Okay, folks, I'm going to ask everyone to take their seats. It's 3.30, and we want to be on time so that we have enough time for questions and that our virtual audience doesn't sit watching their TV screen or computer screen with nothing happening. Okay. I want to welcome everybody to this afternoon's session entitled, How Physical Medicine and Rehabilitation Physicians Demonstrate Their Value to the C-Suite or to Key Stakeholders in General. Before I begin, this is one of several sessions that are going to be streamed live to our virtual audience. So I welcome everybody here who's present at the first meeting of the annual assembly in person in three years, and the first where there's actually a dual audience here in person and virtual, and I welcome our virtual audience as well. Because this is a mixed audience, some instructions regarding how you're going to ask questions, I'm just going to read it off right here. For this session, we'll be using the app to ask questions, and that's both for folks who are virtual and here in person. To ask a question, open the AAP Menor app and find this session. Click on the session and then click Q&A in the lower right-hand corner. Type your questions and hit Submit. We'll be taking questions from our home audience as well, so make sure you're doing that. And at the end of this presentation, we will get to as many questions as we can. So again, thank you. Welcome to Baltimore and to this session. So how PMNR physicians demonstrate their value to the C-Suite. Oh, that's me. Currently a PMNR president-elect for another couple of days. Currently also chair of Rehabilitation Medicine at NYU Langone in New York City. So goals for this session. What we really want to do is to impart on you, and I think you all know this, the value that physiatrists, PMNR, add to medicine in general, and how we can best demonstrate that value to our key stakeholders. The C-Suite and the health systems that you work at, your referrers, payers, and what have you. So the ultimate goals for this session is to understand where we are in the transfer, or transformation, rather, from fee-for-service to value-based care, because we know that's what's happening in medicine. And we're going to get an expert talk on that from one of the leading experts in the country. Think through several key examples of how the strengths of physiatry and PMNR effectively position our field now, and equally, if not more important, into the future that align with the vision of our specialty and PMNR BOLD, which I'm going to be talking to you about in a minute. And also to consider effective means to how you communicate our value to the folks that really need to hear it. The key stakeholders, the C-Suite, the payers, our patients, and our referral sources. So my role over the past year as President-Elect of the Academy has been working with staff, you, and physiatrists across the country on advancing PMNR BOLD. So BOLD is not this buzzword. I mean, you see it everywhere, right? You get it in the emails that we send out on a regular basis. You probably see it plastered on all of the banners and what have you. But PMNR BOLD, it's not a gimmick. It's not a buzzword. It really is the Academy's vision for our future as a specialty and the future of every single person here in this audience, both live and virtual. What we did is to gather information from well over 1,000 physiatrists and understand where does our field need to be going forward, not just to survive everything that's happening in healthcare, but to thrive. And that's key. And over the course of about six or seven years, we worked with five groups looking at different practice areas in musculoskeletal care, pain spine, pediatrics, the rehabilitation continuum of care when someone enters into a hospital through their entire disability, which oftentimes is lifetime, and oncological rehabilitation. We've developed and envisioned futures for each one of those practice areas where we believe we need to be to continue to add value to medicine. For those of you who have heard me talk about this before, there's a triple aim of medicine. The triple aim is to make sure that population health is improved, that patient experience improves, and that we do it all more efficiently. Inefficiency is just a government euphemism for less money. And what we know is that the value that PM&R adds to medicine really hits all three of those things. So our vision, your vision, that I need you all to embrace is that physiatrists are the essential medical experts in value-based evaluations, diagnosis, and management of neuromuscular and disabling conditions, that we are indispensable leaders in directing rehabilitation and recovery and in preventing injury and disease, and that we are vital in optimizing outcomes and function early and throughout the full continuum of care. So we've developed these. We're moving them forward. But we also know that it's one thing to say it. It's another thing to achieve it. We have evidence to support what we do is valuable. We need more. And there are also challenges that we have. So we need that data and quality. That's why we have our registry. And I would encourage centers that have not joined the registry to strongly consider doing so because it's big data that really is going to be important to show definitively our value. We're going to continue to advocate and practice what we're doing. We understand that we need to train not only our trainees, but those who are already in practice to be leaders and to carry this forward and to be the local champions where you are to advance what we do as being valuable. If your healthcare system really wants to achieve the highest level of care and outcomes and efficiency, they need us. We're not a luxury. They need us. We have to address workforce. We know that there are far more people in this country who need physiatric care than there are physiatrists to care for them. So we know we have to find ways to expand our workforce, appropriate use of APPs as part of a team led by physiatrists to expand our reach, to use telehealth in novel ways to expand our reach, to reach the people we know that we can help. And we also need to increase the awareness of our brand value. And to that end, our academy, your academy, has developed a new SCC, a strategic coordinating committee, the specialty brand expansion, whose goal is to increase awareness of what we do as physiatrists to help patients and to advance healthcare. So, you know, and for those of you who are familiar with, well, if you attended the last lecture, you know that we've made a big splash in post COVID. Not because, gosh, this was an opportunity, because we saw the need for our services in treating people with long COVID. But because of what we did, we've gotten tremendous media exposure. So in the past, we were, PM&R that is, you know, medicine's best kept secret. Not anymore. We will communicate our value to those who need to hear it. We'll demonstrate that that value works. And we're going to position ourselves boldly, we probably should have put that in capital letters, now and in the future. Now, that's how we're going to start off. But it really is important for us all to understand, you know, what's happening in healthcare. We are transitioning from fee-for-service to value-based care. It's not that it's something that's going to happen in the future. As you're going to hear, it's happening now. So with that, I'm really delighted and honored to introduce to you Dr. David Chin, who's a Distinguished Scholar