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Radiology Practices

Envisioning A Difficult Future

S&P Global Ratings’ decision to downgrade Envision Healthcare might have been largely overlooked during another busy healthcare news week, but it could prove to be part of one of the biggest stories in healthcare economics.

About Envision – The private equity-backed mega practice employs more than 25k clinicians across hundreds of US hospitals, including roughly 800 radiologists who perform over 10 million reads per year. 

The Downgrade – S&P downgraded Envision Healthcare to ‘CCC’ (from CCC+) and assigned it a ‘Negative’ CreditWatch rating, citing the company’s “inadequate” liquidity, a missed financial filing deadline, and a challenging path forward. Envision owes $700M by October 2023 (and more after that), but S&P expects the company to end 2022 with less than $100M in cash, risking more short-term downgrades and bigger long-term disruptions.

The Background – If you’re wondering how Envision found itself in this situation, a recent Prospect.org exposé has some answers (or at least its version of the answers):

• When private equity giant KKR acquired Envision in 2018, it burdened the company with billions in debt, including a $5.3B first-lien term loan due in 2025
• KKR’s initial strategy involved keeping most of Envision’s clinicians out-of-network (and earning higher surprise billing rates), but Envision moved many of its physicians in-network amid public backlash and looming legislation 
• Ongoing surprise billing legislation spooked investors, causing Envision’s first-lien term loan to trade for 50 cents on the dollar in early 2020, before bouncing back to a somewhat-less-distressed 70-80 cent range later that year
• The COVID pandemic further strained Envision’s finances, as many of its core specialties saw major volume declines (emergency, anesthesiology, radiology, GI, etc.)
• Envision avoided bankruptcy thanks to an estimated $100M CARES Act bailout and help from its creditors
• The final surprise billing legislation turned out to be pretty favorable for Envision, but not as favorable as back in the pre-legislation days
• As of March 2022, Envision’s $5.3B first-lien term loan was still trading in distressed territory (73 cents), and it has other loans to pay off too

The Path Forward – It’s hard to predict how this will work out for Envision, although Prospect.org suggests that it might involve KKR splitting Envision into two companies. One could be saddled with all the debt and destined for bankruptcy, while the other entity (and KKR) could emerge “unscathed.”

The Takeaway

For many in healthcare this is a cautionary tale about what can go wrong when private equity influences are combined with an over-reliance on a disputed business model (in this case surprise billing) and a global pandemic. It also makes you wonder if other mega practices are in similar situations.

Why SyntheticMR Went with CARPL.ai

When SyntheticMR validated its SyMRI MSK solution, they leveraged the CARPL platform to compare conventional knee and spine MRI image quality with SyntheticMR images. Check out their validation process and results here.

Disaster Recovery for the 21st Century

Are you sure your imaging archive is safe and recoverable? See how Intelerad’s Cloud DR disaster recovery solution mitigates the many risks facing your archive by securely storing copies of every image.

The Wire

• Resonance & CARPL.ai’s Platform Partnership: Australia’s Resonance Health announced a new partnership with CARPL.ai, making its FerriSmart (MRI-based liver iron quantification) and HepaFat-AI (MRI-based liver fat volumes) solutions available to CARPL’s global AI platform user base. Resonance Health joins a growing list of AI developers, underscoring CARPL.ai’s role as an AI platform company, in addition to its historical role as an AI development and validation company.

• Mount Sinai’s Mobile PCa Screening: Mount Sinai Health System launched a mobile screening program intended to improve prostate cancer detection in New York City’s Black communities. Mount Sinai’s prostate screening van will perform a range of tests (PSA, digital rectal, genomics, ExactVu micro-ultrasound, and EchoNous bladder scanner), leading to follow-up exams via a separate neighborhood mobile MRI unit and as-needed office visits with MSHS urologists.

• Two Sides to Fracture AI: A new Radiology Journal study review showed that fracture AI tools have consistently matched clinicians, but cautioned that widespread research flaws make it hard to know how these tools would perform in the clinic. Meta-analysis of 42 studies revealed comparable pooled sensitivity (internal data: 92% AI vs. 91% clinicians; external data: 91% AI vs. 94% clinicians) and specificity (internal: 91% AI vs. 92% clinicians; external: 91% AI vs. 94% clinicians). However, 22 of the studies had a high risk of bias, only 13 studies included external validation, and just one study was based on a prospective trial.

• GE & Elekta’s RT Alliance: GE Healthcare and Elekta launched a global alliance, allowing the companies to provide their respective clients with solutions that combine GE’s imaging systems and Elekta’s radiation therapy solutions. The non-exclusive collaboration expands Elekta’s imaging partnerships (it already has a “deep” partnership with Philips), while giving GE and Elekta another way to compete with Siemens/Varian’s increasingly integrated offering.

• Sizing Up CT Dose Settings: MGH researchers proposed using patient T-shirt size categories to guide CT radiation dose settings, suggesting that the method is simple/intuitive for staff and can better represent patients’ actual physique. The researchers analyzed 930K exams to create seven T-shirt size classifications (XXS, XS, S, M, L, XL, and XXL), with dosage ranging from 60% of medium for XXS and 210% of medium for XXL.

