In episode 485, Stacey Richter interviews Dr. Cristin Dickerson on the topic of direct contracting for imaging services. They discuss the high costs of imaging, which can account for 6-11% of a plan sponsor’s healthcare spend. The episode covers the potential for significant cost savings and improved patient access through direct contracting, bypassing traditional TPAs that may have conflicts of interest or contractual constraints.
Dr. Dickerson, who is the founding partner of Green Imaging, explains how her organization has successfully implemented direct contracting, providing affordable and high-quality imaging services nationwide. They also address common barriers such as complexity in coding and payment processes, the reluctance of TPAs, and the habitual referral to 'down the hall' services. The conversation highlights the importance of price transparency, patient education, and how Green Imaging supports plan sponsors in navigating these challenges.
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00:00 Introduction and Episode Overview
00:31 The Case for Direct Contracting in Imaging
01:43 Real-World Examples and Challenges
04:47 The Importance of Data and Transparency
08:49 Interview with Dr. Kristen Dickerson
12:39 Barriers to Direct Contracting
24:05 Overcoming Barriers and Final Thoughts
33:22 Conclusion and Contact Information
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Stacey Richter (00:00):
Episode 485.
"Imaging Costs Six to 11% of PlanSponsor Spend. How Direct Contracting
Can Save Money and Improve Access."Today I speak with Dr. Cristin Dickerson.
(00:22):
American Healthcare Entrepreneurs andExecutives You Want to Know, Talking.
Relentlessly Seeking Value.
Welcome, RelentlessHealth Value listeners.
Today on the show, we're talkingdirect contracting for imaging.
Imaging costs can be in the rangeof six to 11% of total plan sponsor
(00:44):
spend, and you can figure that outif you have the data to add up the
imaging charges themselves, pluscontrast charges, plus professional
services, facility fees, et cetera.
But let me ask you this, whywould anybody direct contract
for services such as imaging?
This, why bother despite the significantcost is not some kind of rhetorical
question, by the way, even though tolongtime listeners it might feel like it.
(01:08):
And to make this even more rhetorical,let's just forget about TPAs for the
moment and disregard what ElizabethMitchell, CEO of PBGH said to me about
some of them who may or may not beskimming 30% off the top of plan spend.
Let's just forget about that now andjust discuss one other foundational
point that has to be locked in to justifywhy direct contracting is a solution.
(01:32):
Are there actually cost differencesbetween different clinical organizations
or quality differences for that matter?
Is that true?
Is that the case?
Do cost differences exist?
Lemme tell you about this, I'm gonnasay pretty upsetting, but also pretty
revealing conversation I had theother day with a friend of mine.
Someone who is a professorat a top university.
(01:55):
So a smarty by any definition,but also a normal civilian.
Healthcare is not her day job asit is not mostly the day job of
many plan sponsors, people in HR.
So it came up, I swear I don't launchinto healthcare industry diatribes
at random dinners with randompeople, or not that often, at least.
(02:17):
But anyway, healthcare costs came up andI found myself talking about all of the
stuff going on with New York Presbyterian.
That DOJ investigation haddropped earlier that day.
And also they have a hospitalup the street from actually
where we were having dinner.
Now recall that part of that DOJinvestigation, and there's a couple of
(02:38):
class action lawsuits afoot, but part ofthat whole thing what is being alleged
is Presy charging way more for kneereplacements and colonoscopies, et cetera.
Like charges double or sometimesthree times as much as other local
hospitals or ASCs, with the samequality . And my friend, she bursts out.
Come on.
(02:59):
She says this really aggressively,actually, like she's saving
me from a conspiracy theory.
She says it is not possible thatone hospital would be able to
charge that much and others so muchless the market would even it out.
No one would go to the expensive place.
In that moment, I took off my tinfoilhad and laid it gently by my side.
No, my heart broke.
(03:20):
Let me tell you.
Just that morning, I had been helping afriend of the family whose kid got cancer
and I was helping them not lose theirhouse to majorly inflated medical bills.
These are the people who are harmedby anti-competitive contracts,
by plan sponsors getting trappedinto discount based contracts with
conspicuously missing net prices.
This is not a no harm, no foularrangement from any given patient's
(03:44):
point of view, what is beingalleged in that DOJ investigation.
So I've been ruminating over the whyhere, as in why this person and others
indubitably like her, why are theyso aggressively opposed to reality?
Is it just that it, does actuallysound illogical on its face
because Yeah, it kind of does.
(04:04):
Or for sure it could be the ageold story that those who are
healthy and well resourced enoughare well and truly insulated.
They aren't sick and they havegood enough insurance at least
so far, and enough in their bankaccount to cover their deductible.
But I don't know.
I'm still reflecting.
I'm confident that many of you haveencountered similar situations.
(04:24):
What did you do?
But I will tell you one thingthat I am very sure about.
It was in that moment that I appreciatedyou Relentless Health Value listeners
and all of you who have spent the timeand the energy and came face to face
with these really unappealing realities.
You have followed the dollar asit travels through this labyrinth
(04:45):
that is a feature, not a bug.
Because you all know the folks who arestruggling to meet rent and at the same
time paying their share of $5,000 MRIswhen down the street there's just as
high quality imaging for 300 or 500.
And as we all know, it's anti-competitivecontracts that often prevent
those of us who do get it to steerand tier and educate members.
(05:06):
And this is why the show today aboutdirect contracting is so important
because direct contracting can helpmake sure that members get a fair price.
Okay, I'm back on track now.
Sorry, it's been a rough week.
My conversation today with the one andonly Dr. Cristin Dickerson delves into the
merits of direct contracting for imagingand the conversation emphasizes the
(05:28):
significant savings that this can offer.
Given that imaging, again,constitutes 6% to as much as 11% of
plan sponsor healthcare spending.
What I think is interesting, slightsidebar here is, you know, Al Lewis
talks about in that episode how ERspend has crept up to around 6% of your
(05:50):
average plan sponsor's total spend.
And I don't know, maybe it's just the 6%callback that maybe wants to say this.
But don't forget a big point that Al madein that ER show and that I underlined
in the ER through line episode thatcame right after that Al Lewis show.
And also this comes up in the podwith Dr. John Lee, who is an ER doc.
The more a plan sponsor tries to controlimaging or diagnostic in general spend,
(06:14):
the more patients wind up going to the ERbecause either they realize or are told
that if they wanna just get to the bottomof what's going on with their bodies
without getting caught in prior authrigamarole, they should just go to the ER.
So paradox and just another example ofhow, what could seem very logical on
its face, you know, control costs thisway actually leads to higher costs.
(06:39):
Anyway, as you listen tothe show that follows.
I also would think about what JonathanBaran talked about in the Flywheel
Show from a few weeks ago, how aplan sponsor can save again, double
digits when they buy good healthcareas their prime directive, not buy
discounts or try to math their wayinto a solution that just adds even
more mystery and more middle people.
Direct contracting is certainly a wayto think about that, and it is something
(07:02):
that certainly Jonathan Baran mentioned.
Shows to listen to or reflect uponadjacent to this one, Brennan Bilberry
about anti-competitive contracts,and there's also a Summer Short
about why they are so intractable.
Vivian Ho, talking aboutwhat drives up premiums.
Spoiler alert.
It's costs driven by bigconsolidated health systems.
We had Kimberly Carleson on recentlyechoing many of the themes you'll
(07:23):
hear in the conversation that follows.
Also the show with Dave Chasetalking about figuring out
whether your TPA and or benefitconsultant is truly working for you.
Wow, that matters.
Keith Passwater (07:35):
Hi, I am Keith Passwater, CEO of Havarti Risk.
As a healthcare actuary, I cansometimes get deep into the weeds
of the math behind healthcare.
Maybe you experience that aswell, getting hyper-focused
to your corner of healthcare.
