Good afternoon, and welcome to this session entitled Back to the Basics, Value-Based Payment 101. My name is Rich Zorowitz. My day job is as an outpatient neurorehabilitation physiatrist and chief medical informatics officer at MedStar National Rehabilitation Network in Washington, D.C. My extracurricular activities for your academy include being chairman of the Innovative Payment and Practice Models Committee. What we are doing today is really talk about value-based care. In this presentation, we have Cindy Moon, who I'll introduce to you in a second, one of our consultants, and two of our committee members, John Om and Erica David-Park. This is going to be the agenda. We'll start with an introduction to value-based payment, followed by some case studies in perioperative rehabilitation and nursing facility and subacute rehab value-based care, followed by roundtable discussion with the panelists and some Q&A as that comes up. I like to always talk about this as being the topic that everyone needs to hear but nobody wants to hear. This is ready or not, as it says, value-based care is here. CMS for the longest time is trying to transition us really from a fee-for-service system to value-based care. So fee-for-service, as you know, basically is we bill for it, we get it. But on the other hand, they want better value and they don't want to pay as much for it. And so the idea behind value-based care is to lower costs but get the biggest bang for the buck for those costs. And the other thing, too, is that patients want to access better care at that lower cost. So it really, it benefits, ultimately benefits patients. The major thing with this is that we're going to need to have transparency, there needs to be equity, and then there needs to be accountability to all of the models that are done this way. So our committee, which is going to be under the, it's HIPAA, not that HIPAA, but it's health policy and practice, is basically one that researches, again, the progressive payment models and practices to do, to basically determine the potential, not only to get better care, but basically have us as physiatrists be the drivers of that care, to be able to figure out what are the things that we do best and then basically sell it so we can be at the helm and do some of these things. And so our committee also is going to work, as we'll talk about maybe a little bit later, to disseminate knowledge about what are called alternative payment models and other care models to our membership. So that is really what we are planning on looking at today. If you're interested in looking at some of the resources, you can grab that QR code off the screen and that will take you to the appropriate webpages on our Academy website. They include things like our Alternative Payment Models Glossary and some of the documents that we as a committee have done, which are Principles of APMs, APM Education and Advocacy, and the 2022 APM Benchmark Survey Report, which is something we do every couple of years. The Coming Soon, which we'll talk about a little bit, is sort of a work of love, developing toolkits of how to really develop APMs for spine care and stroke rehabilitation. And so if we have some time at the end, we'll talk a little bit about that. So with that, we'll get into the meat of the matter and we'll start with our first speaker, who is Cindy Moon. Cindy is one of our really valuable consultants for the Academy and specifically to our committee. She's the Vice President of Healthcare Payment and Delivery Reform at Heart Health Strategies in Washington, D.C. And she's going to give us the 101 on value-based payment. So, Cindy, thank you. Thanks. All right, thanks so much. All right, so I'm going to start. I feel like I'm really short down here, but hopefully you guys can see me. I'm going to start by introducing myself. by providing an overview of value-based payment. And just to be up front, as you can imagine, this is going to be a very high-level overview just given the amount of time we have in today's session. But I'm going to start with that, and then I'm going to do a little bit of a deeper dive looking at alternative payment models in particular, and then also looking at how value-based payment is incorporated under the Medicare Physician Fee Schedule. So starting with that overview, what is value-based payment? So here we're talking about basically the idea that payment can hold providers accountable for achieving desired outcomes. And when we talk about desired outcomes, the specific measures might vary from case to case, but typically, you know, they have focused on improving quality, which could include patient experience as well as kind of the cost of delivering care. I would say more recently, in recent years, payers have also had an increasing emphasis on looking at outcomes associated with health equity as well. And under value-based payment, what we're looking at is movement away from pure fee-for-service payment and towards incentives that drive behavior. So we have things like pay-for-performance programs, which still rely on fee-for-service, but might, for example, adjust payments upward or downward based on performance on specific measures. And then moving even further away from fee-for-service, we have alternative payment models, which I'll talk about a little bit more, as I said. So this slide has a lot of information on it, and if you'll just bear with me as I walk through it. This is developed by the Healthcare Payment Learning and Action Network, and it does a couple of things. So you'll notice that it's kind of broken out into different categories, Category 1, 2, 3, and 4. And that reflects what is called the APM framework that the LAN has put together, which I think is a useful tool because it helps establish a common vocabulary, a common understanding of alternative payment models, but it also kind of shows how different payment arrangements can fall in a spectrum from fee-for-service to more complicated or different payment arrangements that are further away from fee-for-service. So if you look in the top left corner, we have Category 1, which is fee-for-service only, no link to quality and value, then Category 2, which is fee-for-service with a link to quality and value. That could be something like the pay-for-performance that I mentioned earlier. Category 3 is when you start getting into alternative payment models, and 3 and 4 include alternative payment models, but 3 focuses on APMs that are built on a fee-for-service architecture, so still using fee-for-service payments for individual services, whereas Category 4 looks more at population-based payments. So those are the different kinds of payment arrangements that you can think about when you're thinking about value-based payment. What this slide also shows is where we are in our healthcare system today as far as the percent of payments that flow through each of these categories. So based on a survey that was just recently announced, looking at 2022 data, in 2022, over 40% of payments were tied to fee-for-service only with no link to quality or value, which in my mind, I was a little bit surprised that it's still that high. So there's still definitely, I think, room for movement towards greater incorporation of value-based payment. And then at the very far end, we see that in that green wedge, about 10% of payments are in models that rely on population-based payment. So really a wide range of where we are, and I think there is an interest in moving more towards kind of the higher end, the higher categories. And one reason I brought up that APM framework is because this is something that the Academy has also considered. So when the Academy, or rather, the Academy conducted an APM benchmarking survey last year, and they asked respondents to think about the payments that they are receiving and how they fall within this APM framework. So what you can see here is that the picture looks very different from what you saw on the previous slide. And I will just caveat that by saying, you know, it's very hard to do apples-to-apples comparisons. We are not doing that here. But at the same time, it's still interesting to compare regardless. But of course, the methodology is different, and the questions are a little bit different. But what this slide shows is that compared to the 40% of payments, you know, across the health system that were tied to fee-for-service only, when we looked at the PM&R respondents, the members who responded, over 60% are looking at payment only within fee-for-service. So not even any link to quality or value. And then at the far end, only 4% are reporting any participation in population-based models, and only 5% are looking at other alternative payment models. So less than 10% in any type of alternative payment model at all. So pretty stark difference. We can talk a little bit, or I will talk a little bit, about why that might be in a little while. So then looking closer at alternative payment models, CMS defines, so CMS, you probably all are aware, but CMS is the Centers for Medicare and Medicaid Services, and it operates the Medicare and Medicaid programs. So CMS defines an alternative payment model as a payment approach that gives added incentive payments to provide high-quality and cost-effective care. And I would say that this payment approach, again, is not, you know, may rely on fee-for-service, you don't have to, but it also