Welcome to the Academy's National Grand Rounds, Empowering Tomorrow, AAPMNR's Advocacy Initiatives and How You Can Get Involved. My name is Dr. Susan Hubble. I'm a member of the AAPMNR Board of Governors, chair of the Health Policy Practice and Advocacy Committee, and an AAPMNR delegate to the American Medical Association House of Delegates. I am joined this evening by two AAPMNR colleagues who will introduce themselves. We are excited to have you join us tonight. I will start off by introducing the basic tenets of advocacy and highlighting the Academy's advocacy priorities. Next slide. Let's talk about what advocacy is. At its core, advocacy is about supporting causes and helping individuals voice their thoughts and concerns. This can also include guiding people to find the information and resources they need. The concept of advocacy has its roots in Roman law, where an advocate would represent clients in court, emphasizing the importance of having someone to speak on your behalf. There are three main types of advocacy to consider. Self-advocacy, which involves individuals standing up for their own needs. Individual advocacy, when someone supports a specific person, and systems advocacy, which focuses on changing policies and structures to benefit larger groups. Each type plays an important role in ensuring that voices are heard and represented. Next slide. Let's go into the role of healthcare professionals in advocacy. Advocacy involves actions taken by these professionals to drive changes across various sectors, social, economic, educational, and political. The goal of this advocacy is to alleviate suffering and address the threats to human health and wellbeing that they encounter in their work. By leveraging our expertise, PM&R physicians can identify issues and push for meaningful changes that ultimately benefit our specialty and patients. Next slide. These are some of the key reasons to be an advocate. Challenge yourself to do something in addition to your clinical activities, be on the front lines of change, make a difference for your patients, residents, and field, follow your passion, understand upcoming issues for our field, and meet people from diverse backgrounds and interests with common goals. Next slide. This chart shows the America's most and least trusted professions. As you can see, medical doctors are at the top with 67%, and next to the top, excuse me, with nurses a little higher. By advocating, physicians can help create a healthier society and ensure that the voices of their patients and communities are heard. Physicians have the expertise to educate the public and our legislators, and we are seen as one of the most trusted professions. Next slide. Earlier this year, we asked the Academy members to rank our key advocacy priorities by answering the question, what is your top advocacy priority this year? It may not surprise you to see that members are highly concerned about scope of practice threats and payment cuts, as well as related concerns such as prior authorization burdens. Our committee used this feedback to confirm our top three priorities, which are listed in order on the slide. In a nutshell, we are focusing on the issues that keep members up at night. Next slide. Advocacy wins are not always the wins you'd think. It is not just about immediate results, it's about the cumulative impact of our efforts. Each message sent to policymakers, each relationship built with stakeholders is a part of a larger movement. Things take time, sometimes months or years, but that does not make our work any less valuable. I will provide a few examples of very recent Academy advocacy wins and some examples from the past few years. You will see that some wins meant we prevented a negative outcome, and that often is a focus of my HPPA committee as we work to protect our members. Next slide. For example, after about 10 years of advocacy by AAPMNR and its physician volunteers, the Medicare Payment Advisory Committee announced in its June 2024 report to Congress that it is halting its work on developing a recommendation for site neutral payment policies for care provided in the inpatient rehabilitation facility setting. This represents a major victory for both providers and patients in the IRF setting and comes after intense sustained advocacy from AAPMNR and other stakeholders. It was a long fought victory. Alongside our partners in the American Medical Association's Go for Practice Partnership, the Academy State Advocacy Committee responded to Washington, the state of Washington, where a bill was submitted there that would have allowed expansion of Neuropath's Go for Practice, even to allow prescriptions by them. We contacted our members in Washington and were able to get a result so that that bill never did not pass. Following intense advocacy from AAPMNR and countless partners in organized medicine, the Center for Medicare and Medicaid Service, CMS, released a rule that once implemented will require covered payers to establish electronic prior authorization systems, transmit prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests, provide a specific reason for denying prior authorization appeals and publicly report metrics for prior authorization. These are a few more examples of major advocacy wins in the past few years. For those of you who aren't familiar, the RUC is the Relative Value Update Committee, a multi-specialty panel that convenes several times a year to provide input on the values of procedures in the CPT book. We had not had a seat at that table until recently when we obtained that, which was very important for our specialty, and it's a permanent seat. The Academy led a large coalition of medical specialties and IRF stakeholders that supported a fight to prevent CMS from implementing a proposal to allow non-physician practitioners to replace qualified rehabilitation physicians in IRFs. Hopefully many of you have seen the Academy's call to action asking for a whole-of-government response to addressing the ongoing needs of patients suffering from long COVID. And after years of advocacy by AAPMNR and our patient coalition partners, CMS recognized power seat elevation as covered GME for Medicare patients. In this photo, HPNL committee member Dr. Shah is on Capitol Hill representing PMNR about this issue. Next slide. Legislators pay special attention to voices from inside their state and