Good evening. Welcome to today's webinar. My name is Dr. Christina Lewicki-Galp, and I'm moderating today's webinar. During the webinar, we're going to take questions at the end of the session, but you can submit them at any time by typing them into the question box on the left-hand side of the event window. Today's webinar is entitled, Developing the Urogynecology Team, How to Incorporate Advanced Practice Providers, and we are having our presentation today by Dr. Matt Barker. Dr. Barker has developed and led courses in urogynecology specifically focused on the education of advanced practice providers. He's incorporated physician assistants, nurse practitioners, physical therapists, and advanced nurse navigators into his urogyne practice with Avira Medical Group. This team approach to patient care increased access to care for women with pelvic floor disorders and improved efficiency and patient flow within his practice. So, it's my great pleasure to introduce not only my colleague, but also my friend, Dr. Matt Barker. Take it away, Matt. Oh, hey. Well, thanks, Christina, and thanks for having me. I'm excited to talk about developing this team in urogynecology. Being in South Dakota, it's a lonely field here in urogynecology. There's not very many of us out here on the prairie and needing to expand access to a lot of people is what helped me develop utilization of APPs. And I kind of wanted to share some of my experiences and my insight on this and how I developed my specific practice. And hopefully, the people attending and listening tonight on this webinar can gain some information that might help their practice expand. And I think when we talk about developing a team, we also think about the medical doctors and the advanced practice professionals or advanced practice providers. But I think using this term, professionals, is really important, and not just to single out the providers, like a doctor or a nurse practitioner or a PA, but also the other allied health professionals that really help us make our clinic function. And this can be from our front desk all the way up to the physician in that office. And we'll focus on some of those individuals a little bit later in the talk. But here are my disclosures. And what I hope to gain tonight from your learning objectives is really how to understand the growing need for different types of providers who care for women with pelvic floor disorders. We'll talk about and recognize some different care models that can be used to incorporate and work with advanced practice providers, learn the different practice model changes that can be utilized to expand one practice base, and really talk about how we can access care for our patients because that's really the ultimate goal. And what you can see is in the near future, there are not going to be enough physicians to care for our population. And this is a scary statistic. So 60, we're going to be about 60 to 95,000 physicians short, and 2025 is not that far away. And especially the supply of surgical specialists is expected to decline by this time as well. During the time when the healthcare reform was being developed in practice, they only thought that this was an increase of physician demand by 11,000. So even without healthcare reform, we are still facing this daunting concern of not having enough physicians. At the same time, the projected number of women in the United States who we care for is going to be growing rapidly, especially in our baby boomer generations as those are getting older, age of 65. Over 8,000 people turn 65 each day. It's an alarming statistic. And this data shows here that after 2025, this baby boomer generation becomes that over 80 crowd. And for those of you that are out in practice know that a large percentage of our patients, these are your recurrent urinary tract infections, your refractory overactive bladder patients. These are challenging patients that require numerous visits, lots of care. And to meet these demands for these patients is a real concern in our field. And why I say that is because how important urogynecology is to women's health in general. A third of all women and over 50% of women over the age of 5 suffer from some type of pelvic floor disorder. And women seeking care for incontinence disorders is supposed to triple over the next decade. Now this volume of growth for urogynecology is predicted to be as much as 30-fold over the next decade. These are huge numbers. And I practice in a little town of 150,000, but this growing demand in rural areas, people's access to specially trained physicians like urogynecologists is getting hard to replace and we're not even producing enough people even despite these expansions in fellowship. So a person like myself who has his own practice, all this volume and work and you can constantly be working leads to a lot of job stress and how do you handle this influx of patients. Not only that, a lot of us work for larger health systems, managed care, documentation, electronic medical record, the demands and documentation and bureaucracy of the new healthcare and the systems we live in, all these increased bureaucratic tasks make it harder for us to see patients and meet these volume demands. And as we as physicians work harder and harder, it can lead to burnout. And we know that burnout can lead to poor patient outcomes, medical errors and other things that can affect the care we provide. And one of the areas that I saw as I was developing my practice, especially starting a practice by myself, is I need help. And who can help? And it's hard to recruit someone to South Dakota, especially now when it's been, I think, minus five here for the last few days, but today it's balmy, it's 