So welcome, everyone. We're really pleased to be here for a live face-to-face discussion with you all, aspiring and perhaps active medical directors. Today, we're going to concentrate on primarily three areas. We're gonna discuss peer-to-peer reviews, and Kathy and I and the whole team is open for discussion in the amount of time we have for that. I have Dr. Kathy Bell, Dr. Greg Worsowitz, Dr. David Steinberg, my esteemed colleagues with a lot of experience in all aspects of medical directorship and in PM&R. So today, we're gonna talk about peer-to-peers. We're also gonna talk about how everyone is coping and dealing with staffing shortages. And then we're gonna talk about how managed Medicare is affecting reimbursements to inpatient rehab facilities. This is a hot topic. Unfortunately, it's an important topic. It got a lot of publicity in recent months for some difficult things that took place in regard to managed care companies and a relatively brisk public and physician response to criticisms. So let me give me some basic definitions. I'm a frontline medical director, so these are the things that I live and breathe with every day. So I'm just gonna briefly go over the things that I think I want you to have some takeaways. Peer-to-peers are really difficult. What it is is basically an insurance company does not let a patient come into IRF. They're usually managed Medicare or private commercial insurances. So what they do is they require a physician-to-physician conversation. It's usually one of their regional medical directors of the health insurance company. And there are various ones. There's Aetna, UnitedHealthcare, Cigna, a number of them that you can be talking with the medical director. You schedule a call. You have information about the patient. Either they're in the hospital that you're working in, such as in acute care, or you are the medical director of an inpatient rehab, which happens to be my position. And you are discussing with the medical officer of the company why they need inpatient rehab. So I will tell you, I work for a company that does these in all regions of the country in 30 states. And it's the same issues. It's basically the same issues. The peer-to-peer has already denied that the patient is a candidate for inpatient rehab, and you have to convince them otherwise. They have their paperwork. You have your information from your consult, or sometimes there's a nurse liaison involved that gives the history and the current condition of the patient, both medically and in rehab. So how they usually go, I will give you the setup. The experiences and the specialties of the medical directors and the managed care companies are all vastly different. Their temperaments are vastly different. What they hear and how they hear it and what they consider actually should be standardized, but it's not. It's a bit different. They want to know the medical reason they need to be in rehab, and they want to know basically the rehab reason they need to be there. So there's a couple of things I wanted to emphasize with that, because I've done probably 300 or 400 over the course of my medical directorship. So some pointers, and I'm going to be as concise and brief as I can, and Kathy, forgive me if I'm overgoing the information, but I thought we needed to set everyone up for at least a baseline understanding. So number one, no matter what happens on that phone, if it's your first peer-to-peer or your 400th peer-to-peer, always be professional, because you're going to hear things from different medical directors that may or may not make any sense to you at all, and it doesn't do you any good to be confrontational. So I'll say that consistently. Be pleasant, be nice, be helpful. That's all your job is, to get the patient in. Well, at least that's part one of your job. Part two of your job is you need to have information on the patient, and the information that you need to have, no matter what setting you're in, no matter if you're at the acute care setting or if you're at the inpatient rehab setting and you're on the phone with the medical director of the insurance company, you need to have, the key is you need to have more information than they do. So what I've derived over time is that my staff knows I need the clinical hospitalist notes and the therapy notes from that day. And I try to call as late in the day as they will let me at the insurance company side. Because a lot of times they don't have that day's or even the previous day's information. That is your key. You have more information than they do. So the question to ask is to the medical directors, we're here doing this, as the physiatrist, you ask what information do you need or what information would help you that you don't already have? It's an open-ended question. So they start the conversation and it could go in a number of different ways. We don't think there's enough medical necessity. We don't think there's enough rehab necessity. We don't think there's enough of both. So, and then it kind of gets broken down. Sometimes it's just a matter of, they don't have the medical necessity. A lot of that comes from the timeliness of the notes you have. It could come down to, oh, Dr. Lupinacci, if you could just tell me the patient has the lumbar, like a myelopathy, I can pull the lever on the neurologic. So I need to have enough notes to see if the neurologist or somebody has that word in their notes. It could be that simple. It's not always that simple, but it could be that simple. Number two, oh, Dr. Cigna, medical director, do you know that they continue to be on IV Lasix? They have a history of acute on chronic heart failure and it's still being actively treated. They have not transitioned him or her to oral Lasix. And he's only walking five feet and he has advanced cardiac disease and he's been unmonitored in therapy, no telemetry. You have to find an end of why we're better than them. And it also may be educating them what a skilled nursing facility does versus what we do as far as intensity of therapies and our medical capabilities. So, the interesting thing is, it's the details that matter. Some of the medical directors will have a very professional conversation with you and they will want to learn two things. One, when I said, just be professional because it's not only for you on that call, but whatever their previous experiences with the PM and our doc is gonna stick with them. And obviously we want, regardless of what the outcome of that was, that they had a good