district, i.e. voters. PMNR physicians are crucial in enhancing the quality of life for our patients by sharing our insights and experiences, we can help policymakers understand how our work impacts not just individual lives, but also the broader community. If not you, then who? The only people who will speak up for physiatry are physiatrists. If we don't advocate for ourselves, who will? The only people who can effectively speak up for physiatry are physiatrists like us. As the saying goes, if you're not at the table, you're part of the menu. We must ensure our presence in these discussions. Next slide. Legislators pay special attention to, whoops, wrong one, sorry. Legislators want to hear your stories. They want to hear about patients that are affected by the legislation that we're advocating for. We can educate them. Most of them are not physicians, and they're certainly not physiatrists, and they don't know what they don't know. We can help them with that by educating them about our issues. And it's very important because if you're a voter in their district and you're going to vote for them, they do listen. All of the things that we do, like voter voice, are counted. The offices of our congressmen count up how many people send in an email or a message advocating for something and advocating against something, and they use those numbers to advise their legislators. Next slide. Now I'll turn it over to Dr. Antigone Argerio. Oh, no, thank you so much, Dr. Hubbell. Good evening, everyone, and thank you for joining us tonight. Again, my name is Antigone Argerio. I'm currently in private practice in New York at Spine Medicine and Surgery of Long Island. I'll be elaborating a little bit on my legislative and advocacy role shortly, but currently I'm a graduate of the Academy's Future Leaders Program. I am serving on the RPRC committee. I'm the alternate CPT advisor for PM&R to the AMA. I'm also the former president of the New York Society of PM&R, and I'm an active member of the Medical State Society of New York and a voting delegate at the House of Delegates every year. So I guess my hope for you today is to inform you of various local and state advocacy efforts. The Academy is involved in, and my hope today is to inform you of these issues to help you consider how you can contribute to advocacy efforts in your own practice and community. Next slide, please. So I'll begin by sharing a little bit about my background and experiences with the New York Society of Physical Medicine and Rehabilitation, the Medical Society of the State of New York, and the Academy, all of which have been instrumental in my advocacy work and my professional development. I will then discuss scope of practice, which is a critical issue for our profession. It directly impacts our ability to provide comprehensive care to our patients without encroachment. I'll then talk about what is currently being done at the state level regarding current advocacy issues and how individuals like yourselves can get involved in these efforts. We'll move on to discuss physician payment reform, which is another pressing issue that needs our attention and advocacy efforts. And I will then offer some practical steps for how you can begin your own advocacy journey. And it might feel a little overwhelming now, but with a few simple actions, you can actually start to make a difference even today. And then I will conclude by sharing some resources to help you. Next slide. So why volunteer? I know Dr. Hubbell touched upon this a little bit. And personally, volunteering has always held significance for me. But as physicians, dedicating our time to advocacy efforts is crucial. And so there are numerous compelling reasons to engage in advocacy through volunteer work. It promotes and reinforces positive changes in healthcare and legislation. And physician leadership is a crucial part of advocacy and legislation. As Dr. Hubbell mentioned, we need to be the voice of patients and the voice of reason sometimes to make sure that everything follows the standard of care. And as physicians, we advocate every day for our patients. But many physicians do not embrace their potential to be public advocates and influence policy. We actually have a lot of power. And so volunteering is a great way to use that power, and it can be tremendously rewarding. Personally, I feel like I'm a catalyst for change. I feel honor and pride knowing I'm really making a difference in the lives of patients, colleagues, and our medical specialty. Next slide, please. So again, advocacy occurs at various levels. We are focusing on local and state today. But there are advocacy efforts going on locally, at the state level, and nationally. So you can start small, start local. And as you get more experience, you can work your way up. Next slide, please. And so here's a little bit about how I got involved. This started when I was a resident. At the time, I had just heard about the New York Society of Physical Medicine and Rehabilitation, which is the New York State PM&R Society. It was very active. We have one of the, I think it's the largest and most active PM&R state societies. And there are monthly CME lectures that are offered there. These are very educational. They're well attended by medical students, residents, and attendings in the area. And then after the lecture, the executive board would hold a monthly meeting that's open to the public. And this was often followed by a networking event at a restaurant or a bar. And so I began attending these lectures initially for fun and for educational purposes. And I actually started making a lot of friends and connections. Next slide, please. So initially, I was more like an observer trying to figure out how things kind of worked, but eventually became a familiar face because I kept showing up. And I began making very strong connections with leaders of the society. And I started by volunteering really small tasks, setting up and cleaning up after events, taking notes. And so I started really small. And after about a year, I ran for a committee position. A year after that, I was appointed program coordinator. And a year after that, I was elected president of the society. Next slide. So through those connections with other physician leaders at New York Society of PM&R, I met with other doctors that were very experienced in legislation and advocacy. And a lot of