Preview
Exhibit 1
Re: Contact Information and Updates - Casper Radiology
Subject: Re: Contact Information and Updates - Casper Radiol
ogy
From: "Andrew E. Gomes, MD"
Date: 2/13/2015, 4:13 PM
To: Sam Alam
CC: Donna Looser
Hi Sam,
If you could spare some time for lunch or coffee I'd
ve ry much like to meet you. Donna tells me you're
in Bellaire -- I'm a Bellaire High School graduate mysel: if, class
of '94. | live in Sugar Land but can meet
you anywhere that is convenient for you, over the we
ekend or next week - ?
Andrew
On Fri, Feb 13, 2015 at 3:42 PM, Donna Looser < ‘dloo
ser@casperradiology.com> wrote:
Sam,
Thanks for our conversation this afternoon; | enjoyed
it. As promised - my contact info is below. I'm
copying Andrew on this email, so you two can coord
inate a meeting in the next few days.
Best,
Donna
es
Donna Looser
VP of Business Development
Casper Radiology
dlooser@casperradiology.com
www.CasperRadiology.com
914-623-8156 - office
914-407-4765 - cell
314-754-9476 - efax
DISCLAIMER: This email and any files transmitted with it are
privileged and confidential information
and intended solely for the use of the individual or entity to which
they are addressed. This
transmission may contain protected health information as
defined by the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). If you are not the
intended recipient, please
notify the sender by e-mail and delete the original message. Further,
you are not to copy, disclose,
or distribute this e- mail or its contents to any other person and any such actions
are unlawful. This
e-mail may contain viruses. CASPER RADIOLOGY has taken every
reasonable precaution to minimize
this risk, but is not liable for any damage you may sustain as a result of any
virus in this e-mail. The
recipient should check this email and any attachments for the presence
of viruses. CASPER
RADIOLOGY reserves the right to monitor and review the conten’ it of
all messages sent to or from
= this e-mail address.
AG000211
lof2
12/20/2019,
5:56
Re: Contact Information and Updates - Casper Radiology
Subject: Re: Contact Information and Updates - Casper Radiology
From: "Andrew E. Gomes, MD'
Date: 2/15/2015, 5:22 PM
To: Sam Alam
Sam,
print summary of proj
I'm looking forward to meeting you on Tuesday afternoon at 3pm. Please see the summary
of the project here. This is a live cloud-
based document that we are still working on finalizing, but even in its current State |think
it will help give you a big picture overview of
both the business model and the #' 's. Note there are additional hyperlinks in the document itself.
Hence, these documents are
optimally viewed on a computer rather than on paper. | trust you will respect the
confidential nature of the documents.
Juan Nguyen, MD is my Interventional Radiologist partner in this venture. He currently has full-time clinical responsibilities at UTMB in
Galveston and us such unfortunately will not be able to Join us on Tuesday; | will fill him
in though.
This project is not a Go yet, there are still some unknowns and some variables out
of my control. We are still only at the late due
diligence stage, and as such, cost control is critical. | a ppreciate the time you're
taking out of your busy schedule to meet with me in
Tuesday. Thanks very much,
Pattern of Conduct
Andrew
On Sat, Feb 14, 2015 at 9:25 AM, Andrew E. Gomes, MD wrote:
| Looking forward to it sir, have a great weekend
Andrew
On Sat, Feb 14, 2015 at 9:24 AM, Sam Alam wrote:
i Great. See you on Tuesday
From: Andrew E. Gomes, MD [maitto: agomes@casperradiology .com
Sent: Saturday, February 14, 2015 9:17 AM
To: Sam Alam
| Subject: Re: Contact Information and Updates - Casper Radiolo
gy
t How about Tuesday at 3pm at Starbucks Sugar Land Town Square? | live and
work from my home
office very near by. And please do call me Andrew Sam, thanks!