incorporates other kinds of payment incentives that are not solely tied to the delivery of a service. CMS has said that these APMs can apply at various different levels. So it could apply to a specific clinical condition, like cardiovascular care or mental health. It could apply to a care episode, like sepsis or a knee replacement. Or it can apply to an entire population, looking at all of the care that patients receive and all of the costs of that associated care. So lots of different ways that alternative payment models can be implemented. Here I've talked about, I've put some information about some common APM model categories, also relying on categories that CMS has identified. So the first category that they use is accountable care models. And I put that in quotes because, you know, I kind of feel like all models, you know, when we're in this space, they all require accountability to a certain extent, but that's the terminology that CMS uses. And within that category we have both accountable care organizations and advanced primary care models. So accountable care organizations are when groups of providers, which may include physicians, may include hospitals or other types of providers, when they get together and they take on responsibility for coordinating and managing care of a population. And they also agree to hold accountability for quality and cost outcomes. Generally these are total cost of care models, so they're looking at the entire population and all of their costs. And they are also models where the ACOs can benefit from shared savings if their costs are below benchmark levels. I've included links to a couple of accountable care organization models here. The MSSP program as well as the ACO reach model. And I think if you have access to the slides after the annual assembly, you can click on those links to learn more. Then we have advanced primary care models. Here we usually are talking about smaller entities, so not giant ACOs, but like maybe individual practices. And these are practices that include primary care practitioners. The focus is really on kind of improving the way primary care is delivered. Typically participants are responsible for engaging in some practice patterns like changing the way they practice in order to incorporate advanced primary care practices into the way they deliver care. As far as what the alternative payments might be in addition to fee-for-service, we've seen things like care management fees, PMPN payments, as well as incentive payments based on performance on quality outcomes. And then we've also in more recent years kind of seen greater use of either partial capitation or full capitation in some of these primary care models. I've also included links here. And then we also have disease-specific and episode-based models. And I think the models in this space that are most interesting, that might be most relevant to you all are some of the bundled payment models, including BPCI Advanced and the Comprehensive Care for Joint Replacement model. And I know Dr. Alm is going to talk a little bit more about the CJR model. But in this type of model, we're looking at an episode of care and all of the costs that might be associated with it for a specific period of time. So it could be a stroke and the hospitalization and a 90-day period after that. So we're looking at all of the care that's relevant to that stroke and trying to make sure that quality within that care episode achieves certain standards as well as cost staying below a target price. So those are just some common model categories that you might hear about. But unfortunately, what we've seen, for PMNR at least, is that there are challenges with getting PMNR participation in these models. And that's for a couple of reasons. So for example, I think these models, you might have seen that there's a strong emphasis on primary care with limited opportunities for specialty care integration. This is an issue that I think CMS is becoming increasingly aware of and trying to solve for, but I don't think that we're quite there yet. Kind of compounding that is the fact that they incorporate into these models quality measures that may not be reflective of the care that PMNR specialists deliver. And so if APM participants are not being held accountable for outcomes that PMNR can influence, then they have less incentive to incorporate PMNR specialists into their models. Even in some of those episode-based models where there are potential opportunities for PMNR, I think when you look at all of the different range of services or episodes that might be included, the ones where there are opportunities for PMNR might be limited. And then what we've heard anecdotally as well is that there could be cases where the model participants themselves, and these are the folks who are engaging in the contracts with CMS, so like the hospitals and the health systems, they might not recognize the value of PMNR engagement. So again, anecdotally we've heard that these participants might be more interested in referring to PT instead of PMNR, right? And so that also makes it harder for PMNR to participate in these models. That being said, even though there aren't model opportunities, and there I think I was focusing a lot on the models that have been operated by Medicare, there are potential alternatives that you could consider, so potentially exploring APMs or other financial arrangements with private payers, and also looking at ways you can promote delivery changes within your health systems, and maybe even providing a potential linkage to incentive payments. And here I'll note that we're going to hear about some examples again later in this panel, but also point you back to those toolkits that Dr. Zorro once mentioned, because those I think are really going to provide kind of a roadmap for taking on some of these activities if that's something that's of interest. So I think, you know, there's broad consensus that APMs can provide overall value to the health system. That's why there's an interest in doing them to begin with. There's a feeling that, yes, they can address deficiencies. They can fill gaps. They can improve the quality of care and improve equity and lower costs. So I think that, you know, that is well recognized. But I think another thing to think about is that these APMs and participation in APMs can also provide value to clinicians. And we've heard that a lot, and that APM participation can improve or increase opportunities to provide appropriate care. They can also then lead to better beneficiary care and an increased provider satisfaction. Sometimes they lead to more flexibility. Depending on the model, they can provide resources that help, you know, improve and build your practice and build that infrastructure. So for example, if there are care management fees, and then at least with respect to the Medicare program, there are opportunities to receive special treatment or incentives under the Medicare program, depending on what kinds of models that you're participating in. So, you know, I think just keeping in mind that participating in an APM is not just something that payers are pushing downward on physicians, but also that, you know, have the opportunity to provide benefits to physicians as well. But of course, you know, that will depend on a lot of factors. And then on the flip side, there are also, of course, risks you could have to undertake upfront financial investments in order to participate in a model. If you need to change the way your care is delivered, you might have to take on downside risk and be responsible for paying back any excess spending, depending on the model that you're participating in. There could be unintended consequences to patient care. And that's, I think, there you want to make sure that the model is creating the right incentives to hopefully avoid some of that. And then, you know, anytime you stand up something new, there's burden that might be involved, right? Like, it's not going to happen automatically, and so there could be potential burdens that you have to also take into account as well. So on this slide, and also on the next slide, I've included several questions about things to consider if you are interested in thinking about participation in alternative payment models. This is not a comprehensive list, but again, just something to get you started. You know, what APMs are available for participation in your area? You know, are there things that you can control as a PM&R specialist that would make it worthwhile for you to participate? What is the likelihood of successful performance? And so forth. And then here also, I think it's important to look not just at the big picture, but also at some of the small details. So for example, you know, yes, you have to hit savings or, you know, cost spending targets relative to a benchmark, but how is that benchmark set? You know, how are they risk adjusting it? Who are they comparing their performance against? What services are included? So a lot of times, a lot of these, like, nitty gritty questions also can factor in, you know, what quality measures are going to be included? What's the level of performance that you're going to be expected to achieve? So there is a lot to think about as you start thinking about APM participation. And this is just a start, but definitely something that you want to think about carefully before pursuing. All right. And so given