All right, I think we'll go ahead and get started. Thanks so much for joining us this afternoon. Hopefully this mic sounds okay. So this is the session, Strategies for the Changing Quality Landscape. I hadn't pushed anything. Sorry about that. All right. All right, so I'm Cindy Moon. I'm with Heart Health Strategies. We provide consulting services to AAPMNR on regulatory federal matters. And I am also joined by this distinguished and esteemed panel. We have Dr. Carlo Malani, Dr. Chloe Slocum in the middle, and Dr. Joseph Shivers. And they're going to be participating in a panel discussion focused on their experiences around quality improvement and value-based care. But before that panel discussion, I'm going to be providing a brief presentation. I'm going to provide an overview of MACRA, the Medicare Access and CHIP Reauthorization Act of 2015, and the Quality Payment Program that came out of it. And then I'm also going to discuss some updates for the QPP for calendar year 2023 so folks have a high-level overview of what to expect in the new year. So starting with that overview of MACRA, MACRA was enacted in 2015 to reform the Medicare Physician Payment System. You might remember before MACRA, we had the Sustainable Growth Rate Formula in place. Sorry. And the Sustainable Growth Rate Formula, or SGR, essentially regularly called for double-digit payment decreases under the physician fee schedule, which Congress had to come in and make a last-minute fix to avert those payment reductions. So instead of sticking with that system, MACRA instead replaced that with specified annual updates that were put in law. So initially those updates were half a percent, and then starting with 2020 through 2025, the updates went down to zero percent. So not super exciting as far as updates to payment go, but they were seen as an improvement or a better alternative to the SGR. And they also provided for a period of payment stability because there were new incentives put into the system under MACRA, and this period was really kind of included to provide some time for those incentives to take root. And those incentives were incorporated through two separate tracks, which CMS kind of lumped together under one umbrella called the Quality Payment Program. So the first track of the QPP was the Merit-Based Incentive Payment System, or MIPS. Under this program, folks would get an upward or downward payment adjustment based on performance, and those adjustments were based on a composite score across the four categories listed here, quality, cost, promoting interoperability, and improvement activities. And performance in one year would affect payments two years later, so performance for 2023 will affect the payments in 2025. And then starting with 2026, folks in the MIPS track will get an annual payment update of .25 percent. Then we have the Advanced APM track, and that's for clinicians who significantly participate in certain types of APMs that have to be qualified. They have to have strong quality and cost incentives, including requiring two-sided risk. And CMS makes the designations on which APMs meet these criteria, and they're called Advanced APMs. So you have to participate in this Advanced APM, and then you also have to meet these significant participation thresholds based on either the percentage of your payments that go through the APM or the percentage of your patients. So folks in this track are called Qualifying APM Participants, or QPs. And for these folks, they are not required to report under MIPS, and instead they qualify to receive a 5 percent lump sum APM incentive payment, and that's for 2019... for the years 2019 through 2024. And similar to MIPS, that's based on performance two years earlier. So if you qualify based on your performance in 2017, then you would get the lump sum payment in 2019. Then starting in 2026, they have annual payment updates of .75 percent, and you can see that's higher than the payment updates under the MIPS track. That's because I think the intent of MACRA was to try to push more and more people into these Advanced Alternative Payment Models that have these strong incentives for value-based care. So now I'm just going to take a quick tangent away from the QPP to focus on the payment portion of MACRA. And the take-home here is that challenges with the Medicare Physician Fee Schedule conversion factor remain, even after MACRA. So even despite that promised period of payment stability, we're still seeing challenges with Medicare Physician payments. And that's first because payment updates that were included in MACRA are nominal, right, 0 percent to half a percent. And they also do not account for inflation otherwise. So there's no adjustment if costs are rising more quickly. And of course, in these recent years where we're seeing really skyrocketing levels of inflation, it's problematic. And then in addition, under the Physician Fee Schedule, there are budget neutrality requirements basically requiring that spending stay roughly the same, even after changes in RVUs. And in some cases that can lead to pretty significant decreases. And in particular, you guys all might remember in 2021, CMS made significant changes to coding and payment for office and outpatient E&M visits and because of those changes, they expected spending to go up under the fee schedule. So they had to take a corresponding budget neutrality adjustment. At the end of the day, they expected that that adjustment would have to reduce the conversion factor by 10.2 percent. So physicians were facing this 10.2 percent reduction and of course, you know, that was a problem. So Congress intervened. You know, it was in the middle of a pandemic as well. So Congress intervened and they cut that reduction. So it was only a 3.3 percent reduction instead of 10.2. But partly what Congress did is just kick the problem down the road and so we come to 2022 and now, you know, now physicians were facing a 3.7 percent reduction. Congress again intervened and then in 2023, again, you know, based on the physician fee schedule proposed rule that came out in the summer, CMS is estimating a change in the reduction in the conversion factor of 4.4 percent. That's the proposed rule. We're expecting the final rule at the beginning of November. That being said, you know, I don't... I haven't heard of any reason to expect that the reduction would be substantially different from what CMS originally estimated. So again, challenges remain. This is an issue, you know, we're seeing it become this annual cycle again and it's I think creating a lot of frustration among the physician stakeholder community. This is an area where there is a growing amount of advocacy around this including work to try to kind of effectuate more substantive, again, more substantive Medicare physician payment reform to provide more payment stability and more sustainable payments for the long-term. Alright. So going back, because this session is on quality, we're going back to the quality payment program and I wanted to just talk about the current status of the MIPS program. So we're looking at 2023. That's going to be the seventh performance year of the program. Statute did require that many elements of the program be transitioned in over time. So by this point in the program we are looking at many of those features fully implemented. So that includes like the category of weights. For the four categories they are now fully implemented at their current levels. Quality is 30 percent. Cost is 30 percent. Promoting interoperability is 25 percent and improvement activities is 15 percent and that's how those categories contribute to the final score. The maximum penalty is 9 percent and that is true and has been true for a couple of years now. So for folks who are supposed to report under MIPS but don't or for folks who are at the very bottom end of that distribution, their payments under the Medicare physician fee schedule will all be reduced by 9 percent. And then the last one I wanted to point out is that there is a transitional exceptional performance payment adjustment that Congress included in MACRA. It was $500 million a year for the first six years of the program. That is being eliminated now as it kind of expires and so that transitional, you know, adjustment for exceptional performance will no longer apply for performance in 2023. Despite these features being fully implemented there are still lots of changes that CMS is making on an annual basis through rulemaking. That includes things like changes to the program measures, changes to the list of improvement activities, changes to reporting requirements and the scoring rules and the goal there is I think to make the program a little bit more meaningful and also hopefully a little bit less burdensome. Sometimes those goals conflict with each other and I think, you know, as a result kind of the results have been mixed. And then finally, you know, a lot of what I've been talking about is 2023 as the performance year, but 2023 is also the payment year for performance in 2021 and what we're seeing here is that CMS has kind of done preliminary calculations on payment updates for 2023. For folks who score 100% under MIPS they are going to see an upward payment adjustment of just 2.33%. So folks who did everything right, got a perfect score, their maximum upward adjustment is 2.33% and that's... There are lots of reasons that are contributing to that, including because of the pandemic. A lot of people had, you know, exceptions and didn't have to