I am going to be introducing our first speakers here. We have Cameron Wheeler and Michael Picchiaro, who are the Directors of Government Relations for Lobbyit. They're going to be giving us an advocacy update today. So welcome, Cameron. Take it away. Awesome. Thank you. It's great to be here today. I'm Cameron Wheeler with Lobbyit. I'm a Senior Director of Government Relations here, and I've been working with AOE almost a year and a half now. So I'm really excited, and I'll have my colleague Michael Picchiaro introduce himself as well before I get started. Thanks Cam. Nice to see everybody today. My name is Michael Picchiaro. I started Lobbyit in May, joined in May, and started working on AOE just after that. Prior to that, I was an attorney for the U.S. Office of Special Counsel and also worked on the Hill for a few years. With that, I'll give it back to Cameron. Awesome. Thanks, Michael. So like I said, thanks for everyone for giving me the opportunity to talk to you today. So it's been a really successful year for AOE's legislative priorities. I'm just going to give a brief update on everything that we've been working on this year. So with great progress and growing support from members of Congress on several key items, we're really looking forward to the rest of this Congress and next year. Yeah, so I'll start with a little comprehensive update on some of the work we've done, and then I'm going to talk about the fall legislative outlook, and then a little bit about two regulatory items, including the Team CMMI update. So first, we've been lobbying on H.R. 5378, it's the Lower Cost, More Transparency Act. And links to all of this will be, I think, shared in the chat as well, so everybody can see some more details on what I'm talking about. So this House bill actually passed the House in December of 2023. It was introduced in multiple pieces on the Senate side. I want to say it spun off into 12 different bills. So this legislation really aims to increase transparency and reduce health care costs. It requires health care providers and insurers to disclose specific cost information, establishes new payment methods for Medicare and Medicaid, and it extends several of the expiring public health programs. And one key provision of this is that it would help use site-neutral payments to lower costs. So next on telehealth, we've really been focusing on the Connect for Health Act, it's H.R. 4189-S-2016. It's a very heavily bipartisan supported bill in the House and the Senate, it has 65 Senate sponsors and 58 House sponsors, and it expands telehealth services under Medicare. It would permanently extend that coverage. It also requires CMS to provide resources for providers on requirements and quality measures for providing these telehealth services. Telehealth is a big conversation on the Hill this Congress. I think my last count is there's 23 different bills between the House and Senate on telehealth, and you know, so something is going to move at some point on telehealth. This particular bill just happened to be the most bipartisan one, so we've really been trying to focus and get this passed this Congress. Then we've been working on H.R. 2474, it's the Strengthening Medicare for Patients and Providers Act, and this bill would tie the physician fee schedule to inflationary measures and has significant bipartisan support in the House with over 160 co-sponsors. So very exciting, made a lot of progress on that, and especially with the recently announced proposed cut to the physician fee schedule, it's even more important than ever that we get some more movement on this legislation. And then lastly, the Patient Access to Higher Quality Health Care Act, it would repeal the Affordable Care Act's ban on physician-owned hospitals. At the current state, it's largely a Republican-led measure, but certainly keeping an eye on it and advocating for it at every step. So as we enter the fall legislative session and the post-election lame duck period, Lobby It is really closely monitoring discussions around a larger potential health care reauthorization package. So the exact details of the package are still a little fuzzy, but some of the things we know so far is that it's definitely going to address telehealth, it's definitely going to address some of these expiring health programs. It will likely address some physician fee schedule, at least offsets, work on PBM reform, and likely some of the provisions from the Lower Cost, More Transparency Act. So this leads me really well into the fall legislative outlook. So now that Congress is in full swing post-August recess, their immediate attention is going to be working on passing, hopefully passing, appropriations and avoiding a government shutdown come October 1st. And Congress will also be working on measures addressing any expiring federal programs that need reauthorization outside of the standard appropriations process, including some leftover work from earlier this year on tax policy, the farm bill, rail and aviation safety, and more. So with the election coming up, Congress is trying to cover as much ground as possible before they leave for the October campaign season. And some of the measures that they're working on now will get punted until the lame duck period. But I don't really view that as a negative. Any members who are not returning to Congress really like to push through some of their final passion projects. And for many members, that includes healthcare legislation, specifically the bills that we've been talking about, a number of members of the GOP Doctors Caucus are retiring or leaving Congress at the end of the year and have made assurances that they're going to be moving forward some of this pending healthcare legislation before they depart. A lot of them consider this like their last hurrah or their last chance to really make a difference before