Hi everyone, thanks for joining us today. My name is Chloe Slocum, and I am the Director of Health Policy and the Associate Director of Quality at Spalding Rehabilitation Hospital in Boston. I'm joined by my colleague, Dr. Rostefant, and I will be talking about cultivating value and equity in physiatry. The first part of our presentation is going to be by me. I'm going to be reviewing population health principles and some practical lessons for physiatrists in value and equity. I'll be followed by Dr. Slocum, and then the session will wrap up with a Q&A panel at the end. If you have questions during the presentation, please submit them via the Q&A box. We will be reviewing them and hopefully getting to them in the last part of the presentation and discussing them in the panel. These are my disclosures, and I will be starting out talking about some fundamentals, what is population health, and where does physiatry fit in. Then I'll be talking about health outcomes and health equity, again, focusing on the role for physiatry in both examining health outcomes and our concepts of equity. Next, I'll be talking about value-based policies and value-based frameworks and determining what are meaningful outcomes within such frameworks. Next, I'll be talking about quality metrics and the role of big data and the importance of some small details in quality metrics, which is also very important for performance measurement trends with a special emphasis on transparency and accountability. Without further ado, what is population health? Population health, we can think of as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. As a term that's searched or used in literature, we can see the data from, this is just from PubMed, but interest in population health and its importance to research from the basic sciences all the way to sort of very macro public health research has increased exponentially over the past 20 years or so. When we think about population health, we can think about dividing it into sort of three broad buckets with special emphasis on practices, policies, and information. These we can think of as really feeding into and shaping health factors, which are called determinants in other conceptions of this. And the health factors that we can think about, physiatrists are very familiar with some of these, but these include the physical environment, health behaviors, clinical care, and then social and economic status. Finally, downstream and at the top of the screen, we can see our health outcomes. So really broad outcomes might be things like morbidity and mortality and finer tuned, more granular outcomes may include things like function or different sorts of metrics in terms of potentially the achievement on, for instance, a scale or a particular outcome of interest related to a specific health process. So this is another way of visualizing this framework. We see sort of over on the left, different sorts of interventions in terms of policies, practices, and different determinants, be they very broad, all the way down to things like individual behavior and outcomes. And these can be really broad in terms of health outcomes for a particular individual or community and seeing sort of how all of these interact within a population health framework. So the Centers for Medicare and Medicaid Innovation, really called the heart of population health, this intersection between clinical care, where we as physicians tend to be very comfortable and most of our training is anchored, and public health and community services. Now, why do we really care as physicians about public health and community services? Well, it's important when we think about health outcomes as well as health equity and really being able to achieve meaningful outcomes and equitable outcomes for individual patients as well as for a particular community. And when I say community, that can be as small as a physician's practice panel. It can be as large as, for instance, a particular region, a particular state, and even national health outcomes. This is particularly relevant when we think about some of the foundational work in looking at the nation's health outcomes in context. So in 2013, Bradley and Taylor looked at this and they called it the American health care paradox. We see her on the right, total health and social spending among countries in the Organization for Economic Cooperation and Development, largely developed countries. And we see sort of in the blue bars on the bottom that the U.S. by far outspends all of the other countries on health care. But our outcomes are modest at best, and sometimes they're downright mediocre. So we think about where we are in terms of infant mortality, overall life expectancy. These are often not at the top where our spending is, but are middle of the pack and sometimes lower. So this was thought to be by Bradley and Taylor due to partially our mix in terms of the fact that we are spending so much more on health care and less comparatively on social services. But I think we could also argue that our spending in health care in terms of what we're spending it on may also be part of the reason why our outcomes are comparatively modest. When we think about equity, there's been some foundational work on this as well that was done in the early aughts as sort of culminating in the National Academy of Medicine report on equal treatment and looking at disparities and really coining the phrase health care disparities, specifically looking at differences between white and minority populations broadly and differences in health outcomes and within differences, looking at disparities and what contributes to disparity. So, for instance, we can see here a framework where a difference may be due to clinical appropriateness, it may be due to a patient preference, but disparities really don't include that as a cause of difference. What we're talking about when we talk about a disparity is a difference in health outcome that is due to something different about the operation of the health care system or related to things like discrimination, bias, stereotyping, and how uncertainty may disproportionately impact somebody based on, in this