All right, welcome everybody to our presentation on new models of care and PM&R away from the hospital, closer to the home. I'm Michael Boninger. There will be two additional speakers, Natasha and Chris, who will introduce themselves. I am a professor at the University of Pittsburgh and UPMC Medical Center, and president of a new company at UPMC called Innovative Home Care Solutions, which I'll get to tell you a little bit more about as we go along in this talk. None of the speakers have any relevant disclosures related to the talk. And our objectives is really to talk about why you would wanna bring services out of the hospital and office into the community, to talk about the existing ways of doing that, what the future is likely to look like, will hospitals become obsolete, I think is a valid question. And where do health insurance companies stand? What are the models to pay for this going to be? So I always think it's great to start with a patient in mind. And in this case, I'm gonna do two patients just so that we can kind of compare and contrast as we go along, and maybe be able to carry this through the presentations today. So one patient is Tom. He's pictured there with his grandchild. He had a total hip replacement secondary to osteoarthritis from a football injury while in college. He works as a partner at a large law firm. And he is in the hospital after his total hip and recommended for home healthcare for wound and medication management, as well as primarily for ambulation training. Pictured on the left is Mary, who had a stroke after a large heart attack. That's been a part of multiple medical problems for her. She's been hospitalized four times in the past year, lives alone, but has a caring daughter. And the prescription for home health is surprisingly similar medical management, medication management specifically, and ambulation training. So the question is, what would a typical home health agency do with these two patients? How should these two patients be treated? What should the script say? And I think that all too often, what would likely happen is that these patients would be treated relatively similarly. The home health nurses are busy, and we'll talk about that. They'd come into the home. There'd probably be a nurse and a PT ordered because medical management is what's listed here. They would assess the patient, probably, maybe, depending on payer, determine how long they would, or how many sessions of home health they would have, and then specialize their PT program to an extent. But would other programs kick in? So what is the current state of home health, the way that we mostly deliver healthcare in a home environment? So it is highly regulated. It is regulated in ways that go way beyond what we all have to deal with as physicians, which is, does my patient qualify? And that tends to be related to your patient qualifying whether they're able to leave the home. And so that, the primary qualification has to do with whether they can go out for their therapies. And often, someone with a total knee replacement or a total hip replacement can't, as can someone who's had a stroke and has significant mobility needs. The other thing that is very important is that there's a significant burden of paperwork. So if you haven't looked at the OASIS form, I would encourage you to do that. It's 27 pages. And basically, and often, what a nurse does when they enroll a patient into home health is spend, you know, they actually bill an extra unit. So they're spending an hour at least just filling out the paperwork. There are a number of measures in there. And as part of, you know, recent changes in the past few years, there is measures of function across the home health, inpatient rehab, and outpatient space. The services offered are nursing and therapies. And of high relevance is the fact that every single home health agency is experiencing a severe nursing shortage. And I should tell you that if you looked at the objectives of our course, like will the hospital become obsolete? And when you think about COVID, these questions even become more significant. And we wrote those objectives before the COVID crisis hit. The severe nursing shortage has only gotten worse, right? There are people, you know, there's two things that are factored into that. One factor into that is that patients don't wanna go to the hospital and they don't wanna go to their doctor's office if they can afford it. So the doctor is more likely to order home health and our home health referrals after dipping during the height of COVID have now risen to highest levels ever. And the second thing is that our nurses are being exposed, having to quarantine. So we were short nurses beforehand and we are even shorter nurses now. The other thing is that right now, except for demonstration projects, quality is not incentivized. So there are star ratings and you can compare home health agencies online, but they are not tied to payment. The comparisons are important and many payers are looking at that and thinking about how to stratify that. And there are certainly insurance companies that are coming up with narrow networks, but that is not built into Medicare and therefore is not a widely practiced policy in terms of incentivizing payment. The other thing is that there are two payment models. There is a per visit payment model and a lump sum payment model. And it won't surprise you to hear that the way people use home health as a benefit actually differs depending on payer occasionally. If you get paid a lump sum, you're incentivized to do few visits with as high improvements as possible because they track into your star rating. If you're paid per visit, that incentive goes away. And that certainly can impact what home health is delivered. What has happened also during COVID is that telemedicine is now allowed. However, that rule is not a final adjudication. And so it's possible that in the future, telemedicine won't be part of what home health agencies will be able to deliver. Certainly they are now, and that also has changed the landscape for patients who need follow-up, maybe don't need someone in the home three times a week, but could use a touch base and allowing telemedicine is a huge and important gain for really for the field. So the question is, if you are a physician, discharging a patient, or for the sake of Chris's presentation later, you're a health plan, who should get home health? That the criteria of they can't leave the home is an easy one and it makes sense. The most expensive thing is to have a nurse get into a car, drive for a few hours, and then see a patient and drive back. And so if you have a highly concentrated region