The Heart Scan That Could Save Your Life (And Why You Can't Get One) - Kim Mischo

Cardiac imaging expert Kim Mischo spent 20 years inside the cardiology machine — running nuclear stress tests that told patients they were fine, then watching some of those patients have heart attacks the following week. She knew the system was broken long before she could prove it.

Now she can prove it.

A non-invasive scan exists that can detect coronary artery disease at 5% blockage — before symptoms, before a stress test would ever flag anything. It's been guideline-recommended since 2021. It's 99% accurate. And insurance won't cover it.

The reason why is the part of this conversation that will stay with you.

Dr. Philip Ovadia and Kim Mischo walk through the technology, the economics, and the quiet institutional logic that keeps a life-saving diagnostic tool out of reach for most Americans — while a far less accurate, far more expensive alternative continues to dominate cardiology practices nationwide.

This is a conversation about what early detection of heart disease could look like, and why it doesn't yet.

BIG IDEA

Between 50 and 60 percent of patients die from their first heart attack — which means the insurance company never had to pay a single claim related to their coronary disease.

Kim Mischo Contact Info: 
Website: https://clearheartandlung.com/

WEBSITE: Stay Off My Kitchen Table

Like what you hear? Head over to IFixHearts.com/book to grab a copy of my book, Stay Off My Operating Table. 

Ready to go deeper? Talk to someone from my team at IFixHearts.com/talk.

Ready to take control of your health?  Grab Dr. Ovadia’s brand new book Stay Off My Kitchen Table now! 

This isn’t just another diet book; it reveals why it’s not just what you eat, but what your body actually absorbs that determines your health.

If you’re struggling with low energy, stubborn weight, or feeling like “healthy eating” isn’t working… this book shows you exactly how to fix it.

• Learn how to reset your gut
• Eliminate hidden foods sabotaging your progress
• Unlock real energy, metabolism, and longevity

Don’t wait until it’s too late. Take action today. Get your copy of Stay Off My Kitchen Table now.

Learn More:

• Take Dr. Ovadia's metabolic health quiz: iFixHearts 
• Dr. Ovadia's website: Ovadia Heart Health

Theme Song : Rage Against
Written & Performed by Logan Gritton & Colin Gailey
(c) 2016 Mercury Retro Recordings

Any use of this intellectual property for text and data mining or computational analysis including as training material for artificial intelligence systems is strictly prohibited without express written consent from Dr. Philip Ovadia.

