Good morning. My name is Rich Zorowitz. I am from MedStar National Rehabilitation Network and Georgetown University in Washington, D.C. and I welcome you on behalf of everyone to this session on breaking the ice with your C-suite. Let's talk about returns on investment and APMs. Today, we will have Cindy Moon from Heart Health and who is one of our speakers and panel facilitators. Our panelists, our esteemed panelists, will be Mark Gruner, Heck Young Kim, and when he gets here, Chris Standard from UPMC. So, today, the agenda that we are going to have is I'm going to give you, oh, there's Dr. Standard. He's here. Good. The agenda is going to be giving you an introduction and Academy resources. So, I'm going to briefly tell you about the work of the committee that I chair and then introduce several of the alternative payment model resources on the Academy's website. Cindy Moon is going to provide an update on the Medicare value-based care landscape and then we are going to have a panel discussion with Q&A here and then we'll close the session. These guys, some of these guys have to leave a little early because they've got planes to catch. So, don't be offended. You know, they don't mean any harm but they will need to leave a little bit early to go catch their planes. I will close the session then with an overview of the toolkits that our committee has published earlier this year which gives you some insight into building your own value-based care models centered around spine care and stroke. So, what is IPPM? What is the Innovative Payment Practice Models? So, as a committee, we research progressive payment and practice models to determine how we can support you guys and advance the field. We also are trying to disseminate knowledge about alternative payment models or APMs and or care models to Academy members and stakeholders. So, the fact that you're here is wonderful. These are the things that you don't need, you know, you don't know that you need to know but you, so I'm glad that you're here so you will learn from that. And if you were here yesterday for the session from Dr. Walderson from CMMI, hopefully that was very, very helpful as well. So, IPPM has developed a series of resources which are available on the Academy website through the QR code or you can go onto the website and look for them there. We have a glossary of APM terms. We have a document that outlines the Academy's principles related to APMs, highlights of what advocacy work we do and benchmark surveys and then two new toolkits which I will talk about later which promote value-based care models for spine and stroke and we'll be talking about at the end of the talk. So, with that, I would like to introduce our speaker and facilitator. Cindy Moon is Vice President of Healthcare Payment and Delivery Reform with Heart Health Strategies which is APM&R's regulatory consulting firm. Cindy has more than 20 years of experience working on health coverage and payment policy issues. Most recently, prior to joining Heart Health, she worked at the White House Office of Management and Budget, OMB, where she advised on policy solutions affecting Medicare. She earned her MPH and Master's of Public Policy from the University of California, Berkeley and her Bachelor of Arts from Harvard. So, with that, I will turn it over to Cindy to talk about value-based care in the Medicare program and opportunities for us. Thanks, Cindy. Great, thanks so much. So, this is gonna be a fairly high-level overview. For any of you guys who were here for Brian Walderson's talk yesterday, there is gonna be a little bit of overlap. But we did think it was important to share this information in the context of this session in order to set up the panel discussion. If you didn't participate in yesterday's session, I highly recommend it. A lot of great information on how CMS is thinking about work in this space, including involving specialists in PM&R. All right, so just some of the basics to start out with. Value-based care, we generally think of that as care furnished under arrangements with providers that are meant to hold providers accountable for achieving desired outcomes. Typically, that's around quality, performance, also managing costs, and increasingly in recent years, around equity as well. Under value-based care arrangements, payments are moving away from fee-for-service and towards payment structures that incentivize and drive the desired behaviors. On the continuum, closest to fee-for-service, we have pay-for-performance programs. And then we also have alternative payment models, which can include payment structures of varying types that are meant to provide higher and higher levels of accountability. CMS defines alternative payment models as payment approaches that give added payment incentives to provide high-quality and cost-efficient care. You're probably familiar with a lot of the models that are out there. There are ACO models, accountable care organizations that offer opportunities for shared savings. Also, advanced primary care models that try to change the way primary care is paid for, including through care management fees or maybe even capitation. There are also disease-specific and episode-based models. So, for example, you could see a bundle payment model around joint replacement. A lot of these models may require downside risks, not all of them, but many of them do, and I think there's an increasing emphasis on that. And the models also typically require participants to report on quality metrics. And oftentimes, the performance on those metrics is tied to payment incentives as well. On the right side of the screen here, I wanted to just highlight a few things that I think are particularly salient for PMNR. One thing about models is that we are seeing a lot of times that model participants look to post-acute care to generate savings, right? So, that might mean discharging more patients to the home instead of to institutional settings, which is gonna have an impact on the way PMNR's care is delivered. Additionally, at least for models that are run by the CMS Innovation Center, CMS has broad authority to waive statutory and regulatory requirements under the Medicare program. And one way that we've seen them do this pretty regularly is by waiving the SNF three-day rule to allow folks to go into SNF without that three-day prior hospitalization. I mentioned the Center for Medicare-Medicaid Innovation or the CMS Innovation Center. That was established as part of the Affordable Care Act back in 2010. After about 10 years, CMS decided to do a strategy refresh. So, in 2021, they came out with this refresh that really focused on driving this accountable care, right? And they set specific goals for themselves. In particular, they specified that they are hoping or aiming that by 2030, or aiming that by 2030, all Medicare beneficiaries with Parts A and B will be in a care relationship with accountability for quality and total cost of care. They have been pretty steadfast in moving, you know, in promoting this goal and trying to move towards it. They've talked about how they think primary care is central to this goal. And so, they're talking about how they wanna bolster primary care, including through ACO initiatives and advanced primary care models. But they also have developed a specialty care strategy that talks about how they can integrate specialty care into these models. I think previously, they had focused a lot on kind of standalone specialty models, and now it's much more about integrating into primary care. So, that is the direction that CMS has been going over the last few years. Of course, there was the election last week, and so a new administration is coming in. It's not clear about the extent to which the new administration is gonna continue to stick to these goals and priorities, or whether they're gonna kind of shift gears. So, that's definitely something we're gonna be keeping an eye on. I'm gonna be spending a lot of time talking about models in which there's opportunities for PM&R participation. But before I do that, I did wanna spend a little bit of time focusing on the Quality Payment Program. That's because I expect that most of you guys receive payment under the Medicare program through the Medicare Physician Fee Schedule. And the Quality Payment Program is