report and so forth and so it's not necessarily that that will change, but that is where we are now and another kind of unfortunate piece of information is that almost all of that 2.33% is based on that exceptional performance adjustment which is going away. So it's not clear like what level of upward payment adjustments we're going to see now that that's gone. On the advanced APM track, just currently what's going on there, there is substantial participation in the Medicare Shared Savings Program. It had 11 million beneficiaries attributed at the start of 2022 and under that program 51% of ACOs are taking on enough risk to qualify as advanced APMs. CMS also operates a number of additional models that qualify. So there are other ACO models. There are also some bundled payment models like bundled payments for care improvement, advanced BPCIA, BPCIA, and also some primary care models that qualify as advanced APMs and with participation in all these advanced APMs, for 2023 CMS is estimating that between 145 to 186,000 eligible clinicians will qualify for the advanced APM track. That is less than 12% of all clinicians. That is also complicated. There are lots of reasons that are contributing to that including potentially not enough advanced APMs that are applicable to different specialties, but that's where we are and I think that's not necessarily where folks had hoped we would be at this point in the program. All right, now, so that was just basic background. Now turning to updates for 2023, there are some major changes to the program that are taking effect for 2023 including some that are based in statute. The first one is that discontinuation of the MIPS adjustments for exceptional performance that I already mentioned. This second one is also a big one. That 5% incentive payment that's available under the advanced APM track, that was only available for performance or for payment in 2019 through 2024 based on payment in 2017 through 2022. So now we're looking at performance in 2023. That 5% incentive payment is no longer available and I think folks are really concerned about that because groups have reported that that incentive has really been what's enabled practices and systems to make investments to kind of support the practice transformation that's needed to succeed under APMs and also without that incentive, I think there's also a question of, you know, are there going to be strong enough incentives to move into that advanced APM track, which is again where folks had wanted people to end up. And then another change is that in addition to smaller incentives to move into the advanced APM track, it's now going to be a little bit harder and that's because those significant participation thresholds that I mentioned that you have to meet, those are actually... at least one of those thresholds is going up for 2023 participation or performance. So it's going to be harder to achieve that QP status under changes that are included in law right now. All of these are areas of concern. This is another area that there's a lot of advocacy around to try to see if these incentives can stay in place or these changes don't take effect. Alright. So then in addition to those statutory changes, we also have the annual year-to-year regulatory updates that CMS makes. CMS again, they issued a proposed rule in the summer and based on what's in that proposed rule, it looks like many of the reporting requirements are going to largely remain unchanged relative to 2022. That means for the quality performance category, folks are still going to have to report on six measures in order to get full credit for that category including one outcome or high priority measure. One change that CMS is making for this year is that they are expanding the definition of high priority measure to include health equity measures. In the improvement activities performance category, folks are still going to have to report two to four improvement activities each conducted for 90 consecutive days and how many you have to report depends on whether it's a high or medium-weighted improvement activity and also whether there are any special accommodations that apply. For example, small practices have to report fewer improvement activities than other practices. And in the cost performance category, same thing. No change in reporting requirements. No reporting is required under this category because CMS calculates scores based on claims data that they analyze. In the promoting interoperability performance category we are seeing a few more substantive changes. I think the change that might be of most interest to this group is that CMS under the electronic prescribing objective, they are taking a measure query of PDMP that has been optional for several years and they are making or proposing to make that mandatory and they are also proposing to add Schedule IV drugs to this measure. They would assign it 10 points here if they make it mandatory as proposed. And then in addition under the health information exchange measure CMS is also proposing to offer an additional option for receiving credit under this category, that participation in the trusted exchange framework. And then under the public health and clinical data exchange objective they are also revising their definitions for levels of engagement. And then the last item you'll notice on the right hand column is just the change in the distribution of points across the objectives and measures and that's again to account for that query of PDMP measure and also CMS wanted to give more weight to the public health and clinical data exchange objective. So I understand that a lot of that might sound a little bit like gobbledygook and I raised it so that folks are aware that there are changes in this category, but I'm not going to go into more detail because that would take a lot of time and that's not, you know, we didn't want that to be the focus of this. I will note that AAPMNR will be holding a webinar after the final rule comes out. Once we know the final policies to provide more information about the specific changes in the MIPS program for 2023 and they'll also be posting information on the website. So please stay tuned for that. Again, this was just really to provide a high level overview. And then other things to look out for with respect to changes in MIPS for 2023, CMS is making a lot of changes in the inventories for the quality measures and improvement activities, lots of additions and deletions and measures and also lots of measures that have substantive changes. So the reason I bring that up is that if you're reporting under MIPS and you have measures that you've typically used for the last several years, you're just going to want to make sure that they're still in the inventory for 2023 after the final rule comes out. You're going to want to look at the measure specifications to make sure there aren't major changes in how those measures are calculated or the data is collected and so forth. It's just something to be in mind as you're thinking about your reporting strategy for 2023. And then the other change that I wanted to mention is that CMS until now from the start of the program has provided a three-point floor for any quality measure that has been reported and that was to kind of help with the transition into this new system. CMS is now removing the three-point floor for quality measures except small practices will still benefit from that floor in certain cases. So in the past measures with or without a benchmark or that didn't meet case minimum would all get at least three points. Now if you report a measure with a benchmark you can get a score anywhere along the 1 to 10 point continuum, but measures without a benchmark or measures that don't meet case minimums would receive a score of zero. And then the last thing I wanted to note on this slide is that there is no change to the performance threshold for 2023. The performance threshold is the point value at which it's like an inflection point between where you would have a negative payment adjustment or an upward payment adjustment. So at 75 points you get a neutral adjustment. That is not changing. So for 2022 and for 2023 you have to get at least 75 points to get a neutral adjustment and to avoid a negative payment adjustment. And then finally the last item that I wanted to talk about as a major change for 2023 is the availability of reporting under what are called MIPS value pathways or MVPs. Folks may have been hearing about this. This has been on the radar since the 2020 rulemaking cycle, but this is the first year that they're going to be available for reporting. These MVPs were designed by CMS in theory to be clinically cohesive sets of measures and activities centered around a specific specialty or clinical condition or procedure. So we have like an MVP on stroke or an MVP on lower extremity joint repair, for example. CMS has made the reporting requirements here a little bit less burdensome. So you only have to report on four quality measures instead of six. Although you will also be additionally assessed on one population health measure that you would have to select when you notify CMS that you want to report via an MVP. And that is a claims-based measure. So CMS will calculate that measure based on claims. In improvement activities you only have to attest to one to two improvement activities instead of two to four. So again, some reduction in burden. There's no reporting on cost, but you would only be scored on the measures that are included in