Transcript

0:34

Welcome to Stay Off My Operating Table with Dr. Philip Ovadia. Our guest today is Kim Michaud who's got a different, it's exactly in our wheelhouse and also completely outside of our wheelhouse. It's fascinating. So without further ado, Phil, why don't you tell us why Kim is on our show? Yeah. So we're gonna be talking about cardiac imaging today. That's Kim's area of expertise and focus. And, like you said it's interesting that among the many ways that I have started to recognize deficiencies in the way that we take care of cardiac disease in the healthcare system imaging is one of the very interesting areas that has come up and has developed. And so there's a lot of very exciting things that are going on, and that's why I was I had gotten connected with Kim and said, we gotta talk about this on the podcast," because it has been an interest of mine within the practice how we start to leverage these tools and what role they play and we'll talk a little bit about why they aren't playing maybe as big a role as I think they should be. But before we get to all that, I'm gonna give Kim a chance to give her background talk about why and how she got interested and involved in cardiac imaging, and then we'll go from there. Perfect. Thank you for having me, first of all. So yeah, my background is actually ironically nuclear medicine, and later on in the podcast we'll get to the irony. I'm sure Dr. Ovadia knows the irony behind this. But my background is nuclear cardiology specifically. I started my medical career as a nuclear technologist working in cardiology, and then went on to be a healthcare administrator within b- big, both independently owned cardiology practices, and then it graduated to, big healthcare system cardiology. So about 20 years of experience specifically in cardiology. Great. And I'm not sure I would say that going to the big system cardiology was actually graduating or a step up. It might be a step backwards in some regards, but we'll get into all of that as well. For sure. Yeah. It's interesting in the heart disease world, right? That, Let's just talk about generally the role that imaging has played traditionally and maybe we can make some contra- distinctions against things like the cancer world, for instance, where there might be some parallels. But cardiology has developed in a separate way. But yeah, let's just talk about, the general... First of all, what are we even talking about? What is cardiac imaging? And then what are some of the tools that have been used historically, and maybe we'll get into then what are some of the newer tools that we now have available to us when it comes to cardiac imaging. Perfect. So yeah, I'll speak to historically, we- the most prominently used tools or imaging was stress echo just plain echo or stress nuclear testing. And the thing that I've identified over the course of my career, and 20 years ago when we started this we didn't realize how much disease we were missing in the nuclear cardiology and in the stress space. Essentially, you have to literally be almost on the verge of a heart attack to get a positive nuclear stress test. And I'm not saying that there's no place for nuclear stress testing. There certainly is in patients that, we need to look more at function that have later stages of heart disease. But as far as early diagnosis of coronary disease, not a good test. We had many patients. We did 15 nuclear stress tests a day at fac- the facility that I worked at, and we had many patients during that time I was there that we told, "You have a negative study," and they went on the next week to have a heart attack, some of them dying, some of them surviving it, after telling them a week prior that their study was normal. So we, move forward and- But-... we look at the guideline... Oh. Sorry. I just- You have something to say? Yeah. I don't know. I'm just... The, th- Phil said it. We're... Stuff is broken. But the idea that you could walk in, get a nuclear stress test, which by the way I don't actually know what that is, and then be given a clean bill of health and then literally the next week end up with a heart attack I mean- Yes It's absurd. Yeah, I think- It's absurd... it's as absurd as it seems as absurd to everyone else. I just wanna go back a s- a second here and level set, right? To help people understand the problem that we're trying to solve, right? When you have a heart attack, that's generally fairly obvious, right? And the medical system has a pretty good system for taking care of you when you have a heart attack. However, identifying who is truly at risk of having a heart attack, who is on their way to a heart attack and giving, an opportunity to intervene before it gets to that end point we do a very lousy job of in the medical system in medicine, right? And some of it is just around limitations that we had in tools, but, again, the focus largely when we look at heart disease broadly, right? The main advances that have been made in the heart disease space have been around taking care of people that get advanced heart disease and keeping them alive longer.... But we still do a very lousy job of saying, "This is someone that is on their way to advanced heart disease, and let's give an opportunity to intervene and not let it move forward." So with that as- ... the sort of context, let's talk about some of the tools. So you mentioned nuclear stress testing. Just give the brief what that actually is and what the problems have been with it what the limitations are. Sure. With the nuclear stress test, patients come in, we put an IV in. Essentially we take an image of their heart at rest, then we put them on a treadmill, and while they're on the treadmill, if they're capable of walking on a treadmill, there is such a thing as a chemical stress test, but most patients would walk on a treadmill. When we got them to peak exertion, we would inject a radioisotope that would basically go into their bloodstream and go as deep into the heart m- wall muscle as the blood goes. And so if there was a deficiency of blood in a portion of the muscle of the heart, essentially it wouldn't light up because that radiotracer wouldn't go there. And so a patient would have to essentially have a blockage that was reducing blood flow to the point that's why I said, almost need to be on the verge of a heart attack before that study's gonna show up positive. So then you put them back on the scanner after you've injected the isotope, and we look at how deep, and we compare how deep did the isotope go into the heart tissue at stress versus rest and, a- and that's it. And you really have to have probably a narrowing of 90% or greater to have... Or w- we'll say 80%, I'll be generous, but 80% or greater to have that reduction in blood flow. But with coronary CT angiography, we can tell if a patient has 5% blockage, instead of waiting to image a patient until they have 85%. And many of those patients were symptomatic, right? So we're trying to figure out if their chest pain is really gonna lead to a heart attack or if it's some other, that they are having chest