rising out of pocket costs and patients inability to pay their portion, the patient responsibility for the exam. They're sometimes collecting.

you know, nine to 26 cents on the dollar. And we can solve both of those problems. Our lease arrangement makes it possible for us to read the studies. They're not the hospital's patients. They're actually Green Imaging patients. And so, you know, we're leasing the time at their facility and so we can get around the exclusivity clauses. And then also we're gonna pay them, you know, a fair price and pay them promptly and there's no patient collections or insurance verification, no same day second exam discounts, you know.

We try to solve, I've owned five imaging centers in my career and I try to solve the problems that those imaging centers have.

Christopher Habig

In a broad manner speaking, you know, in the healthcare landscape, we hear a lot of criticism. It's opaque. There's no transparency. There's too high a cost. Nobody knows what the actual price is.

I look at Green Imaging as one of the beacons of success. I was about to say hope, but it's not even hope anymore. It's actually proven success that you can have a model in healthcare dealing with very sophisticated machinery and very educated and highly trained individuals, but you can also put a fair price on there and run a successful market based business. So what impact has your approach in Green Imaging

had on the overall direct care medical movement.

Dr. Cristin Dickerson

You know, I really thought that we, you know, I've always built Green Imaging to be something that could see succeed just based on quality. Because my thought was that transparency, the transparency laws, the transparency movement, the competition was going to make a more even playing field. And we really haven't seen that happen. We still focus on quality, because someday it is going to happen. But and not just

That's not the only reason we focus on quality. We focus on quality because that's what's important. But, you know, a high quality at a fair price is something that we're still struggling to find in the markets. The imaging centers themselves, the individual ones don't want to put their pricing out there because they're afraid that the bookers are going to use that to negotiate down their contracted rates.

And some of them are starting to establish, we're seeing some self-pay pricing, and it's usually very fair. Medicare pricing has, imaging has taken the past 20 years, cut after cut after cut to offset increases in E&M reimbursement. And I think it's $211 now from Medicare for an EMRI, which is not sustainable. And it's really, a patient can hardly walk in the door for that.

with helium shortages, labor shortages, all the things that are going on and the high cost of the equipment. And so, we really have not yet seen competition in the transparency department yet. There are a few beacons of hope out there and I welcome it. You know, I think we're a great model for some entities, for some employers, for some patients, but we're not a one-stop shop. There should be options out there for patients.

Christopher Habig

I think that's key to highlight for everybody that says when you say, look, I welcome more market entrance into this who want to play in this world. It's almost a steel, sharp and steel type of a mindset that competition is very, very healthy because all too often in healthcare, we hear people saying, well, I can't publish prices because it's just going to be a race to the bottom. And that's going to affect quality and all this other stuff. And I'm like, geez, guys, do you do you actually understand what's coming out of your mouth right now? Like, you can't possibly believe that. So, you know, I.

on your mindset. And that's always why, you know, I've been a big believer in what the FMMA is trying to do and getting together like-minded people. Because we say the same thing all the time when, you know, it's almost like, hey, this town's not big enough for two direct care practices. And I'm thinking, well, actually it is because that helps educate everybody else and that helps bring in competition and it forces a good patient experience. And that's just so, so important in

to talk, you know, taking that direct care mindset that you have of, look, it's going to be all about quality and it's going to be about not bankrupting our people when they actually need to come in and use us. Green Imaging and you've been really the tip of the spear in a lot of this, reaching out to employers. So walk us through really what your mindset is when you're saying, all right, let's go craft employer plans using Green Imaging, using other allies in what I'm going to keep

as the direct care industry, walk us through kind of a day in the life of what that means to Green Imaging and what that means to employers and their plans.

Dr. Cristin Dickerson

Well, I'll kind of walk through a potential candidate for Green Imaging. Um, you know, we have an employer that comes our way and wants to see if Green Imaging can save money or provide that and or provide better access. And, um, so we are able to get their claims data and Texas, you know, it, it's law that they're, you know, we, we have access to their claims data. It's very interesting. Some of the United actually, UMR.

will only give you the patient responsibility or the plan responsibility, not both at the same time. So that's pretty opaque, but most of the time we can rebundle, we can find the professional fees for the exam, we can find the facility fees for the exam, we can find what are called HICS PICS codes, which are the pharmaceutical codes for the contrast and any medications that are needed. We can rebundle all of those things and compare them to our bundled pricing in that region.

