Thank you very much. Okay. Please stay tuned for the next session on the new world of physician payment. Thank you. Yes, this afternoon we have a panel, or I should say a presentation on the new world of physician payment. This will layer a little more detail on to yesterday's presentation by Dr. Rosenman. This will feature Dr. Doug Hale, OGS president elect, and Ronnie Adam, who is chair of the OGS quality committee and incoming OGS board member. Keep in mind, please, that we do have another scientific session at 430, so we'll try to tie things up at 420, and hopefully there will be time for questions. We'll see. Okay. This is going to be a big change from the talk we just heard, I think. We're going to dovetail a little bit into what Amy Rosenman talked about yesterday. The program committee felt that this was a very important topic for our members based on some survey results we got back about physician reimbursement and what's going on and what you need to know. We've been kind of neglectful in our part, and so hopefully we're going to catch you up here a little bit on what you need to know about physician reimbursement and where it's going. I will say, in the spirit of full disclosure, neither Ronnie nor I knew we were giving this talk last week. It's very hard to get somebody on a national level right now. They're in such demand, and so we had trouble securing people. So you're stuck with us, but we're going to try and distill it down to, I think, very understandable form that you can begin to work with. I wanted to start a little bit by just giving a little history, and you heard some of this from Amy yesterday. But on April 16th, this new law was signed by Congress, and we're now going to all have to live by this. And it's known as MACRA, and MACRA stands for Medicare Access and CHIP Reauthorization Act. CHIP is Children's Health Insurance Program that also was part of this. It brings an end to SGR, which has been in place since 1997, and as you know, rather dysfunctional. But we also have to be a little careful about what we wish for, because we now have a whole new era that I don't think any of us fully understood, and not only do we not fully understand it, the people writing the rules don't fully understand it. A little bit on this history, because the government has been working on this for a while. So back in 2006, one of the first bills that was passed was called the Tax Relief and Health Care Act, and that was the first time we were seeing physician quality reporting come into play. And it morphed into PQRS. At the time, if you participated in these quality measures, you were given a 1.5 percent bonus. Starting in 2013, and remember, there's a two-year lag period. You're going to hear me say that a couple times. So your payment's now in 2015. There's no more bonus. There was the Medicare Improvement for Patients and Providers Act of 2008, and this made PQRS permanent, permanent through 2018 until MACRA's going to take over. So we're just going to keep walking through this. The next was the Health Information Technology for Economic and Clinical Health Act in 2009, and this is where meaningful use came into play. So we now have two different things that we're responsible for, PQRS reporting, and now we've got to be using electronic health records to provide meaningful use. And this is back in 2009. Just to sort of, I think, refresh our memories on how Medicare works, I don't know if many people realize this anymore. We talk about RVUs, but the RVU system, as you can see here, involves three different components. There's a work of practice expense and a malpractice expense. The correction factor, which is the GPCI, is a geographical correction factor, depending on where you live, to give your RVU score a proper orientation to where you do live. That adds up to a total RVU score. That is then multiplied by a conversion factor, and that's how we get a Medicare payment. So this is how everybody is paid who's dealing with the government. There's a few outside things with alternative payment models we'll get into, but this is the general structure of how you're paid. And if you notice, the government has two ways they can decrease this. One is they can decrease the amount, and I think we more commonly relate to this, to RVUs. So we see a drop in RVU payment, and that gets us all up in arms and everybody upset. But they also have a very sneaky way of doing this, and that's that conversion factor. So they can drop that conversion factor, and if you're not paying attention, that's every bit as serious as a drop in the RVUs. So keep your eye on both these things as time moves on. There was, believe it or not, a very small increase in this conversion factor this last year, but it's really been fairly stable with very little increase. So in your current system that you're using, you have three adjustments. You have the PQRS reporting, and I think there's about 280 measures now that you can pick from. These do not have to be, at this point, specially specific. Now, Ronnie's going to talk to you a little bit about everything OGS has been doing to make it specially specific, and I can tell you that OGS is way out ahead of the curve because of the work of all these guys. And it's pretty incredible with an organization this size, the number of measures we've been able to get through. This meaningful use part really has three stages with EHRs, and the first was in 2011, and at that