experience in a conversational manner, should they wish to have a rational conversation, they don't all wanna do that. And number two, I think that they wanna hear that you are a good physician. They wanna hear that you understand the medical issues the patient's going through. You understand the rehab issues. You understand how they're combined and how the combined picture is important to that patient's safe rehabilitation. So, I kind of scrunched all that because that has been my experience and what I have come down to as far as to what I do is protocols. We were speaking with Dr. Warsiewicz and we decided it's really time for us to have some protocols that can perhaps help the academy members understand that there are better ways to do things and not so better ways to do things. It doesn't always work, but from experience, I think we can kind of make it easier for people in training or new medical directors or new physiatrists as staff who are doing pre-screens. So in any event, that was kind of the capsule. The interesting thing, I just wanna end this conversation, my little discussion here is that, so in 1998, you've all heard of Forbes Fortune 500 companies. In 1998, the top 10 companies, none of them were healthcare related. In 2024, of the top 10 Fortune 500 companies, which are, again, the most profitable companies in the country, four out of 10 of them were healthcare insurance companies. So that's, I think we all get a little bit concerned when the company is making that money on at least partially denial of services of patients that probably need, certainly in the IRF realm, inpatient rehabilitation rather than a SNF. So anyways, Kathy, I'm gonna let you- So Mike, you're saying you don't like make a TikTok about your experience with the pre-authorization and get it out there? It seems like that's very effective. We could, Greg, and let's make a note. I think that's, yeah, right, exactly. I don't know. Those of you who are on social media have seen the surgeon that was called out of surgery to answer a pre-authorization, her multiple pre-authorization things. And so it made quite a racket on TikTok. I'm not sure what the end result of that whole thing was, but it was kind of easy, interesting to look at. And of course, our speaker from the most recent AAPMNR annual meeting has certainly done a lot of social media work on whole pre-authorization things in a humorous way, perhaps. But one of the things I'll just mention that you talked about that is really, really important to get the team on board at your acute centers because what happens in the therapy notes can blast a hole right through any plan you have. So it's incredibly important to make sure that whatever acute care hospitals you are receiving potential referrals from, that you have a really kind of strong plan with them and maybe templates and maybe on how this, how physical and occupational therapists talk in their notes in terms of what their recommendations are, because it only takes one junior physical therapist to write something in their note that just will just bomb your whole, everybody's plan for rehabilitation. So it's very important to set those up, set up expectations, set up templates, have a lot of communication about how things are going because that is so key. It kind of, in some ways it doesn't matter if somebody does that and you've got a doc you're talking to an insurance medical director you're talking to who simply just sees that and that's it. I mean, and sometimes that can make the decision. So Mike, do you have a system that you have that works well? Well, you know, the acute care hospitals that we work with all have their own rehab units. And so they've been less than excited about working with us even though we capture all those patients because we're the best. So, but I think it's a great idea if you can get people to work together, especially if you're in the same system. Like I know Greg's very heavily oriented in the acute care concept. So if you can get people to work together in the acute care consult service, I mean, that's the key as well to have actually physicians there. Greg, do you wanna say anything to that? Yeah, I had a couple of notes just from both of what, just to give a little background. I've been medical director for 20 years of an acute rehab and now I kind of switched careers altogether and I work as a consultant in acute clinic in Florida. And I do just acute care consults. And part of my job is this, I do all the peer-to-peers of anyone that I have seen personally. The rule is worse, which does those peer-to-peers. And two things on it. One, you both made great points. My pleasant, nice, helpful. The problem is I've never seen Dr. Lupinacci sweat and I can't sit still. So I have trouble with that at times and it's never served me any benefit when I've gotten a little, one time have I gotten one reverse when I got a little antsy. Second is you got to have your acute care team on board with their documentation. We have a rule. If anybody is contact guard ambulation and the therapist puts IRF in their rec, they have to write an explanation. Why are they cognitively impaired? Do they have visual issues? Are they unsteady? And we never used to do that until I came in and we have to, I think that'll be a big role for us in the acute hospitals, especially as we talk about the penetration of managed care. So, and you got to remember, they, you know more about that patient. Everyone I do a peer-to-peer on, I've touched, talked and walked and you have to have a plan. One is they're gonna call you any time of the day. I'm in the middle of rounds or I may not. I always ask them, like Mike said, can I call you back? I'm in with a patient or I'm in a meeting and they'll say, okay, call me back in 10 minutes. And that way I'm at the computer. I have their records in front of me and I can talk to it. Number two, Mike, you said, get that day. I'll call my therapist. I've had peer-to-peers where they said, well, if they can walk three steps unassisted, they can come in. I'll call my therapist, say, you can make that person walk three steps unassisted. Not make it, you never forge, you never fake information, but you get them to do it on things you can do. And remember, they may have notes from a week ago. Don't get worried. They're gonna say, this is a recorded line. So what, record. I wanna record mine, send me the recording. But I always ask the physician's name, his or her spelling, so I can spell it, so I can put it in the medical