Dr Andrew Greenland: 0:10

Welcome back to Voices in Health and Wellness. This is the podcast where we spotlight the innovators, leaders and disruptors shaping the future of care. Today, we're joined by Dr Kristen Dickerson, founder and CEO of Green Imaging, a pioneering radiology service offering high-quality, affordable medical imaging with full price transparency. Dr Dickinson launched Green Imaging with a bold idea what if you could remove the middlemen, lower costs and still offer world-class care? And over the past decade, he's done exactly that building a nationwide imaging network that's helping patients, employers and healthcare workers alike rethink how diagnostic imaging is delivered and paid for. So, kristen, thank you very much for joining us this afternoon and welcome to the show.

Dr Cristin Dickerson: 0:48

Thanks for having me Excited to have a great conversation.

Dr Andrew Greenland: 0:51

Thank you, so maybe we could start at the top. Can you talk a little bit about the origin of Green Imaging and what inspired you to start the company?

Dr Cristin Dickerson: 0:59

Sure, it was really that I had a problem in my community, which turned out to be a national problem, but that was that there wasn't affordable medical imaging and the chain of imaging centers that was operating in-network was purchased by a hospital system and the price of outpatient imaging tripled overnight. And I was running a radiology group. We were reading for imaging centers that were operating out network because they could not survive on the network rates and they were at 50 percent capacity. So opening another imaging center wasn't going to solve the problem. I was going to have the same problems these centers did.

Dr Cristin Dickerson: 1:37

So Travelocity and a lot of the kind of shared facility models were emerging at that point in time facility models were emerging at that point in time, and so I explored the Stark laws and because radiologists are not referring physicians, we're considered consultants under those Stark laws because we are not the referring physician for the patients that we read the exams for. We're able to do unique relationships with imaging centers. We're able to do per-click lease arrangements, and so I was able to construct leases with the imaging centers that I was reading for that were at half capacity, send my patients there by the unused time on their scanners, send my patients there for the scan and kind of flipped radiology on its head. Traditionally, an imaging center would buy the interpretation from the radiologist and bill for the scan and the interpretation bill globally. And so we decided we would do the opposite. We would buy the scan from the imaging center, read the study and bill globally and share the savings with self-pay patients.

Dr Cristin Dickerson: 2:38

And really most people in this country should be a self-pay patient. 90% of people are never going to meet their deductible and so they should be negotiating the-pay patient. 90% of people are never going to meet their deductible and so they should be negotiating the fairest price possible for themselves. And at that point in time we had a very, very high uninsured rate in Texas as well, and so you know I proved concept with self-pay patients. But I had been a self-funded employer and I always knew this could be great in the employer space. And you know, what people don't realize is that that Blue Cross Blue Shield card does not mean that Blue Cross Blue Shield is paying for that study and they're insured by Blue Cross Blue Shield.

Dr Andrew Greenland: 3:13

Most of the time, it's their employer who's paying for the study, and so employers are getting smart and starting to put solutions in place to save money as well that's meeting so lots of efficiencies in what you've done in terms of maximizing capacity at certain centers, just to all of these things to try and make things more affordable for the patients. Right, Got it. So what does a typical day look like for you as CEO of Green Imaging? If there is such thing as a typical day and I dare say there isn't- there really isn't.

Dr Cristin Dickerson: 3:42

It varies a lot, but I am still a practicing radiologist, so this morning, um, you know, I was reading stat exams and um and reading my routine studies, but a lot of the time it's going out and talking to educating people. That's really what I do. I just spent three days um in denver with the health rosetta, which is a conference for health benefits advisors and for employers who want to make changes. They want to boot UnitedHealthcare out the window and start taking on healthcare themselves, and so I spoke at that conference, spoke to thousands of people and to doctors. They have the Hint Conference as well. Their subscription-based primary care is booming in this country. Doctors from all specialties are going in and doing subscription-based care.

Dr Cristin Dickerson: 4:34

So they were in Denver as well, and so I really spent three days with my community. But that's a lot of. What I do all day is talking to employers, talking to benefits advisors, talking to people who want to change the way that they acquire care, and so a lot of it's just education interesting, and how has your role evolved over the years as the business has grown?

Dr Andrew Greenland: 4:54

I mean, you're in a ceo capacity and you've been doing this for 10 plus years. How has your role changed?

