As rural hospitals work to serve their patients locally, accessing state-of-the-art, cutting-edge or advanced imaging technologies can be a barrier, meaning patients either leave town for care or don’t get care at all. So, how do rural hospitals expand their offerings to give patients the care they need at home?
On today’s episode, hosts JJ and Rachel talk with Brian Madison, president and CEO of The HCS Group, about the need for advanced imaging in rural communities and how to meet it.
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Audio Engineering & Original Music by Kenji Ulmer
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Rachel: As rural hospitals work to serve their patients locally, accessing, state of the art, cutting edge, or advanced imaging technologies can be a barrier, meaning patients either leave town for care or don’t get care at all. So how do rural hospitals expand their offerings to give patients the care they need at home?
JJ: With solid patients, data, strategic analysis, and the right partner.
Rachel: I’m Rachel Lott.
JJ: And I’m JJ Hodshire.
Rachel: And this is Rural Health rising.
JJ: Welcome to episode 82 of Rural Health Rising. I’m JJ Hodshire, president and chief executive officer at Hillsville Hospital.
Rachel: And I’m Rachel Lawn, director of Marketing and Development.
JJ: You know, Rachel, improving health outcomes for communities is always a top priority and certainly just top of the mind for rural hospitals. And diagnostics are a key piece of this equation. But it’s not easy to provide advanced imaging when dealing with all the challenges we experience in rural health care.
Rachel: That’s right. And today we’re talking with someone who makes it just a little bit easier, or should I say a lot easier, maybe makes it possible to bring that kind of care to hospitals like ours. Absolutely. Our guest today is Brian Madison, president and CEO of the HCs Group. And we welcome you to Rural Health Rising.
Brian Madison: Thanks, JJ. Thanks, Rachel. I’m pleased to be here.
Rachel: So, to start, Brian, why don’t you just tell us a little bit about yourself, your background and your work at the HCs Group.
Brian Madison: Sure. Well, I’ve been in healthcare for my whole career, which has been a long time. I won’t tell you how long that’s been, but it’s been quite some time. I’ve been specifically in radiology for about 23 years. And we started a company, we did healthcare staffing. And back then we actually staffed different departments, newcomer medicine departments and ultrasound departments throughout Michigan.
Rachel: Is that what the HCs stands for? Health care staff.
Brian Madison: Yeah. Healthcare Solutions. Yeah, exactly.
JJ: Okay, there we go.
Brian Madison: Very close. So, in 2005, was approached by a health system. They were getting a mobile pet CT scanner and asked me if I’d have an interest in operating and managing it and running it for them. So, we started with one Pepsi T scanner at that time. Today, we’ve grown. We operate throughout the state of Michigan. We have about seven Pepsi T scanners and about 13 mobile MRI scanners throughout the state of Michigan. Have about 60 employees working with our group.
JJ: Well, that’s fantastic. And obviously, we’re going to get into the more specifics of what services that you offer communities like Hillsdale, but I want to start with the why. And we do this on every podcast just to get to know our guests a little bit better. And so, I want to know, Brian, what is your why, what motivates you, and what gets you up out of bed in the morning to do the work that you do?
Brian Madison: That’s a great question, JJ. I first got into healthcare because I think it’s one of the most unique industries you can work in. You touch someone’s life at their most vulnerable moment when they come in to get a Pet CT scan or an MRI. It’s not like going to Disney or buying a new car. We have a lot of patients that are concerned, family members concerned. And so, it really, truly is a calling to work in health care. So that’s why I got into it initially. What gets me out of bed today is, quite frankly, I am very fortunate to work with a group of people that have the same type of passion that I do. And health care is a challenge. I mean, let’s face it. It’s not an easy business, but it’s a business that you feel like you’re doing good, and you can help somebody through a process in which they’re not familiar with, particularly with pet CT, because, of course, 98% of patients going through pet is oncology, and it’s very confusing. Once a patient gets diagnosed with cancer has to work through that. And you need to be empathetic and work with all the partners that are involved in that patient’s care. And it’s a great business to be in.
Rachel: Brian first, let’s just lay the groundwork for those who are maybe not familiar with Pet CT. What is Pet CT? How is it different than a regular CT? And then also I’ve read that there’s such thing as Pet MRI. So, what’s the difference with that as well?