40. But this whole burnout aspect is really where I was kind of going overwhelmed, I needed help from advanced practice providers. And what advanced practice providers or nurse practitioners and PAs can do is help reduce the cost of medical care, lessen the need to train more subspecialists. And you're seeing a utilization of APPs already in OB-GYN, urology. And what's interesting is most of the data on their performance comes out of primary care literature, which shows they perform as well, if not better, than physicians for non-operative routine services, such as primary care. And the growth in training programs has been substantial over the last decade. And again, I think it's this whole demand for this as the climate and the need for healthcare and limited physicians is growing. These master's programs are growing at a rate. And so to get a degree as a physician assistant or nurse practitioner, it's typically a master's degree. And you can see here, and this is kind of older data. I'm trying to see if I can see my pointer here, but the older data here is a large increase, even 2,000 for both training programs for PAs and MPs. But what's interesting is for our resident and fellows, those numbers haven't changed at all, meaning the number of resident physician, fellowship trained physicians that we're training has not increased at all to meet the needs of our growing patient population where the APP programs have increased. And looking at the demand for PAs has increased over 300% just since 2011. These are huge, huge numbers. And it's interesting to talk about as we train these people is understanding the difference between a nurse practitioner and a physician assistant. It all comes down to their training. Anywhere we work, they function at the same level at most institutions. But a nurse practitioner has a nursing background. And I know this is kind of hard for somebody to read, but nurses are trained through a nursing curriculum that focuses on population health. So when a nurse practitioner goes to graduate school for a nurse practitioner degree, they're either doing a patient population. It could be pediatrics. It could be women's health. It could be primary care. And then that degree is to serve that patient population as a population-based education. And their certification and rules of practice are all governed and sanctioned by the nursing board in most states. Where physician assistants, this came about in the 60s to meet the needs for more medical training and really increased during the Vietnam War as they needed more medical training during while we were at war. And physician assistant programs really took off around that time. And the physician assistant model is a master's program that takes two years that models medical education in terms of their basic science and their medical rotations. And all physician assistants have to serve under a physician supervisor and they have to have some type of supervisor role and regulation. But their scope of their practice is determined by that agreement with the MD as well as with the medical boards in different states. And so there is that slight difference in their training and in their background, but they're all basically two-year programs. But as many of us hire them and utilize them, they function at, for the most part, similar roles and expectations. And when you talk about advanced practice providers, especially in the field of urogynecology, you can't forget about physical therapists. And physical therapists are key to the treatment we provide for people with pelvic floor disorders. But there's only two programs in the United States that really certify a physical therapist with advanced pelvic floor or women's health pelvic floor training. And this is the American Board of Physical Therapy where you have to do some, get some certification, take a test and have to over 200 hours of direct patient care. Sometimes they want up to even eight years of training there where other programs and certifications are offered by a company through Herman Wallace. And I think it's key to talk about those groups just from the standpoint of that many of them work in our offices and we work closely with physical therapists, but understanding that to help some standardized care because when I came to South Dakota, people, their ability to do physical therapy for pelvic floor was not standardized and people had different experiences. So this gives you some wherewithal to figure out, do they have really truly an advanced knowledge and certification versus someone who went to a weekend course basically? And so this trends in care, meaning that as the economics change, meaning that we're not making it, have enough physicians come to small communities like in South Dakota. And if there's a labor shortage that occurs, a substitute arises to fill this vacant role. And this is division of labor and skill mix free physicians to manage more patients and oversee more trainees. And so this division for MPs and PAs or APPs is bolstered by the emergence of these different models as team-based approach to developing care models. And the role for APPs in a clinic is really individualized. So in my clinic, we're a part of a larger health system, but my clinic is run as kind of its own entity is that I can have, you know, just one physician, but there might be other things if you're an academic practice where a different physician rotates throughout there, what's the landscape there in terms of who does what, which physician are they working with, what's the practice type like, where it's located, is it a large small practice? Oftentimes, it's individualized to what's the experience of the APP, have they worked in clinics