record. And I tell them that. And that what specialty they are in, because we're supposed to be doing peers of same specialty type. So think that way. Mike, have your medical, your functional issues intact. We often say, hey, think about their social. Insurance company doesn't care about the social situation. It's just a straight medical and functional. A couple, three things. Remember, they need to be seen by a PM&R doc. No, sorry, a rehabilitation physician three times a week. And they'll say, they don't need that. I say, well, they have medical issues. Like Dr. Lupinacci said, you gotta have something medically that's being managed. And then, or I've even been on a peer-to-peer and say, and you can ask open-ended questions. Say, what is a PM&R doc? And what does she or he do? And they'll often say, oh, that's a PM&R doc, like managing spasticity. And I say, I'm sorry, CMS defines a rehab doc as whatever the facility says is a rehab doc. And we take care of medical issues, such as blood sugars, or if they're having problems making, not making the progress they need to make. I have that specialty that I can decide on that and move forward. But I think you're right. I go in mine, there's a simple, I know the doc just wants to talk to me and they're approving it. To a 50-50, where I think I actually made a difference. And don't get beat yourself up. There are some that are just no way. They're not gonna approve it. My last one got denied because the individual said they can't tolerate three hours of therapy a day. First of all, they had gotten PTOT and speech that day. And you don't have to do three hours a day. You can do 15 hours in a week for those patients who can progress and go. So know the rules, know the things. I make a point. If you see the patient in consult in the acute hospital, I'll even say, I saw the patient. I have no affiliation with where they're going. I'm just trying to get the right care for this patient. And I think Mike is right on. I'd love to, I know every doc on this call has had different reasons why they're denied. And if we have ways where we're prepared for that, we can at least make the best argument. We're not gonna win them all. I can just tell you, because look at your, like you said, your fortune 500. But we got to put up our best chance as possible because, and remember, educate, educate, educate. Peer-to-peers are maybe happening by a hospital internal medicine doc for rehab, a nurse practitioner, a resident, or an intern. Based on where you are, your value is. In time, these peer-to-peers may cut the funnel off to your rehab hospital, and we won't be able to serve the people we need. I'm gonna end there, but lots more I could add on. But Mike, you and I have talked about this. And I think it's a passion, almost keeping a, wow, it'd be great if we had a registry of all the reasons people were denied and the most common by what company. And we're trying to do that at my center is by which company denied us. I recently had one, and so you got to know this. Most insurance companies now are outsourcing their post-acute care reviews. So we may have a great relationship with company X, but they've outsourced their post-acute to one of these providers. There's one in Nashville, Tennessee, there's others. And they are real, they're working for that entity, not the main healthcare. And we're starting to have some talks at our contracting level with our acute hospital. Again, know the playing field you're in and what you're doing. Everybody's a little different, but I steal from all of you, so thanks. If I can just say one more thing, and then Mike, you can go with whatever. I have rarely done this, but there have been occasions where things have been so egregious that I have had the patient's family contact the state insurance commissioner or state ombudsman to actually get the family and politics involved. So if you reach a point where it's that egregious, young person with spinal cord injury, brain injury, I don't know, something egregious that I certainly have done that rarely, but have done that. So just want to add that in there. Our advocacy group with the academy has form letters and that you can give the patients now, I just learned this. So after you do a peer-to-peer, family can do a review, but if you feel egregious, which I did in this case, you can give it to the family. Because I'll tell the family, I tried, I talked with them, I touched them. I don't think this is right. Here's our congressman or here's our whatever, and here's a letter that you could send in a format. So that's provided through the academy if anybody ever gets to that. And a couple of last points as we close, we're getting near the time to close this part. I always ask the family to do an appeal with a denial, always. They just need to have a face and a voice in this whole thing. And I just think that, yeah, it doesn't always work, but it's definitely shows the family that you tried and they should try because they do have, they can have a voice in the final decision. So I think- Great, I was gonna just add, Mike, if it's okay. So I've been a medical director since 19, excuse me, 2001. So I think on this call amongst the four of us, we probably have over 100, maybe 120 years of experience in medical directorship. I'm now an executive medical director, which means I can delegate a lot of these peer to peers to others, but then I get the most challenging ones at the University of Utah. The only thing I would add, you heard in Dr. Warsiewicz the comment that these calls can come at all times. There are opportunities that you will have to schedule them where they'll kind of reach out and wanna schedule one, but not always. Sometimes it will come kind of sporadically. I would always caution you to take the call when you are prepared, which means right before you make the call, do your breathing, kind of get centered, get your thoughts properly, get your materials correct, just like Greg talked about. Hear yourself in a positive frame of mind, remind yourself you're the expert and always maintain that sense of curiosity. Like Greg said, ask them, get them to kind of have a dialogue. The more you can talk to them and let them know that you're an expert, knowledgeable, but you're also reasonable and that you've kind of like done your own due diligence to think through and kind of put yourself in their shoes, you'll have a much more. Oops, we may have lost David. That way. All right. All right. Well, we're gonna give you an opportunity