a program is really designed to create that accountability for services provided under the fee schedule. There are two tracks under the QPP. The first is the Merit-Based Incentive Payment System, or MIPS, and the second is the Advanced APM track. The MIPS track is a straightforward pay-for-performance program, right? So, it's still based on fee-for-service. Fee-for-service payments are made, but there are upward or downward adjustments to those payments based on performance across four performance categories. The ones listed here, quality, cost, promoting interoperability, and improvement activities. And performance in one year affects the payment adjustments that you receive two years down the road. For the Advanced APM track, it's really focused on participation in what are called Advanced APMs. So, clinicians can qualify for this track if they meet substantial or significant participation thresholds in what are called Advanced APMs. And they are special APMs that have strong cost and quality incentives, including requiring downside risk. If you're in the Advanced APM track and qualify, you do not have to report MIPS, so you get to avoid some of the burden associated with that. Advanced APM track participants also qualify for temporary APM bonuses that have been in effect since this program was set up. Those bonuses are temporary, though, and they are phasing down and will phase out absent congressional action. And then the last piece that's kind of intended to drive long-term movement into the Advanced APM track is differential payment updates. So, starting in 2026, folks who are in the Advanced APM track will get a .75% annual update instead of a .25% annual update. And that's not huge difference at the beginning, but that is expected to compound over time and create greater and greater incentives to move into the Advanced APM track. And, you know, if you are receiving payment for the Medicare, under the Medicare program, chances are you are in one of these two tracks. So, if you don't know which track you're in right now, I think it would, you know, it would be good to, like, understand which track you're in and also think about, understand how your, how the care that you deliver, you know, translates to performance under that track. All right, but now I'm gonna talk about those APMs that I mentioned. And again, these are APMs that are operated, you know, for the Medicare program and where I think that there are probably the greatest opportunities for PM&R engagement. The first one is the Accountable Care Organizations, or ACOs. Again, these are groups of providers working together to coordinate care and achieve the cost and quality outcomes that are desired. Under ACOs, they are responsible for the entire population of patients that are attributed to them. And they're also responsible for total cost of care and quality for that population. Again, sometimes they can get shared savings and they may also take on risk. And examples of these kinds of models are the Medicare Shared Savings Program and also the ACO REACH model. They do have a fairly large footprint. This year, there were almost 14 million Medicare beneficiaries aligned with ACOs. They also have a track record of moderate success. They generally tend to maintain quality and they also start demonstrating savings. A lot of times, these are gross savings before CMS has to issue out shared savings payments. But with the MSSP program, we also have like a pretty strong track record of net savings even after those shared savings payments have been issued. In this model, there are not real, like formal structures for integrating with specialty care. But that is something that CMS is working on. They talked about how they're developing shadow bundles to try to help ACOs understand how they can work with specialty providers and where the opportunities might be. So right now, it's not formal, but it's a direction that CMS is moving and there are still informal opportunities as specialists to engage with ACO leadership. The next model that I wanted to focus on was the Making Care Primary model. It's the latest iteration of the Advanced Primary Care model type. This just launched in July of this year. It's a more than 10 year model that is available in eight states. And again, the focus is transforming primary care. However, as part of this, CMS has also established that they are aiming to improve consultation, communication, and coordination with specialty providers. So there is a requirement for practices that are in the model to participate and work with specialists who are going to be designated these specialty care partners. These practices in the model have to enter into what they're called collaborative care arrangements with these specialty care partners in order to kind of facilitate that specialty management. Right now, the bare minimum requirement is only one collaborative care arrangement and it has to be with at least one cardiology, orthopedic surgery, or pulmonary disease specialist. But that's again just a floor and these Making Care Primary practices have the option of contracting with additional specialists as well. And CMS did provide a list of different specialty types that can serve in this role as specialty care partner and PMNR is on that list. So there are opportunities there to kind of see how PMNR can fit in and serve in this role as specialty care partner. And further to support that alignment and integration, CMS has also developed new specialty or new model specific payment codes. One is for e-consultation and one is for co-management of patients. So those are new mechanisms that CMS has incorporated into this model. The last model I wanted to focus on was the Transforming Episode Accountability Model or TEAM. This is the latest iteration of a bundled payment model. CMS finalized this as a mandatory model that is going to require hospitals in select geographic areas to start participating starting in 2026. This model is kind of pared down in terms of the different types of services or episodes that it's focusing on. So there are only five episodes in the model focused on lower extremity joint replacement, surgical hip femur fracture treatment, spinal fusion, CABG, and major bowel procedures. But these are all procedures that I think there's an opportunity for PMNR engagement. Episodes start with the initial hospital stay and go through 30 days following the end or following discharge. And under this model hospices will be responsible for managing spending and quality. Their actual spending in the model will be compared to a target amount and that will determine whether hospitals can benefit from savings that they may have contributed to or whether they're going to owe money back to CMS. So those are the models that we think that there are opportunities for PMNR participation, but you know, I will say that there's still challenges there and the opportunities are still like somewhat limited, right? Unfortunately, these models largely are focused on primary care and even though CMS is starting to make inroads in this space and starting to think more about how specialties can get involved, you know, it's still a work in progress and so that is a challenge. It doesn't help that CMS is also focusing on quality measures in these models that don't really like focus on the care that PMNR is delivering and also maybe don't capture the timeframes that we need them to cover to really understand the impact of PMNR, right? So like in the team model, for example, 30 days is really not sufficient time to under, you know, to see the impact of rehabilitation care. So to my next point, even episode based models, the opportunities for PMNR engagement could be limited and again, these timelines, again, make it less important for PMNR to necessarily get involved. Model participants like those hospitals that are the ones who are really responsible for quality and cost at the end of the day, they're the ones who are the participants and they may also not recognize the value of PMNR engagement. And so that's the Medicare landscape, but that doesn't mean that's the only opportunities available. And I think that's really the reason why we wanted to have this, you know, panel discussion here today because there are ways to still kind of promote value through