Dr Cristin Dickerson: 5:01

this was really a side gig for me. I was a full-time radiologist until 2020. And full-time as a physician is more than full-time, as you know. So I did this kind of nights and weekends and really had to subsidize it by being a full-time radiologist. When it became clear we were going to be able to do this nationally in 2020 and COVID came around and you know, the world kind of changed. I decided I was going to take the leap and be full time with green imaging, and so that's when I really, you know, had the time to get out and start traveling and go to these conferences and educate people. And you know I'm on Zoom calls all day and talking to benefits advisors and.

Dr Cristin Dickerson: 5:48

HR directors for companies and CFOs of companies and talking, you know, educating them about a different way to acquire health care for their employees.

Dr Andrew Greenland: 5:58

Fascinating. What major shifts are you seeing in the medical imaging or health care space more generally right now? What major shifts are you seeing in the medical imaging or healthcare space more generally right now?

Dr Cristin Dickerson: 6:05

There are a lot. There are a lot of economic factors going on. Number one the biggest concern for everybody should be 65% of Texans are delaying care or just not getting care because they can't afford it. That's been going on for a while, but that's up from about 40, 45, 50% a few years ago. That is huge, and so I think that's the biggest economic force going on right now. The other is that employers are paying more than anybody on the planet US employers to acquire healthcare. That's not getting better for people and they're not able to touch that healthcare. Their deductibles are so high that by the time they pay their premium they don't have money left to pay for care. And the dirty secret is they don't have to do that and I'm seeing employers all over the country actually able to provide care at zero out of pocket for their employees and still save money from what they were spending with the traditional networks. And in imaging specifically, it is the private equity acquisition of imaging centers and radiology groups and the result there several factors there Hospitals are having. With the first factor I discussed, hospitals are having to increase the price of their imaging so they can try to get to the health plan above the deductible because patients can't afford this debt. You know they're collecting 26 cents on the dollar from patients.

Dr Cristin Dickerson: 7:34

Private equity acquisition of imaging centers means a friend of mine sold some centers in Houston to a large chain of imaging centers. He said his EBITDA tripled overnight. What he could make from the center tripled overnight because their contracted rates were so much higher than his. That also means that everybody who hasn't met their deductible when they go to that imaging center. They used to have really fair prices. They had their cash prices and their contracted rates. Now when they go there they're going to have a surprise bill because the rates have tripled overnight. And then the acquisition of radiology groups means that the surprise bill that people used to get in November, december from the radiology group that they didn't know they were going to get a bill from actually may be as high as the facility bill. We're seeing the professional fees have just dramatically same reason. They're aggregating contracts. You know bigger groups can negotiate and get more leverage with the payers and so again that surprise bill may be as high as the bill for the scan itself.

Dr Andrew Greenland: 8:41

I guess your operation must look fairly attractive to a private equity group. Is this something you'd be trying to kind of avoid and hang on to this yourself? What's your kind of take on this?

Dr Cristin Dickerson: 8:50

Yeah, I mean, you know there are strategic, there are private equity groups that are trying to pull together solutions that can hold down costs and replace the traditional system, that can hold down costs and replace the traditional system. That's not something I'm interested in right now. We're 100% radiologist owned and operated. I own 90% of the company and we're completely bootstrapped. But at some point, the financial risk of that just becomes overwhelming and our need to automate, our need to. You know, ai is not and that's another point of discussion always is AI and imaging, but you know all of the things that we need to do to automate, to streamline this and hold down cost. Ultimately, costs are an investment and so, you know, at some point I will need investors, but they got to be the right kind of investors. That's very clear, you know. We've stayed clear of that for a long time, intentionally and thinking about.

Dr Andrew Greenland: 9:52

You know your clients. I mean, how have millennials and Gen Z clients changed the way you approach the patient experience?

Dr Cristin Dickerson: 9:59

it's very interesting. We feel like we have to take clients in whatever communication mode they want. My mom wants wants to call, I want to email and my son wants to text, and that's just the way it is. And so we have multimodal intake for imaging orders. And you know it literally is some people just want, you know, to talk to somebody who speaks their language on the phone. And we found that during COVID our average phone call doubled in length and fortunately our volume had decreased by 50%. So we were able to accommodate that.