the MVP. And then for the promoting interoperability performance category the requirements there would be consistent with the traditional MIPS program. So, similar, no reporting burden reduction there. Um, MVPs can be reported by an individual, by a group, by a subgroup, or an APM entity. Um, registration is required to let CMS know that you're planning to report on an MVP and which MVP you're going to be reporting under. Um, subgroup reporting is new. That has not been an option for MIPS reporting up until now. Um, CMS is actually stating or proposing that subgroup reporting, um, is voluntary for the time being, but that they will make subgroup reporting mandatory for multi-specialty groups, um, starting with 2026. So, that's an area that we're just going to be watching because there is some concern that that could be pretty burdensome if they require, um, all multi-specialty groups to kind of report for each individual subgroup that's a part of that group. Um, and then the last thing about MVPs that I was going to mention is that, um, while they are voluntary during this initial period, CMS has said that they do want to transition fully to MVPs over time. That's another area that we're going to have to watch. Right now, um, you know, there are definitely not enough MVPs that are available for specialists of all varieties to, um, report on. And so, um, I think there's going to be a lot of work for CMS in order to get to a point where, um, they're going to be able to require everyone to report on MVPs because they're going to have to be developing a ton of MVPs. I would imagine that they'd want folks to be able to report on. Here I've just listed the MVPs that we expect will be available for 2023. CMS finalized some of them in last year's rulemaking. They've also proposed a few additional ones. Many of these look like they are related to care that PM&R physicians provide. However, these, you know, I've heard from a PM&R staff that none of these MVPs are ones that are good candidates for PM&R physicians to report based on the specific measures that are included there. So MVPs, definitely something to keep on the radar, not something that I think is going to be relevant for PM&R specific reporting for the time being, but something we're going to be watching, you know, over time. And that's it for the updates for 2023. Now I'm going to move on to the panelist portion of this session and I'm really so thankful for our panelists here today who've agreed to participate. I'm going to just start by asking each of them to introduce themselves. Tell us a little bit about yourself, where you work, and the extent to which your programs engage in either MIPS or the alternative payment models or any other arrangements for care delivery. And we'll start with Dr. Shivers here. Hi, thanks. So I'm Joe Shivers. I am at the University of Pittsburgh Medical Center. And like most people in large academic medical centers, I don't really think a lot about MIPS. It's something that the kind of program, a practice manager kind of takes care of, and the medical assistants. Funny story about that is we had some staffing shortages at our main clinical office in our department. And the practice manager said on a faculty call, like, hey, you know, we're stretched a little bit thin. So we've got enough MAs to run the clinic, but all they're going to be able to do is room the patient and check those boxes and then do the meaningful use box checks. They can't tell you anything about the patient. We don't have time for that. They just can do the, all the sort of check boxy stuff and then you're sort of on your own, which I thought was a funny sort of set of priorities. I also work in an interdisciplinary program for people with back and neck issues that Dr. Chris Standard started and that I'm trying to help build out. And so I can speak a little bit to the way that we're thinking about quality within that program in the setting of UPMC, which is an integrated delivery and financing system, which means we have our own health insurance wing of the company. Awesome. Thanks. I'm Chloe Slocum. I am a spinal cord injury physician and I am here from Spalding, which is sort of under the umbrella of Mass General Brigham, which is also an integrated system. And we are the physicians at Spalding. The physiatry physicians are part of what's called the Mass General Physicians Organization, which has been participating in sort of one quality incentive program or another. We are currently part of the Advanced Medicare Shared Savings Program, ACO, under Mass General Brigham. And we, the physiatrist within the MGPO, i.e. those that work at Spalding, are what are called partially qualifying providers. And so we choose to report MIPS data at the TIN level. So not at the individual provider level, but at the organizational level. That's how our data is reported. And we have separate institutional and then department level quality programs that sort of predate MIPS. They grew out of the Meaningful Use Program and are sort of still hanging around in one form or another. But we have sort of modest performance incentives that are financial for physicians that are usually on a quarterly or an every six month basis where we'll have one metric that we're measured on that's physician specific or rather sort of everyone within the organization, whether they're physiatry or whether they're urology or rheumatology, has to complete. And this is usually related to something clinical or some training. And then there's a department specific level measure that's sometimes inpatient focused, sometimes outpatient focused, that engages the department and that's really led by the department that we're responsible for. And that is actually, interestingly, not formally aligned with MIPS and not reported to MIPS. But I think sometimes the organization wide level ones are aligned with the MIPS categories. Hi, I'm Carlo Malani. I'm a physiatrist practicing in New York. My focus is on spine and sports and electrodiagnostic medicine. I work at the Hospital for Special Surgery. I'll just call it HSS for short. And the way our department participates here is, you know, at the hospital there's a mix. There's a high number of employed physicians and surgeons. But then there's also some who are private practice and still work in an academic sort of role. So the hospital is an academic hospital, which means we train residents and fellows. Those who are employed primarily and take... Everybody takes Medicare for the most part. And so we participate through... We participate in MIPS at the tax ID number level, the TIN level. And so we have a set of measures that we all participate in and have decided, you know, sort of through the traditional MIPS route makes sense for our department that are tracked through each patient encounter. And actually we track them for all patients we see, whether or not they are part... Whether or not they're Medicare patients. This is because it reduces the burden on the back end for the hospital to try to figure out whether or not we're meeting the standards for participation. That way they don't have to try to parse it out. And so that's primarily how we're doing that. Back in 2014 our hospital created a value office and I think it was maybe back then HSS and MD Anderson who were starting to do some of this or maybe others. But fully sort of with this in mind to try to start participating in these programs, thinking about value, all that sort of thing. Because we're kind of a unique place in that, you know, it's a hospital all focused on orthopedic care. So we're a multidisciplinary hospital. We have specialties like neurology, primary care sports medicine, rheumatology and others. But it all focuses on orthopedic care. So we have... In terms of participating in MIPS there's going to be a lot that can be applied to all departments that are shared, but there are going to be some nuances. So it doesn't face all the challenges as some of the other organizations, but definitely a fair amount. Thanks so much. And I think you started kind of discussing some of this, but can you talk about how additional ways in which the MIPS or APM reporting requirements have affected your institutions and in particular if you, through your work there, have seen any specific steps that they've taken to really try to succeed under these programs? I don't know, Dr. Schreibers. Yeah, sure. I'll steal, we've done some preparatory conversations over the past few days of this, and I'll steal one of Dr. Malani's best lines, which is that people aren't really trying to win MIPS. It's mostly like you're trying not to get penalized. And so there's that line in office space about like the main character saying like you only work hard enough to not get fired depending on the management style. And that's sort of like, it seems like the sort of thing where if the maximum penalty is 9% and the maximum gain is 2%, that suggests that like the vast majority of people are hitting that quality threshold, and then there's a small collection of losers who are getting just shredded to fund the very small bonuses for a large number of people. And so I don't think that anybody's working too hard to like make sure they get 2.3% instead of 2.1% or whatever. It's more a matter of just checking all the boxes to get at least 75 out of 100 points is how I would imagine that PMC is thinking about this. Sure. I can just speak to how our, I think our organization, within an organization, they tend to like, it's a tradeoff. So