that work was through the Medical Society of the state of New York. So I was encouraged by them to join and become more active. So state medical societies are really important. They provide critical legislative and advocacy resources for their state's medical community. And every state has specific laws and regulations that govern the practice of medicine. And so the state societies are a great resource when you're looking for state-specific issues that apply to you. And so eventually, I was appointed to Misny's House of Delegates, where I served as a voting delegate for my county. So the House of Delegates, I know Dr. Hubble is going to get a little bit more into that a little later in the presentation. But it's basically, it's an annual meeting. Physicians representing every county, district, medical school, and specialty will attend the House of Delegates meeting to deliberate on patient health, improvements in medicine, and legislative initiatives that affect medicine and patients. And you can actually vote. And so you could bring things into action or not. And so it's really great. It feels really great to make a difference. And it's actually very easy to find your state society. There's a link at the bottom of the slide here. We can share that with everyone. And you can sign up for a newsletter or sign up for alerts and become aware of issues that are specific to your state. Next slide, please. So my work at the state level then connected me with the AAPMNR's advocacy team. And when I completed my term as president for the New York Society of PMNR, I was invited to the AAPMNR's Council of State Society Presidents. And following one year on the council, I was appointed chair of the council. So this allowed me to regularly connect with other presidents from other states and discuss the policies and issues affecting them. That then allowed me to participate in the Medicare Contractor Advisory Committees, or the CACs, where I participated as an advisor in the development of LCDs or local coverage determinations. So I'm going to explain a little more about what the CAC is and what LCDs are in the next few slides. Next slide, please. Next slide. So in summary, that's my personal advocacy story and how I got involved. In advocacy and legislation. I am deeply grateful for the opportunities and experiences that I gained over the past few years through my involvement, and I continue to remain active and committed. So I hope that I inspire you all to write your own story. So moving on now, I'm going to discuss specific issues that we've been addressing in our advocacy roles, beginning with scope of practice. So scope expansion is probably the greatest concern for our members. The Academy State Advocacy Committee has been following a variety of scope expansion trends. I know Dr. Hubbell did mention one of them earlier regarding the naturopaths, but I have a couple of others here to talk to you about. And so the first one is from Oregon, the first legislation of its kind. It's a bill. The American Academy of Physician Associates voted in 2021 to change the name of PAs, of PAs, to change the name of the profession from physician assistant to physician associates. And so our AAPMNR delegates advocated against that change at the 2021 annual meeting at the AMA House of Delegates, and the House of Delegates voted to oppose the rebrand because it would undoubtedly confuse patients and seem to be an attempt to advance the PA's pursuit towards more independent practice. The Academy will be looking out for the future legislation that is sure to come because PAs are working very hard to push their scope as far as they can. So the Academy will keep an eye out. Next, there's another example from Missouri. This is from Orthodontists and Prosthetists. This is a bill introduced to expand their scope. I believe this is the one Dr. Hubbell was talking about. So this is to expand their scope to evaluate and initiate treatment on a patient without a referral from a physician. Your Academy communicated with the AMA, the Missouri Medical State Association, and our DC consultants on legislation. We're continuing to monitor this. There's a good chance it may be reintroduced in 2025. And all parties agreed that this legislation goes too far, and particularly paragraphs one, two, and parts of paragraph six of the legislation seems to grant them prescription authority for prosthetics and orthotics without any physician involvement. And then lastly, in Washington is naturopath expansion. This is legislation aimed to expand what naturopaths can do. A lot of legislation around the country to expand their scope is currently going on. These are non-physician providers. They have inconsistent state licensing standards, and some known as traditional naturopaths have little or no formal training in the practice of medicine or even prescribing medication. So this particular bill would even give them a prescription authority for schedule two, three, four, and five drugs. That includes opioids, fentanyl, and ketamine without detailing specific education and training requirements that they would undergo. So this is very concerning. Clearly, these naturopaths, they see patients of all ages in any particular healthcare setting with all conditions, and that's all part of their clinical training. So they sort of see a broad base, broad ages and broad conditions. And while traditional naturopathy has avoided drugs and surgery, contemporary naturopaths are attempting to incorporate elements of conventional medicine into practice. However, even the most highly educated naturopaths only get a fraction of the training that PM&R physicians get. So they're required to get 1,200 hours of direct patient contact, whereas physicians are expected to get 12,000 to 16,000 hours of clinical training. Right now, there are five accredited ND and NMD programs across the country. They are all private. And so we believe lawmakers must be very cautious when considering legislation that would expand the scope of naturopaths. Next slide, please. And a priority for our state advocacy committee in 2024 has been to increase engagement with members on various state-specific issues. The Academy has notified members in various states, such as New Hampshire, Missouri, Washington, Vermont, about relative issues to their state. So members want to know what's happening in their state, and