Welcome to AAPMNR Advocacy, Advancing PMNR on Capitol Hill and Beyond. My name is Prakash J. Balan, I'm the chair of the Healthcare Policy and Legislative Committee of the AAPMNR. I'm a clinician scientist at the Shirley Ryan Ability Lab in Chicago. Very lucky to have an esteemed panel with me today who are very engaged in advocacy at different levels. Peter Thomas, who will be our first speaker today, has significant background in actually in the lobbying part of it for individuals with disabilities and he represents Power's Law Firm and he's an AAPMNR Federal Policy Consultant. He doesn't have any disclosures. Matthew Grierson, who will be going last, works at Seattle Spine and Sports Medicine. He's the chair of the Reimbursement and Policy Review Committee. And then Rich Chang, he's an attending physician in sports medicine at Mount Sinai in New York and he's the chair of the State Advocacy Committee and those are going to be your speakers today. So definitely today, please, we want some questions, if there's any things that need to be refined, et cetera, please reach out to us during this talk today. So the agenda is this. So Peter will be talking about National Health Policy Overview. I'll be talking about what we're doing at the AAPMNR in terms of federal advocacy. Richard Chang will be talking about AAPMNR State Advocacy and Matthew Grierson will be talking about Physician Payment Advocacy and Reform. With that, I'll pass it on to Peter. Thank you very much, Prakash. I appreciate that. Well, beautiful day in Baltimore. Thank you very much for inviting me here. I'm pleased to be here with all of you, in particular with Dr. Bruce Gans, who is now with Powers. He serves as our Senior Health Policy Consultant and just wanted to acknowledge that. Thank you, Bruce. Let's get started with the first slide. I do have no disclosures. So I wanted to cover some election-related issues first and then talk about some policies. And I'll try to move relatively quickly and not discuss every bullet on these slides because I really do want to get to the last slide, which has three major policy issues that confront the field. I don't want to spend most of the time on that. But as you may know, you probably know, the Congress is very, very closely divided. You'll see just by the numbers. The November elections are just critical to the policy path, however you feel it should go. The November elections will really determine what happens in a variety of different health care issues going forward. Normally, the party of the President who is in office, the midterm elections, that party loses seats. That's the historical trend. And so I think the Democrats certainly have been working hard not to have that happen this time and to try to change that historical trend. I think the Republicans are, frankly, very excited about the prospects of turning the House and possibly the Senate. There are three scenarios. Either the Democrats hold both the House and Senate, which I just said is somewhat unlikely. If that happens, the President and the Congress will continue to work together in moving forward their agenda. The Republicans could take the House but not the Senate, thereby creating divided government that would slow down many of the issues that really are part and parcel of the Biden agenda, if you will, to the extent that there's a number of things that have already been passed. But whatever remains on his agenda for the next two years would be at risk. The only things that really would probably move or be sure to move would be any bill that you could get enough bipartisan support to pass. If the Republicans sweep both the House and Senate, I think you're going to see a very big turnaround in Washington. You'll see a lot of investigations. The Biden administration will move to much more of an executive and regulatory approach, doing what it can with the federal agencies to implement its agenda rather than working through the Congress to get things done. So the Republicans only need five seats in the House, 435 races that will occur on November 8th. And all they need to do is have a net gain of five seats. And the way the census works and with gerrymandering in the states, after the 2020 election, there was many Republican governors, far more than the Democratic governors, and Republican governors or all governors are in charge of redistricting along with their state legislatures. And so the trend has been to draw the lines in congressional districts to make less and less competitive races. And so I think you'll see that play out in this election. There's a number of Senate races that are extremely tight. A number of them are listed here. Pennsylvania, certainly with Fetterman, who had a stroke, if you recall, in the spring and is working to run a full-fledged Senate campaign while he's still, in a sense, I guess while he's still recovering from a stroke. If he does get in, Pennsylvania will become a huge state for the disability and rehab community because Senator Casey and Fetterman would make a heck of a pair on those issues. They are strong supporters of disability issues and rehab in general. I list a number of other states that are key. One of them that stands out is Georgia with Raphael Warnock and Herschel Walker. That's a very interesting race to watch. But ultimately, many of these will turn on very slim margins, within 1%, 1.5% will be the difference in who gets in or not. So if you're watching the election results on November 8th, don't expect to know who's going to run the House and Senate that evening. It'll probably take a few weeks, at least, to try to figure out exactly which party is in control. The year-end outlook is as such. Right now, we're kind of in a lull, an election lull, because that's, you know, all of Washington has moved to the states and the districts across the country to campaign. And they're getting ready for the big day, November 8th, as I said. After the elections, we expect a lame duck session of Congress, it's called, meaning that the people who are still there, they can make decisions. They don't leave office until the first of the new year when the new Congress is sworn in. But they don't have any political repercussions for votes they take. It's called a lame duck session of Congress. And we expect it to be relatively robust. They have a continuing resolution or an omnibus spending bill to pass by December 16th, or the federal government shuts down. No one really expects that that will happen at this point, but you never know how that will play out. The debt ceiling is becoming more and more of an issue. There was some sparring just yesterday between the President and the Republican leadership about whether to mandate entitlement reforms to reduce federal outlays in exchange for raising the debt ceiling. And they will have that debate. That won't, that vote won't occur until next summer, but this is playing out in the context of the campaigns that are happening across the country. But when you have a massive omnibus spending bill that will need to be passed by the 16th of December, you have a legislative vehicle on which you can attach other legislation. And that is something that offers an opportunity to not only the Academy, but to all healthcare organizations to try to append something to that moving must-pass bill. So possible riders include the physician fee schedule fix, doing something to reduce the cut in the physician fee schedule. Do you remember the sustainable growth rate formula that plagued the physician fee schedule for 20 years? It's back. It's just back in a different form. Each year the shift from specialty to primary care in terms of reimbursement has created, with the budget neutrality provision, has created a situation where the fee schedule year after year goes down 3 to 4 percent. At the very least, there are two other provisions, PAYGO, that's a provision that was put in to try to limit federal spending. That's been routinely waived, but if that goes into effect, that's a 4 percent cut added onto the roughly 4 percent cut that's proposed right now for the physician fee schedule. And there's also the 2 percent cut for sequestration, which I don't think is going to go away. That's currently in effect and I expect that's going to stay in place. So that's almost a 10 percent cut for some specialties, over 10 percent, and it's something that the Congress recognizes it's likely going to have to address. But there is a dearth of offsets. There's very little additional funding they have to spend on fixes like that. There are other important issues that should be attached as riders and we'll see how the Congress does that at the end of the year. The public health emergency was just extended a few weeks ago. That's expected now to expire in the next quarter. They do this