That's why I so appreciateRelentless Health Value.
Listening to the conversations reminds methat our healthcare system is huge, but
we're ultimately here for the patients.
If you wanna make a difference inhealthcare, don't miss an episode
(07:57):
of Relentless Health Value, and Ireally encourage you to follow the
podcast on Apple Podcast or Spotify.
And please leave a review.
Thanks for listening.
Stacey Richter (08:05):
My guest today, Cristin Dickerson, MD, as I have mentioned
several times, is the founding partner ofGreen Imaging, a physician-led radiology
network, pioneering affordable, highquality medical imaging for patients,
employers, and health plans nationwide.
Green imaging round of applause nowhas grown to be an $18 million company.
Love it when you hear a doingwell by doing good story.
(08:28):
I also very much appreciated,Dr. Dickerson offered a very,
very lovely donation to supportthe work of this podcast.
Thank you to her andGreen Imaging for this.
My name is Stacey Richter, and thispodcast is sponsored by Aventria
Health Group and also Green Imaging.
If you're a plan sponsor,please give them a call.
And with that here is myconversation with Dr. Dickerson.
(08:49):
Dr. Cristin Dickerson, welcometo Relentless Health Value.
Cristin Dickerson (08:52):
Happy to be here.
Excited.
Stacey Richter (08:53):
Imaging, six to 11% I think, of plan, sponsor
spend, going to imaging.
Multiple experts have said thatif you want to start doing direct
contracting, start with imaging, andI think we can start to see why, just
by the magnitude of those numbers.
But also it's got less friction for abunch of reasons, like patients aren't
really loyal usually to an imaging center.
(09:16):
So, Dr. Cristen Dickerson,let me ask you this.
Who has figured this out rightnow as far as plan sponsors go?
Is it mainly very innovative,employers or TPAs.
Cristin Dickerson (09:27):
We're seeing larger employers move this direction.
We're moving upstreamin the employer market.
I would say a year and a half ago, ouraverage client was in the 300, 400 range.
Now it's in the 3000, 4,000.
When I spoke with the head of thehealth plan at City of Plano, Andrea
Cockrell on a panel at the HoustonBusiness Coalition on Health.
(09:50):
She said she brought in Green Imagingto solve a cost problem, but what she
found was there was an access problem.
What she was really solving wasan access problem for two reasons.
Number one, it's hard to find some ofthese new exams, some of these myocardial
MRIs, and you know, only in a handful offacilities even in Houston offer this.
You know, we're kind of theheart capital of the world.
(10:10):
And also that people couldn't afford it.
62% of Texans are not getting care ordelaying care because they can't afford
it, and so that you're able to get themthe care they need when they need it, not
delaying things so it's more expensiveand they miss more work down the line.
And the employer still saves money.
Stacey Richter (10:30):
You said a couple of things.
One of them is, you know, I kindof asked you is this, arcane
solution that only a few are using?
And you said no.
This is becoming more of amainstream kind of thing.
And you can start to see why.
It was really interesting what yousaid that, you know, an employer can
do a 0% copay, like no cost sharingwith the employee and still save money.
(10:52):
If someone's spending 6%, 11%of total spend, there's a lot
of opportunity for savings.
If we can save the money and, and improveaccess, that seems like a win-win.
Cristin Dickerson (11:02):
That ethical alignment also helps with the market momentum,
and I think we're getting that acrossthe board in the ecosystem or tribe.
Stacey Richter (11:11):
We, we talked about the why now we, we've talked about the
reasons and some of its costs, someof it's quality, some of it's access,
member experience, member perception.
I mean, anybody that needsimaging like there's a problem.
It's like, here's a way that ourmembers who are in pain or scared
are able to get what they need.
Cristin Dickerson (11:32):
Even getting a mammogram is, as we all know, I mean
best day of the year is when youget your negative mammogram report.
So that, you know, that's really whatI talk about with my scheduling staff
is everybody who comes to you isgoing to be under healthcare stress
and people behave differently whenthey're under healthcare stress.
Stacey Richter (11:50):
Let's talk about the barriers now, right?
So, and, and mostly thinking about thisfrom the standpoint of a plan sponsor who
is thinking to themselves, I would liketo do something here, but they're maybe
at the very beginning of their journey.
Let's just start here.
The first barrier that I am understandingas you're talking is probably just
(12:10):
the complexity of the situation.
Because where there's mystery ismargin, as Anthony Ciccia coined
that phrase, and wow, it is so truebecause it enables margin to be hidden.
Some of the complexity from justlistening to you talk here, I have a
feeling has to do with how services arebeing coded dollars that are kind of
(12:36):
lost or they're put in other buckets sothey sort of disappear into thin air.
Could you explain more?
Cristin Dickerson (12:42):
Sure there are a lot of ways that happens.
I would say that one of the reallyinteresting stories is school district
of Osceola County in Florida.
In 2019, the teacher union wentto the school board and said, you
know, something's gotta give theseschool bus drivers, cafeteria
workers have a $5,000 deductible.
$6,500 maximum out of pocket.
(13:02):
They're functionally uninsured.
And so we did this claims data analysisand what we found was, yes, they
were paying excessively for imaging.
They had about, just on aCPT code by CPT code basis.
We were able to show about 60% savings.
But what also emerged fromthat was there's something
called a hospital revenue code.
(13:24):
And, um, with this carrier, it issupposed to be used only for inpatient,
but there were literally hundreds ofimaging exams that were paid out at
thousands and thousands of dollars.
I think there was one CT scan that waspaid out over $50,000 with hospital
revenue codes rather than CPT codes.
And so those were escaping theclaims adjudication process because
(13:48):
they were a different type of code.
And that that's the perfect type example.
It's something thatthey never had eyes on.
Even if you did a CPT codeanalysis, you wouldn't see that.
And you know, that's wherewe see things like clawbacks.
That's where we see themultiple pre-auth charges.
That's where we see the alternativenetwork charge that might, a lot
(14:09):
of times the RBP fees are higherthan what was paid to the provider.
Just like with the MultiPlan situationagain, where those fees that end up being
higher than what's actually paid out.
Stacey Richter (14:22):
So we're talking about the first barrier to implementing
some kind of direct contracting forimaging, and I boldly said it was
probably complexity and now I'm boldlydoubling down that I think I'm right.
The things that you're talking abouthere are deeply embedded in codes.
Like your average civilian looking atthis stuff might not realize there's
(14:43):
these other hospital revenue codesthat exist, or, you know, Kimberly
Carleson in that episode talked a lotabout bundling and unbundling, right?
Like, so a scan is supposed toinclude all these eight codes,
that's all in the bundle.
And then the employer, howwould you know this, right?
Like they'd get charged the bundled priceand then four codes that are supposed
(15:05):
to be in the bundle kind of thing.
You're talking about,employers are getting
charged for the pre-authsor the prior auths as
a separate bucket of things, or the contrast is
someplace else or whatever.
If it sounds like a self-insuredemployer doesn't have a third party
payment integrity vendor lookingat some of this stuff, all they're
(15:26):
going off of is what their ASOor somebody else is telling them.
There are so many perverse incentivesfor anybody who's in the middle
moving people's money around.
So many different ways dollars canbe obscured so barrier one is just, I
think, the complexity and it sounds likethe answer is, get someone who is an
(15:49):
unconflicted third party to do an audit,or it sounds like Green Imaging or you
know, other independent imaging centerscan also do audits to at least get someone
started where the landmines might be.
Cristin Dickerson (16:04):
It's eye-opening for employers to see what they're
really spending, and I would love toget my hands on their weekly file feeds
that most of them are auto-paying.
And really see what's in there.
Especially with some of these, especiallythe private equity backed TPAs.
I think my suspicion isthere's a lot in there.