to get back on and I'm sure he'll try to do that if he knows that he's not on. Let's see. Well, I hope that was a good introduction for peer-to-peers for you all. I think it's going to be an increasingly important part of your job and there's going to be more and more of them as you enter your career paths and fields over time. It's inevitable that that's going to happen. Let's see. Why don't we go ahead and move on? We can all participate in the next topic, which has to do with how we're managing staffing shortages, which we're all facing, and Kathy, did you want to introduce that? Because I know you've certainly had a lot of experience with managing through that. It gives me chills to think back. I mean, honestly, full disclosure right now, I am not acting as a medical director right now. We get to certain of these topics and it actually makes my hair stand up on end. I think that there are various levels of staffing shortages we can talk about, and I think at one level we have physicians, physiatrists, because I do think that there continues to be somewhat of a dearth of physiatrists who are available for interest in inpatient rehabilitation. And the other one is, of course, the rest of the staff shortages and what you can do about that as a medical director. So I think that there's a lot of different levels to think about this. You know, I think one thing I will certainly talk about with reference to nursing and therapy staff is that, you know, one of the more successful things that I have seen done is to make sure that for all of these folks, there is a path forward in their career at your institution so that if someone joins you as a nurse or a therapist, that there is a pathway for them to continue to expand their skills, expand their leadership if they so desire, expand whatever. I think that's pretty crucial to have something that looks, you know, a developmental path for people as opposed to, you know, just clocking in, clocking out. I think that's very important, especially for young people who are just starting out to make sure that they're going to get that mentorship and development. So I think that's certainly one of the things I think about. I think that's one of the things I think about with young physiatrists as well is working with that. And of course, the third thing is, you know, how do you utilize other categories of practitioners such as nurse practitioners or physician assistants to work with your physiatrists? And so how do you make sure your physiatrists know how to work with NPs and PAs and how do you make sure your PAs and NPs know how to work with physiatrists? And how do you make sure that your NPs and PAs understand how to work with therapists and nurses? It's very complicated. It's really complicated. When we first started doing this, I thought, oh, this isn't, this is a solution. This is great. Yeah. It was steep hill of education for everybody on who everybody was, how you interacted, you know, PAs and nurse practitioners have no clue what to do with therapists, unless you, you know, happen to get somebody who's had some unusual experience. They simply have no clue. It has to be so your curriculum and your work with them has to be included so that they understand, you know, what the whole team is and what people do and how they do it. They don't know that. So I would say that it's, it's, it's a possible solution and it's also a potential problem if you're not aware of the social issues that are going to come up as you start bringing other people in. David? Thanks. And I apologize, I might get booted off periodically, if so, I'll switch over to my phone. Yeah. We've dealt with this front and center. We opened, launched a new rehab hospital and right in the midst of the pandemic in 2020 and you know, expanded our beds and very quickly ran into challenges related to the pandemic. And then that continued. And I think many institutions did when we had major, major challenges and every institution in this country experienced nursing shortages. The impact of that in terms of morale, continuity, you know, lack of relationships and kind of like knowledge. But also the cost to the organization in terms of the budget is unbelievable because the cost of using contract labor is dramatically higher than having regular staff who are employed and have, you know, regular salary benefits. And then unwinding that, what has been a major challenge for every organization where the main organization had to go back and do market assessments for how to raise compensation. And every, especially out in Utah, you know, the competition is fierce for nursing. Not so much on the therapy side. You know, when we post a position for therapists, we often will get 20, 25 applicants, feel like we have our pick of the best, but nursing staff is few and far between. It has taken us a long, long time. The key for that is maintaining retention. And that's true in any workforce that you'll encounter. Not only, you know, in your nursing staff, therapy staff, social work, case management, but physicians as well, is creating a culture that is fantastic. Not just okay, not, you know, average. You want to set the bar high. You chose physiatry because you are a collaborative person. You are easy to get along with. You're a great communicator. You value and respect colleagues from other disciplines. You set the tone for your organization as the medical director. You must be a positive leader who creates a place, leading by example, that others want to come there and work there. There's lots, there will be turnover, right? Because you're not in control of everything. But what we have found is that when people do leave, and sometimes it's because of compensation, at first they think the grass is greener, and then they recognize what they left behind, which is a great place to work, is much more than just the amount, the dollar per hour that you're getting. And most people, I think you have probably heard this, that many times, almost always, people leave an organization because of their boss or because of a toxic culture. So dealing with staff shortages must start with creating a place to work that is nurturing and a great environment. And it starts with your own attitude. The people that you hire and attract around you as the medical director make a big, big difference because you can't be everywhere and all places, but you can coach others to be great leaders. And I know, Mike, you coach probably a huge team across your organization, and you set