pain for another reason. So yeah. And I think it's important to point out that, back in the day when I was doing 15 of those a day, those were being reimbursed at roughly $6,000 a study So n- that's pretty good. I know it doesn't compare to the OR, but it shouldn't compare to the OR. There's not as many costs associated with that. And so but comparatively, CT angiography is seeing a reimbursement rate of $350. So we can diagnose disease at 5% blockage with it. The guidelines changed in 2021. This isn't new technology. This has been around, and the guidelines said in 2021 this should be the first test for early diagnosis of coronary artery disease. So why are we not doing it? There are several reasons. I just- Yeah ... mentioned. We talked- Yeah ... I me- I mentioned loosely reimbursement. That's one of the barriers. So I'll pause. And again, to, to to make it clear what we're talking about here, right? We have many tests in the cancer world that are designed to detect cancer at its earliest stages, right? Mammograms colonoscopy screening for lung cancer with CT scans, right? All of these things are designed because the thinking in cancer world is the earlier we diagnose the cancer, the better chance we have of, saving that patient's life and, improving all the outcomes associated with it. In heart disease world this really hasn't been the thinking, right? The thinking is maybe we're gonna do some blood work, that may or may not actually have anything to do with heart disease, and then when the patient gets advanced heart disease, when they have symptoms when they have a heart attack, right? That's when we're gonna deal with their heart disease. And, that gap in between of okay, figuring out, what are how can we figure out who is really at risk of heart disease, who is developing heart disease, and maybe we can then do something to stop it along the way has been a huge gap. And honestly, it was a technology gap to start with, right? Yes. We didn't have a good way of imaging the arteries without an invasive test, right? So we have- Yes ... what's called cardiac catheterization. That's been the mainstay, that's been around 50 years now. And so you can do an invasive test where you actually put a catheter up a patient's arteries, go into the heart essentially, or right near the heart to be technical, and you put dye directly into these coronary arteries that we're worried may be blocked, and you can see the blockages. But- ... that's an invasive test. It involves risk. It is, It's, not something you want to undertake just if you're screening people essentially, right? They may or may not have the disease. Absolutely. So- Absolutely... before we get to CT angiography, artery calcium scanning. Yeah. Yes. Something we've mentioned a lot on this program. Yep. Something I talk a lot about. That was really the first test that could give us a sense non-invasively of who might have significant disease developing. Yep. So at our center, we actually do calcium scoring as well as CT angiography. And I can explain why, but I definitely would like to explain that with calcium scoring, essentially we're only looking at disease that's calcified. That, that's not the most vulnerable plaque in the vessels. Calcified plaque usually is adhered to the vessel wall or inside the vessel wall, less likely to break off with a change in blood pressure, where the soft plaque is really the risk, and we don't see soft plaque on a calcium score. I would... It's, in my opinion, that a calcium score is better than nothing for certain, but we've imaged patients at our center who have come in for a calcium score who had a score of five, and they're like, "So I'm good, right? Because my friend had a score of 200, and he was good," or, "My friend had a score of 200, and he got a cath, so my score of five must be fine." And we have to explain to patients we don't know, because we don't know if you have 80% soft plaque and 10% calcified plaque or 80% calcified plaque and 10% soft plaque. So we really can't give you... All we can tell you is, yes, you have coronary artery disease at this point. I've never even heard the phrase soft plaque, or hard plaque for that matter. I just thought plaque was plaque That's because to Dr. Ovadia's point, we've not been able to image it or see it before, more recent technology. And I'll say the technology that we're talking about is a high-end CT scanner that can acquire the whole heart in less than a second. And so it minimizes the motion in the picture as well. And so hospital scanners aren't built for that. You can image... Their CT scanners generally can acquire the whole heart over six seconds. Imagine how much that heart has moved in six seconds, and then the computer's filling in that data instead of it actually being true and accurate data. And so if we can acquire the whole heart in a quarter of a second, this is your highest-end CT scanners that can do that. It's not generally what hospitals buy because, quite frankly, and I was a hospital administrator in radiology, we can bill the same CPT codes off of a low-end $1 million scanner as we can off of a high-end $2 million scanner. And so there's no motivation for the healthcare systems to buy the high-end scanner to do cardiac imaging. So then a lot of cardiologists say I'm not gonna- other than preventing heart attacks, but hey, yeah, I missed that one. Yeah. I missed that one. Yeah. Sorry. So- That one gets dropped a lot, unfortunately, in these discussions. Okay yeah, I just wanna, like I said so people are keeping up with what we're talking about. Coronary calcium scanning, that really came, what? Mid-'90s, early to mid-'90s is when-... This technology developed. Because like you said, so we had a technical challenge, right? The heart is always moving, and taking- ... pictures of it becomes difficult. Correct ... that is one of the limiting things when it comes to, okay, we're trying to get pictures of the heart, and the damn thing keeps moving. So ... we had calcium scans at first, and like you said, crude, but, at least gives us some idea about who might be at, risk, who's not at risk. You have a zero score, great. Who's more at risk and, some relative, but it's not a perfect scan because we're getting incomplete pictures of what's going on within the arteries of the heart. So then- Correct ... CT angiography comes along. And let's talk about just from a patient perspective, right? So they come to your center, they get a coronary calcium scan, has been ordered by their doctor. What that technique actually is, what they'll go through, and then if instead their doctor has ordered a CT angi- angiogram the differences just again, so people understand what we're talking about here. Sure. So yeah, c-CT calcium score is super simple. You... Patients are in and out of here in 15 minutes generally speaking. They don't need an IV. We don't need heart rate control. They essentially come in, we ask them some medical questions so that the physician has it for their report, put them on the scanner, acquire the image. Like I said, they're in and out usually in 15 to 