case, their race or ethnicity. But we can think of other patient factors where that could come into play, too, and also contribute to a disparity between or within groups. This study by Schulman in 1999, I thought was interesting and always interesting to bring up at a conference because this was actually done at a conference where they showed physicians different videotapes of standardized patients that looked different but were actually presenting with similar symptoms for a similar underlying diagnosis and found that all of these physicians, who I'm sure were very well-meaning and were striving to provide the best evidence-based care, regardless of patient characteristics, actually provided different hypothetical care within these scenarios that broke down along both race, ethnicity, and gender. So certainly something to think about. And I think nowadays we talk a lot about implicit bias. This is one of the first studies where they really looked at what we have come to call implicit bias or bias in clinical decision-making that may actually influence outcomes, even if it may not be realized by the clinicians in the actual encounter. So for the past several decades, public health researchers have been trying to sort of develop a framework and to describe the different factors that influence health outcomes for both individuals and populations. And so they've looked at things like broad socioeconomic, cultural, and environmental factors, all the way down to individual, what we might call lifestyle factors, and then what we might call things that are non-modifiable, like, for instance, your age or my age. Within health equity research, there is a growing understanding that what we might call the social determinants of health or different factors besides simply just the delivery of a clinical algorithm. But for instance, somebody's neighborhood and built environment, their level of economic stability or precarity, their educational level and things like their social and community context, and how all of these bring to bear upon their health outcomes and how this is important when we think about health outcomes for a particular population. So if, for instance, I'm looking at my patient panel, I happen to be a spinal cord injury physician thinking about all of these things in addition to the clinical care that I'm providing when I'm trying to optimize outcomes for my patient panel. And I'll give you a specific example when we look at this, which I think is a more granular chart by the Kaiser Foundation here, which really lays out all of the different factors which we might think of under the umbrella of social determinants of health. And I think physiatry by and large has done a lot to illuminate these, and then there are other areas where I think we intuitively have a conviction about how certain factors influence health outcomes, but maybe we have less research or maybe we need to do more research. So, for instance, I think within the field of spinal cord injury, we know a fair amount about employment. We know a fair amount about education and someone's level of higher education and how it influences their health outcomes. And we know about things like access to healthy food options and social support systems. I think that we know less at a population level about things like neighborhood safety and transportation, although there's some really, really wonderful research being done in that area right now. And I think that we could say as a field that we know that patients that have access over here on the right side to high quality specialty care and who have access to providers who are available that specialize within the field of spinal cord injury medicine, I think we can say that. But I think that research at the population level would certainly help bolster our claims as a field. And so this is, I think, a reason why physiatry is well suited to really add to population health dialogue and policies around population health, especially around access. But we think about sort of the risk of different factors on premature death and we can see here that health care is really a small component of this and that individual behavior and social environmental factors are large components and that we should consider them holistically. This is a visual that I really like from the Robert Wood Johnson Foundation that I think is also apropos to physiatry. We can see here on the top, equality might be providing sort of everyone with the same tool or everyone with the same access. But when we think about equity and really achieving equitable outcomes, we really want to tailor it to the needs of a specific population. And again, this can really be more at a micro level or a macro level. But the important thing is to be considering the outcomes that are really meaningful for that particular population when you're designing things like policies or practices with the aim to improve a specific outcome. So there's some good news and there's some not so great news when we think about health equity. This study by Trivedi in 2014 showed that public reporting of quality data did, in fact, appear to narrow some disparities between groups just by sort of having providers focus on the public reporting of different quality metrics. But then we see, for instance, within a very contemporary paper in 2020 coming out, we can see that sort of different clinical risk factors between groups are somewhat varied when we think about things like obesity or smoking or age, for instance, in terms of folks' risk of severe COVID-19 infection. There are differences, but they're not necessarily trending all in one direction. But then when we see sort of access to work that can be done remotely, not essential work or work, for instance, in high risk occupations, there are certainly trends here which would help explain why we have seen certainly worse outcomes and more severe illness and excess mortality in certain populations that are also disadvantaged in terms of social determinants of health, specifically racial and ethnic minority populations. OK, so this shows sort of why I think that physiatry is really well suited. I think I've talked a lot about