before? Are they a new grad? What's the physician's comfort level? And all this is regulated by state laws. And then the other thing is as they have supervisory and collaborative models, meaning that do you supervise them and see patients at the same time or is it a collaborative model where you're seeing patients together or at different times and it's autonomy versus independence, meaning that how much do they can do on their own and autonomy is just this idea that they're able to slowly grow and understand what they can do. But as practices develop, autonomy is where this is something that is developed over time as you work with someone, giving up, feeling what your comfort level is, what people are able to do versus this independent model where nurse practitioners and PAs just start practicing on their own. And a lot of this is going to be regulated by states as more states allow for nurse practitioners to practice on their own, whereas physician assistants always have to have some type of collaboration agreement with a physician. Now the different models of care, there is the shared cared model and this is where an MD and an APP see patients together. And this could be where the MD is working there and the APP and they either see patients together or the APP is seeing patients independently and so the shared model can move to an independent model where it's an incident to practice model where the APP and the MD see patients individually or independently. So if you go to clinic, the APP might be seeing follow-ups, the physician might be seeing new patients on their own and they might not interact with those same patients. Where an independent model, APP sees patient independently only when the MD is not in the clinic. If the MD is doing surgery that day and the APP is seeing patients that day or there might be a mixed model. This is where the APP does outreach at a small town and then is seeing patients by herself and then when she or he or she is in the clinic with the physician, they might be seeing patients together. And so it can be variable in how they set these clinics up and a lot of this will determine based upon billing, experience, patient's comfort level and physician's comfort level. So determining that is a good model to look at what works well for your clinic and I think that's just kind of where we have to talk about being things being individualized, but there are different methods and models that can be developed. The interesting thing is with APPs is most of their learning is on-the-job training and there's a need for greater education especially in the subspecialty arena. If you look at a survey of nurse practitioners, entering primary care, 51% felt minimally prepared for practice, 38% felt generally well-prepared and only 10% felt well-prepared and these are people going into primary care and if they're not, half of them aren't feeling well just to go and start practice, imagine a new grad or someone who's not used to a female pelvic medicine reconstructive surgery, there is going to be a lot of education that's necessary. And what's interesting is the amount of work now that's being done by advanced practice providers and this is a study that looked at billing data for Medicare using MPI numbers. This is your National Provider Identification Number and it's individual for APPs and MDs and they divided up those numbers based upon what APPs were doing in urologic offices and so these are the increases in what APPs are doing, neurodynamics, tibial nerve stimulation, interstim programming, pelvic and biofeedback and you can see these huge numbers but even neurodynamics, a 27,000% increase in the last 18 years and so what APPs are doing now is greatly increasing especially in urology offices and urogynecology offices but you can see that they're taking on a larger role. And the American Urologic Association has been fairly progressive at realizing the importance of educating APPs. They have developed core competencies that progress throughout their training similar to what is expected of urology residents. They've developed little curriculums on overactive bladder, oncology, male and female sexual dysfunction, surgical assistant, stone management and so they've recognized the need to increase this education level that hadn't been there before to meet these needs as their APPs are doing more work in their clinics and what's interesting is that these APPs are held to the same standards of practice as a physician. But the AUA's position is that APPs work in a closely and formally defined alliance with the urologist that serves as a supervisory role, meaning that the physician is the captain of the ship here. They oversee the APPs rather than an independent practice model. And they focus on just different levels of skill and I think it's key when you start to identify APPs that you're bringing on into your clinic, are they level one, highly skilled? This is that APP that's been in your office for 10-15 years there. They can manage all their pessaries. They know how to do InterStim. They're teaching your fellows how to do InterStim programming. They can function on their own. Minimal communication is needed. This might be the person that's ideal to do some outreach clinics. Where you have level two skill, this might be new to the field, need a little close collaboration, feedback. Maybe they've been in your clinic for a year or two or they worked in another field for some time and now they're new to urogynecology where they might need to see a patient, run them by you and go back and see themselves. Or you have the new graduate, close supervision, they need a little bit more of a training program. These are the new grads you