October 14, 2025 • 22 mins
Costs are spiking, access is shrinking, and members are stuck on hold while scans get delayed—yet the fix might be hiding in plain sight. We sit down with Dr. Cristin Dickerson, CEO of Green Imaging, to unpack how independent imaging, transparent bundles, and human-led AI can lower trend, reduce friction, and actually make benefits plans feel usable. From private equity acquisitions that quietly triple rates to the national radiologist shortage sparked by years of “AI will replace you” hype, we trace the real-world forces shaping price, quality, and time-to-care.
Cristin shares a playbook advisors and employers can put to work now: build redundancy so a single tech outage doesn’t stall care, keep the front end human while automating the back office, and route members to independent centers with clear, all-in pricing. You’ll hear how a large Texas municipality sought savings but discovered a bigger win—restored access that gave employees back hours and eliminated surprise bills. We delve into what price transparency rules overlook, why hospital quotes are often incomplete, and how direct-pay bundles circumvent games that leave members vulnerable.
We also get practical on tech. Forget AI that “reads the study” in isolation; the real gains come from tools that structure reports so radiologists never take their eyes off images, and from analytics that turn one CT into population health insights like bone density, coronary calcium, and cardiac chamber sizing. Add a clinician portal that lets DPCs and primary care search by code and price, submit narrative orders, and reach a radiologist by phone, and virtual care starts to work the way it should—fast, connected, and accountable.
If you advise employers or run a health plan, this is a roadmap to cut waste without compromising care: utilize data maps and claims rebundling to model savings, favor DPC-centric designs for a simpler member experience, and help independent centers remain independent with fair, direct contracts. Subscribe, share with a colleague who battles imaging chaos, and tell us: where are your members getting stuck, and what would a clear path to a scan change look like for your team?
This episode is sponsored by Benepower, the platform of choice for a modern benefits experience. Benepower is an AI-powered benefits platform offering access to top products and services, enabling consultants and employers to create customized plans, optimize usage, and measure effectiveness. www.benepower.com
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
David (00:01):
Could smarter imaging strategies be the hidden
superpower benefits advisorsneed to win more clients?
We'll find out on this episodeof Shift Shapers.
Announcer (00:12):
This is the Shift Shapers Podcast.
Connecting benefits advisorswith thought leaders and
entrepreneurs who are shapingthe shifts in the industry.
And now, here's your host,David Saltzman.
David (00:25):
And to help us answer that question, we have invited
back one of our favorite people,Dr. Cristin Dickerson, who's
founder, managing member, andCEO of Green Imaging.
Good morning, Cristin.
Cristin (00:37):
Good morning.
Excited to be here.
David (00:39):
Well, thank you.
Thank you.
The last time we had you on wasMarch 15, 2021.
So a lot of stuff I'm sure haschanged.
And yeah, I know, time goes by.
But let's let's start at thatjumping off point.
So since that last conversationthat we had back in March of
2021, how has the independentimaging market evolved?
And let's look at it in maybethree phases: patient demand,
(01:03):
pricing transparency, andcompetition from hospital-loan
facilities.
Cristin (01:08):
You know, uh it's changed dramatically.
And uh the first is patientsfrom just a patient standpoint.
From a patient standpoint,access is a problem.
There are a couple of thingsgoing on.
Number one, you may go to animaging center and you may
expect to pay what you paidthree years ago.
And that imaging center stillhas the same name, but it's been
(01:31):
acquired not as likely by ahospital system now, but by
private equity.
And meanwhile, the price hastripled overnight.
The contracted rates havetripled overnight because
they're aggregating contracts.
And it's likely that they'resplit billing with a radiology
group as well, because theradiology groups are also
private equity-owned and want tocontrol their own money.
(01:53):
So you may have a surprise billcoming as well.
So that's the likelihood from apatient.
Also, it's harder to accessimaging.
2021 was a tough year becauseof COVID as it was, but really
prior to COVID to now, access toimaging is very difficult.
David (02:12):
So it's gotten worse?
Cristin (02:13):
It's gotten worse.
It has gotten less.
Getting contrast or getting aprocedure done that requires a
radiologist on site is very,very limited and difficult.
Number two, there's aradiologist shortage nationally,
just like every other kind ofdoctor, but particularly
(02:34):
radiologists, because we had abrilliant um Nobel Prize winner
who uh 10 years ago said thatradiologists would be um, you
know, obsolete by now, andradiologists' residents stopped
going into radiology.
And they thought AI was goingto be replacing radiology, and
he has retracted that now, butit's not without doing
tremendous damage to the field.
David (02:57):
What about pricing transparency?
Has there been any improvementthere?
Cristin (03:01):
I can usually find one or two facilities in a
metropolitan area that have somepricing transparency.
It's terrible with hospitalsbecause you would have to know
all of the CPT codes.
You know, typically it's notjust one CPT code that is built
with an exam.
Often there's a contrast codeor some other supplies.
And frequently it's also goingto be an outside radiology bird
(03:24):
that reads the study.
So when you get a good faithestimate from a hospital, you're
getting typically one CPT code,the main CPT code, and there's
going to be a footnote that saysother codes may apply.