frameworks. I've talked about sort of definitions of population health. But when we look at sort of our own organization, what is physical medicine rehabilitation? The focus on really improving functional independence, maximizing quality of life, and really in our DNA, understanding the framework of interactions between an individual and their environment and personal factors that are both enabling and potentially serve as a risk for suboptimal outcomes, I think is really what puts us at a particular advantage and I hope will inspire some of you and hopefully folks across the field more broadly to be engaged in some work in population health at a broader level. So I'll talk quickly about value based frameworks, patient value, we're defining as patient relevant outcomes or meaningful outcomes over costs per patient to achieve that outcome. And this is was developed by Michael Porter and Elizabeth Teasburg. But we can think about sort of maximizing patient value by a policy or practice that really helps improve patient outcomes while keeping cost stable or constraining cost. But I think most work so far has been on sort of looking at constraining costs. And this is important due to sort of projected medical expenditures in the next five to 10 years and also the coming decades. So, again, we can see some of the foundational work on this was done by Porter and Teasburg. And then more recently, Porter and Lee have sort of come up with a framework and looking at a step by step process going from one through five. I think most policies that look at value and improving value have really come across the sort of the first two steps in this algorithm by looking at sort of a particular process and trying to improve that particular process, delineating sometimes integrated practice units or sort of defining the team that should work on a particular process or work on a particular outcome, and then sort of measuring things and really a focused measurement of cost. But I think there are fewer programs and policies that have really gone beyond this and just sort of the larger or sort of further down the line goals of value based care. But they're certainly not because of lack of interest. So here we see two major government programs in terms of under MACRA, the merit based incentive payment system and advanced practice models, both of which are value based frameworks. There has also been a lot of interest by private payers in creating value based networks. And there's also been work by health reform researchers or public health researchers on the potential unintended consequences of some of the value based care initiatives, including things like the hospital readmissions reduction program and payment bundles and how they may pose, for instance, risks to vulnerable older adults or smaller populations that a bundle may not have been initially designed for in terms of the actual implementation. And I think we as physiatrists are sort of very attuned to the needs of populations with, for instance, catastrophic illness and disability. These are important, so I talked in one of my first slides about sort of the marriage of big data and attention to small details. And I think these are also important to consider when we think about evolving quality metrics. So quality metrics broadly fall into one of three buckets. They tend to be related to structural metrics, process metrics or outcomes. When we think about the three of these, I'll give you an example of each. A structural metric of, for instance, a health system or hospital might be the number of patients that it takes care of with a particular condition or the equipment that it has on site. Or, for instance, the number of certified professionals, be they physical therapists or nurses who are staffed at that hospital. A process metric does not have to do with intrinsic structure, nor is it an outcome, but it's something that we think of as providing higher quality care. So we can think of this as the number of staff that are vaccinated against the flu each season. And outcomes, we've talked about outcomes ranging from really broad like mortality to granular. So, for instance, some of these gain on a particular scale like the FIM. And these are reported differently by different bodies. So at the state, they may be reported by your state health commission. These, again, range from really broad to granular, depending on your state. And they may vary in terms of particular health condition if there's one that's of particular interest within a particular region. So, for instance, the Maryland Health Care Commission has had an initiative called Wear the Cost, where they're reporting on different costs for procedures, but then they're also monetizing complications that happen with different hospital procedures or hospital diagnoses and are reporting those publicly. There are reports from federal agencies. So the National Health Care Safety Network reports on sort of common complications. And then there are websites like, for instance, IRF Compare, where outcomes are reported for different inpatient rehabilitation facility providers. There are also reports from private payers and business groups, the Pacific Business Group on Health does a lot of reporting. And agencies such as Blue Cross Blue Shield, or rather entities such as Blue Cross Blue Shield, focus on distributing lists, for instance, of providers they feel to be high value based on certain metrics. And perhaps most famously, Walmart has developed a Centers of Excellence program that they use as an employer to direct employees to high quality health care providers. There are reports from independent organizations. Oftentimes, accreditors will report back to a particular organization, but then will report on accreditation more broadly. And there are hospital ratings. Although this analysis from 2019 from Bill Moria and colleagues found that if we sort of match, if we rate the raters or we grade the raters for some of these widely used rating systems in terms of did the outcome match the goal, that few of the rating systems actually performed as they aspired to. And for performance measurement trends, I think this is important to think