leaving. And then in an even more exciting way, new members of Congress taking their place give AOE even more space to find champions for their priorities in the new Congress. So advocacy efforts this fall definitely focus on pushing forward some of the current legislative priorities with the existing champions, but they also include, you know, some relationship building with other members that may be taking over some of the departing leadership roles in the 119th Congress. So then on the regulatory side, I just wanted to briefly discuss two important regulatory updates. The first one is, as I'm sure everybody knows already, the cuts to the physician fee schedule. So in a proposed rule published at the end of July, HHS and CMS proposed an almost 3% cut to the Medicare reimbursement rate, and AOE has submitted very detailed comments on the negative impact that these cuts have had and continue to have on patient care and providers. So we're likely to see Congress take some action at minimum in the form of offsets, but really hoping that there'll be some full legislative efforts coming this fall. They do have a little bit of a longer runway on that than, say, appropriations. It doesn't have to get done before October 1st, but it definitely needs to be worked on before the end of the year. So lastly, what we're here to talk about. So the transforming episode accountability model, TEAMS, I'm just going to give a brief overview of it. I know Paul is going to go into some depth on it. So the model will officially launch January 1st, 2026, and runs for five years, ending on December 31st, 2030. And as a mandatory model, all model policies are proposed and finalized through rulemaking periods. And lobby it will assist in providing any and all updates as they are released, including submitting any comments that are relevant to it. And so I'll let Paul dive really into the details of the model and how it will potentially impact patients and providers. So in conclusion, as we move into the fall legislative session and the post-election lame duck period, lobby it will remain dedicated to advancing AOE's legislative and regulatory priorities, building upon the significant progress made. This Congress will continue to monitor and engage with policymakers on key issues such as physician fee schedule, prior authorization reform, telehealth, and any additional priorities we identify. We're committed to ensuring that AOE's voice is heard and lobby it will continue to be their eyes and ears here on Capitol Hill. Thank you so much, Cameron. Now I mentioned something in the chat, but before we move on to really going on a deep dive into team, did anyone have questions they wanted to drop really quickly into the chat or the Q&A for Cameron or Michael regarding other advocacy initiatives? And while we're waiting to see how that goes, I'm actually going to allow Paul to share his screen for his presentation as well. And Cameron and Michael, I believe are staying on the whole time. So if something comes up, certainly we can pass it along to them. But since I'm not seeing anything right here at the moment, I'm actually going to go ahead and pass it over to Paul Bruning. And Paul is with Sutter Health, and he's going to be giving us a little bit more in-depth information about team. So go ahead and take it away, Paul. Thank you. Thank you, Jessica. I appreciate that. And Cameron and Michael, we always appreciate your input in terms of advocacy and our events or and activities on the Hill, whether that's legislative or regulatory. So thank you for that update. Team is the transforming episode accountability model. It's the latest regulatory value based care model coming out of CMMI. And it is a mandatory model. And there was some discussion on how really is team going to affect everybody and really is it going to have an effect on us. One of the things is, is that this is owned by the hospitals, but it will affect our practices because we still are doing total joints and fusions in the hospitals. So that will affect us. And the other aspect of that is, this is a mandatory model, and it was chosen by CMMI, despite some of the results that I'm showing here based on prior models for bundled payments, BPCI, BPCIA, CJR, which we're all familiar with. If we look at the historical savings per episode into Medicare, the physician groups have done very well. And there's definite savings. While in some of the mandatory models, especially in the last couple of years of them that are reportable, there haven't been savings. But what this tells us is that CMMI is dedicated to moving these forward. They're dedicated to mandatory models. They're going to move these processes forward from inpatient and HOPD to the ASCs and further down the line. It's just that they have better control over the hospital reimbursement side than mandating this on the individual practice side. So as we've stated, this is mandatory, but there is also a voluntary participation for hospitals that so choose to participate. This is the final rule. These are the locations of the hospitals that are mandated to participate within this model. They are the owner, the initiator of the bundle. So as you can see, the Northeast is a condensed area, and there's an area of California that has a high relative condensed area around LA, San Diego, and also San Francisco, which wasn't necessarily surprising to us at Sutter. The anchor episode is an inpatient or a hospital outpatient procedure, and it's a 30-day post-discharge total cost, whereas when we were looking at BPCI and CJR, it was 90. This is now a 30-day post-discharge. The total cost is all Part A, B payments, and this has immediate downside risk potential for certain hospitals. There is some protection for the safety net and the rural hospitals. We'll get into that a little bit more, some questions and