All right, so we like to try to start on time. It's 1.45. Thanks everybody who's here for coming and everybody online who may be streaming or who might watch later on. So welcome to our afternoon session. This program is focused on understanding and demonstrating your worth. Our session's title today is what is the value of physiatry in health care? So the idea for this program was born out of conversations that I've had with colleagues in leadership positions who struggle from time to time to succinctly and clearly define the value of our specialty and what it brings to their hospitals, institutions, and group practices. So this can be a problem when trying to support efforts to grow a department or build academic and patient programs or in other instances that may ultimately affect how we practice or deliver care as physiatrists. So today we're in for a real treat as we've brought together four giants in our field to discuss with us today their real-world examples of successes and failures in demonstrating value to their various health systems and institutions that they've worked for or worked with throughout their illustrious careers. So I'm just going to introduce myself. I'll go through some of the learning objectives today and then I'll introduce our panel. My name is Carla Malani. I'm a attending physiatrist at the Hospital for Special Surgery in New York where I help train our fellows and residents from Weill Cornell in sports and spine medicine. To give some background, my own practice focuses on a blend of traditional sports and spine medicine and electrodiagnostic medicine primarily focused on brachial plexus and peripheral nerve injuries. I'm an advisor for the APM&R to the AMA's Relative Value Update Committee otherwise known as the RUC and I'm also on the APM&R's delegation to the AMA House of Delegates. I'll be the session director for this program and I'm very fortunate to have our highly esteemed panel who I'll introduce in just a moment. I'm kind of still pinching myself they all agreed to take time out of their busy schedule to be here so we'll give them a warm welcome. I've had the good fortune of learning from all four of them either in training or as a young attending working side-by-side. The learning objectives for today are to describe the most common definitions of value-based health care, understand the challenges of delivering value-based care in a U.S. in our U.S. health care system, discuss current models of physiatric value-based care with colleagues and institutions after this talk, and to better communicate the value of physiatric care to colleagues and institutions. So I'll first introduce Dr. Chris Standard. He's the Director of Spine Health at University of Pittsburgh Medical Center. He is he's he created the value-based spine fellowship in spine and musculoskeletal medicine and works extensively on health policy issues at the state and national levels as well as for multiple professional medical societies and hospital systems. Next, Dr. Heekyung Kim. She is a pediatric physiatrist and specializes in pediatric physiatry and brain injury medicine. She founded the pediatric physiatry department at Columbia University Medical Center. She is also a member of the World Health Organization helping to deliver rehabilitation interventions for people with cerebral palsy. She is the chair of the global academic physiatry subcommittee of the AAP, and she is also the distinguished, the Kimberly-Clark distinguished chair in mobility research at UT Southwestern. Next, we have Dr. Heidi Prather, who is currently at the Hospital for Special Surgery, but before that in her in her former life. She was the vice chair of the Department of Orthopedic Surgery and a founder and division chief of physical medicine and rehabilitation at Washington University St. Louis. Currently, she is at the Hospital for Special Surgery and is the clinical co-director of the Comprehensive Osteoarthritis Center and the medical director for shared savings in musculoskeletal collaborations. She's also a former president of the North American Spine Society and a founding senior editor of the Journal of American Academy of Physical Medicine Rehabilitation, the Purple Journal. And then last but not least, Dr. Joel Press, who is the Aaron Krantz chair of physiatry at the Hospital for Special Surgery. He founded and directed the Spine and Sports Rehabilitation Centers at Rehabilitation Institute of Chicago, which is now Shirley Ryan Ability Lab. He has done many things over his career, some of which include being the past president of AAPMNR and also a past president of the North American Spine Society. And just to kind of give some perspective, this is sort of the list of talks that everybody here on this panel is doing over the course of our meeting, so we do appreciate the time they've taken out of their busy schedules. So just to kick us off, I'll kind of take us through this little value equation and we'll look briefly at this. You know, typically when people think of or define value in health care, we think about looking at a desired outcome over the cost of, over the cost needed to achieve that outcome. But the problem is in health care, this equation can get complicated quickly. We often think of, you know, these sorts of things when we try to think about outcomes. Are we talking about outcomes in terms of quality, patient experience? Are we talking short-term or long-term? Are we talking patient-reported outcomes or objective measures? How do we factor in risk? How do we factor in process measures? How do we attribute the outcomes to the appropriate people? And oh yeah, does a health care worker experience count as an outcome? In terms of cost, you know, we think of monetary, but we think of administrative costs, costs to the individuals and societies. We think about indirect, indirect costs, complications, how do those factor in, again, short and long-term, and again, attributing costs to whom. So these are some of the challenges that can come when you start to actually nail down what is value in health care. And hopefully today we're going to hear from the real-world experiences of our of our panel members, some of the successes that they've had in their own projects and endeavors, and then also hopefully learn from some of the failures. And then at the end of the session, we'll have time hopefully for questions that people can ask that pertain, you know, maybe to our own situations back in our communities. So without further ado, we will start with Dr. Chris Standard, who I think may go into a little bit more depth about some of these questions and talk to us about his value-based buying program at UPMC. Thanks, Carlo. I appreciate being up here with all these people. So this is a complicated topic, right, this idea of value. I've been wrestling with this for about 20 years or so. I stumbled into a Medicare committee in early 2000s that was sort of really looking at what value-based care would be or could be as Medicare started thinking about this. I'd never heard the word before 2002, and so I've been stumbling through it for 20 years trying to understand this and what you do with it. And I think the tricky thing, like, that's not so easy for this idea of outcome over cost, right? So improving value should be improving outcomes for less money, right? That gets to be fairly simple math. But whose outcomes and whose money gets a lot more complicated. And we start thinking about value as our field, like we talk about what is the value of a podiatrist? Is that in this equation? Well, that's in this equation or not. And I hear people say we're going to build this thing and track ourselves or we're going to prove our value, right? And what does that really mean, right? And so I think you have to think through sort of what you're trying to do, what population you may be thinking about. You really have to think about the system you're in. Part of achieving value is to make things better, right? You're trying to make your patients better, you're trying to make the people around you better, you're trying to make your surgical colleagues better, you're trying to make your PTs better, you're trying to make your care system better, your payers, but you're trying to help the whole system essentially. That's the only way this really works, right? Everybody's sort of got to get better, right? And so, you know, for my particular example at UPMC, UPMC is an interesting entity. It's a twenty-seven billion dollar a year company. They own 40 hospitals in there in five countries. It's enormous. And they are, they started as a traditional fee for service, right? Bought up hospitals, hospitals made money, they made money, and then they started an insurance company. And the insurance company self-insures of their hospitals. And what they figured out is by about 2015, the insurance company, which is about 35% of their population, made more money than all the hospitals put together. And they went, wait a second, like, we can make more money as an insurer, as a collaborative insurer, than we can as like a bunch of hospitals cranking out volume, right? And they, and so our institution sits on the precipice of this volume versus value thing, right? We're about 60-40 now, 60 percent of our patient volume is not UPMC, 40 percent is, right? And how do you wrestle with this? And in this, they were wrestling with this, and they're going, what do we, how do we balance this? And then we are still struggling here. And, you know, they, I went there, if you look at value and say, how do you start to capture value? Well, you got to look at a place where the value equation is off, like where there's an opportunity, right? The bigger your opportunity, the better chance you have to actually capture it, capture it, and measure it, and demonstrate it, right? If you're trying to make a very marginal improvement in something, it's really hard to capture that, much less get any enthusiasm to do it. So if you track national data, for God knows what reason, back and neck pain are the most expensive health conditions in the United States, which I just find mind-boggling, right? That as a country, we spend more on those two problems than everything else we treat, right? Cancer, heart