—
Hwy 6 & US Hwy 59
116098 City Walk Blvd
AG000222
10f6
12/20/2019, 5:55
CASPER
3N
Executive Summary a
Houston Outpatient Radiology Center
Opportunity
Continuously declining healthcare reimbursement and downward pressure to decrease healthcare costs are driving
ever-increasing demand for outpatient radiology services — both Diagnostic Imaging and Minimally-Invasive a
Interventional Radiology procedures. Additionally, specific enclaves in the greater Houston area, including Sugar
Land, are experiencing rapid growth and population increases. And while the greater Houston metro area is rife
with outpatient radiology centers, none provide the high quality that is possible, none deliver their services as fast
as is possible, and none perform at their true financial potential.
Solution
Establish a new, state of the art, Outpatient Radiolo: gy Center in Sugar Land, offering both Diagnostic Imaging and
Minimaily-Invasive Interventional Radiology procedures. Ever ry facet of this organization would be intelligentl
y designed
according to the principles of Lean operations. Every decision, every process, and every procedure would be deliberately
crafted to maximize speed, efficiency, and consistency.
Business Model
A syndicated partnership of carefully selected physician referrers including Vascular Surgeons, Spine Surgeons,
Orthopedic Surgeons, Primary Care Physicians, and Podiatrists will provide an immediate and lucrative referral
source for the Center. A new standard of speed and quality will drive further growth with referrals from non-
syndicated physicians.
Competitive Advantage
Casper's model is unique and superior due to following:
° 100% Lean workflow and operations systems from Day 1
Maximal exploitation of powerful new technologies in the Radiology space
Standardization and systematization of every facet of the business, which will allow future scalability
Immediate, near-real time report delivery; same day procedures
Culture of excellence and continuous improvement
Emulation of principles that have proven massively successful for multiple non-healthcare companies — eg.
McDonaid’s, Toyota, Costco.
Better, faster, cheaper
Marketing Strategy
© Syndicated Physician Referrers - 20-40% of the business will be owned by high volume referring
physicians, thus aligning their incentives with ours. An ope! n line of communi ication and regular meetin
with these individuals will ensure their satisfaction and ongoing
gs
referrals.
Non-syndicated Physician Referrers - A full-time marketing specialist will identify local physicians
who are
not currently part of a competitor’s syndicated model, and who have unmet quality, speed, or
service
needs.
e Patients - New patients will be attracted through a combination of strong Web 2.0 presence, online
educational programs, and traditional advertising.
Competition
Competitors include Sugar Land area hospital radiology departments and outpatient imaging centers. Many do not
utilize a physician syndication model, and most do not offer the range of services and procedures that we Propose.
Most importantly, none of the competitors employ the principles of Lean operations, and thus cannot compete with
‘our operational performance. :
Projections
CMS recognizes that early disease diagnosis via radiologic imaging and the therapeutic results of minimally
invasive Interventional Radiology procedures result in significant downstream healthcare cost savings, Thus,
gyTeh by
DRISONLINE2174
Outpatient Radiology reimbursements are high. Conservative pro forma projections demonstrate positive cash flow
at Year 1, Month 10, and Net Income of $10-14M/year for years 2-5.
Team 3
=
D
° Andrew Gomes, MD, CEO - Board Certified Diagnostic and Nonvascular interventio: nal Radiologist, expertise in 2
workflow, operations, and technology, Lean Six Sigma Black Belt
° Tuan Nguyen, MD, CMO - Board Certified and dual Fellowship trained Neuroradiologist and Interventional =
Radiologist, radiology hardware, supplies, and clinical subject matter expert
Donna Looser, VP of Business Development - Principal brand, marketing, and sales strategist, facility 2Q
launch
and logistics expert, Lean Six Sigma Black Belt
Linda Noble, RT - Licensed Radiologic Technologist and Center Director with exter nsive experience in facility
planning, build-out, compliance, safety, staffing, training, and hardware application: IS.
Bryan Rhodes, CTO - Healthcare technology expert, specialized experience in cloud: -based Radiology
applications, progressive IT outlook and experience, Lean Six Sigma Green Belt
Launch team - Fellowship-trained Radiologist consultants, clinical and administrative Staff, and experienced
consultants for Licensure and Regulatory Compliance, Physician Syndication, Lean Operations,
Legal, Finance,
and Radiology Marketing.
Status and Timeline
Now - Late Due Diligence
41 Select and engage additional team members and consultants
2. Perform feasibility study
3. Finalize pro forma
Go vs. No-Go?
