Welcome to this session on academy efforts in physiatry-led alternative payment models or APMs. I think one full disclosure is yes, we'll try to spell out all the alphabet soup abbreviations that you're going to hear during the course of this. My name is Richard Zorowitz. I, amongst other things, chair the Innovative Practice and Payment Models Committee for your academy. We are a group that is basically here to try, one, to advocate for and get people to use value-based care, but also putting PM&R at the center of that in the places where we need to be at the center of that. So there are my disclosures, which have nothing to do with what we are going to talk about today. So we said this last year and we'll say this again this year, ready or not, value-based care is here. It is not going away because the current system of fee-for-service really is ineffective, unsustainable, and people like Congress and CMS want to transition over to something other than that because they want better value. But at the same time, patients want to have good care, good access at a lower cost. And so the idea of trying to put all of these things together and then, in addition, making sure that what goes on is transparent, things are equitable, but at the same time having accountability for it so that we can know what we're doing and find out what the pitfalls are and make it better is going to all be very important. I think this kind of says it all. Medicare is cutting back slowly, but it's chipping away at what reimbursement is. And that is certainly not going away. I think for this year, Congress will probably wait until after the midterms to kind of take any kind of action on that for, I guess, pretty obvious reasons. But again, the idea behind this is that ultimately if you want to do the metaphor of the bus, we want to be the driver. We do not want to be the passenger. We want to be able to know where we are going and be at the table to do that. We don't want to be on the bus where we're going to be stuck on the route and we can only go certain places because that's the way that it's set up. So this is what the payment model looks like so far. So four different categories. What we currently use is the fee-for-service with absolutely no link to quality, just basically volume or whatever. Category two then is your fee-for-service with links to quality and value. And so a portion of payment is based upon some of those measures like in MIPS and all those things. Category three then is going to be your alternative payment models or APMs, which are built on a fee-for-service architecture. And so some of those payments are going to be based upon a segment of population or an episode of care, but the payments are triggered by delivery of service. But the thing is that you may be at risk. So basically you may get incentives, but at the same time you may get penalized for what you're doing depending on how you benchmark. And then finally really is population-based payment. You get a patient population assigned to you and you do what you want to do. And if you do well, great. If you don't do so well, okay, you're going to lose out. So capitation is basically the basis of that. So if we look at some of the measurements that have been done, this busy slide shows that over really by 2015 you can see that still there's not a lot of acceptance, although there is a little bit more. So legacy payments in category one is close to two-thirds and then everything else basically falls into those other categories as well. The idea is that what CMS would like to see through CMMI, which is the CMS Innovation Center, is really for all Medicare fee-for-service beneficiaries to be on some sort of direction towards accountability for quality and total cost by 2030. And the same thing, the vast majority of Medicaid to do the same thing. So that puts us about eight years away that things hopefully may or may not change because as you know things do or do not change based on how Congress acts. So what are we doing proactively to make sure that we are in a good place for this? And so this is your committee as it stands today. We will be having some new members starting as of this meeting. So basically what we're doing is, number one, we basically try to check out on everybody to see where you are in some of those payment systems. So we'll show you some results of the 2022 APM Benchmark Survey. Then what we're going to do is we're going to talk a little bit about the principles of APMs and the APM Glossary. Those are things that are out there already that have been approved by the board and now out on the website. And then finally what we're going to talk about, I'm going to be talking at the end about the Post-Stroke Rehabilitation Toolkit. Dr. Glassman will be talking about the Spine Care Toolkit. These are things that we're basically putting together for the membership to allow you to understand what is it going to take to be able to, if you want to set up an alternative payment model, be able to get that into place. So let's start with the 2022 APM Benchmark Survey. So where does the Academy stand? We've looked at 108 member responses and so you can see again, just like the slide I showed you before, close to two-thirds of people who responded basically are still on fee-for-service. Category two ranked next, which is fee-for-service with some sort of link to quality and value. And then a very, very small amount of people are APMs either built on fee-for-service or on capitation types of models. So we asked the question, are there any gaps or barriers you're facing that prevent you from transitioning to a value-based model? Well number one, the first thing is understanding what it is and getting that education. So ultimately that's one of the things that we're trying to do here and why we're glad that you're here this morning to be able to do that and hopefully the people who will stream this afterwards will get some idea of what this is. Number two, probably one of the bigger issues is administrative buy-in. You don't get your administration to buy into this stuff, it ain't going to happen. Number three really is data collection. We've got to have data because if you want to be accountable, we've got to know what you're accountable for and making sure that you're going to have meaningful outcomes, which is why number four, the definition of value may be different for many people. We have to decide what is value and what are we really striving for in our patient outcomes. And number five, and this is playing out even as we speak, is that physiatrists are often not invited to have a seat at the table. And so it's one of those things that I think I know from my own experiences and other things, not necessarily this, that the only way you're going to get anywhere is you've got to open your mouth and say something and really get in people's faces so that they know that we are there and that we do something that is really valuable. The next question was, what would it be like for you to see the academy in the next two years as it relates to value-based payments? So we have all these things. So it really comes down to all the things that we've kind of talked about, so education and also how you can get involved. So I think the fact that you're here is good and there are certainly ways to get involved. Measurement. This is really a very interesting aspect of it because one, we have to get valid and reliable measurements. What are those measurements going to be? We also have to talk about stratification because we tend to see often very complicated patients and so how do you work that into a value-based system so that we are rewarded for taking care of those patients even when their outcomes may not be as good as you might would...as much as you would like them to be. And then number three, the thing that we like to tout for ourselves is measuring on avoiding things whether it's surgeries, diagnostic procedures, and things along those lines. The third thing is advocacy. I don't think I need to say much more than that. I think I already talked about that. But it's important that we have to have and get ourselves seats at the table of wherever it is so that we are not left out and end up being the passenger on the bus as it were. And then finally, reimbursement, which is going to be a really important part of it because there are going to be...for design of these things bundling is coming and so the question is, is how do we do it? Do you do an episode starting acute or as we are trying to do possibly doing a post-acute bundle so that at least we can take care of those patients a little bit better and so that the resources don't end up going on the front end and leaving the patient high and dry at the very back. And then obviously cost of care is going to be very important because we're going to want to make sure that throughout whatever that episode is going to be that you're going to get value. What's important in this aspect is that we don't want it siloed. We want to look at the whole thing. So for example, if you're going to send somebody to inpatient rehab, I always say it is an investment in the patient because even though, yes, it probably will