at Johns Hopkins here in Baltimore, in the Department of Health Policy and Management, who's going to give us an overview of value-based healthcare, where we are now, and where we're going. Dr. Chin. Well, Stephen, thank you very much for that introduction, and thank you to the Academy for inviting me to speak about value-based healthcare. Actually, the Distinguished Scholar is a misnomer. I'm neither distinguished nor scholar. I'm actually a retired partner from PricewaterhouseCoopers. I used to lead the academic medical center consulting practice for the firm. I also used to be president and medical director of the old Harvey Community Health Plan in Boston, for those of you who know a bit of Boston. What I'm going to talk about this afternoon is a little bit, 10 or 15 minutes, about value-based healthcare. And as Steve mentioned, it's something that is happening now. Even though I recognize that for many of you in private practice, a lot of your reimbursement is fee-for-service, particularly from workman's comp, et cetera, and from procedures like spinal injections. So clearly, we're living in both worlds, and so let's talk about how we make the transition. So first, I'm going to provide some context. Then we'll talk about what CMS is doing, which is the 800-pound gorilla, and then some potential models that you might be able to take home and use. So in terms of context, we all know we're in the American healthcare system, and it's the best acute care system, I emphasize acute care system, in the world. We're also the richest country in the world, and represented in this room are the most highly trained, best physicians, literally, in the world. And we have great hospitals, great technology, great research, with the COVID-19 vaccination of vaccines as the latest and greatest example. And we spend a lot of money, $4.1 trillion, and it always lags a couple of years, but my guessing is that the next numbers that'll come up will be like 4.3, 4.4, I mean, trillion dollars, over 20% of GDP would be my guess. So it's a huge industry, and what drives ... So that's the denominator. What drives value, the push towards value, is this. We're a $4 trillion economy. Rough estimates are that anywhere between 15% on the low side to as much as 30% on the higher side, probably more like a quarter, is waste. So a quarter of $4 trillion is a trillion dollars of waste in the healthcare system, a trillion. That's why there's a push by policymakers, going back to the Bush administration, through Obama and even through Trump, about trying to get the waste out of the system, because it's a trillion dollar opportunity. Now where are the sources of waste? The first three are right in the wheelhouse of physiatrists, care delivery, care coordination, and low value care. That's where you can influence things, directly as clinicians. Pricing failures are probably a payer and CMS issue, fraud and abuse, I frankly believe it's not that big a deal, and then administrative complexity is a big deal, but not in your wheelhouse. There are a whole other ... You could give a whole lecture on administrative complexity in healthcare, you all live it, in terms of the billing process. Lots of opportunity to improve, but that's not the focus of this talk. Just remember, care delivery, care coordination, low value care are the opportunities that clinicians have to have a major impact. You can see the numbers, it's roughly about a third of the spend. So a trillion and a half, trillion two, is what we're talking about, is the denominator. The other piece of context is that Amazon has changed everything. So it's made the expectation among patients to have ease of access, right? I'm willing to bet that everyone in this room is a member of a household that has Amazon Prime, right? Who doesn't have Amazon Prime? There's no one here. Well, one person back here, clearly in a minority. Amazon has done terrifically because they made it easy. They coordinate everything, right? It's a prepaid ... You pay 139 bucks, you get free delivery. In Baltimore, you get free delivery in two hours. So it's a pretty terrific value proposition. You can see what you're getting with the peer-to-peer reviews, and basically the bottom line, Bezos's genius was to make retail purchasing frictionless, and that's the expectation that's being driven to all the patients, particularly to millennials, right? They want it frictionless, and I have to say, I've worked with Marlise for a long time, the reality is healthcare, Hopkins, is not frictionless. Any academic medical centers you know has a lot of friction, which means a lot of opportunity. So what's the CMS strategy? We got all this waste going on, right, trillion, trillion and a half dollars of waste, and the focus is on value, outcome over cost, right? Outcomes divided by cost. So right now, for the physiatrist in cognitive areas, you're not getting paid to do care coordination. If you spend extra time to coordinate the care of a patient, you're not getting paid for that. The CPT codes don't fund that, so that's on the cognitive side. On the procedural side, where you see opportunity when I look at high procedure-oriented areas like spinal injections, what I see typically without any data, because I'm not a physiatrist, I'm an internist, is that if there is a procedure that's widely in use, there is enormous variation in the rates per doctor per procedure. Some doctors are using a lot. I'm, you know, Don Burke and I worked at the Harvard Community Health Plan, and we looked at Harvard-trained physicians. On any dimension, we would find 1,000% variation, 1,000%, tenfold variation. That means someone is doing too much and someone is doing too little, and that's an opportunity for value, and right now, the way it works is if you go to some of the models we're talking about, you can get paid for doing better coordination of care. You can get paid for not doing an injection, for not doing low-value care, an injection that won't provide benefit. So that's number one. Number two, you want to align incentives. That's what CMS, we're not going to go to a single-payer system, bottom line. It's not going to happen in the United States. This is not Canada. We were just talking about Canada in the warm-up here. It's not going to happen. It's going to be a private system, so therefore, it's going to have to align with private models in the United States. The third is there's a lot of push towards experiments, like here in Maryland. There's a total cost of care waiver in Maryland. We don't have time to go into the details, but the bottom line is it's saved a lot of money in a very short span of time by just merely putting a cap and allowing the private incentives to push towards saving money, and there's a bunch of alternative payment models. I know there are some sessions in this program about alternative payment models, so I won't go into the details, but there are a lot of different experiments going on consistent with the private market, and it's an alphabet soup about that. You could spend a whole lecture on each one of these alternative payment models. What is CMS focused on? It's the 800-pound gorilla. I know it does not work in workman's comp. So I recognize that physiatrists are living in between the medical world and the workman's comp world. So it makes this transition even more fraught. But the bottom line is that you see the percentages here. This is from the Health Care Action Learning Network. And you can go on the site. Presumably, they're going to get the slides, I presume. So