that there is not a lot of participation in alternative payment models now, and it's hard for PM&R physicians at this point, there's still a lot of challenges. The chances are that you are not in an APM, and if you are receiving payment under the Medicare fee schedule, therefore, then you are subject to the value-based payment requirements under the fee schedule. And so I wanted to spend a little bit of time talking about that as well. And value-based payment under the Medicare fee schedule has been established based on a law that was passed in 2015, the Medicare Access and CHIP Reauthorization Act of 2015. And it did a lot of things, that act, but one of the things that it did was kind of create this value-based payment incentive structure, right? So it created two separate tracks. One is the merit-based incentive payment system, and one is the advanced APM track. And CMS collectively called these two tracks the Quality Payment Program, so you might have heard about these. So I'm going to start with MIPS. MIPS is the value-based purchasing program under the fee schedule. So again, based on fee-for-service, but what it does is it provides upward or downward payment adjustments to your fee-for-service payments based on your performance across four categories. So those categories are cost performance category, quality, promoting interoperability, which is kind of a remnant of the Meaningful Use Program, and then also improvement activities. And CMS looks at your performance on each of these areas and gives you a score in each of these areas and develops a composite score. And that composite score is what determines what your upward or downward adjustments are going to be. I will note that each of the performance categories has its own set of requirements and kind of responsibilities, and a lot of times they don't seem to talk to each other at all. So this program is far from perfect, and I think still results in a lot of burden. But what you see in this program, based on your performance in one year, that affects your payments two years down the road. So if you're performing in 2024, that will affect your payments in 2026. If you are required to participate in MIPS and you don't, then you can get a maximum negative payment adjustment, a penalty of 9% off of your Medicare payments. So it's pretty substantial. You can also, if you do really well, you can get upward payment adjustments. But what the value of that upward payment adjustment is varies from year to year, although it has been fairly small in previous years. Then on the advanced APM side, that is for clinicians who achieve significant levels of participation in a certain subset of APMs. So these APMs have to meet certain criteria related to quality requirements and cost incentives, including that they all have to have two-sided risk. And CMS has to designate these APMs as being what they call advanced APMs. So you have to significantly participate in these advanced APMs. But if you do qualify for the advanced APM track, then you are not responsible for reporting under the MIPS program. So that's a lot of reporting burden that you are not required to follow. Congress was very interested in increasing movement into these advanced APMs. So they had provided a substantial bonus for the first six years from 2019 through 2024. There was a 5% lump sum incentive payment based on performance two years before that. Unfortunately that 5% lump sum payment has run out. Congress did extend an additional incentive of 3.5% for 2025 based on 2023 performance. But as of now, and where we are now with Congress, there is no added incentive payment. So starting in 2024, you're not seeing this added incentive payment for participation in the advanced APM track. That being said, there was still a long-term interest in moving folks into the advanced APM track. The other way that Congress provided that incentive was to provide differential payment updates. So starting in 2026, if you're in the MIPS track, then you would only get an annual payment update of 0.25%. But if you're in the advanced APM track and you're participating significantly in those advanced APMs, then you're going to get a higher annual payment update of 0.75%. And that differential is going to grow over time. It's going to compound over time. And so Congress, you know, was intending that to be a strong motivator to move into the advanced APM track as well. In order to address some of those concerns about the MIPS program being burdensome, being siloed, CMS has developed this alternative way of participating in the MIPS program. So this is still MIPS, but it's a different way of reporting. And they're called the MIPS Value Pathways or MVPs. They are available for reporting starting with this calendar year. And basically what CMS did is kind of try to group measures and activities together into clinically cohesive sets in order to make performance across the four categories a little bit more linked. These also, CMS also required somewhat less burdensome requirements for these MVPs in order to also encourage the use of them. I will note that CMS has said that these MVPs are initially voluntary, but that they anticipate that this is the direction that they want to go. And they have said that they want to fully transition to MVPs over time. So that's something that we're keeping an eye on because right now there just aren't enough MVPs to cover all of the physicians who are on MIPS. But we'll see if CMS makes a lot of progress in that direction. So again, if you are required to participate in MIPS, there are a couple of things you want to keep in mind. You want to check to see whether you are in the MIPS track or the Advanced APM track. There's a website that you can go to, it's on the next slide. It's also possible that even if you're receiving payment under the fee schedule, you could be exempt. And that may be, for example, if you're not seeing enough patients, you're not having enough dollars flow through the fee schedule, or if you're new to the Medicare program. But if you do check your status and you are in MIPS, then just keep in mind that every single physician fee schedule payment that you're receiving, every physician service that you're providing to every Medicare beneficiary is subject to a payment adjustment. And again, that payment adjustment can be as much as minus 9%. So if you are required to participate, I think it's important to remember that and then try to perform well on the different performance categories. Another thing to keep in mind is that you can be in an APM and still be in MIPS. And that's because you could be in an APM that's not an Advanced APM if it's not meeting those criteria. So for example, if you're in the Shared Savings Program but only in a one-sided track and you're not taking on risk, then yes, you're in an APM, but no, it doesn't qualify as an Advanced APM. Also I mentioned you have to achieve significant levels of participation and there are thresholds that are set in statute that have gotten harder over time. So if you're participating in an Advanced APM but you're not hitting those thresholds, then you would still be subject to the MIPS reporting requirements. And then if you are in an APM and you're subject to MIPS, then you would basically have two sets of reporting requirements, whatever is required under MIPS and whatever is required under your APM as well. So again, if you are required to participate in MIPS, the first thing you want to do is just check whether that's the case. The website is qpp.cms.gov participation-lookup. So it's very easy to go there, put in your NPI and figure out whether or not you're required to participate in MIPS. If you are, you want to familiarize yourself with the MIPS reporting requirements. There's information on that website, but there's also information on the AAPM and our website as well. So there's a lot of resources there to learn about the program. And then the other thing that you want to do is kind of understand your organization's approach to MIPS reporting. Because you can report at the individual level, but your group can also report on your behalf. And so you want to understand what they're right, how your group is approaching it, and understand how you fit into that approach. If you are reporting on your own or if you're involved in the decision-making around your group's reporting, you can review the quality measures. They do tend to change from year to year, sometimes significantly, sometimes just in little ways that the measure is specified. You also want to look at what improvement activities are available because they also can change from year to year. And think about what are the measures that you can report that are likely to maximize your chances of achieving a high score. And then if you have been participating in MIPS previously, CMS also provides performance feedback and you can log into the CMS website to get reports on how you performed in previous years. And that can help inform, you know, how successful you've been on the measures you've been using and identify areas where you might want to try to work on improving performance. So that's MIPS. And with that, I am going to, am I turning it over to Dr. Ahl right now? All right. I'm John Ahl, currently serving as the Chair for West Virginia University's Department of Rehabilitation. I wanted to give you an example of where we can look at a way for physiatry