answers. Downside risk is a fact right off the bat for a lot of hospitals out there. As the owner of that, they'll be having to work with the practices that are doing the cases within that hospital to meet the requirements that this program has initiated. As far as the target price, we can get more into detail on that, but the target price is basically based on the prior three years' performance for that organization. What are the care episodes that are being included within teams? Lower extremity joint replacement, just like before, BPCI, CJR. What's new is the surgical hip femur fracture, spinal fusion was included in some, but now it is definitely included. Again, what we see is DRG numbers and HCPCS codes. This is inpatient and hospital outpatient procedures that are being done. These are our anchoring episodes. Is team all downside risk? This is what we talked about quickly in terms of there's different traps. There's no downside risk for some of the lower levels of reward for some of the first year. These are mostly safety net hospitals, rural hospitals. Track two is a little lower level of risk, some upside in through years two through five. Track three is where a lot of the hospitals will be. This involves both risk and reward years one through five. Hospitals, especially safety and rural, will have that opportunity to increase their risk after the first year, see how they do in that first year, and if they do well, potentially increase the potential for some downside risk. This is hospital initiated and owned, so how do independent practices participate? You will be able to participate through and receive payments in a couple of different options. Gain sharing payments are one option, which can be an annual payment between the participant and the collaborator. The participant is the hospital, the collaborator is the independent group. These are taken exclusively from reconciliation payments. Very similar to BPCICJR, there's going to be percentages of savings that will be paid back to that institution. Gain sharing is where those cost savings can be shared with the collaborating independent practices, but this is pain sharing where you need to have measurable, actual verifiable initiatives that are done between the hospital and the group so you need to work out ahead of time how that care is being designed, how you're each participating within that care and set up certain metrics that are measurable that you can verify to warrant that payment from the hospital to those independent practices. Then there's a alignment payment and this is between collaborator and participant and this can also involve the repayment amount. So if you are in a partnership with a hospital and your practice causes a increase in that total cost of care and you're not meeting the target of that bundle, the hospital and you are responsible for that payment. So there is a financial responsibility then for the independent practice to pay back part of that loss and that would be paid back and through the hospital. So there needs to be this collaboration between the hospitals and the independent practices. Some hospitals may have already arrangements where the physicians are employed through medical groups and PSAs that are working with the hospital that are part of that system. And then there's obviously the independent groups that aren't. Those independent groups will have to work out the metrics that show value and can be verified, can be justified to CMMI on why they would receive payments from the hospital for participation with them and part of that gain sharing aspects. So you might wanna know what is the main difference between BPC-ICGR with team besides that this is mandated to be owned by the hospital and the big thing is that there needs to be a referral to primary care following that anchor admission procedure. So what is required is that that patient follows up with their primary care within a given period of time. This is kind of an interesting addition because it's a 30 day look back. And in that 30 day look back, most of the care provided to total joint patients is done by the surgeon and not necessarily the primary care. So in part of the advocacy response to the team request for information, we argued that this was undue. Expense put on the patient because who is best to care for the patient within that short period of time following a total joint that those 30 days, it's the surgeon. Adding that is an additional visit to primary care that is a questionable need if you will and it's adding and taxing a primary care system that's already being taxed and it's hard to get access into primary care. Where we talked about a primary care shortage and yet we're turning around and having patients required to see a primary care provider in that window when what is the benefit of doing that? We challenged CMMI on that benefit. We didn't really get much of a response from them on that except that they're trying to integrate the care as a holistic kind of approach. The other thing that was kind of interesting about that is that this is at a cost. So if we go back and we are looking at a three year look back on our costs, we haven't had to send patients to PCPs before. It's not a huge cost, but it adds up and it adds on to costs that wasn't there before. So these PCP costs aren't going to be considered when we're setting that target price initially and it's gonna be a mandated cost on top of that. Compliance is going to be something maybe Jennifer Otto can talk about. She's from Sutter Hospital and she's kind of helping drive this with Sutter because let's say you're an independent group and this position, their PCP is also from another independent group going to this hospital and we need to get them in and coordinate all of these moving parts and these metrics and problems that are needing to be collected between