because we're reporting everything at the tax ID number level or the TIN level, the average day-to-day physician doesn't hear a lot about MIPS, doesn't necessarily have to understand a ton about MIPS. The organization sort of takes that on, and then they try to incentivize good care and high-quality care in other ways through this program that sort of developed out of Meaningful Use. And so they, for instance, our emergency medicine colleagues had a whole presentation at their national meeting on sort of standardizing and making care uniform across their physician force. And so I think they don't want people thinking too hard about it if it's going to change their clinical behavior. They really want people to try to provide good-quality care no matter who the payer is and no matter what the incentive structure. And so they have these modest incentives, and I would say I think we get, you know, $2,500 is, you know, the one that has been sort of publicly shared in some of these presentations. For completing these, if we complete the full complement, and then we get part of that if we complete one but not, you know, maybe our department-specific measure, but then we forget to, you know, complete our organizational training. And so that's, I think that's how we're trying to engage folks because I think, especially with, you know, we implemented a new EMR, there's a lot people are juggling. And so I think there's also a difference between the qualifying providers and the partially qualifying providers. So I would expect that, for instance, our primary care colleagues and some of the other folks who are fully qualifying providers under the ACO know a little bit more about the metrics in granular detail. But as partially qualifying providers, we're somewhat removed from that. And so our main engagement with the ACO program and MIPS really is through our department and organizational quality incentive program. And those align somewhat. So, you know, just talking about those, we were incentivized to, for instance, complete trainings and monitor things that measure equity, patient access, patient engagement, care improvement through the EMR. So for different departments, this might be related to, you know, training on the PDMP or use of the PDMP. To track, you know, for instance, controlled prescriptions. Some of this might be related to equity and actually breaking down or stratifying outcomes data for a department or looking at use of, you know, patient portal and patient engagement in terms of access through the electronic medical record. And so those are things where, you know, I think that it varies quarter to quarter. But those are... There's sort of a, we don't call it a value office. I really like that term from Dr. Malani. But the quality incentive folks who have been around since like 2006, 2007, and have sort of taken on all of this as the name of the program has changed at CMS sort of continue to unroll different quality incentive things that they try to align with whatever the payment incentive program du jour is. Sure. Yeah. I didn't make up the name. They call it a value office, but whether or not it, you know... So whether or not we're really able to find value right now into the system is... I think that's why we're all here. But, you know, I think the question is, how did the reporting requirements affect the institution? I mean, they created a new C-suite position. They hired like two data scientists. They created a whole office dedicated towards justifying what we do, not just physiatrists, but in orthopedic care because they saw things like bundled payments for joint replacements affecting their surgeons or our surgeons and trying to figure out how they're going to demonstrate value going forward so that we're being proactive about this. In terms of, you know, APMs, other alternative payment models, I think, you know, we've reached out to primary care organizations trying to understand how we can best partner in, you know, a model like this and it's, you know, there's a lot of competing incentives for everybody and so I think there's been that challenge to actually try to formulate an alternative payment model with other organizations. In terms of, you know, reporting, I was kind of mentioning before that they've had to use a very blunt instrument of collecting data sort of from all patient encounters and making sure that we, you know... Well, I think we're going to talk about this in a moment, sort of our day-to-day and how this affects us, but making sure that they're collecting all the same data on, you know, all patients because it's very burdensome to report how well we're doing in, you know, with the quality measures. You know, I don't know that the expiration of the 5 percent incentive for APMs and that sort of thing really changes the approach. I think, you know, Joe mentioned before, I think our take on it is much more, you know, let's just avoid the penalty because it's really hard to probably get that incentive and who knows what's going to happen to it in the future anyway. So really just trying to report to make sure that we're avoiding those penalties. Just jumping off something you said. So it sounds like your organization has thought about developing APMs, but hasn't been able to do that and I think that it sounds like that's just...it's a pretty complicated and difficult undertaking. Yeah. So I think not having that 5 percent incentive... Even with the 5 percent incentive payment they were not able to do it. So I think that's an interesting observation. Yeah. That's exactly right and it's been, you know, and it's not for lack of trying. I've sat in on several meetings, you know, working with the primary care organizations and trying to make sure that we're providing value to them and that we can, you know, kind of have a mutual relationship where this alternative payment model can make sense, but it's just a complex issue and it's challenging to get these underway. And Dr. Slocum, have you heard any...or Scheibers, have you heard any feedback from your institutions about the 5 percent incentive payment going away and whether that's affected your institution's decision making at all? And the answer might be no, you haven't heard anything, but just curious if there's been anything on that front. We haven't heard anything. I think our organization is really focused on the shared savings ACO program. So MIPS is sort of secondary to that. I do know we like incentives, so we're definitely...we're not just trying to avoid the penalties. We like them. If it's on the table, we'd like to keep it. But I don't think day to day, you know, PM&R or the MIPS program is the primary goal with that. I think it's really the ACO incentives is what they're after. Um, I'll have probably more to say about the specific program I'm in a little bit later in the panel. I was just going to actually add, you know, the other thing is the MIPS value pathways. You know, our hospital is actively trying to figure out how to apply a MIPS value pathway to everything that we're doing, because theoretically, you know, that may ease some of the reporting obligations and also it helps standardize things amongst, you know, other participating organizations. But even that has been very challenging, trying to find examples in the community or partner with people to help create those. So...and it's a pretty arduous process, but yeah. Interesting. Thank you. So then I think you alluded to it a little bit. The next question was kind of looking at how do the quality reporting requirements and the performance incentives under MIPS or APMs affect your personal actions on a day-to-day basis? I mean, obviously, it's kind of changed how some institutions run their business. But in terms of how it affects the care that you deliver every day, can you talk a little bit about that? Yeah, I have a tangent for this. So I was telling Carlo earlier, I read a book about a year ago called Punished by Rewards. It's by this guy, Alfie Kohn, K-O-H-N. It came out like 25-plus years ago, but they've updated it. And so the premise of the book is that every time that anybody ever has tried to incentivize quality with any sort of external reward, it has never worked on a durable basis, like ever in any domain ever. And so there's this sort of quest in the world of incentivization and, you know, associated corporate departments and consultants and stuff and no shade to Harvard, that the body of evidence suggests that that doesn't work and that it inevitably compromises the intrinsic motivation, which is sort of like why we're all trying to do a good job for people. And then creates these sort of perverse incentives along the way, however cleverly you try to design the incentive scheme. And so that said, at UPMC, our department has gone. Historically, they did incentivize based on somehow some sort of compliance, sort of like filling out the training sort of things that they do, and they have moved away from that. We have a salary, and then there is an incentive kicker on top of that based on the volume of disproportionately new patients that we see, which I'm not going to hit because I'm still getting my practice off the ground. But within UPMC, we don't have like MIPS-specific clinician level thing. And the plug, it's an interesting book if you are curious to read it. Yeah, the new question was about how it affects our day-to-day. Yeah, that's right. OK. So I think, again, it's a little bit of a trade-off. I'm more of a policy wonk, and so I feel