to fit into these alternate payment programs. Kind of as a background, I'll get into it because it kind of makes fun of myself, but objectives, we want to discuss work being done across specialties focused on patient perioperative care, discuss CMS steps in delivering coordinated care for perioperative care, and then also go into goals of perioperative rehabilitation, possible role for PM&R as we're getting into this new delivery of medicine. Again, we as physiatrists know very well of team-based models. There's other specialties that I think are catching up to where we're at as physiatrists, but the payment system is getting there. Right now is really the time to really get out and try to put what we do from our training of being team-based leaders and doing that in a healthcare setting, a health system, small hospital, even a community practice, but taking those skills and really applying it. Where it begins, so that's kind of what I was saying, it's kind of funny. I serve as the Academy's liaison with the American Society of Anesthesia. It's not really where I kind of started up with the perioperative care, it really kind of fell on accident. My clinical practice is more of a sports med and interventional spine, and so looking at ways that we can really optimize the patient, not only in the care beforehand, but to make sure that the outcomes post-surgical, if they get to that point, are as good as they can be, meaning put through the hospital, decreasing bad outcomes, readmissions, all the things that we look for in everything we do from a physiatric standpoint in our training. What we do here on the patient's safety home, and this is with the ASA, is looking at a coordinated approach to delivering optimization of care for that patient, preoperatively and postoperatively. The ominous part is, this is being spearheaded by one of the other specialties, anesthesia. Why they are doing this, I don't know. Giving a presentation to them this summer at their national meeting, I will tell you their leadership is wanting to push this, and I don't know if it's because of the encroachment that they're having within the OR, to be honest. The anesthesiologists are not too excited at this point. But if it keeps getting pushed, they are directly discussing prehabilitation and rehabilitation afterwards. The bulk of the conversation and part of the meeting I was a part of was centered around that. A lot of what I did leading up into it, giving you background on where I developed some of the ideas, is looking at cancer rehabilitation. If you do a PubMed research on cancer rehabilitation, most of the articles are done in anesthesia journals. So whether they know it or not, they are coming after us to a certain degree. So there's a little bit of a stakeholder where we're going to be at in the future in the aspect of physiatry, because it is being a team-based model system when we're talking about payment systems moving forward. We need to ensure that physiatry remains a big, we've got a stakeholder in it. We've been doing it from a neurorehab and inpatient side. But I wanted to take the approach of what do we do on the ambulatory and perioperative aspect. And again, not saying they're bad. Great collaborators to work with. But again, it's something we need to be very mindful of. So also where this came from, as Cindy was saying, is so there's, within CMS there's a program out right now, it's going to end in December of this year, where they've been having hospital participation in comprehensive care of joint replacement. I'm looking at doing all the things that are previously stated. Where it goes from that point in December, because that's kind of when they're officially closing data collection, will help determine CMS's next standpoint of what that means for us. Is that going to mean that we're going to go into a bundled care model? I don't know. Will that be penalties on orthopedic surgeons? I don't know. But what it can mean is where physiatry really fits into this place, there are, what was the last estimate? I think we're getting up into the 20s and 30 millions of planned ambulatory surgical cases per year. If you look at a lot of the cancer rehabilitation studies out there, most of them say you only need a minimum of three weeks to make optimization of patient care, improvement of outcomes post-operatively or post-treatment. And so again, this is where we can come into play doing that team-based model. Some of it comes to, if you look at the primary care first model that CMS has got proposed as well, really having somebody driving the wheel. One of the challenges of primary care, which I'm sure we all have friends who do primary cares, they don't have a lot of time per patient. So it becomes a very big challenge for them to help steer that primary care first model when you don't have a lot of time to really spend with the patient and your list of comorbidities and things you're trying to treat is very long. But again, the idea of all these models is somebody is driving that train and having that patient-centered focus and mindset in mind. So again, the comprehensive joint replacement program, Medicare Part A and B payment model is for hospital participations. Again, that data collection will end at the end of this year. And so when December ends, what they do with that information, we don't know. It's a retrospective bundled payment model. I don't know. You may be a part of it. You may not be. And again, it's always a good idea to check where you're at so that you are contributing in a positive way. But looking at each kind of DRG, it's measuring out performance measures and different aspects of what they do. Not as much is important in regards to this, but it exists. But we're going to need to figure out what to do from this point forward. What we do, I think, is looking at these quality measures. So this is one of the challenges, and this comes up in a lot of talks, regardless of what sub-area of PM&R that we're doing, is getting objective findings. We need to make sure that we're also dictating what we're going to be looking at. A lot of what we do, we see that works, but a lot of it is subjective. But again, we need to come up with ways to objectify what we're doing and looking at those outcomes moving forward. So looking at kind of that minimum level episode quality, so that standardization of care. So again, identifying what quality measures you're going to follow. The second part of a lot of this is incentivizing hospitals to avoid expensive and harmful events. In the realm of musculoskeletal and perioperative care is complications from surgery, wound dehiscences. So again, making sure that we're optimizing that patient as much as possible. And then the third aspect of a lot of these models that are coming forward are, they're getting tools dictated to them, which are meant to be supportive by CMS. The downside of that is, is that really beneficial for the patient? And so there's yes, and there's no aspects to it if you look at a lot of the tools that are being set up. But again, that's where trying to be forward-leaning and where we might go is what you may want to look at from a perioperative standpoint in patient optimization within your organization. So what have we been working on here at the Academy? or really kind of the things that I brought up to the ASA, and we presented to them from an Academy standpoint some of the things that I've been trying to develop in my own institution. Looking at the surgical stress response, there's a numerous amount of metabolic changes that occur. And so how do we get that patient ready to go as much as possible? Some of it seems very simple, but again, if somebody's not managing these aspects, then it's just not getting taken care of, and that can be from making sure their nutritional status is there, so they can respond to the energy needs during and after surgery. Hemodynamic response, which surgeons are very good at, but this is also where I think the ASA really came into it, is some of this immediate perioperative care, and then looking at the immune response. Again, that's gonna be the overall health of the patient is gonna play into it. Preoperative condition that we look at is cardiopulmonary reserve exercise capacity. This is something that we do as physiatrists already in many aspects, but again, now we're trying to take it from where we typically do that, where we own the facility of an inpatient unit, and taking it to that perioperative period. Looking at energy reserves, metabolic capacities, again, getting into the stress that's gonna go on during surgery, and that recovery cycle, depending on what the treatment is, whether it's surgical or even to a point where we're getting in the realm of chemo and radiation therapies, there are different responses that happen within the human body that we need to make sure the patient optimized for. One of the things, like I was saying before, is looking at objective measures. Again, this is not an end-all, be-all list by any means. These are some of the things that we are doing because they're kind of the most repeated throughout much of the literature. Six-minute walk test, five repetition sit-to-stands, grip strength, time get-up-and-go test. Whatever it may be, maybe something that you approach, whatever surgical colleagues you're working with to develop a program is setting those parameters and how you can develop