Hi, I'm Dr. Chris Standard. I am at the University of Pittsburgh School of Medicine and UPMC. We are going to be talking about value-based spine care and a number of aspects of this. First I'm going to speak about the cost of spine care and particularly about a paper that was just published. Next, Dr. Stuart Glassman is going to talk about payment models in a value-based world for spine care. And then Dr. Santos Thomas will talk about interventional spine care in a value-based world. And then we'll have a brief panel discussion of the topics we all brought up. So I'm going to start. We're going to talk about the cost of spine care. How do physiatrists compare to surgeons? So we're going to discuss several things. First, we're going to talk about why value matters, which is important for this whole conversation. We're going to talk a bit about what AAPMR really has done to address this issue. And the three of us all speaking are part of the Innovative Payment and Practice Models Committee, which has been working on these issues for a number of years now. We'll talk then about the paper that we just published on cost of physiatrists compared to surgeons. And we'll talk about the implications of this kind of data in terms of spine care and where we go as a specialty. So why does value matter? Value matters because we are the most expensive healthcare system in the world. This is data on cost per capita of health expenditures in 2018. And we are double the next closest country, which is Germany. If you get down to countries like Italy and Spain, we're three times what they spend per capita and get down to South Africa, for example, we're almost 10 times what they spend per capita. We spend a lot of money on healthcare in the United States. The problems are that we spend a lot, but we may not get a lot. And we waste a lot. This is a paper by Schrenk et al. that just came out in JAMA last year, looking at trying to quantify the waste in the U.S. healthcare system. Where are the dollars going? They estimated in the end that we spend between $760 and $910 billion in waste per year, which is about a quarter of the entire healthcare spending for the United States. The other big problem with the amount we spend is what we actually get for it. This is a graph showing expenditures per capita by life expectancy. So life expectancy is a vertical axis. And if you look at the entire curve, you can see there's relatively a clean relationship between what countries spend and what they get in terms of life expectancy, except for the one outline on the graph, which is us at the far right. For what we spend, we have a much lower life expectancy than one might expect and that every other country would expect or seems to have achieved. In the end, if you look at what we're doing, what we're doing is just unsustainable. We spend too much, we waste too much, and we get too little for what we spend. And when you extrapolate this out, we start looking at really problems in the healthcare payment system that are coming faster than we would all like. So as of September of 2020, the Congressional Budget Office released a new estimate on funding for the Medicare Hospital Insurance Trust Fund, which insures Medicare Part A. And they now estimate that fund will be insolvent by the year 2024, which is three, three and a half years from now. This is five years earlier than they had predicted just in 2017. They also estimated that Medicare spending will have to drop by 17% to maintain solvency, which is a massive cut in Medicare spending. At the moment, CMS is actually proposing a 10% across the board cut in reimbursement for RVUs, which really is done as a cost neutral mechanism to increase the amount they pay on evaluation and management RVUs. But now we're thinking maybe we need a 17% cut on top of a 10% cut just to maintain solvency. This is a significant crisis coming very quickly for us all. What is the solution to this? This is where we get into what value-based purchasing is value-based care is. There's a large emphasis on coordinated care delivery systems, thinking that if systems work together, if different specialties and specialists and specialties work together, we can coordinate care and we can get a much more efficient delivery of care than the rather fragmented structure we have now. We have to focus on value-based purchasing, meaning that payers will start paying for better value. Payers will pay more for things that work better and provide better benefit to the patient. We really are going to have to focus on evidence-based care. We have to do what we know works and not do what we know doesn't work. In all of this, there's an enormous effort to shift the risk from the payers to the providers, meaning right now the payers essentially are on the hook for what providers choose to do in a fee-for-service world. What they really want to do is shift the risk to us, so we are on the hook for the outcomes of what we do. We become responsible for the costs and those outcomes. In the end, this will hopefully increase incentives to us to follow guidelines and enhance systemic efficiency, hence getting at evidence-based care and value-based purchasing with the goal of improving our value, which is what we get for what we spend. But it's going to fall on us. It's not going to be the payers taking the risk. Why low back pain? Why spine care? Why? Because it's very prevalent and very costly. This is data from IHME at the University of Washington just looking at leading causes of early death and disability, and low back pain is the second leading cause of early death and disability just after ischemic heart disease. So on top of all the disability and financial implications in the disability-related system that come from this, the healthcare costs are tremendous for low back pain. Why is this important to vasiatrists? Well, this is what we do. So this is data on interventional pain procedures from Medicare from 2000 to 2016 that have just gone steadily up and up and up and up, and by 2016, there was one interventional pain medicine procedure performed for every 10 Medicare beneficiaries, and it's hard to justify this, I think, but this is also unsustainable, this kind of growth. There's no money. The money's going down, and the volume is going up. So AAPMR recognized this problem coming a number of years ago and started thinking about how to address this, which is how we got to where we are today. So AAPMR recognized that spine care is a core component of physiatric training and care, and we also recognized that the need to focus on value presents an opportunity for the physiatry. It's not just a risk. There's actually an opportunity there. If we can figure out how to do this and latch on to doing it well, there's a chance to be very successful. So AAPMR has pursued a number of efforts to define physiatry's space in the value-based spine care world. So a number of years ago, they commissioned a low back pain task force and subsequent think tank to think through the future of spine care and what that might involve and what we need to do and what we, as a specialty and as providers, need to think about. Out of this, in part, came our very committee, the IPPM committee, which started as a task force and really is charged with looking at different payment models and different ways of working within the healthcare system and billing to address value. As part of this work, we have addressed payment models regarding back pain, which Dr. Glass will talk about, and we commissioned a study to address the cost of care for physiatric-driven spine care, which is what we're going to talk about now. So this is the paper that just came out. The logo went right