point you just had to show that you had the infrastructure to be using EHRs. So this is relatively new to people, so if you were just typing in people's names or demographic data and that's all you're doing, that was enough to get the reward. In 2014, that changed so you had to show that there were processes that were going on, and what they meant by that was you had to show that maybe you had a physician order entry, you had an interface with your lab, other things that show that there's actually processes taking place within that medical record. Now, the third stage of meaningful use hasn't taken place yet. It's scheduled for 2017. That may change, it may not change. At that point, we have to show that there's clinical improvement taking place through the EHR. So I hope that explains a little bit about what meaningful use is. And the other way they've got us is this value-based modifier. So we now have three adjustments. This value-based modifier, as you can see, is calculated based on the quality of care delivered compared to the cost to provide that care. We don't know exactly how this is going to work, but it seems like it's awfully heavily in favor of primary care physicians and not in favor of surgeons and specialists. So we're going to have to watch how this is going to impact us. Now, recall, the system remains in effect until 2018 and MACRA takes over. We'll get to MACRA in a minute. And keep in mind, everything is based on a two-year lag period. So 2015, if you did not report PQRS measures in 2013, you're going to see a 1.5% penalty across all your CMS payments. You're going to see an increase to 2% in 2016 and 2017. Penalties are going to be added for meaningful use, 3%. And for the value-based modifier, you can see a range here, and that's based on the size of your practice. Larger practices can have up to a 4% penalty. Smaller practices are going to be in the 2% range. You can see the maximum penalties here for large groups, 9% versus 7%. And I think what caught our attention the most was back in 2013 when we had to be responsible for reporting these measures, you can see that only 20% of us really knew what was going on with PQRS. And PQRS is probably the easiest part of this to understand. So just think of these systems where they are, and I think when most people ask me about this, their institution is doing this for them. And that's wonderful, but these are not specialty-specific yet. So if you're going to be compared to peers, right now what's going to happen, if you're under a single tax ID number, you're going to be compared to primary care specialists. So one institution's primary care specialists are going to be compared to another's, and that's how your payment is going to be determined, not actually on the quality of work you're doing in female pelvic medicine, but on the measures that your administration chooses for this. And that's going to directly affect your pay. It's going to directly affect your negotiating power when you go in to sit down with your chairperson to renegotiate or whoever it is that you're going to sit with. So start to process some of these things so that they make sense. Now let's move on to MACRA again. We said it repealed the SGR, and this was welcomed by most people, as I said, but we've gotten ourselves into a whole new kind of quagmire with this. There's going to be positive updates for the first 4.5 years. What I mean by that is there's going to be a 0.5% increase from 15 to 19. That conversion factor, as I said, slightly increased for this year, which hasn't happened in a long time. There's going to be a flat or no increase, 20 through 25. And then beyond 25, this is where we have to start moving. We've got to figure out what we want to do, because you can see they're starting to incentivize us for APMs, which are these alternative payment models. If we stick with what we're doing and just stick with our quality measures, it's going to be at max a 0.25% increase. The APMs give us much greater flexibility to affect what goes on with our pay. The Merit-Based Incentive Program is really just a continuation of the quality program I just described to you with one exception. So MIPS, which starts in 2019, which is part of the law that was just passed with MACRA, is one alternative for payment. PQRS is still in there. Meaningful use is still in there. Hopefully we understand those two things. Still, value-based modifiers in there. Now, the fourth component of MIPS, and the only thing that really changes is this clinical practice improvement activity. Now, you've had a whole other group of members working on a registry for years, and the work that they've put in, led by Matt Barber, Tony Visco, Kate Bradley, Emily Weber-LeBaron, and numerous other people working on this. I cannot tell you the hours they've put in to develop the industry registry, but they're also spinning this down into a research registry, which has been launched, which is very inclusive, and then a quality improvement registry, which is going to hopefully serve these purposes. And that QCDR registry, which Ronnie is going to talk about in a minute, can serve two of these purposes. It can serve number one, the PQRS reporting, and it can also serve number four, the clinical practice improvement. Now, where we've got to decide, are we going to put our time, effort, and your resources? I had somebody ask, what is OGS doing for me in this regard? And I said, what is