Thank you very much for attending our session. Before we start, we have to tell you to remind you to switch your cell phones off or set them to silence for all sessions throughout the annual meeting. Please complete your evaluations. They're really useful for us to know for future planning and know what improvements we need to make in the future. And also visit the pavilion. Lots of great resources and educational opportunities you can find there. So today's session is our annual session on the Capitol Hill updates and advancing PM&R updates for our attendees. So I'm Prakash J. Balan. I'm the director of clinical musculoskeletal research at the Shirley Ryan Ability Lab. I'm also the chair of the Health Care Policy and Legislation Committee at the Academy. Our other speakers are Peter Thomas. Peter is a regular here at the annual meeting. How many annual meetings have you come to this one? 25 years. So Peter is from Powers Law. He's our federal policy consultant. We also have Dr. Kerry DeLuca. She's on our HPNL committee, but she's here as a representative to the OIG project steering committee. We have Dr. Richard Chang. He is at ICANN. And Kerry DeLuca is at the University of Pittsburgh. Richard Chang is at ICANN School of Medicine in Mount Sinai. He's the chair of the State Advocacy Committee. And then we have Dr. Matthew Grierson, who's not at Seattle Sports and Spine, as it's listed here. He's now started his own private practice in Seattle, which is amazing. And he's the chair of the Reimbursement and Policy Review Committee and the representative to the RUC at the AMA. These are our speakers. So Peter will be giving us a broad overview of national health policy. I'll be talking specifically about our advocacy efforts at HPNL. Dr. DeLuca will be speaking about the OIG project. Dr. Chang will be speaking about updates regarding state advocacy, which is very important. And then Dr. Grierson, because he's heavily involved in physician payment advocacy, and he'll be speaking to that. And then we'll have time at the end for questions. The other thing you probably, hopefully, all saw this in your packets as you registered for the meeting. And hopefully, you didn't throw it away with some of the other things that you may have also thrown away. But this is actually very important. These are some of the advocacy priorities for the AAPMNR. And I would definitely say these are some of the things that we've been hearing from members that are very, very important to you as physiatrists in the field. And if there's something that we're missing or you feel is very important, please reach out to the Academy because we're here to advocate for you. With that, I'll pass it over to Peter, who will be giving us an overview of national health policy changes and outlook. Thank you, Dr. Jayabalan. Good morning, everyone. So I'm going to take about 15 minutes and walk through some of the top line national issues, federal policy issues that AAPMNR has been working on for some time. Let me just get started right away. Let me see. Just as an introduction, I've been practicing health care law since 1992 at Powers Law Firm. I'm now managing partner, which goes to show that if you stick around anywhere long enough, they finally kick you upstairs. I also represent, in addition to the Academy, I represent the American Medical Rehabilitation Providers Association and so have a pretty deep understanding of the IRF-related issues. Coalition to Preserve Rehabilitation is a large-scale coalition that the Academy belongs to. And that really fights to preserve access to rehabilitation in a variety of different settings. And then the Disability and Rehabilitation Research Coalition is another coalition that I coordinate. And that really is all about NIH and NIDILRR and federal funding for rehabilitation and disability science. I also have personal experience with disability. I was in a car wreck when I was 10 and lost my legs below the knees and went to rehabilitation for two and a half months in Craig Rehab Hospital in Washington, in Denver, Colorado, and have been using prosthetic limbs ever since. So throughout my life, I've been associated and involved with rehabilitation. So I'm going to quickly go into the Washington update, the appropriations process, a new bill called the Three Hour Rule Bill, or it's actually called the Access to Inpatient Rehabilitation Therapy Act. Just touch on something called the Review Choice Demonstration, which you may have heard of. I'm going to give everyone a MedPAC update, talk just a little bit about telehealth, long COVID, and access to technology and medical technologies. So the first bullet here on the Washington update and the political outlook is just simply a statement of what's going to happen on November 5, 2024. I'm not a political animal in the sense that I don't look at polling and analyze things, but I do pay very close attention to what's happening with the politics. And it looks as though it'll be a President Biden versus former President Trump rematch, which I'm sure everyone is just really excited to see. But that's where we are. Unless something changes, the California decision in the case keeping President Trump off the ballot was not successful. But just listen to that on the news this morning, actually. But the decision in that case was that the president did commit insurrection, which is the first time a court has held that. And what kind of implications that has is really anyone's guess. I mean, we're completely in an uncharted territory with respect to that. And of course, a number of people on the Democratic side continue to have concerns about President Biden's age and would like to frankly see new fresh faces in both parties. Nonetheless, it looks like that's the lot. Pardon me. It looks like that's what we'll be seeing in November 5, in November of 2024. The Congress is very closely divided. The Democrats really hold just a vote advantage in the Senate. And in the House, the Republicans lead just by three votes right now. There is an election upcoming that should make it four. So extraordinarily close margins. And it's anyone's guess who will wind up running Congress in the next four years or two years, I should say, 2025 and 2026. Right now, there are a number of people announcing their retirements, including a number of physicians on the House side. Congressman Guthrie, a number of other physicians who have been really leaders on health care policy over the years are announcing their retirements. And Joe Manchin announced his retirement from the Senate. And that's, of course, an important swing state. It's actually a red state. But the fact that they had a Democrat as their senator could upset the balance in the Senate. It depends on what happens, obviously, in other states. And then finally, there is a new speaker. After about three months, sorry, three weeks of chaos in the House, they finally did elect a new speaker of the House. Mike Johnson is his name. He's quite conservative. Some might say far right. The question is whether he's going to be able to keep his job if he funds the federal government at anywhere near where the Senate and the president are in terms of the funding levels. And I'll talk about that right now. The appropriations process is finally back underway. It had been stalled and was kind of just collecting dust for some time. And yet, the federal fiscal year began October 1. So we are right now operating the federal government under a continuing resolution. Yesterday was the deadline to extend that resolution. And to their credit, Congress did, in fact, wind up extending the deadline through a couple of dates, I'm going to say, in a few moments. But the House Appropriations Committee is really operating with some extraordinarily low funding levels compared to where the president and the former speaker of the House, Speaker McCarthy, agreed in May, if you recall, with respect to the budget debt agreement and lifting the debt ceiling. They agreed to certain spending levels. And the House leadership views those levels as the top line numbers but would like to cut much further. In fact, the House Appropriations Committee has made significant, massive reductions, proposing