PMNR care locally outside of the Medicare program. That could be exploring APMs or other financial arrangements with private payers. It could also be looking into your own health systems locally and kind of promoting how care delivery can change and thinking about how to, you know, link those care delivery changes to outcomes and payment incentives. And so that's what our panelists are gonna be talking about today and so I do wanna turn over now and switch gears to introduce our panelists. I'll start at the end. We have Dr. Mark Gruner. He is a Mayo-trained interventional sports physiatrist practicing with Ortho Bethesda in Maryland and Virginia. He's the co-founder and chief medical officer of Limber, a remote therapeutic monitoring technology platform, a digital musculoskeletal platform for monitoring therapy adherence. Dr. Gruner is also a current member of the Academy's Innovative Payment and Practice Models Committee. Next we have Dr. Hyekyong Kim. She's the chair of the Department of Physical Medicine and Rehab at the Kimberly-Clark Distinguished, oh, and the Kimberly-Clark Distinguished Chair in Mobility Research at UT Southwestern Medical Center. Dr. Kim is a pediatric rehabilitation physician specializing in brain injury, cerebral palsy, and botulinum toxin injections for spasticity. And then finally we have Dr. Standert. Dr. Chris Standert, he's the director of spine health and vice chair of outpatient services at the University of Pittsburgh Medical Center. Dr. Standert's clinical focus is on the non-operative management of spine and neuromusculoskeletal conditions. And he has previously served as the chair of the Innovative Payment and Practice Models Committee. So with that introduction, I'm gonna just kick off the panel with my first question. And if the panelists, if you don't mind please, describing an example of when you approached your organizational leadership to implement a new program or improve the value of care delivered to your patients. Can I start with Dr. Gurner? Yeah, hi everyone. So briefly, so I work for a large private practice orthopedic group. We're the largest, one of the largest private practice ortho groups in the state of Maryland. And so in the state of Maryland the whole state is an ACO. And because of that we have about 50 specialty care episodes that exist. And so from my time previously working at CMMI, building some of these episode models for procedures and conditions, I created a MSK episode with the state of Maryland for Medicare beneficiaries. So what does that mean? So it was a episode focused on trying to reduce surgical spend. And me being the only physiatrist in a group of 57 orthopedic surgeons, this was an interesting model to them. And so what we did was we started with the PTE Val as a trigger code. And then we looked at total MSK related spend over six months. And the benchmark on average in the state of Maryland was $8,900. And working with the state of Maryland we were able to create this episode to try to get more appropriate non-surgical care in orthopedics. And so we created an episode. It was a shared savings model that could be done with any orthopedic group, hospital or physical therapy group in the state of Maryland. And I implemented that with the state of Maryland. So then I had to go to my ortho group and convince them to be part of this non-surgical orthopedic episode. And that's where you really have to think about the ROI and explaining it to them. So because we've had some success in the orthopedic surgical bundle episodes, which is we have... There's about of the 50 episodes that exist in the state of Maryland about 20 of them are in orthopedics and about 15 of them are procedural based episodes over a 90 day period of claims. And so we saved... Working with them previously we saved about $2 million in savings that came back to the orthopedic group. And I was really involved in a lot of the idea behind that. So when I brought this MSK episode they had a little bit of trust with me about, hey, maybe this is a good idea. So I brought them this opportunity. I showed them the clinical opportunities and specifically the return on investment that if we really reduce some unnecessary surgeries, which is hard because the surgeons do a lot of surgeries, there could be a savings opportunity for the group and they were actually interested in this. And so it's a really good model to try to get high value care for non-surgical orthopedics. Thank you. Dr. Kim. I'm in trouble because I don't know this all the terminology. But I'm gonna go like this. I become chair and I learned value-based practice. But what I was doing it now, I work with the county hospital which is the largest hospital in town. And I look at the premental care or care at county hospital. And they don't have really structure. They keep having the patients but they don't know how to clean up. Long wait list. So I proposed like this, for example, we have MSK, no MSK designated physiatrist for this county hospital. so I look at the wait list. The wait list was 12 months. So I said to them that if you fund one physiatrist, MSK physiatrist, I'll clean up. So it's very hard to convince those people, right? So I said, you creating chronic disease, which is gonna bring the cost of care. So for example, you have a knee joint patient, you're not treating those knee pain, they're gonna go to emergency department and then the care go shooting up and they don't have a continuum of care from that point. And then they're gonna come back to ED and then they start to prescribe opioids and then they become chronic pain patients. But if you hire, let me hire my physiatrist, I'm gonna clean up the wait list. So they actually, they listened to me, we hired one physiatrist. We, it took only two to three months to clean up, 12 months wait list to three months wait list. And then nowadays, they're coming back to us, they want us to take care of their old employee health. So we can clean up this old employee. So sorry, I can't talk about. So that's the way I talk with the C-suite or executive people. I have data. Data is extremely important. And then you talk to them with the data. And like me, new chair, I have no clue about all the terminology. But once you have the data, you can win on that. So that's what I can say. That's the way I approach with the data. Thank you, Dr. Sandler. What was the question? I know, I know. I was so, good. Well, the first, yeah, the first question is just to talk about an example of when you approached your organizational leadership to implement a new program to improve value. Okay, so I'm a non-operative spine MSK person. And I have, I'll give you two sides of a coin, which is, so I'm at UPMC now. And the first side of the coin is how I wound up at UPMC. So the institution I was at, I really am not a fan of a lot of what we do in spine care. And I think there's an immense amount of sort of waste and things that should not be done. And my basic clinical job is cleaning up all the stuff that just should never have happened, right? That's my entire day. And so I kind of got tired of it. And I was like, we should do this better. And we can do this better. And I studied value-based care for 20 years. And I went to my institution, said, we can do this better. Like, we can be better at this than everybody else. And we can do this more effectively. And we can coordinate our PTs and do the right thing. And unlike Mark's situation, they had zero incentive to reduce utilization. In fact, our whole institution was built on over-utilization, right? So they had, the conversation ended because they really were not interested. They wanted to know that, what they wanted was a plan to do this when the world changed and they had to. They had no interest in implementation of anything that would reduce surgical volume and spine care. It was quite blunt to me, right? So that didn't work. So that was my failed intervention with a C-suite because they didn't, they had no, they didn't want what I was talking about. And so it goes again to Mark's point of like, you need to be in a situation where you can sort of, there are some incentives aligned with what you're trying to do, right? And they had none. And so I left and went to UPMC. And UPMC is a interesting organization. It has, you know, it's huge. It's 40 