by every 90 days. They give 60 days notice, so look for the middle of November to figure out whether the PHE will continue once again or whether it will come to a close. And when that comes to a close, a number of waivers will change, likely go away, unless Congress or CMS intervenes and makes some changes, including the three hour rule waiver currently for inpatient rehab hospitals. The 60 percent rule is currently waived for IRFs. There's SNF waivers in place of the three day inpatient stay requirement. That will likely go away. And the discharge planning requirements that currently are waived as well. All of those will begin to be phased out and transitioned back to the way it was prior to the pandemic. So there's also significant telehealth initiatives that people are waging to try to extend the current treatment of telehealth, really that was stimulated as a result of the pandemic. Congress can only... I'm sorry, CMS can only do so much. They can... There's a couple of things here, bullets listed on this slide of what is within their authority but they can't do everything with telehealth. Congress has to play a role in extending the current treatment of telehealth. Telehealth is extraordinarily popular and I don't expect that it will go away, but it is also expensive and Congress doesn't have a lot of money to offset other programs in order to pay for the extension of telehealth. So again, that's probably going to be another issue that gets kicked down... The can gets kicked down the road every year. We'll see if they're able to come up with a more comprehensive approach. So I have just a few minutes left and I wanted to focus on three main issues that confront this field and really the field of rehabilitation, post-acute care. The first is called the IRF Review Choice Demonstration Program, the RCD. This is something that CMS rolled out with home health agencies several years ago. It's a way to really put a clamp on the use of services in a particular area. Because of the high error rates and the Office of Inspector General report in 2018 that said that 84% of IRF claims were errors, in other words were overpayments, which no one believes. Really have significant difficulty believing that that is accurate. Nonetheless, they do plan on moving forward in a phased-in approach with an RCD that applies to inpatient rehab. And that means that 100% of patient admissions will be reviewed either in a pre-claim or a post-payment review posture. That's the choice. You know, the choice in review choice demonstration. The choice is you can have your claims reviewed pre-claim or post-payment. You can have guillotine or, you know, noose, depending on what you'd like. So it's really a massive program that is going to create a gatekeeper effect that will ultimately change coverage criteria without CMS going through the proper regulatory pathway to do that. So it's a major issue that we're all confronting. The Academy is working closely with other stakeholder organizations in trying to do everything we can to ameliorate the harshness of this program. The program starts in Alabama, but it then is extended to Texas, California, and Pennsylvania, and then eventually to about half of the rehab hospitals in this country. So it's definitely a major issue that is in front of us, and we're working hard to try to address it. The second big issue involves the Office of Inspector General. And following up on that report from 2018, to try to develop a meeting of the minds on what kinds of patients are truly appropriate for inpatient rehabilitation care. There's much speculation that... And there's this kind of perception, not only among CMS, but also within MedPAC, the Medicare Payment Advisory Commission, that IRF patients are, you know... Rehab patients can go to IRFs, or SNFs, or even home health, and there's not a big distinction, and why are we spending all this money on our IRFs? And of course, anyone who really understands these settings of care, knows how different they are, and knows how critical IRF care is. So we are working with two other organizations, the Federation for American Hospitals, and the American Medical Rehabilitation Providers Association, in really working closely with the Office of Inspector General in a very novel way. They are going to conduct another national audit, much like they did in 2018. They're about to pull 200 claims from IRFs across the country, and the three stakeholder groups I just mentioned are going to be working closely with them throughout the audit, and looking at the denials, and sitting down with the OIG and CMS for two days in the springtime, and talking about specific cases, and going through this. This is a follow-on to work that Peter Esselman and other physicians in the room assisted with, where we looked at seven of those cases that came from the 2018 report with the OIG, and had some fruitful discussions. But this is going to be a much more blown out exercise. We'll also be able to submit a report that ultimately is included in the final report that they publish, and we'll be communicating with OIG in real time as they do this audit. Our hope is to improve the audit process, to clarify some of the criteria and to try to educate the government policymakers and reviewers as to some of the nuances in rehabilitation that they clearly are not understanding. And then finally the United PAC payment, Unified PAC payment system. There has been, since the IMPACT Act of 2014, there's been an attempt to try to figure out a way to take LTAC, IRF, SNF, and home health prospective payment systems and jam them into one. And there's major concern around doing that. It's extraordinarily difficult to do that. And I think there's recognition of that challenge within CMS and MedPAC. But we just got a, went through a MedPAC meeting where every commissioner strongly supported a Unified PAC payment system, strongly supported. And we expect a new report to come out in June of next year that lays out the parameters of how CMS would go about putting together a Unified PAC payment system. It's, we thought that it was kind of moribund. We didn't think that it was really going to be something that the Congress moved forward with or that CMS moved forward with. But it's clearly a threat and we need to work on it to make sure that patients have access to the proper setting of care and aren't just jammed into one payment system that blurs the distinctions between severity and the various patient mix. So I, my time has expired. So thank you very much. Thank you Peter. So next I'll be talking about our AAPMNR advocacy efforts at the Hill as Chair of the Healthcare Policy and Legislative Committee. So I have no disclosures. The first thing that I want to just go through is what are our priorities as a committee that is really advocating for our specialty at the national level. And a lot of our goals are sort of grounded in the goals of the AAPMNR. So transforming the specialty, engaging our memberships making sure that, our members making sure that they're set up for success in the future. Trying to also dynamically engage membership in many different avenues as well as enhancing our organizational strengths as well. And so these are some of the issues and priorities that have really, that have stemmed from that. Such as demonstrating the value of PMNR both in the inpatient realm as well as the outpatient realm. Pursuing legislation and regulations that reduce physician burden. We know that burnout is a big issue in our specialty. And that's definitely something that we've been advocating to look at. Pursuing legislation that funds rehabilitation research and we'll talk about that shortly. GME advocacy, more residency spots for our specialty. Post-acute care reform. And then obviously long COVID advocacy which has been a big focus of our specialty over the last couple of years. The next thing I want to say is just these are some of the organizations or parts of the government, particularly the executive branch that we advocate to. We obviously collaborate or work with Congress, meet with congressional members, particularly when we go to the Hill. I will say that most of the executive branch that we're most involved in is probably CMS. And CMS, and so we work often with the Office of Management and Budget, OMB. So just bear with me, it's a lot of alphabet soup when you start with advocacy. And even Peter was saying quite a few that many of you may not know, so please stop us if you have questions. But the OMB approves CMS policies. And so any policy that CMS is going to introduce, OMB approves it based on the strengths and merits of that particular policy. And then other avenues that we also advocate at is HSS as well. So Peter mentioned the OIG, the Office of the Inspector General. That specifically is