over the reference for it, but this came out in June. Costs associated with the treatment of low back disorders, a comparison of surgeons and physiatrists. What we did for this is we commissioned a search of the CMS dataset from 2011 to 2004. We worked with Dobbs and DiVonzo and Associates, who helped with all the data analysis and extraction. We developed a set of diagnostic codes for what we termed a lumbar spine disorder, looking at various things, not just back pain, but also disc herniations, radiculopathy, spinal stenosis, spondylolisthesis, and related codes. We then went into our dataset and identified patients seen by a primary care provider for what we termed their index visit, for a visit for a lumbar spine disorder. And then we excluded anybody who'd had one in the prior six months. So we wanted people who had not seen their doctor for a lumbar issue for six months before they came in. We then particularly looked at patients who saw either a physiatrist or a surgeon, neurosurgical or orthopedics, for the lumbar spine disorder within six months of that index visit with a PCP. We followed them for 12 months, and we had almost 12,000 subjects. This is what the flowchart looked like. At the start, we found 170,000 people in our dataset with a PC visit for their back. 114,000 of these had no visit in the prior six months. 23,000 or so saw a physiatrist or surgeon, of whom about 11,829 saw a physiatrist or surgeon within six months, and they became our two cohorts. About 3,000 or so in the physiatric cohort and 8,600 in the surgical cohort. So we had a lot of patients. This is a large number of people for a study. So we wanted to look at our two groups, and we tried to compare demographic variables to see how similar they were, recognizing we had some limitations in that dataset. And we looked at outcomes, especially total Medicare expenditures, which we expressed as a per member per month cost. We looked at spine-specific spending, and we looked at surgical rates. In the end, our two cohorts were relatively similar. They're similar for age, gender, and ethnicity, with some subtle differences there, but very subtle. We looked at diagnoses when they saw their PCP. They were quite similar between these two groups. About 62% had either lumbago or backache unspecified. These are fairly nonspecific low back pain codes for the majority of our patients. Interestingly, they were different at the first visit with a specialist. Surgeons tended to diagnose more spinal stenosis and physiatrists more radiculitis sort of codes, and both had less nonspecific codes. We looked at the time from the PCP index to the time they saw the specialist, thinking, well, maybe if people who were very acute were going to surgeons, they would see people earlier than the physiatrists, but that really wasn't the case. They're essentially identical. And we looked at the per member per month cost for all medical care and Medicare prior to the index visit, and that was also essentially the same, meaning medically they were costing the same before they had their back pain episode or their low back episode. When we tracked our outcomes, the surgical rate was far lower in the physiatric cohort, 7.8% versus 19%. Total Medicare expenditures were markedly lower for the physiatry group as well. On average, about $122 a month over the two years after the index visit. Spine-specific Medicare spending was far lower in the physiatry cohort as well, about $3,800 for physiatry and $7,400 for surgery. And keep in mind, those numbers are the mean for every single patient who saw a physiatrist or surgeon. These 3,000 or 8,000 patients in our cohorts, so that's per patient, which is a pretty staggering number when you start doing the math. In the end, our prime drivers of cost, surgery was the biggest driver of cost. This was a third of the cost in the physiatric group and about half the cost in the surgical group. After that, though, imaging injections were the next two highest drivers of cost. The other interesting thing we really found at the end was that the per member per month total Medicare costs were much higher in both groups 24 months after their index visit. And I'll show you that graph in a second. But basically, they cost a lot more for everything that wasn't really accounted for just by spine-specific spending, and this stayed relatively level for two years, and this was about a 50% increase. This is what our data looked like. On the left of the graph, you see the time before the index visit, which is that vertical dashed line, and it's relatively even at $600 or $700 a month for all these patients. The blue cohort is surgical. The orange is physiatry. After the index visit, you see a marked increase in spending, both total medical expenses, which are on top, and spine-specific, which are on the bottom. And you'll see before the index visit, there are no spine-specific costs. In the first eight months, these are all much higher for surgical care, surgeons, for the surgical cohort than the physiatric cohort. After about eight months, they get pretty even, and you can see at the end, those last six months were a good 50% higher than we were before the index visit, and it is just hovering, not going down. Some things to keep in mind with this, this is not a controlled trial. It's a Medicare database study. Some things we couldn't really assess in the study group, which would have been important if we could have controlled for them, pain severity, functional status, neurologic status, clinical outcomes. When we did look at our variables, we had a few that were subtly different, and we had those different diagnoses at the primary visit for the physiatric cohort or surgical cohort. We did a regression analysis to see if that would change our results, and it really didn't have any material change in any of our numbers. So once we could control for everything we could find, we did not find any difference other than the numbers we just gave you, or I just gave you. In the end, what does this show? We concluded several things. One, spine care is very expensive. Those costs are high, which is why people pay so much attention to spine care, why payers pay attention to it, why Medicare pays attention to it. It's very expensive. In the end, the cohort seeing surgeons accrued substantially greater costs and had a higher surgical rate than those seeing physiatrists, surgery being the prime driver of cost, and total medical costs remained substantially elevated 24 months after the index visit for a lumbar spine condition. The cause of this is really uncertain. We don't know if this is that the low back pain resulted in a decline in their health, whether the low back pain just occurred because of or associated with an overall decline in health, whether it is something about spine care that leads to further expenditures, or even whether people had been undertreated for other things before they got there. It's hard to know. We don't know that from what we did. So what are the implications here of this study? So the implications were that optimizing use of non-operative care and reducing surgical rates in particular may improve the value of care. If we can get equivalent outcomes for less money, that is better value. This is an opportunity for physiatry to capture the opportunity. We need to do several things. We have to focus on value and track outcomes. We have to recognize our prime drivers of cost because that's what we have to control. And we have to realize where the data takes us. This goes back to the evidence-based medicine side of this. The data that we have for the treatment of low back pain in particular is most supportive for exercise and psychological