Good afternoon and welcome to the session. My name is Rich Zorowitz from MedStar National Rehabilitation Network and Georgetown University in Washington, D.C. I'm also the chair of Innovative Practices and Payment Models Committee. We're very happy to welcome you to the session on Unlocking Value-Based Care Opportunities for Physiatrists. We are especially pleased to welcome Dr. Brian Walderson, who is the director of the Division of Specialty Payment Models at the CMS Innovation Center in our nation's capital, or somewhere around there, who knows where. Dr. Walderson went to medical school at Johns Hopkins, also got his MPH there. Did not train clinically because he got swept up with all this wonderful stuff on value-based care. What he thought was going to be a short stint at CMMI and has made it his career. So we will be very interested to hear what he has to say about value-based care and how it can help us. So Dr. Walderson, thank you. Yes. Thank you, Dr. Zorowitz. I appreciate that introduction. I forgot to mention one thing. I was also, maybe the most important for this group, the co-president of the PM&R interest group in 2009-2010 at Johns Hopkins, didn't end up... So this is my far favorite specialty, even though I didn't train in it ultimately. But I'm very happy to be here talking to you all today to what is also... Physiatry is a very value-based specialty, just in its nature, in trying to optimize function, focus care on the patient, and really looking for other ways than surgery to sort of help patients out. So yeah, today I will be talking about unlocking value-based care opportunities for physiatrists, and in particular, focusing on our specialty care strategy and sort of pointing out ways that physiatry sort of fits into that overall goal. So I have to, especially after what happened Tuesday, I have to include my disclaimers. This presentation is meant to be a summary of our policies and not intending to signal any future policy changes, nor does it replace regulation and guidance directly from Medicare or Medicaid. And of course, the strategic direction of the Innovation Center is always subject to change, so keep that in mind. Alrighty, so my plan for today is to start with, for those of you maybe new to value-based care, start with a very broad introduction to the Innovation Center, what it is we do, general definition of value-based care. Then I'll move into what was our 2021 strategic refresh, and really what that was, it was the 10-year anniversary of the Innovation Center, and we looked to sort of re-center on our goals and focus in on what models we were finding to be helpful. And then next is really the meat of the presentation, where I'll talk about our specialty care strategy that we rolled out in 2022, and we're working hard at implementing and sort of highlighting where physiatrists, or physiatrists, I should say, might fit into that picture. And PM&R is also not only value-based, but also just a very heterogeneous specialty, which I think presents both opportunities and challenges with adoption of our value-based care frameworks, so we'll get into that a little bit. And then finally, just end with a few resources and provide some avenues that you might provide feedback, so here we go. Okay, so very broad overview. What is the CMS Innovation Center? So the CMS Innovation Center was established in 2010 under Section 3021 of the Affordable Care Act. I started medical school in 2009, so that's really, you know, when you're starting medical school, you kind of are able to get involved in advocacy, and that's really what swept me up into all of this, was the passage of the Affordable Care Act. The intent of the Innovation Center was to design and test new ways to structure incentives, to unleash innovative methods of delivering care, and ultimately, we are seeking to improve quality and or reduce federal spending within Medicare and Medicaid. And so we are essentially positioned to trial changes within Medicare and Medicaid before rolling it out to the broader program to make sure, you know, there's been a lot of sort of disasters and unintended consequences of some health policy changes in the past, and we seek to, in the same way, maybe a clinical trial would work where you have a phase one, phase two, make sure it's safe and effective before you roll it out to the general program. So that's how I like to think about it. The Innovation Center statute, as I mentioned, Section 3021 of the Affordable Care Act, it amends Section 1115A of the Social Security Act, and it extends fairly broad authority to the Innovation Center to waive existing federal statutes and regulations guiding administration of Medicare and Medicaid. It actually was, it's sort of unbelievable, to me, the waiver authority that Congress extended because we can really, you know, pick and choose, as long as it's necessary to the test, what regulations and even statute we can waive to test programs. You know, there's a lot, it's not just unbridled power. We have to go through a lot of channels to get approvals and things, but ultimately, it's pretty incredible opportunity to fix some of the things that exist in the Medicare and Medicaid programs. As I said, extending these waivers are only permissible if they are absolutely required in order to test an innovative payment and service delivery model. And the intent of these models, then, would be to reduce program expenditures while preserving or enhancing the quality of care furnished to individuals under such titles. So the goal, obviously, is to prove benefit in one way or another. And if we do show benefit through one of our models, the statute allows for such a model to be certified and expanded nationally and indefinitely through regulation. And so it's really three scenarios we commonly refer to that allows us to expand models. First is we can generate savings while maintaining quality. We can improve quality without increasing costs, or we can do both. And it's the Office of the Actuary, which is sort of an independent body within CMS who determines whether or not we generate savings. And through a new pathway established through the Assistant Secretary for Planning and Evaluation, ASPE, they are the ones who determine whether or not we have improved quality within a model. So in testing these innovative health care payment and delivery models, we generally organize our tests into what we call alternative payment models. And really what we're doing is seeking to reward health care providers or institutions for delivering cost-efficient, high-quality care. And they generally organize themselves into one of five different themes. It might be a specific health condition, such as our kidney care models. Care might be organized around a care episode, such as total joint replacement, lower extremity joint replacement in our comprehensive care for joint replacement model. It might be centered around provider types. Example is our home health value-based payment model, which is one of the models we've expanded. And