be more expensive than say a skilled nursing facility over the long term, then you may actually save cost because of the fact that patients hopefully get better and have better functional outcomes. So what we did was we put together principles of alternative payment models. So what this was is...what this was was basically if you want an APM, what does it need to have? And so you can use these things if you're looking at new payment models, if you're responding to any rulemaking that comes out of Washington, and also as a framework if we decide as an academy that we want to develop APMs to present to whomever that would be, whether it's insurance companies, CMS, and the like. We can also use these things for discussions of these things with any stakeholders that we have to talk to. Also whether to participate in a new model, because that's going to be very important and where is our role in that going to be? And then also evaluating models that you may be participating in already. So I'm going to go briefly through these. I'm not going to go through everything in real detail, but number one is going to be collaboration and coordination. If nothing else, it must prioritize and incentivize collaborative and coordinated care. As you know, rehab is team and that's how we need to have it. So it's got to be throughout all the people that we work with. It also has to take care of continuity, especially at transitions of care so people don't slip through the cracks, because that's probably going to be the biggest place where you're going to have lapses in appropriate care and things will then, you know, may go south. Has to be patient-centered. Again, it's one of our basic principles and so I don't think I need to say much more about that aside from maybe taking into account social determinants, you know, DEI principles of course, because those play into this as well. And ultimately they have to include function and quality of life as a foundation for what we do. It has to be high value. So it must prioritize the delivery of high value, high quality care. And that has to again be throughout the continuum of the care episode that that patient is going to have. It's also going to have to be based on evidence. So it's not only just the cost that we're going to look at, but we're going to be looking at do they follow, and I'll be talking about this with stroke rehab, does it follow guidelines which have been shown to really produce the best quality care possible. And as a result, you know, we've got to be accountable for those things, but at the same time get rewarded for doing those things. And then demonstrating the value of those things throughout the continuum and not just in the little silos that, you know, that in each of the care environments that a patient may go through. Principle four, accountability. So what are the quality and cost metrics that we're going to use? And making sure that those are meaningful for the patient and for us as well. And also making sure that they are risk adjusted so it takes into consideration the complexity of patients that we do. It has to be driven through physician engagement. Basically again, this is the whole concept that we need to be the drivers and not the passengers and so basically that we can make sure that the patient's needs are really truly being taken care of and that physician stakeholders and champions have to be given a place at the table to be able to develop these things to make sure that again, you know, the right kind of care is going to be given and that corners will not be cut in doing so. And then finally, some autonomy so that we are not necessarily being told what to do, but we can again really advocate for what is right for patient care. Principle six is probably one of the biggest ones is incorporation of physiatry for this. I mean we have to be... We have to have a seat at the table for these things and in certain cases we need to be the leaders in those things and that goes throughout the whole continuum of this developing models as well as implementing and carrying them out. There has to be reasonable risk. So as I talked about before, there may be one-sided risk where we can get... We can be incentivized for this, but not necessarily get penalized or there can be two-sided risks where you can get penalized as well. But if that is going to happen, that is something that has to be reasonable so that it doesn't disincentivize us from wanting to participate in these kinds of things. And then the other aspect of it is making sure that there are large enough populations for these things, because if you don't have a big enough population to do this stuff, you may not have the capacity to assume some of the downside risk that goes along with this. Availability of resources, I think, goes without saying. We've got to be given the tools to be able to do this. Small practices have to be supported. We have to have training, education, ongoing education for all these things, and then things like IT and other things not only for documentation, but for data collection so that we can look at all those things and be able to have that accountability done. And along those lines, that it has to be data driven so that you can really see truly what are your benchmarks and what are the types of things that are going to drive your patient outcomes. The last point I think is also important is the whole issue of interoperability. Basically making sure that systems somehow can talk to one another. So I don't have to say, I really don't, but I will. You know, we have the Hopkins system I know which is on Epic. We have MedStar which is here in town and in DC. We are on Cerner. The beauty of what goes on right now is at least with documentation, Maryland has a system called CRISP which is interoperability. It basically allows us to upload stuff from our individual systems so I can actually see what's going on if somebody is seeing a Hopkins or a University of Maryland patient. So it's really nice and it allows me to be able to provide better care because I don't have to depend on the patient or somebody faxing me stuff. I can actually see that stuff. But that's part of what needs to be done for this. Finally is flexibility and efficiency. We have to eliminate barriers, improve efficiency to advance high delivery of high value care. We have to try to make this, as we like to say, cheap and easy. I mean you want to make it nice and easy, but you want to make sure, as I love to, as in my role of being Chief Medical Informatics Officer at NRH, fewer clicks. We want to make sure that there is no undue burden on us so that we can do the jobs that we need to do and at the same time not compromise patient care just in the name of efficiency. So those are the principles. The APM Glossary so that if you want to go through the alphabet soup we actually have that and there's the website for that out on the Academy website. So if you're like dazed by all the things that we're going to talk about and you want to know what things mean, go out there, we hopefully spell that out for you and we'll be updating that on a frequent basis. So with that, I'm going to turn it over to Stu Glassman. Stu has been on the committee and working very diligently on the spine care toolkit for the committee and for the Academy. He's Deputy Chief of PM&R at the VA Greater Los Angeles and somehow he manages to be a Clinical Assistant Professor at Dartmouth. I'm still trying to figure out how he goes from New Hampshire down to LA, but he does it somehow. But anyway, we'll turn it over to Stu to talk about this part. All right. Thanks, Richard. It's called frequent flyer miles. That's how it works, all right. And I think my circadian rhythm got somehow deleted along the way, so. Yeah, so Dr. Stuart Glassman, Deputy Chief of Physical Medicine and Rehabilitation at the VA Greater Los Angeles Healthcare System. Also private practice as well. And I've been very happy to be here talking about this ongoing project of spine care toolkit, which we thought was going to be a model back in the day, but realizing a toolkit is more helpful for you to fix problems than a model that locks you into one and only one pathway as well. All right, so no financial conflicts of interest for disclosures, but the views expressed in this presentation are not the views of the federal government and the Department of Veterans Affairs. They are my own personal views with working with the team here as well. All right, so we're going to try to improve awareness of the IPPM spine care toolkit, which is not finalized, but we are close. We just have to get approval of a couple of different committees, but we're almost there. Enhance understanding of value-based decision-making in low back pain and spine care, and discuss methods for improving physiatry involvement with spine care programs and systems. So this has been going on for over a decade. The Innovative Payment and Practice Models really came out of a former steering committee called Models of Care back in 2011, which then became the Professional Practice and Awareness Committee back in 2012. Myself, Dr. Benton G. I'm a part of that as well. Dr. Thomas here, also part of our