20 minutes. With CT angiography it's a little bit, it's super important to control heart rate. So patients are here a variable amount of time. We tell patients to allow for an hour and a half when they come in. Our target heart rate for acquiring a CT angiogram, again, we wanna slow down the heart rate so we have less motion. So if a patient comes in at 85, we wanna get that heart rate down to 60 so that in that quarter of a second when we're acquiring the heart, again, there's half as much motion, and that makes a difference for the readers. And so we will reduce the heart rate to 60 beats per minute by giving patients metoprolol IV metoprolol, oral me- metoprolol diltiazem. We have a variety of protocols that we use to reduce heart rate. And by the way, all of our protocols were derived from the Lundquist Institute at UCLA where Matt Budoff sits. And Matt Budoff and Tony DeFrance are my two readers that are here as well, and so they demand that heart rate control because this is not an easy study to read. And so if we can make sure that our protocols make for better image quality, it's gonna make their read more accurate. And of course, being the world leaders i-in the reading space, they want their reports to be accurate. So heart rate control. We put a patient in. We give the patient an IV. When they get to the scanner, we get the heart rate down to 60 beats per minute. We give the patient a tablet of nitroglycerin, and that vasodilates the vessels. Again, we're taking a vessel and maybe taking it from one to two millimeters and increasing the size of it. Again, that's really for the reader so that they can see the vessel and s- they have something larger to look at. And so it's all about image quality that what the protocols are. And so the image itself takes a quarter of a second. Patient's on the scanner, generally speaking, for five minutes. We get them laying down and then they get contrast for this study so we can better visualize inside the arteries the same type of contrast that you give in the cath lab. Yeah. So again this gets to the if you just do pictures without administering contrast, right? You can see calcium in the blood vessel- correct ... but you can't see non-calcified, this soft plaque that we're concerned about. So we give this dye, through an IV, and that now allows us to see the greater detail within that blood vessel, and we can see both the non-calcified and the calcified plaque. And, so this technology has been evolving over the past, we'll call it 20 years or so. The scanners get better, so one of the things you mentioned is how fast the scanners can get the pictures. And if you're trying to get a picture over two seconds, you're gonna get a lot more motion than if you're getting it over a quarter second. So that's been- Correct ... one of the real technological developments. And with that, you also get better resolution, right? Just like people went from- ... watching their old, cathode ray, ra- cathode tube t- television that was all grainy and now we have, 4K and 8K and whatever high def, te- things that we're at. The pictures look a lot different, and it's the same thing when you're looking at the output that comes from these CAT scan machines. So yeah, the accuracy when CT angiography is done on a single beat scanner, high-speed scanner, the accuracy is 99%. And so occasionally I would hear cardiologists tell me I would love to order CT angiography, but every time I do, our image quality is crap, and then we end up going and, ordering a nuclear stress test." That's i- for one of two reasons. Either th- they don't have the technology to acquire a good quality image, or they're not controlling heart rate. They don't have great p- protocols for it. So it's one of those two things. Because really when it's done on the right equipment, it's 99% accurate. There's no other imaging, no other stress test, no other predictor of heart disease that's 99% accurate, great. And I think one more step that's gonna be important for people to understand, and then we can talk about, how the test gets used and why it might get used in certain ways and why it's not being used in certain ways. But the latest development in these, in this scanning, the latest sort of technological development is, Again, if you go back 10, 15 years someone, a patient comes in, they get this scan, and a radiologist, who's a doctor trained to look at scans and/or cardiologists who have gotten that training, extra training now in interpreting the pictures that come out of these scans, they would sit in front of a computer and they would look at the pictures, and they would interpret how much blockage there is, what types of plaque there is. But it ended up being a sort of, we didn't have that high fidelity in these interpretations. We would get something like a s- a common statement that I would see as the surgeon now trying to figure out how much blockage this patient has, right? I would be reading a CT angiogram report, and it might say that in, a certain blood vessel there is a mix of soft and calcified plaque, and there's a blockage that is in the let's call it 50 to 70% range is a- common thing that I would see. And then I'm- Yeah ... sitting there wondering is it 50%, which I might not be that worried about, or is it 70%, which I'm gonna be more- ... worried about. And-... You didn't know. We were guessing. The newest technology that has come along related to CT angiography is now, at first we called it kind of computer-aided analysis, and now we call it AI analysis. So talk about what layer that now adds to these scans. Absolutely. So if a patient comes in and they get a positive scan, let's just say it shows they have 30% blockage on their CT angiogram, and that's the point at which we make the recommendation that they get an AI plaque analysis so that they get more information. We've already identified that the patient has disease, but let's find out what is the plaque mixture, where exactly is the lesion. Does the lesion look like it's mostly soft plaque or is it stable plaque? Is it about to rupture? Is it in a location that's higher risk, more proximal in the heart or more distal in the heart? We get so much information from these AI analysis that essentially, the patient doesn't even ha- have to come back to the center at that point. We call the patient. We say, we've identified that you have coronary artery disease, and we offer the plaque analysis. Now, there's one additional step if a patient gets a plaque analysis, and let's just say it shows that it's in a very vulnerable location. It has a-- there's a lesion that has a lot of soft plaque. We wanna know is there a reduction in blood flow? Does this patient need to go to the cath lab? And so there's something called FFR or ischemia testing where it can take a measurement of what the blood flow is above the lesion and below the lesion, and this is all, of course, via AI, which I know you can do that in the cath lab as well with a wire. This is obviously non-invasive, as I mentioned, and so we can get a measure. We can tell, does this patient need to