then organized around the community, such as the innovation in behavioral health model, which is really set up to support community behavioral health organizations. And then finally, innovation. And this would include models like our cell and gene therapy access models. So that's how they've generally organized themselves. Now our current portfolio, so these are a list of all of our, there's about, we've tested in our history about 50, maybe 55 now, alternative payment models since we've started 14 years ago. And these are all the models that are currently active or announced and will be coming in our portfolio, the next two slides. And I tried to go through and highlight where I thought PM&R could potentially play a role in advancing the goals of the model. The first in our accountable care models, ACO REACH is our active CMMI focused ACO. There they have opportunities for specialists to get involved through our advanced payment option, partnering with ACOs, really looking to do a lot of things under the ACO umbrella. Second care primary is our new primary care model where we have specific specialist focused incentives to help bring along specialty integration with primary care. I'll talk more about that later as part of our specialty care strategy. Then a big one is our episode based payment models, including BPCI advanced, the CJR model, which is actually ending. But our next generation episode payment model, transforming episode accountability model or TEAM, which has been announced and initially rolled out through rulemaking. That is also another opportunity where I think bringing in PM&R early, especially in coordinating care across the sort of anticipated rehabilitation and care transitions during the model could be of enormous value. There are opportunities in those to sort of partner with existing participants or hospitals to gain share. And then I added an enhancing oncology model just because of the needs of, and actually we're working on the chronic aspect of cancer care management and important roles for PM&R on that as well. And then our state and community based models, I think the Maryland total cost of care and what is sort of the next iteration of that, that the state's advancing all payer health equity approaches and development, which has been announced and will be rolling out. I think there's opportunities there, particularly in the episode frameworks. And then the Medicare and Medicaid financial alignment initiatives to really where PM&R could play a role. And then finally, so the Innovation Center over its 14 year history has impacted more than 41.5 million beneficiaries in all 50 states. We've had really pretty incredible breadth and reach. Also included more than 314,000 healthcare providers or provider groups across the nation participating in our programs. So pretty exciting breadth that we've accomplished over the last 14 years or so. So next up is the strategic refresh from several years ago when the Innovation Center turned 10 years old. The current administration decided it was time to step back. And we had done 50 plus models at the time. And it was also during sort of a time of crisis in the country with COVID-19. And so it was an opportunity to step back and say, okay, what have we learned over the past 10 years and where are we going in the future? There are a number of white papers about this on the CMS.gov website, but I'll try to give you a quick overview here. But also remind you that we are going to be changing administration. So way too early to say where this might be headed. But I might also just point out that really the CMS Innovation Center has really been a bipartisan point of coming together because the goals of value-based care have really spanned the gamut. I mean, it's from both parties. It was even a big part of Project 2025 value-based care. So I think both parties sort of acknowledge that we are on an unsustainable path as our baby boomers age into Medicare. So I would be shocked if we really went too far away from the path that we're currently headed with the change in administration. So the strategic refresh. It began with this vision and goal statement. The vision itself is pretty consistent with how we've been organized over the length of the center. A health system that strives for equitable outcomes through high-quality, affordable, person-centered care. Now the goal, however, did mark a shift in direction to some extent, or really a focus in direction. And back in 2021, we set this bold goal of by 2030, all Medicare beneficiaries and most Medicaid beneficiaries being in a care relationship with the care provider is accountable for total cost of care and quality. And so this goal most obviously most cleanly fits, I think, into our accountable care organization models and programs, MSSP as a program, and our advanced primary care models. Also our state-based models. But I think our accountable care relationship also really extends to kidney care, oncology care models where the specialist sort of steps in and takes over for primary responsibility for the patient, sort of replaces primary care, just because primary care isn't trained to really the care is more specialized to where the specialist sort of takes the central role during that time. And I don't have the latest number on where we are. The percentage, I believe it's somewhere between 40 and 50 percent of Medicare fee-for-service beneficiaries. So we're on a path. We'll see if we get there by 2030. And the refresh also included these five unique objectives. The first aligns most cleanly with that goal, which is to increase the number of people in accountable care relationships for quality and total cost of care. Next advancing health equity. I think the COVID-19 pandemic really brought to light some of what have been long time in existence of disparities with underserved populations. So now all of our models have explicit components that try to focus on and improve those disparities. Supporting innovation, we are looking to enable integrated person-centered care really requires novel approaches to care delivery. Technology and actionable data feedback are really, they're not something we interact with directly, but they're absolutely critical to achieving this person-centeredness. With the fax machine and massive stack of medical records that accompanying a patient to a visit is not going to really get us towards person-centeredness. It also includes dissemination, learning, collaboratives, and payment flexibilities to allow clinicians to innovate themselves. That's really what we're about. Fourth is affordability. I think that's obvious. We've been on an unsustainable path for a really long time. Lots of duplicative care. And as I mentioned, baby boomers aging in. We really need to address affordability. And finally, partnership across the system. You know, CMS, we know we don't, we aren't releasing regulations into a vacuum. They really have to fit. And we need to think about purchasers, other providers, payers, states, Medicaid