disease, forget these things, right? Like back pain, right? It's crazy. And we know there's wild differentiation in what we do, and wild disparities in what we do, and frankly, most of what we do doesn't really work and probably hurts people, right, is the truth of it all. And so in there is opportunity, right? You can then say, okay, we can improve this. So the question becomes, how do you do that, right? How do you start to say, we'll just make this better? Well, we'll just operate less. Well, that doesn't really work, right? You have surgeons who are operating, and what else are they going to do, right? And you have people who want surgery, so what else are they going to do, right? And one thing I realized when I got to UPMC is you think about, if you think about spine care, there's largely this paradigm in spine of, you can operate, you can maybe inject something, you can send people to PT writ large, whatever the hell that is, right? And you can Medicaid people if all else fails. Central sanitization, we'll just give them Civalta, right? That becomes our paradigm. And so in that, something is missing, right? And my realization after going to UPMC and seeing that was that what they were doing as a system was they were chasing pain, right, all the time. They weren't chasing health, right? We're chasing the wrong outcome. This goes back to Carlos' outcome thing. What is our outcome? Is our outcome short-term reduction in pain? Probably not, right? I tell people all the time, I can make your pain go away, I'll give you so many opiates, your pain will be gone, you may not be breathing, but you won't hurt. So what good does that do anybody, right? Doesn't do you any good, so I'm not gonna go there, right? So that's not our goal. And so we shift our whole thoughts around, we should be chasing health, not pain, right? We're gonna change how we think about this. And then you start looking at it and saying, how do you get there? And what I realized they didn't have was they didn't have a conceptual model of how to do this is where physiatry starts coming into place, right? In that paradigm of these four things of surgeries and shots and pills and, you know, PT, right? There's something missing, right? The missing is sort of the reinvention of the person, it's actually sort of the rehabilitation, it's actually the restructure your care around their life sort of thing, which they didn't really have and they didn't really have this conceptual model of it. And so we had to start building this idea that you could do something different. We created a third door for people and that took a lot of convincing, right? We then had to find sort of where are we going to do this? Our third door really becomes sort of what we do, which is like we take people and we really try to understand them, we understand their outcomes and their goals, we understand their anatomy and their problems and their biology and their medical conditions and we try to put them together to optimize their functional outcome in their life, right? And we built a comprehensive team which would be familiar to people in physiatry of, you know, spine specific physiatrists with spine specific PTs who are dedicated to us with pain psychologists and a dietician and a health coach and dedicated nursing. And actually remember my first, when I finally got approval to get it, my first conversation with my nurse was how are we going to answer the phone, right? What language are we going to use? How are we going to do this? Language becomes important. But we built this sort of third space of you can do this, you can take people who are complicated and do this and then you had to find like who's this going to be? What are we talking about? I said you have to sort of start picking your population. You then look at like what are the gaps in your care? What are the gaps in your model? Where is, where are the problems? Where are the people going places they shouldn't be going? Where are the people falling in the holes? In our situation, we decided to look at our population. We did an in-depth study of one of our hospitals in the catchment area. So what the hell's happening with back pain? And the care really was terrible, right? We found out that within six months of these people, we took people who came in, they'd never have been seen for their back for a year. Within six months, half got an opiate, half got an x-ray, and 7% went to a PT. And at the end of three years, 25% of them were still being seen regularly for their back when they hadn't been seen. And we went, this is a disaster. That was my gap, right? That became my argument, my moral sort of argument. I was actually talking to Gail Jill's wife a second ago saying like I go to UMC, I have no authority, right? I don't have a budget. I don't have a dollar. I don't have anything, right? So for those of you sitting out thinking, well somebody gave you keys to a castle to do something. I don't have any keys. I don't have anything. The only thing I have really is moral authority, right? It's like this is the right thing to do. And so in this, what happens is the outcome of the patient starts becoming the goal. And when you start saying our patient outcomes are poor, we're not doing the right thing. The care is terrible. Half our patients should not be on opiates. Everybody understands this. The payers understand this because a lot of them are medical, right? All the surgeons understand this. Everybody understood this. They went, that's awful. I actually remember putting the data up at a meeting and one of our spine surgeons looked at me and went, that's terrible. And he looked at me and said, you have to fix this, right? And I was like, oh, okay. It's Friday. I'll see what I can do. And so as we did this, it was interesting. I'll go back to the physiology piece for one second because we were having this, I got there and we were having this process at UPMC. They're trying to revamp spine because it was too expensive for them. They're an outlier. They want to be a leader. They want to start drawing in like private payers. They were in the 95th percentile of our spine surgical rates. No payers sending anybody to them, right? Just not happening. And so they started this structure. So we're going to fix this. We're going to put like the PTs in charge of the intake. We're going to have anesthesia deal with sort of the pain side. We're going to have the surgeons deal with the surgical side. And what happened is the PT said, everybody who comes in back then should see a PT because we should see all of them. And anesthesia said, anybody who's going to go to a surgeon needs to see anesthesia before they go to surgery because we'd rather inject them and keep them away from surgery. And every surgeon said, no, everybody should come to surgery so we can figure out who needs to see us and get surgery. And I went and I met all these people and I sat down with Gwendolyn in my chair one day and I said, this is a mess. It's a mess. And I said, we're the only ones who can fix it, meaning she and I. And she was like, why is that? I said, as a physiatry, we're the only ones who know what everybody else does. My job is to know what the surgeon does, the PT does, the psychologist does, the OT does, the ER doc does, the primary care doc does, what the payer wants, what... I knew whatever he wanted. Rheumatology, pain, I know what they all do. That's my job. And puts me in the middle of it. And since that's what I do, I can then sort of organize the whole system. And so we built this entire structure then to start thinking about putting physiatry very central in this, organizing the whole system, helping a lot with where people go, this sort of concierge or traffic cop or quarterback sort of role, however you want to think about that in your head, right? And navigating the whole system. And so we rebuilt... we built a whole model around this care. And when we went back to our target, I said, you have to go somewhere where you can make a difference, right? There's no point in us building a model to care for everybody with back pain. Because a lot of people with back pain really don't need us. They don't need me. They don't need Heidi. They don't need Joel. Most people don't need us, right? They can get better. Some people really do, though. And you have to find the ones who do, right? So we went after that. We had these 25% of people, we call them spinners. We went after the spinners in the system. So we have to capture them and get them and keep them from spinning. And once they're spinning, we need to stop them. And that became our target. Because when you go to this model, they're really expensive. Those spinners are 80% of the cost, right? So if you can capture that 80% and you can reduce cost by 20%, like millions and millions of dollars is what you start achieving. So we built a model we thought through the conceptual nature of it, and then we've studied our population, we found our target, and that's what we went for. And then we had to start, I had this challenge now, and I still have this challenge of, okay, does it work? Like, what does that mean? Does it work? Right? Like, is it better? How do you measure better? These are all measurements, right? You have to measure something for everything here. So how do I measure better? And we've measured everything. We've measured, we measure patient outcomes. So I heard numbers about, like, the registry outcomes. We have promise data we get. We have promise data on 85% of people who come in, and we have promise data on 59% of our patients three months out. Which is sort of astounding and sort of, the patient report outcome sort of collection rates. So we know how our patients do when they do well. We track it all. But then we started tracking finances. So we're the payer. So we know everything. I know everything that happens to every patient I see. I know every bill they get for everything. So we can track everything. We track surgical rates and ED rates. We track opiate use. We know how many pills they get. We know the number of opiate pills they are prescribed. Right? We know all of those. So we track all of that. Right? And maybe that was enough. But then we started thinking, well, how else do