about when we think about the small details as we sort of come into an age where there's more and more big data that's being aggregated, we would hope that performance metrics would allow providers to improve and self-regulate, would allow consumers to be educated and to empower consumers, and would also allow purchasers to fulfill a fiduciary or public duty. And I think we need to think about the best ways that we can do that with performance measurement, seeing as trends towards transparency and accountability will likely accelerate. So thinking about both the benefits here in the left-hand column of really transparent and accountable performance measurement, as well as some of the unintended consequences here on the right side. And with that, I'm going to hand it over to my colleague, Dr. Zafant, for his portion of the presentation. And I will look forward to rejoining and discussing some of your questions at the end. Thank you. Thank you very much, Chloe, for that stunning overview of the importance of quality, value, and disparities. What I'm going to try to do in the next 25 minutes or so is really play soothsayer and look a little bit about trends. Where do we see healthcare delivery going? What do we see health policy linking to? And Chloe covered some important parts of that. And then take a macroeconomic view about how that might impact the psychiatry and the general healthcare market. So these are my disclosures, none of which having anything to do with this discussion today. So our outline will be demographic trends and challenges at first. Hey, was the country changing? What does that mean for healthcare? Who are our stakeholders that will determine those changes that I will try to look in a crystal ball about? Health systems, advocacy groups, payers, regulators, and industry itself. Macroeconomic drivers in the United States and in our U.S. healthcare environment. Policy issues and trends and fiscal risk and prediction to the best that we possibly can. Okay. This is a trend that favors physiatry, and that's for sure because we deliver care to people and do the right thing. And so the fact that 26% of the U.S. will have some form of disability in the near future is a stunning effect and suggests that we will be able to positively add value to the community if we do it thoughtfully and if we are appreciated. To support that end, the world's population is getting older. And that is just a truth. All of the Western world, most of Asia and South America are getting older and getting older rapidly. And so this also trends a trend to talk about the value that physiatry can provide. This is work by my young colleague Adam Lam who is now in Michigan but was with us as a resident and a fellow. And what Adam did here in a lovely way is he looked at the UDS dataset and was able to look at admissions to brain injury units. And you can see this almost linear rise in age and rehabilitation age for those with brain injury over the last many years. Suggesting, yes, this aging phenomenon impacts us and it impacts the directionality of the care that we are going to be able to deliver. Now, to that end, I play an opposite card. And that opposite card is one that's a foreshadow for our economics part of our discussion. Here we look at the active workforce. What you see is a declining trend by age. So as we get older, there are less people working and certainly during this most recent pandemic, as we will discuss, the impact of this is not small. It's stunning. So less people to support the health care needs of the country. So let's go back and look at stakeholders. How will health systems change? Well, they've gone through what has been a decade, decade and a half of remarkable consolidation. But in some elements, they're going to need to know more than that. The regulators are on top of them. There are a number of different suits or AGs that have been really monitoring closely market share or even perceived market share in various environments. So consolidation may not be the entire answer. The answer may be networks and assumption of risk. And so what we're beginning to see is an evolution that began some years ago in certain parts of the United States, where these large integrated networks are beginning to take risk and they're taking risk for patient lives. And in assuming that risk, they have to become both provider and insurer in some ways, because the number of rate increases is going to be limited. So if we assume that that to be true, the only place to get that increase need in revenue is growth of population, i.e. covered lives and taking out the ticket broker, assuming some of the risk. Now, there are dangers in that. My goodness, it's challenging. But just to foster that, one needs to think about service lines. Now, there are various opinions about how service lines will affect rehabilitation in this country. And service lines are really entities that say, I'm not in the Department of PM&R, I'm not in the Department of Neurosurgery, I'm not in the Department of Neurology or anything else. I'm an integrated spine delivery system or I'm an integrated brain injury delivery system. There are really, really good things to that. Patient access, flow of care. There are some challenges. Departments tend to lose their clout, their entities, individuality goes away. Finances go to the center. And it's all about the model that you used with it and how you distribute the wins and the losses, which are highly variable. In some places, they're remarkably good. In others, meh, not so much. And it's how you establish frontline access. That frontline to spine care could be physiatrists. Or as we'll talk about in a second, it could be another cohort of people with good and bad. Telehealth is clearly a trend in rehabilitation, but in healthcare in general, there's really good to it. We can provide rapid access to patients. We can screen people. People don't need to drive in. It may be an effective use of care in some situations. Certainly for follow-ups, there's a bad. There might be unknown liabilities. And even more concerning than that might be a tendency now for the payers to pay, but in the future for them to ratchet