agencies, beneficiaries need to all come together to achieve those goals and we've really built out a lot of our stakeholder outreach in order to do that. And it's part of why I'm here today, talking to you all, is to really, we're really hungry for feedback and ideas for how we can achieve this. Okay, and then as a mechanism, you know, to test new ideas, how do we make sure that our innovation center is building on what we learned? So as I mentioned, the primary mechanism is, you know, as defined by statute, is the expansion of successful models. I will say, though, that the statutory definition of success is a very, very high bar, at least in the way our actuaries have interpreted it. And so in order to prove budget neutrality, we pretty much have to definitively demonstrate that the model will not increase costs. And to do that, it really means that the point estimate of our models, that, you know, our point estimate of the effect of the model has to be pretty significantly below zero, such that that upper limit of the confidence interval has to be below zero. And that is just very, very difficult to do in an open, evolving system where it's very hard to say definitively and to narrow in, even with some of our, you know, very complex quasi-experimental models to definitively do that. And so that's part of the reason that so far, only four of our model, four out of the 50-some models that we've been tested have been expanded. So what that means is that we've, and just that the bar set by the statute, we realized that there needs to be other, we need to make sure that these models are, and our learnings are scaling in other ways than just expansion. And so the first alternative way we do that is with our successor models. I think the episodes are a good example of that. And it can also be extremely difficult on first try to get all of the incentives right. You end up doing sometimes harm, more harm than good, rarely, but it happens. Quality measures, you all, I'm sure, have had experience with a quality measure gone awry. There was actually one that was particularly for spinal cord injury that just made no sense and was actually causing harm. So in the same way, these models, we want to make sure, and we don't get them always exactly right. So our successor models do that. And we'll do that when we believe there's a high probability of making some of these substantive changes will either generate savings or lead to those quality improvements we're looking for. And then another way to do that is incorporating pieces of our models. So we've done this a lot, incorporating pieces of our models into regulation and permanent programs. This has been done numerous times with our ACO models as one example that have then been brought over and included into the Medicare shared savings programs. And that's happened a lot, most recently with our primary care capitation. And models are adopted through legislation, the intravenous IVIG model that allowed for home infusions of IVIG for certain immunodeficiencies, which just made sense, especially during the pandemic. That was eventually adopted into a permanent program. And then we also are, we've generated really a massive arsenal. If you look through the Innovation Center's website and our evaluations, you can't really because it's just thousands of pages, literally. But in those thousands of pages, we're starting to make sure to pull out some of the evidence of transformative change. Our evaluations teams do a lot of site visits going to capture what is going down, what is happening at our project sites, and looking more deeply, they've been looking more deeply into what led to some of the transformative changes. And actually we're just starting to look into testing some of these transformational changes. Why are some model participants successful and others are not? And then starting there, and then looking to do rapid cycle randomized controlled trials of clinical interventions, which is an exciting new avenue that is new to the Innovation Center that we'll be starting in a couple years. Okay, maybe I'll stop if there's any questions in general before I get into what is really the main body of the presentation here. This is likely to, yeah, sure. Hi, John Che from Case Western Reserve in the Metro system in Cleveland. This may be a little bit of detail. You mentioned the equity component. I work at a safety net hospital where more than 40, 50% are Medicaid and underserved populations. And as you know, depending on what you read, 50 to 80% of health outcomes is determined or associated with the so-called social determinants of health. And you mentioned there's some sort of adjustment that you all do with that, and I was wondering if you could just share with us a little bit of detail as to what that means and so on. Yes. Okay, so yeah. There have been several changes, and a lot of them are model specific. We have a health equity core team that tries to coordinate some of these changes across models, but most recently the team model might be an example. In BPCIA and CJR, we did not. We had adjustments for safety net hospitals and dual patients to provide more resources. Obviously there's different increased needs there. For the team model, we created a totally separate track that is upside only risk for the first three years. We provided different incentives and different quality measures to capture some of the challenges that safety net hospitals face. Other models have included infrastructure payments for safety net practices. We also are either, depending on the model, requiring or voluntarily allowing submission of health equity plans that really encourage all participants to sort of talk about how they plan to structure their programs to make sure that they're addressing some of these disparities. It sort of varies across models. ACO REACH, for example, also includes a health equity adjustment based on safety net status that was, and the Maryland cost of care, the total cost of care model, heart payments that are based on the, it's going for me now, the indicator. The neighborhood level indicator of where the beneficiary is. There's extra, there's tiers of payments based on social need. So we've tried to incorporate where we can sort of, and acknowledging where we need, there needs to be additional investment. And we continue to do that with all of our models. Rural status is another big piece of that. There's rural policies in all of our models. So if you have other specific questions on a specific model, I'm happy to talk to you about them too afterwards. So to the main body of the presentation, I'm going to sort of talk about our specialty care strategy, which my division is responsible for. And we rolled out in 2022 after doing a big listing tour. We went and talked to a lot of ACO specialists, health policy experts, MedPAC folks. And I'm going to, we've broken it down into four elements of the strategy. And here again, I'm going to just point out where I think PM&R fits into the overall vision. So