hospitals and $25 billion a year. It's an enormous enterprise. And it has a fee-for-service arm of all the hospitals and has its own health plan. It insures its own patients. And that creates a very different environment. And so when I went to UPMC, they were in the 95th percentile for surgical spine rates per population for comparative health plans, which if you're paying for all of them is not where you want to be. I'm not sure it's where you want to be as a patient, but it's not where you want to be if you're getting paid, if you're paying for all that. And so they wanted to do this better. And so in that environment, I could sort of retool my message to get to the idea that, you know, if you look at the population and you can find the population of people who are costing the money, right? The people, there's a, you know, if you look at most, it's an 80-20 rule, right? Most populations, 20% of people account for 80% of the cost. If you can focus on those people and find a way to improve their health and make them better in a way that is more cost-effective and in spine, lower surgical rates, you can get a significant return on investment. And so you can actually do better by doing better, right? Which is a very useful pitch for them because they want to provide good healthcare. They want to be known for providing good healthcare, but they want to do it cost-effectively if they can. So the pitch sort of came from that idea that if we think about this and we go focus on these people who are struggling in the system, and, you know, you have to be careful with this phrase of unnecessary surgery. There's no provider on the planet who thinks they do an unnecessary procedure to a patient. If you tell them their procedure was unnecessary, they will not be happy with you, right? Nobody thinks they do that. We can look at the aggregate data and say a lot of these shouldn't happen, but which one and by whom, right? Like, that's hard to do. And so what we were trying to do, and probably what Mark saw also, is that what you're doing is there are a lot of people who are, there are people who are clear surgical candidates, right, they have a progressive myelopathy, they're falling, like, you know, they're a clear surgical candidate, right? Huh, debatable too? Yeah. Yeah, yeah, there are people who need surgery, right? It works for some things. But there are a lot of people in the gray zone where the surgeons are sort of backed into a corner of, like, I don't really have another choice, right? They went to PT, you know, somebody gave them a few injections, they didn't work, we threw gabapentin at them, they're no better, right? I guess, you know, I guess we gotta operate because that's the only thing I can do. Those people you can make something, you can do something different with, right? And that's actually a substantial portion of these people getting surgery. So if you can take those people with very fuzzy indications but no other option and give them another option, you can lower their surgical rates, which is what we did. We dropped surgical rates by 75% in our comparator population. And so I didn't have the data to start that you had. I had data on costs and where money went and where it came from. But we didn't know quite what would happen once we did it. Right, so I couldn't go that way. But I could go the other way, if you can do better by being better, and you can make medical goals that way. I have trouble with that one because institution wants to make money. So they don't want to have those kind of a system. Because I compared with your institution, my institution. My institution values a surgeon because they bring the money in. They don't care about the value base. So teach me. So this was done with the health plan, right? So health plan's a health insurance company. Right, that is a UPMC. That is UPMC. That's the value proposition. That's the value proposition, right? That you can do with the payer. Right, so the payer was the one supporting this arm. That's the reason why they were interested in it. Right, and like I'll give you, so we built this program and we knew what it did and it worked and there was a hospital, another hospital in Pennsylvania in our system that said, it was interesting. They sort of wanted the program and the health plan wanted to go there. And the health plan wanted to go there because again, spine surgeries were pretty high and they didn't have a lot of good neurosurgical or orthopedic care there. And we had these conversations. We got into this discussion of the hospital CEO started the conversation and he said, yeah, I want your program here so I can drive more spine surgery to my hospital. And the representative of the health plan went, no, we want this program there so we don't have so many surgeries going to your hospital. Right, and so, I mean, I'm sitting there like, really, this is the conversation we're having? Right, and they went nowhere. The hospital CEO did not want my program to reduce surgical rates and my health plan did not want to put in a program that would draw more spine surgery into the hospital. It was this conflict. And so, this idea of like we talked, this is all about C-suite or who you talk to. You really have to understand the perspective of who you're talking to, right? And what their buttons are and what their triggers are. And even if you get to like talk to CEOs and things, everybody's got a boss, right? Like what does their boss demand of them, right? And how do they get there? So, you have to sort of balance these conversations. Yeah, Theo, you have a question? So, interesting one is I also went, my question, just one comment. So, I even went to the president with that idea. But then the president was telling me that, for now, we're gonna support the surgeon. For now. For now, and Hyekyong, I'll get back to you a couple of years later. Yeah. Your question. Yeah, anybody who has questions, please raise your hand. Does your health plan have any kind of partnership with the health system? Meaning, do they own a share of the health system? Or are they completely independent entities? Oh, boy. So, I am not an expert on UPMC governance. UPMC, as a company, owns all of this, right? So, the health plan is part of UPMC. All the hospitals are part of UPMC. They're all part of a single entity. They have separate sort of accounting rules, but they're all under the single entity of UPMC. So, the health plan doesn't own, this is part of the problem. The health plan does not own the hospitals, right? And so, hospitals have a different incentive than the health plan. And one of the bigger challenges for a system like this is trying to align all of that. But in the space of what we're talking about, so, you know, had I had to, you know, if I made the same pitch to sort of the hospital, the argument you could make is you could make your surgeons far more efficient by taking some of these patients away from them and having them. And so, the argument I use is the one I just told you, that this is a way to save money by doing better, better care, taking these people on the margins helps. You could make the opposite argument, and I said this at other settings as well, that if you did this right, and you're the hospital insurer, and you can take away all these people with questionable indications, you can do something else with them, you can get them better, you can draw on volume, you could expand the population, and you could get just as many surgeries out of a broader population, right? So, you could still sort of keep your surgeons busy, but you have to, this is where you have to really understand the financial incentives and demands on the people you're talking to, yeah. Thank you so much, it's clear that you guys have been undertaking pretty major challenges and dealing with roadblocks along the way. I wanna go back, because I think part of this is about understanding how those initial conversations started. So, I was hoping you could talk about how you did that initial broaching of your proposal to leadership. What did you do to prepare for the initial meeting? Who did you meet with? What did you need to do to get things set up to even enable those conversations to happen in the first place? Yeah, so, here's the playbook that I think every person should take into