Brian Madison: Sure, great question. Rachel pet is a very unique diagnostic tool. What Pet stands for is Positron emission Tomography. And what it is, it’s two systems, it’s Pet and CT system fused together. And what I mean by that is the Pet part is a molecular part. What we do is we give a patient injection of a radioisotope that is glucose based. So, with cancer, it hyper metabolizes glucose. Okay? So, the Pet part, we inject the patient, they sit quietly for about 45 minutes while the isotope circulates throughout the body. Then when they get a Pet scan, the Pet part shows that there might be cancer cells. But without the CT, you don’t know where the cancer is. The CT shows the anatomy. The computer fuses images together so that now you know exactly where the cancer cells are within the organs. Another analogy would be, let’s say you’re watching the local news and the meteorologist is showing a storm coming in from the northwest, but there’s no silhouette of the states. So, you can see, oh, yeah, there’s a winter storm coming, but you really can’t tell if it’s in Washington or Idaho or approaching Montana. When you lay over the states, you can now see, oh, it is in Montana. That’s how Pepsi t works. You see where the cancer is, you overlay it with the anatomy of the CT. Now the physician can determine exactly where the cancer is in the body. That makes sense.
Rachel: Yes, that is a great. I love analogies. JJ will tell you I speak in analogies and metaphors so that now I fully get it. So, with that, when we talk about advanced imaging services like Pepsi, T, these are, as you said before, very important diagnostic testing. It’s pretty unique, but it’s also a lot easier to find in suburban and urban areas just because it is that higher level of technology. So, from your perspective and in your experience, what makes it so hard for rural hospitals to offer these services? Why isn’t it more common to have Pet CT in a smaller hospital? Well, because of the advanced in the technology, it comes with a high price tag. Right. The unit that we have is north of $2 million. And so, in today’s health care market, for a smaller hospital to spend $2 million and not be able to maximize the capacity every day, five, six days a week, it doesn’t make financial sense. And I think in an environment that we are bringing is a mobile platform, but doesn’t necessarily decrease the quality. We’re bringing that state-of-the-art technology that you find in tertiary urban hospitals to the local community on a day-to-day basis, which helps with the cost, but still delivering the quality.
Rachel: So, it’s really like a cost sharing economy is a scale type of approach between your multiple hospitals that you work with.
Brian Madison: Exactly. Our mobile units move every day. And so, what you’re able to do from Hillsdale Hospital is buy a segment of that unit until their volume grows. And as the volume grows, you add more days. And so, it makes perfect sense because now you’re maximizing the capacity while you’re delivering the service. And it’s really important with Pet because we want to get the Pets scanned. We want a patient to get a Pet scan pretty quickly, right. So, we can get there weekly, but for a shorter period of time. Then we make sure we get all the patients done in a prompt manner where they go to an urban hospital, they may take them a couple of weeks, three weeks or so to get a Pet scan where we could actually get it done quicker. At a smaller hospital like Hillsdale, I.
Rachel: Didn’t even think about that factor. I was just really thinking about the geography. But, yeah, the actual scheduling makes a big impact as well.
Brian Madison: Absolutely.
JJ: You know, before your team partners with a rural hospital like Hillsdale to offer these advanced imaging technology services, how do you specifically, as the CEO or business team analyze, put together, perform on whether it will even be a viable option for that respective community for the beginning, as the discussions occur. Now, if obviously low patient volumes make it tough for hospitals to even offer these services independently, how do you determine the level of risk for you and the hospital that you work with before you begin providing these services?