the tone. And I can tell that that's also true for Greg and Kathy, you know, very positive leaders that help to raise that bar, empowering your staff, having open communication, leading by example, and really have a very clear, intentional plan for retention and recruitment. And I'll talk about the importance of retention because replacing people is difficult. You know, every doctor that gets replaced is a cost to the organization, anywhere from $500,000 to 1.5 million. It is much better to work on hiring the right people and then retaining them. So that's really critical. We went through so many trials and tribulations with low staffing levels and difficulty. We had to cap our census. Even though we had a beautiful new hospital with 75 beds, we could only staff up to 50 because we had shortages and very difficult to find that nursing staff. And then guess what? Just like Greg and other places, we're part of a big system. So our HR department and our recruiters weren't putting rehab at the top of the list. They were, you know, trying to fill nursing positions in the ICU and the cancer hospital. And right in the midst of us trying to expand units, they opened up a new unit in the cancer hospital. That became their first priority. So you've got to recognize what's in your control, what you can manage, and be an advocate because you can do a lot by getting the word out and creating an organization where people want to come to work and stay and thrive. And I think that's really the bottom line answer for what to do. Now, I can't tell you that you can, you know, treat complex patients with fewer staff. You can't do it. So you've got to put quality and safety number one. And if that means, you know, reducing your capacity because you don't have the right staff to do it, you have to protect that. The leaders in a hospital, though, may not see that necessarily. They may say, great, we've got more capacity, you know, push more patients into your unit. So as the medical director, it is your responsibility to protect the quality and safety of the services that you're providing, which means that sometimes you need to get up in the grill of the hospital administrators and explain to them that you need to limit the number of beds that are open until you can ensure good quality care. I've run into that several times. And many times it's not the nursing staff. I've had problems with difficulty hiring and retaining speech therapists. And you're bringing patients in with aphasia and they don't get the end. Your therapy director says, you know, I don't have enough staff to give them adequate speech therapy. You know, that's not a great experience for patients. And you shouldn't continue to bring patients into an environment where they're not going to get great care with enough therapy to get good outcomes. So those are a few of my pearls that I'd want to share. And I'm sure others have much to share in this same area. So Kathy, what are your thoughts? Is there anything you'd like to add to what I discussed? No, I think that's very, it's interesting how things come in waves. We were, I think, you know, in Dallas, we were, we were struggling a lot more with therapists than we were with nurses for some reason. I think our institution did a phenomenal job with, they just went to town with nursing and they decided they were going to be like the number one place for nurses to go. And so they put a huge amount of effort into mentoring nurses and developing pathways for nurses and all sorts of that. I mean, it was a big, big deal. They were, you know, a magnet place and all that sort of thing. So you know, we could attract nurses. Now keeping them as another story, therapists, therapists is another story entirely. And you know, that is hard to substitute. You can float a nurse who can do some things, even if they're not extremely changed. You can't invent a speech pathologist from, you just can't. So that's a real, a real issue. And again, I think that we tend to focus more on nursing often and not, the hospitals, the institutions will tend to focus on nursing and not focus on the other things because they tend to be a little kind of off. Every institution has their own way of how they manage therapists. And they may be, they may be directly under you as a medical director. I did not have direct control of the therapist. They were actually under nursing, which was interesting. And it was, but it was hard to get nursing's attention, you know, for the therapist. And I ended up having to, you know, be on a bully pulpit often to try to, you know, get the institution to look at therapy because it was, it was, it was not seen. I think that we had to do a lot of work with early mobilization, ICU work with therapy, you know, acute care work before they really understood therapy. If it was just with the IRF, I'm not sure that they would have gotten the importance of therapists. I think once we were really able to bring that into more of the acute care settings, people started to see, you know, how therapists really affected through flow and care of patients and, you know, the 30 day readmissions and all that sort of thing. So, yeah. Greg or Mike? A couple of, you made some really great points, which really are issues at every rehab facility all over the country. And so, just very briefly, I would, I estimate that over the next, that each year for the next few years, there are going to be anywhere between 50, I'm sorry, 15 and 25 new IRFs. Whether they're going to be joint ventures with hospitals, hospitals opening their own IRFs, hospital systems that are doing joint ventures or freestanding IRFs. So, if you think about that nationwide, we're having trouble with staffing with what we have now in positions nationwide, whether it's physician or therapists or nursing, I agree with David and Kathy, it's all that. Now, the other trend is that those hospitals are moving into communities that have grown in population, but they haven't grown in sophistication of PM&R services in any of those staffing areas that we talked about. So, my point that I'm trying to make is wherever you go, and I know we all have this experience in our facilities, there's going to be a turnover of staffing all the time. There's going to be a turnover of nursing staffing all the time. You can try to keep the people, but people move. There's so much opportunity everywhere for them. And the thing of this, in your system, as you work with your administrators and administrative, your CEOs in the hospitals