4 Adequate financing?
Angel investor on board? Loan approved?
2. Physicians for syndicate on board?
~ 3. Finalize deal
Project Kick-
1 Identify individual roles & responsibilities
2. Formalize project timeline and milestones
3. Establish regular communication and meeting schedule
Pre-Opening - 4-6 months
1 Build-out, renovation, design
2. Regulatory, licensing, and accreditation paperwork
3. Hiring and training of staff
Opening
1 Fine-tune oj ions
2. Solicit feedback from referring physicians
3. Grow volume and revenue
DRISONLINE2175 G63
De onlifié
‘MEDICAL PLANNERS ~ 7505 Fannin, Suite 312
Houston. Texas 77054
Phone: (713) 777-7737
Cell: 713-385-7979
Fax: (713) 777-747
www. Drisonline.com
wn @ Dris: COT
IMAGING AND --------CENTER
Houston MSA, Texas
PROPOSAL TO PROVIDE
FACILITY BUSINESS PLAN
(@ Healthcare Facility
fer 2020)
February 17, 2014
Submitted by
SAM ALAM, MHA, CHC
Bourd Certified realthcare Consultants
Drisonline.com, lnc
Fannin Medical Plaza
7805 Fanning, Suite 312
Houston, Texas 77054
Phone 733-777-7737
Fax 713-777-7747
Cell 713-385-7979
sam irisonline.com
e.com
re reap eee nema eg ot ETE rte
Confidential Document Copyright 2015 Page i ga.cooos
DRISONLINE1978
DASonlifié _—-
MEDICAL PLANNERS 7505 Fannin, Suite 312
Houston, Texas 77054
Phone: (713) 777-7737
Cell: 713-385-7979
Fax: (713) 777-7747
www.Drisonline.com
sam@Drisonline.com
Payment: As Board Certified Healthcare Consultants, our fees to provide you with the
results of this study, inclusive of all out of pocket expenses will be a total sum of $37,500 dollars,
We will require fees of $5,000 dollars at the signing of the contract and balance at the delivery of
a complete business pian. Qur Guarantee: If for any reason, you determine our services to be
deficient and/or inadequate to your expectations, you will not be bound to make any payment
towards the work we complete for you.
If this agreement accurately reflects your understanding, please sign the Agreement and
email it back to me at sam@drisonline.com. | will cali you promptly to determine the next steps.
Completion Date: Six Weeks.
Contract Amount: The contract amount for the referenced hospital projects is as follows:
Professional Fee: $ 37,000
Reimbursable Expenses: $ 500
We will not exceed our fee estimate without your prior approval and authorization. |i
during the course of our engagement, you choose to request that we undertake additional
services, we would determine mutually acceptable fees at that time.
Drisonline.com, Inc.
By By :Sam Alam, MHA, CHC
Date Date:
Confidential Document Copyright 2015 Page 12
‘SA-00014
DRISONLINE 1988
UGH Radiology
Subject: UGH Radiology
From: "Andrew E. Gomes, MD"
Date: 3/5/2015, 12:42 PM
To: Sam Alam
BCC: Donna Looser
Thinking out loud: Any chance in picking up UGH's Radiology Center at a distressed/fire sale price?
Even if the rest of the hospital shuts down couldn't we theoretically get syndicate referrers on board
for the Radiology Center and keep that going, only at a much higher level of efficiency and operations
than before? Wouldn't have to wait 6 months for MRI delivery either
=
Andrew E. Gomes, MD
CEO - Casper Radiology
agomes@casperradiology.com
www.CasperRadiology.com
914-623-8156 - office
646-596-4926 - cell
917-591-7836 - efax
AG000304
lofi 12/20/2019, 5:52
Re: slide deck 3
Subject: Re: slide deck 3
From: "Andrew E. Gomes, MD"
Date: 2/23/2015, 11:50 AM
To: Sam Alam
CC: Jessica Nantz
BCC: Donna Looser
Your gist is pretty much correct. In the hospital setting there is only so much operational "optimizing"
we can do, i.e. it is very difficult to implement Lean in the complex brown field hospital environment.