down a little bit, progressively ticking the clock in a different direction. So there are advocacy groups and that's for sure. Employers. What do they want? Employers want cheaper healthcare. They want to be off the dime for this. Patients. Patients want access. They want good health outcomes at a reasonable price. Insurers want to hold down cost and demonstrate, whether sincerely or not, and I'm certainly not against them, that they're showing at least equity or better outcomes. The government, as we'll talk about, really has a driver and that is we're spending too much already. We've got to cut the spending. Industry views this in two different ways. How do we leverage what's being done to create new product? How do we curtail our costs? And non-PM&R providers are another advocacy group and we shouldn't forget about that. That is groups of people who provide like services. Everything from podiatry to orthopedics, from neurosurgery to nurse practitioners, who are saying, hey, we can do much of the same things just as well. We view ourselves as separate, remarkable, distinct, and we are, but the world doesn't necessarily provide us with a unique special favor. To that end, I bring up the role that is incipient of APPs, or Advanced Practice Providers. They can be remarkably helpful in helping us provide access to patients, do follow-up care, assist in the management care, and are inexorably needed in many environments. There's also a there's also a negative. The negative is, in reality, the APPs could do much of the frontline care in some service lines for spine and then refer on to orthopedics or neurosurgery, the few people who don't get better with physical therapy, conservative interventions, etc. So, we have to be thoughtful. This is not well yet clear how that is going to be played. Physiatry tends to provide its value over a longer period of time and with complex people. And it's clear that physiatry adds value to much of care. What's not so clear is that everybody sees that up front. We have to be a voice for them. Payers want price transparency. We'll talk about how that might be both a good and a bad. They want a commodities market. What do I mean by that? Well, if you can do it for $400 and you're a four-star provider, someone else can do it for $350 and someone else can do it for $300. Well, reality says, why not pay $300 and make the patient or someone else responsible for that $100? And Chloe talked about quality metrics, and those are going to be a big part of our future. What is a quality metric? Are they too complex now? How do we provide them in the simplicity and over the long term to where we show differential in value-based care she discussed? And bundles, I put bundles really because bundles are great for things that are confined, like a knee replacement. But one has to remember they've resulted in about 4% to 5% improvement in care costs, most of that extraction coming from post-acute care. So are they really the answer to everything? Or is it taking global risk, understanding value, disproportionately rewarding those that provide the highest value, and transparency that some of us may like and some of us may not like? And I'll talk about a mechanism towards that. So what is going to drive behavior and change over the next many years? So state and national regulatory issues. The states have problems, as we'll talk about, but the national view on this is we just got to stop the growth in health care costs. Now, one could argue economically, and I've heard people far more sophisticated than me saying, hey, you know, we spend a lot in health care, as Chloe touched on, but perhaps a lot of that creates really good jobs, and those really good jobs consume other things. So maybe it's not so bad. That's a hard argument to make at a national basis. It's one that's cogent, but nobody's buying it. What does value really mean? Well, is it value in the short term, or is it value over a period of time? Remember, Chloe defined for us value out of the Porter way, outcomes over costs. Well, how long is that outcome to achieve? What is the cost over what period of time? And how does function and things that are more etherical, like return to work, fly into that? There's a deep belief in a national environment that the more physicians in an area, the higher the cost, the more expensive they are. And there is this belief that you've got to get things out of big centers and return them to the community, and a depth of political digress to try to preserve rural and community hospitals that are clearly struggling at this point in time. So I would be remiss to talk about macro issues and not talk about COVID. Nothing has affected the world, at least in my lifetime, quite as rapidly and as devastatingly as COVID. Despite beliefs in certain environments, physicians are not remarkably profiting from COVID. In fact, the health care system has taken quite a hit. Many hospitals have had to freeze hiring. Many hospitals have looked at decreasing salaries or certainly limiting bonuses for employed physicians, and many private practices are struggling. And a national shutdown or curtailment or an overrun of services in the next several months is not going to be a good thing. Services in the next several months could produce a second wave of that like effect. Now, interestingly enough, a few weeks ago, Professors Cutler and Summers here at Harvard in JAMA published a study that I found just lovely. And it was very short but very elegant. In their analysis, the cost of COVID so far in the United States is $16 trillion. That is 16,000 billions. My fear is Professor Cutler and Summers were not quite high enough. There's another conceptual within the government, and Dr. Slocum knows this became one of my favorite words, and that is the belief that health care costs are confiscatory. And what that really means is they eat everything else. So there's all sorts of things we want to do. We want to build infrastructure. We want to build railroads or high-speed loops. We want to invest in education. We want to do all these other things. We can't because health care costs eat everything. It's confiscatory. This belief is fortunately