Good afternoon, let's go ahead and try and get started with the panel. This is going to be hopefully extremely interesting to both all of us who are potential grandmothers and grandfathers, as well as you that are going through fellowship training and will ultimately be having the opportunity to sit for your board. So as just a short introduction, the theme of this year's AUGIE, we've heard sort of on multiple different presentations about talking about sort of our past, our present, and our future. And we've heard how our discipline has begun from being a special interest group of a small number of people sitting around a living room, to ultimately evolving into actually some type of field or area of expertise, and now to actually becoming a subspecialty itself. I frequently get asked, especially in the middle of the pelvic exam, why I do what I do as a urogynecologist. And I typically respond that it's really to generate and try to improve women's healthcare, which is all why we are here. And that 25-plus years ago, when I was in general OBGYN, we would face problems where the patient would come and have had something done by the urology people, and now having symptoms, and the urologist would say it's a gynecology problem. And the gynecologist would evaluation, oh, no, no, that's the urology problem. And these patients were getting shuttled back and forth with tons of finger pointing about what area and what specialty should be able to correct our problem. And fortunately, about 20 years ago, as you've heard, there were some very idealistic individuals who decided that really this discipline was complex enough, and to improve healthcare for women, that we wanted to become really a discipline, and ideally become a subspecialty. And really with that goal, again, of improving healthcare for women. At that time, 20 years ago, no one really thought that this was potentially doable. And there actually were, there was a lot of resistance, even among our field in OBGYN, not even talking about other fields. But we went ahead, and we went ahead and drafted as a committee, our idealistic guides for learning for this subspecialty. With the understanding that essentially in no institution could we really teach what we were hoping to teach. But by setting these goals and these ideals, that we would improve the quality of healthcare for women. I distinctly remember back, I hate to tell you how many years ago, in the middle 90s, being asked as a representative of the board to sit at a meeting where the head of the American Board of OBGYN and OB of Urology, the American Board of Colorectal Surgery, the American Board of General Surgery, they were all sitting around at a dinner. I was the only woman in the audience, or in the dinner, and a number of years younger. But the whole point was, we as a board went forward, as ABOG, and said, this is what we want to do. This is what we're planning on doing. Here are our guidelines. This is what our aspiration is. We want to inform you about this, and we want to have you come along with us on this journey. The response was not always so great. And in fact, one individual in the room was quoted as saying, well, women and men are exactly the same from the bladder neck up, so why do we even need this specialty? At which point, I didn't say anything, but that was sort of, I rest my case. So with the persistence of a number of people that are here in this room today, as well as some of the people who are not with us anymore, we've been able to go ahead and become this amazing subspecialty. And many of us sitting here never thought it would happen, or we were very impatient thinking when it's going to happen, but it has happened. And it gives such a phenomenal opportunity to all the young people here to sort of open the door and take our field just one step higher. So today, what we're going to try to do is talk really about the present and ideally the future of our discipline. So first, Dee Fenner is going to talk with us about issues related to the board itself and the examination for us grandmothers and grandfathers. And then Bob Harris is going to talk with us a little bit about sort of the practicality and some of the coding issues and things that may be affected. And then finally, Nourish is going to be our future in terms of what this subspecialty potentially means and where we might go in our clinical practice. So thank you. Dee? All right, good afternoon. So this is going to be, I think, your opportunity to actually ask Dee in person, for those who have been sending me your emails and your questions with the blog. So I wanted to give you an update of a few things that have changed, really, within the last few weeks. We have been listening at ABOG and the ABU and the subspecialty board to your, hold on, it's moving on its own. How do I get it to go back? We have been listening to you, your concerns, and some of the issues in terms of, for both the immediate graduates as well as those who want to take the certification under the so-called senior bulletin or the grandmothers and the grandfathers. So I wanted to give you just some changes that we actually made when the board met about two weeks ago in Dallas. All right. So many had said, you know what, this year long time period to be able to find the six month window to put my case list together. I had a death in my family. I had a baby. I was in the military. I had issues so that that's too short of a window. And so we recognize that. And so that, I don't know why this, okay, we recognize that. And so we've actually extended that date now to go back two years to get, it's not that you have two years to collect those cases, but you can pick whatever six month window you want to, to go back for two years to collect those cases. I would say for those of you too, there are many people say I do mostly office. I don't do as much surgery. You're going to need to think you have still the next couple of years to maybe rev that part of your practice up or to work with a colleague to be able to have another six month window moving forward if you don't qualify this year. But now you can think about that moving ahead. We are still being watched by the American Board of Medical Sub-Specialists as how we