Because of that yes most of the results were concentrated on the physicians’ end. In the green field
approach of creating a Radiology outpatient center de novo, we have free reign to implement Lean
from day 1 at every level, so cost and efficiency savings (they are really one and the same) are
magnified, dramatically. With this operating model we could:
1. Deliver all results pretty much instantaneously. Do all procedures much faster and at lower cost
than the competition (FASTER)
2. Have near zero errors, and therefore no rework, no delays (BETTER)
3. Dramatically lower personnel and operating costs (CHEAPER)
This has never been done, not in radiology, not in healthcare. There have been attempts with some
degree of success e.g. Virginia Mason, but no healthcare system has truly "McDonalds'ized" it.
Instead, most outpatient ventures focus their resources on procuring "favorable" reimbursement
(read: higher). We aim to do the opposite -- charge less, not more. A Walmart or Amazon strategy if
you will.
Yes what you referto as "reading fees" i.e. revenue:cost ratio per procedure will be much higher than
others.
Yes all those items you enumerated need to be factored in for sure, but even those can be addressed
through a Lean lense:
1. Equipment - One vendor for all, bulk pricing, optimal interoperability. Don't waste money one
“the best" when a cheaper "good enough" will do. Buy a Camry, not a Mercedes. This is not
Johns Hopkins we are talking about, it's an outpatient radiology center that's going to do bread
& butter radiology. Configure and standardize this equipment using Lean. There are literally
hundreds of settings on all this equipment, and all pieces talk to each other. One weak link and
the entire chain falls apart. This is one of my fortes i.e. radiology equipment and technology
and how it works together
Upkeep - Again, go for value, not necessarily the bells & whistles service package. e.g the MRI
scanner and the IR suite are big revenue generators and can and do go down, get the Gold
service package. Ultrasound otoh rarely goes down, and we'll have two anyways, therefore save
costs on service there.
Supplies - Get from one vendor on consignment, basically costs nothing until we use it.
Standardize the supplies and procedures, so the docs and staff have to adapt to it, not the other
way around
4. Labor cost - Only hire tech savvy people, and train them correctly. Adroitness with technology
is
not optional in 2015. Everyone from the radiologist to the cleaning staff needs to have comfort
with basic Windows, Android, and user level technology. How many organizations do you know
AG000267
Lof4 12/20/2019,
5:53 PM
Re: slide deck 3
with high end expensive technology that nobody knows how to use correctly? With a futile
attempt at one Tech support person having to try to change and adjust every setting for
everyone, help with recovering lost passwords (I'd love to dollarize the inefficiency from this
alone, I'll bet it's in the hundreds of millions), etc? We use a screening assessment for all new
hires -- it has nothing to do with healthcare, it's all about technology -- e.g. what email account
do you use and why, what is your email response time, which personal calendar do you
maintain, which smartphone do you have and why. There is a strong correlation b/w how well
one performs on this and how well they work in a radiology setting. Do it this way and labor
costs and turnover plummet.
Operational Costs per procedure - addressed above, this goes down dramatically. Like Henry
Ford took cars from 12 hours and $3000 to 2 hours and $800.
Patient TAT - This too will be shortened significantly, but because this involves a biped physically
moving around it can't/won't be a 5-10 fold improvement like many other facets of the business
will
We don't have that metric for MRI only, but the average longterm per procedure revenue:cost we
have computed thus far is 1220:748 i.e. $472 net profit per case. But we definitely need the help of
financial experts to fine-tune this further
Andrew
On Mon, Feb 23, 2015 at 10:22 AM, Sam Alam wrote:
Andrew: | love your passion — | have reviewed all three slide decks — great presentation to show efficiency
from
MD's point of view. Correct me if | am wrong.
1 You are saying that “Reading Fees” can be lowered and the savings can be passed on (subsidy) to hospitals?
2 Your pitch is Quality, Efficiency (by radiologists) and Faster thruput (with regard to dictating and sending
results).
5 Isn’t this the gist of all three decks. Did | miss something?
You are on the right track and surely, as a Radiologist you have control over the reading fees and sending
of patient
results ~ but the complexity kicks in with respect to the cost of equipment, upkeep, downtime, supplies, labor
cost,
Operational cost per procedure, and patient turn-around time — don’t you think?.