you demonstrate value? Right? We started looking at our money, and we looked at where did they spend their money before we started? Or where did a comparator spend their money? Are they spending their money on EDs and surgeons? Are they spending it on PTs and us? Right? PM&R. We shifted the cost structure. When you start thinking about, then you got to get into like, when you think about cost, you have to get into your economic situation, right? So my economic situation is a self-paid sort of structure, right? So if I can lower costs within my self-paid structure, I'm improving it. If I can shift the cost within my structure, I'm improving it. And if I can keep costs within UPMC, so meaning that when we did this first study, about two thirds of the dollars spent on spine care were spent within UPMC hospitals, on UPMC patients. I mean, 40% wasn't. In our program, 92% or whatever is spent within UPMC. We pull the money back in. All these things become important to the people who sort of run the system. If you run a different system, you have to understand your economic system when you start thinking about your outcomes, right? Your cost outcomes and your patient outcomes, because they vary. And so, you know, if you think about value, you start thinking you can capture this in other ways, too. Like, you start changing things. You start, you can, this idea that you can make everybody else better, right? If I make my surgeons better, what does that mean? What it means is I take these patients, these patients see my surgeons, they go, uh-uh, go see Chris. Right? They're done. They see them once, they're gone. Right? They look at them and they say, I could operate, but I don't really want to operate. I don't think this is going to go very well. If you come back three times, I'm going to operate, so we're going to get you out of here. Since they see me, they don't go back. They don't get the surgery. That's where the surgeries start getting saved, I think, actually, is all these elective optional sorts of things. But then that surgeon now has probably five more follow-up visits they wouldn't have had if they hadn't given that patient to me, right? Plus one bad surgery they didn't do, right? And that starts freeing them up. And then you sort of expand your PT capacity. Then you sort of free up your primary care docs. And then you, again, you start making everybody around you better. And one of the very critical things, this whole thing, is that you have to understand the economic system. You have to understand the ecosystem of the patients you're caring for. And frankly, you have to be better than everybody else, right? Like, I have to know what everybody else... I have to be better than everybody else. I have to know when that patient needs a surgeon and what they're going to do. I have to know when they need a rheumatologist and what they're going to do. I have to know when they need an MRI and when they don't. I have to know when a shot will work and when it won't, right? The best I can. I have to know all of that. You have to be better. And so if you can do that, if you can look at the space around you, you can find a population where things are out of whack, especially if it costs somebody a lot of money. You can go to the person who's spending all that money and say, I may have a way to save you money here and help your patients. And you have a system where you can actually be better and get to better care. You can get to value. So you make great points, Dr. Standard. And I really, you know, I appreciate how you said at the beginning, you know, you didn't have the keys to the castle. You didn't have a budget. And so you identified some areas where, you know, for that system, physiatry really offered value. You also talked about how, you know, physiatry is sort of squarely in the center of all these specialties and really playing a quarterback role. I know, Dr. Kim, I think you were maybe in a similar situation when you started the pediatric department at Columbia. So I was recruited to Columbia and Cornell to open the pediatric rehabilitation medicine where they never had that division. So I decided to be a saleswoman. So I made, I'm the division chief, so I don't have a budget, right? I'm not the department chair, but I belong to two department, pediatrics, PM&R, but nobody give me money. But I have to build my practice. So I said, hmm, how I'm going to make people understand what is PM&R in pediatrics? They have no clue. 150 years, they never had the PM&R in children's hospital. So I made a slide, PowerPoint slides. The title is how you can use PM&R in your special department. So I'll give you example. When I went to emergency department, oh, Hye-Kyung, we welcome you, but you don't need to give any lecture. This is emergency department. Oh, yeah, yeah, you need me. So what does that mean, I said? Your frequent flyers are my patient. We are trauma associate, so all the trauma cases have to go through us. You don't know how to use, I'll teach you. So I had all the brain injury, spinal cord injury, pain patient, a number of them, right? And they don't say anything, so I have to figure it out. And then I was solo practitioner, so I gave myself a number. And then I start to go to ICU and emergency, every department, the oncology, I was sitting at oncology outpatient clinic without any payment. I was just telling them what to do, but for free. But anyway, the outcomes start to come up, especially brain injury patient. I start to set up the clinical pathway for them. So any patient from going through the emergency department, they have to go through me, because I am the pediatric rehabilitation medicine. So how I convince them is I give the lecture, right? As I said, what's the sequelae of the mild TBI? Mild TBI is 80% of brain injury is mild TBI. They send them home without any guidance. So I made a booklet, and then I put that in the website, so they can give that, they can print, and then I put the PMNR telephone number in the brochure, so they have to call. They were very impressed by my aggressiveness, I think. So they hired a nurse navigator. The nurse navigator chased them down until they come back to the PMNR clinic. So within six months, the mild TBI follow-up used to be like a 7% at pediatric rehab medicine, and within six months, it becomes 75%. That's number one. I am not familiar with it, because I'm not very, you know, I'm not the adult world. I'm in pediatric world, so value-based practice, I'm not so sure. But I know what I did. So with that, I was heavily involved with the intensive care unit, because PMNR is all about prevention, as I talk about always, and all about prevention and education. So I start from the beginning. So we started from emergency department, and we bring them to the ICU, and I went to ICU, and then I started to salivary gland injections to prevent aspiration pneumonia. And then they cannot discharge a patient without me after then, because right after the injection, within two days, they stopped drooling, therefore no aspiration pneumonia. So they can discharge the patient, the patient never come back. For 33 months, we are repeating the injection. So we calculated, we actually published, with 34 patients, three and a half years, we were able to save $10 million. And nobody says anything to us, but meanwhile, it's not just economically we did a great job, but the quality of life we provided to family was amazing. Now the parents are able to go to work. My children are able to go to school. They were always in ICU, because I calculated, two days they go home, they come back. Two days they go home and come back. They're always in ICU. So there was another one. The other one, how I provide value is that I started the multilevel botulinum toxin injection with the phenol nerve blocks, and then initially, my institution had only eight patient per year, they did injections. So my aggressiveness is coming up again. I said, we can do something with our own hand. I don't need to write a PTOT order. I hate that. So I said, I want to fix my patient with my own hand. So I start to talk to all the orthopedic surgeon, and what to do. Initially, they told me what to do, because I'm just a rehab doctor, so I said, I can deal with you for now. Later, it's going to change. So just send your patient. So I started the injections, but you have to be very nice. But I totally agree with you. You have to be very nice, but you have to be very knowledgeable. You have to be better than them. You have to know everything, right? I don't know how much they're making money, that I know too. But anyway, so I start to do injections, and then my injection is going up to 2,000 cases per year. And then years later, five years later, I talk about this one this morning. I said, oh, I do something, so I'm doing something. Everybody said I'm great. And I start to think, am I really great as a rehabilitation doctor? What is so great? So my fellow at the time, Barbara, looked at me. What am I doing? Everybody said I'm great, but I don't know what I'm doing as a rehab doctor for the healthcare system. Dr. Kim, you do a great job. But anyway, the time goes, and she came with the two PowerPoint slides, which was before Dr. Kim started to work at CHOP, and after Dr. Kim, this is a previous story, work CHOP. And then the orthopedic surgery was 100% that they were cutting all the tendon to control the spastic muscles. By the time I provided this injections, multilevel repeated injection, they were only doing surgery 30%. But now, I was vividly watching how the orthopedic surgeons' behavior changing. Initially, they told me, oh, you're the rehab doctor, do injection for me. I'm going to tell you from now on, this is a time for you to take over my patient. Do surgery, but you're going to do this type of surgery, this type of bony surgery? They were so happy. They call me, after I moved to New York City, I trained exactly the same way. The surgeon, I went to the OR, because I educated them, as I said, oh, you know, you have to really do the botulinum toxin preemptively before you cut the spastic muscles. I convinced the chief of the orthopedic surgery, right, and oh, Hyekyong, let me try. So he tried, and then his junior staff learned