IPPM group as well. And then around 2015, the PPAC converted into IPPM. Dr. Peter Esserman, one of your former presidents of the academy, and I worked to help get some publications out there about Innovative Payment and Practice Models at a time when talking about ACOs and APMs was scary for a lot of people because it was new, and there was money and risk involved, and it wasn't really a comfortable space for a lot of people, but we've tried to really enhance that as well. So the development of the spine care toolkit. Back in 2015, IPPM worked with the Board of Governors to look at the question of low back pain. If you remember back in 2013, there was a publication in the spine. Andy Haig worked with Priority Health looking at the value of physiatry working with spine care patients, comparing physiatry involvement with surgeons, and ultimately, lower cost and improved satisfaction as well. So we really decided to look at, well, where's the real cost and where's the real savings involved? And as we started to look at those, at the data from Medicare, we started to see that even with those savings, the cost of spine care, if you saw a physiatrist or a surgeon, went up and stayed up and never came back down, which is something we did not think we were gonna see. That led ultimately to a publication in 2020, Dr. Standard, Chris Standard at UPMC and myself and others worked on it, to really try to find out why was it that no matter who the primary care doctor referred the patient out to, the cost went up and never came back down? And we're still trying to sort of answer that question, which is why this toolkit has come into existence. And we thought initially, maybe there's a model that we could create. But ultimately, healthcare is local, no one model's gonna work for every physiatrist in every community. So we decided to move away from telling our members, this many physiatry visits, this many physical therapy visits, this much duration of time. That's not realistic. You really need tools to be able to get to the right place for your community and your patient population as well. All right. So low back pain is very prevalent, very expensive. Even five years ago, costs for spine care were about $150 billion. Globally, about 8% of the population on planet Earth has low back pain at a minimum. So there's a lot of money involved, a lot of patients involved, a lot of disability involved as well. So our goal is for the spine care toolkit. Demonstrate a positive impact on patient clinical outcomes and satisfaction. Decrease costs, increase value with physiatric care. Put together a multidisciplinary team of clinicians involved with patient care for team support and care coordination. Identify the framework of the spine care pathway. And remember, this is all going on during the opioid epidemic. And try to look at how do we decrease the use of opioids. Decrease ER costs, decrease spinal injections if they're not necessary. If they are necessary, definitely use them. Decrease surgeries if they're not necessary. And then look at patient outcomes. At the same time, the academy came up with its registry and how can we utilize that if needed to follow patient outcomes as well. So there are a lot of moving parts all at the same time that it made sense to try to put together this toolkit for others. And then create educational resources for the academy members to be able to understand how to use this information to go to your healthcare systems and get a seat at the table as Richard had said as well. So overall considerations. Patterns of utilization, locally, nationally. Payment models, alternative payment models, APMs, ACOs, FIFA service. What's the team structure? Who are you gonna put together to be on this team for this toolkit? Talk to the payers. Why build something nobody wants? You better think about what they do want. If you're talking to Anthem, they're gonna want one thing. If you're talking to Home Depot, National Employer, they're gonna want something different. If you're gonna talk to Kaiser Permanente, they're gonna want something else as well. So you really need to understand who your market is for and what their needs are as well. One and two-sided risk, obviously, that's gonna come into play with whatever model you decide to create. And then innovation. Treatment pathways, technology, important as well. How do you engage senior leadership in considering a payment or spine care model? If physiatry is not at the table, it's an uphill battle. So try to start that earlier if you can. Try to understand there's variability for administrative structures. Know the departments. And this model is really from a primary care ER focus, not as much from a surgery focus. But we all know that surgery departments have a lot of input to what happens in most hospitals. But at the same time, a lot of the savings can come from primary care. So we decided to really look at the primary care side of dealing with this. Know the stakeholders. Figure out how to have those essential conversations with people. Create a concise and evidence-based message. Physiatry-led spine care is a team-based program that's been shown to improve value and decrease costs. That one sentence might get you a seat at the table to at least be heard as well. Align with future payment initiatives. Look at the fact that models can be applied to either a certain condition, a care episode, or a population. And then again, showing that physiatry does lead to spine care savings is really important as well. So what makes up an effective organizational team in general? Balanced representation, stakeholders. Someone has to be the convener, the messenger. Physician champions. The 10th person is the person that might bring up ideas contrary to the group to get you thinking in a different way. Sometimes. 12 Angry Men, if you remember that film with Henry Fonda. He was the guy that turned that whole room around. And wasn't very popular at the beginning or maybe even at the end. Finance, data, program coordination, administration. All things that are crucial for the effective organizational team. So a SWOT analysis. Strengths, weaknesses, opportunities, threats. How to look at what's in your environment to understand what challenges you'll be facing as well. There's global spine care initiative groups that are working to try to improve spine care. There's other groups that want to cut physicians out of the mix. UnitedHealthcare said to their enrollees, if you don't go to the ER and you don't go to a doctor, but you go to a physical therapist or a chiropractor, we will make sure you have no co-pays for the first three visits. Because they didn't want to pay for all the costs if you go to an ER or go to your primary care physician. Hinge Health during the pandemic created basically at-home activities for patients who couldn't go to therapy centers that were shut down because of the pandemic. Innovative, for sure. And Home Depot really aligned with Hinge Health in 2020, 2021 as a way to at least address some of the changes going on. OptumLabs, for those of you who might be in California, like Hillary's back there and I am here, they're not a hospital, they're not Kaiser, but they are a player in the spine care space without a doubt. Collaboration, surgeons, primary care physicians, payers on future spine care ideas. There may be some people that think along the way we think even though they're not physiatrists. And will there be resistance? Always. Who will it be? Fee-for-service providers, potentially interventional pain specialists, and programs that are looking always at the bottom line and at revenue because they don't want to buy into the model of alternative payment models as well. So I work at the Equinox, which is a big exercise health club all over the country, but right next door is Optum. But there's no physiatrist at Optum. And again, the fact that it's in your neighborhood, it's where you live, and because that's where the patients are. So always look around and not just look for the hospital sign, but there's other players in this space for back pain because it's so prevalent and there's so many dollars at stake. So identify key clinical team members and their roles. Primary care physicians, ER physicians, often a referral source. Physiatrists, which from our perspective should be the team leader because we have the training and the breadth of awareness to really bring these different components together. Physical therapy, nutritionists and dieticians can be part of this. Care management, coordination for staff and nursing, important as well. Pain psychologists. We're not just talking about the 30-year-old low back pain that gets fine without treatment in four weeks. There's a lot of different types of back pain you're gonna see. And a toolkit should be able to be used for any of those that you see. That's a good toolkit. That's why a single model will not work long-term. Spine surgeons, again, some spine surgeons are understanding of the fact that collaboration with non-surgical colleagues is important. Pain management physicians. And again, think about chiropractors, OT, massage, acupuncture. For some patients, that's gonna be helpful for them as well. Ultimately, what to think about with this care pathway. That many patients with low back pain are gonna come from the primary care physician or the ER. If you can, try to get these patients seen within a week from the time of referral. This is by the physiatrist. Conservative care management, directed and supervised. Probably, and again, it's not finalized yet. Again, it's a toolkit. 