a program to objectively see improvement. And when I say that, these are things that we're looking at both preoperatively as well as postoperatively, and moving beyond just the first few weeks. So this is something we're trying to show. We did this beforehand, this is where they're at. We got to the day before surgery or whenever that last therapy visit prior to, but then we're seeing where it ends up at postoperatively and then how we improve that further on. So again, having objective measures moving forward is the last thing we want to do is have somebody dictate what objective measures we need to do in the future. Nutritional status, all sorts of nutritional tests you can do. These are just some of the ones that are probably most common. You'll see a lot of these, as I stated before, in a lot of the cancer rehabilitation literature that exists. Again, this is where some of that self-education is gonna come into play, even to a certain point, how we educate future physiatrists being more involved with really knowing nutritional status, blood labs to follow, different assays to order, so that we can really monitor that nutritional status instead of just say, hey, nutrition is on board, they're taking care of it. Knowing albumin, prealbumin levels, protein levels, what do we need to do to maximize that? Cognitive, this is one that one is very common to us, to a degree of doing your mini mental status, making sure that they can comprehend therapy, and so forth, so different tests. But we need to make sure that we're doing something that we can show objective changes pre and post in order to maximize the patient's outcomes. The prehabilitation cycle, again, probably a very common picture of things that we've all seen in this room. Going back to the cognitive status, again, looking at addressing things like anxiety, depression, different types of mood disorders that they're dealing with, taking that societal approach, socioeconomic status. The other thing, though, really look at, especially in a pain sense, is catastrophizing the event. We see that a lot, where patients may, they may do well in the hospital, even if they don't need inpatient stay, then they have outpatient therapy or not, but they're told to move postoperatively, move, move, move, they get home, and caretakers say, no, let me do this for you. Grandma, don't get up, you just had a hip done. Don't move, don't move. These are where complications can happen. So again, addressing the cognitive approach and the social dynamics that may exist are very important for us in that perioperative period. Again, nutritional status, immensely important, but also, it's not just the setting it up beforehand. Those nutritional reserves that we're gonna develop going into surgery, for example, they're gonna drastically alter as they come out of surgery, so you need to develop a stepwise plan of how we're gonna monitor that, both pre- and post-surgical, really encompassing that perioperative period and what interventions you're gonna take, but again, this is gonna really depend on how much of a well-established team that you can develop, because a lot of times, that's the challenge, is working with that team dynamic when we don't basically own that team, say, on an inpatient rehab setting. Physical status, again, getting away from just sticking them on, and I've seen that way too often when I visit our therapy gym and our orthopedic therapy clinic, so they're not just stuck on a recumbent bike and sitting there for 20 minutes, but looking at functional exercises, really working with our therapy directors and what that means, again, really mimicking a lot of the things that we do on the inpatient half of PM&R, but really bringing that to the ambulatory setting, so again, having relationships with your therapists, especially if you don't, they're not your own within your health system, but looking at those relationships that you build in the community of where you're referring patients to. Our orthopedic surgeons, for example, they do pretty good at this as well, but they would love it if you leaned forward and took it off their hands. Establishing protocols that can be formed, working with the therapist and the surgical team, whatever type of surgeon they are, to help develop what protocols that those surgeons would like to move forward with so that the therapists that we refer to are going ahead with that, and so we build a relationship with PM&R serving as that central hub to it. So again, fast and furious, wanted to make sure to get through, but again, this is a lot of what we're doing behind the scenes from an academy perspective. For me personally, I look at this a big future for our field as where we can grab onto something, own it in the ambulatory setting, but especially before the possible threat of it being taken away from us where others might see that need as well and want to fill that niche for us. All right, thank you. Good afternoon, everyone. Thanks so much for sticking it out. I know it's kind of late in the day, but I'm Dr. Erica David Park. As you can see, I'm the market chief medical officer for AmeriHealth Caritas, specifically community health choices, so it's a health insurance plan that I work for. And I'm gonna just move on here, but what I'm gonna talk about is gonna be a little bit different than what Dr. Om just spoke about. I think the case study I'm gonna work through is gonna be more relevant for physiatrists who work maybe in subacute rehab settings and nursing facility settings. And I think the way I'm gonna talk about it is kind of coming from a bit of a different perspective because I'm working at it from the payer side. So I wanna just kind of impart that information onto you and talk to you about a program that we actively have going. At the end of really discussing how the program works and the quality measures and so on, I wanna just talk a bit about how, as a physiatrist, you could get involved in something like this and get the benefits from this type of a program. Before transitioning to my non-clinical role, I did a lot of work in subacute rehab specifically. So when I kind of converted to a non-clinical administrative side, seeing this type of program, immediately my mind went to, wow, this would have been great when I was in practice because I think to be able to be a part of something like this. So I wanted to at least expose you to something that health plans are doing so that if that's the type of situation you wanna go into, it's something that you can consider. All right, so this particular program that we work at at my plan is really surrounding nursing facilities and subacute rehabilitation specifically. So it's developed to reward the facilities and reward the providers based on improvement and quality specifically. Looking at very specific quality improvement and performance measures, some of which are very PM&R related and I'll talk to you a little bit about that as the presentation goes on. This particular program is relatively new, but it's been around for about a year and a half. So we started it back in July of last year. For our first reporting period for it, so it was just 2022, but we started July. The first reporting period, it was the end of 2022, so December 31st. It worked for nursing facilities that are in our network. So if something was out of network, they couldn't partake in this particular value-based program but any of the facilities that were in network had the opportunity to be a part of this. The measures for this were specific to the health plan population that we work with. And to give you a little bit of background on the population that I work with, it's kind of interesting because it's kind of a very PM&R specific almost, even though it just ended up that way. It's for adults though, it's 21 and above, individuals who are dually eligible. So they are eligible for both Medicare and Medicaid. And in addition, those receiving LTSS, which is long-term services and supports. So essentially what that means is there are individuals who have physical functional deficits and disability. Some of them receiving care in nursing facilities, and that's what this particular program applies to. But we also have a large subset who are receiving care in their home settings. And those ones, they receive things like hands-on caregivers to help them with their ADLs, things along those lines. So it's really, a lot of it's, they're patients that you've properly treated, essentially. So that's really the kind of cohort that we're looking at here. Now to talk about the program, there are obviously specific incentives for people who are participating in it, but there are also some expectations to be able to participate in it. So the incentives obviously are to look at high quality and cost-effective care. So that's what we're, and our aim is for, we wanna make sure that the quality of the care received is as good as possible, but also to, we have to be fiscally responsible and make sure that the care is actually cost-effective that's being received. We wanna make sure that everything is being done appropriately, and then it's convenient for people who are part of it. So we don't want the care to be challenging. We don't want participation in the program to be challenging. We do want it to be convenient also. And another part is the data itself. So part of the incentives are for submission of accurate and complete