go to the cath lab? And I can confidently say when I say that this is 99% accurate, we've sent hundreds of patients to the cath lab in the two years that we've been open here, and I have a good relationship with the physicians who take care of these patients that go to the cath lab. We have no business relationship together. They're totally independent of us and I think that's important to note. But I ask them if ever we get a study that we send you that does not correlate when you get in the cath lab i.e., does... We sent a patient to the cath- cath lab that doesn't need to be there. If that ever happens, please let us know. And before I got on this podcast today, I called the owner of that practice to say, "I just wanna confirm that this has never happened." And he said, "In two years, it's never happened. Every patient who we've sent to the cath lab was a patient who ended up getting a stent," so a patient that needed to be there. Conversely, 10 years ago when I worked in cardiology and we were doing nuclear stress testing, 70% of patients who went to the cath lab then did not get a stent, so that was 70% of patients who went to the cath lab that did not need to be there. And so you ask yourself, that was 10 years ago, right? That was before we had access to good scanning, but why are we not utilizing this more if we can prevent all those unnecessary procedures that, which by the way, don't come without risk. Any invasive procedure comes with risk. And so I can speak pretty confidently to that 99% accuracy 'cause we haven't got it wrong once yet. Just from a math standpoint, never being wrong is actually 100%. I know, but you can't ever say 100% But from a marketing standpoint-'Cause some- ... it's smart- Someday it'll happen to give yourself a little space there. Yes. And, the other... the flip side of Kim's point is again, when we were relying on nuclear stress testing, we used to have a 10 or 20%, at least, miss rate, right? That the patient did actually have significant disease. The stress test was not abnormal. We think, "Okay, this patient's not at risk of a heart attack," and like Kim said, a week, a two weeks, a month later, they have a heart attack. And w- with this technology, we're not missing that either. We're seeing all of- ... the patients that actually have real disease. We're making sure they get appropriately dealt with, and and we're not... so we're not under-diagnosing or over-diagnosing, right? Which are both problems with other testing in medicine. All right. So now we have this great test. It can show us early stages of heart disease. Okay, this should be like mammograms for women, right? You should go get it every- Yep ... year starting at a certain age, and everyone should know about this test and should be doing this test. Not true is the answer. So let's talk about why isn't this test being used more. What are some of the barriers, and what are some of the challenges around this testing from, why aren't doctors talking to their patients more about it, and why aren't patients getting it done more? Okay. Yeah. So I'll start first with insurance. That's our favorite subject, right? Yeah. So insurance isn't covering it. So this is the test that diagnoses coronary artery disease. And I'm slowing down as I'm saying this 'cause I want this to really sink in. This is the test that diagnoses coronary artery disease the earliest, but you have to have a diagnosis of coronary artery disease in order for your insurance to pay for this scan. Oh, brilliant. So when you think about the economics of that, and I'm definitely, my brain is very in tune to economics the insurance companies don't wanna diagnose coronary artery disease early because 60% of patients, between 50 and 60% of patients, die from their first heart attack. That's a insurance company's dream patient, right? They never paid for a claim- Oh... correlating to coronary artery So if we start screening everybody, 50 or 60% of those patients that went on did not cost the insurance company a dollar because they died, they will now have to pay for. My God. So they're not covering it. Insurance companies don't wanna cover it because it opens Pandora's box, right? You get that diagnosis, and all of a sudden you have access to the medication you need. Essentially, you never pay for a coronary CT angiogram again in your life. I- that's really what my business model was all about. We need to create an affordable self-pay option so we can crack that door open to get people the diagnosis that they need so that they can get the coverage that they need. So yes, it hurts a little bit on that first one. You have to pay roughly $1,000 to get a good quality, and there are facilities out there that will do it for four or $500. And we talked about the differences in technology. It's not just the accuracy of the test that, that is the downfall of old technology. It's also radiation exposur- exposure, which I know, Dr. Ovadia, you and I talked about on our first conference call together, and I think even you were surprised to know that with these very up-to-date scanners, patients are getting one to two millisieverts of exposure. That's roughly the same that they get from a calcium score when it's done on a high-quality scanner. My husband had his first CT angiogram on 128-slice scanner, and he got 19 millisieverts. And I know the millisieverts part, that's not important, right? But one to two versus 19, you're talking, you know- We are talking radiation here. We're talking radiation. 15 times as much exposure. And by the way, on his, my husband's report, it said poor image quality. And you don't pay less for poor image quality, right? So yeah, we set out to design a self-pay model so we could open the door for people to get their first CT angiogram as a screening tool, and then determine essentially if a patient comes back totally clean, statistically, they have less than a 1% chance of having a coronary event in the next 10 years. No mammogram or colonoscopy gives you 10 years. So patients that come back completely clean, we say,"Come back in five years. You're good. You're good for five years. Come back in five years."'Cause we don't wanna wait too long because we don't want... We wanna find the patient when they have under 50% blockage because then as a provider, they can go after that aggressively with aggressive treatment and therapy or dietary changes. There's a plethora of tools that they can use to stop the progression of that disease. But if we don't have a baseline study, we don't know how fast a patient's disease progresses. That's different in every patient, right? So one pa- per- patient might get 10%, an increase of 10% blockage over five years, where the next person might increase 10% in their level of stenosis or narrowing in one year. And so you have to have a baseline study in order to diagnose early so your provider, your doctor, whether it's primary care or cardiology. I'm putting a lot of faith in the primary care community here not because I have anything against cardiologists, but I say if you have a cardiologist in America today, you