And just to kind of help, as a panelist, we each represent sort of different experiences, and I think that's also helpful if you have questions that you think we could address individually. I have a small practice of two urogynecologists and some other providers, and it's a private practice, so it's unique in that setting. There are some still that exist. That's my background, and maybe each of you can explain yours, too. My name is Blair Washington. I am a urogynecologist in Seattle, and I work in a large multispecialty physician group, more than 500 providers. So that is my practice setting. I'm an employed physician in that group. And I'm Sarah Boyles. I am part of a four-person group that's part of a larger multisubspecialty group, and I'm in private practice. And I'm not employed and maybe have a little bit more autonomy over some of the decisions that we get to make. So one of the things that we're going to talk about here is why we should care. And I always find the financial components and all the ramifications that we're talking about to be moderately terrifying. I don't know how all of you feel. But I think the other reason that we should care about this program is that the goal is really to improve quality, and this may be a little bit idealistic, but it's to improve quality to get physicians' feedback and then help us improve our care, and then to be transparent to patients as well. I mean, patients are going to be able to see our quality reports. Right now, a lot of our quality measures don't necessarily measure what we consider to be quality or the depth of quality that we want. But I think the onus is on us to kind of move that forward and get it to the place where we want it to be. I don't know if you guys want to say. Yeah. I mean, I completely agree with that. I think trying to define quality is really important, and we're sort of at the beginning of that in our field to quantifiably identify quality. So I think that's really important. I think the other really big reason to care is we should all know how we're going to be measured and how either our practices are going to do it, or for me, in a big multi-specialty physician group, there are people making these decisions for me, and those bonuses and penalties will apply to my reimbursement. And so I should know, and so that's why I care. I imagine all of you, most of you, I'm just going to say one more thing. Have an NEMR system or EHR system, and I'm guessing that you just hope that's taking care of a lot of this. I don't know if you've looked at it, though, and the question, I guess, and that's what I'm dealing with right now is when you look at all these different measures, if you have a quality registry to use, that solved all of them. I don't know if you saw, that was kind of the message for now. Obviously, Jill keeps telling us, you know, use the force loop, you can hear in the back of your head, well, that's the go towards the APM, go towards the APM. That's probably the future, and I think there's a lot of smart minds trying to figure that out. OGS has certainly dedicated some resources in trying to see how can that work in the urogynecology realm. We don't know yet, but in the meantime, at least, if you don't know if your EHR is doing things for you, and if they are, how are they doing it, it may not be getting at what you want to get at. Like, I know, for instance, I use an EHR called, I don't have any relationship with any company, by the way, Athena Health, they report on a lot of quality measures for me, but they're all body mass index, diabetes reporting, blood pressure recording, that really don't say anything about what kind of quality of care I'm providing to my patient, because truthfully, I don't even care on some of those, BMI, I do care, but there's some that I don't even really care about, and yet, that's what they're reporting my quality as a physician. And it's like Blair was saying, patients are going to have access to some of this information as time goes on. And right, it won't happen fast, but I know it happens faster than you think, how quickly people, at least I get more patients coming to see me now, who have researched who I am, in a much more in-depth way than they did just two years ago. So this is going to be part of how they assess us, it's how we get patients. So that's one thing that I care about. The second thing I care about is, if they're going to choose quality measures that don't report anything that's of value to me, it's not real fun to even want to report them, I'd rather just have my HR do it fine. But I've been actively engaged in Acquire since the beginning to see how it works, really, and to see how I can report. And there's some value in that. It helps me to appreciate things that I, you know, it's actually stuff that we ought to be doing anyway, but it's nice to know that I'm getting credit for the things that are good, and I'm seeing that in every one of my patients. So that, I hope, will eventually equate to some of the things that have been discussed. I feel like I'm in the middle of this massive traffic jam, and I'm supposed to navigate through it, and I'm just one little guy in a small little Honda CRV or something, I don't have a big semi-truck to blow through it all. So it's hard, but we've got to start engaging, we can't just stay there and idle, or we're not going to move forward. And I think that's the message that I'm hearing over and over again. So we ought to have some plan in place when we leave today for what we do when we go home, and I don't know what that will be for each of you. What you just described as changes, because the bucket's not getting bigger, but the population is getting bigger. So they're going to try to shrink in some way or the other. That's going to probably have a bigger impact on whatever benefit and bonus we may gain by qualifying for those measures. Now, of course, the reduction's worse if we don't, but truthfully, you know, a 4% increase in our Medicare payments may not nearly be as great as the loss we gain by just reducing that conversion factor by one point. So I'm a little, it's, I feel like I'm a bit of a connoisseur. Alternative payment model, right? I