And also that this does notinclude professional services.
So you're really getting a tinyfraction of what you might
expect to pay.
David (03:43):
Oh, fun and games, fun and games.
Well, you alluded to COVID alittle while ago.
So during the pandemic, youknow, imaging volumes dropped,
I'm sure, significantly.
How did you guys rebound andwhat lasting changes do you see
in either patient behavior orreferral patterns as a result?
Cristin (03:58):
Um, I think, you know, things, yes, especially in Texas
and Florida, which are ourbest, I would say, you know,
most populous states for coveredlives, um, that we were limited
to what was called essentialimaging, only uh imaging that,
you know, couldn't be uhavoided.
Screening was out.
So we were at about 50%capacity as a company.
(04:19):
We took that as a challenge tobecome stronger.
We did not lay anybody off.
We put everybody on specialprojects trying to, you know,
build out the network because atthat time there were challenges
with somebody's tech would goout sick or their kid would be
sick, and you know, we wouldn'thave CT scans at the site for a
month.
So we really built out a muchmore redundant network and we
(04:40):
just built out a lot of projectsthat helped automate things in
the back office.
I never want the front officeto be automated.
That's real people taking careof people.
But we built out a lot of umback office automation that I
think has really made ourcompany um much, much, much more
frictionless.
David (04:58):
You know, we're having that same conversation with some
of our clients.
You know, that everybody's AIthis and AI that.
You know, you can buy an AItoaster and an AI blender.
And, you know, I try to tellfolks, you know, we won't ever
do that on our front end becausewe prefer to use the other AI,
which is adult intelligence.
So you get, you know, actualhuman beings.
It's always, you know, it'salways it's great that we've got
(05:18):
AI, but you ever notice thatall of the satellites and
whatnot that are looking forintelligent life are pointed
away from the earth?
Just an observation, but youknow, so you you took it as a go
ahead.
Cristin (05:28):
When Brene Brown brought this up at a conference
last week.
Um, you know, it's humanity nowthat's gonna be the
differentiator.
And we've taken humanity out ofour lives a lot, especially the
business place.
And so really restoringhumanity and trust, I think, to
the healthcare equation isessential.
David (05:45):
You know, it's interesting because all of the
folks who are building AI are ofthe opinion, at least for the
next five, 10 years, that thebest use of it is going to be AI
alongside human beings.
Right.
Cristin (05:56):
And I for for radiology reporting, same thing, and that
that was ultimately the uh theconclusion there is that you
know, it radiologists are notgoing to go away, they're just
gonna be better.
David (06:09):
And nothing wrong with that.
So you again, something elsethat you touched on in one of
your earlier answers.
The federal price transparencyrules for hospitals went into
effect in 2021.
So from from where you sit,have those rules made any
meaningful changes in patientchoices or employer strategies
around imaging?
Cristin (06:28):
I think there are, you know, I never want to throw
everybody in one bucket.
I am working with a number ofhospitals, especially in Texas,
who see the opportunity to workwith us as an opportunity to
provide transparent pricing.
And we, you know, we are gonnaoffer a bundled price for their
services and we're gonna readthe, you know, we're gonna have
our radiologists read it.
(06:49):
Um we get around theexclusivity with the radiology
groups because we do a leasearrangement with that hospital.
So there's no, and and they'reright, you know, typically their
radiology groups will not givethem cash rates.
Um, you know, they're notcompliant with that.
And so we really give them theopportunity to do that.
So I don't want to throw thebaby out with a bat moderator,
but nationally, not only are isthere a lack of transparency,
(07:13):
you know, there's this goodfaith estimate that's a tiny
fraction of what people aregoing to pay.
Um, it's hard to get those.
They make it as difficult aspossible.
And they're not honoring thoseif the patient has insurance.
So even if the patient iscoming, you know, through us
with, you know, the employer isgoing to pay for this on their
behalf, which is under the HIPAAomniscience law, that's
(07:36):
completely legal.
They are illegally going intothe patient's record.
This they use scrubbers, whichare is a software that goes in
and looks for that kind ofinformation.
They find the patient hasinsurance and then they won't
honor that price.
And we fight that, our ourlegal team fights that almost on
a daily basis.
David (07:53):
Uh and that's the subject of a whole other conversation.
And maybe we'll have that oneday soon.
So, to the advisor side of it,um, have you seen advisors and
even employers being moreproactive about steering members
towards um more independentcenters for cost and quality
reasons?
Cristin (08:12):
You know, I really have.
I've seen even um brokers withthe traditional brokerage houses
are they're coming our way ortheir employers are coming our
way despite them.
And so, you know, I would saythe biggest change I've seen
David since 2021 is the size ofour groups.
I would say 2021, it was 50 to200 was probably the average
(08:39):
growth.
Um, two years ago, it wasprobably 500 to 2000.
And now we're probably onaverage at 5,000 or more.
David (08:48):
Interesting.
Do you do you attribute thatpredominantly to cost
differentials, or is there alsoa patient satisfaction metric
that figures in there?