work this process. They will review everything we've done. And they could, I don't think this will happen, and we're being very careful and diligent in how we move forward. But we can't really change what we've said we're going to do in terms of, oh, maybe somebody just does office practice, that's all they're doing. Well, oncology wouldn't let someone sit for the exam if they just did chemo. So we went in as a surgical sub-specialty. It's very important. And while that's not my personal, I don't make that individual decision as some of you might think I do. I just want to say these are the rules and we do have to abide by them because we are still under the watch of the overriding organizations. All right. There was a lot of concern. Many people feel like you do very few hysterectomies in your practice, either by philosophy that the uterus should stay in situ or the fact that you work with, I don't know, I didn't have any timers on, but the fact that you work perhaps in a practice where the generalist will do the hysterectomy and you come in and do a suspension. We feel like you've already been certified to do hysterectomies. Everybody had that as part of their general boards. And so when you go in to put the case list in, you'll see that it says a minimum and that category is zero. You should still record them. I think we'd like to see that data, but if you don't reach the minimum that we have before the 10, you'll be fine. All right. There's a lot of people, there's been questions. What should I study? Which course? Is the board recommending a course? Does the board have an endorsing a course? The board does not, I really apologize, I'm not sure what's going on. The board does not endorse any course. There's no official course that the board, the board has the guide to learning. It was recently updated by the committee led by Dr. Kenton. So that's what I can tell you. That is our official guide for you. It's also will be very important as we make out the test. If you look at those categories. All right. As I said, senior exemptions, these are very rare. These were really meant for some of the founding fathers and mothers of our specialty who have made significant contributions to our field who are no longer as clinically active. But these, there'd be very, very few if any of these granted. So you're certainly welcome to apply if you think you meet that category. And we're individually looking at every one of those. But I can tell you that those, again, will be very rare. But if you have some special circumstance, again, don't be afraid to ask. And then I just want to say, you know, we're not validating your cases. We're not, urology, for the urology colleagues in the audience. You have to turn in your billing, so actual billing slips. So that's, those are actually validated. For OBGYN, we are not doing that. We are depending on your honesty. If you have any concerns, if you think that in terms of a colleague or if someone you know does tons and tons of general OBGYN and obstetrics. That they think they're going to try to take the examination, you certainly can inform ABOG. And so I just want to say that be careful because ABOG, if you're dishonest or someone is not forthright, they can look at your general certification. So I just want to say, think about that before you would consider that. And I'll just say that ABOG is very serious, as all of the boards are, about their examination questions. You've probably read, and if you keep up on things, in terms of radiology scandal, about having their questions being stolen, and how people knew what radiographs, etc. And then that really makes the evaluation and the certification invalid. So we are very serious about protecting our questions. So I certainly don't let anyone give you 50 bucks to walk out of the exam and reiterate a question or try to take a question. There's very sophisticated software and other things that are used to monitor any suspected cheating. So just forewarned, hopefully that would never be an issue. I just want to say, all the questions are copyrighted, and that there is no one who has access to the questions. I don't, you want to have me take any questions now, or wait till the end? All right. We're going to do a long question session towards the end. Okay. I'm going to speak more specifically about how this might impact us from a coding and billing standpoint. And there are some other issues we can talk about, too, as we go forward, but let's just get into this. So a two-digit specialty code, you guys probably know, we've been considered general OBGYNs by that specialty code, which is code 16, whereas U.N. Oncology, Reproductive Endocrinology, Maternal-Fetal Medicine all have their subspecialty codes. What does that really matter to us? Well, we're going to designate that on our forms when we do our billing. So Medicare will be able to track physicians and what they do, and they do this from a claims processing. So it's really nothing special. It's just that now we'll be recognized, and they'll be able to track numbers and such as they do for other specialties. What's the real impact on this? I think there's probably some misunderstanding on this, even among some of the people we've talked to recently. Nothing really changes. There's no special CPT code. The sling's going to remain 57288. Anyone who wants to can do a sling, pretty much, and use that code. So it won't change what we do from a standpoint of coding and billing. There is one thing that might change that potentially could help us, and that could make a difference, especially within a practice. And when I give coding courses, this is always a question. And the question is, you know, I'm in a practice with a bunch of OBGYNs. They clearly recognize that I'm different, but why can't I bill a new patient? So that probably will change. So the rules are pretty easy on this. If you haven't seen a patient in three years, then that's definitely a new patient. Okay? That's pretty easy. But if you have seen a patient, then you have to wonder, okay, am I the exact same specialty? And thus far, we have been. So if your partner is a generalist, then it's still a return patient. If you haven't, then that would be a new patient. If you're not the