mean, that's why they want to move people over, is because then they have a guaranteed number, because the methodology of the alternative payment model guarantees a number. Models go at risk for managing the volume and the cost, and it gets CMS out of this volume game, kind of 4%. There's been some good data, and we can get it to everybody, sort of showing what happens to your conversion factor as a practitioner if you stay in MIPS long term. It's actually not economically advantageous, particularly when you get to the .25, .75 differential, as well as just the 4%, 9%, et cetera, isn't going to keep up with costs relative to trying to get people into APMs, where the APM methodology is going to provide payment for, you know, what CMS believes, i.e., more appropriate care, and then also the higher conversion factors. So CMS is, just like all insurance, right, CMS is an insurance company. They are no different than a United or a Aetna, Cigna, et cetera, you know, just like the private insurance companies are going to providers and say, hey, I want you to guarantee me this activity for X amount of dollars, right, they've done it with hips and knees particularly, then the insurer can say, well, this is my only exposure. I know I'm going to have 100 hips and knees, and I guarantee a price of $1,500, so that's my exposure, and if the practitioner can't do it for $1,500, well, you know, too bad, right? I mean, that's the mentality we're moving toward, and that's why we all, as clinicians, have to get smarter and learn these choices and ask these questions when we're interviewing folks to come into our group or we're joining a group. It's not just about the normal questions you would ask. It's now about, well, how are you doing your quality reporting? What's your MIPS score been? Are you participating in an APM? Are you going to participate in an APM? You know, it's all these types of additional questions you have to ask because the money's going to depend on it. Can you comment at all, Jill, about sort of risk stratification as we consider this? I mean, I, you know, when you think about being, and maybe it doesn't, maybe this isn't the proper place to have that conversation, but... Risk is going to be taken into account in the cost scores. It is not taken into account in the quality measures besides the benchmarks. So one of the things that is problematic right now with CMS having to figure out the cost scores is how are they going to do risk adjustment for cost? And what they're working on right now, which they hired a contractor to do, in my personal opinion, it's not going very well, is they're creating these episodes of care so that right now the cost measures have basically been total cost of care per beneficiary, right? No adjustment, just straight up, right? So if you treat higher acuity people who have more total cost of care, you don't do as well, right? So medical psych community doesn't like that. The law requires risk adjustment. Macro law requires risk adjustment. So CMS is looking at these episodes of care to be able to compare like costs for like patients. Now, the way they're doing the risk right now is a pretty simple way, but maybe it will be effective. We're not totally sure, but it's a diagnostic methodology where they're asking the medical community to look at these episodes of care and say, okay, well, what are the additional ICD-10 diagnosis codes that these patients could have that we would want to know so that we could compare their cost, right? So we could group like patients to like patients. CMS is not—data systems are not very sophisticated, and so how their ability to do that long term, we're not sure. But there's this whole group going on. Fortunately, and Sarah's going to talk a little bit about cost measures this afternoon, we have not yet had episodes really in urogynecology care to be able to see how we're—how the triggers and the patient groups and the splitting is going, right? Is it going to be laparoscopic together, is it going to be procedure-based, open, laparoscopic, vaginal, et cetera, or is it going to be disease, you know, SUI, mixed, prolapse, et cetera? Currently now, I would say the ones that I'm working on with vascular surgery are procedure-based. Repair of abdominal aortic aneurysm, right? And now we have to go in and split all those different repair methodologies, endovascular, open, fenestrated, because the contractor doesn't know, right? So the cost piece is very much a work in progress and one we need to be cognizant of that eventually our time will come and we will have to work very hard to get those episodes as accurate as we can so that the costs collected are only the costs that should be associated with that patient and also that we can group like patients, like with complications, et cetera. Attribution is a really hard thing for the Medicare program and one they're not very good at. So particularly when you co-manage a patient or you're sending a patient back to the general GYN and you're only keeping them for certain amounts or you're sending back to primary care, CMS doesn't yet know how to split those costs up, right? So it's a problem. It's going to be tricky, which is one of the reasons why we want another year where cost is only worth zero, because we're afraid even to put it in at 10% that it's going to cause specialists, particularly sub-specialists, to scoot down on the total composite score. Can I just respond to that really? I think I'm also on the Augs Quality Improvement Outcomes Research Network as one of the network sites for the network and on the Quality Committee. And one of the struggles on the Quality Committee has been that, is exactly that sort of divide that we as urogynecologists really understand what quality means to us in terms of how we move through a patient care experience, but it is extraordinarily hard to create measures that actually capture that, that then you could report on. And I think as part of the network, that's one of the big goals, to create measures that actually speak to quality. So we're capturing a lot of data now that hopefully will be turned around into measures that are really measures of what we believe are