or your team, your administrative team, you have to have systems that continually up the skills of all the staff levels continuously. You have to have programs to educate everyone and systems to educate everyone because there are going to be new people rolling in. You've got to maintain a certain level of quality and expertise. That's our hardest job for all of us. But I see that on the fact that there's going to be growth and there's going to be more shortages because there's going to be an aging population that need more rehab beds. And so, to me, it's kind of, I know here, we have the discussion every week. Like, where are services? How are they? How do we develop them? How do we develop the new staff? Because they're learning new skills every day because you have new staff all the time. So, that's my two cents to add for the great things that David and Kathy reviewed. Thanks. I would actually just emphasize something you were talking about there, which is there will be new staff all the time, which implies, number one, being involved in that process, working with the managers of the unit and the leaders in the hospital to have a say in the types of recruitment efforts that are going on and as well in the onboarding processes. So, being engaged in that, to show up as a medical director and meet the new people and develop relationships with that and make sure they get the right orientation and onboarding is critically important. There's a direct connection to onboarding and retention. So, being involved in that. As a medical director, you're demonstrating your willingness to wade into some challenging environments because there's not a lot of joy sometimes in the types of work that we're doing. But I think engagement is one of the responsibilities of the medical director, is being really a partner with the hospital management leadership, like you're talking about, but also your colleagues, those who are leading the nurses. See yourselves as a cohesive team. I always talk about triad leadership in rehab. It's the physicians, nursing, and therapists. The three of you together are putting your heads together, and they're just as important as the medical director. If you come into this equation thinking that you are better than them and that you are going to kind of overrule them, and they're experts in their field. Make sure you know that you demonstrate your respect for those leaders in nursing and therapies, and see yourselves as part of a leadership team. So, I think that's really important to emphasize with the onboarding piece. And then being available. I go to orientations. I'm present. I walk the floors. And there's another piece of this equation that's a critical role for the medical director, which is supporting and developing the medical staff. And you cannot ever tolerate unprofessional behavior with your physician colleagues. There's nothing more damaging to a culture that is going to drive people crazy, and it's going to demonstrate your ineffectiveness as a leader if you don't recognize unprofessional behavior and address it quickly, which doesn't necessarily mean you've got to be a disciplinarian, but you do have to be willing to engage in those difficult conversations with your colleagues, sometimes more senior colleagues. And that can be very tricky and very difficult. And that, but that's all part of staff retention. You know, I do, I do worry that a lot of people who go into medical directorship positions fairly early in their career miss a lot of what, you know, being a medical director isn't just signing things off and signing protocols and stuff like that. It's really getting in there and building things. And I think it's hard. And that's why one of the things that I think drove us to try to put something like this together, because it's not an easy job and it's complex. It's a little exhausting. It's wonderful. I mean, when you have a place like, you know, David and Mike or Greg, you know, it's a wonderful thing to sit back and say, my God, look at how this place is going. But it's not for the faint of heart, I think. You know, so I think, David, you really spoke well to that. Thanks, Kathy. Words of wisdom there. Yeah, but it's fun. Hell, yes. Yeah, it's a great thing. No, that's why it's a challenge, but it's good. The only thing I'll add is, yeah, the only control over staffing you have is as the physicians, you admit the patients. And unfortunately, when COVID, we had such a shortage of nursing. We had to cap our admissions. Now, you never want to pull out the nuclear bomb and not do it. I was in communication with our CEO and the others, but that's a last resort. But that was very unusual circumstances. So, again, I think it goes back to David's talk on the very first time we all met. Know your formal structure and your informal structure before making any quick moves. Because I've never met a doctor who didn't need another doctor. I never met a nurse who didn't need another nurse on the floor. Never met a therapist who didn't need another therapist. So, David, your triad is very important to get feedback from all angles. You know, I think, and on that point as well, I think it's really important for those of you who are aspiring to be medical directors, because if your early career, really, if your early career, you need to identify mentors. Because there are going to be things that come up and you're going to question your judgment on things because you just don't quite yet have that experience level. So, identify mentors, people that can help you, can run things by really quickly. And that's part of the reason that I love my job, because I mentor a lot of doctors that are in situations that, you know, for the four of us, we can think pretty clearly on, but it's new to them. It's a new paradigm. So, I think your point about the maturation and the experience level, Cathy, is important just to recognize that as you get into the medical director role. But I agree with the rest of everybody on the conversation. It's a great thing if you can get all these factors aligned more days than not. It's a great thing that you accomplish for your community in PM&R care. So, we're going to end that up on an uplifting note. So, then we have next on Medicare Advantage programs and SNF funding for you, Greg, to launch a bit. Greg, I'm sorry, I got unmuted. I had trouble going muting. But based in, I know our time is running short here. So I had a just a couple quick facts I want to run by you and it kind of goes back to the