that, oh, Dr. Kim is doing some injections, so he invited me, and he was so angry at me. Hyekyong, I'm the orthopedic surgeon. How dare you are going to the room before I cut the muscle? I said, okay, you go ahead. I'm never going to come back. Go ahead. But anyway, so I just walked out, right, and then he got yelled by my patient, do you know who is Dr. Kim? But anyway, he apologized, and then we started to do these older injections. After that, you know what happened? He's always calling me, Hyekyong, where should I cut? Do I need to do surgery? We become 18. So what I'm thinking is this older study, what I learned that value-based practice is you have to really show the outcome what we can do. So I know that I was very impressed by him that I don't know value goes to whom, right? Outcome goes to whom? But it goes to the patient, right? That's what we are doing. So whatever you do, if you can improve the patient's quality of life or your quality of life too, but that's the outcome, value-based outcome. So when you do this kind of practice, you have to really make sure that you are the expert, you know everything before you do that. If you don't know that much, I don't think you can win at all in the game, value-based practice. You have to be able to provide because they're not trusting you. So you become just a technician for them. Oh, do the injection, do the injection to the spine every couple of months, you know? Every couple months botulinum toxin inject, I hate that. I don't do every three months because botulinum toxin works only three months. I have my own protocol for everything. So to answer to your questions, value-based practice for me is preventing the disability by involving all layer for their problems, but not simply treating the disease or disorder, but you have to think about the function and which brings their life back, right? So that I think I care that that's value-based practice. Great. Thank you. So Dr. Press, I know you have particular thoughts about making sure that you're the one who's kind of quarterbacking things, keeping everybody coordinated, and making sure that you're the most knowledgeable in the room. Well, I'm going to go back even earlier than that. I'm going to go back to July 1st, 1988, the first day I started practice. And I guess the first question, who's looking for a job in here? Anybody? Raise your hand. All right, there's a few people. Pete, don't put your hand down. When people are looking for a job, and this is how I thought about it, July 1st, 1988, is one, what do they need where I'm going to work? And number two, what can I do that they need? If you can fit those two things together, and this is, you're working for a system, you're working in private practice, whatever it is, but when you look at those two things, that's kind of what value is. What is it that I can do that maybe nobody else can do? I can do it better than anybody else can do it. This is what value is. What value are you adding to the system that you're working at? What value are you adding for the patients that you're seeing? And in physiatry, there's so many things that we have built into our training that we just don't think about. Chris was talking about the system. When we first talked about this talk, we talked for like an hour, and we said, we've got to cut this down because we just kept going on and on. But what he said to me one time, he said something really brilliant. He said, I didn't know, I mean, when I got there, I wasn't sure what my role was, but then all of a sudden, I realized that I knew what everybody else did, and they didn't know what each other did. And so just by being the glue, so being glue is kind of part of the value of physiatry when you realize that you are that part of the glue that brings things together. So when I started in Chicago many years ago, I kept thinking, well, what do they need, and what do I, am I any good at, or do I want to be good at? And at the point, it was like there wasn't a lot of musculoskeletal care. Well, I think I can do that, and I think they need to do that. So all of a sudden, I was of some value there. Fast forward September 1st, 2016, I went to the hospital for special surgery. They had things kind of established pretty well there in terms of care. So I thought, what do they need, and what can I do? And well, what they needed was kind of a little bit of pulling things together because they had lots of silos, and we still have a lot of silos, and how can we pull those silos together? So I'm back to being the glue and trying to pull those things together. So that's how you look at it, and then you say, okay, well, what is it that they need? Well, in physiatry, like a lot of things, is you have to be able to do the hard stuff, right? Anybody can do the easy stuff. I mean, I think we all know what a commodity is here, right? It's like a raw material that you kind of buy or sell, and a commodity, it just always goes to kind of the lowest price because it's kind of the same thing, right? No matter what it is, it's a commodity. You don't want to be a commodity in medicine. If you're a commodity in medicine, somebody else is going to do it cheaper, like an APP or a PT. And so when Chris and I were talking about healthcare systems and who should be seeing patients with back pain, it probably is not a neurosurgeon or a spine surgeon for sure, right? It's probably not the first person you see somebody who's doing injections because they're going to want to do that pretty quickly. It's got to be somebody who can manage the easy stuff, right? And then you want, if they're not better, then let's get them to somebody who's an expert at it. And then if I can't take care of them and I'm an expert, then I get them to the surgeon. So you want people to be working at the top of their license, right? That's a buzzword in medicine, like work at the top of your license. The top of my license is not seeing a sprained ankle all day long, right? I twisted my knee and I got two days of knee pain. There's a whole lot of people that can do that. They're a whole lot cheaper than I am as we talk about cost on it. So you want to be working at the top of your license, not the bottom. The bottom, they can get rid of you in a second. They can replace you with about anybody. I don't want to be replaceable in that sense. So it's really being able to kind of have that sense of what can I do, and it's the hard stuff. I mean, I say all the time, nobody gets famous taking care of the easy stuff. It's you got to be able to take care of the things that the other people can't. And then when the doctors start referring you, their family members, because they realize, you actually can take care of them, then all of a sudden you got a lot more value to them. And then you, opens doors for a lot more things. So I think keeping that in mind there too, you don't want to be the commodity. It kind of helps because it keeps you relevant through the whole thing. One of the things that we've tried to do at Hospital for Special Surgery is, okay, I'm trying to take all these silos and pull them together. And as we look at musculoskeletal care, what's the best way to do that? Well, it's not having all of these very specialized doctors seeing really simple, straightforward stuff. We need to have your APPs. This is a role. I know the academy is struggling with that too. Like how much independent access do we want them to have? Well, if they can do the job, that's probably, if I'm running the healthcare system and I'm paying for everything, I want the person who can handle it. And then if they need to pass it on to the next person. So I think we have to think in those terms as staying at the top of your license, staying relevant, staying important in the whole scheme of things. I'm going to leave it at that so we have more time for questions because I know we're going to get into a lot of things. Great. Thanks so much, Dr. Press. So Dr. Prather, I know you've had to address this question of how do you create value as a physiatrist? How do you demonstrate values as a physiatrist probably many times over your career in terms of building physiatry at Washington St. Louis, in terms of creating a lifestyle medicine program not just at WashU but now at HSS, and sort of helping people understand where this value is captured. So if you'd speak a little bit about that in your experience. Sure. So you know, you talked about the question of what is the outcome, what's the cost, and my point usually is value to whom? Is it value to the patient? Is it value to the system? Is it value to our universe? Is it value to yourself, right? I know I was worrying about that, about my own value in the system for quite a while. I too, it was lovely to hear, I too didn't have a budget. No path in which to create anything, and no process. Like lack of process can be a big problem when you're trying to create something, and I've done it a couple times in my career, and that's a frustrating thing. So the expectation of, expecting to fail or be slow at something, you have to kind of be there, getting a little less likely to, in age, of being patient with that process. But those things are expected when you're trying to build something, and that will be valuable. I would say, I would also take from Chris's words about, I think the thing that really motivated me moving into where I am now, and to trying to build a lifestyle medicine program at the second time around, is that seeing patients over and over and over again, training people that then saw patients over and over again. We could make, we could help them get better and then they'd be back. The spinners. The spinners were getting me. There was this thing called burnout, but there was also, I wasn't feeling valuable. The system was telling me, oh, great job. You saw 8,900 patients last year. Could you please see, not please see more, you need to see more. Not how you're gonna do it, can we help you? You need to see more and I'm thinking, I just did a really bad job. I don't feel like a very good doctor. I don't really want to do that. I don't really want to do that. And it's a sick system, right? So how do we get back into that? So, you know, moving into this space of trying to apply helping