Stacey Richter (16:22):
Listen to the podcast with Justin Leader called the
Mystery of the Weekly Claims Wire.
Cristin Dickerson (16:26):
One of the major carriers right now is only
giving employers the plan paymentor the member responsibility.
They won't give you both.
And so how on earth can you do fiduciaryduty if you only know a part of
the cost of a CPT code or a bundle?
It makes no sense.
Stacey Richter (16:45):
The show with Cora Opsahl
and there's also a show with Dave Chasewhere we dig into why it is so important
to get data and how to to get it.
The second barrier that I amhearing relative to moving in this
direction is when you hear thatthe TPA won't do imaging or other
(17:08):
direct contracting as a rule, orthey blame benefit design somehow.
How do you think about that one?
You know, how does that transpireand then what do you do about it?
Cristin Dickerson (17:19):
I really personally feel like a direct
contract shouldn't involve a TPA.
There are so many barriersthat we run into with this.
I'm happy, you know, thereare some great TPAs out there.
There are some that areworking beautifully with us.
But there's a lot of resistance, andit's either because they really feel
challenged by their major carrierwith whom they have an agreement.
(17:41):
There is a clause in that contract.
There's also a clause in that contractthat says anything that's excluded
by law, you know, is not valid.
And so really that is referring tothe HIPAA omnibus rule, which allows
individuals or somebody paying foron their behalf to withhold PHI from
the insurance company and pay cash.
Stacey Richter (18:02):
What you're talking about is that, you know, a, a self-insured
employer plan sponsor goes to theirASO, TPA and says like, I wanna
do direct contracting for imaging.
And then TPA says, I can't do itbecause it violates our, insert
carrier name here, contract.
Which it really could.
Every time this topic comes upon the show, I hear from some
ASO or TPA who says, look, I amreally beholden to my carriers.
(18:26):
Like there are certain things whereI just, I simply can't do them.
So could you answer the questionvery specifically, if a TPA comes
and says, we can't do that becauseit's in violation of our carrier
contract, and the employer says, butI still want to, are we at an impasse?
Cristin Dickerson (18:43):
We're not at all.
The employer doesn't haveto involve the TPA at all.
I would say that our larger employergroups are going around the TPA, maybe 80%
of them because it's simpler and easier.
Stacey Richter (18:55):
So if a TPA is just like, look, I got a carrier, I have
a longstanding relationship withthis carrier, I've got a lot of
other business with this carrier.
So for you, your one group, I can'tundermine my entire book of business
because you wanna do something.
The point that you're makingis that you have plenty of
groups who are like, okay, fine.
(19:16):
You do you TPA, meanwhile I'm gonna do me.
And that is managing a directcontract with this imaging
center and maybe others as well.
And you don't need the TPA.
Cristin Dickerson (19:28):
You don't need the TPA.
Stacey Richter (19:29):
Does that get crazy?
Cristin Dickerson (19:30):
And in fact, the TPA can complicate the situation.
Stacey Richter (19:33):
Like so are you just, I mean, if you think about third party
administrator, they're doing a bunchof different things, but one of them
is sending the weekly claims wire.
So basically what you'resaying is you just send a bill.
Cristin Dickerson (19:43):
Oh, we just send a bill, but it has all the, the data that's
needed by stop-loss to provide decrements.
It has, you know, or it would be usedin a stop-loss audit, has all the
information that is sent to a TPA.
Stacey Richter (19:56):
And I guess you don't need repricing or anything like that.
Like one of the reasons why you'dgo through a TPA is because they
have to do all the checking of thecontracts and blah, blah, blah.
But if there's just, thereis none of that, right?
It's just like, here's yourprice, you're gonna pay that.
Then this is a way, yeah.
Cristin Dickerson (20:10):
And the other reason would be a pre-auth and you know, really
pre-auths don't change utilization.
And what we do is we do radiologistprotocols, which are much more specific.
That comes down to iscontrast really needed.
CTs of the chest are ordered 30%of the time with and without,
with contrast, and it eitherneeds to be done with or without.
And so we cut the radiationin half, often decrease the
(20:31):
contrast risk and cut the cost.
Stacey Richter (20:32):
You just said something interesting there.
You said that, you know, one of the,uh, TPAs job is to manage radiology
prior auths, but prior auths don'tactually reduce the number of images.
Is that substantiated by anythingor is that in your experience?
Cristin Dickerson (20:47):
The American College of Radiology Um, did a study a couple
of years ago that showed that, thatthey do nothing except delay care.
Stacey Richter (20:54):
Yeah.
I, you know, I've heard, I think it was AlLewis was talking about that, about this
at one point, and we just did a show withPreston Alexander talking about the float.
So, it is in any given carrier's interesthere to delay care as long as possible.
And there is, I've seen, I'm notnecessarily thinking of any given study
(21:14):
per se, but I've heard anecdotallyquite a bit that prior auths will
push imaging to the next quarter.
So like if someone says, well, how manyimages were prevented this quarter?
There's always a really big number therethat probably somebody can trot out.
But then if you look at how manyof those people got images at some
(21:35):
point in the future, it is a highernumber than you would expect if
inappropriate care was being prevented.
Cristin Dickerson (21:44):
Absolutely.
It also depends on the faircost of what you're doing.
If you've got an MRI that costs $400,how is delaying care for six weeks
of physical therapy, which is gonnacost a lot more than that, that may
be delaying surgery for somebody.
It may, you know, be making things worse.
How does that make financial sense?
If you've got a fair price upfront.
Stacey Richter (22:05):
That's say another really, like if it costs $50,000, all right.
You can start to see whythere's a good reason.
You know, you prevent one inappropriatecase, you wound up saving enough
to pay for a lot of prior authing.
However, if you're doing something thatcosts $400, like the administrative
cost could wind up being, assumingthere's no patient harm, that winds
(22:28):
up transpiring, but you kind of getinto the zone where you wind up with
administrative burden and how much isgoing on, and how many do you have to
prevent in order to make it worth it.
Cristin Dickerson (22:40):
90 something percent of doctors know a patient who
has been harmed or died because ofpre-auth delays related to pre-auth.
Stacey Richter (22:48):
So, okay, second barrier that we're talking about
here, and we expanded our circle ofwhat we were talking about, but we
started out as the second barrier,as TPAs won't do it as a rule, or
they blame benefit design somehow.
And I think what we have comeup against here is that a lot of
times TPAs actually can do it.
It's just complicated, and theymay not want to, or they may
(23:08):
have some perverse incentives.
Other times they really can't becausethey do have a carrier contract,
which is gonna prevent them.
But if you're a self-insured employerand you're thinking to yourself,
but I still really wanna do that,then don't go through the TPA.
There's plenty of precedentfor doing a direct contract.
Not through a TPA.
Cristin Dickerson (23:26):
And they may have their own vendors that they're making money.
They may have an RBP plan thatthey feel like it competes with.
They may have another vendor that'spaying referral fees to them.
So there are additional reasonsthat they don't wanna do it,
that maybe, um, not as apparent.
Stacey Richter (23:42):
Let me also just remind everybody that we've had guests after
guests on this podcast basically saythat if a plan sponsor goes to their
EBC or their TPA and says, Hey, Iwanna do this because it's better for
me and my members and they wind upwith like a 72 page, very complicated
report about why they can't do it.
If the disruption, the D word, as ClaireBrockbank calls, it gets trotted out.
(24:06):
If any of those things happen,that's a red flag that there's
probably money being made somewhere.
Andreas Mang, in the first episodewith him, he said this really crisply.
He's like, you don't need a 5500disclosure form sometimes to tell if
somebody's taking money in indirectpayments by the reaction when you
ask very specific information or youwanna try to do something innovative.
(24:27):
You can tell whether they're workingwith you and trying to figure out how
to do it, or they're giving you 900reasons why you simply can't because
it's gonna disrupt their income stream.