12 weeks of treatment. You probably won't get much more approval from payers for more than that early on. The physiatrist really needs to be the one to complete the comprehensive evaluation. Look for red flags. Assess functional limitations. Consider imaging if necessary, but if you don't need imaging, don't. Reverting to the ANDOD for a second, they came out with a gigantic clinical practice guideline for low back pain this year. And they go through all these different sort of topics of what should be ordered, who should be ordering it, what not to order. So a lot of that will ultimately be in this toolkit. But things to think about now is, as the physician, you can identify, maybe some people really do need to have a bigger workup, and you'll be one to help coordinate that. Look at past interventions, what worked, what didn't work. Think about referrals for different therapies. After that initial evaluation, they should have a follow-up in a few weeks. It may not be with the physiatrist directly, but it needs to be with someone else within the care team. We're looking at trying to maximize patient outcome and improve value while managing costs and resources. What is the exit criteria going to be? Is it based on clinical outcomes? What are you going to use for registries or your own health system data analysis? And then reassessment after discharge from that first 12-week time frame. Six months, nine months, a year out. You kind of want to see what the benefits are long-term for those patients. So consider for data analysis and outcomes. The Academy Registry, Promise 29. You want to document in the record each patient's diagnosis, interventions used. What was the quality that you were looking at? What were those clinical outcomes? What were the goals of the patient? What do they want to do? If their goal is to get back on the golf course, well, you probably want that in there somewhere. They're not going to care about range of motion if they can't hit the ball 150 yards, let's say, or 300 yards. Financial outcome. What did it cost? Was it really meeting the goals that you set? And be transparent with data analysis. In a lot of systems, they don't want to give up the data. They don't want to share their information. That may be an uphill battle for you, for sure. And if the program's working, how do you get the awareness out there? How do you let people know what's happening? Go at it grand rounds. Give presentations to the boards of your hospitals. Meet with the chief medical officer. Online articles, newsletters, local media, medical societies, case managers. Presentations like this, not just for the Academy, but for primary care conferences, payers, insurance company meetings every year. AHIP is a big one in every June. Come up with a marketing kit that the Academy can help you with if you can't do it yourself locally. And again, always look at partnering with other organizations outside of physiatry as well. Reassess. See if the outcomes are heading where you want them to be. Are patients satisfied? What's their functional activity change? We're always going to be looking at that. Were there decreased use of opioids? Were there decreased per member per month costs? That's the spike that we found in doing the original Medicare data analysis that started us down this pathway back in 2015. Are patients going back to work? Are they applying for disability? What's happening with that? And then stakeholder satisfaction and team member satisfaction. You want to make sure you're reassessing all these different aspects of this toolkit. References are out there. You'll be able to utilize those as you create your presentations. The IPPM paper in 2020 that Dr. Stannett and myself worked on. Clinical outcomes of the spine care toolkit. We're hoping if it gets approved through the board next year, should be hopefully on the website by quarter three. So hopefully next summer. And there's already another toolkit for post-acute care that you can look at as an example of what that toolkit might be. And ultimately, if QPPR approves the toolkit, it goes to the board, it should be live hopefully nine months from now as well. So that's the toolkit. If you go surfing Huntington Beach, that's what you'll see one day. And thanks for being here this morning. Thank you. All right. Thank you. Thanks Stu. So what we're going to do now is pivot. We had decided really to take on the two big, I guess elephants in the room, which is spine care and stroke rehab, which are the two big things that we do. So I'll take, I'm taking the side of the inpatient side for capturing value in longitudinal care for stroke. Ben Giopp is the chair of our work group. Unfortunately he could not make it to the meeting today, so that's why you're getting a lot of me today. So some background of why we're doing this. No surprise, the cost of stroke in the U.S. in 2016 was over $100 billion. About two-thirds of it is indirect costs, basically from underemployment and premature death and can also include care costs by caregivers. And age groups 45 to 64 accounted for the greatest stroke-related direct costs. So a lot of what we're going to say about stroke is pretty much the same thing that we said about spine. So I'm going to try to skip through most of that stuff so we don't bore you with a lot of repetition. But the idea is, again, that we're going to try to improve outcomes and try to make this as cost-effective as possible without cutting corners. And so once again, same very similar goals that we had for the spine care. So I'm not going to spend much time on that. So we'll go there. So again, the overview of the elements, the same thing, looking at the economic considerations, looking at innovative care pathways, senior leadership, essential components of the team, doing the SWOT analysis and looking at your outcomes data is all part of it. Identifying your clinical team members. I'm going to spend a little time on considerations of care pathways, recommending increased awareness and influence, reassessing of course very, very important for your program evaluation, and then references. So the interesting thing with stroke is that there have been some data. So this was a study in 2009 in the Blue Journal that was done by a survey in Europe. And what they did was to take a look at, you know, as I kind of made the metaphor before, the physiatrist as the driver rather than the passenger. And so some of the things they talked about was that a physiatrist was called within 40 hours of a stroke event in 44%, but PT in 63%. But on the other side of that, PM&R tended to often be the team coordinator after 48 hours, over almost two-thirds, then the PT. So there is some data to suggest that, yeah, we can, you know, that even on the acute care side, we should be the team leaders, although there are probably not enough of us. But nonetheless, wherever you can do it, that should be, you know, that should be the model. And so this is a table that again shows that in around 73% of the countries that were queried in this particular survey, that PM&R was the head of the team. So again, it shows that we can and probably should be that driver on the acute care side. Interestingly, my late colleague, Alex Dromerick, published this paper. It was actually published posthumously. It was called CPAS, so Critical Period After Stroke, where they took a look at where do you get the biggest bang for the buck in improvement in patients? And interestingly, what they found was that there was an optimal period between 60 and 90 days, lesser effects greater than 30 and no effects six months after. So this is really interesting, because if you think about it, you know, where do we see people in acute rehab? They're not 60 to 90 days. Typically they're going to be 30 days, you know, around that 30-day period, if not less. And so although this probably needs to be confirmed in another, probably a bigger study, but it's interesting, because it shows that in that sub-acute period that maybe we should be doing more for some of those patients. And so what you want to be able to show is, again, patterns of utilization. So as in that study, where are you putting those patients so that they can get the best outcomes? And so again, payment models will matter. Are you using a bundle that covers the entire episode versus a post-acute period? What's your team? The model with the pair, as Stu had talked about, and then the one and two-sided risks are very important. So the nice part of this is that there's been a lot talked about in stroke systems of care. Unfortunately, I've been involved with that with the American Stroke Association. So I was one of the co-authors on this particular scientific statement that came out in 2019, you know, to update the one we had done in 2005. And what we basically