to reduce NIH funding by $3.8 billion. I mean, that's an amazing number to reduce for the world's biomedical research entity. CDC, $1.6 billion cut. Administration for Community Living, $6.4 million cut. Much smaller agency but very important for people with disability. So the House really is proposing $14 billion below this year's levels. That's a 13.5% cut for the Department of Health and Human Services, which is just, it's not possible. You can't cut the budget that deeply in one year. It's just not going to happen. So the Senate numbers are, as I said, much more aligned with the budget deal that occurred in May. And so this is a train wreck waiting to happen. The shutdown was averted. Today would have been the first day of the federal shutdown. That was averted. But they have a two-step process for determining appropriations for the coming year or for this year. January 19th, there's the bills there on the slide will be supposed to be done by then. And February 2nd includes the labor HHS bill and the defense bill and others. So it's a two-step process to try to get the work done. There's no funding included for Israel, Ukraine, or the US border with Mexico, as the Republicans had vowed to include. And the president did sign that bill. So more to follow. There'll be a massive debate over the next month and a half, two months on appropriations. And it's not at all clear what happens to the speaker if they have to pass bills that are considerably larger than his right flank would want to fund. And that's going to be a really interesting spectator sport to watch from a political perspective. The Access to Inpatient Rehabilitation Therapy Act was introduced a few months ago by Representatives Thompson and Courtney. It's a bipartisan bill. Ultimately, the Senate, we're hoping, will introduce a counterpart to that. We're also going to be going in and meeting with CMS to talk about the bill and see if they can include this on their own motion in the regulatory approach this coming year. But ultimately, what the bill would do is reset the clock back to before 2010, when new regulations confined the intensity of therapy requirement in IRFs and limited the amounts of skilled therapy that could be provided to just PTOT speech and orthotics and prosthetics. And ultimately, you still have to achieve three hours per day. That's the guideline. There are exceptions, or 15 hours over a seven-day period. But you can only use those four therapies. Those are the only ones that apply. And this bill would basically say, yes, you need to employ that same rule upon admission. But once the patient gets into the IRF, and once the rehab team and the rehab physician are treating that patient, they would be given greater deference to determine what skilled services would apply to that three-hour requirement. And that's really the purpose of the legislation. It's something that came out of some meetings post-2010 regulations. And we're hopeful that this will begin to move. The Academy is a major supporter of this provision. The review choice demonstration is a massive undertaking, 100% claim review for the states that it applies to. Currently, it's operational in Alabama for all inpatient rehabilitation hospitals, in all cases, Medicare cases, fee for service. There is a contractor named Palmetto that is reviewing every single admission, and either affirms or does not affirm that admission. And if they do not affirm it, the provider has the ability to submit additional documentation and continue trying to get the case approved. So far, the affirmation rate is exceedingly high. Somewhere between 95% and 98% in Alabama is what we're hearing. It's still early. It's only the first three months of the program. But it is expected to be rolled out in other states, including Pennsylvania next, and then Texas, and then California, and eventually about half the states. How the contractors are going to review 100% of these claims in these various states of IRF claims is beyond me. But it's going to take a massive undertaking if they continue to go forward with it. We're pushing back. We're trying to get them to recognize, look, if you're affirming over 95% of these cases, why are you spending all these resources to do 100% claim review for IRFs? And of course, their big concern is the gatekeeper effect and whether patients are going to continue to have access to inpatient rehabilitation hospital care, even if they qualify under the Medicare criteria. Just two days ago, unfortunately, the government came out with a new estimate of error, the error rate for inpatient rehab hospitals and units, as well as the error rate for all other kinds of providers as well. Usually, the error rate for the Medicare program across the board is about 6%. We used to be at 19% last year. And this year, we're at 27%. They're asserting the CERT, called the Comprehensive Error Rate Testing Contractor, is asserting that in a sample of 100 IRF claims that they looked at, 27% were deemed to be either not medically necessary or the documentation was not appropriate for the government to have paid that claim. That's astounding. That's not something that we can tolerate as a field. In fact, that number was much higher a couple of years ago. It was 62% in 2018, 2017, I think. So we've made some progress. But still, just over a quarter of IRF claims that were submitted in fiscal year 2022 were deemed to have been errors. And that's something that we have to continue to work on. It's one of the reasons we're doing the OIG project that you'll hear about soon. A couple more. So MedPAC, very quickly, Medicare Payment Advisory Commission did not recommend its usual 5% cut. They recommended a 3% cut. They also did not adopt the uniform PAC payment proposal, which is huge. That's a gigantic victory. The Academy did not like that proposal. There was real serious concerns about patient access to care. And ultimately, they chose not to move forward with that. But they are moving forward with some site neutral payment policies. And those are concerning as well. Unfortunately, the first we learned about that, they really mangled an interpretation of the 60% rule. They basically said they called the cases that belong in the 40%, they called them non-qualifying cases. And they're making an argument that the government should pay the same for those cases that they pay for SNF care. It makes very little sense. And we're actively fighting that. Telehealth and telemedicine obviously had a huge expansion during the pandemic. And a lot of people don't want to see that retract. So there are efforts through the Congress and through CMS. Telehealth will be treated the same way it currently is through at least December 31, 2024. And then Congress will have to decide what it wants to do going forward. So there have been some real flexibilities in telehealth. And certainly, tele-rehabilitation has also benefited from that. Long COVID continues to be a condition that vexes some people in a very material way. I think the wind has gone out of the sail on Capitol Hill to try to get legislation around long COVID. To be quite frank, there has been stiff Republican resistance to doing anything on long COVID. And so the locus of activity is now at Department of Health and Human Services in the administration. There's been two new entities within HHS that have been created recently focused on long COVID. And there just was announced a new advisory board that nominations are open right now. And I expect that the Academy will submit either a name or names for that advisory board on long COVID advising the Department of Health and Human Services. So there's some real activity on that score, but it's mainly from a regulatory or a executive branch approach rather than legislative. I'll also say that the NIH is spending significant resources. They've announced two rounds of funding for long COVID research. And then the final issue I wanted to bring up and pay special attention to Dr. Anjali Shah. Could you raise your name, Dr. Shah? Raise your hand. Oh, I saw her earlier. I saw her earlier. Okay, my apologies. But Dr. Shah has been working with the academy and has been working with a group called the Item Coalition, which the