Okay, so third barrier thisdown the hall mentality.
There's probably a, acouple of things there.
One of them, it's, it's easier to walkdown the hall, but secondly the doctor's
like, but I need the full report.
(24:48):
And if you go someplace else,I'm not gonna get the report.
Cristin Dickerson (24:50):
There is some legitimate worry when there prior studies.
We've invested heavily in the imagesharing options that are out there.
It's still not ubiquitous that youcan push around images from system
to system, but there are a number ofcompanies that are making that easier,
and we've invested heavily in that forthat reason, because we do know good
doctors wanna see the images themselves,especially the subspecialist surgeons.
(25:12):
They need to see the images.
But what I'm finding isthere's less and less pushback.
As the cost has risen, and so fewpeople are actually getting the imaging
that their doctor's recommending whenthey say, I have a zero out-of-pocket
option that's being honored more often,uh, with, with very little pushback.
So really, I think doctors don't know howexpensive it is often down the hall, and
(25:35):
I think they would be more sympatheticif they actually knew how much it was.
I bet you 60% of doctors can'teven come close to telling you what
that imaging costs down the hall.
And you know, I think patients don't andthey get horrifically high bills now.
I would've thought an ultrasounddown the hall at the hospital
would've been affordable these days.
I just had a claims data set that camein at $1,381 for the average ultrasound.
(25:59):
You know, that's rebundled.
Stacey Richter (26:00):
So if we're thinking about the down the hall as a barrier,
one of the things you are saying, aspatients become more aware, and as
the bills become higher, that fear mayoutweigh the opportunity for convenience.
The fear of having agigantic unknown charge.
(26:22):
The second thing, the patient's worriedthat their doctor won't get the imaging.
And if you're working with a placesuch as Green Imaging or you're
working with a place that has investeda lot in image sharing, which like
if you're an independent radiologycenter, in a way, you better.
Because all the images are gonnaneed to get shared, and if you
don't do it really well for theoriginating physician, then I mean,
(26:46):
what are, what are we even doing here?
Cristin Dickerson (26:48):
Or at least we make it seem seamless.
Stacey Richter (26:51):
Part of the skill is making it look easy.
We talked about three barriershere, and also in the context of
talking about those barriers, wetalked about ways to overcome them.
The first barrier we talked aboutis just the complexity that there's
just so much self-interested behaviorright now and some complexity a lot
of times, sure this is complicated.
(27:11):
But if you want to overcome it, there'scertainly unconflicted payment integrity
vendors, unconflicted benefits advisors.
There's plenty of people who canreally dig in or learning from
somebody else's experience, right?
Like if you hear that an employer inyour area did the math and figured
something out, that there's probablya likelihood that as a similar
(27:33):
plan sponsor, probably you've got asimilar circumstance, I would say.
Cristin Dickerson (27:38):
Yeah, and you know, we have reams of claims data.
I have claims data from all themajor carriers, most independent
TPAs in different industries,different geographic areas.
All of those things make a difference.
But we have thousands of claims dataassessments, so I can usually match one
to an employer and say, Hey, this is whatwe would typically see in that setting.
(27:58):
Even RBP, we can show them RBPclaims data sets, where we've got,
we actually have those fees and wecan show what they're paying in the
background compared to Green Imaging.
The other thing, and I feel like thisis where this trust factor comes in too.
It is that there's no risk with us without competitors often have a PE PM.
I strongly feel that being fee for servicealigns me ethically with the employer
(28:22):
because there's no risk to the employer.
If their members don't useus, , we're not gonna get paid.
So they can go into the firstquarter, their members can use us.
We can compare that to what theywere paying before or compare it
to market prices, some publishedentity, Turquoise, whatever it is.
Use that as the baselineand show them the savings.
(28:43):
And so I, and we do that ongoing withour employers and I really feel like
that's how you build the trust factor.
Stacey Richter (28:49):
That is probably a way for plan sponsors to feel like
they've gotten the best answer thatthey possibly can, and what is really
a gray, murky world where there islots of money getting moved around.
Cristin Dickerson (29:00):
It's actually kind of amusing right now, some
of the clauses that people wantus to put in our agreement.
You know, we're not, we'renot a traditional carrier.
We are somebody who's beentrusted in the market.
And look, this is our promise.
Everything's in our bundle.
It's all in there, and you're notgonna have to pay anything else,
and it's gonna save you money.
Stacey Richter (29:18):
Yeah, keep it simple.
The second barrier that we talkedabout is the whole TPAs won't do this,
or it's conflicts with benefit designsomehow, which again, is a thing.
Chris Deacon just wrote a post about this.
There's a lot of third party deal making.
Had a show with BrennanBilberry about anti-competitive
contracts very specifically.
(29:39):
There's just so many things that aregoing on, which could prevent someone
from doing something, which in fact isin their clients best interest and in
those circumstances, we talked about acouple of different workarounds there.
One of them is just being very demandingbecause sometimes if where there's
a will, there's a way, but if not,hopefully, let's just say the plan sponsor
(30:00):
didn't sign the rights away here, butthere are opportunities to do direct
contracting, not through a TPA who isnot able to do it or doesn't want to.
Either way, it doesn't matter.
You can do it yourself.
And then the third is kind ofcurbing the down the hall mentality.
And one of the things that you impliedin that last answer is that you take
(30:21):
it upon yourself over at Green Imaging,and I would assume that anybody
else in this, the direct contractingbusiness, we're, we're gonna have
Stanley Schwartz from Zero Health,who does direct contracting more on
a broader scale, talk about this too.
And both of you are saying the samething, that it's our responsibility to
figure out how we are talking to members.
Teaching members.
Changing member behavior so that theydon't do the down the hall thing.
(30:43):
And obviously you've got aton of experience doing that
that you can bring to bear.
So members take advantage of this cost,access, you know, all the good things.
It's a win-win.
Cristin Dickerson (30:52):
Yeah, and I think that's where the
member experience comes in.
I really built this company thinking pricetransparency was gonna level the market
and we just had to be the best from acustomer service and quality standpoint.
And, and so that's beenmy mentality all along.
Certainly on the pricing, we have notseen that and the gap has remained, but
(31:12):
I think if people look at our Googlereviews, they'll see just how easy we
make it for people and how much of thehassle factor we take off their plates.
Which is I really think if you canmake it seem easy to members, you get
that traction with an employer groupand you get that water cooler talk
and it, it really starts working.
Stacey Richter (31:32):
Which benefits plan sponsors.
Do you wanna talk a little bit aboutGreen Imaging and where someone
can find out more information?
Cristin Dickerson (31:38):
Sure.
Our website's a great resource.
Lots of videos, lots of links to articles.
www.greenimaging.net.
If you ever have a radiologist question,there's also an email link there to ask
us clinical questions if you need that.
You can request pricing there.
We will give over web chat over thephone, however you wanna request it.
We'll give you a quote.
Um, and it's all in.
Stacey Richter (31:58):
If I am a plan sponsor almost anywhere in the United
States, you have enough facilitiesto have network adequacy in my area.
Cristin Dickerson (32:06):
We do.
We can do a geo access, we can buildout the network where we need to.
We also create bundles.
If we, if there's a pediatric sedationMRI that's needed, we can go, we
know , who we need to negotiate with,the anesthesia group, the radiology
group, and the facility, and createthat bundle on behalf of an employer.
So yes, we're covering the country.
Stacey Richter (32:26):
If there is a plan sponsor listening, who's thinking to themselves
six to 11% of spend, Hmm, maybe I shouldlook into this, a good first step might
be just give you a call and you'lllet 'em know what might be possible.
Or not really, but it might be a goodfirst step to try to figure out what
a potential path forward could be.
Cristin Dickerson (32:44):
You got it.