people get healthier as a part of delivery of care within the physiatry model has brought value back in my personal self. I think, you know, showing the value in the system is another thing. So getting into healthcare, not sick care, is part of the motto I go forward with now. So I would say, you know, what is it to me? What does value-based programming to me mean? It means what I do in an everyday world, to lap onto what Joel just said, is what I do that's different is what's valuable to usually the healthcare environment around me. You know, being feeling like you're marginalized by other specialties or that kind of thing, screw that. What you do is different, that's what makes you valuable. When your knowledge base is extreme and it's something that no one else is doing well, that's where you're valuable. And that can be different for anybody's practice in any different healthcare system. So honoring the fact that you're valuable and unique. The thought about you're the guy who knows the glue and you know what other people are doing and you know exactly what to tell a surgeon, you know, that this is what the outcome needs to be because I'm the one managing this in the long run, right, is really, really, really important. And the thing I also learned, in addition to what you all said, is that we actually can manage a team. And I thought just everybody could do that. What's the big deal? There are many, many other people, specialties, it's not even a part of their awareness of what other people are doing. And being able to manage a team is really, really huge and important and the lifestyle medicine piece for me is something I get to do on a daily basis with that, so I really like it. So in conclusion, what is value to me? Value is what it is to the patient and what it is to the patient is outcomes, but it's the outcome that the patient values, right? It's not my outcome I want them to have, it's what the outcome they want and I have to make sure I'm listening hard enough that that's what we're shooting for. There's value to the system and again, if I do unique things, if I do things that help other people be better in the system, if I help patients get better care from other providers in the system, then I add value to that. And then there's value to self and I really think that has to go beyond the talk about burnout, which is obviously important. But it's kind of like part of the complex of I need to feel like what I'm doing on a daily basis is valuable, not just to the system, but to the patient and that I'm valuable in that method. And I think that's something we don't talk about enough or have even think about considerations for options for that. So that's my take on it. Great, thank you all. So there's one question that's coming in from online and this is from Kathy. She's asking or she says, current insurance only pays for sick care. How can we create payment for well care? So I was, anyway, what are you all said and made me think of all sorts of things as you were talking, right? And so you mentioned saving $10 million. And so the tricky part here is that the way the system is built now, it is a sick care is a broken system, right? Ineffective care pays way more than effective care, right? If you don't make somebody better, if you make them better for a month and they come back, you discharge them for three days and they come back, you get paid again, ta-da, right? If you make them well and they never come back, you don't get paid again, right? So there's a problem there in some ways. If you think about it in the standard like fee-for-service, we get paid. I think fee-for-service is sort of the evil of our country in a lot of ways. We have lots of evils at the moment, but that's one of them, right? Because it pays for the wrong things. And so this idea of value then goes to how do you get, how do you make an economic argument to do these things, right? Then you have to know, you have to understand the economics of your situation. So are you where I am, where the insurer is the payer? We're a single controlled system, right? I can do that. If my insurer isn't the payer, how else can I get value? Well, you know what, if I'm better than everybody else and I'm a little bit cheaper, I can bring them in, right? I can get Walmart to send me people. I can get Amazon to send me people. I can contract with Citigroup. I can do things. I can do it better than they can do it for less money. I can do it that way. If you think about optimizing sort of other parts of your system to run more efficiently because you take care of the things that really cog up the wheels, you're adding value, you're adding economic efficiency to your system. People talk about their capitation structures and their structures of shared savings. Were you just doing it, this better thing, like I said it, Joel said it, she said it, like we all said it, right? This better thing, part of value is better, right? It's gotta be better for your patients. If the patients are better, if you are better at getting your patients better, if you are better at taking complicated patients, nobody can get better at getting them better. There are ways to extract value from the system. And then you just have to find the person who is paying the bill eventually to sort of say, hey, wait a second, you can save me money here and make things better for me. But you have to, that is part of the balance, right? I said the word moral authority. I can say I can do a better job, but at some level, for somebody to fund me to do that, I have to prove it. And I have to prove it in a way that economically works for the person who is funding me. And so you really have to understand the economics of where you are. You have to understand the economic players in your system and you have to use the language of value in a way that effectively transmits to that person or entity the economic proposition you are providing that is valuable to them, if that makes sense. Yeah, that's great. Any other comments? Sorry, I got to comment on that too. So in addition, so firsthand, what I've learned and one of the real reasons other than Yoho down at the end of the table, who I love to work with, trying to recruit me back to HSS, because he's always told me I do a good job and he values me, is that the economic system that you're right, the incentive has to be there. So we're not allowed to know how much we save people. We're not allowed to know that. That's not something, a number you can go get. HSS is self-insured. So I can learn, if I can do a program in lifestyle medicine, I can figure out what we save because they're self-insured, like you're self-insured. And then I know what my clinical costs are for that because I've got a program going and I know what the clinical costs are for the program. I know what the overhead is. I've got that all in a package bundle. I know what that is. And there's corporate partners or insurance people and there's lots of systems that wanna make these partnerships, but this system already has those partnerships. So I know that I can get from a model where it's fee-for-service and 2 3rds of the country's diabetic or pre-diabetic and obese or has pre-diabetes, but there's a minimal number of people that actually have access to a dietician and a dietician at our system is $300 an hour. This is broken, right? This is messed up. And a dietician, 300 an hour, they go by quarters. It's New York. Okay, yeah. In Missouri, it was 200. So, you know, okay. But it's a lot of money, right? For cash. Yeah. I was just free in our program. Right, okay. Right, because of where you are, but for the rest of the world, that's the fee-for-service model. And a dietician, if you don't know, a starting salary of a dietician is somewhere around a McDonald's manager, just a $20 an hour. Yet our healthcare system's not helping reimburse that for a regular insurer. So if we can get to a bundled model, and I know what I'm saving people, I know what my costs are, I can bundle this and it won't matter that they aren't paying fee-for-service for this. And I think it's a short-term solution. I am worried that I've gotten to join the value team at HSS and I'm getting a lot of training in it. And I do worry, though, that a lot of value-based programs, somebody has to take a risk and people are so risk-averse out of coming out of a pandemic, I worry we're gonna lose momentum on that part of it. Great. No, my last comment, it comes down to the employers, because the insurance companies have no incentive whatsoever, the employers do, and the employers may, and if you have the right packaging for them, they'll take a little bit of risk because they're sick and tired of paying too much. So the payers are the way to go. That's it. Yes, employers. I just wanna make sure people know they can come up to the microphones if they have questions and feel free to ask anytime and we'll stop what we're doing and make sure we prioritize questions. Excellent presentation so far. I'm just wondering if you guys have a pulse for what small community outpatient practices can do to demonstrate value? Because obviously we can't all build integrated practice units, we can't, we don't have the funding and stuff like that. So I'm just wondering if you have any sort of idea of how small practices might be approaching this, because it's coming, we all know that, but it still seems like a black box. Can you answer Heidi's question, value to whom? I'm sorry? Heidi's question, value to whom? This idea of value is too abstract, right? You really need those other two words. So to whom are you trying to demonstrate value so we can answer your question? I guess based on what we're talking about, we're trying to show that we're saving costs to payers, right, eventually? Is that what I'm understanding? That could be your understanding. Like Joel just said, the insurer doesn't care. The insurer's a throughput, right? They take a percentage off whatever goes through them. They don't really care if you say, it has to go back to the payer to get to that economic side of it, right? So in a private practice, you could do a couple of things. You either go back to the root payer in some way. If you have a large employer who is self-insured in your