probably ha- already have advanced heart disease. So we need to work with the primary care providers so that patient doesn't go on to ever needing a stent or ever needing bypass. It's possible. Yeah. And it's obviously something I'm passionate about, and, I scratch my head. Yes, there are insurance barriers and cost barriers, and yes, there's a radiation concern, which again, that issue is getting to be less and less of a concern as the technology gets better and better. But there really is a philosophical deficit in the world of cardiac disease management of, that we should even be making an effort to diagnose disease at early stages, right? And I know this is, sounds unbelievable, and Jack's shaking his head for those of you that are listening and not watching. But, the concept of we should be making the effort to diagnose heart disease at its earliest stages is still a very foreign concept within the cardiology disease world. Yeah, and you mentioned earlier, if you flip the coin there and we put that into the oncology world, if we told a patient, "You know what? You have cancer, but we're gonna wait 10 years to treat it," nobody would say that, right? We know what the outcome would be. We know the outcome would be far worse. It's no different with coronary disease. We tell somebody that they have low level coronary disease. You have the genetic predisposition, either that or you have poor diet, you have poor lifestyle choices, you have whatever the cause is, but at least you know you have disease and you can work on treating it now Yeah that's really what this gets to, right? And again as I, have my interactions with the traditional, cardiology world, right? We might argue about, okay, what is the best way to prevent disease from getting worse once we figure it out, but-... We shouldn't be arguing about, has disease and who doesn't.... And again we've, And this is going a little bit off-topic, but, you know- ... we've been sold the bill of goods in heart disease world that your blood tests, and specifically your cholesterol levels, can really tell you, you have disease or not. And, ... the reality is nothing could be further from the truth. So one of the other things that kind of gets, in my brain as to why aren't we using this testing more is that it would unveil things like what we discussed as- ... we're recording this. We had just released an episode with Nick Norwitz, right? And he has a LDL cholesterol level that is astronomically high, and he's got no plaque in his arteries. And we're seeing more and more examples of things like this, right? That if you do start to correlate the traditional blood work risk factors with what is actually happening in the arteries, we're gonna quickly see that there really is not great correlation there. And that whole blood marker-centric management of heart disease is gonna fall apart pretty quickly, and I think that's really- one of the other barriers that's preventing this from being used more often. Absolutely. Yeah, and I'll go back to the cancer correlation once again. If we flip it the other way and we say, w- if we were to tell a patient, "You..." We already talked about that, sorry."That you have cancer. We're gonna wait to treat that cancer till later," that, that would never fly. So sorry I lost my train of thought there. No. I- ... just about the time I think I can no longer be surprised by the utter anti-health behavior of the, air quotes, healthcare community, something like this comes up. I'm still trying to get over, they don't want early diagnosis because they'll die, so they don't have to pay the healthcare costs. Having slightly vented my bile there just a little bit, ... the next question becomes you gotta be actually in the machine to get this scan. This is not something you can do over Zoom.... You're located in a suburb Colorado ... I believe. Yes, Loveland, Colorado, just north of Denver. Where else in the country do people go for these things? So that's the barrier. There, there is not an option for self-pay. There are other places people can go to get a CT angiogram, but if patients wanna do this as a screening tool and they don't have the diagnosis, they need a self-pay option. Yeah. If you go to the hos- if you go to the hospital, like my husband did for his first CT angiogram, we paid over $3,000 for it. That's a barrier. Oh, yeah. Not that many people can, nor will. Why was I willing to?'Cause I worked in cardiology,'cause his dad had a heart attack at a young age, because I wanted to invest in our healthcare, et cetera, et cetera. But that's not affordable for most people, right? And and that's on the low end, honestly. So- ... $3,000 for a poor quality study w- on top of that. So yeah, the self-pay is the important thing. So when you ask, where else can you do this? Right now, we're the only independently-owned, non-hospital, non-radiology group that does self-pay CT angiography on a single-beat scanner. There are other imaging centers that do it, but if you want accurate... And we have patients flying in to Colorado every week from out of state, from out of the country. They're doing their research. People can find... W- we know that, right? They research. I had a patient who came in here who had read the manual on my scanner before he came. Lord. Yeah. Just give me the review. I haven't read the manual on my scanner. Was that one of my patients?'Cause, you know- I, I- ... we have a few like that in the practice. Yeah. No, that one... Yeah. Oh, wow. Yeah. No, I mean- So, yeah ... I, and again, I can speak to this challenge, right?'Cause having a nationwide telemedicine practice like I do, we have patients all over the country, right? And so we say, "Great, we wanna get a scan," "where do we go for it," right? And, Yeah ... my team oftentimes is going through, it's not the phone book anymore, but the internet equivalent of the phone book, and calling around to different imaging centers wherever that patient may live and say, "Do you do this scan? If you do, how much will it cost them?" They wanna pay, they're gonna be paying out of pocket. That is oftentimes you can't get an answer or it's very difficult to get that answer, ... because, they're not used to that. And then, the quality issue is another one that is very difficult to figure out, you have to really get into what kind of scanner do you have, what's your technology. And then, okay, now we wanna layer on this AI analysis. That becomes a whole nother, figuring that out. So having a place like you now have had the vision to set up if we had these available widely everywhere that would reli- that would get rid of a lot of the barriers to getting this testing done now for patients. Yeah, and we are working on expanding. We have centers that will be opening, additional centers in Colorado. We have a center that'll be opening in Wisconsin. We have a center that'll be opening in Texas now, and Tennessee. So it's just spotty. It's really where are there doctors that really want access to this. And people are reaching out to me or whatever, by whatever means, but they wanna start a