Stacey Richter (32:45):
Dr. Cristin Dickerson, thank you so much for being on
Relentless Health Value today.
Cristin Dickerson (32:50):
Always great to have a conversation with you.
Dr. Vivian Ho (32:52):
Hi, I am Dr. Vivian Ho.
I'm a health economist at RiceUniversity in Baylor College of Medicine.
I listen to Relentless Health Valuereligiously because this is the
show for those who are part of thetribe that wants to improve the
quality of healthcare, improve accessto care, and make it affordable.
So make sure that you subscribe tothe newsletter and subscribe to the
(33:15):
podcast and keep up with every episode.
Episode 485.
"Imaging Costs Six to 11% of PlanSponsor Spend. How Direct Contracting
Can Save Money and Improve Access."Today I speak with Dr. Cristin Dickerson.
(00:22):
American Healthcare Entrepreneurs andExecutives You Want to Know, Talking.
Relentlessly Seeking Value.
Welcome, RelentlessHealth Value listeners.
Today on the show, we're talkingdirect contracting for imaging.
Imaging costs can be in the rangeof six to 11% of total plan sponsor
(00:44):
spend, and you can figure that outif you have the data to add up the
imaging charges themselves, pluscontrast charges, plus professional
services, facility fees, et cetera.
But let me ask you this, whywould anybody direct contract
for services such as imaging?
This, why bother despite the significantcost is not some kind of rhetorical
question, by the way, even though tolongtime listeners it might feel like it.
(01:08):
And to make this even more rhetorical,let's just forget about TPAs for the
moment and disregard what ElizabethMitchell, CEO of PBGH said to me about
some of them who may or may not beskimming 30% off the top of plan spend.
Let's just forget about that now andjust discuss one other foundational
point that has to be locked in to justifywhy direct contracting is a solution.
(01:32):
Are there actually cost differencesbetween different clinical organizations
or quality differences for that matter?
Is that true?
Is that the case?
Do cost differences exist?
Lemme tell you about this, I'm gonnasay pretty upsetting, but also pretty
revealing conversation I had theother day with a friend of mine.
Someone who is a professorat a top university.
(01:55):
So a smarty by any definition,but also a normal civilian.
Healthcare is not her day job asit is not mostly the day job of
many plan sponsors, people in HR.
So it came up, I swear I don't launchinto healthcare industry diatribes
at random dinners with randompeople, or not that often, at least.
(02:17):
But anyway, healthcare costs came up andI found myself talking about all of the
stuff going on with New York Presbyterian.
That DOJ investigation haddropped earlier that day.
And also they have a hospitalup the street from actually
where we were having dinner.
Now recall that part of that DOJinvestigation, and there's a couple of
(02:38):
class action lawsuits afoot, but part ofthat whole thing what is being alleged
is Presy charging way more for kneereplacements and colonoscopies, et cetera.
Like charges double or sometimesthree times as much as other local
hospitals or ASCs, with the samequality . And my friend, she bursts out.
Come on.
(02:59):
She says this really aggressively,actually, like she's saving
me from a conspiracy theory.
She says it is not possible thatone hospital would be able to
charge that much and others so muchless the market would even it out.
No one would go to the expensive place.
In that moment, I took off my tinfoilhad and laid it gently by my side.
No, my heart broke.
(03:20):
Let me tell you.
Just that morning, I had been helping afriend of the family whose kid got cancer
and I was helping them not lose theirhouse to majorly inflated medical bills.
These are the people who are harmedby anti-competitive contracts,
by plan sponsors getting trappedinto discount based contracts with
conspicuously missing net prices.
This is not a no harm, no foularrangement from any given patient's
(03:44):
point of view, what is beingalleged in that DOJ investigation.
So I've been ruminating over the whyhere, as in why this person and others
indubitably like her, why are theyso aggressively opposed to reality?
Is it just that it, does actuallysound illogical on its face
because Yeah, it kind of does.
(04:04):
Or for sure it could be the ageold story that those who are
healthy and well resourced enoughare well and truly insulated.
They aren't sick and they havegood enough insurance at least
so far, and enough in their bankaccount to cover their deductible.
But I don't know.
I'm still reflecting.
I'm confident that many of you haveencountered similar situations.
(04:24):
What did you do?
But I will tell you one thingthat I am very sure about.
It was in that moment that I appreciatedyou Relentless Health Value listeners
and all of you who have spent the timeand the energy and came face to face
with these really unappealing realities.
You have followed the dollar asit travels through this labyrinth
(04:45):
that is a feature, not a bug.
Because you all know the folks who arestruggling to meet rent and at the same
time paying their share of $5,000 MRIswhen down the street there's just as
high quality imaging for 300 or 500.
And as we all know, it's anti-competitivecontracts that often prevent
those of us who do get it to steerand tier and educate members.
(05:06):
And this is why the show today aboutdirect contracting is so important
because direct contracting can helpmake sure that members get a fair price.
Okay, I'm back on track now.
Sorry, it's been a rough week.
My conversation today with the one andonly Dr. Cristin Dickerson delves into the
merits of direct contracting for imagingand the conversation emphasizes the
(05:28):
significant savings that this can offer.
Given that imaging, again,constitutes 6% to as much as 11% of
plan sponsor healthcare spending.
What I think is interesting, slightsidebar here is, you know, Al Lewis
talks about in that episode how ERspend has crept up to around 6% of your
(05:50):
average plan sponsor's total spend.
And I don't know, maybe it's just the 6%callback that maybe wants to say this.
But don't forget a big point that Al madein that ER show and that I underlined
in the ER through line episode thatcame right after that Al Lewis show.
And also this comes up in the podwith Dr. John Lee, who is an ER doc.
The more a plan sponsor tries to controlimaging or diagnostic in general spend,
(06:14):
the more patients wind up going to the ERbecause either they realize or are told
that if they wanna just get to the bottomof what's going on with their bodies
without getting caught in prior authrigamarole, they should just go to the ER.
So paradox and just another example ofhow, what could seem very logical on
its face, you know, control costs thisway actually leads to higher costs.
(06:39):
Anyway, as you listen tothe show that follows.
I also would think about what JonathanBaran talked about in the Flywheel
Show from a few weeks ago, how aplan sponsor can save again, double
digits when they buy good healthcareas their prime directive, not buy
discounts or try to math their wayinto a solution that just adds even
more mystery and more middle people.
Direct contracting is certainly a wayto think about that, and it is something
(07:02):
that certainly Jonathan Baran mentioned.
Shows to listen to or reflect uponadjacent to this one, Brennan Bilberry
about anti-competitive contracts,and there's also a Summer Short
about why they are so intractable.
Vivian Ho, talking aboutwhat drives up premiums.
Spoiler alert.
It's costs driven by bigconsolidated health systems.
We had Kimberly Carleson on recentlyechoing many of the themes you'll
(07:23):
hear in the conversation that follows.
Also the show with Dave Chasetalking about figuring out
whether your TPA and or benefitconsultant is truly working for you.
Wow, that matters.
Keith Passwater (07:35):
Hi, I am Keith Passwater, CEO of Havarti Risk.
As a healthcare actuary, I cansometimes get deep into the weeds
of the math behind healthcare.
Maybe you experience that aswell, getting hyper-focused
to your corner of healthcare.
That's why I so appreciateRelentless Health Value.
Listening to the conversations reminds methat our healthcare system is huge, but
we're ultimately here for the patients.
If you wanna make a difference inhealthcare, don't miss an episode
(07:57):
of Relentless Health Value, and Ireally encourage you to follow the
podcast on Apple Podcast or Spotify.
And please leave a review.
Thanks for listening.
Stacey Richter (08:05):
My guest today, Cristin Dickerson, MD, as I have mentioned
several times, is the founding partner ofGreen Imaging, a physician-led radiology
network, pioneering affordable, highquality medical imaging for patients,
employers, and health plans nationwide.