Do you know the Procedure Cost of one MRi and do you know the reimbursement {or your price structure) for
one
MRI? Add that to the equation and see what you get.
Sam Alam
AG000268
2o0f4
12/20/2019, 5:53 PM
Preview
Exhibit 1 Re: Contact Information and Updates - Casper Radiology Subject: Re: Contact Information and Updates - Casper Radiol ogy From: "Andrew E. Gomes, MD" Date: 2/13/2015, 4:13 PM To: Sam Alam CC: Donna Looser Hi Sam, If you could spare some time for lunch or coffee I'd ve ry much like to meet you. Donna tells me you're in Bellaire -- I'm a Bellaire High School graduate mysel: if, class of '94. | live in Sugar Land but can meet you anywhere that is convenient for you, over the we ekend or next week - ? Andrew On Fri, Feb 13, 2015 at 3:42 PM, Donna Looser < ‘dloo ser@casperradiology.com> wrote: Sam, Thanks for our conversation this afternoon; | enjoyed it. As promised - my contact info is below. I'm copying Andrew on this email, so you two can coord inate a meeting in the next few days. Best, Donna es Donna Looser VP of Business Development Casper Radiology dlooser@casperradiology.com www.CasperRadiology.com 914-623-8156 - office 914-407-4765 - cell 314-754-9476 - efax DISCLAIMER: This email and any files transmitted with it are privileged and confidential information and intended solely for the use of the individual or entity to which they are addressed. This transmission may contain protected health information as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). If you are not the intended recipient, please notify the sender by e-mail and delete the original message. Further, you are not to copy, disclose, or distribute this e- mail or its contents to any other person and any such actions are unlawful. This e-mail may contain viruses. CASPER RADIOLOGY has taken every reasonable precaution to minimize this risk, but is not liable for any damage you may sustain as a result of any virus in this e-mail. The recipient should check this email and any attachments for the presence of viruses. CASPER RADIOLOGY reserves the right to monitor and review the conten’ it of all messages sent to or from = this e-mail address. AG000211 lof2 12/20/2019, 5:56 Re: Contact Information and Updates - Casper Radiology Subject: Re: Contact Information and Updates - Casper Radiology From: "Andrew E. Gomes, MD' Date: 2/15/2015, 5:22 PM To: Sam Alam Sam, print summary of proj I'm looking forward to meeting you on Tuesday afternoon at 3pm. Please see the summary of the project here. This is a live cloud- based document that we are still working on finalizing, but even in its current State |think it will help give you a big picture overview of both the business model and the #' 's. Note there are additional hyperlinks in the document itself. Hence, these documents are optimally viewed on a computer rather than on paper. | trust you will respect the confidential nature of the documents. Juan Nguyen, MD is my Interventional Radiologist partner in this venture. He currently has full-time clinical responsibilities at UTMB in Galveston and us such unfortunately will not be able to Join us on Tuesday; | will fill him in though. This project is not a Go yet, there are still some unknowns and some variables out of my control. We are still only at the late due diligence stage, and as such, cost control is critical. | a ppreciate the time you're taking out of your busy schedule to meet with me in Tuesday. Thanks very much, Pattern of Conduct Andrew On Sat, Feb 14, 2015 at 9:25 AM, Andrew E. Gomes, MD wrote: | Looking forward to it sir, have a great weekend Andrew On Sat, Feb 14, 2015 at 9:24 AM, Sam Alam wrote: i Great. See you on Tuesday From: Andrew E. Gomes, MD [maitto: agomes@casperradiology .com Sent: Saturday, February 14, 2015 9:17 AM To: Sam Alam | Subject: Re: Contact Information and Updates - Casper Radiolo gy t How about Tuesday at 3pm at Starbucks Sugar Land Town Square? | live and work from my home office very near by. And please do call me Andrew Sam, thanks! — Hwy 6 & US Hwy 59 116098 City Walk Blvd AG000222 10f6 12/20/2019, 5:55 CASPER 3N Executive Summary a Houston Outpatient Radiology Center Opportunity Continuously declining healthcare reimbursement and downward pressure to decrease healthcare costs are driving ever-increasing demand for outpatient radiology services — both Diagnostic Imaging and Minimally-Invasive a Interventional Radiology