first, why is the Innovation Center focusing on specialty integration? So as I've mentioned, we have this pretty bold goal of 100% of beneficiaries in traditional Medicare, vast majority in Medicaid, in the accountable care relationships by 2030. And this goal seeks for advanced primary care practices and ACOs to provide high quality whole person care at a reasonable cost. And the fact of the matter is that primary care alone is not going to be able to provide the breadth of the needs of these beneficiaries. And it really requires coordinating with, and in some cases, integrating specialty care within their care pathways. So this is the four elements I mentioned. And we first laid it out in a CMS blog from November of 2022. And you can see we have both long-term and short-term goals here. I'm not going to read these out to you. I'll go in detail one by one over the next few slides. So this is all organized, as you can see, around the patient journey from early on to onset of chronic disease, prevention, onset of chronic disease, acute medical events, transitions between them, procedures, and finally, end of life care. So the first element here is enhancing specialty care performance data transparency. And really, I think the goal here is pushing out specialty performance data to other clinicians to help create some of that tension in the market with the goal of then allowing the market to, I think, efficiently distribute the rewards. This never goes well when we try to get in the mix and try to determine what should go where and who to reward for different pieces of care. When it's integrated, we end up messing things up. So we hope that the rewards, and this could be in the form of either increased patient volume or through provider-driven gain-sharing arrangements. And the two primary pathways that I described here is first sharing this data with accountable care entities through specialty performance profiles and dashboards. And then the second is shadow bundles. And I'll sort of define what shadow bundles, that might be a new term for some of you. So first, the data transparency piece. So we are currently working on specialty care performance data dashboards. The first place this will roll out will be to primary care or referring clinicians. And I think that's a key point. When we talk about quality data there, I'm sure there's lots of problems with how we've measured quality. It's very hard to do. We find it with measuring our own quality in the innovation center. You can easily get it wrong if it isn't precisely specified. So I think, though, the key difference here is we're sharing this data with other clinicians who understand the limitations of quality information. I think there's a pretty big difference between doing that and rolling it out to the more lay public who might not understand what might be driving some of those numbers. So beginning in 2025, our goal is to have a data feedback tool that we can release to our Making Care Primary participants. And also, we want to do the same with specialists who have signed CCA's collaborative care agreements with our Making Care Primary participants so that they can sort of get an idea of where they fall in the continuum of quality measures and understand their markets and sort of use that as their own continuous improvement sort of tool. Because that's ultimately where we want to be. We know a lot of practices are already measuring themselves that you can't understand your own improvement without measuring it. And so we really want to sort of come together and use quality measures as a source of improvement, not strictly some way to penalize a practice because that often becomes inappropriate. So I should say here too, specialists will not be accountable for these measures. These are mainly to help inform other primary care providers in their areas. So that will span the gamut of cost, utilization measures, and quality to help inform referrals and to help manage partnerships. And it will also allow primary care doctors to dig into where have their patients themselves been, not just the summary level, but also digging below the surface into tracking because a lot of times they don't have a clear picture of what happens to their patient when they leave the office. So I'll talk a little bit more about that later. Data transparency, shadow bundles. This is where I can see PM&R playing a role. Shadow bundles are essentially Medicare claims data that are packaged into bundles. And sort of payments are set. They can be procedural or condition-specific acute episodes of care. We're also exploring chronic episodes of care and providing those to ACOs for their ACO-assigned or attributed beneficiaries. And the goal really here, we provide benchmark prices as well, the goal really here is to allow ACOs to set up their own arrangements with providers and sort of conduct their own, I guess you could call it a mini-ACO or mini-bundled payment model for their ACO beneficiaries. A lot of ACOs are doing so already and we're hoping to do that. We're hoping to facilitate more of that. We currently provide the data for 34 episodes that are included in the Bundled Payments for Care Improvement Advanced Model, looking to expand into the chronic care episode-based cost measures in the future. So again, this is helping to facilitate partnerships, not necessarily consolidation, but integration and partnership among providers. And we anticipate this data helping ACOs gain insight into their specialty care patterns, helping them manage beneficiaries better and also support ACOs setting up their own episode-based payment arrangements. We did a, I would qualify this as more anecdotal, we did a survey. We plan on doing more formal evaluation later. We've only had these data for eight months now. But we informally asked respondents or ACOs and respondents, 95%, they were very likely or likely to use shadow bundles to do the following things, provide a deeper view of specialist performance. A lot of them have partnerships with specialists and I would encourage any of you with ACO allies in your local area to investigate potential partnerships there, especially supporting patients across the spectrum of rehabilitation after hospitalization and other patients. To support the ACO's ability to engage with specialists, we're seeing them do that. And then to help them base referral decisions off that performance and then finally to create the opportunity to utilize episodes of care as a mechanism to share savings downstream with specialists that are participating as part of their ACOs. So that's sort of the first element, the data element. The next piece of our strategy is really maintaining momentum on acute episode payment models and condition-based models. You can see that's a little later on in the beneficiary pathway. You know, it begins with an acute episode or an outpatient procedure and extends for a period post. So the short-term pieces of that are extending BPCI Advance, which we did through the end of next year to limit any