academy belongs to. And we have been fighting to try to get Medicare coverage of seat elevation in power wheelchairs. We've also been trying to get kind of standing systems in power wheelchairs covered as well. In May, CMS announced that it would in fact cover seat elevation in power wheelchairs, astounding that they have not done this to date, but the fact is that it was deemed under a national coverage determination process to be not only durable medical equipment and covered DME, but also medically necessary for certain beneficiaries. So that's really great news. We're about to embark on an effort to get standing systems covered as well. And let me just end with the fact that they, the CMS did publish a final regulation defining what a brace is or an orthosis. And a large significant advance in that area is that they've deemed powered orthoses to be covered by the Medicare program, which opens up coverage for exoskeletal devices. It opens up coverage for upper extremity and lower extremity orthoses that use power across joints to aid and support a limb. And that is not something that CMS did just a couple of years ago. So that's a really big advance in terms of coverage. Finally, there is a bill and a regulation pending to extend FDA breakthrough approved devices four years of Medicare coverage. That's the bill. The regulation would be less generous. But ultimately, we're working on that as well. And I've reached my time allotment, so I will say thank you so much. Thanks so much, Peter. And we'll take questions at the end. Hopefully we'll have time for some questions. So I'm just going to give, talk about federal advocacy. As I said, I'm the chair of the Healthcare Policy and Legislation Committee at the Academy. And I do not have any disclosures other than me being the chair. I really want to thank the rest of my committee. They are fantastic, energetic individuals. And I'm really just the representative of them in this session. And I also want to thank Chris Stewart, who's at the back there, for all of his fantastic work behind the scenes and also for putting a lot of these slides together as well. So I appreciate that, Chris. So these are some of the priorities that we as a committee have been working on, specifically more at the federal level. And these are just sort of our values and priorities as we go forward, so demonstrating the value of our field to policymakers, but just not to policymakers, but also to the public, fighting for improved physician payments, fighting to reduce physician burden, trying to make your lives easier by removing prior authorization barriers, defending the role of physiatrists against encroachments from non-PMR physicians and non-physicians. It's an issue that not just physiatrists face, but it's definitely something that we're very focused on in this scope of practice creep. And then, as Peter mentioned, long COVID advocacy. We've also been involved in that over the last year. Just some background. We engage with many different governmental agencies. We engage with individuals in Congress, MedPAC, as Peter mentioned, the White House. We work with the Office of Management and Budget, the OMB. We work with the COVID response team in particular because we got a lot of traction in the physicians looking after long COVID, individuals with long COVID. We work with HHS. We also advocate with NIH and NIDILRR and also the National Academy of Sciences as well. The goal is just to show you the span of the work that we do. This is not the totality of the organizations that we work with, but really trying to further many of those priorities that we talked about that I just talked about before. We also sign on to many different coalitions that also fulfill many of the mission and vision that we have at the academy. Some of these are more related to individuals with disabilities. Some of them are research related. And others are more inpatient rehabilitation facility related as well. And we sign on to many letters which other organizations are putting together and we agree with. And so these are some of those organizations that really fulfill much of the things to help our patients going forward. I do want to talk about the three major things that we talked about when we went to the Hill. And we go to the Hill usually every spring and we meet with congressional offices that are local to members of the committee or other congressional offices that we think are very important to some of these asks that we're going to have to Congress. So the first one that we really focused on this year was really this reforming the prior authorization process and supporting and improving seniors timely access to care act. This was bipartisan legislation that actually passed the U.S. House in 2022. It got stalled but we'll talk about that in a second. We also were looking at the physician fee schedule and reimbursement on the Medicare program. And finally we also advocated for many issues related to long COVID in particular this comprehensive access to resources and education. So when we're thinking about what things we're going to talk about in Congress, some of it's timeliness of that particular issue. Some of it is issues that we're hearing from academy members. And when we are advocating at the Hill, we have to put our academy hand in what we think is most pertinent to you as members. So as I said at the beginning of this talk, if there's something that you are very passionate about and you think that the academy should be advocating for, please reach out to us. These are just some pictures of our committee when we went to Capitol Hill. Promise you we just didn't go there for the picture opportunities. We actually did some important advocacy work while we were there. So I do want to highlight some of our wins and accomplishments because our committee is very active and we really are a big part of the academy. And so as I said, one of those major priorities is trying to reduce the burden that we face as physiatrists every day. And so we're working and we have worked well to advance prior authorization reforms through Congress and CMS. We successfully worked, as Peter mentioned, this three-hour rule, the Access to Rehabilitation Therapy Act. And we worked diligently to reintroduce that and so that's going forward. And then we endorsed this Gold Card Act. It sounds very fancy when I first heard about it, that someone would have a gold card. For those of you that aren't aware of this, this is something that's actually first slightly different but was introduced in Texas initially and it was, I believe, introduced by Texas House of Representatives. But this would essentially exempt physicians from Medicare Advantage prior authorization if in the prior 12 months they had 90 percent of their requests were approved. So this could have a significant impact in reducing some of that physician burden. I read online other big organizations like the AMA, et cetera, have also been trying to push this legislation through. And so we've been very strong in advocating for that as well. Others, this is more now related to scope of practice creep. And this is, we've been really involved in grassroots advocacy to oppose legislation that would expand the scope of practice of secondary providers such as nurse practitioners and advanced practitioners and PAs under Medicare. And then similarly to that, there was also very recently the Federal Workers' Compensation Program was going to allow, particularly in the occupational health arena, allow PAs and NPs to provide care without any supervision. And we were certainly involved in opposing legislation that would allow that to happen. Other things that, as has been said many times throughout this meeting, is how much long COVID has become the purview of physiatry. And we were very strong in also advocating for many of these acts, which were, some of them were related to making sure that individuals from underserved populations had access to long COVID treatment and care. Some of it was related to research in long COVID for our patients. And so, as Peter also mentioned, this is, we advocated for this strongly, but there is some issue with sort of the traction of this issue going forward. And