Cristin (08:57):
You know, it the city of Plano in Texas, um, that they
have a wonderful um lead fortheir health plan.
And she's an ex-CFO, which ifthat gives you some perspective.
What she said was at theHouston Business Coalition on
Health panel that we were bothon.
She said, we brought greenimaging in to solve a cost
problem that we knew we had.
(09:18):
We ended up solving an accessproblem that we did not know we
had.
And so I think it's more withthese larger companies, it's as
much about access as it is aboutcost.
And when you know you look atthese national coalitions,
they're quoting their employersas saying they're mem, they're
spending as much on theirmembers being away from work,
(09:42):
trying to navigate the brokenhealth system as they are on the
healthcare itself.
And so I think when we cancorrect that by providing these
people access, getting theirappointments scheduled for them.
They're not hanging on the tubfor two hours.
They're not going through thetraditional authentic process
that may take a week.
When we're getting them thecare they need when they need
it, that's a game changer.
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Now, back to our conversation.
So telemedicine boomed duringCOVID for obvious reasons.
Um how are you guys inintegrating with that kind of
(11:30):
trend?
And um what are you seeing interms of consults and digital
referrals?
Or is that something thatyou're involved in at all?
Cristin (11:38):
It is because my background is with
multi-specialty groups.
I spent the first 13 years ofmy really the first 20 years of
my career totally withmulti-specialty groups.
And I think that is atremendous way to practice
medicine.
You know, the doctors wouldbring the patient down to the
radiology department and say,she hurts right here.
And it's amazing how much moreyou see when you know exactly
(11:59):
what's going on.
And there's no ICD 10 code thatsays she hurts here.
There's just no way to do that.
As many ICD-10 codes as thereare.
And so it was a great way topractice medicine.
Um, I have tried to reproducethat in the digital world.
Um, we have what we call anavigator portal now, where and
(12:19):
it's mostly it's as many, youknow, that we have these nurse
navigators that are using it,and that's fantastic.
We have a lot of DPCs, a lot ofdirect primary care doctors and
other doctors for referring ourway that have complete access
to our team and to me and toanybody they need at Green
Imaging via this portal.
They can search by CBT code andprice and find a study.
(12:41):
They can submit the order, theycan tell us in a narrative way
what we need, and they've got myphone number.
And so I strongly feel, as doesmy partner Craig Cook, who's
also a radiologist, that ouravailability to clinicians, and
that was one of the things that,you know, was not factored in
in radiologists going away, andis that we're the doctor's
(13:02):
doctor.
We're the ones who help themfigure out what's going on
inside of their patient and tiethings together.
And, you know, it's ourknowledge of kind of that
crosses all specialties thatreally makes us different than a
lot of other physicians.
I think pathologists aresomewhat in that uh realm as
well.
It's the same kind of thoughtprocess, but we're really
diagnosticians.
(13:23):
And so I really try to fosterthat digitally.
I will say that telehealth hasdecreased.
There's a good American Collegeof Radiology study that shows
that telehealth has decreasedimaging orders and not in a good
way.
People are getting less,they're going on antibiotics
without the chest x-ray to seeif they have an amemia because
telehealth, it's inconvenientfor those doctors to receive an
(13:45):
imaging report.
They don't have management forthat.
I'm seeing more and more ofthem reach over our way to try
to solve those problems.
But it really created more of aproblem than it did a solution
initially.
David (13:59):
Interesting.
We touched on AI earlier in ourconversation with regard to
radiology, both for diagnosticsand we talked a little bit about
workflow.
What's hype?
What's real, and how are youguys approaching it?
Cristin (14:13):
Um the hype is that you know, I actually had an MSK
company say they were just gonnause AI to interpret their MSK
exams.
That's hype.
That's not gonna happen anytimesoon.
If you're doing that, you'regonna move, you know, you're
gonna miss the lung tumor that'sover there next to the
shoulder.
And it's just never gonnahappen because those solutions
are built to solve one problem,not the all-encompassing patient
(14:36):
and patient experience.
Um, so I think you know thatthat's the hype, the good things
that are happening.
I'm using a tool that actuallyorganizes my radiology report.
So I don't have to take my eyesoff of the images.
I'm scrolling, I'm looking atthe images, I'm saying what I'm
seeing, and it organizes it.
(14:57):
I don't have to go find thosefields.
Those fields are already therein my, you know, it's not like I
know the order in which theygo, but it puts them in the
right place and I'm notscrambling my eyes back and
forth from two different, youknow, on two different screens.
I think that's a wonderfulthing.
Um, you know, and I'm verycareful to make sure it's
working properly.
Um, I think some I'm seeingreports that indicate that some
(15:19):
radiologists are not, but youknow, that's that's certainly my
responsibility.
And the other thing that I seeis there are some technologies
that are enabling us to takekind of a traditional exam and
turn it into a population healthexam.
For example, we have um theopportunity to turn any CT, any
body CT scan into a bone densityexam, uh quantitative bone
(15:43):
density, which is better thanDEXA, which is kind of the gold
standard right now.