might just help, hired on. And recognizing their level of skill, I think is best when you're developing some type of curriculum or education for them. What's interesting now is that they're starting to become fellowships for APPs. These include orthopedics, emergency room medicine, strokes. Even urology has started to develop some one-year fellowships for APPs that kind of mirror their urology residents in terms of the rotations they do, the presentations they're doing, as well as the type of clinics that they're shadowing for a year. AUGS, and I don't know if any of you guys submitted your reviews, but I think it was due February 9th, but it was a review of the APP urogynecology core competencies. So the Allied Health SIG group came up with some competencies that they thought were important for APPs to know and be able to perform and meet criteria that they can perform these things, such as general procedures. This is doing a history and physical exam, understanding lab values, reading urinalysis, and appropriately treating urinary tract infections, just general concerns. But then they also focused on special procedures. Were they able to do a POP-Q exam, bladder insertion removals, SP catheter removal or insertion, bladder installations, skin biopsies such as vulvar biopsies, simple and complicated aerodynamic studies, pessary management, wound management, endometrial biopsy, anal rectal manometry. And so these are suggestions that this group has brought forth for AUGS to look at and determine. I think some of them are very reasonable. Others might not be appropriate for some people's clinic, whether it's performing endometrial biopsy or anal rectal manometry might not be done in some clinics, nerve blocks such as trigger point injections, performing cystoscopy. This gets a little bit controversial and I really hope AUGS when they develop these types of core competencies, have a lot of physician feedback as well and just the SIG group as it's important for us to maintain what is the role of the physician, what is the role of the APP. And again, it's going to be very individual based. I'm sure there's some APPs that are very great at cystoscopy but it's a pretty advanced procedure in the office and that you don't want to miss things. But now our APPs, especially in my clinic, are serving as first assistants in the OR. They're doing suturing and other procedures to close surgical wounds. And so this idea of guiding these competencies, I think it's good for AUGs to start having that conversation as this has become more of an issue as more of us hire APPs. What's key to this too is that AUGs are developing a training guide evaluation form to provide a systematic approach to a competence-based assessment, meaning that you can do this checkoff list as are they meeting the requirements. And I think this is helpful when you hire a new grad or someone's been there. Are they meeting their expectations? And it gives us something fairly objective to measure, to give feedback to. And as we develop a form of core...develop different core competencies as well as a way to evaluate them, it brings us an important point to, will we need some type of a certification test to determine clinical competency and demonstrate that every certified member can adequately perform certain things? And we want to make sure that current practice standards and rule descriptions are defined. But more importantly, that if someone says they can do this, how are we measuring that? And are we measuring that every so often? I kind of equate this to being like our maintenance of certification. Will AUGs be doing that? Will it be done in our clinics? That's something I think that will be developed over the next few years. And hopefully we take a lead role in that as it's important because a lot of things relate to patient safety and standard of care. If you're looking at bringing on an APP or hiring someone, the AUA has this nice checklist in terms of, all right, do they have their license? Have you met all this? But what they bring up is an important conversation that I think is helpful to have is, what is everyone's role? What is the supervisory role? What are their expectations? What kind of model of care are you going to be utilizing in your office? And more importantly, how does the patient want to be addressed? What is their role? I noticed when I hired nurse practitioners and they were new grads, it was hard for them to make that jump from being a nurse to now being a provider. And having this conversation early on really can help you mentor them to achieve their best potential as a new provider. So this helps bring up some good conversation. And in my office, I have myself, I'm part of a big health system, but I have a urogynecology clinic and I'm the only physician in the group. I have a PA, a certified nurse practitioner, and a doctorate of nurse practitioner. Everyone has same roles. Everyone is paid the same. We work with three physical therapists that have advanced training. I think they're through the American Board of Physical Therapy where they have their specialty training. And then we have a nurse navigator with a master's degree in nurse education that I have a slide I'm going to talk about, a nurse navigator, but she kind of helps manage a lot of our, coordinate our care. I think the best thing I ever did was I had a nurse who was just a great leader and she now is a manager to my clinic. Having that RN background and that clinical knowledge has really helped us manage with personnel, job descriptions, utilization of different services within the clinic. On top of my RNs, LPNs, I have a surgical scheduler and a front desk staff. And we kind of call ourselves Team