so, this may be something that we're going to be thinking about as a committee, whether this will be, continue to be a priority. It's a priority for the academy, but when we go to the hill, how much traction can we get in terms of advocacy is something that we're discussing. I think this is my closing slide. And I think one of the biggest things that we want to do as a committee is really demonstrating the value of what we do as physiatrists. And so, one of the huge wins, as Peter mentioned, was this power seat elevation reimbursement for Medicare beneficiaries. It was a huge win, and I really want to thank Dr. Anjali Shah, who's not here, because of her advocacy work, and she's on our committee. One other really important thing that many of you may not be aware of was that the National Institute of Minority Health and Health Disparities, so the NIMHD, which is part of NIH, finally designated individuals with disabilities as having a health disparity. And this is important, because this means that there will be hopefully more research dollars that will go towards research to help individuals with disabilities. So this was an absolutely huge win. And then we've also provided expert input to the U.S. Government Accountability Office, and this was really related to the quality of care available for individuals with limb loss and limb differences. We'll take any questions at the end, and that's all I have. Thank you. And we'll go to Dr. DeLuca. All right. Can you all hear me? Yes. All right. Well, I'm Carrie DeLuca. You got yours? All right. So I do not have any disclosures. I am a member of the Health Policy and Legislation Committee. I am on this task force, which I'm happy to be talking about. I am from the University of Pittsburgh. I'm the Medical Director of the Rehab Network for UPMC and Director of the Inpatient Counsel Service at our major teaching hospital. So as many of you are aware, in 2018, the Office of the Inspector General released results of an audit. So they did a nationwide audit. They pulled 220 charts, which were supposed to represent all of the inpatient rehab stays during calendar year 2013. They audited those charts, and their conclusion was a significant percentage of those charts did not prove that the stays were reasonable and necessary. So this could have either been documentation errors, like omitting something from the pre-admission screening or not having the right signatures on team conference, or it could have been that the documentation didn't support that the stay was reasonable and necessary, so more to the point of needing physician oversight and management in the inpatient rehab setting. So the OIG extrapolated these results and said that in calendar year 2013, they had overpaid by $5.7 billion. Of course, those of us in PM&R would not agree with that percentage of error rate. And so the Academy, immediately after it was released, the Academy, along with other stakeholders, including the American Medical Rehab Providers Association and the Federation of American Hospitals, submitted strongly worded response, as well as submitting a freedom of information request to obtain access to the charts that were involved in the audit. I was not involved with this project until last year, but the Academy did meet with multiple groups, including CMS, the Department of Health and Human Services, and the OIG to challenge these findings. In 2020, these stakeholders were given access to seven charts. So in this audit, 175 charts were deemed not compliant or not meeting criteria. These stakeholders were only given access to seven charts to review from this OIG sample. And the Academy did meet with OIG to discuss these cases, to try to educate the OIG on our perspective and attempt to have more of an open dialogue and certainly to represent the psychiatrist in this conversation about appropriateness for inpatient rehab. So currently, there's a new audit underway. So in 2022, we learned that the OIG is now conducting a new audit. So the OIG now has reached out to major stakeholders. So AAPMNR and the Federation of American Hospitals and AMRPA are all going to be involved in this dialogue and providing feedback to OIG throughout the audit process, which is a major positive development. So we have a steering committee, and I'll give you more information on the next slide, but we have already been involved in this project. Earlier this year, we gave feedback in terms of the sampling methodology and in terms of the criteria matrix under which the charts will be audited. The project will be moving forward currently. I'll explain a little bit later. It's a bit on pause, but when the cases are denied, we have been told that the stakeholder group will be able to review all the denials, which is a major improvement from the last time. We are planning to have a meeting with OIG to discuss the cases and then draft a response to the report. So, sorry, I'll turn this over and make sure I don't miss anything. Certainly, when the Academy was considering becoming involved in this, there's a major time commitment for the members, major time commitment for Academy staff, but this is a really important issue. So, of course, the Academy felt really that we did need to be involved in this. Our hope is that we can improve the accuracy of this audit and future audits. We want to ensure that the voice of physiatrists are heard in this discussion in terms of, you know, especially the medical necessity for patients to be in inpatient rehab and certainly the documentation burdens that we face as well. We want to have an open dialogue with the OIG and its contractor to be able to, again, explain the clinical nature of these decisions, the complexity of these decisions, and certainly to have, again, more of an open dialogue. And ultimately, through this dialogue with OIG, we are hoping that perhaps we can actually, over time, suggest policy changes that can be implemented in the future. So, as I mentioned earlier, there is a steering committee of which there are individuals from all the stakeholder groups that I mentioned. Dr. Daryl Kalin, who's past president of the Academy, is the other physiatrist on the committee, and we have been involved in this committee or in the steering committee from the beginning, and we will be involved until the end of the project. We also have established a clinical review committee made up of 20 physiatrists who are Academy members, and this clinical review committee will be the committee that will review all the denials. So, as part of this project, we've been told that we will have access to all the denials and be able to review those charts and rebut and have this discussion. So, we are very grateful that a number of Academy members have stepped forward and volunteered to be on this review committee. And then, again, I mentioned we're going to have a two-day meeting with OIG after the audit has been completed, after the charts have been reviewed, and so we are also creating a committee of physicians who will go and have that dialogue with the OIG over that two-day meeting. So, this current project has been on pause since May. So, our understanding is the 200 charts that have been pulled reflecting inpatient rehab stays over calendar year, I think 2020, have already been pulled. So, the 200 charts have been pulled and reviewed. However, our understanding is the contractor has not been able to find a board-certified physiatrist to be able to review these cases. So, the audit is currently on pause but will be resumed once the contractor is able to staff that position with a board-certified physiatrist and then the process can move forward. And so, as mentioned before, all of us, all the three stakeholder groups in the steering committee are waiting to hear from the OIG and we anticipate this will move forward next year. And I believe that's my last slide. Thank you. Good morning all. I'm Dr. Richard Chang and I have the honor of serving as your State Advocacy Chair. I have no relevant disclosures. I also serve as a member of the Health Policy and Legislative Committee. It's been a pleasure working with all in the last couple of years. We're close with HP&L. We're a small but mighty committee. We