Good afternoon, everyone, and welcome to our session titled AA PM&R Advocacy, New Administration, New Opportunities to Advance PM&R. My name is Dr. Nneka Ifejika, and I am the outgoing chair of the Health Policy and Legislation Committee. We have a dynamic group of speakers for you today, and we're hoping that we'll be able to answer some questions that you have about what the academy has done for you this year regarding legislative opportunities, as well as provide some opportunities for y'all to answer questions and ask questions that are indicative of where we're going over the next year when it comes to advocacy, and I'll start sharing the slides. So these are our four speakers, and they'll all be introduced in time. We have Peter Thomas from Powers Law Firm, Dr. Matthew Grierson, and Dr. Richard Chang, and these are the topics we're all going to talk about in turn. Now I want to get started with Dr. Chang. Dr. Chang, the floor is yours. Excellent. Thank you, Dr. Ifejika. So again, I'm Dr. Chang, I'm the chair of the State Advocacy Committee. Our role in the Health Policy and Legislative Committee is to identify, survey, and discuss and review and respond to state issues and topics that not just affect physiatrists, but perhaps medicine in general, but may have larger implications on a national level. Next slide, please. No disclosures. Next slide, please. So in my slides, I'll be discussing a number of wins, and what our committee does on a monthly basis. So the first thing we'll discuss is Medicaid protection. As we all know, for the patients we serve, Medicaid is an important lifeline, and every year changes may occur, but especially in the last administration, there were a number of proposals made that members felt, as well as physicians felt, in general, would have hindered patients with disabilities to access Medicaid, as well as, unfortunately, the last administration would have added burdensome requirements, such as work requirements. So one of the actions that we had performed was support a coalition letter to Department of Health and Human Services Secretary Becerra, requesting that the current administration not impose such requirements, and to ensure that such access to Medicaid be continued to patients with disabilities. In addition, you know, from a state level, there are a number of programs in states that try to approve or sort of carry out these actions. For example, in Tennessee, Bill 1115, they had proposed essentially a work requirement and essentially would have restricted access to patients with disabilities. We helped sign on to a letter to oppose this. At this time, in terms of the bill, it's open to comments from CMS. Hopefully, you know, this doesn't go through, but again, it's something that we routinely monitor. In terms of another sort of coalition effort or sign-on that we had participated in was, you know, during the pandemic crisis, there were discussions in terms of, you know, cuts, and we had asked that, you know, any sort of protections be maintained for such patients, you know, especially with Medicaid, especially during the COVID-19 pandemic. So again, for Medicaid protections, besides access, we're trying to make sure that no further requirements or burdensome requirements are imposed and that such patients with disabilities have continued access. Next slide, please. So scope of practice, again, is a very common topic and issue that arises that our committee tackles, as well as the larger health policy committee. A number, I would say, wins, I would say a majority in terms of scope of practice. The first was there was a release to call action to members, and we signed on to join the Medical State Society here in New York, which is my home state, in opposing Bill S-3036 and A-1535, which would have essentially expanded and decreased sort of the requirements for nurse practitioners. That didn't pass. Going to, we'll skip the middle one, I'll discuss why, but another one was in Louisiana, where there was a call action to members in Louisiana, essentially asking their senators to oppose another bill, which would have decreased the education requirement or supervisory requirement for advanced nurse practitioners to practice. It would have included, besides physicians, you know, either a dentist or another APRN, and also would have decreased the number of required hours in order to practice. Fortunately, that was defeated in both the House and the Senate in Louisiana. Unfortunately, just, I would say there was, in Delaware, there was a call to action among members in Delaware for bills HB-141 and HB-21, essentially, again, would have decreased the requirement for APRNs or advanced practice nurses in terms of their education requirement to practice. Unfortunately, that bill passed, but on the flip side, again, there's only two states, Delaware and Nevada, that have this, but again, it's something that we're closely monitoring. More recently, I would say that there's bills with chiropractic that we're closely monitoring at this time. Next slide, please. So this was a useful chart that was created by the Quality Practice Policy and Research Team, as well as the Scope of Practice Committee. You know, given our current healthcare environment, and there are a number of, I would say, healthcare providers or even so-called physicians that perform some services, but unfortunately, they do not have the same educational or training requirements. So mainly, this chart was created as a response to bring to our legislative meetings or even a meeting with the congressional members in order to clarify that, you know, physiatrists have a very valuable skill set in education and are physicians, and that compared to other, you know, healthcare providers that have similar skill sets, they don't quite have the same level of training and may actually harm patients. With that being said, again, we value the teamwork and collaboration with the other specialties. Next slide, please. There were a number of efforts we also made in terms, you know, given the COVID-19 pandemic, you know, now that vaccines are rolling out, but especially there was one bill, the House Bill in Ohio State, which the Ohio State Medical Association had brought up was House Bill 248. Initially, on first glance, it looked like it was, you know, it looked like it would be, you know, preventing members from receiving the COVID-19 vaccine, but the bill sought to be more ambitious to essentially prohibit patients or members from receiving vaccine, essentially preventing any sort of public health measures, such as vaccine mandates or disclosure of vaccination status. Fortunately, this was defeated on a state level. Similarly, I would say during the pandemic, again, besides