And so we've got some code that does this now, but it's still a process that we have to watch very carefully. We have to look for outliers. A lot of, I know with Cigna, we frequently see that exams are supposed to be billed if they're outpatient with a CPT code, but they often have a hospital revenue code. And so that seems to be one way that claims escape adjudication. And so we find very high cost exams under those codes.

but we're able to really give the employer an idea of what they're gonna save. And that savings can range anywhere from about 85% down to if they're on a reference-based pricing plan, we can be pretty flat with that, but when you look at the shared savings or whatever they're paying for the reference-based pricing plan and the noise of the balanced billing that happens, we still have huge savings. And so...

You know, it really depends on what cost containment they have in place. There are some networks that offer really discounted imaging where the reimbursement is super low. But those networks are usually their access can be a real problem for those members. And so access is hard. It has been, you know, right after the pandemic, mammography access was very limited, especially diagnostic mammography. It's getting harder and harder to get diagnostic mammograms because radiologists aren't on site.

Dr. Cristin Dickerson

They aren't sitting there reviewing those studies anymore. They're doing teleradiology. And so I would say the other thing really difficult to access are GI fluoroscopic studies, upper GI's, things that used to be bread and butter of radiology because no radiologists are on site staffing the facilities. They're all reading remotely. And it's a real, it's a really interesting problem to try to access these

exams and you know that's one of the things we're able to solve for is that we have a very broad network and so we can show them the savings there we train their members we have lots of videos we have lots of paper materials that can educate their members about how to use us we work with navigation companies our brand new shiny tool our shiny object right now is our new

Dr. Cristin Dickerson

concierge kind of clashing, navigators can check on pricing. They can upload any documents, orders that need to be, and what the patient's preferences are. And then they can see in real time as we schedule the patient, what the status of that patient is. And so, you know, we work with the employer, and it's very specific. You know, I used to hear brokers say, every health plan is different. Well, it's true. Every health plan is different. Every patient population is different.

Every industry has certain special features that happens with their imaging. And so we really do customize what we're doing with that specific employer. The implementation is key. The implementation of the other solutions in the health plan is also key. One of the things that we ran into real issues with last year was stop loss and that, you know, the people underwriting the plans didn't have a real idea of what the, what solutions were in place and what that meant

to the plan and what kind of percentage utilization had to happen for them to give the decrements that they did. And so I think working with those other solutions in our implementation is also key. And then finally, we are able to provide ongoing savings reports so we can look at what they're spending for imaging over in their Aetna plan and the members that are not accessing us, what the members that are accessing us are doing and compare apples to apples and show them the savings.

Christopher Habig

Do you have any employers who look at that and say, well, this still isn't a good idea. I'm just going to go back to what is their traditional plan over here because I'm terrified that my employees aren't going to understand a new type of a plan or being pushed or navigated one way versus other. They just want this little card in their wallet that has a blue cross and a blue shield on it. And that's it.

Dr. Cristin Dickerson

Well, I think we're starting to see some solutions that get around that. And I think the Houston plan, Houston Business Coalition on Health is actually doing a plan that can be can be an option outside of the Blue Cross Blue Shield plan for these members who are declining the plan because they can't afford the premium would have another option with zero out of pocket. So I think that's a really good plan for those people. What I always say is there's no risk.

Why would you not do this? There's no admin fee, there's no PEPM. If your members don't use us.

Christopher Habig

You don’t pay for it.

Dr. Cristin Dickerson

You don't pay for it. And so that aligns our incentives with the employer.

Christopher Habig

And I love that approach because we see a lot from our from the from the direct primary care side of it where somebody is going to say, hey, Chris, I'm going to bring you up a hundred lives, but I want you to discount your price by half. And I say, well, in what world does that make sense? Because there's no widgets. The doctor's time is just available whether you have one new patient or a hundred new patients like you don't get to there's no set up charges or anything like that. It's not printing t shirts. And they say, well, a certain percentage of these people are never going to come see you.

Christopher Habig

where you earn your money back on it. And it actually blows my mind. I kind of look at them and saying, like, we have two distinct versions of reality. I would love for 100 percent participation, and I need you to pay us for the full price of this. So just pay us for the people that actually value their health and value to come see a physician. Same type of mindset that you're employing over here. You're not asking for payment for people who want to go use the other system. I would say you're just giving everybody an option.

And you can wake up and smell the coffee or not. It's up to you.

Dr. Cristin Dickerson

Yeah, and I could see ultimately, you know, one of the things that I see maybe in the long term is helping those patients who are choosing to stay in the system. You know, yes, we offer this, but if you, you know, if you've met your deductible, let's save your employer some money over here so they can give you more in wages and let's get you to a high quality, lower cost facility.