the Academy also wants to be aware of any relevant issues going on. And we have noticed that targeted emails have a higher open rate than our general member communications and have led to continuous communication with members in those areas. And having an increase of awareness on the ground will help keep the Academy aware of the activity going on at the state level. So regular communication and engagement is appreciated and encouraged by the Academy. So feel free to reach out if you know of any issues in your state. Next slide, please. The Academy has also seen an increase in the last year from members looking to either start or revamp PM&R state society. There are still several states that lack a state PM&R society, and some states have one, but they're inactive or dormant. And the Academy is able to share resources to members. If you know that there's no state PM&R society in your state, we're happy to help you develop one or revamp one if there is one. And so the Academy is a tremendous resource for members who are looking to do that. Next slide, please. The State Advocacy Committee also explores and monitors carrier advisory committee or CAC activities and representation. So these terms were sort of intimidating to me when I first started out. And so what is a MAC? A MAC is Medicare Administration Contractor. It's a private company hired by Medicare to handle administrative tasks. So they process claims. They handle billing. They make sure healthcare providers are paid for the services they provide to Medicare patients. So essentially, MACs help manage and oversee day-to-day operations of Medicare in specific regions across the country. And so what is a CAC? So a CAC or Carrier Advisory Committee is a group that helps guide decisions about Medicare coverage. So it brings together doctors, medical experts, Medicare representatives, and they discuss and review what medical services, treatments, and procedures should be covered. So the goal of the CAC is to ensure that Medicare makes informed decisions based on current medical practices and evidence in order to develop the local coverage determinations or LCDs. Now, LCDs will dictate whether a particular service or an item is medically necessary and reasonable. And so historically, medical societies provided input on local coverage determinations through the CAC process. However, MACs have recently been engaging with AAPMNR directly, looking for subject matter experts. And the Academy has long struggled to identify CAC representatives for each state and region. And we've been told that we are underrepresented. PMNR is underrepresented in this space. And they've been encouraged to consider recruiting for these positions. And this would ensure that a PMNR voice is heard when MACs consider LCDs. So our State Advocacy Committee is exploring prioritizing some form of CAC recruitment. So if you're interested in becoming a CAC representative, there's a contact here on the slide we can share with you to reach out. Next slide. So on a more national level, payment reform is another key advocacy area that all members should be aware of. So this is an issue affecting all physicians across the board. Medicare physician payment is not positively updated annually to sufficiently account for inflation. So that's seen here in this depiction. In red, you have physician update. And then in the other lines there in green and I guess it's blue, yellow and gray, you can see increase in payments, whereas the physician payments have sort of stayed the same across the board or not gone up very much. So Medicare physician payment is not updated annually to sufficiently account for inflation as I said. So as a result, physician payment has stayed mostly flat for the past 20 plus years. The payment for facilities has increased and that would include hospitals. Accounting for inflation, Medicare physician payment has actually declined by 29% in the last 20 years. And so this is an advocacy priority for the entire House of Medicine and it relates to all us physicians. Next slide. And payment reform is a long term goal, which could see some action actually at the end of this year, although it's more likely to take place in 2025 or later. So we have the physician conversion factor. So this is a dollar amount that Medicare uses to calculate how much doctors get paid for their services. It's a key part of how Medicare determines payments by multiplying this factor with the value assigned to each service or procedure. So there's a proposed 2.8% reduction of the conversion factor for 2025. So that means that Medicare plans to lower the amount that they're paying doctors by 2.8% for each service or procedure. So this reduction could result in doctors getting paid less for the same work that they're doing now. And this could affect their income and their resources available to provide patient care. And so while this is a way for Medicare to manage health care spending, it will impact physicians and the services that they offer. And so if we don't act now, there will absolutely be a cut by 2.8% in 2025. So this is an immediate priority for the Academy. And please watch out for a voter voice campaign on this issue later on in the year, likely aligned with the annual assembly conference in San Diego. Next slide, please. So the Academy has endorsed the Strengthening Medicare for Patients and Providers Act. So this is a bipartisan piece of legislation, and it aims to improve Medicare payments to physicians by providing an annual update based on inflation. So the fact that the legislation has support from both political parties means it has a better chance of passing and being enacted into law. So if this does pass, it would ensure that Medicare payment rates for doctors increase each year, keeping up with inflation. And that ensures that we are fairly compensated for the services we provide, especially as the cost of living and operating expenses rise. Next slide, please. Is this the next slide? OK, so where do we start? Where do you start? And so step one, I guess, would be being interested. And you're all here now, so I assume you're ready for step two. So step two is to gather all your resources. And the AAPMNR has a tremendous amount of resources on their website. So if you log on to www.aapmnr.org, there's a tab at the top, as you can see. I believe if you advance the slide, it will highlight