Medicaid in terms of beneficiary, in terms of benefits, rehabilitation, care, and what the skills and the services besides you offers, again, we want to just demonstrate and emphasize to the administration and to Health and Human Services that it is an essential health benefit, you know, as well as, you know, maternal services, as well as psychiatry and psychological services. Next slide, please. So in terms of our state advocacy priorities, there are a number, but I would say for our main goals is, you know, besides tracking and identifying state issues, we're trying to be more proactive as opposed to reactionary. We're trying to work more closely with state psychiatry presidents, as well as state medical associations in order to launch both local grassroots response, and if necessary, we'll speak to the national health HPL team for any sort of bills or topics that may have large implications nationally. In addition, we're also working and trying to expand our existing resources for members, you know, both senior and as well as, you know, young members that really want to dive into health advocacy. Again, it's definitely something everyone can participate in, both little and small, in terms of other measures. Priorities, I know someone alluded to, scoprofac is always a large issue. You know, before the COVID-19 pandemic, we were tackling the, you know, opiate crisis, which still exists. Some essential health benefit access is going to be important, both rehabilitation and habilitation. Again, rehabilitation essentially is to restore a skill or function that was present before, compared to habilitation is to essentially teach a new skill that wasn't present. For example, teaching like deep to a young patient with cerebral palsy. And the COVID-19 pandemic has presented some unique issues or brought forth important issues like telemedicine, and that has been brought to the forefront, particularly. And in addition, we've always been trying to advocate for members and patients with disabilities and chronic conditions. Next slide, please. So, on a practical standpoint, I would say if you're interested on a state level, you know, this is a particular member benefit. You can look up what particular state issues or relevant physiatry that are happening right now and then you can bring to us if you have any questions or needed assistance with. Next slide, please. In terms of action component, voter voice is more as a grassroots component in that once you have identified bills, you can actually send messages to your local congressional members or, you know, through FISVARM, you can also alert members. But again, this is mainly to send emails or template of letters to your local congressional members on, you know, topics that you feel would threaten your practice and your patient care. Next slide. So, again, I'm done with my session. Again, I have the distinct pleasure and honor of introducing Peter Thomas. He's a partner of Powers Law and is also a PMR consultant. And Peter, take it away. Thank you, Dr. Chang. I appreciate it very much. And before I get started, two things quickly. I wanted to say thank you to Dr. Nneka Fejika for all of her work in sharing the Health Policy and Legislation Committee, the health policy that comes out of the academy, by and large, comes out of that academy. And Dr. Fejika has performed great, great work over the last five years. Thank you. Second, it's a Veterans Day. So, for all those who've served and for those who treat veterans, happy Veterans Day. And thank you for your service. I think we can move on. The next slide. I don't have any disclosures to make. I wanted to start with just a few health care figures or individuals who are assisting with the Biden administration's rollout of health care policies. A couple of very important developments. Number one, the Domestic Policy Council is the entity within the White House that really functions as their policymaking operation. And we've never really had, the disability community has never had a dedicated individual on the Domestic Policy Council. We've had disability liaisons at the White House, but never a Domestic Policy Council member. We now have one. Her name is Kim Nackstedt. She comes from the Senate HELP Committee, where she was on that staff. Prior to this, we've been in touch with her routinely. She's reaching out to us and she's really helping with respect to rehabilitation and disability policy and putting those issues on the map within the Biden administration. Next person I wanted to mention was obviously the Secretary of Health and Human Services, Xavier Becerra. Also, Andrea Palm, who worked within the Obama administration at the Department of Health and Human Services, is now Deputy Secretary. Chiquita Brooks-LaSure is the CMS Administrator. She was on Capitol Hill within the Ways and Means Committee and then moved out to the private sector for a time and is now back. The Medicare Director is Dr. Meena Seshamani. The Medicaid Director, who also helps with the State Children's Health Insurance Program is Daniel Tsai. We've spoken with both of them and they're really quite engaged and a real compliment to those agencies. Dr. Francis Collins at the NIH will be stepping aside at the end of this year. We're not quite sure who will replace him at this point, although it's pretty clear that Dr. Fauci will not replace him as overall Director of the National Institutes of Health. The CDC Director is Dr. Rochelle Walensky. I'm sure you've seen and heard from her quite a bit. Someone you may not have known or may not know is Dr. Marcela Nunez-Smith. She's the Chair of the Health Equity Task Force, which is embedded in the White House, which was created by President Biden earlier this year. And they've really focused on COVID to try to get as much equity built into the COVID strategy, not only on vaccinations, but on treatments, on all kinds of things with respect to COVID care. The Surgeon General is Vivek Murthy and yet to be filled are the FDA Commissioner. We've heard rumors that Dr. Califf is likely to retake that position after being at the agency for about less than a year, in about 2016. But it's not clear. A successor has not been named. As well as the Administration for Community Living, which really directs NIDILRR and a lot of the brain injury and spinal cord injury programs, a permanent administrator has not been yet named. The Office of Management and Budget Director was actually voted down by the Senate. So that position is still vacant. The Social Security Commissioner and the Health Resources and Services Administration still do not have directors in place. Next slide. So that's the executive branch. In terms of the legislative branch