same specialty. So when we get this specialty code, you in your practice, if you're partnering with OBGYNs, can bill a new patient if your partner refers a patient to you. Okay? Obviously, if you are the same specialty which we are right now, you can't do that. All right? Did that make sense? It's pretty simple, but that will definitely change for us, for the positive. What's the impact on payment? Nothing's going to change. It's still going to be the exact same amount that we're paid for doing the work that we do. All the codes will remain the same, regardless of the specialty. With the newer quality measures and such, that might end up helping us at some point in the future, because we're going to do a good job of tracking our society. And this new committee on, bless their hearts, this new committee on all this quality, they're very dedicated. I saw them today. That's incredibly hard work, okay? You should really thank all those guys when you see them. That might change stuff for us. So we will be able to track us against possibly other specialties. And if we have better quality, it might end up that a lot of those patients might be diverted to us in the future, which I think has always been our goal in the past. What about private insurance? Well, this might change a little, because you're going to be able to then go with your specialty designation and probably with some numbers. And if you want to do your own negotiating with your insurance companies, then they do consider you different. They don't speak all the language we speak, but when you pop down your new two-digit specialty code, they're going to go, gosh, I only have, I don't have any more of those guys in my system. So yeah, I mean, tell me more. It'll definitely be an avenue for you to talk more to the private insurers and probably be able to have a little better chance to negotiate better rates for yourself. One more thing I'll say that we talked today is just, it's back on negotiation. It's about the RVUs. So, I'm not going to, let's save that for some questions, okay? Thanks. Leave them hanging, Bob, leave them hanging. So I wanted to thank Dr. Paraiso for giving me the opportunity to talk about kind of the future of urogynecology. And I knew that Dr. Barber and Dr. Karam were going to do a great job on talking to you about where the clinical side of our practice or our specialty is going and the educational side and the research side. So what I really wanted to talk about was really on the business side. And when I started thinking about maybe why Dr. Paraiso gave me this opportunity, I didn't want to accept the reality that four people said no and I was the fifth one on the list. So I decided, why would I be suitable to give this talk? And I think one of the things is, many of you who know me, I've been in academics for 15 years. Most recently as the division chief at the Brigham, where I was responsible for the organizational as well as the financial direction of the division. And then most recently have gone into private practice. So hopefully I'm seeing things from both sides. In addition, Massachusetts has been kind of on the cutting edge of health care reform with our esteemed governor or ex-governor, Dr. Mitt Romney, who implemented universal health care. And we've kind of seen the effects of universal health care, which is something that's coming for the rest of our country. And then in addition, wearing those hats of the MD and the MBA, I thought would help in preparing this talk. So congratulations on certification, so what's next for our field? And I think the biggest thing I can say with certainty is that there's a lot of uncertainty. I'm not going to try to be pessimistic or predictive about what's going on in the future because many of us really don't know. But at least where we stand today and where it might take us in the next five years, I can give you some clues on what the discussions are and where we think we are going. But we are definitely going to show a change in the economics and the organization of our health care delivery system. There's going to be change in information availability, transparency, responsibility. And the health care consumer is truly going to start deciding where your dollars are. And that has been implemented almost immediately this year. I predict now, from now on, at least unless things change, you will find that the last three months of every year will be your busiest months of the year. Because what will happen is when you see these patients in the early part of the year and they have stress incontinence and you say you need a sling, they're going to say, well my deductible is $1,000 or $5,000 and I don't really think I need to do that now. So when their kid shows up in the ER in August and they've blown their deductible, now they're going to come to you and they're going to say, I want my surgery, I want the drugs, I want anything you need to give me, because now it's not on my dime. So you're already seeing the price sensitivity of the health care consumer and how they're changing their medical decision making based on what their financial risk is going to be. There's going to be a change to this value-based medicine. That's the new catchphrase for cheaper medicine, but still maintain quality. So we never like to call medicine cheaper, so we call it value-based. And it is going to be based on these measured benchmarks. And we'll talk about how we're going to be measured in the next few slides. I think you're going to see a radical change in the role of the PCP versus the specialist. The PCPs have always been considered gatekeepers, but now the PCP slash ACO complex is going to be a gatekeeper mostly in terms of financial dollars. And we'll talk about how that's going to affect us as a subspecialty in addition to other subspecialties as well. And I think most importantly, you're going to have to see a change in our mindset and our function as a subspecialist. So when I talk to a lot of my colleagues, they say this is the Clinton-esque phase of changing and we have to change healthcare. And that just kind of fell by the wayside, so I don't think this is really going to happen. Now again, if there's a change in the administration or there's a change