or unfortunately inculcated into higher level government. And we can see why. You can see the percent of the economy that we spend on health care, and that is certainly rather very, very high. And as Chloe pointed out, the macro values, either infant mortality or other mortalities, are not well represented in superiority and outcome. What the United States does well and exorably well is high-end, high-fidelity, high-need, end-stage care. We're probably the best. We're the best at mechanistic scientific discovery. Delivering care on a cost-efficient basis to large populations of people, assuring a lack of disparities, things like immunizations, infant mortality, it was stated, not so much. We have another trend we have to remember. And that other trend is chronic disease. Chronic disease is growing because we have an increased survival. We have a lot of mitigatory therapies. So along with aging, we have a problem coming. There are going to be cost management issues with this. There's implications for long-term care. There's huge implications for pharmaceutical costs and mitigation. We don't know how COVID will fare into this. Certainly COVID, as we all know, has had some longer-term sequelae in the data, everything from brain fog to muscle weakness to peripheral neuropathy to cardiopulmonary involvement. And thank goodness the upcoming administration is going to focus on many of these health-related pandemic issues. But it also tends into other things. If COVID becomes a chronic disease, in some ways when, we know that those COVID dollars will eat up other sources within chronic diseases. And even if it doesn't, we know that things that might impact physiatry, like dollars going to NIAID over agencies that are research funding for us, disproportionate valuation of issues such as mental health care and others could either positively or negatively impact our field. Chloe hinted at this slide before, and I just wanted to show it again. And that is the disparities we have in social versus health care spending. If you look at the differences, it's really quite striking, right? We make up for our lack of social spending by delivering it in health care. And in some ways, at least for our population of patients that we serve, it could well be less effective. And as we think about preventing the next pandemic, the next major issues, it certainly may be less effective. But there are real policy issues here. Issues of housing and food security, issues of behavioral health, and something that we don't appreciate with all of these stresses that we have in our country that they may not have as much in ours, is this issue of allostatic load, all the way back to McEwen, this idea that these stressors, these constant stressors produce epigenetic change that affects lifespan. So we have this demographics of survival. We have all these medical successes and success in survivorship that we just talked about. And they result in a complex series of people with long-term sequelae. This is a paper by Haley Prescott that I was lucky enough to be a part of. And this is exampled by sepsis in the ICU, where there are now many survivors. They have long-term sequelae from PTSD to sarcopenia to peripheral neuropathy, very similar to our new COVID cohort. Who's going to take care of these people? Where are they going to go? How are they going to add to cost? How do we think about a budget with that? So there are real trends in rehabilitation. There are shifts towards using less private insurance right now. There are cost containment measures. Hey, is it truly needed? Is it reasonable and necessary? And who determines that and our thoughts about that? There were reforms to Medicare, Medicaid, and workers' compensation. And are those related to cost only? Are they related to issues related to rate reimbursement? Are we trying to remodel from procedures to primary care visits? Chloe touched more elegantly than I ever could on value-based care models. But there's a large potential for disruptive innovation. This is, you know, a sixth to much more of the U.S. economy waiting for someone to disrupt it. And so there are real worries. The states are under financial pressure. There is a belief that interventions, as we've seen, can do good and harm. There's the classical article about when the cardiologists are at an academic meeting, the death rate actually goes down. There are all these non-inferiority studies coming out in rehabilitation. I'll show very briefly one of them by Steve Kramer et al. But can we show less costly, less intensive ways to produce the same outcome in a rehabilitation setting? There's going to be more regulation because it's what the government tends to do, not necessarily thoughtful regulation. Our metrics are challenged. And the short term is the easiest thing to metricize. And it's very highly valued. We just want to think about what this focused period of time is and what was the cost or value we got out of it. The problem is the value may really be determined over a longer period of time. I talked about the commodities market and how that may mix into thinking, and we should be awfully careful of that. And then someone both Chloe and I know, and I know dearly well, Professor Herzlinger at the Harvard Business School, has recently discussed what is the role of a securities and exchange commission in health care? What is the SEC? It's the Financial Regulatory Agency. It's been around for eight decades. It warranties a couple of things. One's common metrics. Two, transparency and financial reporting, like pricing. Three, it works. It allows investors to make thoughtful, even-handed decisions. We had that in health care. Could be a lot of good, but it could be a lot of challenge. And then I want to touch on this for a minute, and that's the fact that there's a lot of waste in the U.S. health care system, and that's hard for us to do. This paper by Schrenk a couple of years ago really builds on the work of Don Berwick and suggests that the total waste in the U.S. health care system is between $760 and $935 billion a year, 25% of all costs. That's stunning. It divided this into various aliquots of waste, failure of care over $100 to $160 billion, care coordination, $27 to $78 billion, over-treatment, $75 to $100 billion, pricing failure, what we just talked about, $230 to $240 billion, fraud, $58 billion, administrative complexity, $265 billion. We live administrative complexity. We know that's true. The other thing that's been brought up by the similar group has been devaluing low-value care. In other words, getting rid of things that don't work. And that's not such an easy thing to do. It's been years yet, and we haven't gotten rid of We haven't gotten rid of low-value care, and that low-value care could be determined by poor evidence, as example by knee washouts for arthritis, eminence, a society says don't do this anymore, or economics, it's just not covered anymore. But it takes a long time to get those things out of our system, and the reason is we're in two canoes. We're in a fee-for-service canoe, and we're in a value-transition canoe. Now, I'm sorry, I'm having a little problem with that, but the post-acute care, this is an older study from years ago that really looked at variation, and post-acute care accounts for a huge part of the variation in spending, and that's why in many ways we're a target, a target with an opportunity to do better and show how much value we have, what we are perceived of as a not necessary. This is a study by our former colleague, as stated, Adam Lamb. In this different paper, Adam, and this is under review at this time, came in and looked with us at profit versus not-for-profit centers in rehabilitation via the UDS dataset, and what Adam was able to show was some pretty distinct differences by population and even by outcome, suggesting that we have our own conflict in our own industry. Neither is necessarily good or bad, but we're not treating the same population of people. That's probably for sure. What about policies like Medicare for All? Well, it's clear that the, at least proposed incoming administration is going to offer possibly Medicare down to age 60. They're going to offer Medicare as a buy-in possible option, but the cost in a Medicare for All could be overwhelming, and there would be implications for patient's choice, and if we think we see protests now, my goodness, that would be substantial. What would it mean for post-acute care? I'm not sure good. I'm not sure bad. It could be that only the absolutely necessary is given, and things that are considered more peripheral are contailed. What would it mean for professional caregivers, and how would this affect health plans by party? Well, we already know that we're likely to get a more expansive attempt at Obamacare if the Supreme Court doesn't overrule it in part or make at least the mandate illegal. How do we show that rehab is cost-effective? Well, I would argue that pieces of this have already been done. In the NHS, Lynn Turner-Stokes did a lovely job in which she was able to follow the cost out over a long period of time of people with more severe brain injury, and she actually found that rehabilitation care was a big winner for the NHS, which you had to look over a couple of years. You had to assume that somebody was on the long-term hook for the cost of those patients, not only in the hospital, but at home. I touched on the fact that there's wide variations in care and that there's a shifting system, and I think we see that because there's huge institutional variation in what should be the right-hand corner of your screen. You see a map of the United States, and my goodness, look at the density of where there are rehabilitation institutions, LTACs and SNFs, and where there are not. And so we see wide geographic variation. We see changes in policy related to auto accidents in Michigan and other places. We see this early incipient competitive bidding market, almost a commoditization, as I touched on, and we see this drive towards bundles, which have both good and bad for post-acute care, specifically for physiatry. So what are some quick trends in rehabilitation? These alternative payment models. Can we do telehealth? Can we deliver it at home? Could there be a medical rehab model at home? And how do we deal with non-inferiority-based trials? I'll show some examples of those, but they have both good and bad to them. So this is Steve Kramer in the right side. He's a neurologist, rehabilitationist in Los Angeles. Steve led a study that we were a part of, as were many rehabilitation institutions, in which they found that a tele-rehabilitation program at home via a gaming device was non-inferior to standard therapies. You could see all the advantages. No traffic, no parking, a different way to deliver it. Could it be substituted, or could it be partially substituted? Could you do this in back pain, hip fractures? Could you allow for mass practice? Can you create one-to-many? Can it be preventative? This, along with a series of biosensors and high-precision medicine targeting, in other words, understanding whose corticospinal tract is intact and how we might predict those that might benefit and those that might not from certain interventions could be particularly important in the near future. Near the end, I just want to touch on the trends in rehabilitation are important. These three wonderful gentlemen tried to get together to disrupt healthcare. They weren't able to do it because of many, many reasons. But we know that CVS Health and Aetna have gotten together, and near the two of them, certainly near CVS is 80% of Americans are near CVS. And there's ample opportunity for them to think about it in a different way, to deliver programmatic high-end services for the masses that get 80% of the top off very, very quickly and leave 20% for those of us who are doing the 80%. So this is from Professor Clayton Christensen who was at Harvard Business School. He recently passed away. And I can claim that was not only a brilliant person, but was a friend. Where do we need to go? We need a link to biology because that is the, in reality, the foreshadow of all discovery and disruption. We need to treat what we can treat and do so in a defined clinical trials way. We need to note that change is our friend, not our enemy, and that we need to be a