Brian Madison: Yeah. Well, JJ, it takes a teamwork on that right. I don’t necessarily know the local community, so I work closely with the executive leadership, like yourself, to determine what is your strategic initiatives. What are you looking to do? If we’re looking at Pet CT, as I said, it’s oncology based, so we’re looking at what strategic partners are you doing on the oncology side that we can team up with to deliver that service? That’s number one. Number two, we know that through our experience we can look at certain physician specialties and get kind of a ballpark idea of what we think that volume would be. For instance, pulmonology. If there’s a group between five to seven pulmonologists, I would expect three to five Pet scans a week. And most of the time they do a lot of solitary nodules. If there’s a solitary nodule greater than a centimeter qualifies for a Pet scan, in fact, they should get a Pet scan. That’s the gold standard of getting a Pet scan before a biopsy. And so that is one. And then secondly, when it comes to the overall cost structure, one thing that’s unique with us is that we do the risk sharing on that. So, we’re not saying, oh yeah, we’ll sign a contract, you’re going to park it there for a day. Good luck, build your business. Our model encourages us to work together collaboratively to figure out what we can do to attract more patients or make them more aware. So, I say of the services that we’re providing and the physicians, and I think the other thing that’s important, particularly with cancer patients, is that they have so many appointments throughout their course of treatment, whether it’s radiation, medical oncology, etc. That we really need to go to those urban areas and say, listen for your patients that live in and around Hillsdale County, Lenawee County, they should be going to Hillsdale for their Pet scan. And here’s the equipment that we have, here’s the radiologist that we have. We can provide the same level of care that you would get in the urban setting, and its less stress on the patient and their families.
Rachel: So, JJ, I want to ask you because you really pushed hard to bring Pet CT services to our community here in Hillsdale. We’ve been working on this for quite a while and you’ve been talking about it for a long time. So as a hospital CEO and as our hospital CEO in particular, why focus on bringing in this particular service? I mean, obviously there’s a lot of specialties and new services that we’ve been working on, but why did Pet make it to the top of the list for you?
JJ: Well, first of all, Rachel, we’ve talked before about a scripture verse that I often use where there is no vision that people perish. And so, I had a vision that we would build out programs such as Pet for our community in particular, for the challenges that we face in a rural, very poor community, and that is transportation. So, to Brian’s point, having patients have this access close to home when they’re sick, that’s the challenge, right? I mean, my mother just passed from cancer. As you know, my sister passed from cancer a few months ago. And the travel that my wife and the journey she had to take before we had Pet, this was just literally one month before we had Pet. My mom passed, took such a toll on both my sister and my mother that it even just resonated again, the reality of these services needing to be here in our backyard for the ease and comfort of our patients. Because when you consider a cancer patient who can’t even control their pain with having our colleagues a drive, 45 minutes to an hour and a half, it’s altering. I took my sister on that drive, and we all were sharing responsibility. Every bump we hit, God is my witness, was excruciating pain. For her, the journey that would normally be 45 minutes was an hour and a half to get there, just maneuvering the potholes and the roads in Michigan. And so, I know firsthand that the difference is she lived ten minutes away from the hospital and on a straight shot right up here on Hillsboro Road. And so, I know the value of this from a family perspective. But beyond that, before even the cancer was introduced to my family for these type of services, I understood that in order to create a continuum of care, in order to have a great oncology program which we’ll be partnering with here into the very near future, we need a continuum of care. And to have the oncology program without a Pet scan, to me, is not effective. And we know that bringing our pulmonologist here, an amazing team of pulmonologists that we have, and understanding that we’re going to have a relationship with an oncology service, that it’s only natural to have Pet here at our hospital, it’s not really. And there’s a risk share here. I mean, Brian’s kind enough where he’s not charging me for a full day of Pet services. He’s only required me to have a few guarantees. And my push then is to make sure that we have greater than that number showing up here, which is a service that I feel is valuable to our patients and their families. Now, I was at an event at Halloween, and I was judging costumes at our local high school, and a gentleman came up to me, probably in his early 70s, true story, just overwhelmingly satisfied, happy, exhibiting smiles, saying, I want to thank you. Now, normally, I don’t get that, Rachel. Normally I get, you know, my bill is too high. You people need to stop doing this. I waited 27 hours in the Er for a Band Aid. You know how the stories go. But this guy was happy and this guy was excited. So, I’m thinking we did something right. He said, I heard your announcement about Pet scan. I’m getting ready to go through treatment, and I can’t imagine driving to and I won’t tell you the place, which is an hour and 45 minutes from here, to have these tests done. I can do them. He literally lives two blocks from the hospital. Those are the stories, the patient testimonials, those are the reasons that’s the why for me is it’s not just a business proposition. The reality of it is we may lose on this long term, but what are we gaining? We’re gaining the patients experience much better. We’re keeping them close to home. And then from a business perspective, we may see a loss on some of that Pet. I don’t think we will. I think your downstream revenue and some other opportunities are great. But even if we did, this community benefit to me is just as important as having the psychiatric ward, which we have in our behavioral health and other services that we offer this community at a cost to the hospital. It’s the cost of doing business. And trust me, the performance that we built, knowing that the volume of individuals that have cancer in our geographical location and knowing what our pulmonary practice is doing we just got the recent I received the recent report from our chartist group, it’s called, and it’s actually a report on how well we do with quality measures. So, I know our quality is good and I know that our patients want to use us, but if we don’t have the modalities to offer them right, then I’m going to be struggling to be able to keep that quality score high. And what good is it if I can’t offer them a complete, comprehensive service? Number two is getting the recent report from Koala, and that report is that we have taken the market in Pulmonology and other services. So, if I’m taking the market in Pulmonology and these other, I need to have a full complement of services. And so, this really just hones in on that continuum of care, Rachel, that keeps patients here close to home, especially when they’re at the most fragile state of their life. To me, it’s just critical.