gaps with our next forthcoming model. And then we did launch a new model focusing on beneficiaries with cancer, the Enhancing Oncology Model that launched in July 2024. And then we also announced a new mandatory episode, acute episode payment model, the Transforming Episode Accountability Model team. And that sort of also includes pieces that integrates better with ACOs. So I'll talk here about our momentum with current models. The Comprehensive Care for Joint Replacement model is, this is actually one of our most successful models to date and is a model my team and I run in our division. This came out, this was a successor model that came out of early success in the original Bundled Care for Care Improvement, Bundled Payment for Care Improvement Model, BPCI Classic, we call it now, that we saw joint replacement was sort of the prototype episode-based payment model or episode-based condition because it sort of has a patterned care pathway that can be replicated. CJR holds participants responsible for patients undergoing lower extremity joint replacement, hip and knee mostly, and making sure that they receive high quality and coordinated care across all providers through the time of admission, if it's a fracture, or the time of the procedure through recovery. That includes physical therapy and other at-home rehabilitation care. CJR began on April 1st, 2016 and actually runs through the end of this year. We're counting down to the end of this model. And I think we are really excited about the results and really excited to carry those through to the next episode payment model. Now, I'm not gonna go through every detail here on sort of the parameters of the model, but I will say, in terms of the evaluation, we saw consistent episode savings across really the entirety of the model, and it was something that began immediately on the start of the model. It was pretty incredible to see almost overnight these savings reductions. But also, and this is something that has become more clear as evaluation teams have gone and visited sites and understood the transformative changes that are going on at the ground level, and really has led to demonstrable impact on patients. And actually, we're just starting to see results from, we took a deeper dive into where ACOs and CJR model, the models overlap, and that is where we've seen some of the most striking transformative change. So really excited to extend some of these learnings and continue testing. This, I'd be surprised if we could, this'll be our third, actually fourth, episode payment model. And I think we really think and we hope we're getting the incentives right. And in particular, I think the concerning area for CJR was on some of the safety net hospital impacts. We saw where they could be consistently in the lower end of receiving the incentive rewards, and that was, I think, one of the major reasons why we decided not to pursue expansion. When you expand a model, you sort of have to maintain all the pieces, the as-tested. And it was really, when CJR was designed back in 2016, health equity wasn't a central piece of what we were looking to improve, and that's been a big focus of TEAM. So TEAM has many of the same components of CJR, including, and this time, a safety net and rural health track, and that aims to support them better and make sure they're coming along with the other episode models, or with the other episode participants. TEAM will run for five years, from January 1st, 2026 to December 31st, 2030. It largely will look the same as our prior episode models. We've shortened the episode to 30 days once the person leaves the hospital, so starting on the discharge date or the completion of the outpatient procedure. And we'll include payment for coordination and emphasize communication between individuals and their caregivers. So, and I think, well, again, to model participants will be hospitals, acute care hospitals, although we are extending the same opportunities to gain share with physicians and hope they take more of an opportunity to do so. We're using the, you know, we use the fraud and abuse waivers of the, to waive the anti-kickback and stark statutes to really free up financial incentives to sharing of financial incentives and referral, you know, easing referral patterns without sort of the fear of triggering one of those statutes. So again, more of the TEAM overview, really the reason for this slide, you can see five performance years, the required episodes, and this will be required for the hospital to participate in. Each episode is really a set of DRGs, a family of DRGs that represent coronary artery bypass grafts, major bowel procedures, lower extremity joint replacement again, surgical hip and femur fracture treatment, and spinal fusion. So I think I could see physiatrists playing an important role in all of these episodes. Again, the getting involved even early in the acute care, particularly fracture for lower extremity joint replacement, and then helping guide the patient through the rehabilitation continuum, and back to then connecting them with primary care and getting them back connected with the accountable care entity. So yeah, I think lots of opportunities there to engage in sharing some of that risk. Yeah, please. If you, a couple months, sorry. Yeah, it's hard over the... I'll go back to them, but just on this one, this is for 30 days after discharge, right? Yeah. From a rehab standpoint, spinal fusion, you don't start PT for longer than that, right? We don't even start rehab for some of these things until well after 30 days. Even joint replacement, now it's 90 days. The bundle's 90 days. Yeah, it's currently 90 days. So 30 days from a rehab perspective is short because if somebody had a bypass surgery, we don't actually do a lot with them. Rehab isn't in that window. Yeah. So these are really acute medical complications after the event, which is actually radically different from a bowel procedure versus spinal fusion. Yeah, and I think, yeah, that you make a really good point. The reason for the 30 days was a push from the ACOs who there was this competition for a long time between ACOs and episodes, and who was having responsibility. So I think we moved to 30 days. I think there's still opportunity, though, for rehab clinicians to help develop a plan of care, help oversee those care transitions, and then integrate them back into ACOs. Now, I think there's also opportunity in ACOs for rehab physicians to, like I said, PM&R is an extremely value-oriented specialty and would be seen by ACOs, I know, as providing that value. So I think, really, it's about that short-term transition. And I know that I've seen, I don't know where exactly, but I've seen also initiatives by rehab physicians getting involved really early in the hospitalization and sort of providing that expert guidance on what would be the best plan of care. So I think that's where this is sort of focused. But I definitely hear you and agree with you that rehab extends much longer for a number of these things, particularly