involved in making sure that the integrity of the HSS is maintained. So that's an important advocacy route for us. And then also I talked about research. A lot of the research organizations, federal research organizations, we do advocate in those settings as well. The other thing that I want to say is that there are a number of... Although we advocate a lot for ourselves, we do form coalitions with other organizations that are generally focused on individuals with disabilities or rehabilitation. I do want to point out that we just, within the last year, did sign on as part of the regulatory relief coalition. This is part of looking at essentially making sure that a lot of the burden in terms of that we face with paperwork, et cetera, that other specialties are also facing, that we are part of the solution to that and advocating for that as well to improve. But these are some of the organizations that historically and we continue to be involved with as well. Next I want to talk about what we do now in terms of actual advocacy and boots on the ground. So we, unfortunately over the last few years, it's been a very challenging time obviously to do in-person visits. Classically we would go to Congress and we would advocate at the Hill meeting with congressional officers. But we've actually been doing a lot of that virtually and this year we had our Hill visit and it was virtual. But these were the major things that our committee really advocated for and lobbied for at the Hill. So the first is restoring physician judgment to IRF care by introducing the Access to Rehabilitation Therapy Act of 2022. So this is essentially the three-hour rule. This is the idea that classically when we think about inpatient rehab we think about PT, OT, and speech therapy. But this is actually to say that we can include recreational therapy and respiratory therapy, particularly during COVID times, in that three-hour rule as well. The next was also the advancing access to multidisciplinary care for individuals with long COVID essentially. And this has been a big focus of our specialty of course. And so a lot of our focus has been both in terms of trying to make sure that these comprehensive clinics or multidisciplinary clinics have funding that goes with them and also individuals can be treated in the community for long COVID-related symptoms and be reimbursed for that, or the healthcare organizations can be reimbursed for that. The other two are streamlining prior authorization by supporting the Improving Seniors' Timely Access to Care Act. This is actually focused on prior authorizations, as I said, and making sure we streamline that process and make it more effective. The major things to look at here is that we are advocating for electronic prior authorizations, more transparency, and making sure the most important part is that these prior authorizations are actually evaluated by qualified medical personnel in that specific specialty. So that's what we've been advocating for as well. I have an amazing committee. It's been very easy to manage this committee, and we have lots of different people. And actually, this was our Hill visit that was virtual this year. And so each of us meets with congressional staffers from our specific district often, or sometimes it's outside our district, but we have some sort of tie to that legislator. I do want to point out, this was the first year that we actually had two residents, sorry, two trainees. One was a resident, one was a fellow, but one of them is here, Manish, and Dan Pierce, who's a fellow. So we do want to include residents. They both represent the FIT Council, and they did a fantastic job. So we're excited to have residents from the FIT Council involved in our advocacy efforts going forward as well. This is some pictures. I promise you I'm not self-absorbed. There's not a picture of myself for a reason there. But these are some of the Twitter feed or social media pictures that were posted as well. And then we did finally have an in-person congressional visit. This was actually our future leaders group that, just as their sort of capstone, they went to The Hill, and they did meet with a congressional team there as well. So we're hoping that over the next year, this coming year, we will be back at The Hill and advocating in person. So what are our wins, or I should say successes? So the first is to say this, what I was talking about, the three-hour rule, that has now been reintroduced in Congress. The Senior Timely Access to Care Act passed the House. We did also delay the implementation of the Appropriate Use Criteria Program, opposition to the CMS IRF Choice Demonstration, as Peter was mentioning, and then the OIG IRF Admissions Claim Reviews, as Peter was also mentioning, that they are engaging with us as part of the solution to this problem because of some of our advocacy efforts. The last few slides are just to say some of the more specific. So Demonstrating the Value of PM&R, this was our largest Hill visit. I think it was helped that it was virtual in a way. So we actually met with 70 congressional offices over the last year. We also had one of our members of our committee, Anjali Shah. She has been very involved in advocating, even before she joined our committee, in advocating for coverage of power-seated elevation systems in power wheelchairs. So she actually visited Congress, gave testimony as well, which was fantastic. We've been pursuing legislation that funds rehabilitation research. Specifically, a lot of it's focused on long COVID. We met with NCMRR, which is the sort of subset organization of the NIH, which is focused on rehabilitation research, advocating for the fact that we need to make sure that individuals with disabilities are incorporated in many of these research studies that are ongoing, but also making sure that there are funding for long COVID-related studies. And then GME advocacy, as I mentioned, more residency spots specifically in our specialty as well. Execute care reform, as this was also talked about by Peter, talking about promoting PM&R as a specialty that can also provide care in SNFs. And that was something that we advocated for with MedPAC. And then long COVID advocacy, there are a number of different bills that are specifically focused on long COVID. Everything from the healthcare that individuals receive, as well as the rehabilitation resources that individuals receive in the community, and then also the research funding that these receive. The last one is this expanded the language on long COVID in the Prevent Pandemics Act. Specifically, we've been advocating for making sure individuals with disabilities are included in specifically research-related studies that may be undertaken, as well as making sure there's a diversity of the population that's involved in those studies as well. That's it. So certainly we'll take any questions at the end and with that I'll pass on to Dr. Chang. Hello again. Pleasure to be your state advocacy chair again. Thank you all for joining us today. No disclosures. Even though our committee compared to the larger HPL group is smaller in size, we're still mighty. We do our best to represent the diverse interests in terms of the spectrum of care that physiatrists can provide to our patients and also geographically as well. So just a brief sort of introduction. We have Dr. Scott Thomas Baker on the top left-hand corner. He's a physiatrist practicing pain management in Lebanon, Tennessee. He's also a former state society president there. On the bottom left-hand corner is Dr. Max Fitzgerald. He's both an inpatient and outpatient physiatrist at Rush University Medical Center in Illinois. He's also the medical director of Oak Park Medical Center there as well. On the top right we have Dr. Raymond Cho. He's an outpatient physiatrist at Stanford Medicine, California. And to round it out we have Dr. Justin Bishop in Texas. He's an inpatient physiatrist in Dallas, I think associated with Methodist Health. In terms of current and future state advocacy goals and priorities, pretty much they're similar and aligned with the national goals that are set by HPNL. In terms of state advocacy goals, again, I would say specifically what we do best is trying to monitor certain bills that generally may be perceived as a threat or potentially may be of benefit. For example, as a threat it's usually scope of practice. As a benefit, we may need to ensure certain benefits for our patients or expansion of certain benefits. A large percentage is responding to certain bills that are being introduced to the state, but what we're doing our best is essentially to identify bills which may be pertinent to our specialty. The website again which I'll discuss a little later is excellent in sort of identifying those key state issues. Generally we work