these different factors. It's adding actually more complexity to it. And the beneficiary obviously has the freedom of choice of who they see, but we still need to be able to coordinate that visit. Consequences for non-compliance are corrective actions. There could be penalties enforced upon organizations that aren't meeting that requirement of seeing the PCP. So that is really the biggest change in terms of teams. It's another BPCI CJR, but it's mandated, it's owned by the hospitals and now we have that PCP component to it and a 30 day window for the target price instead of the 90 day look back that we had before. If you're looking for references, these slides will be available. You can click on any of these and get in and look into some of the more details on your own, but otherwise, that's a really quick high level overview, but we wanna open this up for you to be able to ask questions that we can try and answer for you regarding your individual situations. So I'll turn it back over to Jessica for the panel component. Thank you so much, Paul. That was a really in-depth presentation and a lot of information to cover. So while we're collecting any questions from you all in the audience, we do have a panel here ready to go as well. So I'm gonna go ahead and introduce today's panelists who are gonna be providing their insights on team. So we have today, Alyssa Ashley High from Marlboro Orthopedic Associates, Jennifer Odo with Sutter Health and Zelda Raridan from Spine and Scoliosis Center. And moderating today's panel, we have AAOE PASS President, Megan O'Hara. So Megan, I'm gonna go ahead and give you the floor here so we can get jumping into this panel discussion. Okay, we do have some questions. The first question is, there's a concern about the PCP assuming post-operative care for our joint patients. Can any of our panelists speak to that? Yes, this is a Jennifer Odo. I think the intention of the requirement to refer to the PCP is not for the PCP necessarily to assume full care. It's just kind of that touch base from a medical standpoint, comorbidities pre-existing. I'll also speak to what Paul had mentioned. Most patients will have to get a pre-op clearance anyway with their PCP, right? Before coming into the hospital for the elective procedures. Obviously, hip fractures is a different beast, but post-operatively, even for hip fractures, there's already built in to the continuum of care that referral back to the PCP. So in either case, I don't think the intention is for the PCP to assume care, but Paul, maybe you can pontificate upon that. I would agree. It's not to assume the care, it's to incorporate the care and the comorbidities and the different things that way. Yeah, because I just, oh yeah, sorry, sorry, Paul. Oh no, the question that AAOE had is kind of why to incorporate it as a mandate within that 30 days, especially around a total joint or a fusion or something like that. If this was major bowel disorder, cabbage like some of the other bundles, you know, that might, you know, those comorbidities may play more into it within the 30 days, but on a total joint, for them to get cleared by that physician for surgery, the questions that are gonna be involved are best answered by the orthopedic surgeon. So it was just more of a, I get it. We want to integrate the PCP. We want them to have that follow-up care with their comorbidities and et cetera. But within that window and adding cost and to the next question, the shortage, it's interesting. It's just interesting. I think because the episode care is now no longer 90 days, that 30 day window and the optimal or the ultimate, excuse me, gain, whether loss or in the positive direction is going to be on that risk score, that quality risk score. And part of that is complications and readmissions. So what role does a PCP have in monitoring, mitigating, tracking the comorbidities that preexisted and to ensure that the patient remains on track thereafter? For instance, if patient has a history of CHF or whatnot, it's well-managed before surgery, but of course there's fluid fluctuations during the hospitalization. So closer monitoring in that immediate post-op period by the PCP might help to mitigate some of the complications readmissions back to the hospital. That's what I can think from a clinical standpoint. Yeah, I agree with Jennifer on that. I think it is really trying to bring back that continuity of care that we've sometimes have, I think we've lapsed with the subspecialization and oftentimes the PCP defers so much to the specialty that the patient goes out to. But as an orthopedist, it's very hard for us, that's why we get the clearances to say, we're not the ones that can really make the adjustments in your medication for a diuretic or blood pressure or some of the blood thinners, whatever it may be if you're having these swells and things. So I'm a nurse by trade and I think that's kind of where BCPI was trying to go by having that navigator, that nurse kind of person that was trying to say, hey, let me see if I could integrate all these pieces and hopefully bringing that full circle back to the primary care. So it is not solely on the onus of the orthopedic surgeon who is like, I haven't gone to med school in 25 years, I don't know how to dose blood pressure medication anymore or when to change it or things like that. So hopefully that does help us out because we are being held responsible for these CHF exacerbations when the hip is fine. Just a question, this is a personal question. So our hospital has hospitalists who do all of this within our work community hospitals. So our hospitalist is managing all of their medical problems if they're on the ortho floor. Does that change this model in any way? It is a little confusing. Yeah, I don't think that it does for a couple of reasons. Number one, many of our patients are gonna be