do our best to represent interests both geographically and both practice type. Just a quick shout out to Dr. Baker who's on the far left corner. He's an outpatient pain management in Lebanon, Tennessee. To your left-hand corner on the downside is Dr. Max Fitzgerald. He's an inpatient physiatrist at Rush University in Chicago. On our right-hand corner, Dr. Raymond Chow. He's an outpatient upper extremity physiatrist in Stanford in California. And Dr. Justin Bishop coming from Dallas, Texas, also an inpatient physiatry. In terms of state advocacy goals for this remaining year and the next 2024 year, many of the goals mirror the national priorities as well. Again, we do our best to actively track, monitor, evaluate and respond to many issues that come up every year. Although we do our best to proactively respond to these issues, again, we rely on you as members to be the eyes and ears, especially for those who are experts and have done this for quite some time. In the evaluation of these different issues, for example, scope of practice, which is a very common issue, we do our best to evaluate if further action needs to be taken by the committee and by HPL. As a result, we create sort of networks and coalitions with the local physiatrists, state societies, the general medical state societies, and sometimes with AMA as well. And as you can see, a lot of it is, you know, on-the-ground grassroots efforts, you know, in the form of email campaigns or working closely with the state legislature, the congressional members, with the state society president. And again, last, we try to create resources on the website or, you know, in terms of supporting and creating letters for our members. In terms of priority areas that we're trying to focus on for the remaining year and next year, again, I just mentioned scope of practice. Again, we have encroachment from allied healthcare professionals, you know, many of them that we work with, for example, physical and occupational, physical therapists, and as well as our, you know, colleagues from chiropractic, naturopaths, and again, it's in, as alluded before, you know, other, like, nurse anesthetists and physician assistants. So we all like to work in this same sort of healthcare landscape, but again, we, you know, we want to protect what's best for the physician team, physician-led team, especially with the physiatrists. Prior to the COVID-19 pandemic, we were dealing with the opiate crisis, which we're still dealing with, and again, we're dealing with legislation and regulation in regards to physicians or healthcare providers in respect to prescribing such medications, as well as dealing with legislation to preserve access to rehabilitation and rehabilitation services. Telemedicine is still relevant, even though the public health emergency waiver has ended earlier this year. It's sort of standard practice. I know it's sort of declined in use for many physicians, but we're trying to preserve payment parity and access, especially on the state side. And of course, we're trying to protect and serve the interests of patients with disabilities and chronic conditions. Just like before on the national side, I'd just like to highlight some of the wins made on the state AFSI side. Starting with my home state of New York, for the Department of Health and Mental Health budget, Governor Hochul and the physician assistant group, PA group, tried to remove the oversight clause in terms of the budget. Fortunately, with the strong response from APMR, more than 80 letters were generated from the Voter Voice Campaign, as well as from the Medical State Society of New York or MSNI. This was not incorporated into the final budget. Again, this happens often annually, but again, we appreciate your time and effort to look out for these issues and respond quickly and efficiently. Moving on a little to Michigan, we supported legislation essentially trying to preserve the payment parity or reimbursement for telehealth services in respect to inpatient visits. Again, that's still somewhat debated, but again, I think we're still moderning that bill. In Oklahoma, again, another strong response, and mainly in response to interventional pain management services. The CRNAs, or certified nurse anesthetists, tried to introduce a bill or legislation where they can perform these procedures without physician oversight. Fortunately, with the collaboration of our academy, members such as yourself, and the Multispecialty Pain Work Group, which is a collection of different interventional pain societies, radiology, and spine surgery, that bill did not pass the Oklahoma House. Moving down to District of Columbia, we supported legislation smearing our national efforts in terms of reducing power authorization burden and improving physician wellness. Lastly, I'd like to highlight a national campaign that was recently brought to our attention, essentially encouraging individual states to enact legislation to cover orthotic and prosthetic use for physical activity. It's somewhat a no-brainer, but in the medical indications, it's not explicitly made. So far, we have five states that are supporting this legislation, from Arkansas, Colorado, Maine, New Mexico, and Illinois. I think we're still looking for other sponsors, and I think we're encouraged with the initial response. Just moving on to resources, so in collaboration with, you know, even though it comes from the state side, we look at the state, because such bills or issues can have a ripple effect on other states, whether it's prohibiting or preventing harmful issues, or supporting bills that may be useful to reenact or reproduce in your own legislatures. So in coordination with the EMA, there is a useful patient education resource, essentially highlighting what's a physician, or who's a doctor, and who's leading your team. So it's available as a PDF form that you can post in your patient offices. I guess you can also put it as part of your packets if you're meeting with your local congressional members. Again, just highlighting, because again, with the whole landscape, you know, everyone could be a doctor, since, you know, physical therapists have doctorates, naturopaths have their own school. You know, it'd be quite confusing to patients in terms of how they consume health care resources. Oops, and lastly, I'd like to also highlight the sticky fingers on the website. The best way to engage us is looking at the website in terms of the legislative map tracking, and I would say it's definitely useful for members, especially if you don't have time to look at the individual bills. Depending on your interest, for example, concussion, you could look at what bills are relevant to your specific topic of interest, and I would say, as I mentioned before, you know, there's grassroots campaign letters, and again, we rely on you, even though we do our best to actively be proactive in sort of responding to these individual issues, again, but there's 50 states. So again, we appreciate all the time and effort, and again, please let us know if you have any questions, concerns. We're always happy to interact and find out what's going on. Thank you for your time. All right, good morning. I'm Matthew Grierson. I'm chair of the Reimbursement and Policy Review Committee. I have no disclosures, and today we're going to be talking about reimbursement advocacy at the academy. So our committee is comprised of a number of volunteers who have both enthusiasm and expertise around reimbursement policy and reimbursement advocacy and education. So our main goal is to ensure that our physiatrists are reimbursed at a very reasonable rate, and so we do this through several channels. We communicate regularly throughout the year with CMS through comments on the proposed rule. The new rule just came out a couple weeks ago. And we participate in the CPT and the RUC process where our voice is heard in the development and valuation of brand-new codes and existing codes that are updated that impact the field of physiatry. So we have a very robust team of CPT and RUC advisors and members on the panel for the RUC, and they're going to meetings three times a year. These are week-long meetings that these individuals take out of