OGS doing for you? I said, OGS is you. And I said, so we need you involved in this as well, and we don't have enough people right now working on these things. So the APM, Alternative Payment Models, or Physician-Developed Advisory Panel Review, that panel was just named. I think there's 10 members on that. They just put out a request for information, and so we are responding to that now. I believe it's 145 questions. So that dropped into the Quality Committee's mailbox recently. If you participate in an APM, there's up to a 5% bonus. And in addition to any kind of money, you can drive back to yourself through the plan that you develop. It can meet the quality reporting of an APM. It can be exempted from MIPS, so this is a way that you don't have to go through all that quality reporting. The first year that you participate in this, only 25% of your patients have to be in to qualify for that 5% bonus. Once again, that money can be more if the plan drives more back in. But they also want to see more of the nominal risk here. So there's got to be some financial risk that we're willing to take for this. We haven't started down this path yet, but I think we're going to have to start down this path. And one thing that we've been talking about is a model for stress incontinence. And we need something fairly simple. We need something that we can put into place and work around. We have Charlie Nager and the UT INS paper that was published back in the New England Journal that gives us a pathway that the government would be very excited to look at, which everybody does not need aerodynamics when they go to surgery. And so we need people's minds beginning to turn around this and see where we can take it. But I think we've got a launching place, and we've got to start. This is a slide I borrowed from Amy. And these are the two pathways. And symbolically, I don't know, I like them both going off the cliff. I don't think it's all gloom and doom. This is really an opportunity for us. You know, we're not the only ones being hit with this. But we can come out on top of this. And so far we have been ahead of the game in so much of what's gone on. But we're kind of putting out a plea for you guys that we need more physician involvement in developing these alternate payment models and some of these other ideas. So our task force, our committees have done a wonderful job giving us information, but we're going to need to put in a lot more people hours. And I can tell you, he has no more time than anybody else that's sitting in this room. This is all done after hours. It's done, you know, when you should be sometimes with your families or on the weekends. But we've got to do this so that we can move forward effectively. I'm going to turn this over to Ronnie to let you know just a few of the many things their committees have been working on. Thanks, Doug. So, you know, it's really not all gloom and doom. Let me start with that. I'm off script here, sorry. Ninety-eight, if not 99 percent of this great meeting is about what? It's really about quality and what we provide to our patients and making our patients better. So this is not foreign to us. This is what will inform future measure development. Because the bottom line is it's no longer enough to say, I give quality care to my patients because I know I do. We have to somehow prove that to the people who have the purse strings. And that's what quality measurement is about. It's not necessarily what quality is about, and that's why, if anybody came to the workshop that we had, we sort of separated those out. They're very linked, and it's our job to keep them very linked, okay? And so AUGS has been unique in that it's been looking at the long game. What I mean by that is there's been a quality subcommittee ever since 2005, as far as I can tell, and probably even earlier. Then with the increased national alarm in the high proportion of GDP expenditures that was noticed in health care, combined with some known quality and safety issues, think IOM, Institute of Medicine reports, there was increasing pressure to improve our quality and safety of care, and that pressure has been exerted gradually. And so ACOG recognized that what is coming is this very loud, very big train coming down, you know, instead of those roads, the railroad track. And so I suspect, although I wasn't involved in the big decision-making, that part of it was also related to our secret weapon, Jill Rathbun. She was mentioned yesterday in Amy's presidential address, and rightfully so. So the quality group really became extremely busy around 2009, which included a soon-to-be-published study on the effect of surgical virus. Thank you. So last year, the Quality Subcommittee graduated to the committee level as part of this realization of the centrality of quality and quality reporting, or quality measurement. And that's really everything that we do every day with quality. So I'm going to give you a little bit of background. And that's really everything that we do every day with our patients, isn't it? Also interesting, I thought about this later on, is around 2011, promoting the highest quality patient care was actually incorporated into the ACOG's mission statement, totally front and center. So again, part of this crescendo of understanding of what it is that's coming down the pipe. So ACOG's focus. So yes, we've been developing quality measures specific for our subspecialty, things that we really