procedures. Additionally, specific enclaves in the greater Houston area, including Sugar Land, are experiencing rapid growth and population increases. And while the greater Houston metro area is rife with outpatient radiology centers, none provide the high quality that is possible, none deliver their services as fast as is possible, and none perform at their true financial potential. Solution Establish a new, state of the art, Outpatient Radiolo: gy Center in Sugar Land, offering both Diagnostic Imaging and Minimaily-Invasive Interventional Radiology procedures. Ever ry facet of this organization would be intelligentl y designed according to the principles of Lean operations. Every decision, every process, and every procedure would be deliberately crafted to maximize speed, efficiency, and consistency. Business Model A syndicated partnership of carefully selected physician referrers including Vascular Surgeons, Spine Surgeons, Orthopedic Surgeons, Primary Care Physicians, and Podiatrists will provide an immediate and lucrative referral source for the Center. A new standard of speed and quality will drive further growth with referrals from non- syndicated physicians. Competitive Advantage Casper's model is unique and superior due to following: ° 100% Lean workflow and operations systems from Day 1 Maximal exploitation of powerful new technologies in the Radiology space Standardization and systematization of every facet of the business, which will allow future scalability Immediate, near-real time report delivery; same day procedures Culture of excellence and continuous improvement Emulation of principles that have proven massively successful for multiple non-healthcare companies — eg. McDonaid’s, Toyota, Costco. Better, faster, cheaper Marketing Strategy © Syndicated Physician Referrers - 20-40% of the business will be owned by high volume referring physicians, thus aligning their incentives with ours. An ope! n line of communi ication and regular meetin with these individuals will ensure their satisfaction and ongoing gs referrals. Non-syndicated Physician Referrers - A full-time marketing specialist will identify local physicians who are not currently part of a competitor’s syndicated model, and who have unmet quality, speed, or service needs. e Patients - New patients will be attracted through a combination of strong Web 2.0 presence, online educational programs, and traditional advertising. Competition Competitors include Sugar Land area hospital radiology departments and outpatient imaging centers. Many do not utilize a physician syndication model, and most do not offer the range of services and procedures that we Propose. Most importantly, none of the competitors employ the principles of Lean operations, and thus cannot compete with ‘our operational performance. : Projections CMS recognizes that early disease diagnosis via radiologic imaging and the therapeutic results of minimally invasive Interventional Radiology procedures result in significant downstream healthcare cost savings, Thus, gyTeh by DRISONLINE2174 Outpatient Radiology reimbursements are high. Conservative pro forma projections demonstrate positive cash flow at Year 1, Month 10, and Net Income of $10-14M/year for years 2-5. Team 3 = D ° Andrew Gomes, MD, CEO - Board Certified Diagnostic and Nonvascular interventio: nal Radiologist, expertise in 2 workflow, operations, and technology, Lean Six Sigma Black Belt ° Tuan Nguyen, MD, CMO - Board Certified and dual Fellowship trained Neuroradiologist and Interventional = Radiologist, radiology hardware, supplies, and clinical subject matter expert Donna Looser, VP of Business Development - Principal brand, marketing, and sales strategist, facility 2Q launch and logistics expert, Lean Six Sigma Black Belt Linda Noble, RT - Licensed Radiologic Technologist and Center Director with exter nsive experience in facility planning, build-out, compliance, safety, staffing, training, and hardware application: IS. Bryan Rhodes, CTO - Healthcare technology expert, specialized experience in cloud: -based Radiology applications, progressive IT outlook and experience, Lean Six Sigma Green Belt Launch team - Fellowship-trained Radiologist consultants, clinical and administrative Staff, and experienced consultants for Licensure and Regulatory Compliance, Physician Syndication, Lean Operations, Legal, Finance, and Radiology Marketing. Status and Timeline Now - Late Due Diligence 41 Select and engage additional team members and consultants 2. Perform feasibility study 3. Finalize pro forma Go vs. No-Go? 4 Adequate financing? Angel investor on board? Loan approved? 