therapies. And we start trying to find a way to leverage and optimize those in the care of our patients. We may get a path to a better value. In general, in the end, we have to define indications across the field of spine care. Surgical indications, interventional indications, imaging indications, physical therapy indications. We really need to define this so we're doing what works is what we have to do. And ultimately, I think we do have to study this a bit more and figure out why the costs remain so high for these people. Looking ahead for physiatry, several things to keep in mind. We have the potential to deliver high-value spine care. As a specialty, we truly do. And we can really make a difference in the field and stand out in the whole healthcare system. To do this, though, we have to focus on what works. We have to realize that integrated care will be important. We have to recognize that whatever we do, we will be held accountable for the costs and the outcomes. In the end, we have to define our role in this space and navigate this as a specialty. We have to move forward together to move into this space. And we have to recognize that we have to have a workforce that can provide this type of care, which gets into training issues and education issues. And thank you. That is the end of my talk. Next, Dr. Glassman is going to talk about innovative payment models. Thank you. All right. Hello, everyone from the Academy. Glad to see you virtually. I'm Dr. Stuart Glassman from the great state of New Hampshire. And thank you, Chris, Dr. Standard, for that great opening presentation. I'm going to talk about developing an American Academy of Physical Medicine and Rehabilitation low back pain model of care, reflections on a five-year journey. Just want to give a shout out to my colleagues at the Geisel School of Medicine at Dartmouth and Tufts University School of Medicine, Department of Physical Medicine and Rehabilitation. So no financial conflicts of interest to disclose. So the objectives from my talk are the following. To review the developmental timeline of the IPPM, Innovative Payment and Practice Models Committee low back pain spine model, to discuss the treatment components of a proposed Academy low back pain model of care, to assess the projected outcome data areas of the low back pain model, and to consider fiscal implications of this type of low back pain model of care. So the timeline, and Dr. Standard went over some of this, but I'll give you a little bit more detail because I was sort of there from the beginning. This goes back to almost May 2011. At that time, there was a steering committee called the Public and Professional Awareness Committee. Dr. Marty Lanoff was the chair at that time in 2011. And they were briefed on a directive from the Academy Board of Governors to examine ways to position the specialty of PM&R within the future of healthcare through identification of and communication about innovative models of care. And there was a three-pronged strategic approach. First, identify innovative physiatric models of care from members that were actually doing those care plans and using those models. Second would be promote the models for education and adoption by the membership. And then third, promote the models to insurers, purchasers, policy groups. I then became chair of the Public and Professional Awareness Committee in 2012. And in 2013, we, as a committee, did work to try to identify pilot projects for our Academy members, innovative payment models, alternative payment models, and accountable care organization projects. In 2015, the Innovative Payment and Practice Models Workgroup was established. Dr. Peter Esselman and I were the co-chairs. And this came out of the Public and Professional Awareness Committee. So in 2015, the IPPM Workgroup discussed examples of innovative payment models. What about accountable care organization with physiatry, bundled care payments, value-based outcomes, and other pertinent information and ideas? We looked at spine care, and we looked at stroke options. A decision was made to move forward to try to develop an alternative payment model for physiatry. And around the same time, you have to understand that within the Centers for Medicare and Medicaid Services, there was a lot of focus on APM, alternative payment models, funding, and projects. So as Dr. Standard had mentioned, in 2015, Dobson & DiVonzo Associates from Washington, D.C., were commissioned by the Academy Board of Governors to lead the development of this low-back pain alternative payment model. And the first step was to utilize Medicare claims data and information that was gleaned from a technical advisory panel, stakeholder interviews, and published peer-reviewed literature. And then in 2017, the workgroup became a committee, Dr. Standard was the chair. So our five-year journey to this point, health care, the final frontier, these are the efforts of the Innovative Payment and Practice Models Committee. It's a five-year mission to explore strange new models, to seek out new payments and new practices, and to boldly go where no committee has gone before. Full disclosure, I love Star Wars much more than Star Trek. So the project overview and hypothesis. So what's the need? Acute low-back pain, as was mentioned, is a diagnosis treated by many primary care physicians and specialists, affects millions of patients annually. The direct medical costs, the associated costs, the lost wages are very high. And many of the direct costs are often high because of unnecessary imaging studies and often invasive procedures that may promise more than they actually give. And there's also association with opioid prescribing and the question of whether surgery is beneficial or not. Remember 2015, 2017, the opioid crisis really is rampant across this country and the correlation between low back pain and opioids was pretty dramatic. So we wanted to demonstrate that a physiatric-led patient-centered spine program implemented for patients presenting with certain acute low back pain diagnoses would save costs, maintain or increase patient satisfaction levels, and maintain or surpass level of quality maintaining surgical back centers. Obviously 2013 in the Spine Journal, the priority health study came out, Dr. Andy Haig was part of that, John Fox, and we were certainly looking to what that study had shown and trying to build upon that. Some of the goals were to lead a transformative national PM&R Academy team in aligning with primary care physicians to create and pilot a new value-based acute low back pain spine model. Specific outcomes would include improved patient satisfaction, improved quality of life, decreased imaging costs, decreased invasive spinal procedures, decreased opioid prescribing, and of course decreased surgical rates. Once we could demonstrate that the model was successful, it could then be presented at regional and national meetings for insurance carriers, disseminated to Academy members to use in their local health systems. That was the idea and the plan three years ago. And the team is involved and that's often who you see in the article that was published as well. So this is an image of the low back pain model change team. And this is essentially who you might want to be talking to if you think about creating this kind of transformative spine care model in your community. Obviously patients are at the top, they probably should be in the middle. My graphic skills were not that great, I apologize. And going clockwise, we have PM&R physicians, the Academy staff, the spine registry, which is part of our Academy, behavioral health clinicians, case managers who may be nurses. We talked about chiropractors and