done on an outpatient basis. So there's that quicker discharge, they don't even have a hospitalist first and foremost. But really what I think the impetus for this component of it is in that post-op phase. Regardless of when you get discharged from the hospital, you still need to make sure that you have your medical or your comorbidities managed well to ensure that you have a recovery from a very, from an elective procedure in many cases. Again, not hip fracture, different bucket. And there is a follow-up question on the PCP about what happens if the patient doesn't have a PCP? This member happens to be in a shortage area. So what happens if you don't? Do they assign you one? Where does it go from there? So it's mandated, the hospital has to assign a PCP. If the patient does not have a PCP, the hospital has to, before the patient is discharged, give them a PCP. So a patient can choose or the hospital can choose for them. Now, most of it, we do spine fusions here and we need clearance. So we already know the PCPs. I think most surgeries need that clearance. So it's important for private practices to be in the loop with the PCP before the patient even gets to the hospital. Now, in terms of the PCP, you know, when we did BPCI, we had those navigators who would do pre and post-op with patients. You know, they trying to make sure that, you know, we don't have a readmit. So if the PCP could mitigate that, you know, we had patients show up at the hospital, even talking to the navigators just for a UTI in the ER, you know, that could blow the bundle right there. So also private practices need to have that open communication with the PCPs. And also the open communication with the hospital. If, you know, so there's many moving parts to this. The CMS wanted to create a financial incentive within primary care for the engagement between primary care and specialists. So they threw the primary care into that. And, you know, we all saw this coming with BPCI. BPCI kind of ended it, you know, got extended to 2025. And then here comes teams. And Medicare's goal was to move, to create financial incentives for specialists to move to a value-based care. And Medicare is projecting that 100% of Medicare beneficiaries will be in some sort of value-based arrangement in 2030. So we can see the trend going, we can see it. Also, if you are not in a mandated area, there is that option for hospitals to volunteer and opt in. For that to happen, CMS is accepting letters from hospitals starting January 2025. So you should have some idea early next year if your hospital is participating. Very good. How are, like, what strategies are you using or that have been successful in engaging your physicians? Because this is very administrative and I'm curious to see what the physicians are doing about it. So I think before this even goes into play, physicians need to have a formal arrangement agreement with the hospital, you know, sign something so they know specifically what their responsibility is in terms of gains, and Paul shared about gain sharing and alignment payment, what is the responsibility? How are we going to track those metrics? So I think, first of all, that has to happen. There also has to be, for private practice, for anyone, actually, that, you know, since everything is included in the episode of care for 30 days, we went from 90 to 30, so it's more manageable now, you know, get with your SNPs, get with your home health agencies, evaluate them, make sure they have protocol from you, that they're not going over your protocol, not keeping the patient any longer than you are asking them to. Make sure that when you evaluate them, look at the average length of stay, look at their readmission rates. So you want to be able to get the best of the best out there for your patients to get in where they're not gonna blow up this bundle or this episode. Jennifer, you're muted. I just realized that. I would certainly echo the same sentiments that Zelda's outlined coming from, I mean, I was a patient navigator before moving into more of an administrative role and that continuum of care, that relationship that the patient has with that navigator and the relationship that the navigator has with the home health agencies, the SNFs, and even now the PCPs is gonna be such an integral part in terms of the success of this program. But really it starts with getting the data. How do you know where your opportunities lie? What are your drivers at that local level, at that hospital level, so you know where to intervene? CMS isn't going to provide us with data until I think they said Q4 of 2025, like just before, right before the bundle starts. That's already too late. So you kind of have to start working with your local leaders in the hospitals that you serve or in the hospitals that you perform surgery and really figure out like where do you need to intervene? I'm gonna have to get some cost analysis data in terms of the, so yeah. Yeah, I think the target prices are only coming out late November of 2025. So that's pretty, pretty close, very late, yeah. Yes, yes. You're right, Zelda. Thank you, ladies. Just to piggyback on the data, what are the best practices for tracking and managing the data related to the outcomes of these mandatory care bundles? Well, I mean, I can tell you, you know, with the CGR bundle, you know, we at SenateHealth, we used a third-party vendor, right, to be able to track the claims. So each site got their, you know, got claims for all of their patients they served and they could certainly track, you know, how they were doing. But again, I think it's once you're in the bundle, it's really tracking that patient. As a navigator, I was, I had, we had weekly calls with the skilled nursing facilities if those patients should go that, you know, go into the skilled nursing facility. What's their, you know, status? What's their