Um if it's a chest CT, I canalso do a calcium score CT
evaluation, which is the bestpredictor of cardiovascular risk
for a human being.
And then I can also do acardiac chamber size, which is
kind of an epicardiogram.
It's not an equivalent, butit's a it's kind of a screening
(16:03):
epicardiogram.
And being able to get thosethree exams from like one
screening chest CT is an amazingthing to me and a true game
changer for population health.
David (16:15):
Interesting.
Now, you know, every time youand I see each other at a
meeting, there you're surroundedby a bunch of agents and
brokers, and they they love whatyou do, and you guys make it
very easy and very accessible.
So I'm interested since thatslowdown, you know, the COVID
slowdown, what have you learnedabout working with benefits
advisors and TPAs that help thembuild stronger value props with
(16:36):
their employer clients?
Cristin (16:38):
Um, I think I became an advisor through the Foundation
Institute training as an advisorin the Health Resetta um
program and really came tounderstand health benefits
plans.
And um, you know, I think thatgives us a tremendous leg up.
We know how to work with HSAplans, um, we know how stop loss
(16:59):
works, we know um we have theinstitutional knowledge now that
you know an a very advancedprogram direct contracting would
have.
And I think that has been agame changer.
I can really help them problemsolve.
Um and also I think we offerwonderful tools for sales for
advisors.
If they can just get ade-identified census from an
(17:22):
employer, we can show them, bothon a histogram and a map, how
close our imaging sitters are totheir employees.
If we can get the claims data,we can do a claims data
assessment and actually showthem, rebundle the prices in the
claims data and show them thecomparison of what the savings
would be, even after theemployer offers it at zero out
of pocket.
And finally, if they don't haveaccess to claims data, which is
(17:44):
more frequent than you wouldthink, um we have reams of
claims data from across thecountry, different networks,
different industries, and we cantypically provide a sample for
them of what the savings wouldbe.
David (17:55):
Are you seeing any new plan designs or employer
contracting models emerging thathave made it easier to
integrate high quality, lowercost imaging into benefits
packages?
Cristin (18:06):
I think these new health plans that are
DPC-centric, especially that areadvanced primary care centric,
are a wonderful market entitybecause I think it looks more
cohesive to a member to have aplan with this name, whether
that's Curative Santa, whateverit is, um, to have a health
(18:29):
plan, I think that makes adifference instead of 10
different stickers.
I as much as you know, we loveworking with other best-in-class
solutions and we workcohesively with it, it may not
seem that way to a member who'sgetting this independent TPA
benefits card with 10 differentQR codes on it.
(18:49):
So I really think these healthplans that are, you know,
working with best in classsolutions are a great market
addition.
David (18:59):
Looking ahead, what do you see as the biggest
opportunities for independentimaging over the next three to
five years, especially whereemployers and advisors are all
facing renewed cost pressure?
And frankly, the medical trendnumbers that I'm hearing for
this coming year are justbreathtaking.
Cristin (19:14):
Right.
I think the independent imagingcenters and the office
practices especially are lockedin at terrible reimbursement
rates.
They are at reimbursement ratesthat are not sustainable.
They are going to, if theydon't make changes, they are
going to be bought up by privateequity.
There is just, you know, I havea friend who sold out to
private equity at wonderfulimaging centers in Houston.
(19:36):
He said his EBITDA tripledunder their contracts compared
to his.
That's irresistible.
How can you, you know, notchange things and do that?
So I think if they really wantto stay independent, and I urge
physicians across the country tostay independent, you know,
this this change is not going tohappen without that and without
(19:57):
them.
But the ones that want to stayindependent need to get, you
know, get aggregated.
You can't do it alone.
Get aggregated with people withgreen imaging and with
everybody else that is, youknow, looking for direct
contracts for imaging and getbetter reimbursement.
You can get it.
The differential is so highbetween what's in the claims
(20:17):
data and what you're gettingpaid.
Let us pay you better and keepyou independent.
And that's that's really whatneeds to happen.
David (20:25):
So, one last question as we wrap up.
If if we were to talk, let'sfast forward five years from
now, what do you hope to be ableto say about how independent
imaging has reshaped healthcaredelivery in our country?
Cristin (20:37):
Um, I I want to see them succeed and have the um
have the resources, you know,kind of no margin, no mission,
the resources to employ thesethings that make a difference in
population health.
Not things like whole body MRIscreening, which take us from,
you know, we're down at themillimeter level now with with
breast imaging, with traditionalbreast imaging and with
(20:59):
colonoscopy.
We're detecting things at themillimeter level.
You go back to whole body MRIand you're at the centimeter
level.
That makes no sense.
And so I really think it isgiving them the margin to invest
in the technology that makesthem exceptional and maybe
better than hospital systems.
Um I think people are looking,individuals are looking.
(21:20):
You know, so many people onhealth shares in this country,
so many people uninsured in thiscountry.
And I think people are lookingfor good health care that they
can rely on and that's going togive them information to be
healthier people.
And I think, you know,investing in these AI tools, you
know, we bring those to all ofour imaging centers.