care about, not things that primary care physicians need to care about, but we don't care about that much. There's been significant effort placed on the strategic thought in the MIPS and then the APMs that you just heard from Doug about. And this is ultimately for everybody, for all of us practicing, because in the end we have to keep our practices going in order to keep helping the next patient. Then advocacy with CMS about the future of physician payment and being at the table of policy discussions. Well, what does that mean? That means my wife is usually getting some kind of rash when she hears the word AUGS, because what happens is we end up being on phone calls, we have to write letters, we have to engage with CMS, with NCCI, the coding edit issue from last year, other medical societies, as well as CMS, in order to answer their questions to explain our position and our take on what they want to do next. And this is ongoing and this is several times a year, and it's not just the quality committee. I have to say that the coding committee has done a stellar job in the last few years sort of sorting through all this, and it was also mentioned by Amy yesterday. And so that's what it really means, being at the table, because I think it was Dee Fenner who said, if you're not at the table, you might be on the menu. So the quality committee started up what we call the value study in 2009, the study that I mentioned about quality outcomes. We also provided several NQF measure submissions as well as PQRS submissions of measures. You have to understand that the NQF measure submissions, they took us about two to three years to kind of get through, vetted, understanding the gaps, explaining the validity as well as the feasibility of all this. Very high bar for NQF. It's sort of the highest bar that there is. PQRS measure submissions, they also take quite a bit of work but not quite as high a bar, and we'll see why that's important in a moment. The registry, I echo everything that's been said. The registry steering committee, the registry scientific committee have been working tirelessly to get this off the ground and to make it relevant to what I'm talking about, what these quality measures ultimately will be. So we will be in a good position down the road to answer all these MIPS and all the alphabet soup that you've been hearing here. So this year there was a major coup with the registry in that we became QCDR or qualified clinical data registry certified. So what that means really is that the QCDR represents sort of a reporting mechanism to satisfy PQRS requirements. So this is a way of reporting measures to the proper channels, CMS, et cetera. The QCDR collects clinical data for the purpose of patient and disease tracking to foster improvement in quality of care. The nice thing about QCDR is that it's not limited to only PQRS measures. We actually came up with additional measures that make sense and that are scientifically validated, and they don't necessarily have to be going through that rigorous process that we talked about for NQF or for PQRS. And that's the big coup of having the QCDR designation. So that will be part of the registry that is an ongoing thing that is being developed, and we are way ahead of any other curve that is out there, be it ACOG, be it AUA, be it all these other much bigger players, quite frankly. So coding also drives a lot of this innovation and a lot of this keeping up, and it provides training. It cultivates experts within coding, which is crucial, as well as education to everybody. It's all on the website. And, by the way, if you want to Google QCDR made simple, the second entry would be the thing that you want to read, the 2005 CMS information about QCDRs. So Google QCDR made simple. That's an understatement. So quality network. So this is probably one of our biggest accomplishments this year. We recognize that we really, what we need is a network that will help future measure development, because it's not going to be done with these measures that we have, and we needed something to kind of help the pipeline along. And so we launched this in March of 2015 with 10 sites. Thank you to everybody that submitted the RFI. I believe we had 40 or 50 applicants. We had to limit it to 10 thus far. We have a very eclectic and diverse group of fantastic PIs and fantastic institutions from varying places in the country, and we could even call ourselves international because we do have Canadian involvement as well. The idea behind this is also not just to support the passage of more quality measures in the future, but to also train sort of a cadre of quality experts, and we learn so much from each other. We're in the very beginning of the process. We had one meeting at SGS face-to-face. Tomorrow we're going to have our second face-to-face meeting, and we've been working on the next three active projects that we're going to talk about. Very briefly, I think this was also mentioned yesterday, and so quality in incontinence, anti-incontinence surgery, looking at data variation primarily in practice patterns and outcomes between the surgeons performing surgeries for urinary incontinence, and then the same regarding to quality in prolapse surgery. The CAT study is the always-anticipated yet-not-here-yet outcomes data because everybody talks about processes and what happens, and now we're going to have outcomes data because we're going to go back and look at that