Green imaging round of applause nowhas grown to be an $18 million company.
Love it when you hear a doingwell by doing good story.
(08:28):
I also very much appreciated,Dr. Dickerson offered a very,
very lovely donation to supportthe work of this podcast.
Thank you to her andGreen Imaging for this.
My name is Stacey Richter, and thispodcast is sponsored by Aventria
Health Group and also Green Imaging.
If you're a plan sponsor,please give them a call.
And with that here is myconversation with Dr. Dickerson.
(08:49):
Dr. Cristin Dickerson, welcometo Relentless Health Value.
Cristin Dickerson (08:52):
Happy to be here.
Excited.
Stacey Richter (08:53):
Imaging, six to 11% I think, of plan, sponsor
spend, going to imaging.
Multiple experts have said thatif you want to start doing direct
contracting, start with imaging, andI think we can start to see why, just
by the magnitude of those numbers.
But also it's got less friction for abunch of reasons, like patients aren't
really loyal usually to an imaging center.
(09:16):
So, Dr. Cristen Dickerson,let me ask you this.
Who has figured this out rightnow as far as plan sponsors go?
Is it mainly very innovative,employers or TPAs.
Cristin Dickerson (09:27):
We're seeing larger employers move this direction.
We're moving upstreamin the employer market.
I would say a year and a half ago, ouraverage client was in the 300, 400 range.
Now it's in the 3000, 4,000.
When I spoke with the head of thehealth plan at City of Plano, Andrea
Cockrell on a panel at the HoustonBusiness Coalition on Health.
(09:50):
She said she brought in Green Imagingto solve a cost problem, but what she
found was there was an access problem.
What she was really solving wasan access problem for two reasons.
Number one, it's hard to find some ofthese new exams, some of these myocardial
MRIs, and you know, only in a handful offacilities even in Houston offer this.
You know, we're kind of theheart capital of the world.
(10:10):
And also that people couldn't afford it.
62% of Texans are not getting care ordelaying care because they can't afford
it, and so that you're able to get themthe care they need when they need it, not
delaying things so it's more expensiveand they miss more work down the line.
And the employer still saves money.
Stacey Richter (10:30):
You said a couple of things.
One of them is, you know, I kindof asked you is this, arcane
solution that only a few are using?
And you said no.
This is becoming more of amainstream kind of thing.
And you can start to see why.
It was really interesting what yousaid that, you know, an employer can
do a 0% copay, like no cost sharingwith the employee and still save money.
(10:52):
If someone's spending 6%, 11%of total spend, there's a lot
of opportunity for savings.
If we can save the money and, and improveaccess, that seems like a win-win.
Cristin Dickerson (11:02):
That ethical alignment also helps with the market momentum,
and I think we're getting that acrossthe board in the ecosystem or tribe.
Stacey Richter (11:11):
We, we talked about the why now we, we've talked about the
reasons and some of its costs, someof it's quality, some of it's access,
member experience, member perception.
I mean, anybody that needsimaging like there's a problem.
It's like, here's a way that ourmembers who are in pain or scared
are able to get what they need.
Cristin Dickerson (11:32):
Even getting a mammogram is, as we all know, I mean
best day of the year is when youget your negative mammogram report.
So that, you know, that's really whatI talk about with my scheduling staff
is everybody who comes to you isgoing to be under healthcare stress
and people behave differently whenthey're under healthcare stress.
Stacey Richter (11:50):
Let's talk about the barriers now, right?
So, and, and mostly thinking about thisfrom the standpoint of a plan sponsor who
is thinking to themselves, I would liketo do something here, but they're maybe
at the very beginning of their journey.
Let's just start here.
The first barrier that I am understandingas you're talking is probably just
(12:10):
the complexity of the situation.
Because where there's mystery ismargin, as Anthony Ciccia coined
that phrase, and wow, it is so truebecause it enables margin to be hidden.
Some of the complexity from justlistening to you talk here, I have a
feeling has to do with how services arebeing coded dollars that are kind of
(12:36):
lost or they're put in other buckets sothey sort of disappear into thin air.
Could you explain more?
Cristin Dickerson (12:42):
Sure there are a lot of ways that happens.
I would say that one of the reallyinteresting stories is school district
of Osceola County in Florida.
In 2019, the teacher union wentto the school board and said, you
know, something's gotta give theseschool bus drivers, cafeteria
workers have a $5,000 deductible.
$6,500 maximum out of pocket.
(13:02):
They're functionally uninsured.
And so we did this claims data analysisand what we found was, yes, they
were paying excessively for imaging.
They had about, just on aCPT code by CPT code basis.
We were able to show about 60% savings.
But what also emerged fromthat was there's something
called a hospital revenue code.
(13:24):
And, um, with this carrier, it issupposed to be used only for inpatient,
but there were literally hundreds ofimaging exams that were paid out at
thousands and thousands of dollars.
I think there was one CT scan that waspaid out over $50,000 with hospital
revenue codes rather than CPT codes.
And so those were escaping theclaims adjudication process because
(13:48):
they were a different type of code.
And that that's the perfect type example.
It's something thatthey never had eyes on.
Even if you did a CPT codeanalysis, you wouldn't see that.
And you know, that's wherewe see things like clawbacks.
That's where we see themultiple pre-auth charges.
That's where we see the alternativenetwork charge that might, a lot
(14:09):
of times the RBP fees are higherthan what was paid to the provider.
Just like with the MultiPlan situationagain, where those fees that end up being
higher than what's actually paid out.
Stacey Richter (14:22):
So we're talking about the first barrier to implementing
some kind of direct contracting forimaging, and I boldly said it was
probably complexity and now I'm boldlydoubling down that I think I'm right.
The things that you're talking abouthere are deeply embedded in codes.
Like your average civilian looking atthis stuff might not realize there's
(14:43):
these other hospital revenue codesthat exist, or, you know, Kimberly
Carleson in that episode talked a lotabout bundling and unbundling, right?
Like, so a scan is supposed toinclude all these eight codes,
that's all in the bundle.
And then the employer, howwould you know this, right?
Like they'd get charged the bundled priceand then four codes that are supposed
(15:05):
to be in the bundle kind of thing.
You're talking about,employers are getting
charged for the pre-authsor the prior auths as
a separate bucket of things, or the contrast is
someplace else or whatever.
If it sounds like a self-insuredemployer doesn't have a third party
payment integrity vendor lookingat some of this stuff, all they're
(15:26):
going off of is what their ASOor somebody else is telling them.
There are so many perverse incentivesfor anybody who's in the middle
moving people's money around.
So many different ways dollars canbe obscured so barrier one is just, I
think, the complexity and it sounds likethe answer is, get someone who is an
(15:49):
unconflicted third party to do an audit,or it sounds like Green Imaging or you
know, other independent imaging centerscan also do audits to at least get someone
started where the landmines might be.
Cristin Dickerson (16:04):
It's eye-opening for employers to see what they're
really spending, and I would love toget my hands on their weekly file feeds
that most of them are auto-paying.
And really see what's in there.
Especially with some of these, especiallythe private equity backed TPAs.
I think my suspicion isthere's a lot in there.
Stacey Richter (16:22):
Listen to the podcast with Justin Leader called the
Mystery of the Weekly Claims Wire.
Cristin Dickerson (16:26):
One of the major carriers right now is only
giving employers the plan paymentor the member responsibility.
They won't give you both.
And so how on earth can you do fiduciaryduty if you only know a part of
the cost of a CPT code or a bundle?
It makes no sense.
Stacey Richter (16:45):
The show with Cora Opsahl
and there's also a show with Dave Chasewhere we dig into why it is so important
to get data and how to to get it.
The second barrier that I amhearing relative to moving in this
direction is when you hear thatthe TPA won't do imaging or other
(17:08):
direct contracting as a rule, orthey blame benefit design somehow.