All of our imaging centers canlaunch these AI tools that I'm
(21:42):
talking about through us.
You know, I think really umtaking the time to look at
population health, what'semerging out there, what people
want from their health care, andanswering that question and
giving yourself the margin to dothat is super important.
That will be success forindependent imaging centers.
David (21:59):
If our listeners want to reach out to you to learn more
about what you're doing or howthey can interact or bring what
you guys are offering to theirclients, what's the best way to
find information or to get intouch?
Cristin (22:09):
Best way to get in touch is through me.
It's DRD, drd atgreenimaging.net.
Dot com will take you toCanada.net kiks you in Houston.
David (22:19):
Good to know.
Kristen Dickerson, founder,managing member, CEO of Green
Imaging.
Doc, thanks so much for anothergreat interview.
Cristin (22:27):
So fun, David.
Good to see you.
Announcer (22:32):
The Shift Shapers podcast is a production of Shift
Shapers LLC.
The content and images of thispodcast may not be used without
our express written permission.
Copyright 2023, all rightsreserved.
Could smarter imaging strategies be the hidden
superpower benefits advisorsneed to win more clients?
We'll find out on this episodeof Shift Shapers.
Announcer (00:12):
This is the Shift Shapers Podcast.
Connecting benefits advisorswith thought leaders and
entrepreneurs who are shapingthe shifts in the industry.
And now, here's your host,David Saltzman.
David (00:25):
And to help us answer that question, we have invited
back one of our favorite people,Dr. Cristin Dickerson, who's
founder, managing member, andCEO of Green Imaging.
Good morning, Cristin.
Cristin (00:37):
Good morning.
Excited to be here.
David (00:39):
Well, thank you.
Thank you.
The last time we had you on wasMarch 15, 2021.
So a lot of stuff I'm sure haschanged.
And yeah, I know, time goes by.
But let's let's start at thatjumping off point.
So since that last conversationthat we had back in March of
2021, how has the independentimaging market evolved?
And let's look at it in maybethree phases: patient demand,
(01:03):
pricing transparency, andcompetition from hospital-loan
facilities.
Cristin (01:08):
You know, uh it's changed dramatically.
And uh the first is patientsfrom just a patient standpoint.
From a patient standpoint,access is a problem.
There are a couple of thingsgoing on.
Number one, you may go to animaging center and you may
expect to pay what you paidthree years ago.
And that imaging center stillhas the same name, but it's been
(01:31):
acquired not as likely by ahospital system now, but by
private equity.
And meanwhile, the price hastripled overnight.
The contracted rates havetripled overnight because
they're aggregating contracts.
And it's likely that they'resplit billing with a radiology
group as well, because theradiology groups are also
private equity-owned and want tocontrol their own money.
(01:53):
So you may have a surprise billcoming as well.
So that's the likelihood from apatient.
Also, it's harder to accessimaging.
2021 was a tough year becauseof COVID as it was, but really
prior to COVID to now, access toimaging is very difficult.
David (02:12):
So it's gotten worse?
Cristin (02:13):
It's gotten worse.
It has gotten less.
Getting contrast or getting aprocedure done that requires a
radiologist on site is very,very limited and difficult.
Number two, there's aradiologist shortage nationally,
just like every other kind ofdoctor, but particularly
(02:34):
radiologists, because we had abrilliant um Nobel Prize winner
who uh 10 years ago said thatradiologists would be um, you
know, obsolete by now, andradiologists' residents stopped
going into radiology.
And they thought AI was goingto be replacing radiology, and
he has retracted that now, butit's not without doing
tremendous damage to the field.
David (02:57):
What about pricing transparency?
Has there been any improvementthere?
Cristin (03:01):
I can usually find one or two facilities in a
metropolitan area that have somepricing transparency.
It's terrible with hospitalsbecause you would have to know
all of the CPT codes.
You know, typically it's notjust one CPT code that is built
with an exam.
Often there's a contrast codeor some other supplies.
And frequently it's also goingto be an outside radiology bird
(03:24):
that reads the study.
So when you get a good faithestimate from a hospital, you're
getting typically one CPT code,the main CPT code, and there's
going to be a footnote that saysother codes may apply.
And also that this does notinclude professional services.
So you're really getting a tinyfraction of what you might
expect to pay.
David (03:43):
Oh, fun and games, fun and games.
Well, you alluded to COVID alittle while ago.
So during the pandemic, youknow, imaging volumes dropped,
I'm sure, significantly.
How did you guys rebound andwhat lasting changes do you see
in either patient behavior orreferral patterns as a result?
Cristin (03:58):
Um, I think, you know, things, yes, especially in Texas
and Florida, which are ourbest, I would say, you know,
most populous states for coveredlives, um, that we were limited
to what was called essentialimaging, only uh imaging that,
you know, couldn't be uhavoided.
Screening was out.
So we were at about 50%capacity as a company.
(04:19):
We took that as a challenge tobecome stronger.
We did not lay anybody off.
We put everybody on specialprojects trying to, you know,
build out the network because atthat time there were challenges
with somebody's tech would goout sick or their kid would be
sick, and you know, we wouldn'thave CT scans at the site for a
month.