Rachel: Yeah. And we have heard in the past, not as much anymore, but I wish I could get this done at Hillsdale, or can I get this done at Hillsdale? So, we know that we have patients who, when we don’t offer something, they wish we did, because they would rather do that in their own community, where they’re comfortable and where they know the team and all of that good stuff.
JJ: I agree, and I believe hopefully, you’re less and less of that. Brian, in your experience, what does the ramp up? We talk about ramp ups in our business and for an example, to bring a new provider here, it’s going to take a year to get that provider established. And there’s ramp ups with every type of business opportunity. But in this particular service line, we have CEOs and CFOs and business leaders listening to this podcast across America. And their question may be what’s a ramp up looks like with any new offering. We have to have that referral pattern built. We get that. We have to get that provider to understand the relationship of use. Your local hospital and our hospitalist and our community physicians all play a great role in this and they work very closely together for that referral base. But you have to have a solid referral base. And in your mind and experience, how long does that take?
Brian Madison: Well, it does vary from community to community. But let me tell you, I think that there is a challenge to break referral patterns, right? But here’s how you do it and here’s our philosophy. I truly believe that we’re an extension of a physician’s practice. And when they refer a patient to us and that patient has a great experience, they go back to that physician. So, you know. Thank you, Dr. Smith. That was amazing experience. Secondly, they’re running their own business. And so, what we can do to help them in running their practice better, that helps break those traditional referral patterns. Let me give you an example. I think there’s four things that really drive a successful program. One is that we work with the referring physician office in terms of access. We want to get their patients in as quickly as possible. Secondly, today, because of the complexity of that insurance and authorizations, a lot of physician practices spend money and resources getting authorizations for their patients. But yet they’re spending human resources to do that, and yet we’re getting the compensation for it. In our model, we take care of that. We’ll help them get the authorization. And there’s a twofold benefit on that. One, we have an authorization team that understands the medical necessities surrounding Pet CT so we can make sure that that patient meets those medical necessity before we attempt, which minimizes the number of denials and authorizations and less hassle on the referring physician. And then once we get the patient there, the other important part is that we work closely with our radiologists that they get a report back to actually give them the information they need to improve the patient management of care. And then lastly, it’s really exceeding the patient’s expectations as they go through in their experience. So, I think that the hard part initially is you go out to the community, you explain what you do, you deliver what you promise. And once you build that trust, then things start to happen. And so, there’s a lot of legwork on the front end to get that ball rolling. But I know that they’ll have a better experience in the long run once they use our service well.
Rachel: And, you know, ultimately providing these types of services is about patient outcomes. And I was just doing a little research on, because I could assume that outcomes in rural communities are typically worse for cancer than they might be in urban and suburban communities. And what I found was interesting from a recent CDC study. Rural counties tend to have a lower incidence of cancer, but the death rates from cancer are much higher, which just tells you about the disparity in access to care for a multitude of reasons. And maybe not just access to care, but also actually accessing the care when it is available, because the things we talk about all the time, like transportation, income, even education, some of those kinds of things. But that makes this even more important. And I know that you don’t only serve rural communities with your Pet CT. You also have a mobile you use your mobile Pet CT for hospitals that maybe they’re doing a renovation on their space and they need a temporary option. But working in the rural space in general, from your perspective and your experience, how does the availability of this level of care close to home impact those health outcomes for the rural communities that you serve?