area, they become the payer. They care, right? The large self-insured employers care, right? Because they're paying the bill, right? The actual insurance companies that are transactional in the middle don't care. You have that, and then you have the, you know, can you, even within your insurance structure, find a way to say, we are better at this particular condition that is costing you a lot of money? How can you start doing this? How can you start quantifying what it is you do? How can you start looking at your population? How can you start looking at your cost? Do you measure outcome in some way, right? Can you actually do that in your setting, right? That's what you're gonna be held to. If somebody says, you're gonna offer me value, I'm gonna say, in what way? How much money are you gonna save me? How are my patients gonna do? Are they gonna be okay? Because you can save money by doing nothing, but nobody wants that. That doesn't really work. So you need the outcome side. So in a private practice setting, I would be thinking like, what is it I do really well? What is it I'm seeing that other people don't seem to be doing very well at all? Can I start to track this population of things that I see, like you were talking about, the people who are aspirating, right? So you can do that really well, right? So that becomes an advantage. So you start finding the populations where other people, things are screwed up, other people aren't doing it well, but you think you do a really nice job with it. And then you can start to sort of quantify them. And it gives you an anchor to start saying, what I'm doing is better and different. And then you can kind of get there. But if you're not tracking yourself, you're not measuring yourself, you're not looking at your population, you're not thinking critically about where you might really be adding value to the system, then you have a very hard time sort of getting there. You have to be deliberate about that sort of stuff. I thought you were asking like, just as an individual starting and everything, and I'm thinking to myself, one, you provide better access than anybody else, and you just make sure you get people in. Two, you just treat them well and do a really good job. And that's how you build a practice. I mean, that's a really gross, very simple way of taking care of you and just doing a great job for the patients. Just be better than everybody else. I mean, the bar is not super high in terms of where musculoskeletal care is. You call people, I mean, I could go on for an hour. You call people back, you follow up with them. I mean, you guys are hurting in the front row, you're tired of hearing it. But there's lots of little things to do to just be a great doctor, just be a good human being. That's how you can show value to your patients right away. That's a real simplistic one. Okay, thank you. Microphone two, in the back. Great talk, it's been really, really helpful for me. And my role, just as a little bit of background, is I was hired at a community hospital in Sarasota to build the outpatient physiatry practice at a robust inpatient practice, but there's no outpatient follow-up for general rehab and musculoskeletal, really. So I end up interfacing with a lot of administrators and I don't know how to speak their language. I don't know what metrics they're looking for. Do you guys have two or three metrics that I can help bridge that language gap that can help them demonstrate value? Because these are people with master's degrees that have never seen a patient in their life, but they're asking me, what are some solid metrics that I can start to collect that can be like, hey, this is what I'm doing, because I see it working well on my end, but I'm now getting to a point where it's like, hey, I need more help, I need more people, I need more staff, I need more space. Well, that costs money, Steve. Well, so what metrics can I bring to them and say, this is how I'm showing you in your language that I'm working? Does that exist? The first thing I'm thinking about, if I'm building something, the first question I'm asking is, what do you need? You know, go to them and what do they need? If you're there, they must have a need, and if there's no outpatient musculoskeletal stuff, I mean, that's kind of like a big part of the health costs and everything, so it's hard to imagine that they don't need it. So what do they have already? And then you can kind of take what you have and talk to them about them. You gotta know where they're coming from and what their needs are. Once you meet their needs, it becomes a lot easier. Believe me. Then you start getting support. Find out if they have back pain and talk to them about it and say, what are you doing about your back pain? Yeah. It's like length of stay, or is there solid metrics that I can bring to them, or is it just, it feels like it's more qualitative stuff. It's just, because I'm filling their needs. I'm seeing their patients from the rehab hospital coming into the community because there's no one to do that. You're picking up musculoskeletal stuff as you go. The primary docs have no idea who to send anyone to, so I'm seeing them. The interventional radiologists do epidurals. They all do caudals, so all the neurosurgeons are ticked off because no one does epidurals in a 900-bed hospital. I'm it. So I'm starting to do that, and it's like, how do I quantify all of that besides saying, hey, I'm doing all of this stuff? Like, are there numbers? Are there texts? Is it like a definitional term that I can cling onto that say, okay, I can look into this and get this back to you? Or is it just saying like, hey, I'm doing all of these things. Look at what I'm doing, and I need more help. I'm not so sure I can answer, but when I was a junior, and I was doing a lot of procedures, I said 1,000 procedures, and then they didn't value my work at all until I told them the outcome and numbers. You have to analyze your work, right? And you have to analyze all the procedures, what you did, how much you are bringing to the institution. You have to know exactly. You have to have data. You have to have the number to go to your, that's your metrics. If you don't have the numbers, they're not gonna listen to you, no matter what you do. And then I was able to convince them to provide all the things until I gave them number. You're a pediatric physiatrist. I don't know what you are doing. You're losing all the money. Actually, I was making $2 million for them. They told me that I'm the money, I'm the one who loses all the money. So I said, that's really weird. I sat down, I calculated all the cases, and I brought the number. And after then, it's really totally different. So you should know what you are doing it, I think. $2 million is value to them, to the hospital. Right, like lingo. Yeah, KPI, he say what you need, what's your KPI, if it's a 30-year-old operations person you're working with. The context of which they want that in, the data, obviously the data is so, so key. And you can't know what the downstream revenue is, but you can make a suggestion of how that feeds the system with your data. I think that's what your main point was. Right, and so you don't know how much they actually collected for the floral suite you used if you're using the hospital system one, but they do. You can guess pretty quickly, because once you say, this is how many patients I saw, this is how many I sent for an MRI, this is how many I sent for surgery, I figured out somebody in our system that could tell me what percent of the people that see our department end up in surgery, which is a good leverage point to have. So you had two sides, I'm gonna go one more thing for you. Joel's point of where are they bleeding is an important question to ask them, right? The question of where are they bleeding, because you just heard two different sides of this coin. You can say, I bring in revenue, but then you say, where are you hemorrhaging revenue? Do you have a high, if you look at how things get paid, are their lengths of stay exceeding their DRGs, so they're losing money? Are there readmissions coming in when they won't get reimbursed? Are there reoperations happening because of infection, because nobody did a follow-up? So if they're bleeding on readmissions, they're bleeding on length of stay, they're bleeding on other things for which they don't get paid, then you can address that metric. And so you have the two sides of the coin. You can stop their hemorrhaging, and you can bring things in for them. But it seemed like you were looking for the, where are they hemorrhaging? But I would go ask them that question. Where are you losing, where do you think this is losing? Where are you exceeding your metrics? Where are you off on your HEDIS measures? Where is your care off that you're getting punished for? Is maybe I can improve that for you so you don't get punished. And then again, you're improving value. Yeah, so it sounds like sort of as a general principle, starting off with what does your, who do your stakeholders, who are they? What do they need? And does your skillset sort of match it? And do you think you can offer value to them? If you can't, maybe you come up with a different strategy or change something about what you're doing. But that's sort of the initial place to start. And I think the second part of your conversation about the things that you do well, I mean, one of the lessons I've learned in my life, and I've said this to a million people in this room, you've heard it before, but when you figure out what it is that you are good at, stay in that lane and try not to get out of it too much because you'll find yourself starting to creep into areas and you find yourself doing it. It's like when you're successful, they always want you to do more stuff, like when you're a doctor and you're really good as a clinician, where they try to make you an administrator. It's like, why are you trying to make me an administrator? I'm a really good clinician. You should stay in your lane. That's one. You'll do a lot better quality work when you stay in your lane. Microphone one. To Joel's point, the economist just had an article, the United States healthcare insurers have gone from 36 percent