Urogynecology, but realizing that all these allied health professionals are professionals, are key, and that everyone is on the same page. So when they call the office, they're getting the same information each time. So really kind of thinking about all these people as being part of your team rather than just the physician and the APP, there's much more to that and recognizing those roles. This becomes important because there's this principle of task shifting or task sharing. Task shifting is the delegation of specific tasks to less specialized healthcare workers. So if I see a patient, they had some procedure, wasn't sure about it, I'm not handing that to my nurse. I'm giving it to my front desk saying, hey, can you hunt down these records? Or if someone needs a bladder scan, I'm not asking my APP to do the bladder scan when a nurse can adequately do that and kind of realizing those roles and making sure that the appropriate person is doing that. But also task sharing, and this becomes important where this partnership in which different levels of providers do similar work rather than having less credentialed providers take on a provision completely. So in my office, if you think about we're all providers, APP is an MD that will see new patients, will see follow-ups, will see post-ops, will do interstim analysis, will do PTNS. Those jobs are all shared where myself or the APs can all do those equivalently. And when you have that type of task sharing and different levels of training that are doing it, you need to ensure that safety and efficacy is ever compromised. And as you allow this access to care, they're all getting the same potential treatment. So I think those are good principles to kind of bring up as roles are developing. The reason I brought on APPs was the key thing was to maximize my efficiency. I'm only one person. I can only be in one place at night or during the day and at night. But for here, where they really helped me is I needed a first assistant in surgery. I needed help seeing post-operative patients. If I got called into the hospital to get a consult, see emergency room visits, or if I was in the OR unavailable, someone to work some patients in or what have you. And it seems like, well, how do these people pay for it? Well, they're all billing out on their own, but it is developing some downstream revenue. And that's what systems and clinics should realize, what those APPs don't just bring in their whatever salary. It's all this other revenue that can be generated for your clinic that's very helpful. And other things where I've seen efficiency, as you bring in these APPs, they want to be done at a certain time during the day. They want to find ways to make things easier. So they have been helpful in developing templates, developing standing orders, clinic protocols, patient education. I wrote in here scribes, many people are using scribes, but I think with the way technology and templating and those types of things, I haven't found a use for that. But it might be different for your clinic, but finding everywhere for these professionals to work together to maximize efficiency is key. And that's what led me to a nurse navigator. In this role, I thought was really important is because patients need an advocate and we work closely with the breast cancer center here and the breast cancer has a nurse navigator. So you get breast cancer, you make one phone call, they do everything for you. They get your appointment, they get your surgery, they get your radiation, your chemo, your follow-up. I mean, that's a nice way to coordinate care. And what I was hoping for in urogynecology is like the patients kind of know who they're working with. They always call the same person. But I think what would be a great idea for urogynecology is to have kind of this one person that's for you. And my nurse was actually going to get her master's in nursing education and I thought this was a perfect idea. So she stayed on as our nurse navigator and we have these cards that say, we're here for you. And it's her picture of her and it's kind of like how she navigates patients through this journey of our care. And they'll assist in coordinating care, if they need to get some advanced pelvic floor imaging, how to provide care after diagnosis, following up on things, helping to communicate with their care team. It's just kind of a nice person for people to talk to. But where I've utilized them is having her follow up over active bladder management patients, seeing how things are going. People live 300 miles away, they can help coordinate plans. So when these patients do come back to me, that visit is not lost and we're already planning for the next step in their therapy. So I think that's another role to think about even outside of APPs is this navigator through your clinic and all their, you know, pelvic floor disorders are slowly becoming chronic conditions like overactive bladder, recurrent urinary tract infections, neurogenic bladders. So having this go-to person in your clinic I think is a strength that you might find beneficial to your clinic. But when it comes down to things, the key thing is money and how does this all work The federal definition of CMS is all about collaboration, which they recognize that nurse practitioners and physicians work together and they can also work independently. And it's this collaboration, the nurse practitioner doesn't have to be with the physician all the time. They can function independently. And what you're starting to see is that nurse practitioners, not PAs, are developing their own independent practices. And South Dakota last year passed a law where nurse practitioners can set up their own clinics and practice