estimated date of discharge? What are some barriers? Can we help you with that? Really to try to move them along, you know, to decrease that length of stay, I think Zelda had, you know, poignantly articulated. So I think it's really worth developing relationships within the community for you to be able to manage these patients in all honesty. And in prior programs, there were the requirement for recommended to have conveners help with that. The conveners are not required within this program. They really don't even talk about them in this program, but I know there are conveners out there that will be able to help if you're within this and you're looking for that assistance as we move forward in this as well. I think there was a comment in the chat there from David. Yeah, there looks to be some confusion. The first slide says January 1, 2026. So is this 15 months before it starts or it starts on 1-1-2025 and we need to report 1-1-26? Does that make sense? Oh, go ahead, Bob. No, go ahead, Zelda. You got it. It starts in January, 2026. So yeah, hospitals at this moment are trying to navigate through this, get paperwork. So it gives us this amount of time to go ahead and prepare for it. And BPCI stops, you know, BPCI was extended to 2025. So BPCI stops December, 2025. Yeah, I was going to say to... Sorry. I was just going to say to everyone. Sorry, Bob, go ahead. I was just saying- That was a hard on Zoom. So they stopped one, it rolls right in the next program. And then what was mentioned on numbers is the target price. So your target price you will get in November of 25. And that's what you need to hit in 2026. So that's might've been where some of that confusion was around when the target price comes out. Yeah, so you've got a year to develop, but you don't get your price until a month before you start. Exactly, Paul. And that's what I was going to say. I think one needs to really take this year to determine where their hospital or wherever, you know, whomever they work with in terms of the hospital setting, what their numbers are relative to these episodes of care, right? So looking at the claims data and so on and so forth. That's why we use the third-party vendor so that you can identify your key drivers. For us during the CJR bundle, we knew our episode costs were driven by home health, skilled nursing, and to a smaller extent, you know, just physical therapy thereafter. So we develop improvement plans in terms of how can we decrease that cost of care, still providing with the patient with the highest level, you know, highest quality of care, but then maybe decreasing length of stay for skilled nursing facilities, decreasing number of visits for home health and physical therapy. Thank you. Okay, some questions are coming in. Do we know who the mandatory hospitals are yet? And yes, there are links to that in this presentation. Yeah, you can just do a quick search there's the links. But even if you just, if you just wanted to Google the team CMMI mandatory hospitals, it brings you to the CMS.gov site. And it'll just say, you know, teams on September 5th, CMS published a list of the acute care hospitals that are on there. And then they're requesting all hospitals to submit a list, you know, to see if there's any other potentials and things like that. So at least you can get an idea. At least you can get an idea. And it seems like it's like, you know, again, big cities, big, big things, not more of your rural places right now in some areas, you know, cause you know, you kind of look at it. I'm a very small independent practice. And it's like, well, why do I need to know this? But I do, cause you know how the government works and everything will trickle down. And, you know, I might not necessarily be the one that's jumping on board, but my hospital will be. And if I'm the one that's doing the surgery for my hospital, then I'm going to be having to have that relationship. So it is something that will be pertinent to every practice if you're providing these services. That's a very good point, Alyssa. Thank you. We have another question. If our orthopedic surgeons cover multiple hospitals on the list in our area, will the pricing be different for each? That's a good question. So I will say if I'm basing it on what they did for the CJR, right, there's metropolitan service areas. So if you're, you know, I mean, if your surgeon practices within a 10 mile radius, target prices will likely not be any different, right? With that being said, though, is that one hospital designated as a safety net hospital? Or I don't know. And again, they might set different target prices. So it just really depends on those nuances. This might be a question maybe for Cameron or Michael, but does anyone know how CMS is determining this target pricing? Or is that? There's a really good explanation in the slide set on how they're doing it. It's a little bit complicated to try and explain here unless someone is a little bit more excited about doing that than me. But it's it, because they're looking at also at risk factors involved in HCC scoring. There's a lot that goes into it. It's not just straight, these are your three years and we're gonna take the average. So there's a lot that goes into it and it's different for hips versus knees versus fractures versus fusions. So you can dig into it if you're really interested, might be a little beyond the scope of what we're doing here though. So basically I'll give you the real complicated way they do it. And it means nothing to us, but this is what it is. So they get the regional price, they multiply it by a specific patient hospital adjustment. They multiply that by a normalization factor. They multiply that by a trend factor and they multiply that by a CMS discount. That's how you get the targeted price. Now that's as clear as mud to all of us, but it's CMS, so. So follow up