in Congress, we really have unified government in the sense that the Senate, the House, and the Administration is all run by Democrats. Very thin margins, but they are in charge of all three of those entities. They control the 117th Congress after winning both Georgia runoff elections, special elections in the beginning of January of this year, if you recall. Very surprising result, some would say. But the fact is that the Senate is now 50-50. When that happens, there's a power sharing arrangement. Ultimately, Chuck Schumer, he's the Senator from New York, he is the majority leader. And Mitch McConnell from Kentucky is the minority leader. The majority leader gets to choose the chair people of all the committees, bring bills to the floor, set the agenda for debate, and really runs the show. But there are very substantial rights that the minority has. And I think you can see that play out primarily through what they call the filibuster rule, which means that you need 60 votes to get to an actual vote, to cut off debate and move to a vote on the substance of any bill. If you don't have 60 votes, the bill can die in the Senate. And that's exactly what's been happening with a lot of bills. In fact, a lot of those bills that would otherwise die aren't even brought to the floor, because they don't want to waste their time on the floor of the Senate. So the only way to break that 50-50 tie, there's two ways. One is to get enough Republican senators to vote with the Democrats, 10. The other is to, if there is a 50-50 tie on a vote that only requires a simple majority, and that is, for instance, something called a reconciliation bill, which I'll go into in a minute, then the Vice President of the United States breaks the tie. And so Vice President Harris would provide that 51st vote to pass legislation. So in the House, it's just as thin. Frankly, there's only a three-vote margin that Nancy Pelosi, the Speaker of the House, has to work with. And if she has more than three defectors, and the Republicans hold together as a block, she can't get legislation passed through the House. Three votes, when you're talking about 435 members of Congress, is an extraordinarily thin or slim margin to deal with. And that's one of the reasons you're seeing a fair amount of bottlenecking and a fair amount of delay in trying to herd the cats together to get significant legislation passed. This gives added power to moderates. It also gives added power to progressives and liberals. It also gives added power to some of the more conservative aspects of the Democratic Party, because in order to get legislation through, they really need everyone to be on the same page. And we're seeing that play out with Senator Joe Manchin from West Virginia and Senator Kyrsten Sinema from Arizona. Next slide. So in terms of the 51-vote margin, in order to pass legislation, I said that was called budget reconciliation. That's when the budget committees come together. They agree on a top-line number to address the budget, the overall federal budget. And then they send those numbers through the authorizing committees, and they come up with a bill that meets the requirements of what the budget committee said. There are some very strict rules around that. Every provision within that bill needs to impact the budget. It's called the Byrd rule, after Senator Byrd from West Virginia, who was a real stickler on Senate procedure. And you have to impact the budget in order to be in that bill. So you can't just tack on a bunch of extraneous provisions. They used this procedure earlier this year to pass the American Rescue Plan Act. That was in March of this year. And it was a $1.9 trillion piece of legislation that was not only geared toward economic stimulus and provider relief, but also toward COVID-19 relief generally across the country, and fighting the virus and expanding access to vaccinations and treatment. There's another massive bill that's currently subject to a reconciliation bill. It may or may not get across the finish line. The Democrats are certainly hoping that it will. They're viewing this as kind of stage two of an infrastructure package. The infrastructure bill, which really addressed $1.2 trillion in funding for roads and bridges and broadband, did pass and was signed by the president last week. But this reconciliation bill is designed to build back better with the Biden administration's words and is really geared toward healthcare programs, healthcare, social programs, social spending, ways to spread wealth in a way that to correct some of the imbalances that have occurred over the last 10 to 15 years. There are some complicating factors to that, but the infrastructure bill was in fact passed. The remaining complicating factors involve two things, funding the federal government for the current fiscal year, which began on October 1st. Right now we're under a continuing resolution to keep the government open, and that runs out on the 2nd of December when they're gonna need to do something new. And the second is the debt ceiling, which is the allowed amount of dollars that this country can borrow in order to pay off our existing obligations. If we don't raise the debt ceiling, we will default as a country, we will become technically insolvent, and our credit rating will take a huge hit. It'll be a very significant world economic event if that occurs. Traditionally, raising the debt ceiling has been a pretty non-controversial issue that has been bipartisan in nature. Now it's being used as a real cudgel to try to get Democrats to not continue spending with the bills that they pass. Next slide. So COVID-19 response and the pandemic overall has been job one for the Biden administration from day one. The expectation of a return to normal that many of us kind of sensed and felt in the summertime quickly changed with the Delta variants. A lot of plans to reopen offices and pretty much get back to normal were indefinitely postponed. I've seen it in my own firm and my own practice and around Washington, still very much a ghost town in Washington, DC. I think there's pandemic fatigue for sure. I think there's vaccine hesitancy, which is contributing of course to a prolonging of the pandemic. And we have no idea what variants might be around the corner. So kind of the new normal is what we seem to be dealing with. Luckily, in terms of healthcare, we've come off some of the worst days of the Delta variant as most people can attest, but no one knows what's around the corner, especially as we move into winter. There are new tactics by the White House to expand vaccinations, including mandates. Two major regulations were issued in interim final rule form last Thursday, an OSHA regulation that applies