patient cohort two years later. NQF, what we've achieved there is a measure that is completely approved, and we're actually already maintaining it, and now we have to start thinking about maintenance, and this is the performance of cystoscopy at this time of hysterectomy for prolapse. Two other measures have been accepted. We're pretty much maybe about two or three weeks away from final endorsement from NQF in both of those measures as well. So we actually own these six measures that are PQRS-ready, done. You could actually use them, and you could bring them to your payers and argue that you're doing such a fine job, they should pay you more. Can't promise you it'll work. These are not PQRS-ready yet, but they are appropriate and will be available through the QCDR, so they have been vetted for that functionality. Oh, sorry. I'm done. Thanks, Ryan, again, for all that hard work. I hope we have a few minutes for questions. We do. We're going to get through the end here really quickly, just about what the future is. Just to let you know, again, these rules are being made largely without us, and so we've put ourselves in the middle of this, but we're going to need more help. I've said that, I think, three times now. So we need to get more names. We need to get people. You don't have to understand this completely. We certainly didn't when we got involved with it six or seven years ago, but we need some workers to get involved with this. It's up to the medical societies to guide CMS. Again, they just put out a request that we have to respond to, as I said, 145 pages. Budget neutral. So there will be winners and losers in this, and we want to come out on the right side for all our members, so become involved with this. Importance, it's going to affect us all. You can't count on your institution to protect you. You're going to have to have some knowledge of this really to protect yourselves, if nothing else. Employed status, as I said, does not protect you. I don't think any of us want to be compared to our primary care coworkers. It's wonderful what they're doing, but we don't want our quality work lumped in with theirs. This is contact information. You can get there through the OGS website, and this is Colleen Hughes' website, so if you're interested in doing any of this work, please get on. Do we have a minute for a question or two? If anybody has one or two quick questions, we do have to get moving. The next session starts in ten minutes. Sure. Microphone three. Thank you very much for this presentation. I think it's very timely for those of us who don't know a lot about it. My question to you, Ronnie, is this. These projects that you have ongoing, are these going to establish kind of standards that we will be measured against? Is that what the ultimate goal is? Yeah. Yeah, the goal is that we have our own standards so that we're not going to be using somebody else's. A lot of those aren't very high-hanging fruit, but that's not supposed to be that way. If you remember how PQR started off, it's the same way. These will lead into a true quality improvement. These measures become more and more meaningful. Right, so if you take the one measure that we've gotten through NQF, and that's simply do a cystoscopy after you did an apical suspension at the time of a hysterectomy for prolapse. So we're not here to, you know, alter the face of, you know, what we're doing currently. We're here really to, I would say, summarize what is already known and make sure that we make a measure out of it that provides some idea of what we're doing is right. And make no mistake about it. If we don't do it, somebody else will do it for us. That's not what we want. Okay, one last quick question. Is that working? As a private practitioner, I've tried to get Medicare to recognize me as a subspecialist, and they won't. They don't think FPMR exists. Well, we do. It depends on the area of the country that you're in and who your carrier is providing Medicare. So certain people are. This is a very difficult discussion to get into because there's taxonomy codes and there's two-digit specialty codes. And CMS is trying to decide whether they're going to recognize us based on that taxonomy code or whether it's going to be a two-digit code. And we've been working with AUA on a two-digit code slowly, progressively. We're not quite there yet, but we don't know that we need to get there because we have our own taxonomy codes. So at some point you should have a way to differentiate. The other thing is it doesn't really matter. These are PQRS-accepted measures. It doesn't matter whether they think you're a specialty or not. You can pick these off and put these into your EHR and start using them today. They've been accepted. Now, there's a little bit more restriction than that, but in general, they're there for you to use. You just have to add a few more measures. You have to cover some of the domains that are there. There are six different domains that have to be reported. Three of them have to be reported out of the six. So there's a few other details to that, but those measures are available, as Ronnie said, and they're up and running now. Okay. Thank you very much, and we'll move on to the next session. Thank you. Our sessions are up in six, A, B, and C. And stop by the registration desk and get that aux rock-a-rokey. Is that how you pronounce it? How do you pronounce it?

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