like Pittsburgh, maybe that's only 10 minutes. But if you're in rural Pennsylvania, there can be hours spent on windshield time. So, okay, that makes sense. But what about the patient who's really sick and you're worried about them coming back into the hospital? You know that they might be able to get to the doctor's office, but that doesn't mean they'll go. Should they get home health? And so I think that's a real question. Who should be the provider? Well, you saw my previous slide that nursing can provide home health care, as can PT and OT. I think what might surprise many of the people who are watching this is that PTs have the ability to do medication reconciliation, in addition to wound care, in addition to therapies. All too often, what's written on a home health prescription is nursing and physical therapy. So that's another one to consider. How long should that happen? Well, you know that we've got DRG payment. So hospitals are paid that lump sum, and then it goes from there. We need to think about in a home health environment what should happen and then what technology should be used. And certainly Natasha is gonna talk about that. And I'll touch on that a little bit during my presentation as well. So I wanted to orient you to the company that I am currently president of. I don't say currently, meaning I'm gonna be fired at any moment, but I will tell you that this is a relatively recent development in my career. The company's only been in existence for about nine months. And it's a company that actually crosses the spectrum between UPMC, which has the largest insurance product in Western Pennsylvania. And so it's insurance division and it's health services division. So it's doctors and hospitals. It's the only company that UPMC that does this. And the whole reason is to say, okay, in the community-based space, in home care, let's say we are both a payer and provider, which we are. And by the way, UPMC has the largest home health agency in the state of Pennsylvania as well. What should we be doing to innovate? If we think a patient needs to be seen in the home, even if they don't qualify for home health, maybe we should do that. The company has a board that is half insurance division and half from the provider division. And most importantly, its model is a cost-based model, which means that we are never meant to make a profit. The only thing we are meant to do is charge and provide high value services. As you can see, we have a couple of centers. One is the Home Care Referral and Resource Center. This is our intake. The place to spend most attention is looking at the Innovative Home Care Clinical Center. This is where we provide clinical care. And we'll delve into a few of these programs a little later in the talk. And then we have a special relationship with UPMC's home healthcare company. All of the funds flow through this company. So we are the risk taker or the cost structure, since what we're saying is we get reimbursed cost. And what that gives us is the freedom to innovate. And so we're able to ask those questions. And it's really that that gives the basis for some of the conversation about where things are gonna go in the future. And again, you'll hear more about other models for insurance payment and technologies that can be applied to this important problem. So I wanna tell you about just one project in a little bit of detail that we started on. And that was a project that we did with our orthopedic surgery service line here. So UPMC has strong service lines. And one of the things that we looked at is are people appropriately using nursing in a home healthcare environment? When the total joint replacement bundles came out, a lot of time was spent on where people were discharged. But if they were discharged just to home health, that was thought to be a win. So we shifted people from inpatient rehab into skilled and from skilled into home health and from home health into PT only, that was a huge win for UPMC. Again, impacted rehab. But the question then is once they're in home health, could we do more? And so what we said is let's look at a group of cases and we did a chart review and I'll go into that. The thought was, are there cases that only need PT? And this was then based on risk. And we'll talk about that a little bit. Then we specified the number of visits and we said, you know what? We're gonna pay the PTs to do a phone call follow-up if that's what they think would make them happy, that is obviously more efficient than doing an in-person visit. We then collected data on this whole project and compared it to a similar time last year. So now I know depending on the size of your screen, you might not be able to see this very well, but one of the great tools we have access to at UPMC is a real-time clinical analytics app. So almost everything you see on the screen I can click on and by clicking on it, it selects it and I can look at the outcome and look at other parameters. And so we looked at a very specific group. If you see in green here, it says orthopedic surgery. So we were able to look at this referring surgeon and then there is a risk prediction model that has been built by the clinical analytics team. That model is built purely on UPMC data for the past five years. And we can look at the lowest and lower risk populations and in doing so, we are then able to look at how long in our home health agency was their average length of stay, what percentage of people saw PT and OT and nursing and then do comparisons, which is how really we came up with the idea of saying, why are these patients seeing a nurse in the first place? So we did this study and basically, what we did is we had our liaisons in the hospital look at a patient that had home health ordered. And if home health order included, they were in a low risk category for readmissions as defined by our clinical analytics team. Our liaison would call up the ordering PA or physician and say, you know what, this person only needs PT. We're gonna put them on a special program. We don't believe they need nursing. And by the way, we think this is the right number of visits and this was all based on a chart review and work by the physical therapists in our home health agency who we said, what's the right number of visits? What's the right kind of care? What you can see is that just in a three month period of time, we reduced the average number of visits by two and a half and we reduced the percentage of people seeing skilled nursing by about 20%. And with this data, we also, I'm gonna go back for a second. We also looked at readmissions. There were less readmissions in the time period of our intervention. We looked at functional