stated as some of the recommendations is that a stroke system should periodically assess its level of available rehabilitation services and community resources. So again, understanding what you have. So in Baltimore or DC, yeah, you're going to have everything, basically from acute to IRFs to SNFs to whatever. But for example, a project that I was working with ASA had to deal with stroke rehab in Montana where it's hard to get into an IRF because the IRFs are like hundreds and hundreds of miles and you're going to be dealing more with SNFs. So how do you deal with those kinds of things and get great outcomes? So with that second thing basically saying that the stroke system should ensure that patients are referred to the most appropriate setting to their clinical needs at the appropriate time as well. So how do you do that direction? And so I think that sort of begs the question, you know, and part of the answer is, yeah, we should probably be doing some of that stuff, which I'll talk about in a little bit. So again, what should we be doing in terms of care pathways? Get patients evaluated when they're medically stable. Having... If you have a physiatrist available, having them do an evaluation as well. So not only can you sort of put all that together therapeutically from your therapist, but then also as I like to say, greasing the skids, looking at the medical issues going on that hopefully you can address while they're in acute care to get them into the next level of care as quickly as possible, so it saves costs for the... It saves costs on the acute side and time for the acute side. Overseeing development of that care plan, as I mentioned, and triage as well. And then basically what we should also be doing is potentially evaluating that patient on a periodic basis. Again, we should be the driver. So in IRS obviously we do team conferences every week, but in SNFs where they may not necessarily do this, we should be in there maybe every other week doing this or in outpatients maybe working with teams for either outpatient as well as home health services. Basically if it's something that needs to be done with best practices, how long do we need to do this? And stroke, a lot harder to say because sometimes, you know, improvement will occur over weeks or months or longer. So how do you take that into consideration? The scope of care, making sure that the people that are giving care are the appropriate people. As we talked about on spine, entry and exit criteria. When do we start? When do we stop? And then reassessing that patient periodically to see whether you need more services down the road. So some of this has been already... has been developed. So again, in 2010 I worked with Elaine Miller and a group on a comprehensive overview of nursing and interdisciplinary rehabilitation care as well as in 2016 the guidelines for adult stroke and rehab and recovery, which was something that was endorsed by AAPMNR. So basically we have a lot of those guidelines. You know, that we can use for some of these things. So some of the considerations are that a stroke system should ensure all stroke survivors get standardized screening. This is not necessarily something that is always done on acute, but we should do that and I'll explain why in a second. And then if that patient for any reason doesn't need inpatient services and goes home, making sure that those patients get follow-up so that they can get the appropriate care that they need on the other side. The reason for that is that this article in 2018 basically looks at patients who come in with NIH stroke scales of zero and basically, you know, obviously the NIH stroke scale is really meant for TPA. It really wasn't meant for anything else, but it's used for a lot of other things and so people will think, well you have an NIH stroke scale of zero. Eh, you know what, they're fine. They're not always fine and so we need to be able to go a little bit further and delve into that patient. So this is something, again, as part of your model that AAPMNR needs to be a part of in making sure that that happens. So what we did was this is a special report. Pam Duncan and a bunch of us joined on with her when she gave a lecture a couple years ago at the International Stroke Conference, which basically said that comprehensive stroke centers, you know, are for comprehensive management, but one thing they don't do is they really don't take a lot into consideration on the rehab side for just the reasons that I talked about. Basically, and she concludes by saying here, the state of post-acute stroke care in the United States in acute neurologic centers is where acute stroke was decades ago. Note the disability and move on. So... And obviously we need to do more than just move on. We need to actually teach these... work on these. So there's an urgent need to shift paradigms and look at the quality metrics so that we can do what's called a rehab-ready center. So basically not only are you doing the stuff that you would normally do for the acute care, but then you're really assessing the patient to make sure that they will get the appropriate things to move on. Again, as part of an APM, something that we should do, because that's value. So in addition to that, you have to take care of other things, their social needs, to ensure food, financial, other social determinants of health and availability of a good caregiver. So again, things that should be done that we take for granted when patients come in and when we're assessing them to come into an IRF, but needs to really be done a little bit more on the acute care side itself. For outcomes that need to be done, basically maybe looking at proportions of patients with care plans for transition to transition to wherever they're going. Looking at patients and where are they actually going? Because again, depending on the model of care that you're going to be, you may have IRFs or you may not have IRFs, or you may have IRFs, but because that patient happens to live next door to a SNF and they don't want to travel however many miles to go to an IRF, they're going to go to the SNF, which is obviously, maybe not the most appropriate thing, but that's what they're going to decide and unfortunately you've got to deal with that. Measurement of proportion of patients referred to lifestyle management programs. So again, talking about diet, exercise, all that, making sure that's it. Mortality, disability is certainly something. Promise is something. Stroke impact scale, blood pressure control, looking at some of the risk factors to make sure they don't have another stroke and then some of the things that insurance companies may want to look at, 30-day hospital readmissions, which is what CMS looks at, utilization, return to work, satisfaction and not only patient satisfaction, but satisfaction across the whole continuum. So stakeholders, team members, caregivers, all that, making sure that the model that is there is happy, that everybody is happy doing with all that. So and then clinical performance measures is going to be part of that and again, this was something I was not a part of, but Joel Stein and Rich Harvey, two AAPMNR members, were. So in 2021 this paper came out that really delineates some performance measures. That can be used for stroke rehab. What they summarized was that post-acute care matters and that it's the time to honor the patients and caregivers strongest asked, better access and improve secondary prevention, stroke rehab and personalized care. So again, the model that you're going to use when you're developing these things has to include all of these things and then again, since it's patient centered, you want to make sure patients are taken into consideration and at the same time we want to be the drivers of that. I would love to say that my work here is done. Obviously, I think as you can tell, that is not the case. So we have a lot of work to do still to sort of reach that holy grail. So just to give you some ideas of what's going on, we talked a little bit at the beginning about the Medicare physician fee schedule, but just to give you... and I'm only the messenger. So starting in 2023, an APM has to have up to 75% up from 50% of their Medicare payments or 50% of their Medicare patients coming from an APM in order to become a qualified participant or QP and as required under MACRA starting with the 2023 performance year which will affect the 2025 payment year. Believe it or not, there is not going to be a 5% incentive payment, which is not a good thing. So basically, you do all this stuff, there's no incentive for it. So this is actually a really big issue. So of course, the Academy is very concerned about this, because you're going to basically turn around and say, okay, why are we doing this? If we're not getting rewarded for this, why bother? And so basically, some of these are going to... The Academy's comments will address opportunities for specialists to participate meaningfully in advanced APMs and qualify as qualified participants to date and that you have to, as we said before from the principles, that you've got to be able to cover your infrastructure. You've got to cover your administrative costs. You've