to all businesses with over a hundred employees and a CMS regulation that applies to any provider that has to meet conditions of participation. Interestingly, the CMS rule on mandates for vaccination does not apply to physician offices. But if you are entering into healthcare facilities and you're routinely going into hospitals, into SNFs, into other settings of care, clearly you're gonna be covered under those rules. Booster shot rollout is what the Biden administration has been focused on more recently. And long COVID policies, something that the Academy has taken a very strong leadership role in trying to promote to address the issues of long COVID. We are seeing some real developments there. There was a report issued just this week by the Health Equity Task Force that really delves into many of the recommendations that the Academy had for the administration. It was a real victory for the Academy. We're happy to see that report finally be issued. And the Health Committee, the Health, Education, Labor, and Pensions Committee in the Senate continues to study the future of the pandemic. Not necessarily this one, but what's coming down the pike two, three, five years down the line, and what can the U.S. do to better prepare for the next pandemic? Next slide. There is a major proposal that is pending at CMS in the wake of the Office of Inspector General report in 2018 on inpatient rehabilitation hospital care, where the OIG found that 84% of IRF claims in 2013 from a sample of 220 claims were overpayments. They were considered not medically necessary. That's just not a credible result. That is, you walk into any rehabilitation hospital and that just does not square with reality. However, the report recommended not only additional audits, but it also recommended prior authorization for fee-for-service IRF care. They haven't quite moved to fee-for-service prior off, but they have implemented what they're, or they're on the pathway to implementing what they call the Review Choice Demonstration Project. This would apply to all IRFs in 17 states, three territories, and the District of Columbia. And they would all be subject to 100% claim review, either pre-claim review or post-payment review. But every single admission would be examined and looked at by a Medicare contractor to affirm the appropriateness of that admission. The Academy has very strong objection to this Review Choice Demonstration, as does, by the way, every single stakeholder group that I've seen submit comments on this proposal. There was a comment period in February and just a few weeks ago earlier, this actually last month. The fact is that no one supports this extensive overreach where really CMS contractors will be practicing medicine. They'll be routinely superseding the medical judgments of trained and treating rehabilitation physicians and supplanting their medical judgments with the judgments of a paper review, typically by trained nurses or other kinds of audit contractors. It's a real broadside attack on physiatry. The Academy has submitted strong comments on this issue. We're going to meet with CMS on Monday, along with some of the affected hospital associations. We're very concerned about the gatekeeper effect this will have on access to patient care, as well as the burden it will create for physicians, physiatrists who routinely will have to focus on documentation at the expense of patient care. We'll stay tuned. This is a very hot issue and something that really can impact the field in a big way. Next slide. In addition, there's a major proposal that's been pending for a few years now, and CMS and the MedPAC organization, the Medicare Payment Advisory Commission, continue to work on it. It's called the Unified PAC Payment Prototype. This is a different way of paying post-acute care for Medicare beneficiaries, including long-term acute care hospitals, IRFs, SNFs, and home health. And it's a way of taking the four different payment systems and jamming them into one. The goal is to try to be more efficient in the types of payments that are made to post-acute care and try to improve the quality of care and outcomes achieved. But most people see disaster written all over this. They won't say it that outright because there is an interest in trying to see what they'll come up with. But I must say that there are very remarkable differences between these four settings of care and trying to pay them through one payment system is an extraordinarily complex undertaking. The RTI is a contractor of the CMS, of the government on this, and they're developing a prototype. We expect to see something next year, probably late in 2022. The Academy has been very much involved in commenting, attending technical expert panels, and trying to figure out ways to lessen the impact, the negative impact of this proposal. There's major questions. How are you going to flatten these settings of post-acute care through a payment system and yet still provide the care that people need in these different types of settings? How are you going to account for cognitive impairment when the data doesn't show specific additional resources being used to treat patients with cognitive impairments? How are you going to factor in the COVID experience, which has completely created major anomalies in the data during the years that that's been in place? So there is legislation. The Academy supports it. It's called the Resetting of the Impact Act or the TRIA legislation. It's HR 2455 in the House. There is no Senate companion bill yet, although that's being worked on. And we are trying to generate additional co-sponsors for that important legislation. Next slide. Surprise billing is a big issue that was passed late last year. There's three sets of regulations that are being proposed to implement it. Two of those three have been actually released. The third is expected to be released as late as December. And unfortunately, the surprise billing provisions go into effect on the first of the new year. So just less than two months from now, surprise billing is supposed to go into effect. It will change how that, ultimately it requires patients to pay the in-network rate for out-of-network care unless informed consent is given. That's the bottom line takeaway on what surprise billing is all about. We are kind of bracing ourselves for this. We're also looking forward to seeing what they'll plan on putting out in the third of three rules implementing this very new untested, but comprehensive proposal that will impact health. Next slide. We have other priorities, of course, that we've been working on. Telehealth is one of them, tele-rehab, telehealth generally. Right now in the physician fee schedule, they've pretty much punted