practice. But we talked about the challenges with reimbursement, right? At $350, how do I do this and not lose money? Because we know it's beneficial to the patient. We know it's prevents unnecessary procedures, but how do I do it a- and not lose money doing it? And so that's what I set out to do. I actually took a non-compete leave for one year from the healthcare system that I worked for, and for that year decided to go into the sales world. And so I sold this scanner actually that's sitting behind me, a single beat scanner. And for that year and a half that I was out talking to cardiologists all over the western half of the US, they... I heard the same message all the time, "I want to be able to do CT angiography, quality CT angiography, but I don't know if I can make money doing it." And then it really became not only can I not, can I make money,'cause if you're not making any money then it's not viable. You have to be able to make money. It doesn't have to be gross amount of money. But the difference between 6,000 for a subpar, nuclear stress test for early detection and 350, there's a delta there, right? And so there's organizations like the Society of Cardiac CT. We're all working together to try to get that reimbursement up so that we see higher utilization. But it still doesn't allow access to the patients who wanna do it for screening.'Cause again, if you don't have chest pain or you don't have that right diagnosis, we need access to self-pay so patients can get the screening and diagnose early. Yeah the, insurance and reimbursement aspect of this is a very real problem. Because- ... like you said, if you're a- and, i- if you're running an imaging center, like you said, and you can get paid, you can promote one test that you're gonna get paid, 20x, the other test, obviously you're gonna be promoting that test just from a business standpoint, and that's where we need, the government level interventions and the insurance companies, to start realizing the value of this test.... And lot of work to be done there. And in the meantime- Absolutely... being able to offer it at an affordable cash pay price is, another way to go about this. And, thankfully you're making some efforts on that front. But we need to see that spread as well, so more patients have access to that. And people ask me all the time, "So if you knew you weren't gonna make a lot of money doing this why would you do it?" And I think the answer to that is twofold. First of all this test saved my husband's life. He had this test done. The day before he had the test done, he d- had it done as a screening tool. I mentioned that. We paid $3,000 to get a crappy scan. Huh. The day before the scan, he hiked 22 miles at above 10,000 feet with 75 pounds on his back. Good Lord. He had no chest pain. He didn't go and have the scan done because he couldn't do it. I couldn't keep up with him. Nobody can keep up with him. He's very physically fit, totally asymptomatic. He did it because he had a family history. He did it as a screening tool and to be proactive, but we literally caught him on the verge of a heart attack with 90%-plus blockages, multi-vessel disease, extensive disease, at the age of 50. So if he had this scan done at the age of 40, we would've known that he had coronary artery disease. And of course, there's more than just statins. There's more... we have PSK9 inhibitors, we have dietary changes. We have all the things that doctors can throw at this to treat the disease, but nobody's gonna pay $4,000 a month for Repatha for a PSK9 inhibitor, and your insurance is not gonna give it to you if you haven't already tried a statin and proved that it didn't work. And oh, by the way, my husband was on a statin for five years proactively because of his family history. Yeah, that's a whole nother bucket of worms. Yes. And we see plenty of patients, and I get asked that question all the time. So do you believe? And it doesn't matter what I believe. I'm not a physician, first of all. I don't pretend to be one. It doesn't matter because, again, if we diagnose the disease early, people and providers can do whatever they want to try to treat that disease and get scanned a year or two later and know if what they're doing is working. Yeah. Where- whereas in the statin world before, like my husband, we prescribed it five years prior, five years went by and nobody said, "Oh, I wonder if that's working. Maybe we should go in and look to see if the disease is e- if..." First of all, if he even has disease, right? We throw statins at people. Again, that would be like giving people chemotherapy proactively because their mom had breast cancer. We wouldn't do that. So why do we do that with heart disease? Yeah, this is another very important aspect of this, right?'Cause it's not only about making the initial diagnosis, it's then about following the progression, right?'Cause again, we can argue, and of course I spend a lot of time arguing what the best way to manage this is, but- ... ultimately today, we don't really have a good way of following over time is what we're doing working or not working when it comes to heart disease. Now- ... we have a tool that we can do that, right? Because- ... if you can do this scan with low radiation and low cost, great. Now I can get that scan on you every couple of years, and whatever it is that I've recommended to you whether it be a pharmaceutical or it be a lifestyle intervention or, some voodoo witch medicine, right? I can now evaluate two years later, is your disease worse? Or is it better, or is it the same? And if it's- Yep ... the same and/or if it's better, great. Keep doing what we're doing. If it's worse-... We gotta change course. We gotta figure out something else to do. And that's where I really think the major, advancements in heart disease are actually gonna come from. They're not gonna come from- ... putting patients on medicine blindly and hoping it works out, and, discovering that it didn't work out when it's already too late. We're gonna be able- ... to really evaluate what works and what doesn't work before, people have the major problems. Yep. I do wanna go back to the economics briefly because- Yeah ... I think this is another really important piece. In that year and a half that I was out talking to cardiologists across the western half of the US, and they would all agree that they wanted to be able to do CT angiography. The other common statement I heard is that, "The healthcare system doesn't want me to do this yet. We're gonna wait. We have our nuclear equipment. It's paid for. We're gonna continue to do nuclear stress testing." If I could tell you how many times I heard that, and I would s- and they would say, straight up, "The reimbursement isn't as good. We're gonna lose money if we do that." And I would say, "You're certainly not going to lose money. You have to think of the downstream benefit." If I'm a healthcare system, and today 70% of my patients are going to the cath lab and don't get a stent, that's roughly a six, seven, $8,000 diagnostic cath. But then you flip that, and 100% of patients who go