the advocacy tab. There you go. And so if you click on advocacy, you will get a lot more information. If you advance the slide one more time, it'll show you the drop down menu. Advance one more time, sorry. And so the advocacy tab will bring you to these pages. So you have current priorities and then the academy in action or things the academy has done to address some of these issues. Next slide. And then finally, try joining your local and state societies. And so I live in New York, that would be the medical society of the state of New York for me. So I'm an active member here, I get their newsletter and their email. And so this is a great way to stay up to date with advocacy and legislative issues. Next slide. That's how you join, okay. All right. And then, so in summary, we've explored the importance of advocacy at the local and state levels, highlighting some key issues like scope of practice and payment reform. So thank you so much for your time and attention. And now it's my pleasure to introduce Dr. Ojeo Balan, who will be discussing federal and grassroots advocacy. Thank you. Thank you so much, Dr. Ajuru. And it's phenomenal so much of the work that you've done in the state of New York and now nationally as well. So it's really tough act to follow. So I will be, no, for sure. And I will be focusing much more on the federal and grassroots advocacy at the AAPMNR. My name is Prakash Ojeo Balan. I'm a physician scientist at the Shirley Ryan Ability Lab at Northwestern University in Chicago. From an advocacy standpoint, I'm the chair of the Healthcare Policy and Legislative Committee of the AAPMNR and also represent our specialty at the AMA. On another hand, I serve for a PMNR organization as well. So what I wanted to start with was really, next slide please, is really to talk about my why. And I think Dr. Ojeo already explained that. So I am a physician. I'm originally from England. This accent is not fake. And I did medical school in England and I was initially in the UK to do musculoskeletal care. You really had to focus much more on orthopedic surgery. So I was an orthopedic surgery resident in my second year at Oxford. And then during my residency, I realized that orthopedic surgery wasn't for me. I just really did not love being in the OR. And so my residency director in England basically allowed me to come to the US to do PMNR. If you click forward, please. So in my PGY3 year, I came here to do a PhD. And so I was always planning to do it because I was interested in being a physician scientist. And I did it at the University of Missouri. And the chair of the PMNR department at the University of Missouri was essentially on my committee and suggested to me, based on what you really like, maybe you should think about PMNR as a field. And I really didn't understand it. My dad, my father was a orthopedic surgeon and really also did not understand it. And was like, you should really do orthopedics because everyone will know what that is. But it wasn't my passion. And so I really took a rite of passage and decided, a leap of faith, I should say, and I decided to go and apply for PMNR after having done my USMLEs. And as I'm sure all of you on this call would attest to, that it was the best decision I made. If you can click forward again, please. So since that time, I won't go into my career, but currently, as I mentioned, I'm a physician scientist at the Shirley Ryan Ability Lab. I have my own research lab, but my clinical care is predominantly in treating individuals with knee osteoarthritis. The reason I point all this out, and I think Dr. Ajiri has already gone through this, is if you click again, please. My background has, if you don't mind clicking again, sorry, my background has really impacted my why. And I think when you are doing advocacy, whether it's at a national level, a local level, a state level, it's really important to understand why you want to be an advocate. You're never going to get rich and famous from being an advocate, but rather you're going to be advocating for something that you truly believe in. And I believe in our field. And then if I look more granularly, it's important to realize what aspects of the field you are most passionate about as well. Next slide, please. So finding your why, how do you do that? It's identifying your passions. So as I outlined already, one of the things that was really important to me was advocating for the field of PM&R. My father was an orthopedic surgeon in the UK, had no idea what this field was. And many of us has faced that in our careers of having patients or family members that don't understand what we do. And so being on the forefront of advocating for that was really important to me. I'm a physician scientist, so I'm passionate about rehabilitation research and I'm willing to pay $15,000 for that. I'm musculoskeletal care, passionate about my patients, particularly those with disabilities. I'm passionate for regarding GME funding to make sure that our medical education is well-funded and our residents are well-supported. And also I'm passionate about diversity, equity, and inclusion-related initiatives, either at my local institution or more at a national level. Next slide, please. And as I said, I'm the HP&L Healthcare Policy and Legislative Committee Chair. And one of the things that we do in sort of more of this federal advocacy level is that we're trying to decide what is impacting our members the most. And for any of you, I know many of you on this call probably have survey fatigue, but when you get those surveys about specific things that are impacting you in your everyday career, sometimes decisions regarding what we advocate on is made on those survey responses. So I'd encourage you to just, depending on the survey, to really look at it and decide what is impacting you because we listen to what you are saying in terms of what's impacting you in your everyday careers or in everyday lives as a physiatrist. So we have really, as a whole, prioritized legislation that is related to physician burnout and improved access to care for our patients, particularly those with disabilities. And one of the major barriers that our members consistently mention, as Dr. Aguirre also mentioned, is prior authorization. And that seems to be a major burden, particularly not just for us as physicians in contributing to burnout, but as also a major barrier to