on treating telehealth in the current manner through the waiver process under the PHE, the public health emergency. And that will likely stay into effect through 2023 as they collect data and try to figure out what to do with telehealth on a longer term basis. The Affordable Care Act was up for review this past June. Actually, the arguments were made earlier in the year, but thankfully a majority of the court decided that the ACA did in fact survive that challenge. The plaintiffs did not have standing to sue and they dismissed that case. So the Affordable Care Act, despite repeated legal attempts to invalidate it, continues to remain the law of the land. And I think you'll see in the coming year after this new open enrollment period, which is currently in effect, you're gonna see an increase in signups, in enrollment for ACA plans, probably well over 10, maybe 11 million people. End of the year package for Medicare, it's likely that the Congress will try to do something in the next seven weeks before physician extenders run out, before the payment changes to the physician fee schedule, a 3.5, 3.6% cut in the physician fee schedule. Sequestration, which is another 2% cut on Medicare and PAYGO requirements, which is another 4% cut on all government programs. I think you're gonna have to see some kind of legislation that lessens the impact of what will wind up being a roughly a 10% cut for particular physicians. I just don't see that happening. There may be some of those two out of the three are likely to get passed and dealt with. We'll have to see what happens to the 2% sequestration cut. But there's other bills that the prior authorization bill has got widespread bipartisan support trying to rein in Medicare Advantage plans. And we continue to work on that as well as other priorities. Next slide. Dr. Grierson. All right. Thank you so much. And so I'm Matthew Grierson and I'm a chair of the Reimbursement and Policy Review Committee. And our committee addresses legislative advocacy, policy advocacy, specifically as it relates to physician payments and the work that we all do. So I have no disclosures. Let's move on to the next slide and talk a little bit about reimbursement advocacy that the Academy has been doing for you as members. Our Reimbursement and Policy Review Committee, we meet regularly, once every couple of months, but we also weekly discuss items that come up related to reimbursement issues for our specialty. And we are engaging with CMS and other peers throughout the year whenever policy issues come up and make comments on policy proposals throughout the year, always trying to fight for physicians out there in the field specifically physiatry. There is a lot of advocacy work we do both with CPT and the RUC. And these are the two entities that meet throughout the year to both create the codes that we use to bill for all the services that we do throughout the year, but then the RUC then goes to evaluate it. So the two entities are the CPT and we've got two members of the Academy, Dr. Annie Purcell and Dr. Scott Horn. They serve as the physician advocates to the CPT panel and they consider new codes, revisions to existing codes. And then once the CPT panel votes on those codes, those are then sent to the RUC. And the RUC committee, we have two members of the Academy, Dr. Carlo Malani and Dr. David Reese. They are our Academy advisors to the RUC. So anytime there is a code that comes up that needs to be surveyed, you've got Dr. Malani and Dr. Reese out there fighting for you at the table, making sure that every gauze you use in clinic is counted every minute that you are with a patient is counted and all of the value of all the services that you provide is appropriate. Let's go to the next slide. In addition to this, really exciting this year, many of you probably have already heard that for the first time ever, PMNR has a seat at the table of the RUC. So what I was just talking about earlier, those were the advisors to the CPT panel, as well as the RUC. They're able to advocate on behalf of the specialty. They're able to make arguments at the table, say why this code should be valued in a certain way. But then there is a panel of people who actually vote on those codes. And this year I have served as the first person seated in the AAPMNR seat along with my alternate Dr. Clarice Sin. And we've been working very hard to build a strong reputation, helping everybody at the RUC really understand the role of physiatry. But we seated on the RUC actually don't advocate for any one specialty. We're there more not able to serve in that advocacy role like Dr. Malani and Dr. Reese there in the photo, but it is important to have that physiatry perspective because it has been so markedly absent over the years. And so we're very excited to be able to participate now in this way and thank the academy for their support. Let's go to the next slide. So this year, there's been a lot of updates in terms of the CPT and RUC work. Many of you are, well, everybody is now using the new outpatient E&M codes and there have been some new revised guidelines that have come forward from the CPT panel including new code descriptors and then of course the values for those new codes. And the big goal of that is to help reduce some of the documentation burden that has been keeping many of our physicians up until 10 p.m. doing pajama time at the computer. And so we'll see how that ends up working out in the years ahead, but that was one of the biggest changes that has occurred to E&M over the last several decades. In addition, there are some new codes that have come out. We're gonna be discussing these in further detail in another session, but just to briefly review those, there are some therapeutic monitoring codes that are coming out next year. There's a new procedure code for intraosteous base of vertebral nerve destruction that comes out next year. And then there are some revised values for the facet ablation codes that are gonna be coming through for 2022. So next slide. So just to take a step back to recall what happened to the physician fee schedule, in December of 2020 last year, CMS had finalized the fee schedule and there were significant payment cuts and it was gonna be a big hit to our specialty for this year. Unfortunately, there was last minute legislation that was passed that helped soften the blow. So the final cut ended up just being 3.3% rather than 10.2%. So I sort of see my position a little bit as a thankless position because we don't always, we're not able to always avert every single cut, but to avoid a 10.2% cut and soften it so it's just a 3.3% cut was a big accomplishment and we couldn't have done it without all the support of our academy