• Izotropic’s $2M Placement: Izotropic completed a $2.05M private placement (826k share warrants) that it will use to build its initial IzoView breast CT scanners and support its clinical trial and FDA authorization processes. The IzoView CT leads with its 3D / 360-degree imaging capabilities, which Izotropic claims produces similar image quality as breast MRI (in a 10-second scan) and superior image quality versus mammography and ultrasound. 

• Including ROs in Nodule Management: A new JAMA study highlighted the importance of including radiation oncologists in pulmonary nodule management teams. The prospective study included 1,150 patients with pulmonary nodules who were managed by a multidisciplinary team (radiology, thoracic surgery, pulmonology, medical oncology, radiation oncology), finding that 13.8% of the patients underwent surgical resection and 6.7% received radiation therapy. That’s very different compared to the two year period before radiation oncologists joined the panel, when 20% of patients underwent surgery and just 1.5% received radiation therapy.

• Walmart’s Clinic Expansion: Walmart continued its Walmart Health clinic expansion, announcing five new Florida health centers that offer a range of medical services (yes, including imaging) and mark the retailer’s first Epic-integrated locations. Although Walmart’s push into healthcare appears more conservative than its retail and online competitors (e.g. Walgreens or Amazon), it now has at least 20 locations and has been actively building out its healthcare team, partnerships, and strategy.

• CT-FFR’s Pre-TAVR Impact: A new European Radiology study detailed how CCTA-based AI analysis could help avoid unnecessary invasive coronary angiographies (ICA) performed before TAVR procedures. Using data from 95 patients with severe aortic stenosis who underwent pre-TAVR CCTA exams and ICAs, the researchers found that analysis of ML-based CT-FFR measurements and CAD Reporting and Data System classifications (CAD-RADS) could have identified 65 patients who didn’t require ICAs (ICA benchmark = patients with CAD-RADS ≥ 4 — or with CAD-RADS 2/3 and CT-FFR ≤ 0.80). 

• Ligence’s Echo AI CE Mark: Lithuanian echocardiography AI startup, Ligence, announced the CE class IIa certification of its Ligence Heart solution, paving the way for the company’s European rollout. Ligence Heart automatically performs functional and morphological cardiac measurements in 2D transthoracic echocardiograms, which they’ve found to be non-inferior to cardiologists’ results and could allow four-times faster reporting times.

• GE & Imeka Neuroimaging Alliance: GE Healthcare will incorporate Imeka’s neuroimaging tech into its BrainWave MRI analysis and visualization solution. Imeka’s software combines diffusion imaging and AI to map white matter integrity, giving BrainWave’s clinical and research users more insights into central nervous system diseases and disorders.

Making PET/CT Accessible

Thinking about adding PET/CT to your clinical offerings but don’t have the patient volume to support a full-time scanner? Check out Siemens Healthineers’ fleet of Biograph mobile PET/CT solutions to learn how we can provide reliable, high-quality imaging with a focus on the patient experience – no matter the location.

The Resource Wire

• Think your imaging center patients and staff might be open to a better check-in process? See how Radiology Associates of Daytona (RA) streamlined patient check-ins with Fujifilm’s Synapse RIS-integrated Royal Kiosks. 

• Discover how Magnolia Regional Health Center started catching more cancers sooner when it adopted Nuance’s PowerScribe Lung Cancer Screening Program and PowerScribe Follow-up Manager.

• Thinking about AI ROI? Check out this AIMed conversation featuring Blackford CEO, Ben Panter and Lahey Hospital & Medical Center’s radiology Chairman, Dr. Christoph Wald discussing how to demonstrate the value of healthcare AI.

• Check out how Novarad’s enterprise imaging patient storyboard view gives specialists more and better information from across a hospital system to better care for their patients.

• See how SPECT/CT substantially improved health outcomes for non-small-cell lung cancer treatment planning compared to planar imaging, while remaining highly cost-effective, in this new GE Healthcare-supported study.

• Creating your AI adoption plan? This Arterys report details what clinical, efficiency, and regulatory factors to look for in radiology AI vendors.

• Explore how United Imaging is reinventing the medical imaging business, including downtime rebates, lifetime upgrades, and making sure their customers truly are successful.

• Canon Medical is making its way through the US on its 2022 Mobile Tour, bringing its products and solutions directly to hospitals and providers in 50 US cities. Tune in to see when Canon is coming to you and watch highlights from its tour stops along the way.

• Deciding between public and private cloud? Watch this brief Change Healthcare animation detailing the operational benefits of public cloud hosting for imaging.

• Learn how Salem Regional Medical Center improved its radiology workflows and cut service and syringe expenses after adopting Bayer’s MEDRAD Stellant FLEX system.

• Have more echo studies than sonographers? See how Us2.ai was able to classify, segment, and annotate echocardiographic videos with similar accuracy as expert sonographers. 

• Check out this Imaging Wire Show interview with Riverain Technology’s Chief Science Officer, Jason Knapp, where we discuss the evolution of imaging AI, how to get generalizability right, AI’s path forward, and much more.