status changes and the functional status changes were the same. So just having a PT involved actually seemed to maybe slightly improve care and reduce the number of visits overall in home health. Over this three month period of time, that small change for a home health agency about our size was about $50,000 worth of cost savings. And it's estimated that throughout UPMC system, this is probably well over a million dollars worth of cost savings and kind of more importantly, it frees up a nurse who would otherwise be busy, who otherwise can then see a patient, like maybe the patient who we talked about who had a stroke, who has more medical complications, more problems and the nurse can have different conversations with the patients. Also could free up a nurse to see that patient who's discharged from the hospital, doesn't qualify for home health normally, and is concerned about the risk of readmission and think a nurse seeing the patient in the first day or two could prevent that from happening. Most of the literature says early nursing intervention in the home can prevent readmission to the hospital. So in this final slide, I just wanted to talk about some of the programs that are listed under the Innovative Home Care Solutions company that I'm involved with. And so, one of them is Advanced Illness Care. So all of these are programs that bring the care to the person in the community and try to keep them in the community, the theme of this. Advanced Illness Care is a palliative care program. So it's for people who are maybe not quite ready for hospice, but are saying they really don't wanna go back into the hospital. Our goal is to nurse them back to health, improve their function, or to help them transition to hospital and to have the goals of care conversations. You're gonna hear more about a hospital at home model from Natasha. We have a hospital at home model that we're actively working on. And really, for the right patient, do they need to be hospitalized? Making that decision after we say we're gonna admit the patient, we say, okay, you're a health plan member, you qualify for this program, would you rather go home where you can sleep, where you can eat the food that you like and not have constant bothers, and we can connect you using the technology that Natasha will talk about as well. We've also talked about for those people on advanced illness care, having a rapid response medical team, which is a set of parametrics that work for our company. And they are, and this is in place, they can go to the person's home. If the person has medical complaint and they're saying, I need to go to the ED, treat on the spot, connect with telemedicine technology on the spot and prevent an ED visit and a hospital admission. And you get the hospital doors, you save costs if you can keep someone home. Our connected care is remote monitoring, which you'll hear more about. We have 800 patients on connected care. It's asynchronous communication with the patient. We can text them, they can text us. And on a daily basis or every other day basis, it asks them how they're doing. It gets weights, vital signs. We stood up a COVID program in a matter of weeks in the early spring as a way of letting us discharge someone who we were worried about but did not want to keep in a hospital that we were worried about getting full. And optimizing home health like the orthopedic surgery project demonstrates. One of the points I would make is that physiatrists have a critical role in this, that function is the greatest predictor of a person's future status. And restoring function is the way that we focus these programs. Acute medical treatment, but what's been seen in the hospital at home models is actually that you need to have that second phase, which is the rehab phase. It's not just you're in the hospital at home and then you're discharged. It's in the hospital at home, then you're discharged to home health and you get the PT. Those are all part of a good hospital at home program. And so I think this is a great place for our field to be. I think it's the future for our field. And I think you'll hear from Chris and Natasha about unique roles we have in our health system here that enable us to impact that future. I appreciate your attention. I wish we could all be together. If you have questions about this presentation, feel free to email me. My email address is listed, but it's just my last name, boninger at upmc.edu. Thank you. Okay. So thank you, Mike, for kind of starting this conversation and I will start my part with a statement that I think that we all can agree on on this really turbulent times where there is very little we agree on actually is that there is no better place than home. And if you ask any of your patients, whether you see them in an acute care hospital, inpatient rehab, post-acute care, what is their goal? They will tell you uniformly, our goal is to go home. Now, many of the times, even though they tell us that, we cannot get them home right then and right now, but then we can pose a question, can we then move these settings of care that they need to be at, whether it's acute care hospital, inpatient rehab, or a skill level of care, can we move that to their home so that they can be home and we can achieve their goal? And in my mind, the answer is yes. The reason for that is because we are so fortunate to live in this 21st century, century of technology where there are so many innovations coming every day. And if we combine resources that we already have in our hospitals together with resources from home health services with all the smart healthcare technology, we certainly can develop something which is called hospital at home, inpatient rehab at home, or a skilled nursing facility at home. And the key part of it is the smart healthcare, which basically comprises of telemedicine or telehealth, wireless sensor networks, and internet of things technologies. Now, before COVID, at least in my vicinity and my colleagues used telehealth kind of communication with patient and telehealth very sporadically. And the reason for that not only was because it was really kind of best for certain types of patients. And we are just setting our ways to see patients with hands-on examination. It was also equally so because the reimbursement wasn't really clear on telemedicine or telehealth. Now, one of the good things of COVID, if we can say that there is good things about this, is that the emergency, there was some emergency policy changes from Medicare and followed by commercial insurers, which started reimbursing telemedicine or telehealth visits. So for that reason, now physician and other health professional are seeing 50 to 175 