with the physician members of that state as well as the local state medical societies in terms of sort of creating these alliances and these grassroots campaigns and sort of drawing up support for certain bills. And as a result we create these large networks. And in addition, like all of us in terms of what the academy is doing, we're trying to create these educational resources to have members be able to engage with their state representatives even on the local level because again initially it might seem daunting, but I would say it's relatively easy once you know the process. In terms of priority areas, similar to on the federal level and national level, I would say a vast majority is scope of practice. As one pandemic ends, another, the old pandemic and from the opiate epidemic is sort of reemerging, it's ugly head again. So we deal with that. I would say a good majority of other bills are being introduced essentially to preserve health benefits, both rehabilitation and habilitation efforts. And I would say for COVID-19, even the pandemic's improved, I would say in terms of long COVID, that's a very big issue in terms of state issues. You know, the academy, our members are champions in regards to this particular topic. And as Peter mentioned, alluded telemedicine, it's been a great benefit to our patients, but as the public health emergency waivers have started to maybe end, again, it's something, it's a particular topic that we hope to preserve for our patients. And again, we do our best to protect our patients with chronic conditions and disabilities. In terms of wins, again, there's a pretty much exhaustive list, but we'll focus on specific wins in these states. So on the left-hand corner, I'm not going to go into the minutia per se, but on the left-hand corner in Kentucky and Wisconsin are bills in relation to expansion of scope of practice for advanced practice nurses or APRNs. There, usually, bills are introduced to weaken the relationship with the supervising position or in terms of loosening education requirements. In Wisconsin, that bill was vetoed by Governor Evers. In contrast, in Kentucky, that bill was passed in the House, but it wasn't advanced in the Senate. Similarly, in South Dakota, in regards to physician assistants, again, similarly, they would like to remove the physician supervision requirement or they would like to supervise their own PA colleagues, but in the end that bill was defeated. So again this is an issue that we constantly monitor as well as your local state medical societies, but again that doesn't end there. In Louisiana, actually this was interesting this past year, this was scope of practice involving spinal medical specialties. An orthopedic surgeon in Louisiana introduced a bill proposing that essentially neurosurgeons, orthopedic surgeons can only perform procedures of the spine, particularly surgical procedures. Our committee essentially received this bill and actually a number of other specialty organizations took hold of this as well and were very upset with this. And given this uproar, this bill wasn't even discussed at the Health and Welfare Committee and was deferred, but again it's something that we're continuing to monitor given that a number of, especially in the interventional pain field, they're doing some of these percutaneous procedures. In Massachusetts, I would say on the positive side, that doesn't involve turf wars per se, sort of brought on by the Brain Injury Association in Massachusetts, legislation essentially to preserve follow-up care to patients with brain injury among private insurers. In terms of position statements, the Academy holds a position in regards to our self-referral to physical therapy or direct access to physical therapy as a patient. We are against it. This position statement came about because again there seemed to be a growing trend among states introducing these bills, especially among PT organizations, physical therapy organizations, to essentially access their services without the supervision or a form of physical therapy prescription. Unfortunately, for example, in New York that occurs, but we are trying to advocate as well that if there is access to physical therapy directly there should be some kind of supervision for the physician or again if it's out of scope in terms of essentially making a diagnosis or treatment, it should involve the physician early on. In New York, it's within a month. Other states, the time frame hasn't been sort of outlined per se. Another one was in Virginia actually. In this case, this was both I think proactive by one of our committee members, another member of Virginia, where Virginia Department of Health created a mandate for rehabilitation for any patients discharged from a rehabilitation facility, whether it's acute or subacute, they had to have some kind of follow-up care. In that state, the follow-up care was fragmented. Fortunately, I say less than a week, they were convening on a board meeting and luckily, Drs. Wayne and Kunz were able to represent us in terms of being able to provide their input and in terms of the task force or workgroup besides administrators, inpatient hospital facilities, we actually have a zonatrist on the workgroup to be able to represent our patients and input and again making sure that patients actually receive follow-up care. Because most of the time when patients are discharged in acute setting, outside of acute setting, sometimes they may not have a zonatrist in their community setting, especially in more rural communities. Uh, this is to highlight PMR Advocate. On the website, the advocacy section is awesome. Um, you know, be able to create, you know, a template of letters to your local state legislatures, your congressional house council members, state senators. Um, there are three bills that are active right now. Actually, Dr. Grierston, I think I saw this morning, had one in regards to the Medicare Physician Fee Schedule. So I encourage you all to use that and actually for our trainees it's important, because we have to, uh, have them understand that this is important to both their practice and, uh, and in terms of the patients that they serve. And again, if you have any other questions that arise, again, this is usually from state society. We usually respond, but we're trying to be more proactive. Uh, please reach us at healthpolicy.aapmr.org. And with that being said, I'm going to pass the baton to Dr. Grierston. Thank you. Hello everybody. I'm Matthew Grierson and I'm chair of the Reimbursement and Policy Review Committee. We're sort of the committee you love to hate because it's like you all want to be valued for what you do, but it's never enough. But... All right. So I'm going to move to the next one. I have no disclosures. I do serve as the... I sit on the physical medicine rehab seat on the AMA RUC which we'll talk a lot about that today, but reimbursement advocacy is one of the real core advocacy priorities of the academy. We have an emphasis on ensuring that there's appropriate reimbursement for all of the services that we provide. And so annual activities for our committee, just to update you on all the work that we've been doing is we have regular meetings to discuss timely issues as they come up. We're sort of continuously evaluating these requests, prioritizing areas for action and addressing gaps in member education. We engage with regulatory bodies like CMS and other payers, so all the major insurance companies out there. And we comment regularly on the annual fee schedule that was just referenced and we engage in comment processes regarding any new medical policies and other efforts. Two big intensive efforts that we participate in and these are volunteer efforts. And a pretty significant amount of resources from the academy goes into doing this because of their importance is the AMA CPT panel and the AMA RUC. So our previous CPT advisors, Dr. Annie Purcell and Scott Horn, they recently stepped down from their position after many, many years successfully representing the academy. And so very recently we've recommended two new representatives, Dr. Joe Shivers and Dr. Antigone Argerio and they will be officially confirmed hopefully by the AMA in November. We try to have a strong leadership pipeline so that we've always got leadership pathways for people who are interested in this work so that, you know, there's a big learning curve along the way. And so we're always looking for people to be more involved and to help train them for this important work. But on the RUC we've got two advisors who... They're actually advocating for us at the AMA RUC, Drs. Carlo Malani and Dr. David Reese. And so they're the ones who are actually going up onto the... at the table really arguing on behalf of our specialty for our codes. But in addition to