2. Physicians for syndicate on board? ~ 3. Finalize deal Project Kick- 1 Identify individual roles & responsibilities 2. Formalize project timeline and milestones 3. Establish regular communication and meeting schedule Pre-Opening - 4-6 months 1 Build-out, renovation, design 2. Regulatory, licensing, and accreditation paperwork 3. Hiring and training of staff Opening 1 Fine-tune oj ions 2. Solicit feedback from referring physicians 3. Grow volume and revenue DRISONLINE2175 G63 De onlifié ‘MEDICAL PLANNERS ~ 7505 Fannin, Suite 312 Houston. Texas 77054 Phone: (713) 777-7737 Cell: 713-385-7979 Fax: (713) 777-747 www. Drisonline.com wn @ Dris: COT IMAGING AND --------CENTER Houston MSA, Texas PROPOSAL TO PROVIDE FACILITY BUSINESS PLAN (@ Healthcare Facility fer 2020) February 17, 2014 Submitted by SAM ALAM, MHA, CHC Bourd Certified realthcare Consultants Drisonline.com, lnc Fannin Medical Plaza 7805 Fanning, Suite 312 Houston, Texas 77054 Phone 733-777-7737 Fax 713-777-7747 Cell 713-385-7979 sam irisonline.com e.com re reap eee nema eg ot ETE rte Confidential Document Copyright 2015 Page i ga.cooos DRISONLINE1978 DASonlifié _—- MEDICAL PLANNERS 7505 Fannin, Suite 312 Houston, Texas 77054 Phone: (713) 777-7737 Cell: 713-385-7979 Fax: (713) 777-7747 www.Drisonline.com sam@Drisonline.com Payment: As Board Certified Healthcare Consultants, our fees to provide you with the results of this study, inclusive of all out of pocket expenses will be a total sum of $37,500 dollars, We will require fees of $5,000 dollars at the signing of the contract and balance at the delivery of a complete business pian. Qur Guarantee: If for any reason, you determine our services to be deficient and/or inadequate to your expectations, you will not be bound to make any payment towards the work we complete for you. If this agreement accurately reflects your understanding, please sign the Agreement and email it back to me at sam@drisonline.com. | will cali you promptly to determine the next steps. Completion Date: Six Weeks. Contract Amount: The contract amount for the referenced hospital projects is as follows: Professional Fee: $ 37,000 Reimbursable Expenses: $ 500 We will not exceed our fee estimate without your prior approval and authorization. |i during the course of our engagement, you choose to request that we undertake additional services, we would determine mutually acceptable fees at that time. Drisonline.com, Inc. By By :Sam Alam, MHA, CHC Date Date: Confidential Document Copyright 2015 Page 12 ‘SA-00014 DRISONLINE 1988 UGH Radiology Subject: UGH Radiology From: "Andrew E. Gomes, MD" Date: 3/5/2015, 12:42 PM To: Sam Alam BCC: Donna Looser Thinking out loud: Any chance in picking up UGH's Radiology Center at a distressed/fire sale price? Even if the rest of the hospital shuts down couldn't we theoretically get syndicate referrers on board for the Radiology Center and keep that going, only at a much higher level of efficiency and operations than before? Wouldn't have to wait 6 months for MRI delivery either = Andrew E. Gomes, MD CEO - Casper Radiology agomes@casperradiology.com www.CasperRadiology.com 914-623-8156 - office 646-596-4926 - cell 917-591-7836 - efax AG000304 lofi 12/20/2019, 5:52 Re: slide deck 3 Subject: Re: slide deck 3 From: "Andrew E. Gomes, MD" Date: 2/23/2015, 11:50 AM To: Sam Alam CC: Jessica Nantz BCC: Donna Looser Your gist is pretty much correct. In the hospital setting there is only so much operational "optimizing" we can do, i.e. it is very difficult to implement Lean in the complex brown field hospital environment. Because of that yes most of the results were concentrated on the physicians’ end. In the green field approach of creating a Radiology outpatient center de novo, we have free reign to implement Lean from day 1 at every level, so cost and efficiency savings (they are really one and the same) are magnified, dramatically. With this operating model we could: 1. Deliver all results pretty much instantaneously. Do all procedures much faster and at lower cost than the competition (FASTER) 2. Have near zero errors, and therefore no rework, no delays (BETTER) 3. Dramatically lower personnel and operating costs (CHEAPER) This has never been