members reaching out to their legislators to really make their voices heard. And so the nice thing is that that legislation also maintained these increases to the reimbursement for outpatient and office E&M codes. And so again, the moral of the story here is that that last minute legislation prevented what could have been a catastrophe, but it did as things do in the world of government, it did kick the can down the road a little bit and we are gonna need a permanent solution to prevent more drastic future payment cuts down the road. And so let's go to the next slide. And so again, the root of the issue is this issue related to budget neutrality. And if you're not familiar with the concept of budget neutrality by law and the Medicare physician fee schedule, it can only go up or down by 20 million per year. And if there is an increase or decrease beyond that, then the relative value units, there is a conversion factor that is adjusted. And so that conversion factor is multiplied by the RVU to ultimately determine the physician payment. And so you'll see that conversion factor go up and down over the years. And so in 2021, the increases to the E&M RV use like far exceeded that $20 million. And so there was a need for a significant cut to that conversion factor. Again, all of this is written into the law and CMS is not able to change this without legislation. And so that legislation that was required last year is unfortunately also gonna be required again this year. And we've already heard earlier about some of the challenges related to passing legislation in the current environment. But let's go to the next slide. And sort of talk about the issue at hand here. So in July, CMS proposed payment rates for 2022. And all of these potential cuts that are coming down the road end up totaling another about 10% cut to our specialty. And so we're getting to the end of the first year, end of the 3.5% increase that Congress approved for 2021 that I just talked about earlier. So that is ending at the end of this year. And then we've got this re-institution of sequestration which will be a 2% cut, which that had been paused due to COVID. So these are all things that are just kicking the can down the road and now we're down the road trying to deal with these. And then there's the pay-as-you-go, the pay-go cut which will be another 4% which is needed to balance the American Rescue Plan Act related to the PPP loans and provider relief funds. And all of that surpassed the federal spending threshold which is sort of how we got here. And so let's go to the next slide. And so this is my last slide but this sort of goes into what are the next steps? Because it's all, it sounds doom and gloom. And it is urgent. You know, I think there's a lot that we can do as members to try and influence the process. The Academy has been making comments through the Physician Fee Schedule comment letter urging CMS to partner with Congress to provide positive updates to the fee schedule. So there's not such a drastic cut. We've participated in coalition letters to Congress urging action on all of those impending cuts. And we're partnering with other medical specialties and of course the AMA. And it's now late 2021. There is right now an ongoing grassroots push for members to contact Congress urging them to avert these cuts. And so if you haven't already heard about that grassroots push, check your email or look back at your inbox and there are some great links that you can as members go forward to very easily contact your senators and legislators and help avert these cuts. So thank you so much for listening. Let's go to the next slide. And I'm going to now turn the time over to Dr. Abedjika. All right. So this is my final presentation as HPNL chair. This has been a wonderful five years. I can't believe it. And two and a half terms. So I came on right after finishing my leadership fellowship. And so I want to give a little bit more information about what we've been doing over the past year but also a little bit of information about retrospectively over the past five years how things have changed considerably when it comes to in-person advocacy versus virtual advocacy. I have no disclosures. And so I want y'all to take a look at the academy priorities versus HPNL priorities and look at the substantial amount of overlap. And so you can see the four academy priorities are on the left side of your screen, transforming the specialty, preparing members for success, dynamically engaging membership and enhancing organizational strength. HPNL priorities essentially have to overlap what the academy wants. We are representing you in a forward-facing motion when it comes to going to Congress, going to CMS, fighting with the OIG and making sure that we're able to get what we need to protect our specialty and to protect our members. And so we're going to go over these four priorities, demonstrating the value of physiatry, continued pursuit of legislation and regulation that reduces physician burden, pursuing legislation that advances rehabilitation research, GME advocacy and post-acute care reform. And so these are the people that we really interact with on a regular basis. As you can see in Congress, there are four main committees, two in the Senate and two in the House. So the Health Committee and the Finance Committee in the Senate, Ways and Means, Energy and Commerce in the House. And when we have advocacy days and Hill Days, we make sure that we meet with representatives from each of those four committees. So on top of us asking for your zip codes to figure out where you live in this country, if you have advocated with us, you will notice that some offices that are not a part of your zip code are usually within those four committees. We have three new relationships this year. One is with MedPAC. Peter Thomas just spoke a little bit about why we need to meet with MedPAC more often. The CDC, when it comes to COVID, we must meet with them, as well as the National Academies of Science and Medicine because we want to advance rehabilitation research. Peter also talked a little bit more about the OIG. And I want to give you all a little bit of background about what the OIG is. So the OIG essentially comes up with data that they are able to accumulate to support a cause. And usually when that cause comes to play, it negatively impacts us financially. And so the report that came out in 2017, 2018, essentially saying that inpatient rehab facilities are admitting patients inappropriately was almost like a receipt. And so we send that receipt to the OMB, which is the Office of Management and Budget. Those are the people who determine whether it makes sense to continue funding, for example, inpatient rehab