question, when BPCIA, the target prices amongst hospitals less than 10 miles apart could have had a 60% differential in this member's market, this would drive surgeons to facilities with a higher target price. Do you anticipate the same with a team? It's a good question. My guess, just having been in this area for a while is your surgeons are gonna figure that out. And if they figure that out and they see that, if they have a co-management or a co-agreement with that hospital with a higher price, this is being recorded, right? Yes. If this was unrecorded, I would say, I would guess they might move them to the higher price target facility. That's my unrecorded statement. Okay. If the hospital was not listed as mandatory, does the panel envision that all hospitals will be doing this over time after 2025? Just like, well, go ahead. You're the hospital expert. I'll let you do this one. I mean, CMS clearly is learning from these initiatives, right? They're changing little elements, right? That maybe worked well, maybe in their favor. Again, you know, and so I think that it's very, very hard to predict. I think it depends on how this goes, right? This mandatory for these, you know, small, or this small number, not small number, but these specific hospitals, whether or not they actually roll it out to all. And what would that look like? They're looking like, they have projected that in this five-year period, it's going to save them $481 million. So it's looking like there's gonna be a trend. I don't particularly know. Yeah, we'll see. I mean, if you look at the prior trends, the mandatory hospitals didn't fare very well, but we're still moving forward with another mandatory model, a little bit changed, a little bit modified. So CMMI is all in on value-based care and developing these models. So I just see these models expanding and moving from inpatient, outpatient, ASC, incorporating more bundles over time, because now we have hip fractures in here. So it's, over time, I would envision more and more hospitals and potentially the next iteration having independent groups be able to participate. Yeah, I would agree with that, Paul. You know, it may not be necessarily, you know, joint replacement specifically, because I will say, you know, as you continue to process, improve, process, improve, process, improve, that gap between, you know, what you can gain and what, you know, and the quality of care that you can deliver, it gets, you know, smaller and smaller, right? In terms of being able to get below a certain target price, unless you're going to continue to drive down that target price, you know, so. We have another member question. In terms of risk share and upside, is there a fixed bucket of funds, like we've seen from MIPS or other CMS programs, or will hospitals be able to actually receive their savings? My understanding is that it'll be based on the savings and shared savings. When that gets allocated and adjudicated with the hospitals is, what, Jennifer, is that like up to six months to a year after the fact? So it'll take time to have that. Right, but we certainly, you know, it was not like MIPS. I mean, we got our gains, you know, but to Paul's point, it did take, you know, six to 12 months, I believe. Are there any incentives for the hospitals to participate or opt in on their own and not be marked as mandatory? Yeah, if you take a look at, if that hospital takes a look at their numbers and there's a huge opportunity to gain, then they would theoretically opt in. And I think that's what hopefully, you know, the takeaway today is take a look at your metrics, take a look at your numbers, take a look at your costs. Do you have, you know, are you in the vicinity already of this target price that they've projected or not? If not, then you have an opportunity maybe to gain quite a bit and improve care and all the other great things obviously associated with this, but. Yeah, that altruistic improvement of care and quality and integration and everything is great. And that's a big part of it. If you look at San Jose as the third highest cost in the country for total needs, my guess is one of the reasons why they were chosen as a mandatory. But if I was in the top five expense for hips or knees or something like that, there is opportunity for savings. And if there's opportunity for savings and you can share in those savings, volunteer program might not be a bad idea if you can afford the expenses of developing it and the staffing to run it. Yeah. How would the teams interact with ACOs and other existing at-risk or regulatory programs from like MIPS reporting? Well, I think as we talked about initially, of course, you know, we know the BPCI programs are gonna be, you know, done before this starts. However, based on, you know, from the CMS, you know, frequently asked questions, you know, slide deck, they basically said that they would coexist. You know what I mean? They would run in parallel, if you will. And so, let me just pull up something here. I apologize. Yeah, MIPS is not gonna go away. Yeah. So this is not a typical CMS replacing a program with a similar program with extra added to it. No. No, no. That's interesting. Do we have any other questions from the audience here before we either move on or wrap up? Or any other final comments while we're collecting any last minute questions from each of our panelists regarding the program that you want to share? I think this is something that is showing the hand of CMMI and the direction they're going with value-based care. And they're going to continue to move in this direction, whether they've been able to show some of the results or not. They're developing these programs, they have ideas and possibilities that they see as trying to drive value, and they'll keep continuing to move in that direction. I'd be interested in seeing more of the data on