Christopher Habig

I would love for employers to start doing that because I'll have conversations with people just in my kind of close network. And every once in a while, I'll get somebody that says, you know what, I'm going to go choose more of a Freedom Healthworks type of a plan over here and ask for a raise because they're not paying my benefits. And I don't think any of them have been successful in getting that raise. They just say, they're just a little confused, like, well, wait a minute, why wouldn't you want this insurance plan? And they're saying, well, it's half my paycheck. Why would I actually want that? You know? But I, if employers are doing that, I salute them.

I would, gosh, if anybody's listening, I'd love to talk to you because...

Dr. Cristin Dickerson

Well, we actually have a state representative, James Frank, who is doing that. And what he told his employers, he's, he's doing a, you know, our kind of ecosystem health plan in Wichita Falls, Texas, of all places, which is not an easy or inexpensive place to get healthcare. And what he told his members is that, you know, anything we save is going back in your pockets, it's not going in my pocket.

So whether that's 401k, whether it's wages, everything that's saved is going back to you. And he's had tremendous success.

Christopher Habig

of these two pieces of legislation I know you're intimately familiar with them and actively worked on them to benefit the great the people of the great state of Texas.

Dr. Cristin Dickerson

Well, and I would say James Frank and then we also have representative Oliver Sun out of Houston, who's an anesthesiologist have been, you know, critical to getting these passed. House Bill 711, I didn't see as such a milestone because I feel like the HIPAA Omnibus law has, affords that to everybody. And that is the fact that a health plan can't insist, you know, that it is exclusive.

there is not exclusivity by the BUCA plans, that they cannot demand exclusivity. And so, you know, that was a really nice step. I think it made employers more comfortable with that clause in their contract that says, you know, you can't carve out imaging or whatever services, except we're excluded by law, that makes sure that that, you know, that excluded by law is not just the HIPAA Omnibus statute, it's actually this House bill in Texas.

And so, you know, I've really tried to make that part of my mission to get the word out. But what it is, is that for any health plan that's regulated by the Texas Department of Insurance, so that is ACA plans, what people consider Obamacare marketplace plans, whether they're individual, they are small group or large group, PPO's specifically, if a member has a service that is less than the, pays less than the average price in the network.

Dr. Cristin Dickerson

that the insurance company must accept the accumulators. They must accept that accumulator toward their deductible. So they have to apply it against the deductible. And so the law was pretty loosely written. They have since tightened it up and it now has to apply to the in-network deductible, which is even better. And there's still some pushback right now about how the...

how the insurers are going to ingest the information. I would say, you know, that's one of the things we've spent a lot of effort on the last couple of years is going to electronic claims. And that I think that's going to pay off here because we're actually supplying our patients with a HICFA form that they can actually submit. And then there's nothing, that's what the, you know, the insurers are ingesting from, you know, from

providers all over the country. So there's no way they can say we can't adjust this. So I think what this is going to do, and I'm trying to be very creative with how this can be implemented, but I talked to a friend of mine who handles small group healthcare plans in Washington state. And I said, why couldn't you then buy the cheapest plan in Texas, which is going to be a qualified high deductible healthcare plan at the biggest deductible possible?

as a catastrophic plan. And then just pay for care, pay for the oil changes underneath that, pay for the direct primary care, pay for the imaging, pay for these things until you have a real catastrophic event and then the insurance kicks in. So I think it really provides that vehicle now in Texas without the constraints of the HSA, which is a whole other story, but getting around those first dollar exclusions.

you know, that you just don't turn on the HSA portion of this plan, you don't qualify the plan. And so now you have this great catastrophic coverage, they can get the care they need, but you can pay for the oil changes underneath it.

Christopher Habig

I think it's a step in the right direction for sure. I'm always wary about high deductible plans just from my standpoint, because most Americans don't have savings to actually cover that. So it's always some middle ground, but I salute what

you've done in the work you've done down in Texas, because, you know, it can be a leadership example for the other 49 states or probably in reality, like about 33 of them that would actually be looking at Texas to be doing something to want to emulate what Texas is doing. There are some states, like you mentioned earlier, they're like, probably not going to be thinking innovatively along the lines there. So

Dr. Cristin Dickerson

Well, Tennessee has actually done it and I must give them credit and Cicero Institute is really trying to spread this nationally.

Christopher Habig

So other states like to copy and paste. There's very few states that go out there and be like, I wanna be the first one to jump in because it's...