facilities, or cut money back, or send out the auditors to audit all of our charts. So as you can see, the receipts get carried from office to office, but you can also see they live in the executive branch. And so it's important from an advocacy perspective that we kind of hit all of these offices and we hit all of these branches because we have to be able to intercept the process as it goes through. We can't wait until the end because by the time we wait till the end, these things are enacted into law, it affects our physiatrists significantly financially, and also increases our administrative burden. And so over the past several years, we've switched over from in-person advocacy. And if y'all have ever been on Capitol Hill with us, we're running from one side of the hill to the other, we're catching the trains, we're meeting people in hallways, to virtually. And you can see here on this line chart, look how many offices we have been able to visit. We've literally gone from visiting 25 to 30 offices in 2019 to almost 60 in 2021. We've also been able to double the amount of participants. And if you have gone and advocated with us virtually, thank you so much. We'll probably be calling you again. So we greatly appreciate your feedback and look forward to meeting with you again. Don't worry, I'm not getting off the hook either. I've already been told I'm gonna be advocating within a few weeks. And you can see some of the people here on the screen and we're all smiling and thanking all of you for all your continued support. We do not see a real shift in this occurring over the next two years or so. There will be some version of either hybrid visit to Capitol Hill or in-person. I think in-person is not gonna be around anytime soon. As Peter said, Washington, DC is pretty much a ghost town right now. And people are doing a lot more virtual advocacy. We love it within the HP&L committee because we can connect with more academy members, see more academy members and truly have a larger amount of people coming to advocate for our specialty. There is indeed strength in numbers. We greatly appreciate your participation in this advocacy cause. And so what were our Hill Day priorities this year? So our AAPMNR call to action on long COVID was a very important priority for our field. Physician burden reduction and patient access to rehabilitation. And you can see here, HR 3173, we spoke about a little bit earlier. The Connect for Health Act of 2021, the Access to Inpatient Rehabilitation Therapy Act. And again, the TRIA Act, which is Resetting the Impact Act, HR 2455. And so here are some of our wins. We had a lot of wins in 2021, but I have to say it's because of years upon years of advocacy from HP&L committees before me for decades. And I have some of y'all on the call, former HP&L chairs, former HP&L members. Thank you. All of your work over the past 10, 15 years truly came to fruition this year. We greatly appreciate you. So demonstrating the value of physiatry. We successfully expanded the Hill Day to meet with over 50 congressional offices, which is twice as many as in-person visits. And we gained recognition on Capitol Hill for being able to do that seamlessly. You can see here, reducing physician burden. We are, especially it has a very high number of burnout, a very high proportion of our faculty do burnout. And so we advanced the reintroduction and advancement of the Seniors Timely Access to Care Act, the Improving Access to Medicare Coverage Act, the Resident Physician Shortage Reduction Act. And then we expanded the IRF three-hour rule, the 60% rule, and we repealed the Appropriate Use Criteria Program. We pursue legislation that funds rehabilitation research. And this is something that we have to consistently advocate for because the NIH budget only goes up a small percentage. Unfortunately, that can disproportionately negatively affect rehabilitation research that can encroach on our funds. And so we effectively push intersectionality and including people with disabilities in equity issues in rehabilitation research. Then as far as post-acute care reform, participated on the RTI Technical Expert Panel to inform the report to Congress and CMS. And we advanced the AAPM&R's Unified Post-Acute Payment Principles with MedPAC. We expressed support for most of them, which was very wonderfully received by us. And so what are our priorities for next year? Where are we going with this? So again, we have to demonstrate the value of physiatry and further expand our Capitol Hill presence. I just said it. We're probably going to be calling you or texting you, asking you to join us. And we hope that you do. Continue pursuit of legislation and regulation that reduces physician burden. We've got to streamline prior authorization. We need to expand the list of qualifying conditions for IRF's under 60% rule. Cardiac issues, some types of cancer, not covering 60% rule. Transplant, not covering 60% rule. We have to expand that out. Expand the list of therapies that qualify under the three-hour rule. Respiratory therapy, vocational rehabilitation, so we can individualize treatment plans. Continue pursuit of legislation that funds rehab research. I'm a researcher. We've got to continue to push for funding to advance our field. And then post-acute care reform. Delaying implementation of that impact act. Effectively informing CMS report to Congress. Giving them accurate information. The OIG got it wrong. We've got to make sure they get it right. And then advancing the specialty in any post-acute care reform. And so I want to bring back all of our speakers so we can answer some of your questions. We do hope you have some. If you don't, we've got some canned ones, so it's fine. And if you have any questions, comments, or feedback, you can reach out to our staff at the email address listed here. We thank you so much for listening. And we look forward to your questions. Everybody back? Hey, everybody, unmute yourselves. We're back. Are there any questions in the chat? There was just a question, Dr. Fredricka, about what does expanding the three-hour rule and the 60% rule mean? And you did just address part of that after the question was answered. Maybe you addressed it because you saw it on your screen. I'm not sure. No. To that, just a little bit more if you'd like me to. That'd be wonderful, Peter. So the three-hour rule prior to 2010, when CMS issued new regulations in the IRF space that determined medical necessity and created all of those now documentation requirements that have been now finally adapted to, but really are quite burdensome. The fact is that they used to count more therapies, more skilled modalities, they called them, toward the three-hour guideline. And