their practices, and so we thank them for their efforts. Dr. Carlo Malani and Dr. David Reese, there are two representatives advocating for us on the RUC. Dr. Clarice Sin is my alternate. She and I serve actually on the RUC. We're the first physiatry members on the RUC. And we're very thankful also for Dr. Joe Shivers and Dr. Antigone Argerio who advocate at the CPT level. Some recent efforts from the CPT panel and the RUC, just to highlight, you know, most of the work that we do, it does seem to be very convoluted. It seems to be secret. It's not secret. We actually publish all of the data every year after the final rule comes out. Part of that is because, you know, things change along the way. But it is very confidential initially. But what I can tell you is in 2022 and 2023, our teams participate in efforts in a couple of spaces. Number one, with ultrasound guidance codes. Some updates were made to the practice expense codes for diagnostic ultrasound. So you'll see slightly higher reimbursement rates for 76882, the limited ultrasound code. Also the values were updated for the two spinal cord neurostimulator codes. So 63685, which is the insertion code, that's actually going to retain the same value. For those of you in the know, if you have a code and it keeps the same value, that is a major win as it relates to the RUC. And then 63688, that will decrease a little bit for 2024, that's the revision code. So don't do any revisions. But although in terms of telemedicine coverage or coding for 2025, we can't tell you a lot right now in terms of details. A lot of this is still, you know, working through the process. But you can expect to see that there's going to be new telemedicine coding guidance for 2025. Of course our academy is going to be very up to offering education on these changes as well. So finally, I'd just also like to highlight, if anyone would like to learn a little bit more about the RUC process, there is a new podcast, Advancing PM&R, if you go to episode number three, you'll see a very familiar face talking about the CPT and RUC process and my experiences as I've been opening a brand new practice in Seattle. So let's talk to the big issue right now on everybody's mind, the Medicare fee schedule. So for 2024, and this is across the whole entire field of medicine, this is where we are laser focused right now in terms of trying to avert this cut right now. It's 3.37 expected cut unless Congress takes action. And if everyone goes to your email, you will see that there is an Advancing PM&R advocacy action alert. This is an opportunity for you to encode your emails and write to your Congress people and senators to try and avert this cut. Right now we've had over 525 physiatrists sign on to this letter. So we need each of you in this room to add your name to the chorus, because what we need to do is fix Medicare now. I'm not going to start a chant, but it's very important that right now we have some opportunity and some movement with the movers and shakers in Congress to potentially having some more permanent updates. Right now physicians are the only group where our payments are going down in Medicare. Every other group, payments are going up. Every other group, it moves with inflation, but not physicians. And we need this to care for our parents, our grandparents, our patients, and basically so that practice is sustainable. So I'll get off my soapbox there. But this cut is due to statutory requirements that every year there has to be a budget neutrality So if certain codes go up, other codes must go down. And as new codes come into the system, actually the pie can't get bigger. So the system as a whole, reimbursement goes down. So again, this is a big high priority for our academy and across medicine as a whole. Other big topics, split shared visits under Medicare. This has been a big topic in the last couple of years and has been a significant area of our advocacy. So this term is, if you're not familiar with split shared visits, this is when there's an E&M visit in the hospital that's performed jointly by a physician and an advanced practice provider such as a PA or a nurse practitioner. So in a very concerning proposal several years ago, CMS suggested that the biller of the split shared service, the person who gets credit for it, is the one who spends the most time with the patient. Well, we as physicians typically are a little bit more efficient in terms of our care for the patient, whereas someone who is less experienced or typically what's been found is the PA or the nurse practitioner is spending more time with that patient. So they would actually get credit for that. And it would be billed at a 15% less rate. And so we were very concerned about that proposal because it would disadvantage those physicians participating in the care of those patients. So in 2022 and 2023, we sent comment letters to CMS. And we're very active in terms of trying to get them to change that policy to include medical decision-making. And as physicians, we're very clear in being able to document that medical decision-making. And so now people can either bill based on time or using that medical decision-making. And CMS was finally swayed to our comments. And so right now they're defining the substantive portion of the encounter as either more than half the encounter time or medical decision-making based on the new CPT guidelines that if you missed the lecture that was just an hour ago, you'll be able to watch it on the Rewind for the conference today. But we will be developing further education on this policy coming out in December. So stay tuned on that as well. Another big thing that we do on our committee is we review the local coverage determination. They're the process for each of the Medicare jurisdictions in terms of how they decide how different codes are paid. And so when different codes come up, we send representatives to these local coverage determination meetings to try and influence the process. Last February, there was a report, Therapeutic Monitoring Codes. Dr. Mark Gruner helped represent the academy for that, which was a big win where the Medicare contractors decided not to draft a local coverage determination policy, which gives our physiatrists more freedom in terms of use of those codes. Last April, Trigger Point Codes were under consideration. Dr. Antigone Argerio represented our academy. We're still waiting on the final outcome from that draft LCD. We'll see where that goes. In August, Dr. Joe Shivers represented the academy. We're also waiting on a draft for that. In addition to those listed on the slide, two other members attended a recent meeting on botulinum toxin, Dr. John Barada and Dr. Christina Kwasnika. And so we thank all of our volunteers who are working on our behalf to ensure that physiatrists are getting reasonable coverage for the work that we do. We're also involved in a multi-specialty pain work group, where through this work group with other specialty societies, we are stronger with bigger numbers, more support from pooling our resources together. And as many of you know, payers often restrict coverage of pain-related procedures and services. And so we work through this work group to ensure that we have a louder voice when it comes to these pain services. And so we submitted a joint letter to Blue Cross Blue Shield of Tennessee to support coverage of peripheral nerve stimulations. We provide feedback to Meridian in terms of their interosteous basal vertebral nerve ablation policies. Big important thing for my state, Washington State Healthcare Authority, we helped submit comments to urge them to reverse their position of non-coverage for peripheral nerve stimulation. And also through the Medicare LCDs and other processes, we wrote letters in support of coverage of SI joint injections and procedures. So lots of work going on behind the scenes. It really does take a big, huge team. By the way, that's a plug. If any of you are interested in getting more involved, there's always calls for help, and we always could use your support, especially at the state level. This is another way to get involved, just on an individual level. There's a physician practice survey that's going to be going out