in cardiac rehab and that sort of thing. But I think by that point, we're looking, for longitudinal rehab, I think opportunities or needs, we're looking to integrate with the ACO and sort of have the ACO take the reins at that point. So I think that was the thought there. But that's a good question and valid concern. Actually, yeah, did I? Yeah, I think I covered everything here. And actually, before I get, I wanna just pause there, maybe, through two of the elements. Any other questions that, yep? Kind of following on Chris on the rehab team. So we know that with spinal fusion, the epidemiology of that says that it's pretty arbitrary who gets a fusion. And we did a study at Michigan that said that if you inserted a physiatrist between primary care and surgeon, you get rid of one third of back surgery. And so there's this whole piece of that that, I mean, good luck saving money after the fusion's been chosen. But I wonder about those bundles going forward to saying, hey, you're doing too many fusions anyhow. Right, totally, upstream. And this is what we talked to Chris about. It's hard. And this actually kind of, what I was, it's kind of moving, yeah, you're dumping the gun on element three. But it's, yeah, that's something we've thought about and we've stood upon this and actually low back pain for a very, very long time. One of the challenges though is when do you trigger an episode? You're catching a patient on, and we talked to Chris about this, you're catching a patient at all these, they could be at any point. And where you take that snapshot, from our standpoint, it's so hard through claims to understand where that patient is on their journey. Or even understand whether it's an acute emergency spinal stenosis patient that needs to go to surgery. We can't see the red flags in our claims. So it's very hard to, we went through the analytics of this and pulled every adjuster we could think of from claims and from, I even went to the, I even was trying to get social security data. They don't like sharing data with us for, especially income and those sort of sensitive. So I really chased that down too. And we tried adjusting every single way and we couldn't, we just don't have the explanatory power to do some of that. But we are, we have some thoughts on, and I'll talk about that on element three. But it's, yeah, huge challenge. Yep. Do we have a, oh, thanks. I'm curious. So you said the total joint program episodic cost reduction was noted. My question then becomes, how about total cost? In other words, was there an increase in the number of total joint replacements as a result? And so was the total cost also savings as well or no? Great question. That was something we were very acutely aware of and concerned about in that, if you create a bundle, are we advertising joint replacements more frequently? Are we increasing the rates? And there were some, it's so hard because it's, this is an open system where the rates are changing over time because of baby, there's so many external variables. But we spent a really long time in the evaluation, looking at markets and comparing them with or without joint replacements. And we don't think we impacted, it's really hard to say definitively, but we're more convinced than we aren't that we did not cause an increase in unnecessary utilization. And we also, the statute requires total cost of care reductions in order to expand and that's, so that's the primary, so that's the primary metric we look at. And there were total cost of care reductions, even though, to his point, where the trigger is still part of that. There's still a fee-for-service non-value component in there in that you do a joint replacement, you get a big bundle. We don't think we made that worse. One thing we're working on in team and one thing I'm not certain if it will be a required component where we've been flirting with, I probably shouldn't be saying this, but we've been flirting with this shared decision-making measure as a way to, in my mind, shared decision-making and giving people the full, informing them fully on what the outcomes are likely to be given where they're at is a much better way than trying to do a pre-author. And because, in fact, it also is a, we did notice early on, but ended up washing out a disparity between, and this is actually model-driven, but this is a known disparity between patients who are black and white patients. On white patients, there's a disparity in the utilization. The thought is that there's over-utilization among white patients relative to black patients where there's under-utilization. And we found some small studies that really, when you include a shared decision-making component, you see, and sort of, I think consistent with the hypothesis was it actually led to fewer white beneficiaries receiving joint replacements and more black patients receiving joint replacements when you give them the, when you inform them of the benefits and what's likely to happen, be an outcome of their joint replacement, which I thought was really cool. And one way we could address a racial disparity that wouldn't trigger lots of concerns with our general counsel on how we approach sort of those health equities. So we're looking at, there wasn't a good existing reportable measure to include in that, and we're looking into developing something there. So yeah. Yep. Hi, my name's Michelle Gittler. I also work in a safety net system. And I'd love to give more chest pain to your people who are worried about triggering issues related to equity. We noticed two things and then a question. One is decreased access for individuals who have higher structural determinant of health. They live on a third floor or they have obesity or they don't have caregivers or they don't have transportation. They're not even getting into the system to get a joint replacement in the bundled models. So that's problematic. And then the associated question I have is I'm so curious as to how you're measuring those structural determinants of health. Like is it just zip code? Or are you actually collecting real data about the individuals? And then knowing all of that, the equity implications are way bigger than I've had food insecurity in the last 180 days. So, yes. Okay, so yeah, that is absolutely true that and we've looked also into these, we've looked into how patients flow into our bundled payment model. What is the pathways? Who's coming in through referrals from primary care and who isn't and what's causing that? It's hard to tease out. One, yeah, and it's area. So the area deprivation index is one thing we use. We don't, we can't collect directly from beneficiaries that data. And we also the, well, race data is very iffy. It's, yeah, not, it's often not self-reported. So one thing we are trying to do to the extent we can is collect more of that data through our models from providers. There's been pushback, some things we can't do because of concerns with lawsuits from people to lack of a better word. But right now we, and we've, so we've