Dr Cristin Dickerson: 10:35

But it's very interesting when people are under healthcare stress, they really want a real person, and that even includes that our web chat is made by real people. It's not bots, it's not AI, it is real people responding to people. So we feel like there are a lot of different ways and the younger people, a lot of the entire process can be handled by secure text. So even our older people usually will receive a text on their phone. But a young person just basically takes a snapshot of their order and their benefits card. Uh, text, that term, main number. That starts the referral process and you know they'll have a voucher on their phone. Gives them the date and time of the exam, uh, the address of the facility and any prep needed for the exam and what's?

Dr Andrew Greenland: 11:27

what has green imaging had to do to adapt to these kind of requirements from your clients? You've talked about various modes of communication, particularly young people wanting texting, all these kind of things. Have you had to put things into place to cater for these demands?

Dr Cristin Dickerson: 11:43

It's really cybersecurity. That is what we're having to adapt to. I can't tell you how many times a day we get attempted cybersecurity threats. We are. We we've been stuck to audited, stuck to type two, which is even a higher level audited, not because we're a company that size that should have to do that, but because we are aggregating data of PHI and we feel a responsibility to do that. But because we are aggregating data, health, phi and we feel a responsibility to do that. And so you know it's really. I think the expensive and the hard part of doing this is, you know, being loose enough to accept people communicating with us in all different ways, but tight on the cybersecurity. So that's really the challenge there.

Dr Andrew Greenland: 12:30

Got it, and do you see these generational demands as temporary trends or part of a broader, lasting transformation in what you do?

Dr Cristin Dickerson: 12:38

I think it's a broader, lasting transformation, although when people are under again, when people are under healthcare stress and they are, even if they're having a screening study, having a screening mammogram you know, the best day of the year is when you get your normal screening mammogram result. So even if people are getting minor what we consider minor testing done, they're under stress when they reach out to us and so it's really keeping to me. How do we communicate succinctly, in a frictionless way and still have the warmth that human beings need? And that, to me, is the challenge. I don't think people are going to read the whole text anymore, ever again. They're never going to read prose.

Dr Cristin Dickerson: 13:25

But you know, I think this proneness we have to everything moving fast will continue. But I still think in healthcare we number one. We have to restore trust in healthcare. It's gone away, and so when people's employers put green imaging in place, they're always skeptical this is just a cost containment something. So we have to get past that. We have to let them know we're real people who really care about them and are really going to take great care of them. And so we have to. We have to amp it, that piece of it, up, so much to get past the brevity that everybody wants and needs.

Dr Andrew Greenland: 14:01

Thank you, and I'm thinking about the green imaging as a business. What's working really well for you in the company from from your perspective and your team's perspective.

Dr Cristin Dickerson: 14:11

I really think it's that. It's the human touch. If you look at our Google reviews, we have 4.8 Google stars, despite the fact we're practicing healthcare, which does not always go perfectly, and I think if you look at those and read them and see how appreciative people are, or they call our concierge shop by name over and over again, and I think that's really the difference.

Dr Cristin Dickerson: 14:35

You know you can use an app to go find an inexpensive place to get imaging. Now we're not. We don't want to be the cheapest place to get imaging. We want the imaging centers to want our patients. We want them to take great care of our patients. Open evenings and weekends for our patients. When we have a large group in a tightly geographically aggregated area. But you know, anybody can find an imaging center. It's the piece on top of it, the being cared for and the not having to hang on the phone for an hour to get an off and to get your appointment taken care of. Those are the things that I think really make a difference.

Dr Andrew Greenland: 15:12

Well, congratulations on achieving those kind of reviews, because that's very powerful. We all know the power of the Google review and, similarly, what's been particularly frustrating or challenging in what you do.

Dr Cristin Dickerson: 15:22

It's the variation in how claims are processed. I mean, every doctor on the planet understands this. You know the billing issues we did. Originally we just did invoices to our employers and to our TPAs, but it became clear to scale we had to do EDI, which is, you know, the electronic way that claims are processed in this country, and you know we are not contracted with who we call the BUCAs the Blue Cross, Blue Shield, United, Cigna, Aetna plans, intentionally. That's just that didn't work in my old life, I hated it, and so you know we're not contracted with those. But the independent TPAs are as challenged or have as difficult a time processing claims correctly as the larger ones do, and so I think the real frustration has been again, just like in a traditional practice, it's getting paid.

Dr Andrew Greenland: 16:24

And from another sort of business perspective. I guess there are a number of metrics that you're particularly interested in. Can you tell us a little bit about the kind of things that you pay particular attention to and perhaps the things that you're most interested in improving?