health data. That's pretty key. To participate in a program like this or any value-based program, the data is the main part that we wanna look at. And if a facility was not able to get data that's accurate, or there were gaps in the data, areas where they weren't fully complete, that sort of thing, that wouldn't really work. So getting proper data and exchange of data is a very important part of this. Now, in terms of expectations for people, for the facilities participating in it, there really has to be accountability, particularly of continuity of care. Because one important part, and I'm sure you're all aware, is in things like where there are transitions of care, whether it's from someone going from a facility to the hospital or a hospital to home, any type of care transition, those are areas that are rife for problems. That's usually when we get errors and medication errors and gaps in care and that sort of thing. So making sure that we're accountable for any continuity of care is very important. Obviously, we wanna make sure that there are improvements in health outcomes, and that's kind of a no-brainer, I think. If we're gonna do any type of value-based program, you wanna show value and show that the individual's health is improving in different domains. Other key parts are reducing re-hospitalizations, and I'll talk about that a little more, but that's an area where I think physiatrists could be key in for certain specific conditions, and also reduction of preventable ER visits. Okay, so it's a dense slide. I'm not gonna go word by word in this, but generally how this program works is, so with a skilled nursing facility or a sub-acute rehab, they have a base per diem rate that they're paid. So every person, so say I'm a patient in that facility, they get paid, they pay the facility X amount per day for me to be there. But the way that this program works is that there's a fee on top of that. So if a facility meets all the requirements and they improve quality and everything's going great, they'll get an additional performance incentive payment on top of the regular amount that they get paid. So in this case, there's no, it's not like a downside risk situation where they get money, they have to pay money back. In this one, it's just like all positive. So if they improve in things, you can gain an additional payment on top. The way that the payment is calculated is based on the nursing facility's scores in specific quality performance and also potentially preventable events measures. And I'll explain the potentially preventable events essentially are things like avoiding hospitalization as ER visits. So the score is based on how they do there. And the scores themselves are in relation to the other facilities that are also part of this program. So it's basically kind of like ranked, so we'll get a score, but it's a comparison score, depending on really coming to like a percentile ranking based on how you do compared to the other facilities. So the overall score is, there's like a score for each one of the different quality measures, but then there's also like an overall general score that a facility will get. At the end of the year, when all the data and everything comes in, the facilities actually receive a score card, which I'm gonna share a picture of in a little bit, but the score card kind of explains everything. It says, all the different quality measures, this was your score compared to all the other facilities. These are your percentiles. And if they qualify, like this is how much of a payment you're gonna get. The payments are annual. This is the way we work on ours, at least. And each plan is gonna have something different, but the way we work with our plan in this particular value-based program is we do annual payments based on like a cycle of the year before. So for 2022, we look at everything, analyze the data and so on. And then in 2023, that's when you get the payment for it. And again, it's based on that percentile ranking and so on. The facilities had to be at least in the 60th percentile to get an incentive. Anything that's not that is, quality is not good enough essentially, so they're not gonna get an incentive. And fortunately for the first year of the program, the majority, more than 50%, the majority of the facilities were able to get an incentive payment. So I thought that was a good thing. All right. So again, these, just to share, so you are aware for this particular program, these are the quality performance measures. And some of them are PM&R related. Some of them are not. But looking at this, so these are the ones we have are readmissions, pressure ulcers, falls, flu vaccine, pneumococcal vaccine, antipsychotic use and UTIs. Obviously the flu vaccine, the vaccinations and the antipsychotics, obviously not related really to what a physiatrist is doing, but the readmissions, I think that's a category where definitely if there's a physiatrist who's working in a skilled, in a subacute rehab, they can have a lot to do with preventing readmissions. You know, there's a lot that can be done, especially if someone's going in once or twice a week to see patients. And there are things that they're observing that they could do and interventions they can do on those visits that could help to prevent someone from going back into the hospital prematurely. So that's definitely an area where there could be an improvement. Not for everyone, pressure ulcers. You know, some, personally, when I worked in subacutes, I didn't really do much work in wound care, but I know some physiatrists do. So I think specifically if anyone does work in the wound care realm, that's another category where a physiatrist could really make a difference in terms of getting that facility to meet those quality measures. And falls, I think, is a huge one. Falls prevention is definitely something that's just a concern across the board for facilities, a concern for health plans. It's just really, you know, an area that we want to consider. And for a physiatrist, that's definitely something that we could do something about. You know, considering that we're looking at function, we're looking at strength, balance, and so on, that's really an area where a lot of impact could be made. All right, so again, another dense slide here, but essentially what the potentially preventable events are, they're just essentially like hospitalizations and ER visits that could have been prevented in some manner. So it's not gonna be something like, you know, if someone had a stroke, where obviously there's nothing that someone immediately could have done to prevent that if they were just gonna have that stroke at that time. But for other things like falls, you know, if someone had a fall with an injury that happened in the subacute, that's something that could have been prevented, and that's something that potentially an intervention from a physiatrist could have prevented. So that's, and that could be like for an ER visit or for a hospitalization. So things like that, where having a physiatrist make those interventions could have prevented something, that's another area that we look at, and that's another category that's looked at for the quality measures. Okay, so just to share, this is not a real one, but this is just a sample of what a scorecard would look like. So a nursing facility, you know, at the end of the year, when all the data is looked at, they would get something like this, just showing, you know, those different measures. It would give them their rate, their rank compared to the other facilities. And then all the way down at the bottom that would let them know, like, if they qualify for an incentive, it would give them the amount and the total payout that they would get. Okay, all right. So now this section I want to talk about just more specifically how a physiatrist could participate in a program like this. I think a key thing is if you're already working in subacutes and skilled nursing facilities, that is great, you need to definitely be in there and performing the consultations. But in addition to just doing those consults, the relationship building is a key part if you want to be able to get any benefit out of this type of program. Really just talking with the key players and building relationships with individuals in those subacute or skilled nursing facilities, that would be, you know, whether there's a physician group that works in there that works with the administration, you'd want to make sure you're connected with them, like an internal medicine or anything along those lines. But also the administration in that facility would be important too. So whether that's, you know, like if they have a CEO that's there, or if they just have more just like clinical administration, either way, I think it's key to not just go in and do your consults. You want to make sure you're just building those relationships with the individuals that are there, and that's going to make it more likely that you could participate in getting the financial potential benefit from something like this. In addition, you know, in addition to the facilities, you know, if you have any contacts within health plans, that is another way to also build relationships there. So that would be like, you know, clinical like myself, but also others, like there are usually others that are working in like the value-based payment department. I mean, that's actually, you