physical therapy being part of the potential treatment team for low back pain, emergency room physicians, because many times low back pain patients will present to the emergency room rather than go to their primary care doctor's office. And of course, primary care physicians, insurance medical directors, certainly the people we want to include in these discussions as well. And again, not every system could have all of these people together, but this is a good framework to sort of think about. So referral, consultation, evaluation, follow-up. The referral would typically be, we presume or we sort of envision, patients with low back pain referred to physiatry after a lack of initial progress. We know the membership that we have, the number of physiatrists in this country, we can't see every patient with low back pain, that would not be possible. And for this model to work, we really think that the physiatrist needs to see the patients within a few weeks from the time of the referral, seeing them earlier rather than later. This is not seeing patients six months down the road. It's seeing them within the first couple of weeks for sure. Consultation evaluation, looking at the differential diagnosis, review of red flag signs, assess functional limitations, review interventions, treatments, and medication options. And then have a follow-up, hopefully within a few weeks, and then follow at least face to face for probably 12 weeks, and then ongoing follow-ups, phone calls, telehealth visits over the course of a year, potentially. And again, a four to 12 week treatment timeframe upon referral from the primary care physician or emergency room physicians. Now I just want to give a caveat to say, the model that I'm talking about is not finalized, is not established. We are in the process of working through all of these ideas, and we have a while to go until we could even potentially say, here is the actual model. It's going to be more of here's the framework, and here are the choices and the options you probably would have. So keep that in mind. We would want to have follow-up data collection for a year after the patient enters the program. Determine what's typical for therapy visits, over what timeframe. We're going to work with other academy committees in doing literature searches for best practice and guidelines of what really makes sense for this. How many physician visits? If we think about the Medicare trust fund and the payment cuts over time, we're going to have to do more with less. And having more physician visits and more face to face interactions may not be the answer because the money is going to run out much sooner than we even thought two years ago. Behavioral health will be important. Where do physical therapy and chiropractors fit in? Just being open to the components of the treatment options that are out there. What about identifying pilot centers to begin implementation? There have been some academy members who in their own health systems have tried to do back pain models and even got funding from the CMS Innovation Center. And sometimes the outcomes were not what they were hoping for. So we may want to identify some of those pilot centers. And then registry data involvement. Data points proposed through the registry, demographic information, coping mechanisms, change in pain scores, promise scores at different timeframes, interventions used, what were most helpful, length of time to achieve pain resolution or pain decreases of a certain desired amount, recurrence of pain issues over 12 months, and compliance with the plan of care. Some of the different data points that the registry has that could be used. Different metrics. Some of the things we've really talked about from the beginning is decreased opioid prescribing, decreased advanced imaging, decreased spinal injections, improved quality of life, and of course decreased surgeries. So sort of big ticket items to think about, especially as we think about the financial changes going around in healthcare as we sit here as well. So aligned with all of the discussions we've had at IPPM is the fact that the Academy's bold initiative was also looking at aligning physiatry muscle skeletal care with primary care involvement. And we could be a frontline partner for non-emergent MSK care. Looking at medical training, looking at education that physiatrists can provide. And really working collaboratively with primary care providers. And we actually think that aligning with primary care physicians is probably the best choice versus aligning with surgeons because so many more patients will see their primary care physician before they see surgeons. If you listen to what's coming out of the White House and Sema Verma and HHS, primary care is going to be a focus going forward as payment models change. So this might be the alignment that we want. Okay. So there was initiative one and then initiative two. And then the opportunity to transform or create comprehensive MSK practices and that physiatry led MSK practices that are comprehensive will be the standard integrated care model and be valued over traditional surgically focused MSK models. As healthcare reimbursement shifts away from fee for service into value based care. And again, increased coordination of care. And physiatrists have to have adequate and appropriate training to meet the needs and demands of this model. So what are the challenges? As we sit here and think about, this sounds great, how are we actually going to do it? So will an alternative payment model, will it work in certain markets where there are not a lot of physiatrists? What markets will be able to be a demonstration project and be more successful? How will we get provider and payer buy-in? Pilot centers, insurers, healthcare systems. Getting paid less is maybe not the focus for healthcare systems in 2020 given what COVID has done to the bottom line of almost every healthcare system in this country. So this may be a challenge for them. How would the academy or any other at-risk entity, think about national employers, Walmart, Home Depot, Boeing, incentive primary care physicians to refer low back pain cases to physiatrists. How would surgeons and other specialists respond? We'd have to have outreach and education. Identifying quality metrics. You've got to prove what you're talking about. You've got to show it saves money, and you've got to be able to collect the data properly. A lot of health systems do not want to share their data. They don't want to send their information to our registry. That's a challenge for sure. And then looking at prior studies, prior trials, lack of success, if something didn't work in another health system, maybe the feeling is it can't work in any health system. And we think if we create a better model and opportunity or framework, perhaps it'll be more successful. So this picture is maybe one of the last pictures before life changed forever as we know it. This was from February 25th, 2020. Dr. Standard and I were meeting at the Center for Medicare and Medicaid Innovation in Windsor Mill, Maryland, close to Baltimore. And it was talking about spine care. We were invited as the academy to talk about different ideas of where spine care was going. And we had the opportunity to talk about the things we've looked at through the Innovative Payment and Practice Models Committee for the last number of years. And it was pretty amazing to be there and at least have a face-to-face, frontline discussion and potentially be part of the solution down the road. Less than a month later, everything changed as we know it, but at least up until that time in February, we were fortunate to be part of the discussion group. So thank you for