like I'm a little bit more tuned into this. But I have a great case control, which is my husband, who's in the same department, and it's not a policy wonk. And it doesn't touch his life very much with the MIPS tag attached. I think that there are certainly things that, if we were to speak at an organization level, they would probably want folks to see, which is that they do talk about the fact that the population health incentives, which is sort of what they call the ACO incentives, are reinvested into programs to help with certain clinical domains at the end of the day. Again, I think I can sort of logically make that jump. But my husband, who's no shade, he's a spine interventionist, but not a policy wonk, would not necessarily see that whole pathway. I think that in our quality incentive program, there are things that we do see that are more concrete. I think sort of the health stream trainings is sort of the less concrete thing, where you set the computer, you complete something, it says it's attached to your username, it says you've completed it. I think other things, there is a big push to get sort of everyone on the portal and electronic access, big push to get PDMP access for providers. Massachusetts is, probably no surprise to anybody, sort of a hyper-regulatory state. And so there's a lot of requirements that are usually coming at docs. We went to all electronic prescribing last year. And so everyone has to have a lot of authentication and a lot of requirements that the state is pushing. And then our Medicaid program is totally broken up into different ACOs. And so sort of at the state level, we hear a lot of the policy jargon. But I think in terms of people's clinical practice, I think the organization, honestly, is pretty satisfied if people engage in the quality incentive program and then just try to provide good clinical care. I think they're satisfied with that. And so it seems like a trade-off, but it's sort of a pragmatic one. So the question is, how does it affect how we deliver care? And I think what I'm about to say probably could be attributed to process issues or logistics that could be worked out. But I think the reality is that it's really hard to work them out. And when you apply a program like this on top of current logistics, it makes things really challenging. So I think it affects the conversations I have with patients, and it affects time. And I don't think it necessarily does it in a good way all the time. So I think it definitely takes a lot more for me to make sure I've met all the checkboxes. So like you said, the prescription drug monitoring programs, having to make sure anytime I'm wanting to prescribe a pre-procedural Ativan or anything like that, that I have to check everything, sign off that I've done it. This adds at least five minutes just to get out of the EHR that I'm in to try to go back and do it, copy and paste a reference number and make sure that I've done everything. And this is just something simple for somebody who has claustrophobia. This isn't related to really treatment or anything like that, but just to get a diagnostic test, like an MRI. In terms of meeting other metrics, so we had a list that we could choose from from the traditional MIPS pathway. We were able to kind of choose for ourselves and based on our department. So because we're all participating under the same tax ID number, our data is pooled. So we may have high performers or low performers within that, but hopefully we're averaging out to someplace good. And so we got to choose. And so for example, two of the measures are BMI and smoking status. So if somebody comes in for a trigger finger, I have to have a conversation. And again, this is applied to every patient, whether or not they're a Medicare patient or not. Because the hospital has a tough time discerning who's Medicare. So anyway, so I have to have a conversation about if this person's obese, are you ready to lose weight? Do you want me to provide you information about a nutritionist? Do you smoke? Okay, you do. Are you ready to quit smoking? And this is like, for them, irrelevant, right? And they came in for what they thought was gonna be a quick 15 minute visit. And so now we have to figure out how I'm gonna artfully weave this into the conversation, which I'm happy. I think there's an argument to be made from a lifestyle medicine standpoint or whatever, but perhaps that's a better conversation for their primary care physician. And because there is a limited number of metrics that we can use to participate in the traditional MIPS pathway, these are kind of the best ones we've got. I picked from the least bad. And so we have to figure out how to get all this done. So I think that, yeah, it can be challenging. It can add challenges. And I want to go back to that for a second, in a second. But I did also want to give you, Dr. Shivers, a little bit more opportunity to kind of talk about your program and a little bit about how, given that you're rather insulated from MIPS and so forth, what is your approach to quality management and quality improvement and value at UPMC? Sure, so I just finished up a fellowship that UPMC started under the leadership of Gwen Soa and Chris Standard in what they're calling value-based spine and musculoskeletal medicine. And the idea was to try to train somebody to work in this little fantasy land oasis that we've attempted to create. So the premise is Chris Standard was recruited from UW to UPMC several years ago with a goal of trying to help the UPMC folks redesign their spine MMSK pathways. And the concern for the insurance folks is that there's a lot of low-value care in that space. So value is quality over cost, right? So there's a lot of surgeries and injections and things that are done to people in excess without really noticeably improving their lives in any measurable way. And in Western Pennsylvania, that was an especially intense pattern for historical regional reasons. And so what Dr. Standard ended up creating was this interdisciplinary clinic they're calling the Program for Spine Health that was based on some other work they'd done at UPMC already, but it's sort of like a, it's similar to an interdisciplinary pain clinic that we had at the VA in Colorado when I was there as a resident. And so you see the doctor in our clinic, you don't see multiple providers on the same day. It's just sort of, we're in a network together and there's a close relationship. And so we can refer to really expert physical therapists. We have a nurse coordinator who's managing everything. We have a pain psychologist, we have a health coach and we have a nutritionist. And we all meet regularly with each other and have close relationships and sort of know how each other tend to think and practice. And so the financial model is that we bill just on a fee for service basis. We lose money because we have long patient visits and we have a pain psychologist and we have the health coach and the nutritionist don't take any co-pays at all. And we're backstopped by the insurance company because it seems like within this model, we dramatically decrease the amount of spine surgery compared to a comparator population. And so I don't wake up in the morning excited about like slightly reducing the number of spine surgeries in Western Pennsylvania, but I think that it's a pretty fulfilling environment. And the reason people seem to not be getting as many spine surgeries is that they seem to be sort of happier campers. And the idea is that you're, the sort of philosophical model is thinking of chronic painful spine and musculoskeletal conditions in the way that we think of things like brain injuries and spinal cord injuries, where we don't say like, oh, you have a spinal cord injury and it didn't get better with Botox. Well, like, sorry, go see anesthesia pain. We say like, oh, you have a spinal cord injury and it didn't get better with Botox. Let's think about other strategies that we can use towards the larger goal of promoting your function and independence and quality of life. And so we don't do a lot of interventions. We do order a fair bit of imaging. I don't know if anybody knows Dr. Standard, but I know some of you do in the audience, I guess. He's a really rigorous diagnostician. And so we really do try to figure out the answer. And we don't do like a lot of sort of like kumbaya and chanting and like aromatherapy or whatever. It's more trying to put the locus of control with the patient. So we don't really bill ourselves as like lifestyle medicine or wellness. We're trying to give people medical diagnoses and at the same time diminish over-medicalization and promote resilience. And so within that world, again, we're backed up by the insurance wing of UPMC. And so what they care about is, does it seem like we're saving money for the system? And so far we're at a pretty early stage. I think we've seen like 600 unique people so far in the few years that they're doing this. And so with the addition of me, we're like doubling the program because it's Dr. Standard and Karen Barr. And like both of them are sort of fractional people from the perspective of the program. And then I and Jim Eubanks is gonna come next year and we hired an APP named Angela Petrosky. So anyway, so we're growing the program and we'll see if it works or if it's just sort of a cult of personality around Dr. Standard, who's an amazing physician. Like, is this scalable? So anyway, so that's what the insurance company cares about is these sort of cost savings