our patients having necessary care on a timely basis. Next slide, please. So one of the major issues, as I mentioned, is trying to find ways that we reduce some of that administrative burden that our patients face and our physicians face as well. So we worked closely with other stakeholders this year to reintroduce the Improving Seniors' Timely Access to Care Act. And this is essentially bipartisan legislation, which we have endorsed at the Academy, which will reform prior authorization using Medicare Advantage programmatic plans. We have advocated two times this year at the Hill, at congressional offices through the HP&L Committee and also the Future Leaders Program. And one of the major things that we've advocated for is that we want this legislation, which we feel is strong, would solidify many of the previous regulatory gains on prior authorizations and reform them into statutes that are essentially rules that will be abided by. This legislation, which you can look up, currently has more than 200 co-sponsors in the U.S. House of Representatives and more than 50 co-sponsors in the U.S. Senate. So as Dr. Giroux mentioned, it's wonderful to have bipartisan legislation. This is clearly seen as a major issue. And many of the representatives and senators see it as a major issue. So we've had typical buy-in from this particular legislation from the offices that we have visited. Next slide, please. The next thing is to talk about is the Gold Card Act. So the Gold Card Act, or getting, which I love the term, but getting over lengthy delays in care as required by doctors. So this act is actually focused on prior authorization. So if you have done, in particular, in regards to Medicare Advantage plans, so if you had done prior authorization successfully 90% of the time, you will then be given some sort of leeway in future prior authorizations that you may need to apply for. So this was initially in Texas, but is now being introduced more nationally in this House resolution as outlined here. The other things that we're also seeing from Medicare Advantage regulations is that we've had two major wins. One is the, in particular, the electronic prior authorization or the ePriorAuth rule, which is finalized in January 2024. This allowed electronic prior authorization rather than a phone call to a specific person regarding trying to get approval for this. And then there are also other Medicare Advantage rules finalized in April 2024, which builds on the final fiscal year 2024 rules. And we can provide that information if anyone is interested. Next slide. Other acts that we have also been heavily involved in advocating for, one specific act that our committee has been strong in advocating for is the Access to Rehabilitation Therapy Act. This is actually more related to the three-hour rule. This act really works on giving the physician, the physiatrist or the rehabilitation practitioner, the ability to actually have autonomy in the type of skilled therapies that an individual will undergo while they're in an inpatient rehabilitation facility. As we know, the three-hour rule classically is that individuals will get three hours of therapy. That'll be PT, OT, speech therapy, five times per week or 150 hours, sorry, 150 minutes per week. But one of the major issues with that is that it doesn't account for certain types of other skilled therapies. In particular, if someone needs respiratory therapy or someone needs recreational therapy, those are not accounted for in the current rule. As you'll know, during the pandemic, there was actually removal of some of these rules for the three-hour rule. And what was found was that there was no increase in the amount of therapy minutes that individuals had or any abuse of this type of waiving of the rule. So we believe that providing that autonomy to the physician to appropriately prescribe the types of therapy that someone needs during their rehabilitation stay is important. And so this has been reintroduced as a house resolution. And we've also endorsed the Long COVID Research Moonshot Act. This is essentially a very large amount of money that will go towards researching long COVID, which is more than a billion dollars this will provide. And we've been involved in engaging with CMS on the Office of the Inspector General's IRF Review Choice Demonstration. This review choice demonstration basically would provide, would mean that all IRF admissions would either have 100% pre-claim or post-claim reviews. We have been working diligently with CMS to make sure that physiatry has a voice. And we wanna also make sure that these reviews are performed by individuals who are skilled to perform these reviews in the first place, ideally a PM&R physician. The demonstration has already gone into effect in Alabama and Pennsylvania, and we are heavily involved in assessing with CMS the success or issues with these types of reviews. Next slide, please. So I've outlined to an extent just many, a few of the many things that we are undertaking right now. I think it's very important. Those of you that have joined this call right now are clearly passionate and interested in getting involved in advocacy, or maybe you're just interested in what the AAPM&R is doing from an advocacy realm. But one thing that you can all do is actually join one of our voter voice campaigns. Some of you may have received an email from me in your inbox for specific voter voice campaigns. Chris has just provided the link in the chat, so please take a look at that. It really, so for example, if we have something that is, as Dr. Gerry mentioned, which is the physician payment reform, and we have an ask of your congressional representatives, it takes five minutes. You can go online. You just put your zip code in. You obviously put your name, zip code, and where you work, and then it auto-generates a letter that will go to your congressional representative based on your zip code. And we have, this has been relatively successful. We'd love it if even more people are involved. We've had members, totally our members have sent more than almost 3,000 letters to their representatives in the last Congress, and it's a wonderful way to get engagement from your congressional representatives in some of the things that impact us as a whole. And you can also edit the letter if you feel that you want to, instead of using the preformed letter as well. But