you can go on the site to this learning network and find out about case examples of things that have worked in other areas of medicine. So you can apply to medicine. But you can see here in 2022, 25% Medicaid in value-based payment, 25% commercial, 50% in Advantage, and 50% in traditional Medicare, which is more the MIPS stuff, the merit-based incentive payment model. In 2025, you see how the numbers progress there. So the CMS, typically what happens when you take a look nationally in terms of policy, the commercial sector follows what CMS does. So you can predict that the private payers just go under the radar, under what CMS is pushing. Again, I can't comment on workman's comp. I really don't know a lot about that particular area. So in light of the CMS strategy, what have corporations done? One is that in every single one of your markets, I'm willing to bet that there has been provider consolidation among physician groups and among hospital systems. That's gone on nationally in response to trying to get more scale to get more waste out of the system. The second area is around nationally. Take UnitedHealth Group. It has quietly become the largest employer of physicians in the United States. 52,000 physicians are employees of UnitedHealth Group. 52,000. Just to give you a perspective, Kaiser historically had been the largest employer, has about 28,000. UnitedHealth Group's strategy is to become a virtual Kaiser, to be like Kaiser but without the bricks and mortar, and to have all the services across the continuum of care, an area that certainly physiatrists can play in as well. Amazon, seeing that this area is full of friction, has tried some different forays. Amazon Care, they just closed that and they bought one medical for a couple billion dollars. Primary care concierge model, again, prepaid. So there's a theme there. They bought PillPack to be able to provide pills in one pack. So you had the issue of the average Medicare recipient is on like seven different drugs. So what PillPack does is package the drugs they need for each time of day. So let's say if you have to take five drugs at noon, there's a pack, PillPack, that has the five drugs you need to take at noon. That's how they take the friction out of taking your medicines in terms of compliance. And then Alexa, very interesting place since Amazon's basically a data company, has now put its software in the places that I've mentioned here. So they're trying to embed themselves not only in your home with Echo and things like that and ring doorbells, but they're embedding into healthcare institutions. So here are the potential provider models that you can use. Now this is a busy slide, so hopefully, again, as I mentioned before, that this is something that you can look at afterwards. I've given you the reference at the bottom, but this is what you can take home. So as I said, I come from a consulting background, so it's a classic two-by-two business school table. Across the top, you're talking about the entity. Are you talking about a provider group or a health system or a risk-bearing intermediary? Now there's a little blurring right now. Some of you may have heard the term payvider. So UnitedHealth Group has become a payvider, both an insurer and a delivery system. Johns Hopkins is a payvider. It has Johns Hopkins Healthcare and it has Johns Hopkins Health System. So that's a kind of a blend that's not on this chart. On the vertical axis, you see whether or not it's a chronic condition or an acute condition. And then inside each of these boxes are a set of attributes that you should take a look at. And again, hopefully, you'll get these slides. So whether or not the specialist will tolerate risks. If I know most doctors, most doctors hate taking risk. By definition, we are non-risk-bearing or risk-averse individuals. Whether or not the clinical scope is narrow or broad. Whether or not the specialist can exert clinical control. And then what the practice structure is like. Are you highly fragmented in a fee-for-service operation or are you more like in a provider group? And then finally, whether or not there is a lot of integration with PCP. There are pieces of the physiatry practice that function very much like a PCP. So if you take a look at each of these boxes and then try to answer the question, where do you sit? Then you can start thinking about the different models. And I'll just briefly cover the models, what the characteristics are like, and then you can plug and play later on. So an episode-based bundle payment is taking a discrete episode. A good example might be a hip fracture or something like that. So that's an episode payment around a very time-limited area. Number two, a bundle payment in terms of convener. You might be able to say, look, we have a bunch of these that we can do as a society. Not just hips, but other joints, other things, shoulders, spines, et cetera. Bundle that in. And again, if you can reduce the expenditure around, for instance, injections, you can get paid for saving money on not doing the injection. Then the number three is condition-based. So you take a whole condition like low back pain or some kind of workman's comp disability and bundle that into a whole condition. And then the last one is to be the vendor, which is much more integrated. Being the entity, being the pay-vider that takes the risk and the delivery system for this and delivery of this. So those are four examples. And again, I've given you some criteria to judge whether or not they might fit in your particular local situation. So I've tried to do in this brief summary is give you the context that we have a terrific healthcare system. It's gonna stay private, but it's got a lot of waste. And when there's a lot of waste, there's a lot of opportunity to take that waste out for mutual benefit, for the benefit of providers, benefit of patients, benefit for society. The patients are certainly expecting more convenience. And again, the coordination of care that physiatry can provide will be key. CMS is pushing, as I said, the 800-pound gorilla. It's pretty clear that we're going down the value-based payment model, we're not going back. And then finally, I've tried to give you some concrete examples. And with that, I will turn it over to Marlise. Thank you. Okay, I'm delighted to bring Dr. Marlise Gonzalez-Fernandez up, she is Vice Chair of Clinical Affairs, Associate Professor at Johns Hopkins, and she's gonna be talking about value of physiatry as an acute care setting. Thank you. Well, thank you, everyone, and thank you for being here today. And we're gonna talk a little bit about what we can do in the context of the acute care hospitals where we are embedded to add value to that equation. And again, the hospital, and especially in Maryland, is always thinking of throughput. Throughput is valued now and will continue to be valued in the future. How can they get their patients through the hospital out safely, and what the length of stay is gonna be? So again, providing that early functional evaluation and recommendations is really, really important. So again, we can come in early when the patients are being treated, and provide therapy recommendations that are meaningful in those cases. Patients can go home sooner, and then we can really make an impact on the length of stay. So for example, one of the programs that we've done is how do we optimize this for stroke patients? So we devised a small pilot study where we evaluated stroke patients on day one when they were admitted to the acute hospital. And