got to cover your EMR. You've got to cover what it takes if you're taking on this kind of risk and any other investments, because it really truly is an investment and ultimately, as we all know, when things started happening, when we went on PPS for example, we had to hire people actually to take care of collecting that data for the IRF-PAI. So how do we take care of that, because to get this means investing in it, and if you're not going to get anything back for it, throw up your arms and whatever. So again, we're concerned about sunsetting the APM incentive program, as well as the future imbalance of incentives between APMs and MIPS not only discourages movement into programs, but basically go back into MIPS. If clinicians go back to MIPS, they're competing against less-resourced programs, which could then skew distribution. So there's a lot of push and pull with this stuff under what's supposed to be a budget-neutral program. So to hear more about this, we're going to be doing another lecture this afternoon on strategies for the changing quality landscape that will be in this very room at 2.15 this afternoon. So if you want to hear more about this, please come back. This is a really, believe it or not, a very important issue. I always kind of say this is sort of the under-the-radar kind of thing, but it's still a very important thing that over time is going to affect potentially every one of us in the room. So I hope that we've been able to provide a lot of good information for you. If we haven't, certainly please ask questions. We'll move on to that section and please use the microphone, because this is being recorded and people who are going to listen to this later will want to hear all these questions. So please. Hi, Rich. Hey there. So to some extent, I feel like having this talk here is like preaching to the choir and what really concerns me is as more and more people are moving away from traditional fee-for-service Medicare and joining Medicare, as Dr. Gutierrez calls it, Medicare Disadvantage, that we are seeing increasingly, despite sharing clinical practice guidelines, which were wonderful and we were all so psyched about in 2016 and the VA came out with endorsement for clinical practice guidelines, we're just... I'm just really astounded at how these Medicare Advantage programs are getting away with denying stroke patients inpatient rehab and I'm just wondering... I almost feel like you need to go talk to a managed care conference. How can we better tackle that so that our patients are getting the level of care they deserve and not... I've been in a lot of conversations with medical directors from these Medicare Advantage programs and it's extremely frustrating and of course, they're not PM&R physicians. So yeah, I feel the pain. I think even with us at NRH, we've definitely been talking about that aspect of it and it's... Even though I largely do outpatient, but I do cover the inpatient side and when I do... I just covered a couple of weeks ago and yeah, social workers were basically talking that more and more people are going on to Medicare, as you like to call it, disadvantage programs. I think there is two... I guess there are two aspects of it. Yeah, we got to get a seat at the table of those things, which is again, a lot of this stuff is hard because there's just not enough of us, but yeah, getting out and maybe talking and getting more data is going to be very... I think will be very helpful. Data is always a good driver and then just getting out and as I said early on, if you have the opportunity, open your mouth, get involved, take a risk of talking about these. It's hard, but I can tell you in some case and for me, doing things like stroke rehab at the American Stroke Association, I've been doing this for 30 years and it's still a battle, but I think we're slowly beginning to make inroads, but that's... You're not going to win battles quickly, but hopefully. Yeah, and if you think about why are Medicare advantage or disadvantage programs not sending patients to IRS, but to subacutes or SNFs, it's because of ultimately the financial implications of that decision making. The argument we're going to have to make and health systems have to make is there might be a short term benefit in decreased cost of going to a SNF and maybe the outcomes short term are okay, but what is the long term financial implication and outcome to those patients? You've got to be able to have a rebuttal and a discussion on the terms that those payers will listen to because maybe it's not the best care no matter what the price is anymore. Maybe it's adequate care so our patients don't die. That may be where their head is at. You have to really think about if you had to manage 20 million lives around the country, what would your guidelines be? Then you can finally... What I'm saying is that the economics is part of the discussion and you've got to really understand that it's not the economics we want to have, but it is out there. You really have to understand how to have those discussions because just saying patients should get better care is not going to be enough to convince them anymore. That's all. Right. Then I'll let Dr. Fleming have her question. I think to add on to that, as I talked about earlier, on one hand we want to talk... That's why we want to talk about with bundles trying to include some of this stuff, but at the same time the problem is, as I mentioned with some of the data, you have a lot of cost that is indirect, which frankly Medicare Advantage, they're going to say, well, you went to a stiff and now you're going to a nursing home. Who cares because it goes to Medicaid. We don't have to worry about it anymore and that's a problem. We've got to figure out in terms of what's in their heads, what's meaningful to them and really try to see if we can spin it that way. Unfortunately, that's the only way we're going to get anywhere. Dr. Fleming. Yes. Thank you both for a wonderful presentation and both of you mentioned things that I've been thinking about for a while. I'm at JFK Johnson Rehab in Edison and my clinical research right now is taking patients post-stroke. We know that they're going to be discharged from the hospital, so my work has really been building a more robust outpatient program for patients to go to and we're using modified cardiac rehab really in that sub-acute phase first 90 days or so. We're showing that we're improving function, we're decreasing mortality, decreasing re-hospitalizations and just like you were mentioning, we actually had a meeting with CMMI and they said, oh wow, your data looks great, but actually when you're reducing mortality, that doesn't help us. It only helps us when the patient dies because then we don't have to continue paying resources towards them. I'm finding more and more as I'm in these conversations, we almost need clinicians to learn how to speak MBA speak, how to speak these other terms because we need someone to bridge these two worlds. We can't not have the clinical outcomes and the importance, but you're exactly right. They're saying, yeah, that's great, but what about the bottom line? How do you guys see that moving forward? Do we need to invest in more physicians in developing that business mindset? How can we leverage maybe telehealth to do some of these other things? I feel like we need to start really thinking way beyond what we have right now, so I'm just interested in what you guys have to say about that. Sure. Full disclosure, myself and some others in this room have MBAs and MD or DO degrees, so we've thought about that for sure. On FIS form, there is a member community, which is called the Business of Healthcare, which you can bring these questions up for sure. The academy has ... I know that before the pandemic, there was going to be an annual sort of MBA light course that was going to happen through, I think, the Kellogg School. It's important to understand that healthcare is the biggest GDP sector of this country's economy, and there's a lot at stake. You have to understand the resources and the value, because at least if you can talk about that, then people will listen to you, no matter whether you're a physiatrist or an orthopedic surgeon or whatever. It's difficult, because you're also talking about patient lives and quality outcomes and patient satisfaction, and a lot goes into that. I believe that given what our training is, having that financial understanding is crucial to getting heard by others as well. Before Carolyn talks, I want to introduce Carolyn as well, Carolyn Millett and Megan Rupp. We can't do our jobs without them. They are our two resource people and academy staff who helped us with this presentation, by the way. We thank them both for their help in helping us to do the jobs that we are trying to do for you guys. So, Carolyn. I just wanted to quickly add on the managed Medicare, Medicare Advantage issue. That's a major advocacy area for the academy. One of the things that we have ongoing right now is a FOIA request for some of the criteria that managed Medicare is using to deny some of these cases. I think that lack of transparency is part of the problem with the questions that we're trying to