done, not in radiology, not in healthcare. There have been attempts with some degree of success e.g. Virginia Mason, but no healthcare system has truly "McDonalds'ized" it. Instead, most outpatient ventures focus their resources on procuring "favorable" reimbursement (read: higher). We aim to do the opposite -- charge less, not more. A Walmart or Amazon strategy if you will. Yes what you referto as "reading fees" i.e. revenue:cost ratio per procedure will be much higher than others. Yes all those items you enumerated need to be factored in for sure, but even those can be addressed through a Lean lense: 1. Equipment - One vendor for all, bulk pricing, optimal interoperability. Don't waste money one “the best" when a cheaper "good enough" will do. Buy a Camry, not a Mercedes. This is not Johns Hopkins we are talking about, it's an outpatient radiology center that's going to do bread & butter radiology. Configure and standardize this equipment using Lean. There are literally hundreds of settings on all this equipment, and all pieces talk to each other. One weak link and the entire chain falls apart. This is one of my fortes i.e. radiology equipment and technology and how it works together Upkeep - Again, go for value, not necessarily the bells & whistles service package. e.g the MRI scanner and the IR suite are big revenue generators and can and do go down, get the Gold service package. Ultrasound otoh rarely goes down, and we'll have two anyways, therefore save costs on service there. Supplies - Get from one vendor on consignment, basically costs nothing until we use it. Standardize the supplies and procedures, so the docs and staff have to adapt to it, not the other way around 4. Labor cost - Only hire tech savvy people, and train them correctly. Adroitness with technology is not optional in 2015. Everyone from the radiologist to the cleaning staff needs to have comfort with basic Windows, Android, and user level technology. How many organizations do you know AG000267 Lof4 12/20/2019, 5:53 PM Re: slide deck 3 with high end expensive technology that nobody knows how to use correctly? With a futile attempt at one Tech support person having to try to change and adjust every setting for everyone, help with recovering lost passwords (I'd love to dollarize the inefficiency from this alone, I'll bet it's in the hundreds of millions), etc? We use a screening assessment for all new hires -- it has nothing to do with healthcare, it's all about technology -- e.g. what email account do you use and why, what is your email response time, which personal calendar do you maintain, which smartphone do you have and why. There is a strong correlation b/w how well one performs on this and how well they work in a radiology setting. Do it this way and labor costs and turnover plummet. Operational Costs per procedure - addressed above, this goes down dramatically. Like Henry Ford took cars from 12 hours and $3000 to 2 hours and $800. Patient TAT - This too will be shortened significantly, but because this involves a biped physically moving around it can't/won't be a 5-10 fold improvement like many other facets of the business will We don't have that metric for MRI only, but the average longterm per procedure revenue:cost we have computed thus far is 1220:748 i.e. $472 net profit per case. But we definitely need the help of financial experts to fine-tune this further Andrew On Mon, Feb 23, 2015 at 10:22 AM, Sam Alam wrote: Andrew: | love your passion — | have reviewed all three slide decks — great presentation to show efficiency from MD's point of view. Correct me if | am wrong. 1 You are saying that “Reading Fees” can be lowered and the savings can be passed on (subsidy) to hospitals? 2 Your pitch is Quality, Efficiency (by radiologists) and Faster thruput (with regard to dictating and sending results). 5 Isn’t this the gist of all three decks. Did | miss something? You are on the right track and surely, as a Radiologist you have control over the reading fees and sending of patient results ~ but the complexity kicks in with respect to the cost of equipment, upkeep, downtime, supplies, labor cost, Operational cost per procedure, and patient turn-around time — don’t you think?. Do you know the Procedure Cost of one MRi and do you know the reimbursement {or your price structure) for one MRI? Add that to the equation and see what you get. Sam Alam AG000268 2o0f4 12/20/2019, 5:53 PM