the physiatrist was not only involved in making decisions of whether the patient was adequate to go to an inpatient rehab facility, but we also tried to determine what patients were likely to be able to go home if we heightened their therapy, and which of those patients would actually lead long-term care and were better served in other long-term facilities. So the patients who were likely or potential to go home were increased in therapy while they were in the acute hospital. We call that our ARISE program, where the patients receive extra physical therapy and occupational therapy more than a standard of care with the goal to send them home. And then those patients who we know are gonna end up in an inpatient rehab are actually the ones that receive what's considered standard of care and those that are gonna be to other facilities. So that adds great value to the hospital as it is, because then the patients are moved through in a very busy hospital, as you can imagine, as Hopkins where beds are typically at a premium. And this model was very helpful as well as we went through the pandemic because we translated that model to moving patients who had COVID through the hospital. Can we heighten the therapy that we're providing to patients after they start recovering from COVID and make sure that we can send the majority of them home so we can actually keep the hospital going and there are beds for patients to be treated, again, in the middle of what was obviously probably the most difficult time of our medical careers. So again, determining that timely and optimal post-acute setting is incredibly important. So who are the key decision makers? There's always the directors of the hospitals, but it's also getting buy-in from our colleagues. So to make it work for stroke, we really needed to make sure that the neurologists were involved, that they understood what we could do, how there was no real overlap with the work they were doing, trying to keep the stroke patients safe and determining what was the medical management of the stroke and treating all those problems, but also understanding that we can help them manage their functional side, understand what's going on, and also help them manage what are gonna be long-term complications that we can see starting in the acute hospital, and then obviously try to bring the patients faster to where they need to be. In this case, our biggest partners and potential hurdle is to convince the case managers and social workers that this is the right thing to do. Again, in the context of these decisions, they're used to sending referrals to a certain place, just trying to get a clear answer as early as they could. So we partner with them so they were involved in the process of determining what was gonna happen and what was the discharge plan early on to try to eliminate that conflict. So again, how do we position ourselves with those decision makers? Again, we emphasize that impact, that early identification of conditions can bring to the care we provide and how we can help the hospital overall provide better care and care that is timely without short-cutting the needs of the patients. And again, offering to pilot the program in the acute hospital was a good way to eliminate a lot of the risk and the financial risk that the hospital would have had to assume if in fact this would not work and it was a terrible idea, which we demonstrated it was not. And again, from stroke, it's gone to using it for transplant patients, and we used it during the COVID pandemic, which was very helpful for everyone, and we were able to provide rehabilitation care for patients who were in the hospital. And the other, I would be remiss if I don't mention that partnering with physical and occupational therapists in a hospital is of paramount importance. They are the ones that will be providing increased care and our therapy managers are the ones that have to figure out how do I give more physical and occupational therapy to patients without getting more staff that is not readily available. So working with them to understand where the needs are, where the patients could be served more, who needed a little bit less, and how to make it work is critical to be able to improve those functional outcomes for those patients. So on that, I'll pass it along. Thank you. Thanks for that so much. Next up, in another example of how physiatry can add value, pleasure to introduce Dr. Jonathan Whiteson, one of my vice chairs at Rusk Rehabilitation. He's gonna be talking about the value physiatry adds to skilled nursing facilities and subacute rehabilitation. Dr. Whiteson. Thank you, Steve. Certainly an honor to be up here with a great panel and thank you for listening. No disclosures. These were sort of the questions that we were asked is to think about as we were going through, but I'm gonna go through all of them. In terms of what are the current, or is the current fee-for-service or traditional models and the strengths of PM&R within these models. And in the skilled nursing facility, I'm gonna talk about sort of two buckets. One is the independent practitioner, the practitioner that goes out and walks door to door to each individual SNF and looks to set up a business agreement and arrangement and to work within those SNFs. It's almost like a solo practice kind of idea. A physiatrist will go and see patients at multiple different sites, do their own billing, et cetera. The other is a system that I think everyone is also familiar with in terms of there are companies, established companies, which represent or which contract with SNFs and which also contract with physiatrists and match the two. Physiatrists will go to multiple sites as well. The billing is done through that company that hires them. It's somewhat of a volume-driven process. But there is a degree of value in each of these systems when we think about the stakeholders. And certainly a main theme of that value is that the physiatrist is really the essential physician when it comes to rehabilitation. And you, meaning the sub-acute system, they need physical medicine rehabilitation. They need physiatrists to really help their patients achieve function. What about future models of a value-based system and the strengths that PM&R brings? Well, we go back nearly a decade to the bundled program. And many of you will be familiar with this. You've been in practice at that time. But that really sort of initiated a change and a look towards value-based care. And then there was a payment reform system within the SNF system, PDPM. This really catalyzed the drive towards value-based care. And the goals of PDPM were really to reduce expenditures in the post-acute care setting, to reduce an administrative burden, and to improve outcomes. You're sort of getting the idea of value-based care. And value, this sense of value, is really what's sustaining this drive and really pushing us forward. And there's no doubt that SNFs have that need to improve quality and improve outcome, but at the same time maintaining adequate therapy. So where does the physiatrist engage in this PDPM model? Certainly, if we think about our acute care model, we can translate that quite readily to the SNF model in terms of what we do in identifying primary and comorbid conditions. And this is really important in terms of reimbursement and these patients whether they go to IRF or SNF they have many of them have earth-level complexities and identifying them and I And treating them is really essential and the physiatrist plays a great role in that perspective