So we really built out a muchmore redundant network and we
(04:40):
just built out a lot of projectsthat helped automate things in
the back office.
I never want the front officeto be automated.
That's real people taking careof people.
But we built out a lot of umback office automation that I
think has really made ourcompany um much, much, much more
frictionless.
David (04:58):
You know, we're having that same conversation with some
of our clients.
You know, that everybody's AIthis and AI that.
You know, you can buy an AItoaster and an AI blender.
And, you know, I try to tellfolks, you know, we won't ever
do that on our front end becausewe prefer to use the other AI,
which is adult intelligence.
So you get, you know, actualhuman beings.
It's always, you know, it'salways it's great that we've got
(05:18):
AI, but you ever notice thatall of the satellites and
whatnot that are looking forintelligent life are pointed
away from the earth?
Just an observation, but youknow, so you you took it as a go
ahead.
Cristin (05:28):
When Brene Brown brought this up at a conference
last week.
Um, you know, it's humanity nowthat's gonna be the
differentiator.
And we've taken humanity out ofour lives a lot, especially the
business place.
And so really restoringhumanity and trust, I think, to
the healthcare equation isessential.
David (05:45):
You know, it's interesting because all of the
folks who are building AI are ofthe opinion, at least for the
next five, 10 years, that thebest use of it is going to be AI
alongside human beings.
Right.
Cristin (05:56):
And I for for radiology reporting, same thing, and that
that was ultimately the uh theconclusion there is that you
know, it radiologists are notgoing to go away, they're just
gonna be better.
David (06:09):
And nothing wrong with that.
So you again, something elsethat you touched on in one of
your earlier answers.
The federal price transparencyrules for hospitals went into
effect in 2021.
So from from where you sit,have those rules made any
meaningful changes in patientchoices or employer strategies
around imaging?
Cristin (06:28):
I think there are, you know, I never want to throw
everybody in one bucket.
I am working with a number ofhospitals, especially in Texas,
who see the opportunity to workwith us as an opportunity to
provide transparent pricing.
And we, you know, we are gonnaoffer a bundled price for their
services and we're gonna readthe, you know, we're gonna have
our radiologists read it.
(06:49):
Um we get around theexclusivity with the radiology
groups because we do a leasearrangement with that hospital.
So there's no, and and they'reright, you know, typically their
radiology groups will not givethem cash rates.
Um, you know, they're notcompliant with that.
And so we really give them theopportunity to do that.
So I don't want to throw thebaby out with a bat moderator,
but nationally, not only are isthere a lack of transparency,
(07:13):
you know, there's this goodfaith estimate that's a tiny
fraction of what people aregoing to pay.
Um, it's hard to get those.
They make it as difficult aspossible.
And they're not honoring thoseif the patient has insurance.
So even if the patient iscoming, you know, through us
with, you know, the employer isgoing to pay for this on their
behalf, which is under the HIPAAomniscience law, that's
(07:36):
completely legal.
They are illegally going intothe patient's record.
This they use scrubbers, whichare is a software that goes in
and looks for that kind ofinformation.
They find the patient hasinsurance and then they won't
honor that price.
And we fight that, our ourlegal team fights that almost on
a daily basis.
David (07:53):
Uh and that's the subject of a whole other conversation.
And maybe we'll have that oneday soon.
So, to the advisor side of it,um, have you seen advisors and
even employers being moreproactive about steering members
towards um more independentcenters for cost and quality
reasons?
Cristin (08:12):
You know, I really have.
I've seen even um brokers withthe traditional brokerage houses
are they're coming our way ortheir employers are coming our
way despite them.
And so, you know, I would saythe biggest change I've seen
David since 2021 is the size ofour groups.
I would say 2021, it was 50 to200 was probably the average
(08:39):
growth.
Um, two years ago, it wasprobably 500 to 2000.
And now we're probably onaverage at 5,000 or more.
David (08:48):
Interesting.
Do you do you attribute thatpredominantly to cost
differentials, or is there alsoa patient satisfaction metric
that figures in there?
Cristin (08:57):
You know, it the city of Plano in Texas, um, that they
have a wonderful um lead fortheir health plan.
And she's an ex-CFO, which ifthat gives you some perspective.
What she said was at theHouston Business Coalition on
Health panel that we were bothon.
She said, we brought greenimaging in to solve a cost
problem that we knew we had.
(09:18):
We ended up solving an accessproblem that we did not know we
had.
And so I think it's more withthese larger companies, it's as
much about access as it is aboutcost.
And when you know you look atthese national coalitions,
they're quoting their employersas saying they're mem, they're
spending as much on theirmembers being away from work,
(09:42):
trying to navigate the brokenhealth system as they are on the
healthcare itself.
And so I think when we cancorrect that by providing these
people access, getting theirappointments scheduled for them.
They're not hanging on the tubfor two hours.
They're not going through thetraditional authentic process
that may take a week.
When we're getting them thecare they need when they need
it, that's a game changer.
David (10:03):
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Now, back to our conversation.