listening. I'm now going to turn it over to Dr. Santos-Thomas, who'll talk about interventional procedures and value-based care and where we go from here. Thank you. Hi. Welcome to our annual academy meeting. This will be on demand. I'm going to continue talking about what Dr. Standard and Dr. Glassman spoke of defining the role of physiatry in the future, in particular, where interventional spine will fit in. My name is Santos-Thomas. I don't have any relevant disclosures that would affect this talk, but I do want you to know that I'm employed by the Cleveland Clinic. As an interventional physiatrist, I belong to the IPPM group with the academy. I'm also involved with several other organizations at different capacity, as you can see over here. I don't have any financial disclosures that affect this conversation. The question is value-based care. What is value? In health care, we know that the value is described as quality over cost. But what is a quality measure in health care? We know that CMS uses at least seven different things to value quality. Of those things, they include mortality, safety of care, readmissions, patient experience, and timeliness of care. But did you know that they also use effectiveness of care and efficiency of imaging usage also as part of their decision-making? Well, they do. And the conversation has been about containing costs for many, many, many years. Since I was in training, I can remember somebody always talking about, we got to contain costs, we got to contain costs. There are a lot of reasons for the expansion of costs or the increase in costs. Oftentimes, we cite that there's a growing population. We have a lot of seniors. There are higher disease prevalences as well as incidences. And that there's disparity in the service utilization and the price of some of the services that we offer are not that good or they're too high. We often talk about how to contain costs. We often say that let's give our consumers or the patients a choice to control the cost. We want to lower the number of tests. We want to lower the number of procedures that are not proven or borderline. This would be one of the things that interventional physiatry has to look into. We have to increase competition among the healthcare providers. And oftentimes, we talk about negotiating prescription drug prices, which is a bigger thing for some of the chronic conditions that we see. So we know that there are a lot of players in this arena who have very different interests. As employers, their goal is to decrease the overall cost of care that they have to pay for. They're cutting the cost to their employees and their families. They want to increase the revenue. The reason for that is they want to expand their brand name. They want to offer more products line. They want to research and they want to bring more medicine and innovation to the forefront. So they clearly have a desire to increase the revenue. They want to decrease the utilization of services because some of these things do not give good value. They want to knock that off. They're consolidating services. So you'll see that they keep cutting out certain things that have some overlap with other services and they'll take some of them out, consolidate those things to control the cost. And they have hired a number of administrators over the years to contain the cost and you'll see some details of that in a short time. So you wonder what a full-time physician's net revenue is. Well Merritt Hawkins published some data in 2019. They noted that each full-time equivalent of a physician brought in about $2.37 million. And the same data was done in 2016 which showed that it was $1.56 million. So clearly you can see there has been about a 52% increase in just three years. So physicians are certainly costing more out there. They're generating more revenue but there's also an escalation of this thing which may not be sustainable for too long. So you wonder what an outpatient practice does in America. Well AMA published this data in 2018. They said that we as outpatient providers cost about $2.3 trillion in economy. We support about 17 jobs and pay about $1.4 million in wages and benefits. So as physicians, our goal is to care for the patients but there are forces that require you to do more. Oftentimes your employer will ask you to generate more revenue. How do you do that? Well, one of the things we first do is increase the number of slots you have for the patients in a given time. You end up spending less time with your patients but at the same time you end up seeing more patients. So that's one way of increasing revenue. You might be encouraged to do more cases or more procedures that may have higher RVUs. That's a concern if they're not appropriate. They may be asking you to consider ordering more studies, things that may not be of great value sometimes but there's place for all of these things like EMGs and X-rays and MRIs for those of us who do intramuscular spine medicine are familiar with. We oftentimes order physical therapy. Recognize that this is not inexpensive. There's a lot of costs associated with doing physical therapy. They're also going to encourage you to consider diagnostic and therapeutic injections which also increases cost of care for the patients. So you have to figure out where as interventionals do we add value to this spine care model that's out there. We cannot continue to do what we've been doing for years and decades because there are limited resources. As Dr. Standard earlier mentioned that Medicare Part A is at risk of insolvency over the next few years. There's significantly greater scrutiny that we have now. We talk about the paradigm shift. Well, clearly that has happened. So in the past it used to be one side fits all. Well, now we do personalized medicine. In the past, medicine was somewhat fragmented. Now it's all integrated. Everybody's part of a team. We used to be provider-centric. It was all about the physician who provided the care. Now it's patient-centric. We're giving patients more of an autonomy, more choices. We used to be centralized. Everything used to be in a hospital. Now we're doing more and more in community settings so that we're bringing healthcare to the community. We also recognize that it used to be procedure-based in the past, but now we're outcome-based. In the past, we used to treat sickness. We used to run towards illness, but now we're encouraging preventive care. Sickness and wellness is strongly encouraged. So when you look at this little chart here, this is to see which payment best fits your payment plan. On the bottom left-hand side, you'll see things like immunizations and simple injuries. When you look at fee-for-service, these things are somewhat easier to manage. You submit a bill. You get paid for that. In this case, for example, let's say immunizations or vaccine. You can set up a price, $15 for the flu shot, let's say, for an example. You come in. You pay $15. You get a flu shot. You don't get any volume discount. You don't get any extra for bringing your family. When you go up to the left top, you'll see that things like where there's episodes of payment, where things like hip fractures are. In this case, the variation of cost is high, but the frequency is not that often. Hip fractures don't happen that often. So we can manage these things, but the cost variability is there. If you look at the bottom right side, things like chronic diseases like COPD is a little different. In this case, you have a high variation in the frequency, but the group of people are small. Usually, these are elderly people who have different amount of illnesses. They have different comorbidities. They may dictate different