And then it's about promoting throughput and throughput really means efficiency getting patients out of the SNF at this You know in an efficient time and length of stay. It's really case management I'm not saying we are case managers, but we play a tremendous role in case management and the physiatrist Absolutely plays a role in prognosticating in terms of functional outcomes and therefore helping set length of stay Coordinating with the interdisciplinary team and making sure that that communication goes on. We're great That's what we are born with or we're trained to do in terms of that collaborative communication And there's also working with patients and families in terms of expectations How many of you have had a patient who says no? I'm not going home because they didn't know they didn't realize and communication really makes a difference in that perspective So in terms of a value-based model, what does value-based care look like and you've heard various iterations of this It's about enhancing the patient experience Excellence and outcomes and being fiscally efficient as Steve said doing more for less But it really does encompass the continuum of care and we can't think that working in a SNF is in a vacuum It's just one episode of care It's really the continuum of care right from the time the patient was admitted into the hospital and then thinking about All the way back into the community. It is a patient centric model But the physiatrist is absolutely central the linchpin and forgive my crude artistry here, but this is a Model, which I think you know, it makes sense to me the physiatrist and physical medicine rehabilitation this field within the middle and the health Hospital system is really intrigued and very interested in what we're doing to help improve efficiencies the earth and the sniff as well are vested in our Expertise in terms of improving efficiency, obviously the AAP MNR is invested in this we as individual physiatrists are Residency training we can't turn out great physicians who can work in for in sniffs and know what they're doing without training them How many of you were trained in sniff rehabilitation in your residency? I am sure very few the patient is also really vested and wants to know that we're taking care of them And then we think I put taxpayer community, but really the the global economy of our nation So in terms of future based models and the strengths of physical medicine rehabilitation our experience at Rusk Rehabilitation There's no doubt the bundle program really kicked us into gear to think about how we were going to take care of our patients Why would they go on a sniff because it was cheaper certainly cheaper in the moment than sending them to an earth So we understood that I work in cardiac and pulmonary rehab. So all of my patients I was told because we were part of the Bundle. Oh, we're not gonna send them to sniff anymore. We're gonna send them to us We're not gonna send it to earth anymore gonna send them to sniff. So we created a sniff cardiac rehab program We reproduced our model In the in the sniff and I went and worked there and I saw my patients there and we took care of them and we Had a very vibrant model that we got people out in the same amount of time that we got people out from our acute cardiac rehab program and they had just as good outcomes why because I was the physiatrist that I spoke with the Therapist that I spoke with a medical director and I spoke I was that central role and so it can be done It really does work And and we also as we push forward at Rusk in terms of hiring physiatrists to work in all of our sniffs and we have 16 Sniffs that NYU has sort of preferred partnership with we hire them in terms of a hybrid model So it's not they're only working at a sniff, but they're part of an academic rehabilitation center. They may work in our clinic They may work in our acute floors as well as sniff. They may be doing IT They may be doing research, but it is this hybrid model that keeps very Excellent and academic physiatrists engaged in the continuum of care, but also very much engaged in sniff work We devised a job description I'm not going to go through the details here But it really is very detailed from soup to nuts from there the role of the sniffers artist in our acute care setting But also all the way through this the sniff environment and into the community And various different models and programs and actually something that I forgot to put down here was a transitional care Management model which if any of you have heard of is really you know What happens to the patient in the in the month when they leave? either a sniff or an earth in terms of readmission reduction and the Physiatrist plays a crucial role in transitional care management if you've not heard about it You really should look into it because it makes a tremendous difference in terms of readmission reduction So what about the strengths of this? Well, obviously it satisfies the key stakeholders It satisfies the physiatrist because we have work it satisfies the academic Department of physical medicine rehabilitation Because you know that that's where their docs are working and there is a great collaboration it satisfies the health care system because we are improving the efficiency and the Transfer of patients through out of the acute care system and into the sub acute system It satisfies the sniff because they want to show market value to potential customers It clearly satisfies the patient because they have better outcomes So how does the physiatrist win and how do we show value to the to the stakeholders for the independent? Practitioner there's flexibility in that model. There's minimal overheads There's earning potential and there really is value to patient and sniff in terms of these companies that hire physiatrists and place them in In sniffs, these are established opportunities. There's a tremendous earning potential Physiatrist is part of an organization. And again, there's tremendous value to the patient to sniff and also to the bottom line of the company But we have to see and ask ourselves. Are these individual practitioners? are these companies really working in a True value based system or is there nuances and changes of evolution that has to happen? are they really buying into the continuum of care the Academic model which I described to you, which is what we practice at rusk. I think does fill all of the buckets I'm not going to read through all of these but you can look at the slides, but it really does satisfy the physiatrist our careers our field of medicine the APM and are the c-suite And the sniff itself The key decision makers I think are obvious and I've mentioned them a PM and our physiatrist the companies the patients hospital and health system leadership sniffs Policymakers and hospital associations that represent us as well and represent at the state and federal or national level In terms of how do we position ourselves? Well, you've heard this term PM and our bold but PM and our bold plays a major role in helping physiatrists to position themselves to Function efficiently at a sniff level and you need to develop those strategic alliances Will all those key stakeholders that I mentioned you need to have a business plan as well Nobody's gonna listen to you unless you can present some idea of a business plan And this is we're a data and metric driven driven system. If you don't have metrics, no one's gonna listen to you So start to collect your metrics These are some of the metrics that we've