sponsored by the AMA. And so if you get an email about this, and if you're in a position to influence your practice or your group to be able to provide information through this survey, it's actually going to be very important to help influence CMS decisions about how the practice expense part of how our codes are valued is calculated. If you see any of that come through your email boxes, please do not delete for them to the right people. And it's going to be really helpful. So takeaway messages. What can members do? Make your voice heard. So join our grassroots advocacy on physician payment. Fix Medicare now. Should we start chanting? All right. Sorry. So visit our AAPM and our Member Action Center. Another really good, if you can't remember that, remember FixMedicareNow.org. That's an email that you can go to. And it's sponsored by the AMA. It's another way to get those letters out. I'd probably do both, both the Academy and through the AMA. Let them hear from all angles because this is very important that we are laser-focused as physicians, as a specialty to get appropriate payments. So if you do have any issues that come up in your individual practices, please write down that email, HealthPolicyAAPMNR.org. We always review those as our committee, and we're always happy to help there. We want to be a resource for you as a member benefit for being a member of AAPMNR. So watch for that survey. And with that, I will conclude my part. Thank you. All right. Thank you so much to our great speakers. And I really want to say before I forget, thank you so much to the Academy staff who support all of these committees for all that you do. I know it's a countless number of hours, and you have to put up with us as well. That's probably the worst part. But I really appreciate all that you do, and we all do as well. I also want to give a plug for a webinar that's currently up on the AAPMNR website, which Dr. DeLuca and Peter did specifically on the OIG project. It's very informative. I think it's definitely worth considering listening to. Medicare. Medicare. Oh, sorry. Medicare. I clearly have not listened to it, as I've just proved, but Medicare Advantage, that would be great. So listen to that as well. Any questions that anyone has? Yes. Yeah. If you have any questions, please step to the mic, because this is recorded. Do you want to repeat the question? Surely. This week, there was a lawsuit filed against UnitedHealthcare alleging and a very detailed article in Stat News, which we can distribute if you'd like to read the article. It's a long article, very in-depth reporting. The article is very complementary in timing to this lawsuit, but ultimately, the allegations are that UnitedHealthcare, its Medicare Advantage plan, used a product called NaviHealth and imposed in its skilled nursing facility patients, patient mix, a rule that you could not deviate from the expected length of stay by more than 1% on the aggregate, and that there were significant consequences for employees, some of whom got fired, some of whom were docked pay, if they deviated from that one percentile length of stay. So the allegation is that patients were being prematurely discharged or discharged at the length of stay, no longer than the length of stay that NaviHealth would spit out. And of course, UnitedHealthcare purchased NaviHealth a few years ago. So this is a very serious allegation. UnitedHealthcare denies it and will fight it strongly, I'm sure. But the article in Stat News was pretty damning. It was a very in-depth kind of expose, a lot of examples of real patients and what they went through during this investigation that found some pretty significant problems with how United Healthcare is doing that. Now, that obviously has implications on the IRF environment as well. And a number of the same patients that were discharged early from SNFs also did not gain access to IRF care. The question is, my one question that I had was, this is really all about patients that were prematurely discharged from SNF, even though they continued to need SNF care and it was medically necessary to treat them, continue treating them. What about all the patients that never got access to SNFs or never got access to IRF? And so those algorithms are used not just to reduce lengths of stay, but they're also used to determine Medicare coverage. That's now been prohibited by the Medicare Advantage regulations. But we have no doubt that the plans, MA plans, will continue to do whatever they can to try to get around those regulations. So it's a very active area, legislative, regulatory, lawsuits, the courts. So more to follow, but it's an extremely important development. There's another question, I believe. Yes, I have a question in respect to scope creep. So basically, what do you think is something that the opposing side is doing that they're doing well that we can sort of be prepared for or maybe even adapt, aware that in terms of their curriculum for nurse practitioners, they have more advocacy education now? Not necessarily suggesting that we switch to that in the medical side of things, but I do believe that they do have more tools when it comes to this issue. Great question. Great question. I wouldn't say we don't have great resources. I mean, I would say, first off, you would start off by participating in your local state medical society and trying to be involved with the resources they have there. I mean, as a physiatrist, I know a number of states are trying to revamp or don't have an existing physiatry state society. But again, the academy has resources and faculty to help that. I mean, they have numbers. And they make relationships with their local congressional members and try to foster those. But at the same time, we work closely with the local state societies and community groups essentially to, I guess, also try to educate patients in terms of what we do. Just because they're more active in terms of maybe legislature doesn't mean, again, that they're always successful. Again, we do our best, again, not just from the academy side, but also from the medical state society side to sort of be on top of it and try to prevent such legislation either to be introduced or to combat it. Again, usually, it's like, unfortunately, maybe to the last second or the last week or so. But generally, we get support. But I would say, in terms of recommendations, I would say, first, try to get involved in your local state society. Maybe also try to speak to your local congressional member and develop a relationship with them. In the newsletter that just came out, there is some advice regarding what to do on off-season. At the same time, though, again, while we're trying to combat scope creep, which, again, is a perennial issue, at the same time, I feel like if we have discussion with these other groups, I think it would help to clarify what's possible. Because again, I just feel like at one sense, we want to prevent inappropriate services from people that don't undergo the same amount of time, training, and money, but at the same time, we work with them as well. So again, it's a larger discussion. But I think those are small baby steps that you can do. So unfortunately, I must admit, I'm a bit ignorant to the idea of being part of these advocacy groups and things like that. And the reason for that is I'm in a busy practice. I can't take time to do all these things. What do you guys do? Because I'm assuming this is all volunteer. Is that correct? Correct. And I think that that's a big problem. When you look at organizations who are very strong nonprofit organizations, they run like a business. People are paid to do advocacy and things like that. Are we making changes so that you can get more people involved and motivate them to get involved? Because if it's strictly on a volunteer basis, I think that that's going to be a challenge always to motivate people to take the time to advocate. We obviously need it. And again, I don't know otherwise, but I'm assuming that if we just continue this volunteer process, I just don't know that the level of effort might be where we want it to be. Because I think many of us want to help, want to support, want to advocate, but it's very difficult if there's