consideration. So, a lot of it was already mentioned, but step one, understand the financial motives of the people you're trying to sell to. Just like how you're trying to understand expectations from a patient's perspective, you need to understand what the CEO is going against and what's top of mind and on the agenda of what they want to accomplish that year. Step two is the data. So, in the value-based care model that I kind of talked about, that I knew could be successful, the way the value-based care model is a shared savings model. So, if you beat your benchmark in a previous year, you can earn money. And by participating in this value-based care model, you also get an APM bonus of 5%. So, I actually quantified what the clinical opportunities using claims data from the benchmark data to identify the opportunity. So, in this non-surgical musculoskeletal value-based care model, there are five clinical opportunities that I saw from data that showed that there could be savings seen and better quality of care for patients. So, the first one is, there were studies showing that early adherent therapy could lower downstream healthcare spends, like unnecessary surgical spend. Secondly, in addition to showing them those clinical studies, I showed them the benchmark data that showed when someone goes to physical therapy and in their first 30 days, there's a higher utilization of surgery that is done in those 30 days, and it was done across the whole state. And so, we saw that there was an opportunity for savings if we could do therapy better than other groups in the state of Maryland. So, we thought, hey, there's a high utilization of possibly inappropriate surgeries. There's a really good opportunity there. Second, by taking some of the surgeries and moving from a hospital to an ASC, that was a clear site-of-service saving. So, I explained that to them. So, proper utilization of therapy, improving adherence, surgical utilization spend, showing them actual claims data, site-of-service changes, and then there were a few other opportunities where we saw inappropriate imaging, advanced MRIs during the first 60 days after a physical therapy evaluation. And so, there was about four or five things that... And then the fifth one was the ED admissions. So, I had ED admissions, imaging utilization, surgical spend, site-of-services. I quantified that based off of different service lines. So, we did that for knee and hip replacements. We did that across surgical spine fusion, microdiscectomy, and we saw that there was opportunities. And then I explained to them the ROI, an ROI, return on investment, for anyone that's not in the business language of things, of the potential savings that they could have. And so, when I quantified that, there was about anywhere between $8 million of potential savings, and I gave conservative estimates with thresholds that could be achieved. And I think coming together with that type of proposal, new, you know, a CEO would take that seriously when there's actual money that could be earned that affects their daily job. So, those are just some of the recommendations I would have when you're thinking about generating a proposal on any initiative for a group. I don't have that kind of experience yet, but when I talk to C-suite, I just, I go with what we can do, PM&R, at this time, because the problem what I have here, our institution, even we cannot directly talk with the insurance company. They hire the Southwestern companies, so we, different institution goes, they are representing four different institution, and they're dealing with the insurance company. So, it's very hard to talk with our C-suite to talk about these things, but just I'd like to give an example. What we do is, I was talking to the CEO or president that PM&R is not dealing with only disease. We are dealing with disabilities, which means we are not only treating the disease, but we are preventing disability. Therefore, putting the PM&R in the front is gonna decrease the healthcare cost. So, for example, and then I start to give all the example with the C-suite people. For example, when I started the salivary gland injections, in 2003, nobody was helping me, but I started, and then three and a half years later, we took a look at the data, and then we were able to save $10 million with only 34 patients after the repeat injection every three months to prevent aspiration pneumonia, which means we were preventing the ICU admission. Therefore, when we calculated, it was $10 million. And then, orthopedic surgery, while I was doing multilevel botulinum toxin injection with the phenol nerve block to cerebral palsy children, we were able to decrease orthopedic surgery from 100%. They're all going through the surgery, orthopedic surgery, to relax the spastic muscles at that time. After I joined the children's hospital, we were doing multilevel injections. Therefore, I was able to prevent orthopedic surgery by 80% over six years. So I showed that data and graph, and then I asked them to help PM&R to be in the front to prevent all the disability. That's the only thing I can do at this point, because we have a very difficult, a different situation at this time, because the state university is very different way they run the institution. Yeah, so I agree with all that, and I certainly agree with data, and I really agree with, like, know your audience, know the people. The other thing you have to think about, so this is my own sort of, my own scars of this, and actually, a lot of this, essentially, in these questions, I'll actually, not to plug our toolkits on spine and stroke, this is why we wrote them, right? This is these very questions. This is what's in there. So the other really important thing is sort of this idea of gathering allies and being very aware of obstacles or enemies, right? Your own mini sort of internal SWOT analysis. You are never going to do this by yourself, never, right? If you don't have somebody to help you, right? If you don't have somebody to help you, you'll never get there. If the majority of people you're trying to sell are totally opposed to what you're trying to do, you'll never get there. So I didn't do this very well at my first institution. I just sort of thought, well, God, this is so obvious, right? This is so bad. We can be better than horrible, can't we? Like, this would be really good, right? But it didn't, like, yeah, but, you know, it didn't go over so well. But what seemed obvious to me, having been in the trenches my whole life, didn't get anybody, didn't get me there. So you have to sort of curate people around you. You have to talk to people involved in the process. You have to talk to people who know the people in the process. You have to sort of gather your allies. You have to get, you know, if you're in physiatry and you're trying to do something that is in direct opposition to the interests of your orthopedic and neurosurgeons or rheumatologist or whatever, you're gonna have a hard time, right? So you have to get a way of describing what you're trying to do that gets them to buy in, right? But if you go to leadership and you've got five other departments behind you, right, it's a much easier conversation, right? So you have to gather your allies. You have to go out and have lunch and go to clinics. And, you know, when I went the first three months, I was UPMC. I probably talked to 90 people in three months. I interviewed everybody I could find. I said, who else should I talk to? Who else should I talk to? Who else should I talk to, right? And I talked to all of them to understand their perspective and what they're up against and, you know, sort of work through it. So this idea of gathering allies and being very aware of, if, you know, truthfully, if you're trying to save money for somebody, that's somebody's money, right? Somebody else is making that money now. Who is that? Are they gonna be happy about no longer making that money? If you're not aware of that, again, you could get blindsided. If it turns out your allies are sort of, your obstacle and enemy people are less powerful than your friends, you will probably do okay. If they're more powerful than your friends, you've got to keep working. The other thing I would say is that, you know, Jim Eubanks is in the audience. He was one of my fellows. And I met