Dr Cristin Dickerson: 16:37

Yeah, you know. Number one is our net promoter score. You know how we're doing with patients. How would patients recommend us to friends and family? And that's first and foremost Um o are. You know how quickl you know access to care problem and how quickly w scheduled Um can we get our preferred sites.

Dr Cristin Dickerson: 17:02

Do w sites that we've got grea that we're using on a dal. Appreciate us, you know. Help us hold down costs, take great care of our patients, hold spots on Friday afternoon for us so that if we have a staff, we can keep somebody out of the ER. Those are all things that really matter to us. You know, from a financial standpoint, you know obviously there are metrics. You know we've got to. You know you can't have a mission without a margin. And obviously there are metrics. You can't have a mission without a margin. And so trying to keep the 10% margin going so that we can continue to grow and take care of our employees is, of course, critical for any medical practice and challenging. And those are the things that matter.

Dr Andrew Greenland: 17:51

Brilliant and which are your biggest bottlenecks right now in terms of what's going on in the business?

Dr Cristin Dickerson: 17:59

I would say there's certain geographic areas that are really, really challenging for us when they're hospital dominant. The Northeast is a challenge for us, geographically largely hospital-based, They've maintained great reimbursement with the payers because their patients are more spread out geographically and there are very few independent imaging centers in those areas. Boston has been a challenge for us. Wisconsin has been a challenge for us. It's really made. Wisconsin has been a challenge for us. It's geographies where it's challenging to find facilities for our patients.

Dr Andrew Greenland: 18:39

If you could wave a magic wand and fix one thing in the business tomorrow and we'll take billing as a given, because that's a kind of universal thing to North America what would that thing be?

Dr Cristin Dickerson: 18:50

Chaos, the dramatic variations in how health care is provided. I saw a statistic yesterday, or I heard a statistic yesterday, that it's not just what it's costing employers directly to provide health care for their employees. It is the time their employees have to spend away from work to acquire health care. There's a second cost and that is how much time they have to spend acquiring health care in the current system, and it's all because of the chaos and the barriers that are put in front of patients to acquire care.

Dr Andrew Greenland: 19:31

Interesting. Maybe talk about growth in a moment, but I was going to ask if you had a sudden influx of new leads or clients. Obviously a nice problem to have, but what would break first in your system?

Dr Cristin Dickerson: 19:45

What would break first? Probably geography. What would break first? Probably geography, and we do have a huge influx coming in for the end of this year and the beginning of next year. The challenge is geographic build out of the network and not just geographic build out.

Dr Cristin Dickerson: 20:02

Our original model where we read the studies is the best because we control the images and the reports. And access to images and reports is a problem for doctors across the country. Getting, getting you know reports, auto fax to them. They don't come a lot of the time. Even if you look at a doctor's prescription pad, a lot of times the fax number that's on there is not the one where they really want the reports going and it goes into a dark hole. And so access to images and reports is a challenge.

Dr Cristin Dickerson: 20:35

And so really, our getting back to our original model where we read the most of the studies is critical for us and a limiting factor, and we'll get there. It's just to get big and to have enough facilities to do this nationally. We had to serve as more of a traditional network, even though it's still our radiologists who are protocoling the exams, even though it's still our radiologists who are protocoling the exams. It's our radiologists who are. You know, if there's ever a question of quality, we're going in there and looking at it. We're reading about 43% of the exams right now and we need to get back up to, you know, 75 probably is realistic and control those images and reports.

Dr Andrew Greenland: 21:17

And that is, you know, what keeps things slick and moving nicely is there a creative fix for this geography problem that you've you've mentioned, or are you just really stuck with where, where things are in in space? I'm just trying to get a sense of what the what, the creative solution for this is well, I think hospitals are starting to listen to us.

Dr Cristin Dickerson: 21:37

we're starting to have a really good value prop for hospitals. When I built this, I you know I had five imaging centers and so I know their pain points, including hospitals. You know we provide clean radiologists protocol orders. We there's no author verification on their part. We pay their fair price and we pay them promptly and so we answer a lot of the pain points and for hospitals right now it's trying to collect from patients. So if I can get the right person at a hospital, I can usually convince them to work with us and we've done that. We have some really great relationships in Texas now with hospitals. We have Baptists in San Antonio, we have Ascension in in Waco, we're about to work with Ascension in Temple and we work with Oak Bend in Richmond, texas. We really are starting to get those relationships rolling. I think that will solve our problem down the line. It's getting to the right person at the hospital and they're having open ears. But if I get to them I can convince them that this is a better way to do things.