that, as of 2021 we have an official seat on the RUC and I serve in that official seat and I hold that with my partner alternate, Dr. Clarice Senn. And so we're able to there to help sort of craft and guide the process along the way providing that input from physiatry. And just to get into some of our recent efforts, we have three meetings each year including during the pandemic which we met virtually, which was almost as fun as having a RUC now every day for an entire week. But we did achieve a lot that impacts 2023 payments and some of those key highlights include the inpatient and SNF E&M guidelines, updating the code descriptors. These were recently revised by CPT and then new values were recommended by the RUC. We also have a new code for neuromuscular ultrasound that was also developed by CPT sort of through a member driven effort and then later valued by the RUC. And then there are some additional codes for interventional spine procedures that were re-evaluated. This one for interlaminar, interspinous process stabilization and distraction device without open decompression or fusion. So that was re-evaluated by the RUC recently as well. So this is some of the big drama here of course and this is sort of alluding to that fight that we used to have every year called SGR. I don't know if everyone remembers that but it's sort of feeling like a little bit like Groundhog Day, Groundhog Year every year. Now there's always these new cuts looming down in the future that we're always trying to stave off. And so, you know, this year with the physician's fee schedule there are some pretty significant cuts that we need your help as members to help us address and there's been a similar push this year as there was last year to cut some of these, with these major cuts in the fee schedule. And these cuts are across all specialties although some are more impacted than others. Physiatry isn't necessarily at the top of the cuts but we're not at the bottom, somewhere around the middle. And that includes a 3% cut that Congress delayed last year. We were successful at kicking that count down the road but now we've got to deal with it. There's a 1.42 budget neutrality cut. So that's whenever you increase codes in a, you know, for a certain type of procedure. There's only one pie so that gets sort of doled out between all the different specialties in terms of... And as it turns out because of all the additional value with the E&M codes that's going to be about a 1.42% cut that's been proposed. There's a sequestration cuts of 2% that were paused for COVID and those are back on the docket this year as well as the PAYGO cut of 4%. So it all sounds very scary and it is but we're working hard behind the scenes to try and do our best to make sure that the impact from us is as limited as possible for our specialty. We've got short-term goals for our committee or the Academy in general has short-term goals and long-term goals around Medicare payment reform. And as an immediate priority we're really focusing on those 2023 payments and this includes a big push to avert the physician fee schedule cuts and the sequestration cuts. And we've recently supported legislation that addresses that 4.42% cut. But longer term we really need to focus on the fact that these annually cuts, you know, they must end. We need to stop kicking these cans down the road and physicians really need to see a positive annual update at a minimum. If we can't get positive updates at a very minimum we need to be able to keep up with inflation and rising practice cuts. And here's a really important slide that the actual AMA put together which I think is very eye-opening and shows exactly how egregious some of this Medicare payment issue has become. If you look at all these other settings, hospital, inpatient, LTACHs, skilled nursing facilities, hospital outpatient hospitals, hospice, ASCs, the one group on this graph here where they're getting Medicare updates in terms of their payment schedule is physicians. So it's a pretty glaring issue here. And so it's the only category that's set to experience a payment cut in 2023. So we're advocating at least for a 0% change. We may not be able to get an increase like these other settings. But it's also important to keep in mind that even though you may work in these other settings, what this is talking about is actually the codes that we bill as physicians. And so there may be, you know, you may work in these other settings, but actually it's the physician work that is the one that's not being updated. Here's another slide that also just shows you how big of a problem this has been. Payments under the various fee schedules are charted here, looking at inpatient, outpatient, SNFs. And then you can see the consumer price index going up along the way. You can see practice costs going up along the way. You see a very flat line for physician payments. And so, you know, this is gonna be an important point that we're gonna be making moving forward is why is it that physicians are being singled out in this process? And it's very important for us all to... You know this isn't something that's just impacting our specialty and it's nice to know that we're not the only ones out there fighting for these changes. Because it really does impact all of medicine as a whole. So sort of sobering statistics. I know it's... These questions... These presentations always make me leave feeling depressed, but also at the end also empowered because together we are stronger and we'll talk about ways for us to sort of impact moving the needle moving forward. So the big root of the issue, at least right now is this budget neutrality. I think this is the biggest issue right now is this issue of budget neutrality which is where changes in the physician fee schedule, it can only increase or decrease expenditures by $20 million per year. And so if... Because you've increased the RVUs for say E&M codes, if that's more than $20 million per year, then the way that they contain cost is by decreasing that conversion factor to all the physicians. And so we don't really have... Not only is that a problem, but we also don't have a process for regular updates to address inflation or cost of living increases like we do for all those other settings that I mentioned earlier. So in conclusion, we are working very hard to address these issues with physician payment. We're looking to prevent 2023 cuts while still planning ahead and looking for long-term solutions for the future. We have very recently, and many of you, hopefully you've gotten the email earlier this morning, we're supporting legislation in the House and now there's a bill in the Senate too that we're hoping to support that will address this 2023 cut. So we've launched a grassroots campaign. It started October 13th. If you didn't get the email, then just go to the APMNR website to the Member Action Center and there you'll be able to send an easily quick letter to your Congress and Senator, your representatives to ask them to support both short-term and long-term solutions, because we continue to foster these partnerships with our leaders. Also across all of the different specialties, this is not just a physiatry issue. This is a physician issue. Physicians with a capital P, you know, our entire profession is impacted and it impacts the ability of us to provide high-quality care for our patients. So with that, hopefully we'll get a bunch of letters sent out today and thank you for your time. Of course, any questions you can email healthpolicyatapmnr.org and that goes along with any specific questions about CPT codes along the way. We're always happy to take those questions. Thank you. Thank you so much to these great talks and updates. We are going to take questions. We have plenty of time, so please come up to the mic because this is being recorded. So if you don't mind doing that, I do want... before I do that, I do want to shout out to our staff. I think we wouldn't be able to do all of this. I'm going to embarrass her, but Brit and... I know she's going to hate me, but... and Brit, Melanie, and Reva, who was also involved as well, and many of the other staff members as well. I'm very grateful and thankful for all of your support. So thank you. Thank you. Peter, any thoughts? I've heard that talked about, but to tell you the truth, that's not been something that has risen to the top of the list. There's a lot to do in telemedicine to get telemedicine to the point post-PHE where it has been with all these waivers in place. It could very well change dramatically if Congress doesn't move and act to do something with telemedicine. So it's great that you raise it because we can try to put that on the radar screen of folks that may not be really focused on that. And we can talk offline a little bit in more