of the profits in all of healthcare to 42 percent. I don't see them looking to make any less. I think Joel again brought up, I don't want my people seeing a sprained ankle. My question is this. Where do you see healthcare moving a bit where these insurance companies are saying, I like to be 45 or 50 percent of the profits, and I think a physical therapist can see a sprained ankle and probably could see a back, and I think we know that they actually cost less to them. I don't think they care about cost, the payers care. We should be making partnerships, I think, with companies and with something like UPMC where it's enclosed and they're going to see that spine surgery is expensive. HSS is hiring another spine surgeon. Not as if we don't have enough. I see a lot of the healthcare systems are trying to figure out how do we pull money from insurance companies, but insurance companies are trying, how do we pay people less, and maybe these providers are less. Where do you see physiatry's role going forward when insurance companies start to say, maybe you don't need to see a doctor, maybe you can just see this physical therapist? I think personally your point about getting rid of the insurance companies is the best thing. Go to the payers and negotiate with them. A story I had very early in my career when I went to our CFO in Chicago and said, can we go to this insurance company that's paying us X and take 100 consecutive patients that were okayed for surgery and let me add them and see how many of them we can avoid the surgery on and then we'll just share the savings with you. They said they don't want nothing to do with it because insurance companies make 18%. They're capped by law. They can't make more than that. If they sell a million dollars of insurance, they make $180,000. If they only sell 500,000 because you save them too much money, they make half of that. There's no incentive to insurance companies to save money. You have to go back to the payers, not insurance companies, but employers. This is why Walmart is self-insuring on these kinds of things too because they're trying to get that middle man out of there. Do you think they're going to go away from physicians to that first line of care? Right now- I think they will move more and more away from physicians as the first line of care for simple stuff. If you have heart failure in some of these new programs, you're talking to the nurse and she's monitoring your fluids unless something's wrong and then they bump it up to the cardiologist. You don't need the cardiologist first. Where do you see us in that? We have to be the point of first referral. We are the musculoskeletal experts. The easy musculoskeletal stuff, I think you can train a lot of people to do it. I really do. My wife's a gastroenterologist. She's pretty good at musculoskeletal stuff that's easy. You know what I mean? You can train a lot of- I don't know if that was a good example. I don't know if it was a good example. I could be in trouble later. I don't know. Anyway, my point is a lot of people can do that. A lot of people do it. Work at the top of your license, not the bottom. You want to be that point where this is where they go to you for your expertise. This is what we have. I think we didn't mention anything about ourselves because who speak to insurance company? Not physiatrists. They don't know what they are doing it. Am I wrong? When I become chair, I met COO. I told her that I like to sit with the insurance company to appeal our cost. They said, no, no, no. Who is sitting at the table? Not even hospital executives. They hired the Southwestern Medical Group. They are the ones who is- Do they know what we are doing it even? Do they know PM&R? Physiatrists, we have to really grow into the leadership and going into- At the table, we have to sit at the table. We are just talking by ourselves. There's a whole talk on advocacy going on right now, unfortunately, but hopefully that's going to be recorded, but we'll hopefully have more on that at future annual assemblies. Microphone one. I think that as a specialty, we attract people that are team players, right? We have everyone willing to jump in and help whenever that's needed. I think on the granular level in clinics, if paperwork needs to be faxed, everyone in this room has probably just said, I'll figure it out, instead of asking for another assistant or an MA to help or finding somebody else to do something that's non-doctor required. I think that if you can speak to the culture of who we like about ourselves, what we like about ourselves, what we pride ourselves on, actually may be a detriment to being more efficient in our clinical settings because we can't advocate for ourselves when we can see five more patients in clinic in an afternoon if we had somebody helping check in patients, but if we're doing it on our own anyway, we're not going to get the attention of someone that says, well, you're doing it just fine, just add five more patients. How can we advocate for ourselves, but still keep the mindset of we're going to get it done because it's the right thing for the patient? I think we should understand the word team, right? So a team does not mean everybody does everything. The difference between, you can think about a team versus a group, right? A group is a bunch of people in the same space, working on the same thing, doing their thing, right? They may all sort of do the same thing. You may go get a, if you're getting faxes and somebody else is answering a phone, you're functioning as a group, right? A team really functions, everybody does their job, but in the process of doing so makes everybody else better at doing their job while moving towards the same objective, right? So the team-based structure of physiatry is to sort of take the people around you and help organize them in a way where they all work more effectively together to get to the same objective. And that does mean assigning tasks, a team like, you know, a basketball team has a point guard and a center and whatever, like they're all different positions. They do different things, right? And so you have to sort of set your team up that way. I think the personality feature of sort of I'll just go do it at some level, you have to sort of say, look, this doesn't work, right? I can't go, like, we've had this discussion in our department, like, I don't really like seeing my colleagues walk across to a fax machine. That's a waste of their time, right? And they should be doing something else because we need them doing something else. And that's Joel's comment about stay at the top of your license. You have to think actual team structure, not sort of group, not individuals, not a bunch of passive individuals in the same space. That's kind of spinning, right? You need to build a team with a goal, with a mission, with a directive, with a pattern to get there, I think. But that is the gift of this specialty that I think we just forget all the time. It is a gift that you had all those meetings, those team conferences where you're sitting around the room like, okay, they're going to report, they're going to report, and you're kind of wondering what you were doing all that for. This is what you're doing it for. I mean, I watch what Heidi has done with the lifestyle medicine, and there's nobody in that place. They have all those services around there. But who can pull the whole thing together? And Chris, when he was talking about UPMC, there's a lot of smart people around UPMC that run PT. I mean, there's some of the top people in the world in all these places. But none of them know how to pull those pieces together. So I mean, that is the gift that everybody has in here, whether you know it or not. It's there. So I mean, don't ever give up on that. Not giving up, but the PM and I, our personality is the problem, because we are rehabilitation doctor. I have difficulty with my own faculty members when I ask them to be efficient or be demanding. Ask your staff to send a fax, print, discharge the patient. Oh, no, I'll just do it. We are nice people, you know? I cannot just stop talking to my patient. I have to listen until they finish. So I think there's some way we can educate our trainees that PM and I doesn't mean that you have to be spending time 60, 70 minutes to listen to them only, but there's a way we can be better. But most of my faculty members are, I'll do it, I'll just do it. Then they turn around and they complain. Nobody's helping me, right? That's who we are. But you go, surgeon, they don't do that. They don't touch any fax, any copies, nothing. They don't touch patients a lot. What are you talking about? I'm sorry. Microphone two. Hi, my name is Karis. I'm actually a trainee. I'm a fourth year medical student at UCSF in San Francisco, and I'm applying to residency right now. So I've been thinking about when I'm done with residency and I'm trying to add value to some employer. So I guess my overall question is just how do you think trainees through residency can implement all of this thought of value-based care? And then does that mean that more of us should be considering fellowships or MBAs or something to add value to our potential employers? To me, I think you don't need to worry about anything else, but you make yourself as the best, so you already become expert in anything. But I think you don't need to worry about what fellowship I'm going to do or should I do fellowship. I don't think that that matters. You have to find out what you like to do. If you find something what you like to do, and then while you are in residency program, you can train yourself as a specialist already. I encourage everybody to go to general PM&R, because general PM&R, if you like it, if you already made a decision, during residency, we're going to train you as a MSK doc, we're going to train you as a spine doc, pain doc, pediatrician, you can handle everything. But if you don't choose what you like to do, then it doesn't matter, right? So that brings value. Make yourself as a special person and the best resident and very knowledgeable and passionate, and makes you who you are, so you don't need to worry about I'm going to go fellowship or not. Go fellowship if you want it. If you don't want it, be