future and things you need to be aware of as a medical director. And I pointed you to this, I'm sure everybody has gone to medpac.gov. If you have not medpac, M-E-D-P-A-C dot gov. And then under it go under research areas. And then under that, it'll have post-acute, our research area. And if you have never gone there, I use this as my basis for a lot of general information coming out. In December 2024, they looked at assessing payment adequacies, updating IRF services. And since we know what makes the world go round, and it's the green stuff, kind of gives you an idea of what's going on. Mike pointed to it, our very first conversation on why I'm worried about peer to peers, especially with Medicare Advantage and the penetration of Medicare Advantage. And then it has what the growth is. So right now there's about 12,000 IRFs in the country. It's about $9.6 billion of fee-for-service Medicare. That's fee-for-service Medicare. And if you look at it, fee-for-service Medicare, not Advantage, Medicare ENB, is 51% of all discharges from rehab hospitals. And think about that. That pie may be shrinking as Medicare Advantage is growing. So last year for Medicare fee-for-service, days went up 7%. So while it's still shrinking, those days are going up. So you can see who the hospitals are targeting. Occupancy was about 69 or 70%. This is across the board, may not be your center, may not be, but that's the average for Medicare and all. Hospital-based units last year from Medicare made up about 1% of the margin, where freestandings had a 24% margin. So think about it. We're seeing freestanding units pop up everywhere. Hospital-based units, oftentimes because of the way they spread overhead, their costs are really having trouble. Interesting, your freestanding units, and just so you know, it says there right on the report, 44% are owned by one company. And that one company the past year added 440 beds, kind of Mike's point. We're adding beds to this pool all the time. So that's the freestanding. And then they go on to say Medicare Advantage, if you look at it, about 60 million people are almost to where I am, and Mike's not quite there yet, that are Medicare eligible. But of the 60 million in 2024, 32 million, in other words, 40%, 54, over half the Medicare eligible people were signing up for Advantage plans. So let me think. We're adding beds. Medicare is one of the best payers, easy to get in, but less people are going into that. You can see the storm that may be coming that we need to get out in front of. So the Medicare Advantage, if you live in Alaska and the Dakotas, you're doing okay. If you live in Florida or Hawaii, it's taking over. And again, just go to the internet, type in Medicare Advantage and penetration, and you'll get state maps of where it is so you get an idea. Well, Greg, there's one other thing to consider, and that's that it's very likely that our next HHS director is a big fan of Medicare Advantage. So I think that we're going to see a continuing and bigger push, and there's a lot of lobbying that way, because there's a lot of money. Oh, yeah. Well, you think it's kind of what we've all talked about, the money and where it is, and you're making margins of 24%. That's a pretty good business proposition for the owners of the business, i.e., healthcare. And so I think you're right on target. I fear it as a person coming into Medicare, and that, wow, if now 60% are on Advantage, why does the government, i.e., Medicare A and B, want to try and run a health plan in this competitive, expensive business? So we just need to make sure we lobby appropriately. There's things going on. So MedPAC, which is who recommends to the, what they said was there's going to be plenty of access of rehab beds, 69% occupancy, and beds are growing. And the base rate to send hospitals, as we know, you get a base rate, and then based off our CMG and comorbidities, just how much we're paid for PPS should drop by 7%. Now, that would hurt margins, but then it saves money for the government. So, Mike, you wanted to give me a little outlay. I would recommend anybody go to MedPAC. There's a nice little slideshow, and it'll talk about SNFs, IRFs, home health, give you all the numbers you need and what you want to look at. And the picture it's painting is post-acute care has been very profitable. And if we think peer-to-peers are something that are going to go away, they're not. I expect we'll have a lot more. So, I'm going to just say, I think everybody needs to be hyper alert in the next three months because of what is happening with government databases and audits. I think that we are very likely to see kind of a breathtaking change, potentially, in the next couple of months in Medicare. As somebody who's on a traditional Medicare plan, I am. I am not certain I will be on a traditional Medicare plan six months from now because I think that it's, I have a feeling that, as you said, Greg, is the government going to run, you know, something if they can form it out to companies? And, yes, I'm with you, Kathy. As an individual, I worry because Medicare, I'm a few months away. But the bigger thing is, and I don't want to paint a doom and gloom on this, is just be aware of what's going on. So, how do we try and hear our voices? And the one good thing and the only good thing is when there's chaos is when there's the most opportunity. So, if we're not prepared and we're not intelligent and we don't take the time to advocate for our things, yes, then we're stuck with what we get. But I will encourage you, be aware of this. So, when you talk to your CEOs, when you talk to your systems, then when you make your arguments, bring a solution. Bring an educated solution or bring an educated thought pattern and the information's out there. It's very easy to access, but this is back when MedPAC came out as a book. I used to get it. Now, it's all right there and easy to look at. I'd encourage everybody, just take the time, gloss through. It will go over payment systems, all sorts of simple things. So, Mike, that was mine in a nutshell to say, look, I think Medicare A and B may get smaller and smaller. Who knows? It may even go away. Medicare Advantage is getting penetrated heavily in states, and that's when we first started most of our peer-to-peers where I do their Medicare Advantage programs. There are certain other payers, commercial payers that are very tough, which we keep track of. I can name names, but in your state, it might be different based on how it is. So, we're