part of that disruptive change, both economically and inventively. And we need to understand the benefits and perhaps the non-benefits for what we do. So I'm going to leave it there and thank Chloe for leading this fabulous discussion. Awesome. Thanks. So I wanted to get to some of our Q&A first. I have some sort of standard questions that we can focus on. I think that I want to thank Drs. Merritt, Dr. Karabin, Dr. Weinstein, and Dr. Watson and Dr. Mayer for their questions. If we don't get to them all, Ross and I are available. I'm going to put up after our, I'm going to put up our contact here on the last slide. But Dr. Merritt had some questions that were great about institutional barriers to addressing disparities as well as single payer systems. I think that institutional barriers are, institutional barriers are, I think, something that is cited oftentimes by providers as being one of the most formidable things. But I think I'm encouraged that, similar to the Trivedi article that showed that public reporting really helped reduce some disparities, that there tends to be a Hawthorne effect when the data starts to be examined on a granular level and really reported, that a rising tide sometimes lifts all boats, but also there is interest in equity from, for instance, independent bodies like US News and World Report really trying to figure out how to measure equity and how to report it to hold providers accountable. And so I think that's an encouraging development. Obviously, the change can't come soon enough. We've known about this for several decades at this point. And as for single payer, I think it's one way to think about reducing waste, but I think there are models in terms of looking at Taylor and Bradley's take on, even just a health system in developed nations, there are ways to reduce administrative complexity and excess costs that don't necessarily involve single payer, but that is certainly one take. And Dr. Karabin, I think that, Dr. Karabin asked about MACRA, if certain payment initiatives will do a lot to mitigate health disparities. I think that, again, they're in sort of the data gathering phase of value-based healthcare. And I think that we need to look at such models when they're further down the road, but also be intentional about designing them to reduce disparities. And I don't necessarily think that MACRA or MIPS or alternative payment models really in their foundation is set out to do that, but I do think that they cause providers to be more accountable for certain things and certain outcomes. And so I hope that that will move the needle, but I'm not optimistic that the payment initiatives in and of themselves will reduce the disparities by themselves. Ross, I'm gonna let you take Dr. Weinstein's question, but he had asked who is in the position of setting, who in sort of policy circles cares the most about PM&R and what stakeholders need to be targeted first in terms of thinking about ourselves in the broader global context of health payment and policy? Well, I don't know that there's an independent love of PM&R. There's no independent dislike either. It's not that there were disproportionately valued or disvalued. It's where we can show that we provide unique and remarkable value in any given environment, right? There are agencies that become familiar with us over time and therefore begin to see our value in doing that. So in many of the entities that have now looked at closed caption care where they're at risk, physiatrists are the lead entity for let's say spine care or other entities. The problem is that there are other places that are trying to replace them with APP, one cheaper, not necessarily one better. To Chloe's point in the last two seconds, we don't necessarily have to go to a single payer. There are a lot of logical systems that are very, very disparate in administrative cost as I showed that if you could consolidate those to a single format would reduce care, the cost of administration hugely. Awesome. And we just had two come in at the end that I'll try to try to field, maybe three. So Dr. Mayer, who's from an interesting model in Maryland, asks about what degree the for-profit fee for service nature of the health system contributes to high costs and poor outcomes. I think that's certainly an argument. I think the sort of the pretext of value-based care really is to shift us away from fee for service and more towards something that's payment for quality rather than quantity. And so I think we could argue that a focus on quantity above and beyond any other performance metric really does a disservice to providers broadly, not just PM&R. There's a question about disability and how it fits in and if it should be a social determinant of health from Dr. Anaswamy. I know in some frameworks, it is sort of a carve out in terms of how it's displayed. I think other frameworks integrate it into sort of a different domain or they break it out in terms of the, for instance, the ICF model and have it as part of a larger framework but not necessarily a social determinant of health in and of itself. I don't know if you had thoughts on that, Ross. No, I agree totally, Chloe. I think my own thoughts parallel yours that I do think that when we think about social disparities, however, it is not even considered even at the medical school level in some environments. And it's now just that the AAMC is making people sort of appreciate that. So when we think about it fundamentally as we take on these issues academically and in other environments, I think it does need to be inculcated in both the educational system and how we evaluate and think about and metricize and research about disparities. All right. Awesome. Well, I wanna thank everyone and thank Dr. Safat and thank our audience. If you would like to connect with us, our contact information was on our slide and should be also available in the APMNR directory. And thank you all for joining us on this Sunday afternoon and hope you have a great rest of the conference. Thank you all. Bye.

population health

healthcare

physiotherapy

health outcomes

health equity

value-based care

transparency

quality metrics

telehealth

cost containment