generalist. I agree with everything she said, although maybe in a different way, and quote one of my favorite songs, keep your eyes open. And I mean that in several ways. One is you may not know what your, I mean, I think there's a lot of pressure on what your passion and do what you like. I think you kind of fall into what you're good at. I thought I was going to be a stroke doctor in a rural community. And Yoho down here said I was good at, yeah, and I'm working in Manhattan and somebody down the table said, you're really good at this. I go, I am? I didn't know that. But you know what I mean? It's just, I don't worry about you don't know. Keep your eyes open. And I say keep your eyes open as you're going through training. We were recently given virtual scribes. It has changed my life. Okay. His name's Toan. He lives in Cambodia. He's coming to the Christmas party. Okay. So it has changed my life. I gave the scribe, the virtual scribe, to someone who's graduating our fellowship who's now at Stanford. I've known her since she was a med student. She's been in and out of my career. We've been out. I gave it to her. This is a wonderful human. Very compassionate. She's awesome. And I said, you should try to advocate for this at Stanford. Go see what it's like. And she came out. She goes, oh, this is really great. She goes, I don't know that I've ever looked at somebody while I took their history. Keep your eyes open. Be aware. Be aware of not only the patient in front of you, but what others in the healthcare community are doing. Because that tells you where your value will be. And you'll fall into the thing that you're good at. You know, you're a third year medical student. I have a future son-in-law who's a third year medical student. So I'm going to have to sit down with him and talk to him. Because it used to be when I talked to my son and my daughter about what they should do in life, I said, you know, find out what you really, really love more than anything and that's what you should do. And then I realized there's two other parts of that. That's good. But I mean, I want to play in the NBA. That was never going to happen, right? So what are you really passionate about, number one, I think keeping your eyes open to it. The second part is what can you be great at? I mean, that's really important. You don't want to be really average at something if you're passionate. You want to be really great at it. And then the third piece, which I never really thought about until I understood value a little bit more as I started to work. What is needed? You know, and needed by the system, needed by the patients, whatever. So when you put those three things together and get the overlapping Venn diagram and you get that middle spot, home run. You're there. But I'd like to add one more thing. Last one? Yeah. Wait. No, because I really think it doesn't matter you're a resident and faculty member. You should own your field. So I'd like to ask you to be an owner of what you do. Then I think everything can be solved. So one, huge props for showing up as a third year med student at a PM and Army. Fourth year. I think she's fourth year. Fourth year. Fourth year. Fourth year either way. He said third year. I thought she said fourth. So this idea of like, the people are here because I assume they want to change something. You cannot change anything if you are not a really good doctor as a doctor. The only reason, Heidi said the same thing essentially. I had no keys. I had nothing. She had no keys. Why do people listen to us? Because we're really good at what we do, right? And we really care about our patients. And if you can transmit that, then you can start to go somewhere. So the goal of residency isn't to sort of get into a fellowship. It's to be a really good doctor, right? And that's going to change. I mean, you have to be. And then if you really want to learn the language, if you really want to be this person at the table and seat, you do have to learn the language. You start thinking, what am I going to do that's going to get me there? I'm going to join a committee as a resident that's in policy. I'm going to start learning a language. I'm going to start understanding what people are talking about, because if you don't have the, somebody asked a question about where you don't have the language, you can't communicate with the babies. Other people don't have the same language we do. They don't speak Greek, which is what you're, what we're all learning, right? So be really, just be a really good doctor. Enjoy what you do. Embrace the whole doctor thing. And then learn how to transmit and communicate if that's what you want to do. I think I remember the day you said the same thing to me when I was training with you and I asked you a similar question. So props for being consistent. Microphone two. Hi. So outpatient solo MSK pain in Chicago. And I tell people, anybody who'll listen, follow me for a day and you'll see how you should practice effective medicine. And it's for the patient as well as an insurer. I don't order MRIs. I don't do unnecessary EMGs on radiculopathy, because if you can't diagnose radiculopathy without doing the EMG, you should go back to school, right? I try to do the right thing, and I do do the right thing with patients. I don't inject. I don't talk people out of injections all the time, I talk them out of MRIs. I actually, the only feedback that I've gotten from a payer was when I said, we had a, I can't remember what I talked to him for, but he very pejoratively said, we don't like the fact that you're just charging 992, 4-4s and 4-5s, just high evaluation charges. And I said, because I don't see patients again. Like Joel said, I love seeing sprained ankles, because I never see sprained ankles. I see the tougher cases, because that's what I've ended up doing. That's my niche, to see the more difficult cases. So I tell them what's wrong with them, they don't end up coming back. So I don't have returns. I don't have cheap visits. Some of them come back, the majority don't. So that's my extent of contact with payers. Being an outpatient, you guys have great resources that you've developed yourselves even, or your systems have. I don't have a system by which, other than selling myself, which doesn't always work, to be able to show my numbers. I mean, if somebody in the room here can figure out some software to figure out how I can somehow show my value and my worth by not ordering MRIs and not doing procedures, gee, I would love that. And the second thing, I love what you guys are saying about being a good doctor, and that was what I used to tell people, everybody, even gave a PM in our lecture on how to market yourself. Be a good doctor. It isn't necessarily so anymore, because I'm in Chicago where there's three or four large groups that really don't want to refer outside of those groups, and they tell their doctors, don't refer outside of those groups. Fortunately, I started before that happened, so I still have a referral base and life is still good. But boy, I see guys and doctors in Starbucks, and they go, Marty, we miss you. We wish we could send you. And I mean, that's really nice, but things are really changing. So being a good doctor, it's nice, and I think it's self-value and it's valuable to the patients we see, but it's hard to maintain a business when you're not in a system, being just a solo private practice guy, and I think it's dying because of that. And I want to hear what you have to say, I didn't want to just lecture you. So my comment of being a good doctor, one, everybody should be, but in the context of enacting change. If you want to go be a change leader, you want to be an agent, you want to go to the table, you better be good at what you do, otherwise you won't be able to drive anybody to do it. That was my point. Not to dissuade people from going into private practice as a really good doctor. The tricky part, obviously you know the private practice part, the tricky part is if you're that and you're living in a fee-for-service world, and you have to understand sort of all the payers around you and who pays enough for your services and how you make this economically viable, and this is why if you track nationwide, the AMA tracks doctor surveys every two years, private practices are just going boom, boom, boom, boom, boom, right? And the percentage of people under 40 going to private practice is now like 20%, right? Whereas your generation, my generation, way higher, right? So it's, the whole thing economically is very, that's a different conversation, how the economics of private practice work is different, but. And any ideas of how to, is there software out there, is there some way to track through my EHR, do you have any suggestions, not being an institution, how to prove my worth or value that I think I have, but how do I get them to know that? You'd have to have numbers and you'd have to have some comparison, you'd have to have, like Joel said, the insurance company doesn't care for the most part, you have to get back to the person paying the bill to care, so you have to sort of see what, if you're working in a space where you're seeing, you know, insured patients for, you know, large insurers who are middlemen largely, it's very hard to sort of then say how do I demonstrate value in this space, right? You have to get back to sort of the economics and who's the economic payer, what kind of model you're going to try and demonstrate that to, and then you got to track your data and you got to sort of, you have to build a virtual team to do it, because the only, probably, it's very hard to capture all this without a team-based structure. Yeah, and the other side of that, too, can come from the advocacy piece, which, if you want to hear more of those talks and how to get involved and through the AAPMNR and other organizations, state medical societies, please let us know, because we'll try to offer more of that through the session, so thank you to all the panelists today, we really appreciate all of your perspectives.

value-based care

physiatry

preventative care

challenges

demonstrating value

health systems

outpatient practices

coordinating care

healthcare system

partnerships

preventive care