primarily used the Area Deprivation Index. I know there's been some controversy there on, and so it's zip code, of standardization of the index and the over-representation. It actually, I think, housing prices may be way over. There was a really fun, I had fun, might not be the right word, interesting back and forth in, was it health affairs? Battling it out on between the derailers of that index and ADI and other, and challengers it was. So we're looking into also rebalancing that, standardizing the Area Deprivation Index so we're not just looking at housing prices. And then there's also places like Hopkins in particular is sits in the middle of a very deprived neighborhood, which for years maybe we weren't, there's a lot of initiatives now, but there was, you know, people come from all over the world and wealthy people, wealthy countries. And it is, you know, serves a lot of that population as well but is it, is the safety net, is Area Deprivation Index accurately reflecting who the wealth of a place like Hopkins is probably not. And so we are constantly digging into that and trying to improve. But again, we have limited ability to collect that data through just our one-time Medicare enrollment through social security directly, but trying to encourage it and help and encourage one way around it with these health equity plans is we really want them to track their own disparities to understand it. It's problematic when we do it, but to understand where they have, where providers have gaps to make up is part of that health equity plan. So yeah, it's, there's some, there's a lot to be desired. We've pushed hard over the last four years in getting there and facing a lot of, our general counsel is very, very, you know, sort of, it makes them, it gives them heartburn to talk about these issues from that side. So, but I think we've made progress. Okay. So let's see, 15 minutes. Yeah, so I'll try to, yeah. For the purposes of recording and all that, yeah, let's try to hold questions so we can finish this presentation. Okay, so financial incentives for primary care to encourage specialty care engagement. And I'm gonna jump through a couple of these things. The first, there's two pieces of that. The first piece of element three leverages incentives established through the making care primary model. That model includes new codes to pay primary care for the use of e-consults and enhanced referrals. And then there's also requirements that they establish collaborative care agreements with specialists and a new payment for those specialty care partners. That is sort of a billable, what is meant to be a capitated monthly payment, though billable each month, to collaborate on care for, between primary care and specialists for the care of that beneficiary. And the next is about a push from the specialty side for setting up incentives for specialists to collaborate with primary care and accountable entities in optimizing that care. So this is just a basic overview for making care primary model test. It's gonna be a 10-year model that started, past tense now, in July 2024. There's three tracks across each track. There's more accountability, more expectations for integrated primary and specialty care. And so this is a busy slide, but it does a good job in laying out the incentives that we've put in place to incentivize specialist integration with making care primary model participants. So along the left side here, you see there, I kind of touched on the payment. There's a new payment for the e-consults and ambulatory co-management. Data, I talked about that at the beginning where we're creating these interactive data feedback tools so they can have insight into some of their specialty care partners. Learning tools, we're collaborating with stakeholders, state Medicaid agencies, health care partners to help to integrate better. The AAMC is a big one. They have a lot of experience with e-consults and collaborative care arrangements. And we're hoping to leverage some of their tools to share with our model participants and specialty practices and CBOs, for that matter. Peer-to-peer learning, lots of this work is going on right now, helping to build really evidence-based tools. We're making sure that, and being very, very careful that each piece of our learning system has an evidence base to it. We're really making sure of that and not just recommending things that sound like a good idea, but that have really been validated at this point. And I'll jump onto here, which is really the other side. So we're trying to push on one side from primary care through primary care specialty incentives, but then we're also trying to come at it from the other side with what is our ambulatory specialty care model concept. We released an RFI in the 2025 physician fee schedule, page 1,125 or something, I don't know how many of you saw it but yeah, it was part of that physician fee schedule. We got a good number of comments, including from the AAPMNR, really appreciated that. And really here, we're seeking to take baby steps, in a way, on building on the MIPS value pathways, which is a new framework that is utilized in MIPS and how we can utilize those MIPS value pathways to push specialists further into value-based care. So the MIPS value pathways are sort of this new reporting framework that attempt to streamline and standardize MIPS reporting. The MVPs include all the same categories that are included in MIPS, you know, the quality measures, the cost measures, the PR, promoting interoperability, the improvement activities, but all centered around either a specialty or what I think are more effective, the condition-based focus, and are packaged in sort of a specialty-relevant way, with the goal of making comparisons more relevant. And, you know, as of right, like currently in MIPS, which was a product of MACRA, MACRA left a lot to be desired, but there's a lot of problems with MIPS. I know a lot of you know. Our thinking here is to use our ability to waive some of those problematic pieces of MIPS or to change them in some way, and to create more reasonable comparisons. Right now, I think chiropractors and cardiologists and PM&R doctors are all in the same pool that everyone has a score out of 100, and you're all ranked against each other. It makes, it's kind of, I don't want to talk badly about a big part of the Medicare program, but some of, you know, a lot of it is just, it kind of leaves you scratching your head, and we want to fix some of those things. So I think there are several reasons we are thinking about leveraging these MVPs. The first is that the MVPs really include all the components of what we would typically include as in an APM, or in an APM in general, an alternative payment model. This includes those upstream chronic condition episode-based cost measures, which really, one way we mitigate, I think, the variability you see in that snapshot that I was talking about earlier is sort of turning them into a cost measure, and you can sort of mitigate the risk that isn't one-to-one