know, there's a subset that's there too. So you'd want to make sure that you're having conversations there in addition. And then depending on, you know, where you're at, there may be connections in state agencies in addition too that could be helpful. You know, if you, if this is something to consider, what you would want to do is make sure that you're looking at data, and really getting baseline data would be an important thing before any actual interventions, because you want to be able to demonstrate that, you know, you're starting somewhere, and that the interventions that you're making is actually making a difference. So that part is kind of key, because otherwise it's difficult to really show that what you did as a psychiatrist is what's actually making a difference in moving the needle. Starting and getting that initial baseline data is very important. And that would be different things. So, you know, baselines, you want to see like what is their rate of readmissions in conditions where you think you could have an impact. So just get that from the baseline from them. And then over time, you want to demonstrate if you and your practice are able to make a difference in that. Other things you want to look at potentially are, you know, things like pain control, falls prevention, functional improvement, but always, again, starting with that baseline data so that you can show that there's actually been a change. And the last bullet I have on here is not really relevant for this value-based program I talked about, but if you're thinking about building or trying to put together a value-based program elsewhere, like maybe at a facility you work at or something like that, patient satisfaction data is also relevant. And, you know, some value-based programs will also look at that, too, because there's wanting to see also, too, you know, how people are feeling, both in terms of pain control and things like that, but also what their experience of care is like. So getting that type of information can also be helpful in putting together a program. All right. So I think at this point, I think that is my last slide. And we're on to roundtable. But definitely, there'll be time for other questions. So what we're going to do for the last 10 minutes or so is have a roundtable. Hopefully we'll also have some time for Q&A. But I'm going to turn it back over to Cindy to lead the roundtable. Great. Thank you so much. I think your presentations have been really helpful, and I wanted to dig into them a little bit more for the sake of the audience. I had a couple of questions for Dr. Alm and Dr. David Park, and then some for the full panel as well. So Dr. Alm, can you talk a little bit about how your participation in those models has benefited your practice, and also maybe what challenges you've experienced? Yeah. So one of the big benefits outside, obviously, outcomes for the patient from a financial aspect is if we're doing it right, we're utilizing different aspects of our health system. And that goes, for example, we utilize medicine, nutrition, bariatrics, endocrinology, rheumatology. So all these services are involved in this optimization program we have, so we're really utilizing multiple specialties. And so from a reimbursement standpoint, it's bringing revenue into our health system. The challenge of it is, and this is where a physiatrist needs to be educated to a certain degree on starting the process, and in many cases, but it can be delay of getting it going. I mean, imagine referring to a rheumatologist in your health system, it usually takes a while. Fortunately, we've set it up as a program, and so we try to expedite them getting in because it's not meant for this full rheumatologic workup, but again, it's for specific aspects to it. But from a pro standpoint, we're definitely bringing in more revenue towards our health system. So the downside is, as a physiatrist, I definitely have to know more than I would say I did before really starting this and had to kind of reteach myself some of this to get the ball rolling and also having a good program set up. And then also just following up, you know, I think in your presentation, you talked a lot about the quality measures you're tracking and kind of how care delivery has changed. Can you talk a little bit about the linkage to payment as well? Yeah, so we're trying to lean forward with it. I'm working with our medical informatics department, and so we're building a lot of these outcomes directly into our EMR, and so that they come up almost as a therapy page, much like you would look at, you know, a CMP panel would come up, but so that these things are readily available, we can pull data from it, develop research studies from that data moving forward. So again, if you're going to do this and looking at kind of the future of our field, we definitely need to have informatics involved and utilizing our EMR systems to their fullest capabilities, and so not letting that data just get lost, because trying to do data mining, if you've done any research, can take forever. I mean, you have to hire an entire person just to do it, versus if you build it in there from the beginning and do it right, you can have that stuff readily available, just pull up that data. And then Dr. David Park, can you talk a little bit about why your company decided to focus on quality of care in nursing homes? Sure. I think, hopefully you can hear me. For our plan in particular, we have a large number of individuals who are nursing facility eligible, so either they're living in nursing facilities or they are in the community, but they're at a level of care that they would require nursing facility care, but are receiving, you know, home and community-based services where people are giving them care in their homes instead. So because that's the particular cohort of individuals that we're looking at, how people are doing in nursing homes is very important to us. And really looking at the quality that people are receiving, if someone ends up having to transition from home and they live in a nursing facility, we want to make sure that they're just getting the most appropriate care that they can, because, you know, it's really a situation where they depend on us, essentially, and we really just want to make sure that the quality they're receiving there is as optimal as it can be, so that's a long and short answer. Great. Thank you. I have a kind of unique perspective coming from the payer side. I was wondering if you could speak about opportunities for your contracted providers. You know, I think you talk about a model that you developed, you know, from the plan side, but are there opportunities for maybe some of your contracted providers to come in and raise ideas about potentially implementing an idea of their own? You know, for example, we have these toolkits that are in development, and might there be an opportunity to bring one of the, you know, implement a toolkit and try to work with you to implement a model? Yeah. I mean, I have to say, personally, I'm always open. Definitely that's something that, at a health plan, and also a lot of my colleagues at health plans, we want to hear about innovative models, you know, key things are that we want to make sure that quality is improved, but also that we're being fiscally responsible, so the kind of combination of those two things. So whenever people come with great ideas, and I think the toolkits are great ideas, we're always open to hearing about it, and I can tell you, too, from personal experience, I actually have had providers in different areas, unfortunately no physiatrists, but it's primarily been primary care doctors who've come and just, like, wanted to present an idea, and I'm definitely open to it, but I think, and I can speak to that myself and from my plan, but I know in talking to other colleagues who also work for other health plans, everyone wants to at least hear the ideas and just kind of take it from there and see if it's something that can be built. So I would recommend to anyone in the room or in other rooms, if they have an idea like that and there's something they want to do, not to feel like, you know, the plan's not going to listen to me, at least present it, put it out there, definitely if you can speak to maybe someone medical, so if you're going to talk to, like, the CMO or a medical director at a plan, they're pretty much always open to hearing something, I mean, it might, schedules might be a little tight, it might take a while to, you know, get a meeting, but you could definitely get something out there. I would highly recommend it. Great. And then I'm going to open up this question to the whole panel. Can you talk about how you see providers and payers working together to advance value-based care? Does anyone want to start? I mean, I think the big thing is, is you need somebody to kind of take the charge on it. And again, obviously, selfishly, I think we as physiatrists do a good job at it, but as we get into very much value-based care, I mean, having siloed care as individual specialties is not going to be the answer to it, and so there's a lot of what we need to have somebody be the proponent for the patient and help take that charge, but again, I think we as a specialty are optimized to do that, because we do that from the foundation of our training, and so taking what we do, say, in the inpatient setting where we all