analyses. And then for our own quality metrics, we track PROMIS scores on everybody, essentially every time they come into the clinic. And so that's sort of how we try to tell if we're doing what we would consider to be a good job for these patients. Thanks. Yeah, thank you. And so I think that's interesting because that's a different way of approaching value and thinking about the quality of care that patients receive. And then we have this top-down approach that we have under MIPS and advanced payment, advanced APM track. So kind of taking it to out of level, I think the next question then is, what do you see as kind of, and I think I'm gonna merge the next two questions, but what do you see as kind of the pros and cons of a program like MIPS or the advanced APM track in terms of actually providing incentives to deliver high value care? And to the extent that it falls short, you know, what changes are needed to really kind of push that transition to where we all think it needs to be? Sure, I think one of the things, like an organization, I think meaningful metrics, and I think the MIPS value pathways is sort of a stab at this, but I think meaningful metrics that are specific, for instance, to specialties where there may be higher numbers of partially qualifying providers would be a step in the right direction. And I think that's partially why the MVPs have sort of developed. But that's really something we try to look at. At a broad organizational level, I think that's why we have the quality incentives that we do. They really do have something that tries to engage the department. And for instance, at our department level, nobody's totally removed unless you're there for, you know, like 12 months. They try to do inpatient metrics, outpatient metrics that are trying to, again, looking at care continuity, sometimes looking at, you know, patient safety, things like, you know, use of shared decision making that try to engage providers from across the department that may not be very engaged with formal quality programs. And I think the drawback of the programs as they're structured, specifically within sort of larger organizational contexts, I think is that providers can be somewhat insulated from this. And I can see that being, for instance, a risk if you change to a different setting. So if you get a new job at a different state, obviously, you know, if you've been insulated and you don't know anything about the quality programs and you're expected to sort of jump in with both feet and learn everything about a new quality system, I think that's part of the risk of sort of remaining somewhat sheltered from MIPS or from the APM logic. I mean, I think some of the pros of a program like MIPS kind of come to light when you think about the theoretical goals of a MIPS value pathway. Finding measures that are most meaningful to those in practice in specific specialties that can be developed by themselves or those who practice similarly. And then that sort of thing can be sort of rubber stamped and made available to all who participate in Medicare. That seems to be an efficient way to try to get at, you know, developing quality metrics. You mentioned MIPS here, but then you think about the other parts of the program like APMs and those, you know, the goal of these programs is clear, to try to get people to work together, cut costs, reduce variability, because that's where a lot of, you know, the cost comes from, standardized, you know, good quality care. But I think the cons develop when you think about how they're being implemented and what happens in the meantime. You know, it's hard to get people to go along with the program unless they're gonna feel some pain if they don't. But I think here the, it's all stick and no carrot, it feels like, you know, and that isn't always the best to motivate or, I mean, I guess it can be motivating, but when you talk about actually trying to develop good quality, which is part of the value equation, right, quality over cost, then I think that you don't necessarily get that. So I think that's a con. I think it's much more heavily weighted towards the cost portion of that equation. And when you just cut the cost, like sure, you get a little bit more value for it, but are you getting better outcomes overall? I don't know. So I think that's one of the bigger drawbacks. And then as far as kind of changes that are needed to really move to more of a value-based system, do you have any thoughts on that too? Sorry, say it again. Change, the changes that are needed, you know, to the extent that MIPS falls short, what changes are needed to kind of, you know, really kind of push towards a more value-based system of care? I could go on for a long time, I'll try to keep it short. I mean, I think it, what changes? So it changes just specifically in the program. I mean, I think one of the issues stems from, and I think we talked about this in an earlier talk, is the budget neutrality portion of Medicare. That's written in by law. So, you know, when you talk about incentives or penalties, it really does feel like robbing Peter to pay Paul. So, you know, everything, all of the resources that are gained from penalties, theoretically some of that can go to the incentives, but, you know, that's one of the bigger things. I think some of the bigger changes might be, you know, an even longer timeline for changes to these penalties and incentives, trying to help facilitate organizations to come to the table. I mean, I know you can't, you know, you can't spoon feed people or organizations, but I think it really can be very challenging because of all the different incentives to get everybody's goals aligned, you know, from different specialties to state societies, hospitals, you know, to get everybody on the same page. And I know the goal of the program is to try to get this to happen organically, but, you know, then you got a lot of people teaming up, and I think that if there could be more facilitation, then that might be helpful too, along with, you know, again, just a longer timeline to try to get some of this done. I think there's always a problem when the people at the front line sort of don't know what's going on or why you're doing it. And I think part of that is the programs, even though the bill does pay for performance programs, it seems like a lot of them are still sort of stuck in the pay for reporting phase. So they're sort of paying people to report and generating a lot of data. But as Dr. Malani said, it doesn't necessarily make sense to a patient or provide it organically about why you're asking a specific question during a visit if it seems sort of clinically uncoupled. And I think until we get to the point where there's agreement about, you know, what the performance measure should be. I know we, especially in physiatry and in post-acute care, we're very interested in access to care, you know, and how we can measure that. But I think that a lot of the MIPS program measures are meaningful at maybe a primary care level, but they haven't made as much headway in terms of, again, just, you know, passing the common sense test for the specialties. And so I think the registries, I think, is one way that that sort of has grown. But still, I think at sort of a program level, I think more can be done systematically by CMS to engage folks and understand individual performance. So like, you know, if a patient's looking at a provider or something like that, you know, being able to see what their outcome generally was or the performance generally was would be helpful. So I think transparency and then just more meaningful metrics. Yeah, all great thoughts. I would add there have been a couple of recent kind of prominent articles that have talked about how these programs are not only robbing Peter to pay Paul, but they're robbing rural primary care solo practices to pay for urban academic centers that have the departments to comply with all of this regulatory burden. And so these sort of value-based programs are kind of inherently exacerbating existing inequities, seems to be the way that they go. The rich get richer and the poor get poorer because the poor can't afford all of the steps that are required to comply. It's sort of like the No Child Left Behind Act. My parents are both in education, so we talk about these things a lot. That's sort of like the, I don't know if you're familiar, but it's basically like if you're a high-performing school, then you get more money. So like the rich suburban schools where they have like invested parents, a lot of like high property tax evaluations and whatever, like win all the bonuses and then the poor underperforming schools get like punished. So that's like, that'll teach them to do better. Like take that Detroit or whatever. So I think that's a problem. I think that to Dr. Slocum's point, not only is it a problem that the physicians on the front line don't understand this, but I can't imagine that as a patient with a spinal cord injury in Boston, you're going to like choose Dr. Slocum because she has like a higher percentage of like asking people about whether they smoke or not. You're going to see her, you know, based on like some actual representation of like her real value. And so it's sort of worse from that. And then the other, I don't know, I guess another place where I think, you know, I can't imagine how we get there, but like nowhere in here is like, did you get the right diagnosis? Right. Like you'd think at some level, like what you care about in a doctor