depth. It's an important issue. Thanks for letting me know that. I'll bring that back for sure. Any other questions? Yep. Could I mention one other thing about telemedicine since we do have a little bit of time? You know, the position... I work a lot with disability organizations and the disability organizations were concerned that telemedicine... You know, it's kind of a double edged sword. There's a very significant advantage of telemedicine for people with disabilities of all kinds. Just breaking down the barriers of getting to a physical appointment really results in many instances in a lot greater access to care which is just great. But there are instances where and if you've read the New York Times article on physicians and views of treating people with disabilities, there are concerns that people with disabilities may be relegated to telemedicine without the opportunity to really see their physician or other providers in person on a routine basis. And that's something that I would think we would have an interest in making sure that does not happen. Telemedicine should be I think it's a wonderful service and it could augment care but it shouldn't be... patients should not be required to do telemedicine if they truly believe they need an in-person visit or the physician believes that they need an in-person visit in order to truly assess the patient. So that's... we're kind of straddling the fence on that and making sure that that's put forward in the policy debate. Great presentation by all of you. Stuart Glassman, New Hampshire and California. Don't ask me how but it exists. So earlier in the talk was the issue of trying to improve access for IRF patients overturning denials, reimbursement and yet also advocating to get physiatrists in SNFs as well. And the course before this one we had this big debate between IRF directors and SNF directors. A dichotomy of our specialty and patient access, Medicare Advantage issues but also physiatrist roles. From your perspective how do we balance out really those two sort of opposed but symbiotic aspects of what we have to advocate for? Because one seems to be at the disadvantage of the other. So thoughts on that? It has been, as you know Stuart, it's been a major issue for us for a few years, this definition of a rehabilitation physician in the settings that we should be in or are not allowed to be in. And I think right now it's not been a priority of... it has been a priority in the past. It's not been something that we advocated at the Hill this coming year and I don't know if I have the correct answer to what you're saying, but it is something that we are certainly looking at. Peter, did you have anything? I would just say that... I would hope that there's no... that those two... that physiatrists practicing in those two settings is not mutually exclusive. I would hope that you'd have physiatrists available in a variety of settings in addition to IRFs and SNFs and, you know, there's... a while back we talked about the concept of the physiatrist as kind of the gatekeeper for rehabilitation and if not the gatekeeper then kind of the case manager, if you will, of rehabilitation driving the patient to where they needed to go. And whether that was a SNF or an IRF or elsewhere, we've talked about that concept in the past and so I would hope that there's not a... I just want to point out Dr. Glassman was a former state advocacy chair, so I guess speaking on the state side, I guess for that Virginia, actually it was a mandate from the Department of Health. So I don't know if that's... if it sets precedent there because that's still an ongoing process, you know, it may be able to go through that route where, again, if they do... it's a mandate in law that here, they're part of the workforce that a physiatrist should be involved in that whole spectrum of care from acute to sub-acute so we don't have these, you know, petty battles from the insurance side. So I don't know if that could be another route. One other thing I just wanted to say aside, I don't think we mentioned it, is the review choice demonstration and the fact that in the APMR physiatry, we are going to have some test cases that we are going to be able to review with the... as part of... with the OIG to basically decide how many of these are appropriate, this is inappropriate for inpatient rehab. So I think there is some engagement of physiatry in trying to make some of these decisions, even though we may not disagree... may not agree with the review choice demonstration, it is an opportunity for us to get in front of that issue. Oh, sorry. Go ahead, yes. Hi. Carolyn Millet with the Academy. I just wanted to add to the telehealth conversation. Recently, we joined the Alliance for Connected Care, which is sort of a coalition advocating for telehealth issues. And the Interstate Licensure Compact is something that has been kind of in the works way pre-pandemic, but I think the pandemic has highlighted the importance of that and that would allow for some of what you're talking about, Dr. Esselman. So I think we're going to see that being much more of an advocacy priority for both that alliance and for the Academy moving forward, because it is feedback we've been getting from members that once some of those flexibilities state to state have kind of disappeared as the pandemic is kind of dwindling, it's definitely something that our members are missing, having that flexibility. Thank you so much. Do you have a question? No, I was going to say, the Interstate Compact. Any other questions? I have a couple of questions actually for our panel. Oh, do you have a question? Please. All right, so thank you all for doing everything that you do to represent the physicians and the PM&R field. So I kind of have two questions. One, I know that during the opioid, the COVID pandemic, DEA, I'm sure, had relaxed some of its regulations with opioid treatment with medication-assisted treatments through telehealth and getting patients started on that. How do you see that kind of, is that going to be, do you think that will be phased out as well? Because I know that's been helping a lot of patients who have substance abuse disorder to kind of get into that pipeline and start getting treatments. And also, as a second prompt question, as a medical student, as a DO medical student, we do DO Hill on the Day, and so what advice would you have medical students to kind of get their foot in the door with advocacy for PM&R? Yeah, that's really, I can't answer the first question, so I'll leave that to the panel. The second question is a really good one. I think there's many different levels of advocacy. There's a study actually, because I've been looking it up, 90% of physicians believe that healthcare advocacy is really important, but only 20% ever get training in it. So I think that's, there's a dichotomy there. So I think there's, one of the things is opportunities within your medical school to advocate in the local communities, and certainly, I'm at Northwestern, and a lot of our medical students get involved in that to begin with. So get involved in community organizations to sort of advocate for individuals with disabilities, whatever it is. Then there's obviously organizations like the AMA, et cetera, and we have some great representatives from the AMA in this room, could certainly give you some pointers in that realm as well. And I don't think there's, I don't know how many physiatry-interested medical students are involved in the AMA, but that's a great opportunity as well on a more national, broader level. We don't have medical students involved in our committee currently, but certainly that's something we could visit in the future, even if you were just to listen in on what we do and how we advocate, that's a really good point. So lots of opportunities, go ahead, Stuart. And one of the plugs, so we, at Northwestern last week, one of our chief residents organized this DACMED, which is an organization, the Disability Advocacy Coalition. It's present at a lot of medical schools, and it's specifically meant for what Dr. Glassman was just talking about, how to advocate opportunities to meet and collaborate with other individuals interested in disability advocacy, and that's at a lot of medical schools as well. And the first question, sorry, your first question, that I can't answer because I don't prescribe a lot of opioids, any thoughts on that? Oh, Britt, you can answer that, yeah. Hi, yeah, so the AAPMNR does have an opioid and pain management task force, and so we have been supportive of controlled prescriptions and medicated-assistant treatments throughout the pandemic via telemedicine, and we are generally supportive of those waivers continuing. We are still trying to determine if there are certain parameters that we would like around