started as PGY2s, but then taking that further and looking at how we've organized those teams, but on a health system level or even a community level, to deliver that value-based care. Dr. Zerwitz? So what I'll basically say is, I think the real bottom line is we have to work together, because it's not going to work otherwise, but basically you have to really look at the needs of each side. So providers want to be reimbursed for what they do. Payers want to pay, but they want to keep their costs down. So what we really need to do is, by working these ways and being innovative, you've got to make this a win-win for both sides. If you don't do that, it's just not going to work. I'll go on next. So I agree with both. I mean, I think, you know, a key thing is just making sure that you're proposing and putting your ideas out there. And I think, you know, payers and providers, it's all the same team, really. You know, we're all trying to make sure that people are getting appropriate care. We're all trying to make sure that things are done in the right way. And we do have to be cognizant of financially how that, what the impact is there. So I think kind of coming into it from that idea and that frame point, not thinking it's like, you know, we're supposed to be at loggerheads, but that we can work together. You know, as I noted before, I mean, definitely going to the plans. I mean, there's no reason that you can't go and do that. I think the main thing is just finding who the connection is there. You know, and like I said, I would start with, go to another doctor to start, to start off with, whether it's, it doesn't have to be a physiatrist, but whomever is the medical director or CMO of that plan, try to just connect with that person and just start there. You know, if that, if that's not the one who's going to be creating the value-based program, they can at least get, you know, help you get your foot in the door. And then they could connect you with probably, they likely would have like a value-based team who puts the things together more specifically, but they can at least like connect you to the, those individuals. But yeah, I mean, I see no reason that at least having been on both sides of the table, having been, you know, in practice for like 15 years and then before making the transition and being, you know, non-clinical, I've seen both sides and I really don't see a reason that we can't work together. Great. And then just a last question for the panel. What advice would you give to audience members who are interested in further engaging in value-based care? I think Dr. Park probably spelled that out very nicely. Number one, talk to people, because again, that's, you know, communication is going to be the best way to make this work. But I think number two, I will of course give the shameless advertisement for the toolkits that will be coming out towards the end of the year. The toolkits, which really have been developed over the course of the last few years, really, by our committee, show how really, what are the concepts to be able to develop an APM both as a continuum of care, as demonstrated by stroke rehab, as well as outpatient, which is demonstrated by spine care. It really talks about, you know, what does it take to innovate, because innovation is going to be, again, one of the real keys in terms of making sure that we are giving the best care. It also talks about, really, how do you go about communicating and understanding the stakeholders and identifying those stakeholders so that you can build a team. Because Dr. Alm, I think, said this very early on, is that, you know, like anything in rehab, this is going to take a team, and it means that you're going to have to have, you know, every single stakeholder at the table and with buy-in, and that includes payers, that includes administration of wherever you're working, because if you can't get buy-in from all of these people and hopefully make this a win-win, it's just not going to work. Anything else from the other panelists? No. No, nothing to add. All right. Thank you so much. And with that, I think we can take some questions, if we have any, from the audience. Yes. Hi. John Shea from the Metro Health System in Cleveland. First of all, thank you for this very timely discussion. I do have two high-level questions. One is more PM&R relevant, the other is relevant to all of medicine. So, you know, the World Health Organization International Classification Function has been presented for us in the world to use. It seems to me the so-called outcomes that CM is interested in right now is really limited to a level of health status, physiology, and impairment. It does not appear to, which is primarily a biomedical model, it does not appear to incorporate and integrate the other two levels, which is at the level of activity, the level of societal participation, community reintegration, vocational reintegration, and at the level of quality of life, which is the biopsychosocial model. Is there any interest, cognizance of CMS to know those other outcome measures may actually be more important for a population, number one? And number two, we also know that, depending on what you read, with respect to health outcomes, we only can influence 20%. That is, social drivers of health, we know, can be anywhere between 80% to 50%. And yet, at the end of the day, we are going to be asked to be held accountable for that portion that we have very little agency. So if you can address those two questions as we go forward. Yeah, I can take the CMS question at least. So sorry, I really feel like this is in the way. I think you raised really important points about how, you know, what the impact is of care and how there are bigger ramifications besides, for example, the cost to the Medicare program or the impact on kind of clinical outcomes. I know certainly the Academy has raised, in comments to CMS, they have raised to their attention that there are longer-term outcomes, bigger picture impacts, other impacts, including, you know, on, like, return to work and so forth, that are important things to consider. I think it is a little bit challenging for CMS to take them into account, just given the charge that they have. And especially in the case of alternative payment models and the work that CMS does through the CMS Innovation Center, they're really kind of focused on looking at quality of care and also costs under the Medicare program. And so, you know, even if they are aware of bigger picture things, it might be a little bit hard for them to prioritize that issue. Are any of the panelists able to speak to the second question? I can start with the second question. Sure. Yeah. I agree 100 percent. So much of what is done is physicians don't have, like, control over. So we really have the social determinants of health. Physicians don't have control over any of those aspects, you know, what neighborhood someone's in, what their setting is like, things like that. I mean, those aren't really things that we can directly impact. However, obviously, they have a huge impact on someone's health. One thing I can say, at least from my plan, and I know other plans, too, is that we do we are looking at those social determinants of health, those social drivers of health. We actually collect data on it specifically and really track and see how things are going. Some of the programs we design are surrounding that. So if we notice that there are targeted areas where there are gaps, we can try to shape a program surrounding that. I could say that from that side, you know, in terms of how CMS is doing it. I know they're talking about it. I know, as Cindy noted, you know, it sounds like there are some gaps there and some challenges there because it's a tough area. But at least when we look at programs, we're fully cognizant that, yeah, physicians can't. How are you going to change someone's neighborhood? You know, I mean, that's just really it's a tough thing. Yeah. And with respect to CMS, too, I do think it is a priority for CMS, too, to look at social determinants of health. I think they're starting at a fairly low baseline. So they need to even figure out what data to collect, how to collect the data to get it uniform, and then, you know, how to incorporate that data into their assessment of quality. So it's definitely with this administration, we've seen a huge emphasis on health equity, but it's a work in progress. You know, when you work at a safety net hospital, when your patient population is 40 to 50 percent underrepresented minority, and the organization down the street is 90 percent white, their outcomes just by those demographics are going to be different. So safety net hospitals are going to be penalized if that is not taken into consideration. »» I mean, I do think they are trying to take it into consideration, but it's a little bit hard. And also, you know, you don't want to, I think CMS is also concerned about not having lower quality standards for disadvantaged populations. So there's a lot to balance in that consideration. »» Yeah, I think the thing you want to take into consideration, too, I know in stroke and a lot of stuff that I know some of the neurologic colleagues have talked about.

value-based care

healthcare providers

value-based payment models

MACRA

MIPS

Advanced APMs

physiatrists

perioperative care

rehabilitation

patient outcomes

social determinants of health