collected and we feel are really attributable to the physiatrist And can help strengthen our position when it comes to the physiatrist as a key player in the sniffs I'm gonna finish by saying that in 2020 I was proud to chair a sniffer think-tank that spawned a sniff work group They're going to be two upcoming one certain upcoming publication the PM and our journal in a few months looking at the role of physiatrists and sniffs and that will be followed on the on our website the a PM and our website Looking at job descriptions the very job descriptions that physiatrists can play from a consultant model through to the medical director in sniffs and that that Website that's put there is the last statement, which I think came out in 2016 This is the work group and the peer reviewers and thank you so much for listening All right, thanks so much for that Next on our list of ways and venues in which physiatry can add value I'm delighted to bring up two of my colleagues Kevin Cornero Who's associate professor at the University of North Carolina and Saloni Sharma who's medical director and the orthopedic integrated health system? Hello everyone, so everyone's probably pretty tired I want you guys to come away with one big point, which is we are made for this We are made for a value-based care. Okay, the current model. I think my colleagues have done a great job talking about this I don't need to read you slides, but we know it's fee-for-service. We know it's procedure driven We know we're not really paid for thinking and keeping people healthy. The future model is really gonna value that we've got quality Prevention coordinating care and that's really what we've done as a resident I spent months really years at McGee rehab and Jefferson rehab and that's all we did. We talked about preventing wounds We talked about preventing autonomic dysfunction. All we did was health prevention and health promotion That was a huge part of it besides acute rehab and the therapist work So I think we are made for this and it's really about Advocating using a AP Mars resources and having your voice heard as this change occurs. So I want to show you a little picture It's the things that happen in the future are gonna focus on quality, right? Prevention and cost savings and I think my colleagues has been a great job talking about that But quality of life patient satisfaction These are all already key metrics but preventative care and multidisciplinary teams and that's where we excel. That's what we do No matter whether you're outpatient inpatient Sniff wherever you are This is what we do and we excel at so we can really position ourselves to be the leaders in this field No matter where you are and what type of medicine type of psychiatry you practice. This can make a big difference So if you come away with one thing I really want you to think about this is what we are trained to do and we just have to raise our voices and use our resources and Advocate for this that we can be the leaders as a transition occurs I want to talk about one thing low asterik on the bottom the bio psychosocial approach So I think we are uniquely trained to address that. I was asked to talk about examples real-life examples So this is a program I've come up with it's called orthopedic integrative health It's a combination of conventional health care conventional MSK care plus lifestyle medicine and integrative care So it's not trading one for the other it's combining them and optimizing outcomes. We're using global promise scales And I think that's really important. It was mentioned the other talks too. It's not about being upset or feeling left out There was a course I took the Stanford physician well-being course and they actually talked about don't get mad get data And that's what we want to do here, right? We don't get mad. We don't feel left out We don't be left behind so we need data and whatever you can do if you can have a patient intake form That has two or three questions that you can standardize and use for data collection No matter what you're doing at some point you can use that even if you don't know how now at some point you can use That so I think it's really important that we're always doing things that are easy to embed in our practice But they're also going to help us in the future So I'm going to turn it over to Kevin and he's going to talk about his examples, too So, you know, this is a high-value based talk when you're giving a talk and getting a tan at the same time from the lights out there, so So, you know several years ago we Embarked on this process PM and our bold and Steve mentioned earlier, you know over a thousand Physiatrist participate in this and these are three models that physiatrists you all came up with That we sort of refined over time and that first model there Integrating physiatrists into primary care is a biggie and why so, dr Chin mentioned earlier speaking a little bit about bundled care, etc You know primary care is going to be at the forefront of that and if we're there with primary care embedded in their practices They see what we're doing. Dr. McMullin will speak about this in a few minutes How a successful practice can be in this area then they have no choice, but to see our value if we're there with them That second model establishing a comprehensive musculoskeletal practice many of you are part of practices like that Those are also very effective because we have shared decision-making Share cost center and we can look at the cost of care in our patients We can look at decisions that we're making together and look at outcomes patient reported outcomes So data is something we've all spoken about in depth But that's the best way to get data if we're working together to do it That third model is establishing a spine practice a standalone spine Sort of pain physiatric practice, you know helping the primary care doctors, but also giving surgeons the right surgeries to do They want to operate on patients that they'll have good outcomes And if we're able to give them give those to them, then they'll also be happy. So we'll be filling both ends there So who are these key decision makers who can help us so CMS has been mentioned earlier obviously that's a big part of the you know the payers And if we don't they don't know who we are We're not going to be successful. And so being part of those discussions I know we're a small specialty, but in a small specialty There's a lot of value to us working together many other groups can't do that because they don't have numbers Because they have too many numbers and two Disparate practices, but we can all do this sort of together and our Academy's done this They've been to meetings at CMS. We had a paper a spine paper Dr. Standard and all a white paper that came out that they published. So those are all advocating for our field In your own individual institutions hospital system leadership need to know who we are in musculoskeletal Medicine, it's not just the orthopedic surgeon or the primary care sports medicine doctor who's creating high-value care. They need to know that we're there Again primary care leadership in your own institutions should know who you are. I know the value you bring into their patients And then the big, you know players in orthopedic surgery Neurosurgery currently are really big players in the fee-for-service model, but I know being in a neurosurgery department They're a little worried about that in the future that we're gonna play a little bit more of a role You know that money that they would do on spine