is like, are they like doing their basic functions? Like, are they accurately giving a diagnosis and prognosis? And there's no way for like somebody without a medical degree to like review your chart and figure that out. And so that can't ever be on the table in terms of this sort of quality reporting. And so I think that we historically have not done a good job as physicians or like humans of like policing ourselves and like doing the right thing always. But I also think that defining quality is going to be tricky to do really, really well at the national level, even if we have a lot of input into it. Thank you so much. So we're, I want to make sure we have a little bit of time for questions. So I'm going to just ask that you answer this last question as quickly as possible. What advice do you have for your fellow physiatrists here in the audience who are navigating, you know, the changing quality landscape? So I'll just start with something and I will try to keep it brief. So, you know, this is, this sounds pretty depressing and it feels like a lot of doom and gloom. But I think the biggest thing here is the call to action from everybody. That's what I take away from it. I wear a couple other hats with AAPMNR. So I'm on the delegation to the AMA of the House of Delegates, which sets internal policy for the AMA. And I also am an advisor to the RUC. And these are ways, you know, that I choose to participate. Not everybody can do the same thing, but I think, you know, Medicare sometimes, CMS sometimes seems, you know, and we interact with CMS through these avenues. So Medicare sometimes seems to respond only to outrage or, you know, outcry from a large vocal group. And we had a couple of policy talks from some of the other people in the room this morning. And so I think it's really critical for the academy, but also the members to know how to do it. I mean, the academy knows how, but I think it's also very critical that we help, you know, we start educating everybody on how to do it. And so I think it's really critical for the academy to start educating everybody how to do this at a very grassroots level. We can say, you know, go talk to your legislators, but some, you know, most people don't even know where to begin with that. So I think, you know, if people want to know how to do this, if departments want to know how to do this and they don't, then I think talking to the academy and saying, hey, look, there's a demand for this sort of training at a broader level, then I think that's a really good place to start too. Because I think the academy wants to do this. It's just sort of, you know, trying to figure out how. I think just for the clinicians, I would say it's just like a start simple conversations around, you know, with your practice manager, with your department chair, you know, how is my value being measured? You know, how do I contribute value that's, you know, not just like a productivity statistic? And then asking about, you know, how that fits in the larger context within your region, within your state, you know, and asking how that gets measured. I sit on a quality measure alignment task force in the state and we talk about things and sometimes people aren't even aware that, you know, certain metrics exist for capturing disability data. And so I think asking the questions with curiosity and humility and then realizing that you may be able to be a voice of particular expertise in certain areas of why physiatric care is of really high value to providers or administrators or legislators who are not as familiar with the care that we provide in rehab. Yes, I think to build on what Dr. Silcom just said, you know, there's a New York Times article recently about how doctors don't want to see patients with disabilities in general when they are talking honestly behind closed doors. And so, you know, capturing not only those indices of socioeconomic deprivation in terms of, you know, justifying resource utilization, but also as you're saying, sort of capturing disability and making sure that policymakers are understanding that that is a difficult thing to undertake. And then, you know, I think that also building on what Dr. Silcom said, like sort of trying to understand where you're adding value and where in your day you were, like, conscious of, like, not adding value and you're just sort of, like, doing the thing because you have to, like, fudge it so that you can fill the bed on the inpatient rehab unit going into the weekend. Like, be attentive. The sort of, like, David Foster Wallace, like, the what is water? Like, think about, like, oh, like, this could be better if, like, somebody mentioned earlier, like, if you prescribe a personal trainer to people, like, oh, that'd be great. Like, you can't do that tomorrow, but, like, that'd be nice if you could do that someday. So, yeah, what does ideal look like and what are the barriers in the way? Great. Thank you. Thank you so much. And I think we have a question from the audience. Quick question. Thanks so much to all the panelists. It's really helpful. I was just wondering, do you see any pathway to having someone with a medical degree at the table policing? Because I think it's very clear that the reason we're in this quagmire is because ultimately the only person that can accurately judge a physician's performance is another physician. It really comes down to that. I mean, I know we, I know that a lot of these governing bodies try to pretend that's otherwise, but it really isn't. And I was just wondering if you see any way that some of these regulatory decisions can be made by physicians? I mean, I personally know some of the physicians that work with CMMI, the Center for Medicare and Medicaid Innovation, and I know that they're, you know, they're wonderful people and their heads and their hearts might be in the right place, but they, you know, they don't have time to study every specialty exhaustively. And so they just are not really aware, even when they talk about post-acute care, like what that looks like and what all the different parts of the landscape are. So it'd be like me talking about, you know, Idaho. Like I have family in Illinois, but like, you know, I could tell you a couple of places in Illinois, but like, I could tell you about the state, Idaho, but no offense to anyone from Idaho, but you know, the, you know, I can't tell you in detail about that. And so I think, again, approaching it from a place of curiosity and humility and realizing that even physicians, you know, and I, again, my husband's a spine interventionist. I actually had a dream about the other night that I was doing spine injections and I asked him for help and he said, no, that would be unethical. And I thought to myself, this is a dream. I'm not credentialed to do this. But you know, it's something similar to that where it's like, even if we have a physician, it still may not be the perfect solution. But I think that certainly a physician would be more equipped to listen to our appeal and to approach that from a rational standpoint. And I was going to say, you know, you're not alone. So, you know, one of the biggest ways to elevate your voice and have a seat at the table is to participate in state organizations, state medical societies, the AMA, you know, I think there's historically been controversy about the AMA that exists till today, but they really are, we really are in it for physicians and patients. And so elevating, you know, your message through policy, bringing it to House of Delegates in, again, your state, your state medical societies and specialty societies like the AAPMNR, telling people what you're experiencing and what you want to see done about it, that's really the biggest, that's really some of the fastest ways to get your voice amplified and have a seat at the table because everybody's trying to work at this. We're not the only organization doing it. There's other specialties that have the same problems. And so the more we can work together on that, that's why I was saying before, like, you know, letters to CMS where 20 state societies sign on or all 50 or, you know, 20 specialty societies say, hey, look, this is a problem and it's going to be a problem for access to care. I mean, they pay attention to that. You know, I was sort of tongue in cheek with outrage, but when people sound the alarm, they kind of take notice a little bit. I think to your question about, certainly there are MDs in the room who are making the decisions and designing MIPS and all this sort of thing and they're doing their best. I think to your point about only a doctor can really judge the performance of another doctor, there's sort of, you know, only a general contractor can judge the performance of another general contractor. Only a, you know, virtuoso violinist is really going to be able to hear how good the other person is. There's a level of expertise, but that happens at sort of the individual level and it's hard to scale. And so I think at some level that those sorts of conversations about, like, did I get this right and how can I do better are better located within a facility and, you know, based on a peer or a mentor relationship and sort of having the case discussion. Like, wow, I feel like I kind of missed it. Like, I really thought it was this and then it turned, you know, I did the treatment and they didn't get better. Like, what would you have done in this situation? And, you know, you review the case together. I think that's how, I think that's how quality