in the focus and the direction that we're taking healthcare, this may not happen. But there are certain things that support the case for change. Most importantly, probably, that Medicare is now predicted to become insolvent by 2024. When I was going to business school, it was 13% of our GDP. Currently, it's 17% and it's predicted to become 20% of our GDP by 2021. And the most recent data suggests that one out of every $5 that are coming into a household are being spent on healthcare. So it's becoming an ever-increasing component of our budget. As Dr. Karam talked to you this morning, population over 60 is expected to double in the next 30 years. So healthcare utilization is going to probably increase, at least at the current rate. We typically have an unsustainable rate of medical resource utilization. I mean, the number of incontinence procedures over the last five years has doubled with technology, with better diagnostic skills, with more marketing. And so as a result, we're seeing more and more medical utilization of expensive technologies. And the question becomes is, is quantity and the technology correlate with quality? I think one of the things that people are questioning is we rank number one in healthcare expenditure with an average per capita expenditure of about 4,500 per patient. And we rank 27th in life expectancy. By contrast, Japan spends $2,200, and we have a life expectancy of 77 years old, and they have it of 82. So we're trying to figure out, we're spending a lot of this money, and where does the quality come in? It hasn't helped that we have a deteriorating economy, and we have this widening of a class gap that may end up developing a secondary healthcare system, which we'll talk about. Clearly, we talked a little bit about the price sensitivity of the healthcare consumer. There are large companies, mobile and e-health companies, that now allow you to put your zip code in, the CPT of your procedure, and they will tell you what the doctors close to them charge and what their rating is. Now the problem is the rating is coming from vitals.com. So if the coffee in your waiting area was cold, the parking was really bad, you're going to get kind of dinged on that vitals.com rating. But that's the best substitute they've got currently. And increasingly, there's increasing political pressure, but I think the most important thing is that they're having a hard time in Washington budgeting medical expenditures. So the new model is going to be risk sharing, which is code for you take all the risk. And what they're going to do is they want to be able to calculate how much is this going to cost. Think of the casino. They love you guys to play the slot machines because they know what the payout is of a slot machine because it's all computerized. They will never, ever lose on a slot machine. They know exactly what they're going to spend and what they're going to make. They just have to decide over what time period, depending on how often that slot machine is going to be used. So, you know, we talk a lot about terminology, and I just wanted to briefly talk about the terminology of change because you're going to hear a lot about these things. And I wanted you to get a sense of what it is. So when we look at the terminology of change, it really started with the Patient Protection and Affordable Care Act. So it's great because that is kind of the official terminology for what we familiarly call Obamacare, but it really talks about protecting the patient and kind of paints us and the health care system as maybe kind of the antagonist in that. What they're really trying to do is create this patient-centric medical home where it's all clustered around the primary care as the gatekeeper and focusing on prevention rather than treatment. And the primary care and the gatekeeper actually becomes the controller of funds and resources. So the first implementation is this ACO program, which is called an Accountable Care Organization. And the first three years is called the Medicare Shared Savings Program. It's called the Pioneer ACO Program, where they've basically selected 32 systems around the country, and they are basically allowing them to enroll, and that will start in 2013. Just to give you some sense of kind of where the country is, five of those are in Massachusetts and four of those are in California. So out of the 32 that are going to be implemented over the next three years, nine of them are actually in California or Massachusetts. And the way this is going to work is that hospital systems and home health services and physicians and surgical centers will all be bundled into a system. And then what will happen is the initial Medicare Shared Savings Program will be that they will benchmark where we are in spending, and they will mandate that we reduce our spending over the next three years by certain benchmarks. And if we don't reduce that spending, then we get penalized. If we do reduce that spending, we share in those savings. Now, the New England Medical Journal basically said that all programs, at least 80% of them, will be unprofitable for the first three years. And the reason being is because the implementation costs of these programs is anywhere from $2 million to $14 million. And that doesn't include the technology costs that keep occurring over time. The private insurers in Massachusetts have followed suit. Now they've basically created this thing called the Alternative Quality Contract, where they use those same benchmarks. Now, over the first three years, it will be benchmarked on savings. After that, it's going to be a population-based payment, and we'll talk a little bit about that. ICD-10, thankfully, has been delayed because of the uncertainty of the health care program. They didn't want to add ICD-10 to that. But what that essentially does is it changes our classification system from 15,000 codes to 70,000 codes. Now for a specialist like us, we don't necessarily are going to be impacted as much because our code system is fairly narrow. But for PCPs and hospitals, it's going to involve a lot of evolution and a lot of cost. It will also allow the government that, including electronic medical record, to actually track us. So now they can track you very, very