to the cath lab actually need a stent, one or two or three stents. That's a 10 or 20 or$30,000 procedure. It- the economics of it would work itself out if we would do what's right, and if we could get the healthcare systems to not put revenue ahead of patient care, or patient outcomes, I should say. Yeah, patient outcomes. And it's not doctors. I wanna be very clear. I'm, I worked for a lot of my f- cardiologists, and I'm friends with many of them still today. It's not doctors not wanting to do right by their patients. Doctors got into healthcare because they wanted to help people. Exactly. It's not that at all. It's being part of a system, and frankly, we watched it. I started in cardiology when it was an independent practice, worked there, then they were consumed by the healthcare system. And now many of these people would do anything to get out of that system and go back to the way it was before. Yep. And I do think we're gonna see that over the next decade, the unraveling, because I think we're losing doctors at far too fast of a pace. Their job satisfaction is poor. They aren't practicing medicine the way that they want. They don't have the autonomy that they want. So I think we'll see it unravel, but it's not gonna happen overnight. Wow. Th- like I said, this is right smack in the middle of our wheelhouse, and also really way outside it. It's a cool... Thanks, Phil. This was, this is really good. Kim, tell folks where they can get more information about what you do. Granted- Absolutely ... there's not a lot of places where this is an option, but hey, at least- Yeah there's one. And you have to start somewhere, right? I knew- Gotta start somewhere. I picked Loveland, Colorado, A, because it was close to my home, but B, because it wasn't a major metropolitan area, and I wanted to prove that through my business model we could make this work financially in the top 30% of cities in s- in America instead of the top 2%. And I've made it work. I was profitable at four months into business. So we've made it work, and I do think we'll see this expansion go pretty quickly. I- it's almost not a day goes by that I ha- don't have somebody reaching out to me saying, "I wanna put a ClearHeart in my practice. I wanna..." And again, they have a cath lab, they have the interventional piece. They wanna fine-tune that, too. There are so many people that need care, so many people waiting a month or two months to get into a cardiologist. These cardiologists want to be seeing the patients that need them, not the ones that can be taken care of by their primary care providers. So I do think the expansion will happen more quickly than we think, but unfortunately, at a rate of 600,000 deaths a year, it won't be fast enough for a lot of people. Yeah So the website is? Sorry. Yes, clearheartandlung.com. So you can go to clearheartandlung.com. We're always changing the website. We'll- w- we're posting, where we're opening l- new locations. We're actually going on the road this summer. We're have a mobile RV that has the same scanner in it as this one, and we'll be hitting the road and going across Arizona into Texas to Louisiana, and then into Florida. And so we're gonna go out and find people that need scans, and we're gonna save one life at a time. That's amazing. I took a quick look at your website. Okay, a little more than quick, and one of the things I noticed is that there's multiple sets of scans. Yes... clear comprehensive package, calcium score, lung screening, bone mineral density, just a whole bunch of stuff. Yes ... I don't wanna open up a, an entirely new direction here that would probably be better with a, another podcast, but maybe giving a quick overview of what all those other things are doing? Absolutely, yes. We tried to design packages that would work for every type of patient. So there's some patients, many patients, that are sent to us from their preventative care doctors. They wanna know, do I have 5% stenosis, and if I do, I wanna make this change and that change. They wanna get scanned in a year to check to see if that's changed. And then you have people that just wanna know, am I gonna have a heart attack this year, or am I gonna have a heart attack in the next couple years? And so we try to figure out through conversations with patients what is it that they hope to get from this, and so that's how we help tailor that. The pieces like the bone mineral density, we'll be offering epicardial fat analysis very soon. All of these additional tests, like the bone mineral density, the AI plaque analysis, the AI ischemia, those are all tests that are derived from the data from the scan. And I'm very passionate, my background being nuclear medicine, about keeping exposure low. So if a patient's gonna be on the scanner and they need a bone mineral density, if they were gonna go get one next week, get one now because we just pull the data from the spine, which is behind the heart. We're not giving them any more radiation exposure. And so that's where some of those add-ons... And then lung cancer obviously being, a high, a cancer that happens pretty prevalently, we felt like that was another really important screening piece. Very good. And one more thing. Sure. About the comprehensive package. Oftentimes people will come in just to get the plaque analysis and the CT angiogram, and then they'll say, "Okay, I wanna understand this better." And so we have doctors, Dr. DeFrantz does most of our concierge consults with patients not to become their doctor, but simply to help them interpret the results that they got. Especially he and Dr. Budoff both read all of my studies, and so they've worked together at some capacity for over 30 years. They know each other's work, and so it gives patients the opportunity to get a really in-depth dive into their results, and that's part of the comprehensive package. Phil, I love how you keep coming up with these things that A, I don't think you can surprise me, and then you do. And then, B, really expand the options for folks to do a better job taking care of their own health. So- Yes. Yeah, That's really what this is all about, patient empowerment and being more proactive, taking back control of your health, like we talk about all the time. I wanna thank Kim for coming on. I knew this would be a fascinating conversation. I think the audience will really learn a lot from it. And we are hopeful that the, this becomes more commonplace. But in the meantime, people can empower themselves to go get this done, and it's a great way to figure out where you really stand regarding your risk for heart disease. Our guest has... Thank you, Kim. Our guest has been Kim Mischo. Did I s- did I pronounce that right? Mischo? You did when you introduced me. I am asking. Kim Mischo. Thank you. Kim Mischo. Kim Mischo... guest has been Kim Mischo. of Clear Heart and Lung. You can find out more about this t- ti- this scanner and scanning and what they do at clearheartandlung.com. So for Dr. Philip Ovadia, this has been Stay Off My Operating Table. We appreciate you all being with us, and we'll talk to you next time