there, just to make sure there are patient protections that are in place. So that task force is trying to come up with the position that we would stand for the Academy. Yeah. Sorry, I keep interrupting you. No, no, please. I'm Jennifer. I was an advocacy chair at my medical school as a med student, so I can comment on the value of being a med student advocate, and a lot of times, too, because, and this goes to maybe my more philosophical question is, how do we as physicians, and maybe specifically in PMNR, optics, because a lot of times with physician advocacy, I feel like we have an optics problem, like when I see the graph about us losing funding, but the hospitals and everyone gaining, in my head, I'm just like, oh, well, the AHA just lobbies better than we do. But med students are great as lobbyists, too, like because I remember going to the Hill or going to the state legislature, and they're much more sympathetic to the high-minded idealistic med student, and I feel like sometimes physicians, you know, even though we want to do what's right for our patients, we want to advocate for our training and our specialty, I still feel like a lot of times we're vilified as rich people just trying to line our pockets or something, you know, and so I think there's value to being a med student, too, just because you can be a face of the profession that has a different voice. Yes, exactly, and so that's my question is, how do you feel like we're doing from a pandemic standpoint? And I know it's been challenging because you've been lobbying virtually, as far as your interactions with the legislative bodies, as far as their reception to physician issues and healthcare issues in general, have you had to change how you're portraying things and focus more on patient issues or focus more on access issues instead of, like, the payment stuff? I know that there's different challenges to each of those. Great question. I'll have some thoughts, but I'll let my panelists answer that, or Rich has any thoughts, or Peter. I would say two things. The first is that it was amazing how, not just Congress, but the federal agencies and, frankly, the private sector, when the pandemic hit, it's amazing how many entities, individuals were able to shift to a virtual environment and still get their jobs done. I think there was a built-in institutional resistance to work from home that I think has completely been eviscerated in many industries, in many areas. There's obviously some places, in particular medicine, that you can't just rely on virtual. But the Congress seems to be very comfortable with working virtually. I think the staffers are very pleased to not have to go in all the time and to not even turn their cameras on sometimes when you're meeting with them. I think they like that a lot. It makes lobbying much more efficient. When I would go to the Hill, it would be pretty much a two-hour endeavor, even just to have a simple meeting with one office, just because of the transportation up and back, getting in through security, doing the whole thing. By the time you're back in your office working, it was like an hour, 45, two hours for a half-hour meeting. And nowadays, you can do eight Hill visits in a relatively short period of time. And in the meantime, when you have a half-hour free, you're returning emails, doing other things. So it makes lobbying, frankly, a bit more efficient. And I don't think we're going to go completely back to only doing in-person lobbying. But certainly, I'm looking back forward to the day when we can do more of that. Because there are a lot of interactions that occur in the hallway, on the way in, on the way out, just kind of glad-handing a little bit, chatting, maybe seeing the member of Congress that don't happen when you're on Zoom. And that's a big part of advocacy and finding out things through the grapevine. You miss a lot of that nuance when you're doing it in a virtual world. So I'm personally looking forward to getting back. I hope that, in part, answers your question. Let me defer to you. But I wanted to talk just a little bit about long COVID when you're done. Okay. Matt, did you have a comment? I mean, to answer the question about, do we have better marketing or advocacy efforts than the hospital associations, I mean, I think as physicians, we're much better in fighting with ourselves than we are with joining up and working together as a unified voice as a team. You know, there's a lot of controversy even around whether or not people want to join a group like the American Medical Association. But the reality of it is, if we come at it with a thousand different voices and a thousand different directions, a thousand different ideas for how to move forward, we're never going to succeed. And so I think, yes, messaging is a big thing, and that's a big part of, you know, those of us who go on to the Hill, yeah, we don't emphasize, like, please pay me more, you know, value me. But it is a big access issue. You know, I see clinics in my city closing their doors to Medicare patients. You know, every year, more and more clinics are shutting the doors. And so, you know, those are our parents, those are our grandparents, those are our family members, our loved ones. And we want to make sure that they're getting the best care that they can. And so that's part of the messaging that we move forward is, you know, they're not going to get that care if we don't value the services, you know, that are provided. So it's a complex answer, and I'm sure there are great communications people who hopefully can give us better strategy. And I just want to add to what Matt said. It's a great question, is, you know, I think one of the key parts in advocating is actually knowing what your constituency is, who you're representing. And the second part that I found very effective and I think was really effective from Matt's talk is data. So that, you know, that graphic that he had, the couple of graphics he had, was very effective rather than just telling someone what we feel, and then it looks like we're physicians asking for more money. So I think those sort of things, using data to even some of the long COVID stuff in our institution, we've used some research studies to sort of garner input to say, like, physiatry is very effective in treating these patients and getting them better, and they do better when they come to inpatient rehab than go home, straight home. So I think there is that using that data can be very effective as well. Can I say one real quick thing about long COVID? I want to say that during the pandemic, many associations, many lobbying organizations pretty much hunkered down and were reactive to what the new reality of dealing with COVID was all about. And there was plenty to do, the PPP loans and all of that. But I want to credit the Academy leadership and staff for selecting long COVID as a proactive policy issue to work on and to really singularly define PM&R as the physician organization that led on long COVID. And it's had tremendous benefit to this country. I got to tell you, this long COVID issue, the Academy was way ahead of the curve and really set the agenda in that area in a way that that gave us, that was a COVID-related kind of a PHE goal that was really achieved in a very significant way. And the Academy led on that, and I was really proud to be associated with that work. Thank you, Peter. I'll just add to that, just in terms of our advocacy. The one thing I did participate in the virtual hill visits earlier this year, and one of the things that I noticed is usually we do come with the approach of trying to explain things from the patient perspective. But this year, and Dr. Javalon, you probably had the same experience, that they were very receptive and welcoming to understanding the issues that physicians were actually having. And I think that's even demonstrated in the fact that there is the Dear Senator, Dear Colleague letter that's in the Senate that's advocating for physician payment. So I do think that they are very open to hearing about the issues that physicians are experiencing. So that's just my perspective. Thank you, Britt. Dr. Goodman. Hi. Thank you. I'd like to applaud you all for your work and the presentation today. I really appreciate it. Thank you. I have a question. We clearly talk a lot about, you know, the presentation a lot about CMS, right, you know, legislative governmental policies. Think about more even private industry and private insurance companies. It seems that they have a financial incentive to kind of follow along and sort of couple their own payment systems to what CMS is doing. Is there methods, either legislative or otherwise, to, I don't know if the word is decouple some of that or sort of diverge some of that? We have not. I don't believe that we have