carefully about what you're doing, when you're doing it, and quality. And then finally, you've got the Health Information Portability and Accountability Act, which is all about how we're submitting claims, electronic medical records, prescription writing, and security of patient information. So the challenge of change, I mean, one is the uncertainty and unpredictability. If you think we have it bad, these hospitals, I mean, Brigham has an operating budget of $5.5 billion. They have to decide if they're going to build a big ortho center, which will probably open in three years, but the codes and the reimbursement for ortho may change. And so it's very hard for them to predict what's going on. I think that's really where the fear comes from. We are going to need to change the mindset and principle and practice, and you'll see that because of the ACO model. There's going to be a restructuring of traditional organizations, the infrastructure, and the clinical pathways. And then again, unfortunately, the only way we can reduce healthcare costs is to ration them. And how you ration them, whether you reduce the cost of treating a condition, or you reduce the number of patients that you're going to treat, or you prevent the development of that condition, it's going to be a combination of these. Now payers are going to start guiding behavior. So in Massachusetts, if you want to go to a top-tier hospital like the Brigham, the patient is going to pay 30% more out of her pocket. And they're trying to guide those patients to lower-cost hospitals. So they're going to basically do that with carrots and sticks. And those carrots and sticks are going to be to the patients, and they're going to be to the physicians. The GI doctors in Massachusetts will get 35% less for a colonoscopy if they do it in the hospital. But if they do it in their office or in ASC, they'll actually make their full payment. So they're trying to guide how we actually practice medicine. But I think as Dr. Harris always says, we can succeed, just tell me the rules. And I think the biggest challenge is this population-based payment system, which is really going to be what the ACO basically brings. And that's going to be this plastic surgery financial model. So the plastic surgeons, they're cash only, they say, you need this procedure, this is what it's going to cost. They get a fixed fee, and now they have to basically pay for the implant, they have to pay for the hospital, they have to pay for the anesthesiologist. So if they can take that procedure to a cheaper hospital, cheaper anesthesiologist with cheaper products but still maintain quality, it puts more money in their pocket. And this is basically what's going to happen. Eventually what will happen is the ACO will get $1,000 for every covered life for the treatment of urinary incontinence. So the ACO gets $1,000. The PCP now gets the brunt of that, the lion's share of that money. The PCP now says, oh, she has incontinence. I'm going to send her to a subspecialist. Now depending on how much that subspecialist costs, the PCP will keep or spend more money for them, which in turn will also keep or spend more money for the hospital. And so what's going to happen is that if you do less for your patients but can still maintain satisfaction, you will actually get more of those referrals. So there's going to be, and again, contrary to what we heard earlier, I personally think there's going to be a marked reduction in procedures. One because we have to ration health care, second because now we're actually getting paid more to do less as long as patient satisfaction increases. You're going to have this altered fee-for-service model. So what will happen is the urogynecologist or group of urogynecologists will go to that ACO, who they're a part of, and they'll say, we can take care of incontinence for $75 per patient. We'll just call that a number. The next group of urogynecologists who might be associated with that ACO will say, we can do it for $60. And at the end of the day, it's going to be this request-for-proposal competition. Whoever can do it for cheaper, they'll give you the bundle of dollars, and now they'll say, you spend it the way you want. If you do more testing or more procedures, it's going to come out of your pocket. There's probably going to be a severity-based resource allocation. Right now we don't see any difference between a woman who leaks once a month or once a day in terms of taking her to surgery. Over time, we probably will differentiate in terms of consuming those resources. There'll be a sharp change in referral patterns, because if you're not a member of the ACO, you won't get referrals from that ACO. Now there will be an opportunity for certain providers to be members of several ACOs, and it's going to be very similar to the physician association patterns that we currently have, where they operate on a withhold from insurance companies. It'll just basically be much more global. And then this emphasis on cost-effective care, a shift to low-cost institutions and specialists, a proliferation of mid-level procedures, and then there will be areas where you'll decide whether I use technology or I don't use technology. Speaking to some of the talks we had about Eurodynamics, many providers may say, you know, the cost of catheters, the cost of machinery, and the cost of labor to do Eurodynamics, I don't necessarily need that. As long as I can maintain that quality, I'm going to give that up. Robotics is going to be under greater scrutiny, and you're going to decide whether that's how you want to do it. And then the real question becomes is, is urogynecology a subspecialty that predominantly belongs in a tertiary care center or more on the suburban side? In Boston, we found that urogynecology oftentimes can be practiced very effectively, as well as MIGS, in some of the smaller hospitals, where you really don't need the resources that ONC, REI, or MFM need. But thank you very much. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. 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Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

urogynecology

panel discussion

evolution

board

examination

coding

billing

healthcare system

challenges