times more patients via telehealth than they did before the pandemic. But that also means that potentially these visits can account for 250 billion or about 20% of what Medicare, Medicaid and commercial insurer will spend on outpatient office visits and home health, which is impressive. Now, if you're still kind of reluctant whether you should use telemedicine or telehealth just because of the reimbursement part of it, then you have these resources of the AAPMNR, which are kind of give you really good resources about coding and billing and how to get reimbursed for your visit. Now, the thing that really kind of enable us to bring all the healthcare levels to our homes is really the technology. And there is something which is called the internet of things, which focuses on connection of devices, objects and things to each other, to internet and to its user. What that actually means, that by putting a wearable sensor on your patient, which is interconnected to wireless sensor network and then further interconnected into internet of things, you can basically completely monitor that patient in every aspect. We can monitor their physiologic functions, ECG, blood pressure, blood glucose, oxygen saturation. We can monitor their function, which is really important for us as physiatrists. We can detect any emergency, so we can be sure that they're safe, so we can do safety monitoring. And also we can do security monitoring, social and cognitive and sensory assistance, which is extremely important for like independent safe aging at home. Now, all these data can be aggregated, transmitted to the cloud, and we can analyze it further. Now, I just picked up some of devices which really fascinate me. And I think the most, the biggest innovation in medicine to my mind in the last 10 years is really in diabetic management. If you asked me, I don't know, even five years ago, if that would be possible to check your blood glucose without getting the blood or poke fingers and get blood work, I really, I could say yes, maybe in a science fiction movie. But today is really possible just by wearing either a sensor on your skin or implanted in your skin. And just by swiping the smart device over the sensor, you can figure out what your blood glucose level is, which is really fascinating. Now, the same you can do with the blood pressure just by swiping the smartphone over your wrist, you can see your blood pressure, you can see your heart rate, or by just wearing a smartwatch connected to your smartphone, you can figure your heart rate. And also you can kind of find out your heart rhythm, which is really crucial for patients, for instance, who are suffering from atrial fibrillation. All the smart home, and it's kind of like the basic part or basic piece of gerotechnology and aging at home. So smart homes, basically, we already have at home. What that means is you just plug into your phone and by your phone, you can unlock, lock your house, you can control your temperature, you can control your humidity, you can control whether you turn off onto your stove, you can control your kids if you want, you can monitor them, control whatever you want, which is kind of scary to a point from a privacy perspective, but can be very useful. So we can remotely monitor whoever we want to. And then in the healthcare aspect, other than this home automation of temperature lights, let's say you wake up in the middle of the night, had to go to the bathroom, the lights will go on automatically and stuff like that, which from a safety perspective are extremely important. We can also monitor wellness of our patients, which is extremely important in the concept of hospital at home or any type of healthcare providing at home. Now, these are some other kind of gadgets that really, again, fascinate me personally, which medication management is a huge thing. And if you look at these two devices, these are basically automated medication dispenser, which at a certain time, not only kind of alert you to medication, but the drug less, which is a. Now, what does that mean? That means that every patient can be given a different wearable device, whether it's an activity tracker, we all, a lot of us wear it like a Fitbit, inertial sensors, heart rate, blood pressure monitor sensors, glucose level meters. And then we can track patients parameters in real time. We can analyze them and store them on the cloud for later analysis. And based on the data we can give them or the program can give them personal suggestion how to improve their medical condition. Above all that, these devices can detect any life threatening conditions such as atrial fibrillation or like significant tachycardia and they can alert not only the patient, but more so they can alert us. So what really this internet of things mean for us as providers means that we can be, we can have timely information about our patient's health condition, whether they're in the hospital, whether they're at home, in the gym, in a restaurant, it doesn't really matter. We still get the information about their health situation. These data are then collected and they can be analyzed and used to identify the effectiveness of treatment, learn more about their illnesses and monitor the progress. Let's say we can monitor medication we're giving our patient through these devices. Now it all bring us back to the, to our beginning, which is hospital at home. Can we make a hospital at home other than when we play, to play hospital at home? Yes, we can because there are existing models which are named differently. There is hospital level of care at John Hopkins, Brigham and Women's Hospital in Boston, Mayo Clinic outside of US, of course. Then at Mount Sinai, it's called hospitalization at home and they also have rehabilitation at home. There is an advanced care at home model, Jacksonville, Florida and Wisconsin. In Tennessee, there is a Contessa home recovery model and multiple VA hospitals across the US have some type of hospital at home models. What does, who is eligible for this? Obviously, you know, not every patient would be a good candidate for hospital at home. You have to have a select condition, infections, exacerbation of asthma, heart failure, emphysema. Those are just the one that are already reported. Like in my mind, infection would be example, would be a person who had like a lower extremity cellulitis. They do not need to be in a hospital. They can stay at home and get IV antibiotics and wound care at home. So that would be a perfect example for a hospital at home patient. Oncology care. I think that hospice, home hospice is trailblazing and leading the way what you can do at home. And it's fantastic how good of a