important quality outcomes in our field. But they're in the process of refining now, I would say. I'm going to comment on that, because I look at it a little bit differently. So I train for the AAMC, train faculty on quality improvement, patient safety, and then in other venues. And the thing is, is that what you bring up are things that have to be addressed totally, right? But you've got to start somewhere. And when I look at what they're trying to do, and I showed you the curve about narrowing the variation, moving the curve to the right, I actually don't think this is going to work or have it come to full fruition until two generations of physicians. So I also am involved with residency education. And so we're starting to do the CLAIR, one of them safety and one's quality improvement. The faculty don't know anything, okay? And so we're kind of forcing them to know a little bit, and they're passing it down to this current group of learners. These current group of learners are going to have a higher level or understanding that we have. And when they move into our position, so that Generation X or Gen Y just actually entered the faculty levels in 2013, they are going to have a little bit better knowledge of quality than what we do. And that they're also going to be undergoing this kind of movement, and so it's the docs that they're going to be teaching are going to be the ones that make the effect of all of this. So, I mean, yeah, it's twofold. One is the control cost, but I think we haven't met society's needs in terms of quality. I mean, you see it all the time, the IOM report, all this stuff. Sort of some activities that AUGS is thinking about and hopes all of you will maybe help us with as we look forward, right? This is evolving. And one of the sort of activities that we're starting to look at, all of medicine's starting to look at is patient-reported outcomes measures. What's important to the patient? There's some tools that different areas have started to get a better sense, that's one. I think we're also hoping that the registry, particularly ACQUIRE, if enough AUGS members participate, that it will give us some good data to understand, can we start to create quality measures that track over time, right? They really look at not just that surgical episode when the patient was there in the hospital or there with you for that, you know, 24 hours to 48 hours, a couple days, and then there are 90 days of follow-up, but what about that patient's outcome a year from now? Can we somehow tie that back to the care that patient was given for some period of time previously? It's really been complicated for the quality movement around outcomes, what we would really think of as outcomes measures, not just process measures that are a little longer time window, but how do you get those long-term follow-up measures and really look at how did that patient do long-term? Did they have a good solution to their problem? But I think registries are going to give us the tool to do it, our research networks that we've been putting together, we hope will give us the tool to do it, so that we get out of these kind of binary, did you do this or did you not do this activity, and make it a little more meaningful. Quality measurement, I call it the big black hole, right? I mean, it is not a spectator sport, and it is a contact sport, and we have evolved a lot as a physician community over the last couple of years, but we are still, whoo-hoo, in the infancy, right? I mean, we're really still at the tip of the spear, and even at the tip of the spear, it's a lot of work, and it's a lot of activity, but I think that AUGS is putting some tools in place with the registry, with the networks, with this stuff, the committee is going to try to start thinking about a plan for patient-reported outcome measure development that we maybe are going to continue to evolve fairly quickly relative to some of our other colleagues in the community. So, you do not have to declare how you're going to report as a group or as an individual, until March 31st. So, you run the numbers as a group and an individual, and you pick the highest one. 2018. Yeah. So, you collect your data now, look at it between January 1 and March 31 of 2018, and then declare. One of the things that Bob just said is so key, you can't, because we're in a shorter reporting window for 2017, i.e. 90 days, you should check your data before you make your choice. Now, some large faculty practice groups are not giving people a choice. You have to report as a group, but we do know of some big faculty practice plans that are giving their people choice to be able to report either way. So, now that assumes probably that you've got some flexibility, you're big academic groups letting you do measures by, or quality by department, or more registries than just one or two. But, and I also know some big groups who are going to report as a group this year, but have already decided they're going to give flexibility for individual reporting in 18. Right? So, I think that you want to understand your data, and then make your choices. One of the things that CMS does have on the QPP website, and again, if we can, maybe this afternoon we'll show you all the QPP website, it has the benchmarks that are available for every measure that has a benchmark. So, you can really get a sense of where you would fall, and what your points would be, and then that, I think, will help people decide how they want to go in to the program. It's a little complicated. I'm not going to tell you it's not, but I do think that if you have your data or you're participating in a registry that gives you a dashboard that shows you how you, each physician in your group, each eligible clinician is doing against a group, and how the group's doing against the national benchmarks, that makes it much easier for your practice to check how you're going to go. The other thing, too, is you also have the choice between doing your specialty-specific or whatever is out there. So, you run it both ways, too, and again, see which maximizes your score. That's the point, is maximize the number.

quality improvement

healthcare

patient care

transparency

reimbursement