Brian Madison: It’s. Great question, Rachel. Really? I think with Pet is actually a diagnostic tool that’s used to stage a patient’s cancer, and usually many times, depending on the indication, the patient won’t start care until a Pet scan is done. And what’s interesting to me is some hospitals will say, well, Pet scans, they’re not stat, they’re not like a CT, they’re not like an MRI. And I beg to differ with that. If it’s my family member JJ, like your mom, and that if they get diagnosed with cancer, it is stat, that initial status.
Rachel: Preach it for the people in the back.
Brian Madison: It is extremely important. Me and our staff, we are passionate about this. And I always tell our staff, treat these patients the way you want your family member treated. And if that was the case, we would do everything we can to get them a Pet scan as soon as possible. And so that’s the part that I think in a rural community, if they have to drive an hour and a half to get care in an urban setting is really busy, there could be a three, four, five-week delay in getting treatment, and yet the treatment stalled until they get that Pet scan right. And then tying into that. I think the other important part in the local community is we got to make sure that people are getting the proper screening today with lung screenings, CT. So, there’s an interesting statistic with lung cancer that we have all this technology, but yet the five-year survival of lung cancer is the same as it’s been for the last 20 years because it’s a silent killer.
Brian Madison: It’s a silent killer. What they need to do is we need to do a better job. And now it’s covered by insurance to do CT screens, do CTE lung screening, identify maybe there’s now a small lung nodule that we do a Pet scan on and we treat that immediately as opposed to patient presenting in the Er with complications. That’s the stage four. So, it all kind of ties in together. And I think we can do a better job in the rural community in promoting that to improve the outcome of care if and when they do have cancer.
JJ: Brian, that’s spot on. And it’s for all of those reasons why I chose to go with HCs as our partner. First of all, Nicole called me and she said, hey, this guy looks like Clark Kent. He acts like superman. This guy is amazing. His company is awesome. And I’m like, all right. And it’s true. I mean, all the above, this is a podcast, but the guy is and at the end of the day, though, the mission driven is what I like about this program. You are not focusing on just driving the volumes, driving the volume. That’s a component of business. I get it. But to your aspect, it’s a stat. And offering this in our community will truly impact lives. And so, the relationship that we play is that a hospital my size, we’re called a Tweener. And that’s in between the bigs and the critical access. So, we’re tweener hospital, right? And so, we do not have all the financial resources to go out and purchase all of this technology on our own. So, the relationship and if you’re listening to this podcast and you’re in a rural hospital setting or in critical access hospital setting, and you’re thinking to yourself, there’s no way I can afford Pet technology or MRI technology. Let. Me tell you the way that you can accomplish this. To provide these services to your patients in your backyard is to contract with someone like HCs or with HCs. I’m sure you’d love to hear from you, because this technology that can cost hospitals a significant amount of capital, it can be reduced by having this type of arrangement. And you slowly build your volumes. And for us, Rachel, it’s going from my goal is to go from one day to two days to three days. And hopefully I’m being truthful, that we have a full program here where patients know that they can get that next day scan right here at Hillsborough Hospital. To me, that’s a huge piece of providing service to the home. And this is so critical of rural hospitals. And you can accomplish it through arrangements like this. Now, let me just ask you, and I know we’ve been talking about Pets and all of all of those services, but you also do mobile MRI, correct?
Brian Madison: Yes.
JJ: Just for the conversation today, what does that look like in terms of those services?
Brian Madison: Well, it’s a similar approach, but the stereotype of a mobile MRI, at least in the Michigan market, is all that’s old technology. You know, nobody wants to do that. And we’ve really taken the same approach with MRI. Our systems are wide borne systems, new technology, faster systems. A channel count in the MRI is actually the higher the channel count, the better the image. We have, again, academic type MRIs, but they’re in a mobile trailer, mobile coach. And this is not like a semi-trailer like you see down the freeway. These mobile coaches are $500,000 coaches. I mean, they’re very expensive. They have to be their medical coaches. But we bring wide bore, high end MRI technology to various facilities throughout the state of Michigan.