quality healthcare they can provide to their patients. And we should learn from them. Geriatrics care, which is gerotechnology, smart homes. Aging, everybody wants to age at home. Nobody wants to go to a nursing home. So this is really a way to go. Follow-up care after certain surgical procedure, whether it's total knees, total hips, that can all be done at hospital at home or just home. Some certain cases of MS, multiple sclerosis, Parkinson's. So those are just reported cases that they did well with this setting hospital at home. Now there are some criteria, of course. These patients have to have a stable residence, which is a no-brainer. They cannot be homeless shelter patient. And they have to need one person assist for mobility just because it's really hard to get more than one person to help at home. Now, how do existing models look like? What do they entail? So they entail at least one daily visit from a doctor or a mid-level provider. And this visit can be in person or telemedicine. At least two daily visits from a nurse. There is always an on-call service 24-7. In some programs, there is a service which is called recovery care coordinators 24-7 who are coordinating this whole level of care. If needed, home health aid, physical therapist, or social worker. We would kind of disagree if needed. It's needed. And we would add occupational therapy speech as needed. Vitals can be monitored via those sensors. I talked previously to the doctors and nurses' smartphones. All blood test imaging can be done at home. And again, we're talking about more simple imaging for like a CT, MRI. Obviously, patients would have to go out of their home. Pharmacy services, which means all medication management can be done at home, including IV medication, wound care, respiratory care, and even behavioral counseling. Now, what are the wins of this type of care? So what these reports are reporting, the results are very, very hopeful. Granted, we are talking about smaller sample of patients. So looking into these programs, they're reporting that they're having lower rates of 30 days hospital readmissions, lower rates of ED visits, shorter average length of stay, improved six month survival rate, and better functional outcomes. Also, which makes sense, the much smaller number of lab and other diagnostic tests are done within the home setting versus in the hospital setting. There are lower rates of delirium because there are lower rates of psychotropic medication used at home. And lower rates of restraints, if any, are used because, have in mind, we are dealing with the elderly population, which sometimes develop delirium just by being in a different setting, which is usually, of course, a hospital or the ICU. So we are kind of eliminating this risk factor of delirium. Majority or all patients, of course, slept better. They're sleeping in their own beds. They ate better. They're eating the food they like. And they move around more because they feel comfortable. They feel familiar with their home. Now from a business perspective, and Chris will touch much more on this, what's really kind of the positive side of this program is that hospitals were able to shift high acuity care patients from hospital to home much earlier, which saves a lot of money. And according to some of the reports, it can be like 19% to 38% lower health care costs than if these patients stayed in a hospital. And there is a better satisfaction rate of patient and family who underwent these programs. Now what are the kind of cons or negative side is that, of course, not all conditions can be treated at home. There are some high acuity patients that just need to be in a hospital, simply said. There is no sense about that, or in the ICU, unfortunately. And also, for now, there is no payment model in place for this reimbursement. Having said this, when I was looking into this different, for me, kind of a new world, I did find that there is, due to COVID-19, CMS expanded payments for care providers in patients' home, and that was from May 2020. And even kind of more recently, CMS announced $165 million addition to support home care to reduce the America overall reliance on nursing homes. Really, the trend is going away from any type of kind of facility, whether it's a hospital or a nursing home. It's kind of the trend is really to keep people home and get them home as soon as we can. Now there is a lot of unknown about this ideas, hospital of home, or inpatient rehab at home, or skilled nursing facility at home. First, what about the family caregivers? Is that a help to them, or is it a burden? In the hospital, they're just visitors. There is no hands-on help with their loved ones. Now at home, it's a different story. They would have to do a hands-on help with their loved ones. Now I think one of the biggest question is going to be, are we as physician going to buy into this idea? Are we so stuck in our own ways? You just sit in the car, go into the hospital, see 40 patients, that's it, sit back, go home? Or you want to drive around, or you want to do more telemedicine visits, or you want to see them in their office. I mean, that's something to be seen. I think we have to have a lot of mental flexibility to kind of process this idea. And then equally important is, is our leadership going to buy in? The question is, the three of us, we come from a really a big health system that owns, to my knowledge, 64 hospitals. Now think of it, if you take away majority of the patients, which are usually hospitalized and keep them at home, then what are you going to do with all these buildings and infrastructure and all the secondary auxiliary services there is kind of helping us keep patients in the hospital? I read this really interesting vision in one of the articles I came upon. And it says, how do you envision hospital in 2030? And I loved it. It says enormous ED with operating rooms and ICU rooms built on top. I mean, sounds like science fiction, but I think it's coming our way, like it or not. And so for the end, you may ask, so where are we? Like, where is physiatry? Where is PM&R in all this? I think if we add a PM&R physician to the existing model, whether in the capacity of a primary or consultant, whether through in-person visits, telemedicine visits, or a hybrid. And if we add home PTOT speech at a certain frequency, intensity of certain quality, I think we can have an inpatient rehab at home. Now you can kind of argue that we can do everything, except can we really provide quality rehabilitation at home? What about the equipment? Now I will finish this, my part with kind of idea that really, idea that kind of pushed me into talking about this topic and thinking. So