independently. So knowing the rules in your own state become important as you develop your practice. And for people who are in private practice or in some systems, you have what's called Incident 2 services or the billing. So these are services that you as a physician bill out your professional fees or Part B services under Medicare. And the Incident 2 rules mean that for you to bill out Medicare at 100%, this has to be performed in the physician's office, those performing the services must be employed by the billing practice, the physician has to personally perform the initial service as a new patient established to the plan of care, as well as remain actively involved, a physician member of the group must be physically present to render assistance if needed, direct supervision. So if you're billing out at 100% physician level to CMS and you're in an office, that physician or a partner has to be there while the nurse practitioner, APP, is billing. If they're not there and the APP is functioned by themselves independently or as a model of care where they're in the clinic by themselves, the APP will bill out at 85% of the physician fee schedule for Part B of Medicare. Now, we do not do Incident 2 billings for people that are provider-based billing. So talking to your clinics or talking to your health systems that you work for, you know, this is specifically for private practice, but if you're a provider-based billing, meaning that you're a part of the hospital, you cannot bill out Incident 2 billing, and I'll talk about that in a second. But other things that can bill out Incident 2 billing, I mean, if you own your own practice, if you have PA, nurse practitioners, you have PTs in your office, you have a clinical psychologist, OTs in your office, if you're there and they're seeing patients at the same time, you can bill this out at 100% rate. But if you're not there, then you have to bill it out at 85%. So what some provider-based billing clinics, like where I work at, we have a shared service. So Incident 2 billing does not apply. And this would be similar to what's done in the hospital when you do surgery, you round on a patient or you get a consult and you see a patient with your APP together, that's a shared service. And for you to bill out 100% rate, you have to see the patient with an APP together. So the physician must document his or her portion of the encounter with the patient and the elements of the exam, visit, and medical decision-making that they personally provided. So rather than, when I'm in the clinic, if I'm working and seeing patients and my APP is seeing patients, because I'm provider-based billing, I have to physically see that patient and tell them what I did during that visit and document that for me to bill out at 100%. If I do not see them, even though I'm in clinic, they can only bill out at 85% rate. And for CMS, they want to see a substantive portion of that visit involves some portion of a history exam, medical decision-making, and key components of the service. And a lot of that has to do with medical decision-making, and that's what I'm most of the time documenting on as well as if I do an exam or I did a portion of the exam I did. But this key thing is documenting this is key to it. And the reason I kind of focus on billing is that as the macro or the new healthcare law that relates to changing from fee-to-service to quality payment models is that physicians and physician assistants, nurse practitioners, CNAs, we're all tied to this type of billing. So as healthcare laws have changed and we're being graded, and these are like things like MIPS or alternative payment models, we're being judged based on our quality, our utilization of EMRs, improvement activities, patient satisfaction scores, and in the future, potentially cost-saving mechanisms, your APP and you yourself are just as important for you both to be involved and engaged in these quality measures and making sure you're meeting these metrics because over time, we are going to be associated with a huge change in potential revenue generating or a revenue loss if we're not meeting these needs. So having this conversation with your APPs about the importance of macro health law is really important because of the potential cost savings and revenue you generate for your clinic. There are concerns about adding APPs, the cost associated with it. Some people are worried about the loss of the doctor-patient interaction. Me personally, my patients have liked working with APPs. If you look at the generalized data, those patients have been...satisfaction scores have actually improved with APPs. They can spend more time. How are we going to educate and train new grads, the scope of practice and procedures, what they're able to do? Again, we talked about the reimbursement, liability. The liability changes for your overall liability insurance isn't a huge change, but it is something to think about and having those conversations about what are everyone's scopes of practice and how they're going to be overseen. But I mean, it all comes down to the health. Our demands are so hard to meet the needs of our patients that we're seeing, how many we have to see in a day, the follow-up, the documentation, all these things makes it important for us to develop a team-based approach to managing our clinics and every team should strive to make the highest and best use of the education, training, experience and talents of each member and making sure that we're all maximizing our potential. But always remember that the patient's the most important part of this team and getting their engagement and showing them how your practice runs. You might be seeing my APP next week or my nurse will call you