How do you think about that one?
You know, how does that transpireand then what do you do about it?
Cristin Dickerson (17:19):
I really personally feel like a direct
contract shouldn't involve a TPA.
There are so many barriersthat we run into with this.
I'm happy, you know, thereare some great TPAs out there.
There are some that areworking beautifully with us.
But there's a lot of resistance, andit's either because they really feel
challenged by their major carrierwith whom they have an agreement.
(17:41):
There is a clause in that contract.
There's also a clause in that contractthat says anything that's excluded
by law, you know, is not valid.
And so really that is referring tothe HIPAA omnibus rule, which allows
individuals or somebody paying foron their behalf to withhold PHI from
the insurance company and pay cash.
Stacey Richter (18:02):
What you're talking about is that, you know, a, a self-insured
employer plan sponsor goes to theirASO, TPA and says like, I wanna
do direct contracting for imaging.
And then TPA says, I can't do itbecause it violates our, insert
carrier name here, contract.
Which it really could.
Every time this topic comes upon the show, I hear from some
ASO or TPA who says, look, I amreally beholden to my carriers.
(18:26):
Like there are certain things whereI just, I simply can't do them.
So could you answer the questionvery specifically, if a TPA comes
and says, we can't do that becauseit's in violation of our carrier
contract, and the employer says, butI still want to, are we at an impasse?
Cristin Dickerson (18:43):
We're not at all.
The employer doesn't haveto involve the TPA at all.
I would say that our larger employergroups are going around the TPA, maybe 80%
of them because it's simpler and easier.
Stacey Richter (18:55):
So if a TPA is just like, look, I got a carrier, I have
a longstanding relationship withthis carrier, I've got a lot of
other business with this carrier.
So for you, your one group, I can'tundermine my entire book of business
because you wanna do something.
The point that you're makingis that you have plenty of
groups who are like, okay, fine.
(19:16):
You do you TPA, meanwhile I'm gonna do me.
And that is managing a directcontract with this imaging
center and maybe others as well.
And you don't need the TPA.
Cristin Dickerson (19:28):
You don't need the TPA.
Stacey Richter (19:29):
Does that get crazy?
Cristin Dickerson (19:30):
And in fact, the TPA can complicate the situation.
Stacey Richter (19:33):
Like so are you just, I mean, if you think about third party
administrator, they're doing a bunchof different things, but one of them
is sending the weekly claims wire.
So basically what you'resaying is you just send a bill.
Cristin Dickerson (19:43):
Oh, we just send a bill, but it has all the, the data that's
needed by stop-loss to provide decrements.
It has, you know, or it would be usedin a stop-loss audit, has all the
information that is sent to a TPA.
Stacey Richter (19:56):
And I guess you don't need repricing or anything like that.
Like one of the reasons why you'dgo through a TPA is because they
have to do all the checking of thecontracts and blah, blah, blah.
But if there's just, thereis none of that, right?
It's just like, here's yourprice, you're gonna pay that.
Then this is a way, yeah.
Cristin Dickerson (20:10):
And the other reason would be a pre-auth and you know, really
pre-auths don't change utilization.
And what we do is we do radiologistprotocols, which are much more specific.
That comes down to iscontrast really needed.
CTs of the chest are ordered 30%of the time with and without,
with contrast, and it eitherneeds to be done with or without.
And so we cut the radiationin half, often decrease the
(20:31):
contrast risk and cut the cost.
Stacey Richter (20:32):
You just said something interesting there.
You said that, you know, one of the,uh, TPAs job is to manage radiology
prior auths, but prior auths don'tactually reduce the number of images.
Is that substantiated by anythingor is that in your experience?
Cristin Dickerson (20:47):
The American College of Radiology Um, did a study a couple
of years ago that showed that, thatthey do nothing except delay care.
Stacey Richter (20:54):
Yeah.
I, you know, I've heard, I think it was AlLewis was talking about that, about this
at one point, and we just did a show withPreston Alexander talking about the float.
So, it is in any given carrier's interesthere to delay care as long as possible.
And there is, I've seen, I'm notnecessarily thinking of any given study
(21:14):
per se, but I've heard anecdotallyquite a bit that prior auths will
push imaging to the next quarter.
So like if someone says, well, how manyimages were prevented this quarter?
There's always a really big number therethat probably somebody can trot out.
But then if you look at how manyof those people got images at some
(21:35):
point in the future, it is a highernumber than you would expect if
inappropriate care was being prevented.
Cristin Dickerson (21:44):
Absolutely.
It also depends on the faircost of what you're doing.
If you've got an MRI that costs $400,how is delaying care for six weeks
of physical therapy, which is gonnacost a lot more than that, that may
be delaying surgery for somebody.
It may, you know, be making things worse.
How does that make financial sense?
If you've got a fair price upfront.
Stacey Richter (22:05):
That's say another really, like if it costs $50,000, all right.
You can start to see whythere's a good reason.
You know, you prevent one inappropriatecase, you wound up saving enough
to pay for a lot of prior authing.
However, if you're doing something thatcosts $400, like the administrative
cost could wind up being, assumingthere's no patient harm, that winds
(22:28):
up transpiring, but you kind of getinto the zone where you wind up with
administrative burden and how much isgoing on, and how many do you have to
prevent in order to make it worth it.
Cristin Dickerson (22:40):
90 something percent of doctors know a patient who
has been harmed or died because ofpre-auth delays related to pre-auth.
Stacey Richter (22:48):
So, okay, second barrier that we're talking about
here, and we expanded our circle ofwhat we were talking about, but we
started out as the second barrier,as TPAs won't do it as a rule, or
they blame benefit design somehow.
And I think what we have comeup against here is that a lot of
times TPAs actually can do it.
It's just complicated, and theymay not want to, or they may
(23:08):
have some perverse incentives.
Other times they really can't becausethey do have a carrier contract,
which is gonna prevent them.
But if you're a self-insured employerand you're thinking to yourself,
but I still really wanna do that,then don't go through the TPA.
There's plenty of precedentfor doing a direct contract.
Not through a TPA.
Cristin Dickerson (23:26):
And they may have their own vendors that they're making money.
They may have an RBP plan thatthey feel like it competes with.
They may have another vendor that'spaying referral fees to them.
So there are additional reasonsthat they don't wanna do it,
that maybe, um, not as apparent.
Stacey Richter (23:42):
Let me also just remind everybody that we've had guests after
guests on this podcast basically saythat if a plan sponsor goes to their
EBC or their TPA and says, Hey, Iwanna do this because it's better for
me and my members and they wind upwith like a 72 page, very complicated
report about why they can't do it.
If the disruption, the D word, as ClaireBrockbank calls, it gets trotted out.
(24:06):
If any of those things happen,that's a red flag that there's
probably money being made somewhere.
Andreas Mang, in the first episodewith him, he said this really crisply.
He's like, you don't need a 5500disclosure form sometimes to tell if
somebody's taking money in indirectpayments by the reaction when you
ask very specific information or youwanna try to do something innovative.
(24:27):
You can tell whether they're workingwith you and trying to figure out how
to do it, or they're giving you 900reasons why you simply can't because
it's gonna disrupt their income stream.
Okay, so third barrier thisdown the hall mentality.
There's probably a, acouple of things there.
One of them, it's, it's easier to walkdown the hall, but secondly the doctor's
like, but I need the full report.
(24:48):
And if you go someplace else,I'm not gonna get the report.
Cristin Dickerson (24:50):
There is some legitimate worry when there prior studies.
We've invested heavily in the imagesharing options that are out there.
It's still not ubiquitous that youcan push around images from system
to system, but there are a number ofcompanies that are making that easier,
and we've invested heavily in that forthat reason, because we do know good
doctors wanna see the images themselves,especially the subspecialist surgeons.