my little mom go to preschool and they don't have a gym at their preschool, neither they have gymnastic classes. And so, because there are many preschools that don't have a gym or gymnastic classes, somebody thought like, oh, okay. So they made the gym bus, which they did. They took a regular bus, took out the seats, put in equipment, and that gym bus goes from preschool to preschool every day. So it provides gymnastics to the kids. So maybe we can bring high quality rehab to the homes of our patients, whether it's in a, you know, vision of a bus or whatever. So I think that we really have to start thinking outside the box instead of just thinking how to fill our beds in our inpatient rehab, which is extremely important. But I think that time is slowly going away. So with that, yeah, I would ask Chris to take on and kind of enlighten us what is the financial aspect and how really feasible these ideas are. Hi, I'm Chris Standard. I'm also at UPMC in the University of Pittsburgh. I work with Natasha and Mike. And my task here is to help understand, help us all understand how the payment structure works as we think through different ways of caring for our patients down the road and both what are our obligations and opportunities. It sort of goes both ways on us. I have no disclosures of any sort. So what we're going to talk about briefly is what is the problem? Like, why are we even in this boat of talking about different ways of doing things? And what is the solution? And if you think through the solution, how does that really play out in the real world, both from a payer perspective and from our perspective as rehab physicians? And are we a cost saver or a cost sink for people? And finally, what do we need to do as a profession, as providers to think about this differently? So this is the problem. We spend a lot of money in our country. So this is total health expenditures as percent of GDP comparing the U.S. to other westernized countries. And we clearly are way ahead of everybody else. We spend about twice as much per capita as every other country. And by 2020 this year, our health care expenditures hit 18% of our GDP, way more than everybody else. Our problem is we don't get a lot for this. So we spend a lot of money, but our health outcomes are poor, which leads us to a very poor rating in terms of medical efficiency. So Bloomberg ranked 56 countries across the world in terms of their health care efficiency, and the U.S. came out 54th. We are tied with Azerbaijan, and we're ahead only of Bulgaria. If you're curious, the top three in terms of medical efficiency are Hong Kong, Singapore, and Spain. If you go to our big payers, and particularly Medicare, this is what Medicare spends on health care every year. And it's gone up from 1990 to 2019. We're now at about $800 billion Medicare spent last year. That'll be even more this year. And just watch the steady climb up. This becomes unsustainable. And we know it's unsustainable. This number was just released by the Congressional Budget Office last month. They're recording this in October. But as of September 2020, the CBO estimates the Medical Hospital Insurance Trust Fund will be insolvent by 2024. That's the trust fund that pays for Medicare Part A. In 2017, they had predicted it would be insolvent in 2029, and it's dropped five years just in the last three. They estimate that Medicare will have to decrease its spending by 17% just to maintain solvency. And already at the moment, we're looking at CMS proposing a 10% cut across the board on health care payments, largely to actually allow for an increased payment in E&M RVUs, evaluation management RVUs. But people are getting upset about this cut, and we're looking at a much bigger cut coming because Medicare is going to run out of money. In the end, what we're doing is unsustainable. We spend way too much as a country, we waste way too much money, and we get far too little for it in terms of our health outcomes. So if you think through that, what is the solution? These are the solutions people talk about, and this is what you read and hear when you start talking about how we do it differently. We get into coordinated care delivery systems. We need to work together. We have a very fragmented health care delivery system. So coordinated care seems to be one of the big answers. You get into paying for value, not so much paying for volume, paying for how much you do or how intensely you do it, but paying based on the outcome of your care. Really shifting to evidence-based care, trying to do things that we have evidence for, right? You have to do what works, not just what you think works or what you've done before. The big thing we have to think about as providers is this focus. The payers really want to shift the risk from the payer to the provider. Currently, the way the system works in a fee-for-service world, which we'll talk about, is physicians bill, and they bill the payers, and the payers pay the bill, right? The risk on the payer is that they don't necessarily know how much health care people utilize and how much their bills will be, but they have to pay them all when they come, and that's where they are at risk. They want to shift that so we are at risk for what we do and what we bill, and they start paying us if it works. Theoretically, if they did this, that would increase our incentives to follow guidelines and enhance systemic efficiency and do things efficiently and ultimately to improve value, which is the goal, especially for people receiving care and paying for care. This is a busy slide. I'm going to go through each of these categories separately so you can see them. I put them all up as one. If you're watching this on a, obviously, you're on demand sort of setting watching this, you can slow down and read through it, but if you think about how you deliver care differently, there are basically four sort of categories of ways to do this and ways to pay for it. You have a fee-for-service category that's pure fee-for-service. You have a modified fee-for-service where you're linking fee-for-service to value. You have another structure where you're still in fee-for-service, but you're thinking about shared savings, and finally, you get out of it entirely, and you get a population-based payment. We're going to talk about what each one of those is. So the first is really straight fee-for-service. This is traditionally what we've done in the United States. Essentially, you bill for a service you do. The payment for that bill is typically tied to the RVUs, and there's an accepted rate for what you get paid, and when you bill for your service, you get paid for what you did, and that is straight-up