Dr Andrew Greenland: 22:42

I mean, you've been doing this about 10 years now, and so if you were starting your business again tomorrow, what would you do differently with everything that you know and everything that you've been through?

Dr Cristin Dickerson: 22:50

Gosh, I don't know. Resilience is such a it so drives doing things better that I don't know that I'd trade anything or do anything differently. It really did take walking this path and really learning the mechanics. I guess I would have learned the mechanics of healthcare better, of how healthcare payment systems work, how third-party administrators work, how stop-loss works, the catastrophic coverage that employers put behind their plans. I think I've probably I have become a benefits advisor, just in self-defense and I probably would have done that Now.

Dr Cristin Dickerson: 23:30

I was actually a managing partner of a big multi-specialty group early in my career, so I already knew the traditional system pretty well. But it's really once you get into the mechanics of an individual health plan where, had I had that knowledge earlier, we would have averted some problems.

Dr Andrew Greenland: 23:52

Thank you. It sounds like you run a fairly streamlined operation, but are there anywhere areas that you feel like you're perhaps behind the curve? I don't know whether aspects of technology, operations or marketing. Is there anything that you feel that you have to catch up on?

Dr Cristin Dickerson: 24:06

You know, if any, I would say automation. Except we're very cautious there. You know, one of the things we're learning kind of the first round of radiology AI has failed and I was very skeptical about going into the interpretive part of AI. We have no investment there because we've all been through the computer aided detection. You know Medicare's paid billions of dollars for mammography computer aided detection that does nothing more than an experienced radiologist can do and so I've gone into that very skeptically.

Dr Cristin Dickerson: 24:40

Now we have used AI where we can't nothing patient facing, but we've used it. I use it to organize my radiology report so I never have to take my eyes off of the images I can dictate and it puts it in the proper order. Of course I oversee that, but I use that to add. It adds maybe 15 percent efficiency and time to my work. But the hassle factor and I think my ability to interpret and not be interrupted, never taking my eyes off to go make sure I'm in the right place on the report is really really helpful. Even if it didn't add the efficiency, I think I would use it for that reason.

Dr Cristin Dickerson: 25:22

So I'm you know we're watching very carefully. Now I do know that when we applied for our malpractice this year. They were going to ding us for using any interpretive AI. We were going to have a higher rate because they're experiencing malpractice issues with some of these. So I think I'm not going to say we're behind the curve on that. We're watching it very skeptically and we will jump in when we find solutions that we think really benefit ourselves as physicians and our patients Got it.

Dr Andrew Greenland: 25:58

As CEO. What keeps you up at night when it comes to the future of green imaging? Maybe nothing, but I just wondered if there's anything that kind of stirs you in your sleep as a manager in your business.

Dr Cristin Dickerson: 26:10

Sure, growing too fast and not being able to take care of people optimally, that's my fear and there's a lot of interest in what we're doing right now and you know we're just having to. I mean, you know, kind of even going to this conference was a. You know we had so much influx of people interested in new business and we pretty much have our channels full for next year. So you know it's how do we balance that? Keep people interested and optimistic for change, but scale it smartly, intelligently intelligently?

Dr Andrew Greenland: 26:51

I hear you. What about the future? So where would you like green imaging to be in six to 12 months time? Is it around the growth thing, or are there other things that you've kind of got your eye on for the future.

Dr Cristin Dickerson: 27:01

For me it would be getting patients through the pipeline as more quickly you know being and being able to really um take on. You know we've had about 30 growth year over year in um in patient care and being able to add 50, 70 and so we can help more people would would be lovely wonderful.

Dr Andrew Greenland: 27:26

Kristin, thank you so much for your time this afternoon. It's been a really interesting conversation hearing about what you and what you do at Green, imaging the model that you have and how it's so different from what other people are doing, and your very honest and informed description of how you do your thing. It's really really interesting. So thank you so much for your time, really really appreciate it and I'm sure other people will be interested to hear what you have to say, and we'll put your contact details on the bio page of the podcast so anybody who wants to get in touch or find out more will be able to do so. But thank you very much fantastic thanks for having me.

Dr Cristin Dickerson: 28:01

Thank you.