not some internal motivation to get away from practice and substitute and go to advocacy. So just a thought. Your point is well taken. I think, and I'll just speak personally now, I think the Academy's actually done a fantastic job over the last few years to make it easier for busy practitioners to advocate in different ways. You don't necessarily need to be in our committee or be at the Hill or go to your local congressional district representative to advocate. Even just filling out one of the voter voice campaigns is very impactful. I mean, when we did our last voter voice campaign for Medicare reimbursement issues, we got several hundred, if not more than 1,000 responses. So I do think the Academy's done these sort of steps to make it easier for individuals like yourself who are very busy. One thing also on our committees, it's not just academicians such as myself on these committees. There are private practitioners. We have individuals from different types of settings, even some who work in the health insurance sector that are on our committee in the past. So there's different levels of advocacy. And I totally appreciate that it's not for everyone to have the amount of time to dedicate to it. But I think they've tried to make it easier. It would be great if I was paid to do all of this, but it's not possible right now. So is there consideration to pay someone to advocate? Like, we're just voicing these things and then have somebody paid to actually employ that? OK, so. Peter is paid. So I'm paid. Well, good. Hopefully, we're supporting you well. The Academy does have, oh, here's Melanie. The Academy does have a paid staff and devoted individuals who know these issues well, working hand-in-glove with Washington-based firm Powers, through me, essentially, and my team. And that's morphed over the last 30 years in different ways. But there's always been a consistent Washington presence that the Academy has had throughout the decades. Melanie? I was just going to add, yeah, we definitely have an Academy staff paid team. And I wanted to tell you that you are advocating if you are paying your dues. That is so much support to us. And not all physiatrists are members of this organization. So that is a huge support. Anything else you do is also icing on the cake. But that's huge. Go ahead. We have limited dollars. What about industry? Who has bigger dollars? Melanie, do you want to speak to that? We absolutely partner with industry. We do. We partner with them on some of these reimbursement issues and things like that, if that's what you mean. But you're right. We could continue being creative on that, for sure. And just to step in here, so of course, we need every physiatrist to be a member of the Academy. We need every one of those voices. It's not just about the money. It's about the power and the collective voice. But in terms of money, I think physicians are one of the only specialties where we don't always, we're not, we volunteer a lot of our time. We give a lot of ourselves to other people. And what we don't understand, like for instance, the lawyers do, is that when you are in Washington, when you are in your state house, there is a degree of politics that money speaks in terms of getting resources and lobbying power. So there are PACs out there, like AmPAC and all the state PACs and different specialty PACs. And so those are other ways to contribute. And I just think that we as physicians, we don't always consider the impact and the value that those individual contributions can really be very helpful in terms of making sure that we have the resources there in DC and other spaces. So just in addition to being a member of the academy, making sure all of your colleagues are members of the academy, because without their voices, we are not as strong as we could be. May I also say that I'm not aware of any association, any association that pays its volunteers, the people who advocate from the field that they're in. I'm not aware of any organization that does that. Just for the record. Thank you for the question. Thank you for the presentations, they were excellent. And I think the other point that we shouldn't miss is that we don't do this alone. This is not only about the physicians. There are many other organizations that collaborate with this, advocating for research, advocating for access into rehabilitation, AMRPA, along with the academy have done an incredible job. There is a lot of collaborative work going on. But I couldn't disagree. Funding PACS and doing other ways of putting our word out there is important. Yes. Hi there, first, thank you for giving this talk. I find it really interesting. I'm actually a medical student at Georgetown. I'm part of the Health Justice Scholars. And as part of that, we actually have, me and a team of two other medical students, we are meeting with the staff of senators from our states, Tennessee and Massachusetts, to advocate for medical-legal partnerships. And these meetings are gonna take place right after Thanksgiving. So I wanted to ask you guys if you had advice for how we should be approaching these meetings. There's quite a wide range of how they feel about how much money or time should be invested in healthcare, particularly considering in Tennessee, it's quite conservative. And one of their websites, I remember, specifically said, I support lowering spending on healthcare. So I just wanted to ask for general advice that you might have. If I may, you've got two very different states. You're walking into two very different political situations there. So I'm not sure one recipe is gonna do the trick. I would be as, in Massachusetts, I talk about healthcare equity. I talk about patient access to care. I talk about all the kinds of things that Democrats tend to want to hear. And I don't think you're gonna get much pushback about spending less on healthcare from Massachusetts. You will in Tennessee. And so that's a question of maybe talking about getting the most value for what we're spending in healthcare that you, I mean, even those offices will appreciate the fact that the Medicare fee schedule is scheduled for a cut in 2024, and every single other healthcare provider group is scheduled for an increase. That they'll understand is there's something wrong with that picture. But they understand healthcare well. They're not on the same page politically, but I would tailor the message most definitely. And then also make sure that you're very specific about what you're asking for. It's not an opportunity to complain. It's an opportunity to express where the problems are and what you'd like them to do. So be as specific as you can about your request. Happy to talk offline as well if you'd like to. Yeah, thank you so much. Just to add on a state side. I mean, that's super exciting for medical students aspect, and I'm pumped that you guys are involved with the process. I would say it's just what Peter mentioned. Research the congressional members that you're meeting with. Again, it's an opportunity. You only have about 10 to 15 minutes to essentially pitch, to educate and inform, and at least open a dialogue, even though they may, you anticipate that they will be resistance or may not disagree with the viewpoints that you present. And again, you may not be with a congressional member. They're healthcare staffers. So again, just starting that discussion, I think is a starting point, especially with a state that you feel, or congressional members, you may not, they may not be as supportive. But I would say, I would also look at the background and the legislators that you're meeting with. So again, money's not always everything. It does help, but if you have a coalition with your local state society, that'd be fantastic. And again, if you don't, we can help with that. Kudos to you for the advocacy work already. That's fantastic. Well, thank you so much. All right, I think it's a zero on the clock there. So I think we're out of the session. Thank you all so much for attending. Thank you to our panelists. And please reach out to us if you have any questions regarding advocacy or getting involved in advocacy at the academy. Thank you.

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