up, recognizing the importance of all members of the team become key to all this. So hopefully there's going to be a lot of discussions because a lot of this is kind of individually based upon where you're at, what part of the country, who you're working with, are you in an academic setting, are you in private practice? So hopefully I can answer some of those questions tonight. But I think the key thing is that we need to become... Patients have to become the leaders of these teams that are evolving to meet this high demand especially in the field of women's pelvic health. And care models need to be developed to maximize the individual strengths of different types of APPs. We've standardized the core competencies so we need to figure out what it is that APPs need to know and understand in urogynecology and how do we maintain this access that people are getting the same quality of care whether it's in South Dakota or New York. And the other thing we can't forget is that the APPs need to work with their collaborating physicians to develop and expand their skills. It's not they just come out, okay, here we do it. They have to realize the importance of continuing medical education as well, which leads me to my final point, and then I'll take your questions, is AUGS is sponsoring an APP course April 19th through the 21st in Lowe's in Minneapolis. It should be a great course. A lot of great speakers and topics that really kind of mirror what the SIGs had in mind in terms of their knowledge base for their core competencies. So I hope you or your APPs can attend this. With that, take any questions. Matt, thank you so much. That was super helpful. The floor is now open for questions if anybody would like to type in your question, but let me ask you a couple of questions, Matt, if you don't mind. Do you have a preference on, you know, a physician's assistant versus a nurse practitioner? That's the most common question I get, and if you noticed, I have a PA, a certified nurse practitioner, and a doctorate of nurse practitioner to make it... That's about as political as I could be in terms of covering all my bases. I think, though, for physicians, it's a lot easier to start out work with a physician assistant just because I think our curriculum mirrors one another. But I think we also have to look at the nursing background and what nurse practitioners bring, their approach to medicine, and really have an open mind. But I think what's... So they each have their strengths, but at the end of the day, they're all going to be doing, at least in my clinic, they all have similar roles. The important thing is for, like, because nurse practitioners are population-based, if someone did a nurse practitioner degree in pediatrics, well, they can't come and work at a urogynecology office because of their scope of practice. And most of the nurse practitioners are either primary care or there's even women's health tracts as well. Do you... You know, you mentioned the reimbursement, and, you know, it's something that in academic practice I feel like we don't talk that much about, so I'm curious, do you see challenges and reimbursements with APPs? I don't, and I'm not sure how if academic centers are provider-based billing or not would be a good question to ask your chairperson, because that's going to really change your workflow in terms...and billing practices. And I think all institutions, whether it's private practice or academics, you really have to focus on the downstream revenue potential, meaning that I didn't do all this training to put in pessaries all day long. You have all these operative skills and you should be doing surgery, and that was what our hospitals want us to do, and it's very effective. And so they're realizing that they can free you up to be more active surgically is key. And also, I think if you bring this data in terms of the demand for urogynecology, I'm sure all you guys all have waiting lists to get in to see you. I mean, it's just there's such a demand for it, and I don't see us being able to pass this on to urology or have OB-GYNs do this. By people whose sole focus is urogynecology, I think it makes it right for academic programs or even private practices to expand their services with APPs to kind of get people into the door and kind of oversee so that care is standardized and those needs are met. And with the billing, even at that 85%, most of these people can pay for themselves with follow-up visits and in-office procedures, whether they're doing stimulation or biofeedback therapy or interstim programming or PTNS. There's a lot of things where they can be utilized that can help overset the cost of their salaries. Well, we have one question, and that is, will you be sending out a copy of the slides? And to answer that question, the webinars are all going to be posted on the AUGS website. So, if you're a member of AUGS, as you are, if you're joining us tonight, then you will have access to Dr. Barker and Matt's...all of his slides. So, I guess on behalf of the AUGS Education Committee, Matt, I want to thank you so much for your time and your talk for tonight. It was really, really helpful and educational, and I think, you know, very practical as, you know, the climate of healthcare changes. So, thank you again. Thank you very much. I appreciate it. And I think that concludes our webinar for tonight. I want to thank all of the participants and also everyone who joined us. And again, remember that the webinars will be on the AUGS website for posterity. Have a good night, everyone.

urogynecology team

advanced practice providers

access to care

pelvic floor disorders

models of care

physician shortage

provider types

reimbursement considerations