fee-for-service, and the problem with this or the problem people propose with this is the incentives are wrong. You really just incentivize to do a lot, especially do a lot of things that pay a lot, and there's no incentive to do them well. There's no incentive to have good outcomes. There's no incentive to be efficient. There's just an incentive to do more. So to help correct this, the next shift came to sort of link to value. This goes back to our Medicare reporting programs, essentially, that they started using. It's called pay-for-performance, right? So rather than just saying, I'm going to pay you whatever you get, I will link a percentage of that to whether or not you do things I want you to do as a payer, like report quality metrics, so fall risk, complications of various sorts, use of health information technology, care coordination activity. So there's a bump sort of linked to the fee-for-service pay based on reporting of quality metrics, with a theory being that if you're doing all these, if you're meeting all these metrics and you're looking at falls and complications, that you will be providing better care. So they're just paying on the assumption that will happen. The third approach is really getting into a shared savings approach. This is a bit different now. This isn't, it's built off of fee-for-service, but you're looking at incentives tied to utilization of other specific or total services. So here, an ACO is a shared savings structure where the ACO agrees as a whole to say, we will spend less on this particular population for healthcare. We'll spend 10% less in terms of service and we'll bill you for 10% less, but we want half of what we save you. And you get paid for that savings. You can incentivize people not to send people to EDs. You can incentivize, you know, lower imaging rates. You can incentivize a bunch of different services. And basically in standard, most fee-for-service models now, the providers then have a positive incentive to do that. As they drop the utilization, they get a percentage of what is saved. You have to look at this importantly in this idea of one or two sided risk. One sided risk, which is the most appealing to most doctors, I think, is simply there's a potential to be paid extra if you meet the savings target. If you say you hit 10% below in terms of delivery of service of a particular service, you get a bonus, right? You get a 5% bonus or whatever it may be. And this is positive for payers. They like to see things go down, but they want us to do is get to two sided risk, right? This has two things. Not only can you make money for meeting your target, if you fail to meet your target, you pay a financial penalty. So you lose money, right? And this is a lot more unnerving for providers because you're really carrying the secondary risk of penalty. So if you don't meet your target, you don't meet your goal, you pay them back a penalty for failing to do that. We'll talk about why that's such an important thing to keep in mind. The fourth way to think about payment is to get out of fee-for-service altogether and start thinking about paying for population based care. So you can think of like a hip bundle, a bundle for hip replacement as sort of an episode based payment or a condition specific payment where you pay for a specific condition for a certain amount of time. And can you expand that from a hip replacement to say a stroke? You probably can. Can you make it for an MI? Can you make it for a CABG? You probably could if you thought through it, right? But what you're getting is a single payment to cover all the care for a condition based episode. And allows you to do a bit more of what Mike and Natasha were talking about. Sorry. The other option you have is you can get a comprehensive population based payment where rather than being paid for just a specific condition, you're being paid for the global health care of a population. This is something like a Medicare Advantage program where health insurers are paid a fixed amount to maintain and to care for patients under Medicare. But for their total health care, not just for their hip or their knee or their stroke or their back or whatever. If you take it one step farther, you get into integrated delivery and finance structures where essentially the insurance company then owns the hospital and owns the employees, the providers, the nurses, it owns everything. Theoretically, if the payer is the biller, is the hospital, is delivering the service, is paying the bills, you get a closed financial loop with all the incentives linked together. And that gives you a chance to be more efficient and again to think outside the box like Natasha was talking about. So how does this play out? You can think about it theoretically, but how do payers actually think about this and approach this? If you're curious about this, you can go look at this website for the Health Care Plan Learning and Action Network. This is a consortium of public and private health care leaders dedicated to providing thought leadership, strategic direction, and ongoing support to accelerate our health care system's adoption of alternative payment models. The groups involved in this organization represent payers that cover 80% of American lives. 226 million Americans are covered by the people who belong to this consortium. These are the people who control health care in our country. And the data comes from that same scope of patients across the country. So they do several things. They have a measurement of effort every couple of years. They look to see where is the money going. As of 2018, about 39% of U.S. health care dollars are going for straight fee-for-service. You bill, you get paid. About a quarter were tied to a pay-for-performance type program. Again, fee-for-service, but with quality metrics. And about 36% of health care dollars in 2018 were tied to those categories three and four, where either you have a shared savings and risk model, you have a bundled payment model, or you have a population model. And that actually increased fairly substantially from 23% just in 2015. It's a decent jump in three years. If you ask these same payers what they think will happen, what's going to happen with APM, the overwhelming majority think APM participation will increase. This is what they want to see happen. A small number think it will stay the same, and nobody thinks we are going backwards. So for those who think APMs are difficult, are daunting, are challenging, they're very comfortable with a fee-for-service model, they are uncomfortable with change, I don't think you have a lot of choice. It's going to change. This is a really interesting sort of concept that they