I say guideline on purpose because it's not an outright bar to admission that the patient does not receive three hours of therapy. There are certain exceptions, 15 hours over a seven-day week, other kinds of some degree of flexibility, although they have tightened it up quite a bit. The 2010 regulations really tightened it up. We are trying to say, look, PTOT speech in O&T does not a rehab hospital make. There are plenty of other skilled therapies that can and should be being provided, should be available to physiatrists and to treating physicians and the rehab team to count toward the three-hour guideline that are skilled services that are part of a treatment plan that are prescribed by a physician to treat a patient with therapeutic goals in mind, not diversionary activities, but truly skilled services. And there's no reason why some of those should not be counted toward the three-hour guideline. So we do have pending legislation. It's not yet been introduced in the house, but we have some real good interest on both sides of the political aisle to introduce a bill that would reform that three-hour guideline. Right now, as you know, the three-hour rule is waived as a result of COVID. 60% rule is currently waived as a result of COVID. But when the PHE ends, those snap back into effect. And what we're trying to do is figure out a way to not just return to the old rule, but to try to figure out some compromise going forward. Really quickly, the big fear of modifying the three-hour rule and the 60% rule was that you'd have this huge spike in admissions. You'd let all new kinds of patients in. You'd spend a whole lot more money on inpatient rehab. These two rules have been waived over the last year and a half, and that has not happened. That just simply hasn't happened. So those fears of over-utilization have not materialized. And we'd like to try to use that to our advantage to provide physicians a bit more flexibility in the services that they prescribe to patients in that setting. Thank you, Peter. I see a question in the chat. What other specialties are seeing threats to payment cuts and by what percentage? Any as bad as 10% for PMNR? Matt, I think this is you. Yeah. So I remember looking at that number from last year, and I think we were on the high end. I haven't actually seen numbers for other specialties for this year, but some are just two or three and others are up in the 10% range. And I think it does disproportionately affect us compared to others. What I will say is if you're looking for things to do, the Academy is moving forward with a voter voice campaign. And so if you go to the Member Action Center, there's a way for you to contact your legislators. And I put that link in the chat earlier. And if you're really interested in these types of things and really wanna put your boots to the ground, we are looking for new Academy member volunteers for our Reimbursement and Policy Review Committee. And so we would love to, if anyone is really interested in this type of work, to bring you a part of the team and help us fight. I see another question in the chat. MedPAC, has the AAPMNR taken a stance on the MedPAC recommendation that medical record review should be done of high margin IRFs with unusual case mix and coding? Do you want me to address that, Dr. Pedjiga? MedPAC has weighed in on that issue and they have identified additional audits as an important component of trying to rein in what they'd consider over-utilization in the IRF sector. They also have focused on margins, high margins in the IRF sector and how that might be. And the OIG has made this argument as well, how that might be ginning up additional admissions to IRFs. I think that, frankly, so the answer to the question is yes, MedPAC has addressed that. I think it's a much more systematic problem though, than that. When you've got an OIG report that does a nationwide sample in 2018, they published it, they used 2013 cases, but frankly, we've looked at a sample of those cases and they're really no different than the cases that are coming through inpatient rehab hospitals today. When you have a government report that says that 84% were medically unnecessary and that they were overpayments that the government should not have paid, that's an indictment on the entire field. That has really little to do with various types of, whether you're for-profit, nonprofit, rural, urban, the fact is that's a really damning indictment. And frankly, I think many people that read that report who are in the field laugh at that result. It's not a credible result. There's not 84% of the patients admitted to IRFs that don't need services and that there's rehab physicians across the country just admitting them willy-nilly because it's going to somehow gin up additional funding. That's just not happening. So it's a really skewed version and view of what IRF care is and the value of IRF care. I went through IRF care. I was in a rehab hospital for two and a half months as a 10-year-old bilateral amputee. And I must tell you, I know it from a personal perspective and I get these calls all the time about people, my mother had a stroke, my sister has MS, always asking, I need to get them into an IRF. The value is there. You know the value is there. We need to figure out and convince the government that they're just misinterpreting this. They're using the contractors that are just not educated and trained enough to understand what's being provided here. This is complex care being provided and these decisions are medical judgments. There's a lot of work to be done there. Just quickly, there was another question. I might bang this one out as well. Does the Academy work with the AHA, the American Hospital Association or other organizations? We work with a lot of organizations. We're part of coalitions with patient organizations and groups. We work with specific coalitions that address access to rehab services, access to assistive devices and technologies, disability issues generally. We work with the Federation for American Hospitals, the American Medical Rehab Providers Association, other post-acute care providers and provider associations, certainly the AHA. The Academy has tentacles throughout the stakeholder community and works routinely to try to leverage the voice that it has. We thank everyone for attending this session and we look forward to getting emails from you with any additional questions. We'd be happy to answer them. Have a good annual assembly and stay safe. Thank you, everyone. Thanks, everyone. Everyone.

AA PM&R Advocacy session

Medicaid protection

scope of practice

telehealth

COVID-19 response

reimbursement advocacy

legislative priorities

physiatrists

policy and legislation