surgery Is gonna be cut so we have to play we're gonna play a bigger a larger role So we need to be there and advocating for ourselves there and then a high cost of care is the emergency room And so if we can show data on admissions decrease admissions How we're keeping people out of the hospital in these high value high cost Conditions like back pain for example, we're gonna have a large role to play So, how do we do this what are practical tips for doing this? So care pathways are one practical way of doing this. So establishing a care pathway in your system So we had a low back pain care pathway when UNC decided to go into the ACO pathway We create a low low back pain care pathway that the primary doctors Used and they know who to call like if they have an issue with a patient They're not able to take care of them. They call us and we're available to them We see them in clinic or we'll do a phone call, etc So being available in a model like that would be really helpful And give you some so really good points with them and then team management So this is something difficult to do in some instances and not in others But have the ancillary staff or the allied health staff be part of your team So physical therapists are a huge part of what I do, right? I can't take care of a patient without them seeing a physical therapist 100% of my patients pretty much physical therapist But if they're part of your cost center and your system and you can control costs and show value to what they're doing That's gonna be very very advantageous so not being separate but being part of it and lead lead obviously that that area and Then everyone's mentioned data and we talk about data all the time But it's really really really important in the small specialty like ours to have data outcome data cost savings data Because that's the only way we're gonna be able to negotiate. So on that Chris Thanks so much And delighted to bring to the podium Christopher McMullin who comes from us from the University of Washington He's going to be talking about musculoskeletal primary care and how they can align and add value All right, thanks so much and Thanks to the Academy for let me talk to you about this talk to you about my practice Which I think is really Neat system and hopefully something That I can share with you that shows how valuable we can be to our primary care colleagues So I'll just tell you a little bit about my practice and how it came to be so I'm at the University of Washington in our sports and spine division and Am a musculoskeletal physiatrist. I work in this clinic Pictured here. So I work in a primary care clinic very fortunate to Be able to work in this this place this clinic opened in the clinic, and then myself and my partner, Dr. Eric Chin, who's also a musculoskeletal physiatrist, work in this clinic. Between the two of us, we're there five days a week. And I just wanna emphasize that this is not a separate clinic space. I work next to the family medicine doctor, so we're at the same desk, our patients share the same rooms, we share the same medical assistants, they go to the same front desk, so I'm really embedded within that practice. How and why did this come to be? I think within our system, in the University of Washington, I'm very fortunate to have the providers that have been in our system for a long time, and PM&R has played a prominent role in our system for a long time. We have a system where when patients have a musculoskeletal concern, they're routed to a physiatrist in most cases, so we are kind of the front lines for those patients. And I thank Dr. Stan Herring, Dr. Stu Weinstein, who's here today, who helped kind of establish this system over time. But if you are gonna be kind of the front line for those musculoskeletal conditions, then you need to make sure you have access and that patients can see you. Patients don't wanna wait two months to get in to see you, they wanna be able to see you right away. And so if you're gonna be that front line of care, you wanna be providing that level of convenience and ease for your patients. So while we had established kind of this flow of patients at the University of Washington, we wanted to take that a step further and see can we kind of meet patients where they're coming into the system, which is at the primary care clinic. And so that is what we've done, and that's where we sort of got the idea to physically embed a physiatrist into that space. So how has that gone on over time and what's the value in that? Well, there's really been value to all of these key stakeholders. So the patients especially, I think, appreciate this system in their access to care. Amazon was talked about earlier. My office is surrounded by Amazon buildings. I'm in downtown Seattle. My patients are the software engineers that designed this system. So yes, they very much want access to their doctors. And the other thing about where we are located is my patients live and work and play downtown and they walk everywhere they go and they don't wanna drive to a center for their care. They wanna be able to access their care easily. So being in that community, my patients walk to clinic. They can get to me easily. They can see the same provider. They can go to the same clinic to the same provider they have already established with. They go to a front desk where they already know the receptionist. They have the same MA room them. So it's just a very familiar experience for the patient and just makes their life that much easier. For my primary care colleagues, I think there's a lot that we offer and a lot that we can offer. Musculoskeletal pathology is a huge percentage of what family care providers see as a presenting complaint. Back pain is number four. Arthritis is number six in sort of number, in the top 10 lists of diagnoses that come into a primary care provider. There's some estimates that over 50% of the presenting complaint to a primary care doctor is musculoskeletal. Patients have 15 minutes with their family med doctor if they're an established patient. Imagine that patient coming in with back pain, right? They have to, the primary care doctor has to get through their entire system, their medications, their primary care, and then the patient says they have back pain. And it really hurts and they need something to happen now, right? Having me available in clinic allows that family medicine provider to say, you know what, I don't have the time to see this right now, but Dr. McMullen works literally across the hall. We can get you in to see him quickly. He can spend a lot more time with you and you're not gonna have to wait. We even have built into our schedule same day appointments in some cases. So I will see people same day, at least within a few days or within a couple weeks. The primary care doctors I work with have expressed that with each of my consults, they feel like they maybe learn a little bit. So I am very connected to those providers. And when I see a condition, then I go back to them with that feedback. This is how I manage this condition. And over time, you can educate that sort of population of primary care doctors you work with. Cheaper and quicker diagnostic testing. So we have X-ray and ultrasound available on site. And this has a couple of advantages. I think ultrasound in particular, you know, I've had some of my family medicine colleagues ask me about a patient, you know, hey, I've been seeing this patient that has shoulder pain, it's been going on for six months. I think maybe they have a rotator cuff tear. Should