They want to get reelected, right? And very few politicians want to be innovators. But if they see something working, then they're going to go out and do it and bring them to the citizens of their state. So looking forward, I mean, are you having conversations with the people you worked with in other states? And you mentioned Tennessee before Texas there. But are you getting interest in phone calls from people saying, hey, what is it that you guys did and how do we do our own version of it?

Dr. Cristin Dickerson

Absolutely. And fortunately, I have some really good foundation and institute members to pass them off to, you know, who can really help with this, help with the, you know, the direct wording for the legislation. That's very much part of what we do. But we actually hosted a webinar, our Houston Free Market Medical Association chapter, and we had about 65 percent

Dr. Cristin Dickerson

to what we were doing and they were not all Texans and not all local. And so there's definitely a national interest in this. And I probably get an email a day or a LinkedIn reach out a day about the legislation. So there's definitely interest and there's interest in what else can happen that can free up this market and make things easier.

Christopher Habig

So just kind of recap, you know, industry that we view traditionally has been resistant to change. We've highlighted some different things that you're doing on the corporate front, or I call corporate, Green Imaging front, being active in the legislation. And I think a lot of people are kind of fearful of that to call up their state rep and call up their state senator and say, here's how this can impact me, or here's some different ideas. So it's always interesting to talk to

about to say like ordinary people by no means what I consider you to be just an ordinary person. But the impact that you can have by just being involved in these conversations is truly life changing for a lot of people, even as big as the state of Texas is concerned. So I want to bring this back to the day job. I want to talk about Green Imaging looking forward. What other landmines do you see that are out there that, you know, either has a market fix or legislative fix that you can see as potentially screw

things up or running into resistance or are you just free and clear, sailing away?

Dr. Cristin Dickerson

I would say the big problem in our ecosystem right now is coordination of care. We have these companies, very innovative companies, they've got their own model and the way that they're doing things and are trying to save costs. So we're not maybe as flexible in their workflows because they're certainly cost savings and doing things one way.

how we intersect, you know, I would say that what I call radiologist medical management is critical. We are the first person who frequently knows about a cancer or a surgery and our being able to convey that way ahead of the ICD-10 code going across to somebody who's monitoring those and looking for codes that might, you know, result in a surgery, that surgery's already happened. That...

that person's already gone down the hall at the hospital to the orthopedist and had that surgery. And so where we can intervene, but we have to know the other solutions that are in place. So I think it's really integrating the pieces. And what I'm seeing two things emerge in the market right now. One is navigation. It's obvious then, when we said this years ago, we had built an app for patients to self-schedule. They don't know what to schedule. They don't, they can't read the doctor's order to even

think about what to schedule. And they need handholding when they're in times of healthcare stress. Even a mammogram is stressful. And so navigation I think is proving to be critical in our ecosystem and something that we've now fostered the solution to help with that. And then the other thing is people actually creating health plans and not just pulling solutions together. There have been some,

not quite disasters, but close to that we've seen in the market as people start trying to do this. But you know, you've got to dip your toe in the water, you've got to find where things can go wrong and some more power to them and we'll keep, you know, fighting the good fight. But I think health plans are the next, very innovative health plans are kind of the next step that really integrate the solutions

Dr. Cristin Dickerson

are really underwritten appropriately, you know, that the stop-loss is appropriate, and, you know, whether it's ag stop-loss or whether it's individual stop-loss, those things are all considered, and everybody is aware of them. Everybody's aware of the plan design, and that's one of the, you know, bad plan design is deadly to a solution. And so where people are putting plan design, traditional plan designs in place,

it's been a killer. So I think those two things navigation and more innovative health plans and I love the ones that are DPC centric. I think that has the most, you know, there you're getting the navigation and the great primary care.

Christopher Habig

Dr. Cristin Dickerson with Green Imaging. Dr. Dickerson, as always, it's an absolute pleasure to speak with you. Don't be such a stranger next time, you know, when we come on to discuss the next world changing initiative that you're a part of. Appreciate you coming on the show once again.

Dr. Cristin Dickerson

Thanks so much. Enjoyed it.

Christopher Habig

And to our listeners, thank you, as always, for tuning in. If you're intrigued by the potential of direct care and all its many forms and want to learn about learn more about simplifying your healthcare journey, subscribe to this podcast, Healthcare Americana. Share this episode with somebody that you think might benefit or might enjoy the listen as well. And let's continue to make healthcare more accessible to everyone. Once again, I am your host, Christopher Habig. Thanks for listening.

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