episode spending that can be highly variable, and still get a reasonable signal on what, you know, physicians might be doing to improve that care pathway, and to derail the, you know, primary care referral to an orthopedist to immediately to back surgery. And so that, it also helps like with this, make a fairer assessment of efficiency. The MVPs also pull in relevant quality and care transformation components. Next, it also creates alignment between MIPS and our APMs, allowing a smoother transition from fee-for-service into more significant risk arrangements. It's sort of a nice glide path into taking on more meaningful risk. The other thing is MIPS value path, the MVPs are applicable to multiple specialties. It's really hard, it would be really hard for us to create a, you know, a PM&R focused alternative payment model. It's just, I think, leadership, the political leadership are much more interested in making very broad sort of market impacts, impacts and less so on, you know, picking out individual specialties. And then finally, because we could design the MVP-based payment adjustments to be budget neutral, an MVP-based model could overlap really freely with, and avoid all the complex payment adjustments and infighting that happen when episode models overlap with accountable entities. And so in this way, we really are thinking about intentional overlap. We used to avoid overlapping like the plague because it sort of corrupted results of our models. Now we really see it as, and this really was born out of some of the effects, digging in, doing a deeper dive on where these models overlap in the wild and just seeing incredibly transformative results. And so in this way, we can create shared accountability and align incentives without creating just insane complicated methodologies. So now I will say we have no idea where this is going in future rulemaking. We have no idea whether or not the next administration is gonna be interested in something like this. So I don't want to get ahead of myself by saying too much more about it, other than I think we've been thinking about, and one reason we talked to Chris, who gave us really interesting, helpful feedback, although it was challenging some of our assumptions in a good way, that for low back pain as a potential focus of an MVP. And I know this is also, though, a condition you all think about a lot in terms of a value pathway. But before anything, yeah, there will be lots, before anything like this rolls out, we'd be, in future rulemaking, there'd be a lot more opportunity to discuss. We've been talking to Carolyn Missitt and the APR folks about where this might head. So I would just keep an eye out because we may be talking about this more, we may be not, who knows. It's really, we really aren't sure where we'll be headed. But finally, with three minutes left, element four, this is really the most nascent of the elements where we're really still thinking about this, or have started discussions about the next, I was about to say the next generation ACO model, which in fact is the name of one of our ACO models. It's the next iteration, I guess, of our ACO models and how we can better integrate specialists. We don't wanna consolidate everyone anymore. We've, I think, done enough of that. We want to integrate and facilitate sort of partnerships and sharing of risk. And really under the ACO umbrella, you can do that without, it allows us to waive these meddlesome statutes like the anti-kickback and STARK, as I mentioned, and create opportunities for specialists to join ACOs. And ACOs really are pushing into the specialty space. They've, I think the first few years, there was so much to do in primary care that primary care was their focus, but we've had lots of ACOs coming to us, talking to us about involving specialists. And I would urge all of you in the PM&R field to really take advantage of that. Like I said, PM&R is so value-focused and would provide such a helpful, provide such helpful input for ACOs. So we also are hoping to learn more from element one, which is providing this data to ACOs, seeing what they do on their own, and help, to help us inform what that would look like in a future model. And I think more to come on this. If you all have ideas, we're very hungry for ideas and thinking about how we can allow this to happen naturally. We don't want to be too meddlesome and create these regulatory requirements. We want to facilitate these things to happen naturally. More to come on this, probably more in the 2026, 2027 timeframe after as a follow-on to ACO REACH. So this slide just shows how each piece fits together on the patient journey across the continuum, because that's really the important part is the patient experience and making sure where that's as seamless as possible. And then this slide also is illustrating how it all comes together. The episodes and measures that we disseminate through element one should track through element two in the acute episodes and other condition models should track through element three and the MBP-based framework that we are considering leveraging. And then that should track through element four, which would be to allow ACOs to hold themselves and their specialty care partners accountable while sharing risk and allowing the benefits of the care transformation accrue to them. Okay, so that brings us to resources and feedback. I think the slides are shared, but I'll note our most recent Health Affairs Forefront article on progress of implementing the person-centered value-based care strategy. That was a 2024 update. We'll probably do another one in the spring timeframe. And actually, we are releasing our own metrics in the implementation, I think, sometime later, January-ish. So that'll be fun. You guys get to watch us hold ourselves accountable to quality measures, which I know would be exciting on that side. And then, because God, yeah, I know, we've... And then the CMS Innovation Strategic Direction webpage, which is up. And then stay in touch. We have a couple email addresses. Get in touch with us. You can also meet with us as a specialty care strategy, as we did with Chris, as we did with AAPNR. We love hearing from stakeholders. Get lots of important ideas before we embark on this big model design venture. So yeah, thank you, everyone. Really appreciate you taking the time and choosing this session. It's fun. And welcome to take questions. Well, in terms of, yeah, since we are... We're ending. Officially, we're out of time. Yes. But if you have questions, please, for purposes of recording and stuff, we are gonna end here. But if you have questions for Dr. Walderson, please come up and ask. Thank you for coming. Thank you. Hi, how's it going? Hi, how's it going? Good.

value-based care

CMS Innovation Center

alternative payment models

comprehensive care for joint replacement

Transforming Episode Accountability Model

healthcare quality

data transparency

accountable care organizations

clinician collaboration

healthcare innovation

stakeholder engagement