Jim very early in his residency. And the first thing I told him is that if you want to change the world, you got to be really good at what you do. Be a good doctor, right? Because you really have to be highly competent because you have to be able to handle every question about every angle of what you're talking about. And if you don't know it inside and out, you can't do that. And you can't get the surgeons to be your allies if you don't know what the heck they do, right? If they have no respect for your clinical skills, nope, they're not gonna be your ally, right? They're just not, right? And, you know, good doctors know who good doctors are, right? You all know who the better doctors around you are, right? Everybody does, we all do. You want to be one of them. And so as you learn this, as you get there, you have to be really good at what you do, and you have to know the ins and outs, and you have to understand what the other sort of service lines, services involved and what you're trying to adjust do so that you are working to make their lives better as well. And so I think those two things are really important in this process. Great, thank you. I guess I'll just close with one last question, and I feel like we have touched upon a lot of this, so feel free to, you know, if there's anything else, like is, I feel like you've given such good information to the audience for thinking about how to build the argument and approach these kinds of changes, but if you have any additional advice that you want to provide for folks who are thinking about approaching the C-suite, their leadership, any other last words of advice? Well, C-suite is a very interesting suite, right? So, as he said, like he met 70 people, I try to meet everybody, I try to have meals with them every time, I try to drink with them every time, right? You have to be in the front, you have to be cute. I think the reason why I am saying funny way, because PM and I, physiatrists, we are very shy. Many times we are just physiatrists, that drive me crazy. So when you go to suite, you have to show who you are, right, you have to be present, you have to wear nice clothes first, right? You have to be representable over your department or your community, I start with that, and then you have to kind of know what's the institution mission, and you have to align with their mission to present to your business or your goal. If you are totally different goals, what you have, they're not gonna listen to you, right? Because I try to bring value-based practice to my institution, they say, hmm, we have to make money, Hyekyong, right? So they say, I'll talk to you a couple of years later. So I turned my gear to go to county hospital, because they have a similar, yeah, incentives. I said, I'm gonna do business with them, I don't care about my own institution, because they will learn later from my work from other institution. So I changed my gear to county hospital, where a huge hospital from Dallas, all the rich people putting the money over there, and then now they are craving for physiatrists for every corner. So in a way, for you to approach C-suite, you don't need to directly approach C-suite over your institution. Have them come to you later. So I will be successful with other C-suite, right? And then I will bring this one to my institution so they can come to me. I'm gonna wait for them. They will absolutely come later to ask me how they gonna use us, right? Because I always use the terminology, please use a physiatrist. So I was knocking each department, and then I give a lecture. So for example, we have a brain institute where they don't know because we are the member of brain institute. We have a neurology, neurosurgery, PM&R, and psychiatry. And then one day, neurology chair told me, Hyekyong, I'm not so sure what you guys doing here. Okay, wait. Where did you work? So he came from the place where they don't have PM&R under orthopedic surgery, right? I said to the director of that center, I said, Bill, I have to give a lecture. You guys all coming, okay? So I prepared a lecture, how to use PM&R. And then I put all the PM&R values that we are preventing the disability. We are not taking over all disability. No, no, no, we're gonna prevent disability. After that, oh, now we understand. Now I'm heading to pediatrics to give the same lectures, right? So this kind of stuff we have to do that. I know we are talking about money, but for you to get the money, you have to tell them who you are first, what we can bring to the table first. All important. Yeah, the other thing I would say is that, one, practice your language, right? Make your message clear. These books of, I don't know how many, do you guys read all these books and things? The books start with why, right? I think it's a really helpful book in terms of how you sort of define what you're trying to do. But you start with your why, and you'd be very good about your language. And I had a conversation this spring with a former CEO of a large health company that really did a lot of transformational work, which is why I was talking to him, to understand it. And I said, so if I came to you, what can I say that would help you understand this? And he pointed out a couple of things. One, he's not a doctor, right? Even if he were a doctor, he's not necessarily a specialist in what I'm a specialist in, right? Trying to explain back pain to a nephrologist, like, eh, take a little while, right? He said, one, I'm not a doctor. And he said, two, if you think about what I would have to do to do anything, he has a boss. His boss is the board of directors. So he has to go back and convince his board of directors to do what you just said. So you have to put it in language where he can, one, see it in his own head, and actually explain it in his own words, or her own words. This is a male that's talking to him, using he. But this idea that when you're talking to somebody, there's almost always somebody higher in the food chain above them, right? So they're gonna have to answer to that person. And so you have to give them enough language and enough vision that they can see what you're talking about, and be able to explain it one level higher up, and understand why that matches their priority, right? So it is sort of thinking through this a bit, and thinking through that conversation, and realizing that, you know, where does this go eventually? And, you know, when you talk to people, it's interesting, we talked a lot about economics, and people, all these people have, it's about money, right? You hit the C-suite, it's about money. But in that, they're all in healthcare for a reason. They really do, most of these people believe in better health and better healthcare. They sort of do. They're not all just pure, like, make-money people, the ones I've met anyway. And a lot of them have a personal, like, healthcare's really personal, right? They've had a whole life in healthcare. They have parents, they have kids, they have a spouse. Like, they're not, they're, like, they get it, right? And so, sometimes, if you can get into a conversation where you can get at these personal drivers and understand why someone else might be invested to invest in what you're talking about, you can, that's really powerful, right? If you can get to that sort of, their why a little bit, right? Why are they in healthcare? What's important to them, right? And everybody who goes into a C-suite, they don't, they usually don't go in just as a place builder. They have, like, there's a goal. They're trying to do something, right? And so, if you can figure out what that is, it's really helpful, right? Because then you can align yourself. So, I had a very interesting experience with that because it's all, we are in a healthcare system. So, our CMO made a video to work on the, decreasing the length of stay for the OcuSite. So, they made a slide. And then, my princess sitting there, but they said they didn't even call the PM&R. There are two case, right? There are two case scenario. So, one was they don't need the PM&R, so they can discharge, but one is exacerbation of the MS. So, they didn't even call PM&R. They call, they say, according to therapist, the patient can go to SNIF or something like that. So, my colleague sent the video, and, hey, Kyung, look, this is what's