treatment plans, but again, it's a smaller population. But back pain is very different. In this case, you have high variability and high cost. You can see that simple sprains, strains, or surgery, they all present as back pain, and it's very expensive to manage this care. Clearly, you can see where this could be a problem. So you always wonder, is back pain considered a service line or a product line? Well, service line is something where you focus on a particular medical condition or a procedure. It is oftentimes under the same management or governance. It can be done in an ambulatory setting or in a hospital setting. Product line is slightly different in which a group of related products that a company sells under a single brand. Let me give you an example of service line. When you look at service line, Cleveland Clinic has a spine center, which is a service line. We are under this group where we manage from simple sprain strain to complex spine surgery. Product line is also at the Cleveland Clinic in terms of, let's say for an example, kyphoplasty. We have interventional physiatrists, we have pain management physicians, we have orthopedic surgeons, we have neurosurgeons, and we have interventional radiologists who all do kyphoplasty. So although it's still kyphoplasty, the pedigree is a little different, but the product is essentially the same with very minor variations. So the tools that interventional physiatrists often use are injections, invasive procedures. Well, there's a cost associated with that stuff. Things like simple procedures like trigger point injections, just some of the more complex things like the spinal cord stimulators and vertebral augmentation. Now we're dabbling with regenerative medicine, which is the next hot topic that people have shown interest in. So what does the future hold for back pain, and where does interventional physiatry fit in? Are we cost containing, or are we causing greater cost to our patients who are using our services? You have different employment options. You can be part of a private practice or academic practice, or you can have a hybrid practice. There are advantages to all and disadvantages to all. You can start off your own practice or you can use your skill sets and join a multi-specialty group or you can go into the academic medicine. What payment plans are best? Clearly, this topic is not going to be covered in my lecture, but we briefly mentioned fee-for-service. Let me just go over some of the other things that are out there, things like bundle payment, in which you get a single payment for the well-defined episode of care, including the facility and all the continuum of care. And in capitation model, there's a single risk-adjusted payment for overall care for the life of the patient. When you look at that, what typically is aligned with value is bundle payment. You have higher chance of getting things out in the open. The transparency is better. There's competition on value. There is strong incentive to improve efficiency because your payment is going to go further in these cases. So what are the strengths of physiatry or especially interventional physiatry? Well, physical exam is clearly the thing that we have to look at. We have broad knowledge in orthopedics and neurology, and we are truly the primary care physicians for MSK issues. Disability evaluation is also something we do. Remember, low back pain is the number one cause of disability worldwide. We do acute and subacute rehab also. We are by design team leaders for back pain. We can work with primary care physicians as well as advanced practice providers to contain the cost of spine care. At the same time, we can partner with surgeons to improve their efficiency and perhaps decrease the cost or sort out the ideal patients for them for surgical options. So you can see that there is a large potential for physiatrists and especially interventional physiatrists to decrease the cost of care for our patients. So the question is, what is cost effective? Is it better to just educate our patients, offer medication, maybe consider physical therapy, and in some cases, interventional spine and even in less frequently surgical options? At present, there is no payment for educating a patient. We are not paid for minimizing the resource utilization. There's payment for unnecessary utilization of expensive care, and back pain is one of the leading causes of unnecessary utilization of resources. So with all the technology we have, the wearable technology, the remote access and all, can we really use that to our advantage? Can we be compensated for eliminating surgical cases in many of these patients who don't need it? Can we be compensated for avoiding interventional physiatry options? Can we be paid for avoiding physical therapy by having them spend time with us and educating them? These are all the things you have to think of. So know that the insurance companies are watching you. They know every single thing you do. They have charts on you in terms of what kind of utilization you have, how often you do procedures, how often you see patients, how often you have repeat cases. They can easily pull up this data, and they would want to know why they want to pay for procedures they do not give relief for your patient or they do not improve the function of these patients. If their patients are still being off work, what's the reason for that? Why should they pay for the procedures that are supposed to bring them back to work? Are they still utilizing resources like physical therapy and still costing them tremendously? Were you able to avoid surgery? That would be very beneficial for the patient and also the insurance companies because that's usually the biggest ticket item for them. Does it make sense to pay for a procedure for the short-term and long-term benefits for their patient as well as for the insurance company? Take a look at this chart. Who has not seen the benefits of having more administrators? Well, you know there are metrics for every one of us at all meetings. They give you the metrics. When you look at this thing, you can see the exponential increase in administrators over the years. Over the last 50-plus years, administrators have gone up by almost 3,000 percent. The first blip came around in 1982 or so when the DRGs were implemented. Then again, when HIPAA was implemented in 1996, there was a slight bump up again and then additional bump up again when the adaptation of EMRs were implemented in 2009. So you can see the steady increase in hiring administrators. Remember, they don't generate revenue. They are monitoring your activity. You're the revenue generator and the things that you support are being monitored by them. So let me give you some caution about where spine care is headed. When I was in my fellowship, we used to bill for epidurography. There was an extra payment for that stuff. I looked back on the website and then I noted that in New Jersey in 2009, if you bill for epidurography, it was about $121. But if you did not bill and write a separate note for epidurography, you only bill for fluoroscopy, you were paid about $68. The difference was about a little more than $52. So some of us who do 20, 30, 40 procedures in one day, that's a real number. So you can see that you'd be losing $52 per patient by not documenting epidurography. Guess what? You can't do any of that stuff now. You get the same payment with or without the documentation of epidurography. In fact, it's expected that in your note that you put down what kind of flow pattern was noted on your procedure. We already know that the EMG reimbursements have gone down. The next thing that we all are doing is ultrasound. Recognize