been involved in sort of that divergence since I've been on this committee. I think a lot of our focus has been more at the federal level or CMS level. But that's a great point. I feel like that they set the tone and then these insurance companies follow on. But we have not been advocating in that sort of realm. I mean, on my committee, we do a fair amount of work with individual insurance companies and their individual policies. And sometimes they follow suit with what CMS says and sometimes they're divergent. But it's usually more on a policy by policy basis. I think we as a committee are trying to think about ways to form some of these relationships with the insurance companies to sort of be more proactive about it in the future. But right now, we don't have a lot of those relationships or it's a long-term goal to develop them because I think it's an important piece that is, I think, a weaker thing that we can strengthen. Two quick things. Medicare Advantage, this Timely Care Seniors Act is all about Medicare Advantage. Those are private plans that serve the Medicare program. They're up to half of Medicare beneficiaries now are covered by Medicare Advantage, not fee-for-service. And so that is a bill that would directly impact prior authorization and all of the rigmarole that you have to go through to get approval of services. We expect that that would have a flow-down kind of effect to other private plans. And the other thing that we have done and we've participated robustly over the last 12 years is regulation under the Affordable Care Act. And setting standards for private plans, responding to the benefit and payment parameters annual rule. We just responded a couple weeks ago to the non-discrimination provisions of the Affordable Care Act to make sure that clinical algorithms are not used in a manner that supersede clinical judgment and Medicare standards and other kinds of medical necessity criteria. So we've done a fair amount in that area, but it's more difficult because private plans clearly are not under the purview of Congress and the federal agencies. It's just more difficult to impact them. Thank you. And just a quick follow-up about Long COVID. Advocacy is not just what to advocate. It's how to advocate and when to advocate. So in the summer of 2020, the AAPMNR is part of the Mobility Caucus for the AMA, which is made up of neurosurgeons, orthopedic surgeons, physiatrists. We started to hear some of the stories of COVID recovery happening. It was about four months after the epidemic really started. And we talked about, let's follow this. Maybe we'll discuss it, bring it up at some point. November of that year, 2020, the AMA meeting was virtual. Anthony Fauci was one of the invited guests and was speaking about a syndrome after COVID where people were debilitated but didn't have a name for it. Now, of course, we knew we had already mentioned that amongst ourselves three months earlier. We were able to create an education session for the AMA, still virtual, in June of 2021. And then we're doing it again next month in Hawaii in person for the AMA on long COVID. And we're talking about the collaboration with the academy, clinical perspectives, and it was realizing that you had to really look forward and figure out who to partner up with at the AMA level. We have two board of trustee members, a former past president, part of the panel. Dr. Malani is going to be speaking as well as myself and Dr. Vasudevan, who's at UPenn, and Britt, you helped get it off the ground this time. So thanks for all the work and working with the AMA staff. But it's looking forward, thinking about what you want to accomplish. It takes years sometimes. So it's not that you have a bill that you're going to get through that next month. It sometimes is years ahead of the curve. And like Peter said, PM&R was ahead of it for long COVID. So that's an example for it. Thanks. Thanks, Dr. Glassman. Dr. Hubble. Yeah. I just want to talk a minute about advocacy and how important it is at all levels. You know, at the state level, the states control insurance companies that are private and their regulations, the State Department of Insurance controls those. So it's really important to know your state legislator and your state legislators or the House or the Senate, and to meet with them. And each medical school, I think, has a medical student group that works with advocacy, working with the State Medical Association. A lot of times it's free for a medical student to join. Like in Ohio, it's free for them to join the Ohio State Medical Association. So you can get your feet wet on that. But that state-level stuff is really important to your day-to-day life. Peter works with everybody in Washington, but there's a lot of insurance issues that are covered at the state level. And so if you're a practicing doctor, get to know your representative. I know my congressman, he walks up to me and says, hi, doctor, how are you doing today, do you have any concerns? You know, this is important, very important. And I also know my state legislator, state representative, and state senator. They don't know anything about medicine. They need us to help them understand certain bills. And the good thing about joining your state medical association, in addition to the academy, is that they have their finger on the pulse of all these state bills that are coming in. There's hundreds of bills that go in. Some of them are totally ridiculous, as far as they have no idea what real healthcare is or what science is, and you read them and you go, you can't believe what goes in from some of the legislators. But they need us as physicians to be able to help them understand that. So get involved at the state level and that's a good place to start, because it's right there. And then... and also at our level. So thank you. Thank you. Thank you so much. Do you have a comment? Dr. Malani? Okay. Thanks for great information and from everybody. A question regarding the virtual nature of some of the on-the-hill efforts and all that. So what... Are there any opportunities for... You know, we've been talking about how to get other people involved who are interested. Of course, there's the leadership academy. But just thinking about how to get people involved more from a grassroots perspective. If there's lobby days, you know, we need to have a unified voice so there's a coalition that's going to make that message apparent. But what about just having, you know, kind of volume? So being able to see people and sort of the low barrier to entry for a lot of people to show up on an online forum just to kind of demonstrate the interest that comes from the academy and that sort of thing. Are there opportunities there? Does that make no sense? You know what I mean? Like just in terms of kind of showing how we are unified. I think it definitely does make sense. I mean we do have a lot of emails that go out for sign-on letters and specific things that we ask members to sign on to. I think there was one that went out this morning specifically. So I think that is a great point in creating some sort of, I think to Dr. Hubble's point, then maybe then leading on to some local efforts in specific cases. I think the challenges with big hill visits with massive amounts of people is tough for us to manage as staff, I think, if I speak for them. So that may be a bit challenging. And there's also a training piece too, you know, that needs to go into, as has already been outlined, of how to be an effective advocate as well. That I think all of this is making me think we need to do some sort of session maybe at next year's academy about how to be an effective advocate, talking about some of these things. Do other organizations do things like that? I don't think they normally do situations where you just have observers. But I kind of like the idea, because it not only demonstrates to the person you're meeting with that there's a lot of people who are interested in this behind the person who's speaking, but it also may stimulate, kind of stoke the fire in them, the observers, to take a more active role and to become better advocates and more direct advocates. And when we send out requests for people to sign on and send in letters to their congressman, we'd love to have the highest possible return on that investment possible. And that might be a way to help do that. Happy to talk about that further. Awesome. Thank you so much. Great rallying cries for us all to be advocates as well. So thank you so much for joining the session this morning. Thank you.

federal advocacy

state advocacy

physician payment advocacy

national health policy

reimbursement advocacy

Access to Rehabilitation Therapy Act

Senior Timely Access to Care Act

scope of practice

opioid epidemic

telemedicine

physician advocacy