why the PCP, I know of the integration and the components and the different things like that, but was there data that showed that patients weren't managing their diabetes or their medications or those comorbidities within that window of opportunity that caused CMMI to add that component to it? Or was this just, we really want to integrate care, so we're going to throw in a PCP, right? How are some of those decisions being made? Use the data to support the direction that they're moving in. It's not going away, it's just going to continue to propagate and being on that front line of knowing what's happening, being able to advocate on behalf of your providers and your organization is really important as this continues to move forward. Yeah, I mean, Paul, anecdotally speaking, when we were looking at our quality and those who were returning for re-admissions and re-complications, a lot of it had to do mostly with medical things. I think to Alyssa's point, it wasn't their hip or their knee, it was all the other medical kinds of things that brought them back through the ED. As a small practice that is looking at this and did find my hospital on the list, so now where do I go from here? And I'm sure everyone else is kind of looking at that too and saying, now, is the hospital supposed to reach out to us or are we reaching out to our hospital and where do people go from here who may have just found out during this presentation that they are needed? Megan, double check. No, I don't want to know on a Thursday, I'll find out Monday. That's a really good question, though, Alyssa, especially for small practices. You know, the smaller you are, the harder these challenges are. So I'd love to hear the answer, Zelda, Jennifer. Well, you know, unfortunately, we're in a mandated area. So I've been reaching out to the hospitals, you know, I want to know what our responsibility is. I want to know where they are, you know, what our metrics are, what the doctors are on the hook for, how we're going to move forward. Unfortunately, this just, you know, the final rule just came out on the 28th of last month. So, you know, hospitals are like, give us a minute here, you know. But I'm going to keep, you know, pestering them until we know something, because I don't want at last minute, you know, being, you know, they drop the ball, we drop the ball, you know, something surprisingly comes up. And then, you know, it's extra burden on the staff here. And then I have to hire people at the last minute. So I need, you know, specifics. So yeah, I, you know, I found out we were in a mandated area. So I'm already in talks with the hospital. So I think, you know, especially, you know, we were on the hook for spine fusions. Yeah, we need to know. So if you know you're in a mandated area, just reach out to your hospital, let them know that you want some open communication. As soon as they know, you want to know. Yeah. Yeah, I'd echo the same thing, communication early and often. You know, it's only going to benefit everyone involved in all of this. It's here to stay. And keep your panelists, keep these panelists on speed dial and quick email. Well, I was gonna kind of throw everyone on the spot and just say, you know, this has been a really good presentation. And, you know, conference is opening up for registration in another week. And this would be something that I think would be valuable for a panel or something to have at conference and to know, you know, it'd be a couple months into 25, but we're going to have more information. And this way, people can already know, start formulating their questions and bring it to conference so we can keep this discussion going. I think Alyssa just nominated you all to be on a panel at conference. So. Well, and it sounds like Wendy did, too, in the comments. So, yeah, I definitely think that, you know, we can we can do a regroup. And I think that we'll probably see something on this at conference. And even outside of conference, obviously, this is a priority because it is going to be affecting everyone. And you heard it from, you know, lobby it as well, that they're going to be continuing to keep eyes on it so that our board, our advocacy council and by them through to all of you will be informed on this program as much as we have. We will provide over to you. So absolutely. And I would just say if you've got questions about this, you know, I'm I'm sure, you know, our panelists are happy to be responsive either in email or, you know, drop in and collaborate. Like, let's make this one of those things that, you know, everyone keeps everyone informed together, because if you have that question, chances are somebody else does, too. We can keep this conversation going outside of this conference call webinar. And absolutely. And send questions to AOE if you don't feel comfortable doing it and collaborate. And we can always be tapping into the resource of our volunteers on this call and otherwise who are, you know, in the trenches on this already and make sure that we can try to answer any questions that you have and provide them up the chain as well. If it's something that needs to be, you know, given to lobby it, too. So awesome. Okay. Thank you so much to everybody here. Cameron, Michael, Jennifer, Alyssa, Paul, Zelda, and Megan. Appreciate all of you taking the time to put together a great presentation for everyone. And if anyone has follow up questions, please don't hesitate to reach out to AOE. And as I mentioned at the beginning, this was recorded. We'll have it in our AOE Learning Center. And all the resources here, including a couple of additional just, you know, CMS resources, are going to be in with that recording on the Learning Center. So thanks, everyone. Appreciate your time. And look forward to seeing everybody on the next webinar.

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