So telemedicine boomed duringCOVID for obvious reasons.
Um how are you guys inintegrating with that kind of
(11:30):
trend?
And um what are you seeing interms of consults and digital
referrals?
Or is that something thatyou're involved in at all?
Cristin (11:38):
It is because my background is with
multi-specialty groups.
I spent the first 13 years ofmy really the first 20 years of
my career totally withmulti-specialty groups.
And I think that is atremendous way to practice
medicine.
You know, the doctors wouldbring the patient down to the
radiology department and say,she hurts right here.
And it's amazing how much moreyou see when you know exactly
(11:59):
what's going on.
And there's no ICD 10 code thatsays she hurts here.
There's just no way to do that.
As many ICD-10 codes as thereare.
And so it was a great way topractice medicine.
Um, I have tried to reproducethat in the digital world.
Um, we have what we call anavigator portal now, where and
(12:19):
it's mostly it's as many, youknow, that we have these nurse
navigators that are using it,and that's fantastic.
We have a lot of DPCs, a lot ofdirect primary care doctors and
other doctors for referring ourway that have complete access
to our team and to me and toanybody they need at Green
Imaging via this portal.
They can search by CBT code andprice and find a study.
(12:41):
They can submit the order, theycan tell us in a narrative way
what we need, and they've got myphone number.
And so I strongly feel, as doesmy partner Craig Cook, who's
also a radiologist, that ouravailability to clinicians, and
that was one of the things that,you know, was not factored in
in radiologists going away, andis that we're the doctor's
(13:02):
doctor.
We're the ones who help themfigure out what's going on
inside of their patient and tiethings together.
And, you know, it's ourknowledge of kind of that
crosses all specialties thatreally makes us different than a
lot of other physicians.
I think pathologists aresomewhat in that uh realm as
well.
It's the same kind of thoughtprocess, but we're really
diagnosticians.
(13:23):
And so I really try to fosterthat digitally.
I will say that telehealth hasdecreased.
There's a good American Collegeof Radiology study that shows
that telehealth has decreasedimaging orders and not in a good
way.
People are getting less,they're going on antibiotics
without the chest x-ray to seeif they have an amemia because
telehealth, it's inconvenientfor those doctors to receive an
(13:45):
imaging report.
They don't have management forthat.
I'm seeing more and more ofthem reach over our way to try
to solve those problems.
But it really created more of aproblem than it did a solution
initially.
David (13:59):
Interesting.
We touched on AI earlier in ourconversation with regard to
radiology, both for diagnosticsand we talked a little bit about
workflow.
What's hype?
What's real, and how are youguys approaching it?
Cristin (14:13):
Um the hype is that you know, I actually had an MSK
company say they were just gonnause AI to interpret their MSK
exams.
That's hype.
That's not gonna happen anytimesoon.
If you're doing that, you'regonna move, you know, you're
gonna miss the lung tumor that'sover there next to the
shoulder.
And it's just never gonnahappen because those solutions
are built to solve one problem,not the all-encompassing patient
(14:36):
and patient experience.
Um, so I think you know thatthat's the hype, the good things
that are happening.
I'm using a tool that actuallyorganizes my radiology report.
So I don't have to take my eyesoff of the images.
I'm scrolling, I'm looking atthe images, I'm saying what I'm
seeing, and it organizes it.
(14:57):
I don't have to go find thosefields.
Those fields are already therein my, you know, it's not like I
know the order in which theygo, but it puts them in the
right place and I'm notscrambling my eyes back and
forth from two different, youknow, on two different screens.
I think that's a wonderfulthing.
Um, you know, and I'm verycareful to make sure it's
working properly.
Um, I think some I'm seeingreports that indicate that some
(15:19):
radiologists are not, but youknow, that's that's certainly my
responsibility.
And the other thing that I seeis there are some technologies
that are enabling us to takekind of a traditional exam and
turn it into a population healthexam.
For example, we have um theopportunity to turn any CT, any
body CT scan into a bone densityexam, uh quantitative bone
(15:43):
density, which is better thanDEXA, which is kind of the gold
standard right now.
Um if it's a chest CT, I canalso do a calcium score CT
evaluation, which is the bestpredictor of cardiovascular risk
for a human being.
And then I can also do acardiac chamber size, which is
kind of an epicardiogram.
It's not an equivalent, butit's a it's kind of a screening
(16:03):
epicardiogram.
And being able to get thosethree exams from like one
screening chest CT is an amazingthing to me and a true game
changer for population health.
David (16:15):
Interesting.
Now, you know, every time youand I see each other at a
meeting, there you're surroundedby a bunch of agents and
brokers, and they they love whatyou do, and you guys make it
very easy and very accessible.
So I'm interested since thatslowdown, you know, the COVID
slowdown, what have you learnedabout working with benefits
advisors and TPAs that help thembuild stronger value props with
(16:36):
their employer clients?
Cristin (16:38):
Um, I think I became an advisor through the Foundation
Institute training as an advisorin the Health Resetta um
program and really came tounderstand health benefits
plans.
And um, you know, I think thatgives us a tremendous leg up.