like I said, it takes less than five minutes and can be highly impactful. Next slide. As was mentioned, we've sent a large number of letters and very, very impactful, as was mentioned as well. Next slide. As similar to Dr. Ojiri mentioned, this is the website. Next, if you click on that, I think it comes up. Click on advocacy. These are some of the information. Oh, next slide. And this is what those asks look like, and you can do it right now if you'd like. But again, great way to get involved in advocacy and also to hear about what some of the things that the AAPMNR is advocating for as well. And with that, I will pass over to Dr. Hubbell. Next slide, please. Hello again. I am the delegation chair for the AAPMNR delegation to the AMA, and we also have a thing called the PMNR Section Council, and I'm the chair of that. I travel with three other representatives from the Academy to AMA meetings twice a year. We also have a lot of Zoom meetings throughout the year that we're dealing with issues at the AMA level. Next slide. So the AMA House of Delegates includes a lot of different representatives, and this slide is just listing which ones are there. All the states have delegates based on the number of AMA members in the state. We have delegates from AAPMNR based on the number of AAPMNR members who are AMA members. So it's very important for you to join the state association and for you to join AAPMNR because those numbers count. The picture on the slide is the AMA PMNR Section Council, which meets twice during most of the meetings of the AMA, and we also meet virtually. And some of our representatives are delegates from New York, California, Washington, and other specialty societies that they're all PMNR representatives. Any PMNR resident medical, any PMNR residents welcome, and medical students specifically interested in PMNR are welcome to come to that meeting where we go over all the items of business. It's crucial that PMNR is there because our viewpoint is necessary in most things. And most people don't think of the things that we think of that need to be addressed. Next slide. So a resolution is an item of business. It's a policy proposal that we submit to the House of Delegates to be discussed and voted on. We've had several resolutions that have been positively voted on by the AMA. Sometimes they're amended to put different language in, but they're always are positive for us in the end. Since the 2023 November interim meeting, APMNR has submitted three resolutions that have become AMA policy. Because of the work of our delegation in 2023, the AMA urged the US Census Bureau to halt the proposed changes to the disability questions in the census, which would have led to the disability population to be significantly undercounted. The AMA sent a letter to the Census Bureau as did APMNR, and they have halted that proposal and they're looking for more input from the disability community and from individuals who deal with patients with disabilities. During the annual meeting in 2024, we submitted two resolutions. One that was for shoes and shoe modifications for pediatric patients that require AFOs and KFOs. And the other was for public and private insurance coverage for adaptive sports equipment, including prosthetics and orthotics. And if you watch the recent Paralympic games, you saw the types of prosthetics that are being used and in those kinds of intense sports, we want those to be covered so our patients can participate and be active and be healthy. We have a meeting coming up in November where we have two resolutions that will be submitted. Next slide. As a part of the AMA, there's another caucus, it's called the Mobility Caucus. And for last year and this year, Dr. Stuart Glassman is the chair of that. There are 23 different specialty societies that are in that organization that focuses on increased mobility function and independent living for patients. And we advocate on behalf of policies that do impact PM&R physicians. There are neurosurgeons and many other special, orthopedic surgeons and other specialties involved in that. The picture is Dr. Glassman being congratulated by Dr. Strunk who was the past chair of that caucus. She is a neurosurgeon. At the last AMA meeting, we did do a CME session called Equity in Healthcare, Breaking Barriers for Patients with Disabilities through Physician Advocacy. Next slide. Why is it important for physiatrists to be involved? Well, we are few in number. And as you've heard, there are many places that do not have PM&R residency programs and have no idea what we do. We must support ourselves, but we must have the support of our fellow physicians. If we get AMA to support a policy that we ask for, that's helpful because their voice is very loud in Washington. It's popular to give lip service to the disability community but we're really the only ones that advocate for that group of patients. So we need to continue to be there to represent them. Next slide. My why? I think I can make a difference. I've seen resolutions that started at my local Allen County Society of Medicine that have gone to the Ohio State Medical Association and then been referred to AMA and passed there and then went into effect. It took a few years, but one of the things that we advocated for was the rule that they had, that you had to sign a verbal order at the hospital within 24 hours, which we did not think was practical or even reasonable. And that finally got passed and got changed. But that started in Allen County, Ohio. And we make connections in organized medicine. We can engage with physicians and other specialties and states for common goals. We get informed, we learn so much from the other physicians and their testimony. And we look forward to meetings for discussion, friendships and difference we can make. And if we don't do it, who will? Next slide. So my summary for this whole presentation is get involved somehow. Join organized medicine. Your membership counts. If we get more AMA members in AAPMNR, we'll have more delegates in AMA. So it does help. If you don't have the time, give the money, join and pay the dues because the numbers count. Progress isn't easy and it isn't fast and we have to be persistent and kind of keep working on it. My last point is vote. Many people are not voting for their state issues and their federal issues and we need to vote and be a part of that. Next