I'm going to talk a little bit about the changes that are going to happen starting in 2018. Some of this is information that we've heard, but I'm just going to go over it again. I'm going to talk about pace, cost, and incentives. Those are the big changes that are going to happen after this year. And then talk about quality measure development and refinement. A lot of my slides have been taken from the CMS slide deck as well as from the MGMA slide deck, and I just want to thank them for those resources. I didn't do a disclosure slide, but I have no disclosures. I just wanted to take a second and put up this quality strategy aims from CMS. And just to remind us, I mean, you know, you get so bogged down in these details and how difficult it all is that, you know, we're really trying to go to better care, smarter spending, and healthier people. And it's a very lofty goal, even when the details feel very clunky and difficult. So starting with pace. So we've seen this slide a couple of times. You know, this year CMS tried to make it as easy as possible. Sixty percent of the measures of your score is based on quality. Those are measures we've seen before with PQRS. There's no cost data for this year. And then 15% with improvement activities, 25% with advancing care information. And this is the pick-your-own-pace year, right? If you submit no data, you'll have a negative reimbursement. But if you submit some data, you'll at least be neutral. And so it really is a good, easy time, and it's hard to remember that. If you submit some data, you'll have a modest positive adjustment. And then if you submit for the four-year, you technically could have a modest positive adjustment. And so the key points with this is just that it's really a great time to test your own system and make sure that it works because it is going to get more difficult in the future. And I think this is all information we've covered really well. So the next point is cost. Right now there's no cost component for 2017. Initially it was supposed to be 10%, and then the final rule, it got taken away. The cost data, like we've said, you don't have to submit anything. It's just taken from your claims data. And even though it is not part of your score this year, CMS is collecting the data. You can get that feedback. You should check your feedback in the summer of 2018, that QRUR report. This data is all based on the Physician Value Modifier Program, and they're really collecting the total charges per beneficiary. We're going towards cost measures. And that's going to be an important change. So the reason that cost is felt to be important is that 80% of medical costs are attributed to physician decision-making. So not physician salary, but we drive the cost in medicine. And most of us have no idea what our decisions, what kind of cost implications there are from those decisions. And so we're moving to cost measures. So what is a cost measure? So cost measures represent the Medicare payments for items and services furnished to a beneficiary during one episode of care. And all of these issues have to be defined moving forward. So to have a cost measure, you have to define the episode group. So an episode group is really the conditions and the associated charges. And I think, you know, for some cost measures, that seems pretty simple. I mean, I think I can figure this out in my mind for a sling pretty easily, but it becomes pretty complicated. Jill and I were talking about, you know, some vascular surgery cases. And when you throw in a lot of comorbidities and multiple physicians, I think this becomes a lot more complicated. So you have to define the episode group. You have to assign the cost to the episode group. So what costs get assigned to what? I mean, think about a hospitalization and how complicated that can be. You have to be able to attribute the cost to the responsible physician, right? And that has to be reproducible. And everybody has to agree that it goes to that physician. And then this is where the risk adjusting comes in, right? I mean, if you're doing, you know, let's say a sling on someone who has no medical conditions versus someone who has multiple medical conditions and ends up getting admitted because of those medical conditions, making sure that you're not comparing those patients to each other when you're looking at cost. And then I think, finally, the most important component is that, to the extent possible, cost needs to be aligned with quality, right? If we're driving down cost and driving down quality, then this doesn't make any sense at all. So I went through and I looked at the episode group. Because, you know, when I read all of this, I'm always thinking, okay, so what does this mean to me, right? How does this impact me? What should I be looking at? And episode groups are divided into three different categories. So there's acute inpatient medical conditions, chronic episodes, and then procedural episodes. So there's nothing that is kind of urogyne related in chronic episodes right now or procedural episodes. But there are a couple things in acute inpatient medical conditions that maybe I could see. And they're really complications of surgeries, right? So GI obstruction, kidney infections, other kidney or urinary tract diagnoses, and PEs. And even, you know, Jill and I were kind of talking about this. Even if I had a patient who had this, I don't know if it would be attributed to me, right? There are a lot of details here that are being worked out. So CMS has really looked to gather a lot of stakeholder input on this, right? I mean, everybody has very strong feelings about this. And as Jill mentioned, it's one of the reasons that cost was kind of postponed, because we really don't know how to do this. And, you know, the stakeholders have been really clear with their feedback that