We know how to work with HSAplans, um, we know how stop loss
(16:59):
works, we know um we have theinstitutional knowledge now that
you know an a very advancedprogram direct contracting would
have.
And I think that has been agame changer.
I can really help them problemsolve.
Um and also I think we offerwonderful tools for sales for
advisors.
If they can just get ade-identified census from an
(17:22):
employer, we can show them, bothon a histogram and a map, how
close our imaging sitters are totheir employees.
If we can get the claims data,we can do a claims data
assessment and actually showthem, rebundle the prices in the
claims data and show them thecomparison of what the savings
would be, even after theemployer offers it at zero out
of pocket.
And finally, if they don't haveaccess to claims data, which is
(17:44):
more frequent than you wouldthink, um we have reams of
claims data from across thecountry, different networks,
different industries, and we cantypically provide a sample for
them of what the savings wouldbe.
David (17:55):
Are you seeing any new plan designs or employer
contracting models emerging thathave made it easier to
integrate high quality, lowercost imaging into benefits
packages?
Cristin (18:06):
I think these new health plans that are
DPC-centric, especially that areadvanced primary care centric,
are a wonderful market entitybecause I think it looks more
cohesive to a member to have aplan with this name, whether
that's Curative Santa, whateverit is, um, to have a health
(18:29):
plan, I think that makes adifference instead of 10
different stickers.
I as much as you know, we loveworking with other best-in-class
solutions and we workcohesively with it, it may not
seem that way to a member who'sgetting this independent TPA
benefits card with 10 differentQR codes on it.
(18:49):
So I really think these healthplans that are, you know,
working with best in classsolutions are a great market
addition.
David (18:59):
Looking ahead, what do you see as the biggest
opportunities for independentimaging over the next three to
five years, especially whereemployers and advisors are all
facing renewed cost pressure?
And frankly, the medical trendnumbers that I'm hearing for
this coming year are justbreathtaking.
Cristin (19:14):
Right.
I think the independent imagingcenters and the office
practices especially are lockedin at terrible reimbursement
rates.
They are at reimbursement ratesthat are not sustainable.
They are going to, if theydon't make changes, they are
going to be bought up by privateequity.
There is just, you know, I havea friend who sold out to
private equity at wonderfulimaging centers in Houston.
(19:36):
He said his EBITDA tripledunder their contracts compared
to his.
That's irresistible.
How can you, you know, notchange things and do that?
So I think if they really wantto stay independent, and I urge
physicians across the country tostay independent, you know,
this this change is not going tohappen without that and without
(19:57):
them.
But the ones that want to stayindependent need to get, you
know, get aggregated.
You can't do it alone.
Get aggregated with people withgreen imaging and with
everybody else that is, youknow, looking for direct
contracts for imaging and getbetter reimbursement.
You can get it.
The differential is so highbetween what's in the claims
(20:17):
data and what you're gettingpaid.
Let us pay you better and keepyou independent.
And that's that's really whatneeds to happen.
David (20:25):
So, one last question as we wrap up.
If if we were to talk, let'sfast forward five years from
now, what do you hope to be ableto say about how independent
imaging has reshaped healthcaredelivery in our country?
Cristin (20:37):
Um, I I want to see them succeed and have the um
have the resources, you know,kind of no margin, no mission,
the resources to employ thesethings that make a difference in
population health.
Not things like whole body MRIscreening, which take us from,
you know, we're down at themillimeter level now with with
breast imaging, with traditionalbreast imaging and with
(20:59):
colonoscopy.
We're detecting things at themillimeter level.
You go back to whole body MRIand you're at the centimeter
level.
That makes no sense.
And so I really think it isgiving them the margin to invest
in the technology that makesthem exceptional and maybe
better than hospital systems.
Um I think people are looking,individuals are looking.
(21:20):
You know, so many people onhealth shares in this country,
so many people uninsured in thiscountry.
And I think people are lookingfor good health care that they
can rely on and that's going togive them information to be
healthier people.
And I think, you know,investing in these AI tools, you
know, we bring those to all ofour imaging centers.
All of our imaging centers canlaunch these AI tools that I'm
(21:42):
talking about through us.
You know, I think really umtaking the time to look at
population health, what'semerging out there, what people
want from their health care, andanswering that question and
giving yourself the margin to dothat is super important.
That will be success forindependent imaging centers.
David (21:59):
If our listeners want to reach out to you to learn more
about what you're doing or howthey can interact or bring what
you guys are offering to theirclients, what's the best way to
find information or to get intouch?
Cristin (22:09):
Best way to get in touch is through me.
It's DRD, drd atgreenimaging.net.
Dot com will take you toCanada.net kiks you in Houston.
David (22:19):
Good to know.
Kristen Dickerson, founder,managing member, CEO of Green
Imaging.
Doc, thanks so much for anothergreat interview.
Cristin (22:27):
So fun, David.
Good to see you.
Announcer (22:32):
The Shift Shapers podcast is a production of Shift
Shapers LLC.
The content and images of thispodcast may not be used without
our express written permission.
Copyright 2023, all rightsreserved.
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