slide. So we have just a couple of minutes. I don't know if there's any questions, but if there are, we can take those. And if there aren't, please put questions in that if we don't answer them, we will send you a reply. So are there any questions? I cannot see the chat with what I have. And we've stunned everyone into silence here. Yeah. I think I have a quick question, more so a question for rising residents or residents like, what is the best avenue for us to get involved? Well, each state has residents at the Ohio State Medical Association has a resident section, which deals with state advocacy. And there's a lot of things that are state run and state that only the state can affect. So that's an important thing to look into, to see if you can become a part of that. There's also the AMA has different residency resident delegates, there's some that are called regional delegates, where they represent a region of the country. And our current resident and fellow delegate from AAPMNR was elected to one of those positions. So she's representing in addition to AAPMNR, one region of the country. So I think that's important. The other thing is to find out in your residency or people that you know, if any of them are delegates to your state medical association or the AMA. My first experience at an AMA meeting was with Dr. Claire Wolfe, who is a longtime delegate from Ohio. And so sometimes you can tag along with them if you have time to do that and learn from that. So most places want more people to volunteer, especially residents. So does that answer you? Yes, thank you. Jalen, I would just, thanks so much. I'm guessing you're a resident when you asked that question. No, I'm a fourth year medical student, but I'm hoping to get involved in residency. No, no, no. That's great. I mean, everything that Dr. Hubbell said about the AMA is really important. I would say one thing is at your, even right now, or when you join residency, that one way to just start is to get involved in local committees within your hospital system, because that's a great way to highlight that. Like, for example, being involved in your house staff association is a great way just to begin with, because then they realize what PM&R is within the department, within the university structure as a whole, or within GME. That's a great way. Within your department of PM&R, there are committees, we, for example, have a wellness committee, we have a DEI committee, we have other committees that you could also be involved in. So you're often advocating for your colleague residents. And then, I think that's a great way to start, get some experience. And as Dr. Giroux mentioned, then get involved in sort of state society level stuff would be probably the next level. And then you sort of build your experience, your confidence up to then think about more national type leadership. That's essentially the way that I did it, but that might be a good way to start as well. Thank you so much. That's so helpful. And AAPM&R also has some, has residents on the FIT Council, which is in the rep, and they're appointing members to our committees. We have a FIT member on pretty much all of our committees. So you can involve, get involved that way too. That's an application process that happens through the FIT Council, which you can look up online. Are there any other questions? Is the AAPM&R website the best site to see the current bills issues? Then how do you decide which ones to make the priority for 2025? Thanks so much for the question, Claire. I, yeah, so I'll probably, if you're talking about more federal level issues, and I'll let Dr. Ojuri talk more about state level issues, certainly our, our website is pretty well updated in terms of issues that are forthcoming, impacting physiatrists, PM&R physicians. The ones that we decide, so for example, on our committee for full transparency, we have a priority list that our committee comes up with. We have nine members, nine to 10 members of our committee. We set our priorities at the beginning of each academic year, and then we basically go through them. We have a discussion. It's generally pretty democratic in the way that we do it, and we decide what is impacting our membership. So one important thing to remember is who you advocating for. You are advocating for yourself to an extent, but you're really advocating for your members. So I think that is what, that is how we decide. So many of those emails, like I said, that you get with voter voice campaigns and other things, the number of members that fill out those voter voice campaigns gives us an idea of how, how important or how impactful that particular issue is to our, our membership. So that's, that's another way, another metric that we use to decide, prioritize what's impacting our members. And so those are some of the things to think about. Hopefully that answers some of your question. Go ahead, Dr. Ojuri. Just to add a little to that, every state is so different. So there are some issues or bills that are proposed just specifically in one particular state that may not affect other states. And so you may not see, well, actually we do have a section for that in AAPMNR. So the AAPMNR website has so many resources, and there's one specifically for state advocacy also, and the state advocacy committee sort of monitors this. And so they are listed there. You can also check, like I said, your state society website, state specific issues will also be listed there. And so yes, these are regularly monitored. And then there's a council for state society presidents that the AAPMNR has, we meet annually at the annual assembly, and then a few times throughout the year as well. And we sort of, you know, discuss any issues that are state specific and bring it to each other's attention. And if something needs to be escalated and addressed, we do we do so. Okay, great. Thank you for answering that question. Appreciate it. And kudos to both of you for being medical students and already thinking about advocacy. That's wonderful to see. It's great. Okay, I think we're past our time. So thank you all for coming. We really enjoyed talking with you. Feel free to contact any of us for any kind of thing in the future. We're happy to help.

advocacy

healthcare

policy change

systems advocacy

PM&R

physician burnout

Gold Card Act

long COVID research

voter voice campaigns

organized medicine