trying to take a graded, educated approach to it, but boy, then to your CEO of your rehab hospital, it's going to be important to get people in the hospital. So, we've got to make sure we pay attention of barriers that aren't allowing our patients to be served, and this could be one of them. So, we've got to come up with some solutions, but we'll do it. We're going to figure it. It's going to go. I hope you're right, Craig. We've got to make it happen. It's an opportunity to call to arms, be aware, educated, and figure where we can push on the pressure points. Well, I think this is a point where you really have to do your homework right now because, again, there's no question that things are going to get broken and have to be put back together again. It's going to happen in the next couple of months, and it's going to happen with Medicare. And so, just having watched the last three weeks, it's going to happen. So, I think that, again, you all have to be ready. You need to know what you're doing, and you need to be ready to deal with that. This includes, I will just add in this entire, we're getting a lot of pressure from Medicare Advantage programs to scrutinize. In some cases, they're criticized for ignoring the traditional Medicare criteria and coming up with arbitrary criteria or just write out just ignoring them. And I've had reviews that have happened where the reviewer says, just appeal it because I'm not going to say yes. Because they have numbers that they've got to turn in. They're being watched for how many they deny. So, they're denying cases that they know are going to be overturned on appeal. But I think the critical piece here is only admit patients that you can truly defend that they meet criteria. And there are systems that I'm aware of that put tremendous pressure to admit anyone. They just want to fill the beds. And the medical director's job is just to say yes and push them through, even though you're like, I don't know. This one's kind of iffy. It's on the margin. I've been told by administrators, and they brought in consultants many times in hospitals that I've worked, that the consultants can guarantee some financial benefits because they're going to open the floodgates. And that you've got leakage out of your system, and you're not admitting patients who can come to your rehab unit. And it's going to be great for the bottom line. And yes, some will get overturned on appeal, but you know what that means? It means the medical director is going to have to suffer through all of those appeals and get in front of administrative law judges and try to defend a case that you know in your heart maybe could have done just fine at home or in a sniff. So don't put your reputations on the line to admit patients who you don't truly believe belong in your unit for good, solid reasons, and they meet criteria. I think we've described to the group the challenge, right? Because you all here are the future of what direction you're going to take to support your patients. Because most patients in the age groups that we're seeing them with the level of complexity of medical issues they have, they cannot possibly advocate for themselves, the majority of them. And so you are their advocate, and sometimes you're their only advocate. And what we're describing here is the possibility that the safety net for the high complexity older generations that we're all going to be part of here as we pour into health systems, how are we going to have a safety net so the wrong decision isn't made at any point, at any juncture? And you really are the ethical leaders, you're the physician ethical leaders to make the right decision for that patient at that time. However, whatever direction it goes. And that's my two cents from the old man in the sea. Would you do it again, Mike, be a medical director? Oh, absolutely. There's no doubt. I mean, and I don't want people to get discouraged. I think we're sounding like a bunch of, no, this is, hey, these are things, and we've met all sorts of hurdles in our field different times, is to be aware, like all my partners said, just be educated, be aware and know what's going on. So when you make your decision, you're making, you know, database decisions and let the chips fall. And it's more fun. I've had, I wouldn't trade it for anything. But if you think about it, since we all started, look how much this specialty has grown. Yeah. Despite all our challenges, and there's no evidence that it's not going to continue to do that. No. Yeah. We'll adapt. We'll figure it. Yeah, exactly. Exactly. And the other comments or thoughts from the group, this was great. It's so fun to talk to your peers and hear different viewpoints and perspectives and getting all our experiences and present thoughts together. It's really, it's been, it's been great. It's been great to have our crowd here of the future. Go ahead, Greg, were you raising your hand? Yeah, real quick question. It's easy. We're compatriots. I'm wondering if, do we have a group of, and at times some of the, you and I have talked before, some of this is therapeutic, it's like a support group in a sense. But do we have, we see things different because we're, you know, more advanced in our careers. But do we have a group of young medical directors where they meet and kind of hash out, you know, what they're going through without old long in the tooth people? You know, we have the, the Academy has the inpatient rehab group, but I don't think, as a matter of fact, Craig DeTomaso is the chair of that. And I can ask them if they're contemplating any subgroups of that. I was just curious, sir, if this group, if this group had ideas, since there's a group of medical directors, how we can help each other. Yeah, I can see a really good section growing online. Well, think of all the positions that are going to be out there that are, will continue to be. It's a good thought. All right. Any other thoughts? And this was a great conversation. Thank you all for joining. Thanks for the audience as well. We have a number of things in the chat. We'll make sure we get those covered. There's a few things. We'll make sure we get those answered sufficiently. All right. Well, thanks, everyone. Thanks so much for everyone's time and attention. Thanks, team. Appreciate it. Bye bye.

medical directors

peer-to-peer reviews

staffing shortages

managed Medicare

inpatient rehabilitation facilities

insurance negotiation

workplace culture

Medicare Advantage

patient admissions

healthcare challenges