I go ahead and order an MRI and send them to you? Or do you just want to see them? And I'll say, yeah, just send them over. I'll do an ultrasound. Maybe we don't need an MRI. And then I can treat their problem from there. Triage for urgent musculoskeletal concerns. So often a patient, you know, comes in urgently, they might have a fracture, an acute trauma. And my family medicine colleagues are often equipped to handle this to some degree. But where they often get lost is if they need a surgeon, who should see them? Is it the knee replacement surgeon? Is it trauma surgery? Is it, you know, shoulder and elbow? Is it sports surgery? And so often I can just help them triage, getting that person to the right place. And in some cases it can be me. You know, I can manage the non-operative urgent issues. For our surgeons, this was touched on earlier. Our surgeons want to see patients that they can operate on that are good candidates for surgery. We can help be sort of the funnel for those patients and make sure they're getting referrals that are appropriate. For the system, musculoskeletal injuries are often patients' first introduction into a health system. So I see young patients, you know, 24-year-old patient who maybe sprains an ankle, otherwise healthy, hasn't established with a PCP, and they see me. And at the end of the visit, it's, you know, I'll say, hey, I noticed you haven't, you don't have a primary care doctor. Why don't you stop by our front desk on your way out and establish with one of our providers? So we can bring patients into our system that way. So just briefly, again, the key decision makers here, so the PCPs, our physiatry group, orthopedic surgeons, the system administrators, these are the people who you want to collaborate with when we're making these decisions. And, you know, how do you position yourself with those decision makers? I think you emphasize these points, you know, what value that we can actually bring to the system, that we can optimize and streamline outpatient musculoskeletal care, and that we can keep patients in the system and bring patients into the system. Thank you. Great, thanks so much. Okay, I just want to remind everybody that if you want to ask a question, please type it into your app, those of you who are here, and as well as in person. First of all, I want to thank this tremendous panel. Thank you so much for great presentations and for sharing your practices with the folks here in the audience. I'm going to read off some questions. Some of them will be open-ended. I'll allow anyone to answer, or I may direct them to someone in particular. But the very first question is, how do we objectively show value if asked as individuals? You know, I will say, I'll just start off at NYU Langone Health. As chair, I am given a set of metrics that I am told to achieve, and those metrics are all value-based metrics. What they observe to expect a length of stay is not so much on my rehab unit, but of those on the acute care service who come to rehab, as well as other metrics, you know, mortality and hacks and the like. And that is just one way of showing value. But I would put that to the panel as well. It was us. It was physiatry. It was the rehab department. We put our physiatrists, we put our patients show the value, collect the data, money talks, but outcomes in terms of reduction of complications and length of stay, et cetera. Thank you so much for that. In a value-based system, how are we going to deal with physiatrists who are wasteful? I think, Dr. Chin, you mentioned that fraud and abuse is probably not a big factor in cost, if I heard you correctly. OK. Thank you so much. Are there other ways of adding value to throughput in acute care? Are there bedsides, identifying patients who could benefit from more PT, OT, thereby accelerating their DC home? Yeah, that's just one of the ways that we can do it. But identifying the functional limitations that our patients have early on and proceeding with treatment early is one of the best things that we can do. And it's the most unrecognized part of the work we do. Getting in the acute hospital, again, is based on the acute hospital needs. And that's why it's so important to help work on length of stay and throughput. Once we are there, we can certainly demonstrate all the value that our early interventions could have. And again, there's many, many examples that we could talk about. And I was also at that it's really the physiatrist who probably knows better, not probably, definitely knows better where this patient is going to best be treated in the long term, what level of care is going to be most appropriate. And that just really helps, not just the throughput, but really the overall cost of care going forward. Most of the recommendations seem to be from high-density programs. Any recommendations for providers in regions which don't have enough physiatrists and therapists for that full continuum of care. A couple more questions. Value equation, cost as a standard measure, dollars, how do you influence the outcome measures? Great. Thanks so much. One last question, unless someone types quickly. I'm going to interpret this just a little bit differently. There's a we talked a lot about on focusing on decreasing length of stay in acute care hospitals and rehab's role in that. How can we address the cost of care and efficiency in the entire health care system? I'll take on some of that. Dr. Whiteson mentioned in multiple hospitals where rehabilitation has gone into the intensive care units where we're actually, yes, getting people up and walking who are on ventilators. And we talked about how that increased throughput. What we didn't talk about is the cost savings in getting those patients out of the ICU quickly cuts other costs, radiology costs, medication costs. A lot of those patients who used to stay in the acute care hospital in the ICU for a longer period of time without that rehabilitation and physiatry input ultimately went to oftentimes an IRF-level care, subacute, or even long-term care. Our data shows that all of those decreased. That was not included in that $1.5 million that we saved. So lots of ways in which we can do that. I don't know if anybody else wants to add. OK. OK. We have some quick typers and two minutes and 16 seconds left. OK. How do patients with severe disabilities fit into the value-based framework? Obviously, there are ample opportunities for prevention of complications, spinal cord, brain injury. We know that. How do we advocate for investing in better outcomes and access for that? And we have, I think, time for one question, and I'm going to just focus on this one. While embedded with primary physicians, is the physiatrist care treated as a separate visit, that is essentially as a specialist referral? All right. And with that, I think we are, we want to stop exactly on time. We may have time afterwards if you want to come up, if folks are willing to stay. But I want to thank you all for coming to Baltimore, in particular, this presentation. I want to thank our virtual audience for joining us today. This will be available for those who are registered for several months to come. So many thanks. Advance PM&R bold. Be the local champions where you are. And again, thank you for coming to the Academy and the Annual Assembly. And have a good time, everybody.

physiatrists

value-based care

healthcare settings

fee-for-service

demonstrating value

acute care

skilled nursing facilities

primary care

musculoskeletal care

rehabilitation

care coordination