have. So this is the stated goal of this organization, to accelerate the percentage of U.S. health care payments tied to quality and value through the adoption of two-sided risk APMs. This is what doctors are generally averse to. This is the type of alternative payment structure where you can make money if you meet the target they want you to meet, but you can lose money if you don't make it. But this is where they see the real change occurs. This is what they think will change provider behavior and improve the value of care. And if you look at the table, that is a chart of their goal, their aspiration. If we say in 2020 we are at 30% in Medicare, traditionally in Medicare Advantage, in two-sided risk, they want that to be 100% within five years. That is a very short time for a very radical change in our system in how we get paid. But that is what they are pushing for. So if you look at this a bit and you say, you know, where is the money in this? So fine, you will get a shared savings, you will do less care. Well, what care becomes less? What is overutilized? Where is the excess care you want to chop away to save money to get part of your savings, right? It is interesting when you look at this because rehab keeps coming up as that target. So Kevin Bozek, who is at the Dell Medical School now, wrote an article in 2013 looking at total joint bundles and where the opportunities for cost savings lay if you were to build a total joint bundle. And they found that 36% of the cost of a total joint at that time were from post-acute discharge, and there is high variability in how that was spent and in the rate of spending accrued. And that looked like a prime target for savings. And indeed, when you look at what happened, there is a review in 2017 of the effects of total joint bundles. And what were the effects of the bundles in the healthcare system? There is a reduced length of stay, there is a reduced rate in readmissions, and there is a reduction in admissions to inpatient rehab facilities. People are going home much more than they were in total joint bundles, which means they cut out a lot of the rehab component. If you look at ACOs in general, this is a review of ACO programs involved in the Medicare Shared Savings Program from 2017. And what is in quotes there is the very first sentence of the abstract. Post-acute care is thought to be a major source of wasteful spending. Participation in an ACO in the Medicare Shared Savings Program was associated with a reduction in post-acute spending, a reduction in discharges to facilities, meaning more people at home, and a reduction in skilled nursing facility length of stay. And the conclusion of the paper was that significant reductions in post-acute spending occurred without any clear deterioration in quality of care, meaning they were felt to be not essential or helpful. So what do we do as physiatrists? This is where it gets tricky for us, right? So we need to think in terms of system-based care. This is an advantage for us in some ways because we really are trained in this method all the way through. We work with other providers of various specialties and with PTs and OTs and all sorts of people. We need to start thinking about how to maximize value of care and think about care coordination, think about high versus low-value care. We need to think about how to keep our patients well after discharge. If you start saying that the money that we're spending that we may not need to be spending is occurring in the post-acute setting, the post- discharge setting, we're talking about rehab services, we're talking about readmissions, we're talking about ED admissions after discharge, by keeping patients well, you may be able to avoid a lot of those charges. We have to start maximizing the cost, sorry, the use of lower-cost sites of care. Does this mean home? That would seem to be the lowest-cost site if we could get there. And how do you get there? And then what is the incentive to get there? How do you get paid to get somebody there, right? To do this, we have to adapt, right? I think ultimately, kind of like Natasha was just saying, we cannot and will not be able to sit in our offices or our inpatient rehab units and bill and walk away and say, we took care of the patient, they get discharged, there's somebody else's problem, they're going to their PCP, they're following up with their surgeon, they're following up with their oncologist, whoever they're following up with. We can't just stay in our offices and say, we will do this, we'll do another injection, and we'll walk away. We have to become accountable for long-term outcomes in utilization. And in some ways, you have to think that, to think about extended care, we have to take responsibility for the care of a population over time. And we have to look at what happens to them after they get discharged, what their outcomes are, what care services they utilize, and can we both increase their health, increase their quality of life, increase their functional outcomes, and decrease use of expensive services and utilization. To do this, we really have to look at what works, what does not, and what people need, right? Everything we do does not work. Everything we do is not what our patients need, but we need to think about that very critically. We have to think about it irregardless of what the RVU's associated with it may be, and what the payment may be. Because ultimately, you're not going to be paid to do things to people, you'll be paid to ensure that they stay well. And that's a different way of looking at the patient. To accomplish this, we really have to leverage team-based care, we have to leverage technology, and we have to leverage data. As Mike said, there's a lot of data and analytics that go into this. Natasha talked a lot about various technology you may have to incorporate to do this. Team structure is good for rehab, and we have to get outside the box. You have to go back again and think critically, does this really help my patient? Do they really need this? Is there a better way to deliver this service? And can I then come up with a way to work with my payers or with my hospital system so I can be paid to do what really helps them and keep them well by recovering some of the money from things that don't help them so well. That's it. So thank you. That is my email there. If you have questions, it would be great to be talking to you all in person and taking your questions and hearing what your thoughts are and your experiences are. If you want to share any of that with me or want any more information, please feel free to contact me. Thank you very much.

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