ask. It's an ongoing issue. Those FOIA requests, obviously, can go on for several years, and it's already gone on for almost a year. We're hoping to get some degree of transparency with some of those decisions, which will give us the leverage to hopefully improve some of the denial issues that we're seeing. It's ongoing. Right. Yeah. Thanks, Carolyn and Megan. I also want to mention Kate Stineford, who is not with us any longer, but she was really involved with the origins of IPPM and the original publication that came out as well. One of the toolkits or the toolkit that's on the academy website is the post-acute care toolkit. So, this whole discussion of SNFs and IRFs and stroke patients is the post-acute care world, and talk to your healthcare system, who actually makes decisions for all of that. As physiatrists, we should be the ones helping to lead those committees, because then you really can start talking about following costs. If your health system owned a SNF and owned an IRF and owned an LTAC, well, then you could probably figure out actually where patients should go to the right level of care and get the best value for that. Yeah. Thank you. Daryl. Some of the points I was just going to make. So, Stu, Rich, thanks for a very provocative discussion. You know, one thing I would add is, number one, you're doing the right thing, so keep doing it. Who you talk to makes a difference, though, right? So, if you're talking to a private payer, they don't care about your exercise program because that person's going to be in somebody else's... on somebody else's insurance a year or two later. They rotate, right? If you're in a Medicare program or a Medicare Advantage program, yeah, that person's going to stay alive, but they have chronic disease that's led to a mild stroke and mild disability, and ultimately they're going to be back in the hospital. So if you're reducing their cost, even if they're alive, they can't wish that person dead because they're not just going to fall dead in one day. They're going to have multiple re-hospitalizations and costs that they need to manage over the rest of their life, and who's better to manage that than PM&R? So I think there are business ways of addressing those concerns. I recently had a sit-down discussion with Humana Medicare Advantage. They're in hometown. I'm in Louisville, Kentucky, and made it very clear to them that we were seeing a very disturbing trend of denials to IRFs for very appropriate patients, and many of which were saying this term that we all hate, which is, care can be provided at a lesser level or a lower level care. So I just wanted to make sure everybody knew that number one, that is totally inappropriate and illegal. Medicare has actually made a statement in 2010 that said you are not allowed to say that. So when you see that in a statement, make sure that your Medicaid or Medicare Advantage programs are not using that terminology because it's inappropriate. Keep track of that. They have actually, Humana has said to us, we're not going to use that language or not make sure our providers know not to use that language anymore because it's not acceptable from a Medicare perspective. Remember all of our patients in Medicare Advantage programs are supposed to be getting what Medicare would also provide, but that's why we call it disadvantage is because they're not. My bigger concern going forward, and the question maybe I pose to you guys to think about is as we move to more alternative payment models, as we move to a bundled payment system, what Stu brings up is important, which is if we can all create post-acute networks within our systems where we have our IRF, our SNFs, our home health care, our outpatients connected in some way and we can collect the data, maintain the quality, then we have a hope at some point when impact starts to come around and start saying, well, we're going to pay you $50,000 for the next 60 days. You figure out what to do with it. The only hope we can have is, number one, that it's deregulated so that we can move people wherever we want without concerns or without prior authorizations, and that, number two, that the physiatrist is the one who dictates or determines those resources because right now when Medicare Advantage says no to me and I appeal and they say no to me and then I appeal again, I go to NaviHealth, and NaviHealth is going to say no because that's how they make their money. So we have to be worried about these for-profit conflict of interest issues where we're looking out for what's best for the patient, and yet we're talking to somebody whose sole interest is to make money by reducing cost. And so those are where I think physiatrists need to really get involved now because I think alternative payment models may not be any better for us if we're not the ones making a decision of how to utilize the resources within it. So, comments? No, I totally agree. And so I think the important thing is that's why you need, as part of the toolkit, I mean, not only I think what we've talked about is sort of being able to talk business speak on one hand, on the other hand, being able to talk the quality side, which is why I threw in the fact that you need to know what are your practice guidelines and what's out there that you can say, hey, look, this is an organization that recommends and there is level one evidence to say that there is stuff to do. So you sort of have... And this is kind of where we're headed with us. So our committee, for example, we want to work with EQPC on the quality side because you've got to marry the business side and you've got to marry the quality side. So that's kind of where we're going to be headed. And now I'm going to be Henry Fonda in the 10th man because what I may say is that, or will say, post-acute care decisions, it might not just be the physiatrist. You might want a geriatrician there. You might want a primary care provider there. And collaboratively you work together and then maybe you really make the best decision because you're getting buying input from the other clinicians that really are involved with those cases. And think about ahead of time, have a geriatric nurse practitioner spend time on a rehab unit with you or a fellow in geriatric spending time. Have a primary care NP spend some time on the rehab unit and in the post-acute world. It might open their eyes up and make it easier to actually eventually create a form that works for post-acute care overall. I'm Steve Reese. I come from South Louisiana and part of the Ochsner Health System. And what we have, talking about our post-acute networks, we actually have been working hard on developing post-acute networks throughout and have done a fairly good job of it. And in fact, in physiatrist being in charge of this, in January I will take over as a medical director of post-acute and transitional care for the system. And part of the problem in all of us talking here, we are trained to look at our individual patient and always... And I teach the residents. When you're in that room, that's the most important person in the world to you. And that's how we... But I would hate to be the one that had to figure out how to pay for all this stuff. And I think the other thing I tell people all the time is, you have to understand the purpose of an insurance company. It's not to take care of people, it's just to make money. And so at the end of the day, when we understand that, and you understand where they're coming from, and their mindset, then you can start to have those conversations. You are right telling that we have to show how we are financially advantageous to them. But we've already done that, and they've ignored it, right? You have the Dobson-DeFazio study from a long time ago that said, hey, look how great we are, they don't pay attention to it. But we are going to have to continue to do more and more research, support the foundation, and say, look, what can we do, how can we do this, why don't we come up with things? And that's where a lot of this is going to be coming from, is our research going forward. But we also do have to integrate, the lines are going to be very, very blurred, and the more we try to keep them separate, the more they're trying to blur them, and say, okay, you can't do this, you can't do that. I think fighting the Medicare Advantage plans, what's really going to happen is somebody's going to have to sue them and win. And once they win, that's what happened a long time, 15 years ago, when these people thought they were in the ivory towers and could just make decisions without any type of ramifications. And when medical directors started getting sued individually, then they started changing things. From the standpoint of getting involved from a... and knowing more, there are MBA programs, but there are also, through the AAPL, there's also a certified physician executive program. Not everybody can afford to go and take an MBA program, but you can get a lot of the information you need to be able to talk to the people that are going to be paying for this and the decision makers by getting that information. So there are a lot of different opportunities out there to do this. But, you know, one of the