improvement at, like, being a doctor at its core, I think that's sort of how that happens. But, you know, more broadly, certainly what Dr. Maloney and what Dr. Slocum said. Great. I'm Rich Zorowitz. I'm the chair of the Innovative Payments and Practice Models Committee. And thank you very, very much. This really ties, we tried to, we advertised this morning to try to get you to get people over here. But I, you know, and if you haven't heard and if you weren't with us this morning, please go back and when it's available, please listen to the session this morning, because there's a lot to, you know, to get there. There are things that the Academy has been doing. Principles of APMs, for example, we have a whole document that is out there. So if you're interested in APMs, see from our perspective what needs to be on that APM. We're putting together toolkits for, again, not models, but a toolkit, some basis if you're looking for things like for spine care and for stroke rehabilitation. So I think it's really important, you know, to start getting that idea of what's going on there. So the Academy really is working very hard. I think from what you've said too, you know, when CMMI, anything that's open, you know, we are trying to respond. And if you see that stuff, respond to it. It's, you know, it's very, and actually let the Academy know that you're responding to it, because it's better in the kinds of numbers. I think in terms, it's interesting because I could probably give a whole lecture myself for everything you guys have talked about. But, you know, I think some basic issues that I think that come up are, and I think Cindy really, I think spelled this out, but I want to reiterate it, is sort of the outcome measures business of what's going on. That's something we really have to come up with ourselves. It's a really difficult thing. On the inpatient side, probably a little bit easier because it's sort of getting from point A to point B and either the patient goes home or they go to another facility. I mean, there's some basic things you can talk about. On the outpatient side, a lot harder. I mean, even with spine care, I mean, the question is, and this is always things that bug me, you know, to the nth degree and have been bugging me for 30 years plus, is what do you really use as an outcomes measure? You know, quality of life, okay, is nice. But, you know, if the patient wants to go gardening or if the patient wants to go back to work or, you know, how do you really, really, really, really measure that kind of thing? And I think even what's harder is for somebody like myself, you know, doing neuro rehab, dealing with people with chronic conditions, how do you measure that too? I mean, just keeping them on an even keel is, you know, it's another whole issue, but is that, you know, how do you make that, it's value, but how do you make that value? So that's, you know, that's kind of some of the things that we have to think about there. The other thing from the policy side, and I'm sort of glad that Chloe brought that up, Maryland, by the way, as you may or may not be aware, Maryland is the only state in the country that has Medicare waiver. We have Medicare, we have the, it's the Health Services Cost Review Commission that runs everything in the state. And it's really interesting, because I actually practice in DC, although I worked at Hopkins prior, so I've lived some of this. But it's really interesting, because you brought up some of the issues of, like, PDMP. Here's a really nice, interesting thing. We've been really proactive with that. We actually incorporated that. We use Cerner, we have it as part of the system. It used to be we had to sort of, you know, interface with it, but we now have it part of our provider view. So it's right there, so you don't have to go anywhere else to find it. So if you haven't, talk to your, talk to Epic, talk to Cerner about getting that kind of stuff in there, so you have it right there. So it makes it much easier to click through. You know, I think otherwise, you know, some of the other things, yeah, I totally agree. I mean, when you're looking at BMI, you're looking at smoking. Okay, well, I mean, for me, you know, who deals with stroke, yeah, I mean, I think that's actually pretty appropriate. If you're dealing with a trigger finger, obviously, maybe not so much. But again, I think it's just going to be a matter of, you know, of talking about, you know, what really is pertinent to you and really having to come up for ourselves and try to figure out what those outcome measures are going to look like. I'm sorry, it's not a question. It's really just more of a comment. Thank you so much. And we're actually at 3.30. If folks are willing to bear with us for this last question, that would be great. This is also for you as well, Cindy. So I think choice is going to matter. Some of the measures are really difficult to justify during a visit and what I'm wondering is, we've had some recent issues. We... Our organization allowed us to pick some. The problem is, with the full list, our EMR did not have the ability to turn some of them on and I wanted to ask the panel as well as you, Cindy, do you see that often in terms of what is allowed out there and are they able to turn that on easily? Is it a limitation? Because that goes back to choice. So, you know, we shouldn't be asking about hemoglobin A1c, but two that we picked were depression and falls because those are quicker, easier and to go back to others, we have the MA do the initial screening and the physician only does it if it's appropriate or necessary, but it contributes to the larger sort of goal of the organization, ACO. We're a track one upside risk only. Yeah, I would say that that's sort of exactly how we do it. To Dr. Malani's point and to Dr. Zawid's, we have PDMP as something that they've measured before, but we have... It's embedded into Epic and so it's two clicks with us. It's much less cumbersome than like me having to go to a separate platform and log in and do second factor authentication. Certainly, I think within our workflows, we have ones that are collected sometimes. Again, they're collected by the MAs and they're really only flagged if there's something that is sort of out of the ordinary for us. Within the state task force that I'm on, it's something we're sensitive to because we have a lot of required metrics that honestly get captured mostly in primary care. They're not even PM&R, but it's, you know, whenever we talk about adding a measure, we're always sensitive to that because we don't want the primary care physicians to be responsible for collecting a telephone book of data, which essentially they are sort of every year on people at their annual visits. Our workflows, they're coordinated to usually be collected sort of at the point of somebody either coming in the door. Some clinics are really tech savvy and have been able to do it on iPad, sort of again linked to an Epic questionnaire. But, you know, the clinic I practice at, it's like pen and paper and it gets entered later. Yeah. Yeah, and it's not an issue that I've heard a lot about. I imagine that that's, I know this doesn't sound helpful, but it might be like a contract issue with the EHR vendor to see what the capabilities are and how you can hold the EHR vendor accountable to some performance metrics. And then, you know, there are also other vendors that you could potentially also explore like QCDRs or registries that might also be able to help support a kind of more targeted measure reporting strategy. So I'm not sure that that's super helpful, but... No, it's just again asking, you know, and choice. Do you guys have choice? Will you have choice in terms of those metrics and how you contribute towards the greater, right? There's yours as a department, but the real goal is going to be once we're all collectively in an ACO and every care, once it becomes capitation, then it doesn't matter your department. It's just the full attribution of the entire organization. Sure. I think we, again, built into our incentive program, I think the organization as itself doesn't want the physicians to rebel or be unhappy or leave, you know, and so they try to build in choice as much as possible. And I think that the extent to that filter, it doesn't filter down to the individual physician getting to choose which metrics they do, but I think it filters down to certain things they expect of everybody. Certain things are department specific and within the department, I think our department realizes that there are different metrics that will be valid for inpatient versus outpatient providers. And then within outpatient, specifically, there are things that may be relevant only to, for instance, proceduralists or people from specific service lines that, you know, others may not be, you know, for... I wouldn't expect you to be collecting neurogenic bowel and bladder data on, you know, sports medicine cohort, but, you know, that there's, again, it needs to make clinical sense. Yeah, we have the same thing. We had the initial list whittled down and then from that list we could choose for our individual practices what we wanted to cover. Thank you. Great. Thank you so much and thanks to the panelists again for all their insights and willingness to share with us.

quality incentive programs

MIPS

APMs

healthcare delivery

penalties

organizational level incentives

value office

data scientists

reporting requirements

physician input

policy decisions

high-value care