(25:12):
They need to see the images.
But what I'm finding isthere's less and less pushback.
As the cost has risen, and so fewpeople are actually getting the imaging
that their doctor's recommending whenthey say, I have a zero out-of-pocket
option that's being honored more often,uh, with, with very little pushback.
So really, I think doctors don't know howexpensive it is often down the hall, and
(25:35):
I think they would be more sympatheticif they actually knew how much it was.
I bet you 60% of doctors can'teven come close to telling you what
that imaging costs down the hall.
And you know, I think patients don't andthey get horrifically high bills now.
I would've thought an ultrasounddown the hall at the hospital
would've been affordable these days.
I just had a claims data set that camein at $1,381 for the average ultrasound.
(25:59):
You know, that's rebundled.
Stacey Richter (26:00):
So if we're thinking about the down the hall as a barrier,
one of the things you are saying, aspatients become more aware, and as
the bills become higher, that fear mayoutweigh the opportunity for convenience.
The fear of having agigantic unknown charge.
(26:22):
The second thing, the patient's worriedthat their doctor won't get the imaging.
And if you're working with a placesuch as Green Imaging or you're
working with a place that has investeda lot in image sharing, which like
if you're an independent radiologycenter, in a way, you better.
Because all the images are gonnaneed to get shared, and if you
don't do it really well for theoriginating physician, then I mean,
(26:46):
what are, what are we even doing here?
Cristin Dickerson (26:48):
Or at least we make it seem seamless.
Stacey Richter (26:51):
Part of the skill is making it look easy.
We talked about three barriershere, and also in the context of
talking about those barriers, wetalked about ways to overcome them.
The first barrier we talked aboutis just the complexity that there's
just so much self-interested behaviorright now and some complexity a lot
of times, sure this is complicated.
(27:11):
But if you want to overcome it, there'scertainly unconflicted payment integrity
vendors, unconflicted benefits advisors.
There's plenty of people who canreally dig in or learning from
somebody else's experience, right?
Like if you hear that an employer inyour area did the math and figured
something out, that there's probablya likelihood that as a similar
(27:33):
plan sponsor, probably you've got asimilar circumstance, I would say.
Cristin Dickerson (27:38):
Yeah, and you know, we have reams of claims data.
I have claims data from all themajor carriers, most independent
TPAs in different industries,different geographic areas.
All of those things make a difference.
But we have thousands of claims dataassessments, so I can usually match one
to an employer and say, Hey, this is whatwe would typically see in that setting.
(27:58):
Even RBP, we can show them RBPclaims data sets, where we've got,
we actually have those fees and wecan show what they're paying in the
background compared to Green Imaging.
The other thing, and I feel like thisis where this trust factor comes in too.
It is that there's no risk with us without competitors often have a PE PM.
I strongly feel that being fee for servicealigns me ethically with the employer
(28:22):
because there's no risk to the employer.
If their members don't useus, , we're not gonna get paid.
So they can go into the firstquarter, their members can use us.
We can compare that to what theywere paying before or compare it
to market prices, some publishedentity, Turquoise, whatever it is.
Use that as the baselineand show them the savings.
(28:43):
And so I, and we do that ongoing withour employers and I really feel like
that's how you build the trust factor.
Stacey Richter (28:49):
That is probably a way for plan sponsors to feel like
they've gotten the best answer thatthey possibly can, and what is really
a gray, murky world where there islots of money getting moved around.
Cristin Dickerson (29:00):
It's actually kind of amusing right now, some
of the clauses that people wantus to put in our agreement.
You know, we're not, we'renot a traditional carrier.
We are somebody who's beentrusted in the market.
And look, this is our promise.
Everything's in our bundle.
It's all in there, and you're notgonna have to pay anything else,
and it's gonna save you money.
Stacey Richter (29:18):
Yeah, keep it simple.
The second barrier that we talkedabout is the whole TPAs won't do this,
or it's conflicts with benefit designsomehow, which again, is a thing.
Chris Deacon just wrote a post about this.
There's a lot of third party deal making.
Had a show with BrennanBilberry about anti-competitive
contracts very specifically.
(29:39):
There's just so many things that aregoing on, which could prevent someone
from doing something, which in fact isin their clients best interest and in
those circumstances, we talked about acouple of different workarounds there.
One of them is just being very demandingbecause sometimes if where there's
a will, there's a way, but if not,hopefully, let's just say the plan sponsor
(30:00):
didn't sign the rights away here, butthere are opportunities to do direct
contracting, not through a TPA who isnot able to do it or doesn't want to.
Either way, it doesn't matter.
You can do it yourself.
And then the third is kind ofcurbing the down the hall mentality.
And one of the things that you impliedin that last answer is that you take
(30:21):
it upon yourself over at Green Imaging,and I would assume that anybody
else in this, the direct contractingbusiness, we're, we're gonna have
Stanley Schwartz from Zero Health,who does direct contracting more on
a broader scale, talk about this too.
And both of you are saying the samething, that it's our responsibility to
figure out how we are talking to members.
Teaching members.
Changing member behavior so that theydon't do the down the hall thing.
(30:43):
And obviously you've got aton of experience doing that
that you can bring to bear.
So members take advantage of this cost,access, you know, all the good things.
It's a win-win.
Cristin Dickerson (30:52):
Yeah, and I think that's where the
member experience comes in.
I really built this company thinking pricetransparency was gonna level the market
and we just had to be the best from acustomer service and quality standpoint.
And, and so that's beenmy mentality all along.
Certainly on the pricing, we have notseen that and the gap has remained, but
(31:12):
I think if people look at our Googlereviews, they'll see just how easy we
make it for people and how much of thehassle factor we take off their plates.
Which is I really think if you canmake it seem easy to members, you get
that traction with an employer groupand you get that water cooler talk
and it, it really starts working.
Stacey Richter (31:32):
Which benefits plan sponsors.
Do you wanna talk a little bit aboutGreen Imaging and where someone
can find out more information?
Cristin Dickerson (31:38):
Sure.
Our website's a great resource.
Lots of videos, lots of links to articles.
www.greenimaging.net.
If you ever have a radiologist question,there's also an email link there to ask
us clinical questions if you need that.
You can request pricing there.
We will give over web chat over thephone, however you wanna request it.
We'll give you a quote.
Um, and it's all in.
Stacey Richter (31:58):
If I am a plan sponsor almost anywhere in the United
States, you have enough facilitiesto have network adequacy in my area.
Cristin Dickerson (32:06):
We do.
We can do a geo access, we can buildout the network where we need to.
We also create bundles.
If we, if there's a pediatric sedationMRI that's needed, we can go, we
know , who we need to negotiate with,the anesthesia group, the radiology
group, and the facility, and createthat bundle on behalf of an employer.
So yes, we're covering the country.
Stacey Richter (32:26):
If there is a plan sponsor listening, who's thinking to themselves
six to 11% of spend, Hmm, maybe I shouldlook into this, a good first step might
be just give you a call and you'lllet 'em know what might be possible.
Or not really, but it might be a goodfirst step to try to figure out what
a potential path forward could be.
Cristin Dickerson (32:44):
You got it.
Stacey Richter (32:45):
Dr. Cristin Dickerson, thank you so much for being on
Relentless Health Value today.
Cristin Dickerson (32:50):
Always great to have a conversation with you.
Dr. Vivian Ho (32:52):
Hi, I am Dr. Vivian Ho.
I'm a health economist at RiceUniversity in Baylor College of Medicine.
I listen to Relentless Health Valuereligiously because this is the
show for those who are part of thetribe that wants to improve the
quality of healthcare, improve accessto care, and make it affordable.
So make sure that you subscribe tothe newsletter and subscribe to the
(33:15):
podcast and keep up with every episode.
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