JJ: Yes, you do. And just to speak to that, your expectations are also high of the facilities that you go into as well. You’re not going to allow us to be backed up to an old, nasty loading dock. In fact, your specifications cost me a pretty penny that we had to build out, and we put nice glass over the area where you enter. And I appreciate that because you want the patient experience to be the best, and they’re not coming into a rinky dink trailer and walking into like, the back end of a semi. Don’t think of that when you hear this today. We’re talking State-of-the-art high technology. We’re talking beautiful environment as you walk into this. So truly, truly world class as we think about it, delivered right into these respective communities. So, Brian, we could speak probably on this issue for another hour because I think your passion is as real as ours in terms of providing services to rural communities or you wouldn’t be doing this. Obviously, it’s a labor of love because you could easily, just with your experience and background, you could fly off to other places and you could certainly do much more, probably for a better return on your investment. But I really appreciate the commitment that you’re making, at least as I see it here in Michigan with the relationship to Pet and the other services that you’re offering. It’s truly a ministry almost of sorts. And you can see the passion, you can hear the passion in your voice. And that is just it’s incredible to see it, because what you know is that the end result of this test specific to Pet will and does change lives when someone’s life is in the balance. What we’re dealing with isn’t just about making little trinkets in factories. We’re talking about life, you know, life and death situations for people. And I really appreciate your approach about taking care of the patient, the holistic approach I do well.
Rachel: And I just have to say, you know, we talk a lot in the healthcare industry about health equity, and we don’t talk enough about rural health equity. And this is one of those issues that for us who work in rural healthcare, it’s at the forefront of the health equity conversation for us. But services like this and what you have built and are able to bring to rural communities. Is part of the effort to improve health equity in rural communities compared to urban and suburban, so that your zip code doesn’t define your likelihood of surviving a cancer diagnosis.
Brian Madison: So true. And I guess from my perspective, when I first met JJ and your leadership team, I also saw that passion as well. And that’s the key part about this. We have some clients that it’s your responsibility to do that. It’s a team effort. And I think that type of passion and commitment to do better and build something in the community, it will be a win. I’m really excited about the opportunity to.
JJ: Work with you, and we are going to make this thing great. And so, Brian, I want to thank you again for joining us on Rural Health Rising. It’s been a pleasure to hear about your passion, your business, your industry, and the impact that it is making in rural communities just like Hillsboro. So, thanks for joining us today.
Brian Madison: I appreciate the opportunity.
JJ: Before we close, we like to do a fun segment with each of our guests. So, we want to know what is your most unique rural experience or one of your most favorite memories that is unique to rural life?
Brian Madison: Well, I tell you, I make memories every summer on Devil’s Lake, on the sandbar. So, I live in Lenawee County. It’s a neighboring community, the Hillsdale County, and I moved there about a year and a half ago because I won. I love the community, I love the rural area, and there’s nothing like Devil’s Lake in the middle of summer on the sandbar. In fact, my daughter is saying, hey, dad, it’s right up there with Christmas to her. I mean, it’s Christmas and sandbar on Devil’s Lake.
Rachel: That’s awesome.
Brian Madison: Every summer we’re making better memories, and I hope that maybe this summer we can have you out there and enjoy some time as well.
JJ: Absolutely. I would love to do that. And until we can do that, I want to wish you the best in your endeavors and thank you for your partnership here at Hillsdale Hospital. Next time on Rural Health Rising, we’ll have another great conversation with another great guest, so be sure to tune in.
Rachel: And with that, don’t forget to subscribe wherever you get your podcasts. And if you like what you hear, leave us a five-star review on Apple podcasts and tell others why they should listen to your feedback helps more listeners find Rural Health Rising.
JJ: And you can now find us on Twitter. I’m at Hillsdale. CEO JJ. Rachel is at Rural Health. Rach. And you can also follow the podcast at Rural Health pod. Until next time, stay safe, stay healthy, and stay strong.
Rachel: Rural Health Rising is a production of Hillsdale Hospital in Hillsdale, Michigan, and a proud member of the Health Podcast Network, hosted by JJ Hodshire and Rachel Lott. Audio engineering and original music by Kenji Olmer. Special thanks to today’s guest, Brian Madison. President and CEO of the HCs Group. For more episodes, interviews and more information, visit ruralhealthrising.com.