that the insurance companies are beginning to limit the payment for the ultrasound. They are paying for the injection, but they're limiting the usage of ultrasound. So the question to us is what is next on the chopping blocks or something that's going to be squeezed a little bit more? Is it an individual procedure that is being done more often than others? Or is it a solo or a specialty providers who continuously utilize certain services? Or is it the high utilizers of invasive procedures? There are doctors who line up three procedures for every patient who walks in. The insurance companies know that. Will they be the ones who will be dinged? Well, these things must be monitored and must be addressed, and you have to be cautious. So the question is, do you join a large academic practice where you have to give up some autonomy, but you'll have some security of having a steady paycheck? You'll have more micromanagement of your care and your activities you do. Or you join a solo practice or a single specialty or a multi-specialty where you have more autonomy, but you're at risk of other things such as decrease in income. So these things have to be in your mind when you sign up for a job or when you look for fellowships. Can you live with 10 to 30 percent pay cut at this time? Remember, there are significant issues with overall budget that's out there for health care. It's going down and there's utilization that's going up, so something has to give. Know that there are some incoming storms and know what the market forces are. There's always some changes going on there, and you have to have your knowledge base updated all the time. Make sure you prove your relevance. You must proceed with caution. And as Yogi Berra said, future ain't what it used to be. Thank you very much. Now we will join Dr. Glassman and Dr. Standard for a brief discussion. In the meantime, if you have any questions, please direct that to the Academy staff at the healthpolicy at aapmnr.org. Thank you very much. Look forward to having you ask us questions. Dr. Thomas and Dr. Glassman, thank you for great talks. That was really helpful. I think this is all really thought-provoking for our field in general. It is for me. We're going to have a bit of a Q&A, and so we're going to ask each other questions a bit about what we just talked about and what we just heard. And if those of you who are watching this have questions, we'll give you a way to submit them back through AAPNR so we can try to answer them for you. So, I'm going to start with Dr. Glassman. So, part of what you proposed in that was this realignment of working with primary care as your primary audience rather than sort of aligning so much with surgeons. A lot of physiatrists tend to work closely with surgeons and work in their offices and are often employed by them. To get to primary care, though, we have to make a case to the primary care people that we're the ones they should talk to, and we have to engage them. Do you have any suggestions for people if they want to start engaging their primary care communities and thinking about them as high-value providers? Well, sure. I think it's always important if you are employed, talk with your employer, talk about the idea that you're considering and what value that idea could bring to your employer's practice as well as to the patients that you serve and the primary care physicians as well. I think primary care physicians have so many things that they're taking care of in their day-to-day practices that certainly if physiatrists are able to appropriately treat some of these muscle skeletal conditions and offload the work from their office to the appropriate treatment center, then it's a win-win for the patients, for the referral primary care physicians, the emergency room as well, and ourselves. And it fits in with as accountable care organizations develop over time, primary care physicians will look at our specialty as being part of the discussion. So I think that it's important to understand how to reach out to those providers, identify which primary care groups see a lot of the back pain patients, go to their meetings, maybe present grand rounds or go to their internal medicine monthly meetings, and bring up these ideas. Talk about the literature, talk about the data, and really give some input as to how you can change the current practice for the benefit of everyone involved. Yeah, that's really interesting. I think in our system, for example, a lot of primary care docs have shared savings agreements with the payers, with the health system, where if they can lower things like ER visits or imaging rates, they get essentially bonuses or other financial inducements from the health plan. It's an interesting way to think about because that's not traditionally what we've done. Dr. Thomas, quick question for you. I looked at those numbers from the Congressional Budget Office and Medicare and the Medicare Trust Fund, and it's frightening in a way. The sheer drop in insolvency is a big deal. And the drop in payments they're talking about, they're already talking about a 10% cut for everything that essentially is procedural and not E&M. And then thinking another 17%, those are huge cuts. And there's a bit of a race to the bottom there. You start thinking nurse practitioners come in, nurse anesthetists, physician assistants, other providers come into the interventional space potentially. The question of why us? Why physiatry and how do you maintain the value in seeing a physiatrist and make it so that you are not just interchangeable with everybody else who can put a needle somewhere? How do we approach that, do you think? Up until surgery as a physiatrist, instead of having to do just oral medication or PT or injection, we can do it all. So when you go to a person who is not fully trained in this area, they lose out. So I think for us, we can assess them upfront with a good exam. We can start with the medications and rehab, everything conservative. Most of it is educational. Access for them to come back just to say hi to me because it's costing them money. I do my follow-ups by phone in most cases, post-procedure. They are given paperwork to keep track of how they do so they don't have to remember everything from the beginning. So I try to make it easy on them so that they don't end up utilizing care, especially in the aging population. The resource is somewhat limited, but I'm very cognizant of the overall cost of care for these patients. So what you're talking about also is not being so hyper-focused on simply the procedural component. It's actually doing the other things we're trying to do and trying to leverage that a bit. Absolutely. So if you look at my cases, there are patients who are sent to me for procedures and I tell them it's not the appropriate procedure for you. And in fact, if you haven't tried other things, there's no reason for me to put you at risk of some potential harm because invasive procedures have risk of harm. There are times they send me patients for cervical procedures and I have to talk to them about stroke, seizures, paralysis, death. And I ask, are you bad enough to consider surgical options? And they say, no. I'm like, then can you live with this? Then yes. So I don't do the procedure if they can manage their function. And if they're not thinking about surgical options and they have not tried medication and rehab, I do that before I expose them to surgical interventional options or the invasive options. I do my very best to keep them out of the invasive procedure section. Do you guys have questions that might pop in the heads of people watching us talk, listening to us? Sure. So I have a question if that's okay. And I think