going on at our institution, right? So, it's already done. So, I was very calm. I said, how I'm gonna win this game? So, I talked to that person, said, calm down. Let me think. And then, and then, I had opportunity. Yes, I had opportunity. So, I had, I called the meeting, and then I told him, he's CMO. I say, you know, let's put his name, Jack. Jack, now I have to call his first name, right? I don't call Dr. So-and-so. Jack, by the way, I had a chance to see that video. Let's review the video together. Oh, hey, Kyung, it's very short meeting. Just, it takes only nine minutes. I move fast. So, I stopped over there. So, have you ever thought about PM&R when you have this kind of patient? You know, yeah, but we didn't call. I said, can you, please do not distribute this one to case managers. They will have wrong information, or you have to make it again. He said, oh, it's so expensive. I said, what is more expensive than making mistake, right? And he was thinking, mm, okay, I will cut. And they modified the video, which is a miracle that they listened to us, right, PM&R. So, they had to add PM&R on that. The funny thing is, that's not the funny part. Afterwards, he called me, hey, Kyung, by the way, my mother-in-law is in the Occult Medical Center. I want you to help me to bring her to PM&R inpatient. Okay, I have been waiting for that, right? I said, really? And then your physiatrist came and see my mother-in-law, that my mother-in-law is not the candidate for inpatient rehab. No worries. She is now. Yeah, I'll handle it. So, I sent a senior, senior consultant, and she went there, immediately she changed. She found some indication. We can fake it, right? Perfect candidate for inpatient rehabilitation. After that, he start to think, what is the candidate for inpatient rehab, right? So, talking to see Swedish, sometimes it's a ridiculous way we can approach them. We hold this example, right? Take the opportunity, and you have to stand up, but at that time, if I was extremely depressed, what happened? Nothing happens. All right, thank you so much. I did want to open it up to questions. We have a question here. Thank you, more of a comment. You talked about being at the table. You talked about engaging, understanding motivations of the C-suite. You also talked about awareness and understanding of our specialty. Both of you did, over the last 10 to 15 minutes. A lot of what I have seen and experienced in the two years I've been chair in Penn State is they don't know what they don't know. And that has been my biggest obstacle. I, very soon after I joined the department, I met with the value-based care team. Like you said, Cindy, earlier, most of the measures, and they do participate in value-based care, are not applicable to PM&R. Most of them are not applicable to ambulatory care, period. It's... They're specialists at all. And they don't know the opportunity of additional incentives and savings because they don't know the things that they don't know. And nobody has told them the opportunity of specialized care, specialist participation in cost savings and all the things that you mentioned. It's not even in their framework of thought. But yes, they do have the motivation to save money and they want to increase value, provide best care. All of those motivations are aligned with what we want to do. But the awareness is not there. And it is... There is no easy recipe to change that. We, I think, as a representative of your field in the C-suite or in your institution, you have to be constantly cognizant of identifying opportunities, which will allow you to then interject and, like Hyekyong said, a story or an anecdote to then increase awareness and change sort of the understanding of how we can provide value to everything that's going on. There is no easy recipe. I don't know if any of you have any additional stories, but I've found it to be a big struggle. I think, one, stories do help. Patients help, right? I think, you know, I was thinking when you were talking that, like, I worked for Stan Herring for a long time and one thing he told me when I was very young was like, when a colleague asks you for help, there's one answer, right? Yes. He says, can you see my mother? Yes. Can you see my daughter? Yes. Can you help me with this? Yeah, there's one answer, right, when somebody asks you for help and that sort of helps the thing. So one of the things, one of the turning points we had was that we went and we said, okay, we're gonna, and they were supporting us. I had a person who was supporting me say, we're gonna go look in the quality division of our system. We're gonna see what happened to people who went into one of our hospital catchment areas with back pain over a year. Can we look and see, like, I was like, what happens, right? What are we trying to fix, right? And we did this, we found, you know, we did this study and within our own system, we have a database and we had about 2,500 people who came in with back pain and hadn't had a back pain bill filed in six months before or whatever. And we said, what happened to them? And it was utter chaos. They went everywhere, right? And this is 2015 data, but within six months, half of them had gotten an opiate, half had gotten imaging of some sort, about 10% went to PT and about 20% went to surgeons, right? This was like back pain, like back pain, right? And so we had this data and we had a big meeting and I threw the data on the wall and one of our lead neurosurgeons went, oh my God, no wonder my clinic is like this. You have to fix this, right? And so like things like that really helped. You don't need like a huge piece of data, some little snippets of like, look at this, here's a story and I agree with you, there's one real problem with physiatry or like if I think about, you know, one of the struggles I still have is that it's not in their imagination, right? The idea you can see, this is a rehab thing, you can see somebody with a complex chronic problem, you can talk to them, you don't actually have to do anything to them, you can talk to them, you can explain it, you can explain the situation to the therapist and the team you work with, you can put resources around them and their life can get a hell of a lot better because you listened and took care of what they're concerned about. It's not obvious to many people and so painting that picture, but it's little things, it's like stories and this is a patient and this is why and here's somebody who did this and so when I talk to leadership of various sorts, like yeah, I put a couple of patient vignettes in there, like this is what happened, right? Because then they can sort of relate to it, but you have to steadily build this, they can't, it's like it's not there, you have to build it in their head that they can see it. Yeah. Thank you, I think this will be our last question before we, yeah, come on. Okay, thank you, I'm Jonathan Whiteson from Rusk at NYU and this was an excellent session, thank you so much, very important conversation. We have nothing to do if we don't have patience. I agree with the conversation about the metrics and the stakeholders, but I wonder and I value your comments on patients as stakeholders and how we might engage patients and their feedback because the CEO are very interested in patient loyalty, brand loyalty and keeping patients coming back lifelong and how can we as PM&R docs who I think establish wonderful relationships with patients utilize that to our benefit in terms of this conversation? Thank you. So one thing I didn't do that I wish I had done is I didn't start with like a patient experience group and talk to patients about what they, the people I didn't talk to when I got to Pittsburgh were patients, right? What was their experience with spine care in their system? Frankly, the picture I got from everybody else is like, oh my God, they must hate this, right? But I hadn't done that and I actually, I just finished a master's in healthcare transformation when we did a study and I actually learned how to like run an experience group which I'd never done before. I was like, wow, I should have done this seven years ago. So I think you can do that. You can actually go talk to patients and find out what they need. You know, we collect stories, right? We have patients who come in to our clinic