things, excuse me, again it comes down to is we have an obligation to all of our patients that we're taking care of now. But we also have an obligation to patients that haven't even had their strokes yet, that haven't had their back pain yet, because if we don't do things right and we don't figure this out and help them to figure it out, we're not going to be able to take care of anybody. And so, you know, it's important that we, again, support the foundation, support research, get involved, learn more, go to business courses and become involved in this. My journey has been a little different in that about 10 years ago my hospital system, I became the chief medical officer for the system, not just for the rehab hospital, but for the system itself. So I've had 10 years of being able to look at things from a wide perspective and understand that this system hasn't been self-sustaining since we came up with it in 1965. And so we have to keep figuring out how to do it and make it better. Thanks. Thanks. And remember, you know, the AAPMNR is part of the House of Delegates for the American Medical Association. I'm one of the national delegates. Susan Hubble is the chairperson. Dr. Malami is the young physician delegate. There are ways to work with the AMA to address these questions and bring up resolutions and, you know, utilize other physician leaders around the country to work and help us address these concerns with Medicare Advantage programs and access. Steve. So just before, I just want to make note for the recording, because according to our recording we are out of time, but I will take those last... I'll take Dr. Natz and Dr. Simmel and then we will wrap up. Hi guys. Dr. Steve Natz. So as you know I'm, I guess, well invested in the subacute skilled nursing facility environment and including stroke patients. I think that we do our service and we do our specialty and our patients a disservice when we try to really split, you know, we try to protect acute inpatient rehab. And I've heard some comments here this morning saying that, you know, acute inpatient rehab is obviously better for stroke patients. I'm not so sure that it is. I mean in a skilled nursing facility environment we see those stroke patients in that 30 to 60 day window where they're really starting to make progress. And I think you would probably not be so protective of IRFs if you had good physiatry and good programs in subacute environments that you felt comfortable sending your patients to. You knew that they were going to get good care. You knew they were going to get good outcomes. And, you know, I guess that's been my opinion over the last few years is that we're, you know, in particular the company that I work with is trying to get really good physiatric care into all different levels of post-acute care, right. So I guess that would be my comment is that, you know, please, you know, from the academy standpoint I don't want my academy protecting one particular level of care. Right. I mean I understand places like AMPRA and stuff have to kind of do that. They're hospital based. But, you know, and I think that there are skilled nursing facility organizations that are marketing to, you know, that are marketing to Medicare Advantage plans saying, look we can do this cheaper than, you know, than an IRF can. So... But I think our academy should really be protecting physiatrists in all different levels of care. So I'm going to go ahead and make that statement. So my response... I don't necessarily disagree with that and actually one of the reasons is because the recent project that I've been working on with the American Stroke Association is Mission Lifeline Montana. Exactly the case where in rural areas they are dependent more on skilled nursing facilities than they are on IRFs, because there's maybe I think one or two IRFs in all of the state of Montana and obviously hundreds and hundreds of miles. That said, what we're trying to do is to raise the bar. And so what our job has been, has been to actually develop guidelines and performance measures for skilled nursing facility stroke rehab. So, you know, I think that... But that's the key to doing all that and I think to me, you know, my holy grail since I've been working with ASA on stroke systems of care is exactly that. I've talked to Dr. Semmel, my boss, about the idea of, you know, why don't we identify... You know, even if they are coming to IRFs, why not identify several places within the D.C. area, you know, where we can say, hey, you know, get CARF certified, you know, because CARF does subacute... You know, they do skilled nursing facilities. So get them, you know, if they're willing to make that investment, you know, let's do it with the incentive being, hey, you'll be our preferred place to send patients when they're done here if they need to go to a SNF because we know they're going to get good levels of care. And then the same deal, if we have to deal with, say, Medicare, you know, Medicare Advantage, you know, you can make... Again, if we are having physiatric care there, yeah, there's that possibility that if you can raise the bar and know that they're going to get good levels of care. Not that I'm saying that we shouldn't, because the guideline very... Our guideline very specifically says, from 2016, that if a patient qualifies for an IRF, that's where they should go. That's... You know, there's no question about that, but if, you know, but making sure that in those other levels of care that the bar is raised high enough that we know that those patients are going to get the kind of care that they deserve so that they're going to get the best outcomes. I appreciate your support. No problem. Thanks. Thanks, Rich. I think your point is well taken on the SNFs. I think on the other side of it, in acute rehab 30-35% of the nation's inpatient rehab admissions are stroke. So this is a huge topic in my opinion. I would also say from a strategy perspective, we have two IRFs within our health system, one of which we aggressively expanded our consult service, one of which we didn't. The same one we expanded the consult service. We began a fax appeal program with Medicare Advantage and we're overturning 75-80% of the denials. You can't do that as the IRF. You can do it as the consult doc that we've placed at that acute care hospital. So I think there's a strategy component. I think that's a good short-term fix. I think if there's anybody from Atrium Health, they're miles ahead of all of us in how to do this and I think happy to partner with us on how to become a bit more aggressive and I think we need to learn from each other. So I do think there's strategies out there. Also I guess my two cents would be as we look at high-intensity gait training, things that involve more staff than a SNF might be able to do, I think it will also increase the case if it's more well-adopted in the U.S. and if we all agree that it is as useful as some say it is. I think that speaks to the case for acute rehab. I think we need both acutes and SNFs. We're never going to meet the demands of stroke patients, but I think what we want to not do is lose the option to make good choices for our patients. So while we do want to expand into potentially SNFs and having all the options within our health system, I think our health system needs to realize we need to have physiatrists speaking for our health system at every one of our referral sources. And we've had success outside our system placing physiatrists. I was a bit surprised to see that. So I guess that's my two cents. I don't know if you agree. No, I totally agree. And full disclosure, Jenny is my boss. And other disclosure, that means that since Jenny is my boss, that's MedStar, which basically means NRH down in D.C. and we also have the unit at Good Samaritan Hospital here in Baltimore. So just so that you know where this is all coming from. So no, totally, totally. I mean I think those are good strategies to think about. And again, I mean I think it just brings home the point, you know, that to close really that we've got to put people... we've got to get physiatrists in all the key places. I mean there are not a lot of us, but nonetheless we've got to get people, you know, we've got to get them in the SNFs. We've got to get them on the consult services. We've got to get them in the places where we can advocate, you know, and hopefully make the best decisions for our patients. And so those are the models that we need to work on. So given that... Oh, I'm sorry. And hopefully have some data and research that we can publish that supports it, because at the end of the day we can talk about it in a qualitative sense, but we have to really be able to show that we've proven, you know, that it makes a difference. All right. The Academy's registry discussion is going to happen in 10 minutes in the Learning Center at the Exhibit Hall. Good commercial. Okay. Hopefully we'll see you this afternoon. Thanks, everyone. Thank you very much.

physiatry-led APMs

value-based care

payment models

APM adoption

barriers to transitioning

Spine Care Toolkit

IPPM

care pathways

post-acute stroke care

rehabilitation services

care coordination

evidence-based practices