about one of our other IPPM committee members, Dr. Benton Giap, who was one of the medical directors for Anthem and Wellpoint in California. We've talked about the fact of how to get these ideas, not just to primary care providers in your community, but also to the payers and the insurers. I think about one of my colleagues here in New Hampshire, who is medical director for one of the largest health insurance plans. He has been very interested in the work we've been doing for the last three or four years with IPPM. So the question to you, Chris, is you work at a health system now that does basically self-insure many of its employees. And how have you seen the dynamics change because of that role that the health system now has taken on? And what we as physicians have to understand if we ever want to approach insurers with these kind of models? I think if you go traditionally to how we work in a pure fee-for-service system, you simply submit a bill and you get paid. And the payer is collecting money from the employer and the patient to pay for their premium. And the money you're getting is coming out of what they got for their premiums. And so if you start spending a lot of money, they start increasing their premiums, basically. At some point, that doesn't work. At some point, the market will say, we can't keep increasing our premiums. Employers won't pay more. Employees won't pay more. We all won't agree to keep paying more for our insurance. So therefore, the providers can't just keep ratcheting up what they do and the cost of what they do. And that becomes problematic. And you hit different systems. So the other system approach is called an integrated delivery and finance system, an IDFS, where that becomes the insurer is the employer, right? So if the insurance company owns the hospital and owns the doctors and therefore owns the people and is paying the people submitting the bills, they have a very different incentive structure, right? The incentive is not to collect as much revenue as you can. The incentive is to keep the people paying you premiums happy with their care and healthy and out of hospitals and out of ERs and away from unnecessary things. And if you do that well, you can actually lower the premiums to your patients and take more market share from your competitors who have to keep raising them. And so in that dynamic, when you start looking at health systems like that, they just have a very different structure. They want to keep their patients healthy, and they want to do what works, and they actually have the capacity to do things that don't necessarily reimburse in a fee-for-service structure. You can get into health coaching, you can get into dietician, you get into behavioral health, and you can pay for them up front because they have a return on the back end in terms of lessening expensive care and expensive utilization. So in a system like an IDFS, then you have a different leverage with the payer because then you're on the same side as the payer. You're trying to provide better care, you're trying to help them get better value, and you get more resources to really help your patients that you may not have now in order to help them do well and avoid other costs down the line. So when you think about these models, you have to think about what kind of structure you're in. If your hospital makes lots of money off of every MRI that's done and every surgery that's done, it's hard to partner with them on reducing them. You have to find another partner who's interested in that, which would probably be the person paying the bills more than the hospital. But every payer essentially is interested in the same thing, is interested in getting more for their money. So you can approach the payer with these ideas in mind that you are trying to help their bottom line by keeping their patients healthier, and you may need to help them think differently about what services they want to provide to do that. Yeah, it's a different setup. I got a question, and this is with the political climate that we're in right now. Do you think it would matter one way or the other which administration takes over with the changes that could be implemented soon for us? Because both parties have different preferences perhaps. Do you think one would be a softer landing for physicians or healthcare system in general? I don't know. Personally, if you look at the current administration and what CMS is doing, they really are trying to, at the moment, trying to shift reimbursement to E&M codes. So from proceduralist to primary care to patient care providers. And I think that is important to the current administrative structure. And that's been a fundamental conflict in medicine. In some ways, what they propose sort of divides the House of Medicine a bit. You have the people who do a lot of evaluation and management codes, a lot of direct patient care who like that bump. But if it comes to the cost of procedural and surgical interventions, the other side of the coin doesn't really like that cut. And so it's split the House of Medicine a little bit with their current proposal. In some ways, I don't think it matters a whole lot who goes in because the trust fund is running out of money. COVID costed a lot of money. It's going to run out of money. And at some level, you have to shift the business model to find better value out of it. I think there certainly are differences in where that money comes from. And do you expand Medicare? Do you expand access to health care through government-funded mechanisms? They're clearly different between the two parties. In the end, though, they're both going to be faced with the same problem, that they're running out of money to pay for it. And the current taxing structure, payment structure, funding structure, and expense structure for Medicare is not adequate. It's going to run out of money quickly. And I think they're both going to have that problem and both going to be looking for solutions with relatively similar impacts on us in some ways myself. I don't know the true answer of what you're asking, though. I don't know what you think, Dr. Glassman. I'm going to be the host of it. Sure. Hopefully, the health economists that will weigh in on these questions and answers remain apolitical. And then we as physicians really need to then weigh in with our elected officials and congressional members to try to say, look, leave the politics on the side if you can, because this is about patient lives. This is about long-term decision-making for health care benefits and health care outcomes. And we've got to be able to reach a solution that makes sense for our entire country, no matter what the outcome is. For our entire country, no matter how you vote. Yeah. I mean, whatever we do, our population needs—people need health care. They need to be well. We're physicians. We're supposed to care for our patients. And there's a huge—whichever party is in control of the wheels of power there, the obligation for us is to do what Dr. Glassman said, keep advocating for our patients and for means to care for them effectively. But given the finances, how we've been doing that may not be the way we will be doing that. Exactly. I agree. Yeah. All right. Thank you all. So those of you who've been watching us, we really appreciate your time. And again, if you have questions, you can forward them on to AAPMNR, and we will do our best to get back to you and answer them. Thank you very much.

cost of spine care

value-based spine care

healthcare expenditure

coordinated care delivery systems

physiatrists vs. surgeons

low back disorders

AAPM&R low back pain model

bundle payments

interventional spine care

patient-centered care