every day like, oh my God, I never thought it could be this good. And my nurses now have, they have a form and a template and say, hey, would you be able to tell us about this quickly, right? And we collect them. So we get our press Ganey deals, but they're kind of blinded and you can't like throw them out publicly and whatever. But we get these stories and say, can you do this? And they, they appear on our website and they appear places. And, you know, we, we actually had a situation where we have a, we have three full-time PTs who cover two of our clinics. They just see our patients. They don't see anybody else. And the, the PT organization wanted to repurpose one of them, wanted to take one away and put someone somewhere else. And so we went to his patient said, you know, they're talking about taking Mike away. Oh my God. Said, here's an email, right? For the head of the physical therapy group. Here's his email. Tell them what you think. And we sort of, we, we, and in 24 hours, they got like 25 angry emails from patients saying, you can't take Mike away. And the next day we had Mike again. And so you can do that. And it's tough. I'm not big on like, you know, I'm there for my patients. I have a very hard time asking things of my patients because I'm really there for them. I, you know, I've had development. So ask them for money and stuff. I have a really hard time doing that personally. I'm not good at it. But these, but letting them tell their story, often they're happy to tell their story. So things like that, like collect stories, collect the energy, collect, the people are positive. They have good reaction, get, you know, start collecting that stuff. And then you wind up with a, your army is your patient, right? You're right. Our patients really like us. Yeah. So thank you to the panelists and everybody. Stay here. Don't go anywhere. What we're gonna do, what I'm gonna do for the next, for the next 10 minutes, just to wrap up, is do a very shameless advertisement for the toolkits. This is something, and you'll see the background of it, but I think something that very much ties into what we're doing. So the toolkits, as I told you at the beginning, were built really over several years. They started under Chris when he was, my predecessor before, while he was chair of IPPM until 2021. They started by doing spine care. When I joined the committee in 2020, we started stroke and finished this up after that fact, or after that time. Basically, we identified that PM&R were struggling to find their place with value-based care. And so many of these models, you know, were done originally for specialist care because of surgical issues. But the thing is, we wanted to actually then really expand it out to other things. So the toolkits, as you'll see, one is back pain, which is gonna be one of the, really one of the models for outpatient and stroke rehabilitation, which is really there for inpatient. But the thing that we wanted to do in this was look at concepts behind it. We didn't wanna prescribe because the thing is, we know that out there, there's a lot of different practice models. And so we just wanna give you the idea of how to do this. So as Cindy was telling you, you know, Medicare already has APM models out there. And you know, you guys may be participating in ACO. You may not even know the fact that that's happening. But by engaging in the toolkits, we're hoping that you become really more familiar with the language of APMs and begin exploring whatever opportunities you can, you know, to get value-based care into where you are working with. As described in these things, stroke rehab and spine care are huge cost burdens. And so, you know, there are really opportunities for cost savings. And we are the key to doing that. We are ones who can be the drivers of it. And we should be the drivers on it because we have the real opportunity to provide really high-quality care at lower cost. So the toolkits are expensive, extensive. I suggest get your highlighter, get a cup of coffee, sit down and read, you know, download it if you need to and really go through it. And I'll walk through this a little bit. You can see some of the things that are on here. But basically, number one, I think as Chris and Cindy and all the others were talking about, we're talking about really the economic considerations of why APMs and spine care are necessary. We look at statistics. So you'll see some of the data that, you know, that we've been talking about. And we also include, you know, environment assessments, which as Chris mentioned, really encourages you to do a SWOT analysis, see what is out in your environment and see what the strengths, weaknesses, the opportunities and the threats are going to be. This really helps you, you know, identify the things that are out there so that when you go to talk with your C-suite and your allies, you'll have all this data to be able to do this. And so I'll discuss engaging in senior leadership next. We next offer recommendations for quality and clinical and financial outcome metrics as well as guidance regarding how to assess your program. So again, all real important aspects of trying to do a value-based program. And then we are also gonna describe who are the key members. So basically, all the different specialties on the outpatient side, your therapists and all the other people, both inpatient and outpatient. And of course, these are not exhaustive but important things that you need to know. As Chris said before, know your allies because when you come in numbers, that's what is going to help you get what you want in the end. So aligned with this then, it also describes how to engage. And I think we talked a little bit about this. So understanding the steps to obtaining buy-in, know who you are talking to, recognize what they are after. I think Chris made an absolutely wonderful suggestion. The book, Why, is really, really good in terms of understanding what you are all about. It's not the what, it's not the who, it is the why and what is your mission. Provide the data is, again, something that has been mentioned. And then finally, what you've gotta do is you've gotta be able to talk in their language and as it states here, create an elevator pitch. You don't have a lot of time. They have short attention spans. Get that message across as quickly and as clearly as you possibly can. So the authors on the stroke side, which was myself as well as others, wanted to really highlight opportunities. So one of the things that we acknowledge is really the fragmentation of care. So really the whole idea of the Stroke Toolkit is really trying to get that continuum of care put together and trying to see if you can get your partners so that you have everything from acute care all the way down to outpatient. It highlights, and I think one of the things that I'm proudest of is that we included a section of really what does it take to innovate? What are the components? What types of innovation are out there? And so if you really want a good synopsis of that, that's a good place to work. And then we also look at the potential for opportunities in the different stroke rehab care settings. So you'll see all that in there as well. So the message really is, it's out there. Access it. Tell your friends about it. Get them to access it. It is in the members only section. So as a member of your academy, as a member of the academy, this is some of the resources, this is some of the value added that you have by meeting members of this organization. It's under the quality and practice section, under, as you can see here, the alternative payment models. And it really, it will really give you stuff if you want to look at, there is also an executive summary that we put together so that at least you can get a summary of it before you go delving into all of that. With that, I will, if there are any questions, please ask. And otherwise, we will go from there. So any other questions? Otherwise, we'll give you five minutes back. So thank you very much for your attention and have yourself a good one.

value-based care

physical medicine

rehabilitation

C-suite engagement

alternative payment models

Accountable Care Organizations

bundled payment models

healthcare payment reform

patient feedback

cost savings

quality improvements