it's important that physicians are involved in this process. It's important that, you know, we're really aligning quality with the cost. You know, the information that you get, that you get it in real time so that you can make adjustments to your behavior, right, which is why that you get that, you can get the feedback report. And then, you know, the one thing that comes up time and again when you read this is that everybody's really afraid of unintended consequences, right? And what could happen when we do this if it's not done very well? So cost is going to become more of an important component. Right now it's at zero. Next year it could be at 10 percent. It's not really sure if it's going to be at 10 percent yet. And then in 2019, cost will be 30 percent of the score and quality will be at 30 percent of the score. So it's going to become a more important issue over time. So same message, access your quality report, review your data, and look to improve your performance with this, because it will become increasingly important over time. So incentives, this is something we've talked about a lot. The incentives are going up, right? As the incentives go up, the stick goes up as well. And so all of this will be more important for us over time. And I'm not going to dwell too much on this because we've talked a lot about this. So this is just my transition slide. This is a picture of the Oregon coast, beautiful but deceptively cold for those of you who have never been there. So quality measure development and refinement. We've touched on this. I think we're all a little bit disappointed with the measures that we have. We don't really consider them to be quality. We're a little bit limited by what we can do with our existing technology, what we're willing to do. We don't want to spend a lot of time putting this data in. It's hard to track our patients down in 10 years. I'd like to know what my 10-year sling outcome is. But those things are difficult. And so this, too, is a very iterative process. So CMS's strategic vision is to evaluate and build on the existing measures to develop a person-centered portfolio of measures that can positively drive health care outcomes. So it's a pretty lofty goal. The goal of the quality measures is to measure health care and to improve health care over time. And to create a quality measure, you need to focus on the areas of medicine where there's a lot of practice variation. Then you need to study it, figure out what the best practice is, and then develop measures that incentivize that good behavior. So I think it's easy to kind of come up with quick quality measures, but to really do the data and the work to create the measures is fairly expensive, time-intensive, and difficult. And you end up having a lot of conversations like, you know, if you're looking at bladder injury after prolapse, do you include injuries from a TBT trocar, right? Should that be included? Should that not be included? And figuring that out, we decided no. There have been a lot of lessons learned in quality measure development over the past years. CMS has kind of outlined those lessons in this slide here. And I just want to point out a couple of things. So the first is that it's important to partner with frontline clinicians and professional societies when developing it. They really want us to develop the measures along with patients, caregivers, and communities. There's also recognition that there's a lot of clinician burden of data collection for measure reporting, right? We all complain about this. It's not what we want to do. And there's recognition that that needs to be made easier over time. There's also aligning measures across pairs, right? So having one system, as other pairs may or may not use these measures, there should just be one system, right? So you don't have to report different things to different people. It's hard to imagine making things more complicated, but it seems like we could. Then there's some talk here about just how difficult it is to create good measures. And then there's this big push to develop meaningful outcome measures, developing patient-reported outcome measures and appropriate use parameters. And then developing measures that promote shared accountability. So CMS has created a quality measure development plan kind of moving forward because there are so many gaps, and we know that there are a lot of places where we need measures. There are six different areas, but I'm really just going to talk about the outcomes and the patient-related outcomes. So the first category is under clinical care. There are some areas of medicine where they really feel like there are huge gaps in the measures, and those are areas like ortho, palliative care, pathology, radiology, mental health, and oncology. So there's a push for measures in those areas. But for most of us, it's looking at outcome measures. In safety, they're looking at measures of diagnostic accuracy, safe medication use, care coordination. Patient and caregiver experience is a really big one, and they're looking at patient-recorded outcome measures. And when I first started reading about this, I just kept thinking about all of those ER surveys you always read about where the only people that rank the physicians highly are the patients that get opioids. I don't know if you've ever read those. And I was thinking, well, I don't know how great of an idea this is, but there's a lot of really great information in that area. So then they're also looking at population health and prevention and affordable care. I think we're going to see more overuse measures over time, but these aren't as pertinent to us as surgical subspecialists. So what outcome measures do we have right now in Urogyne? So we have three, and the three outcome measures we have are proportion of patients with a bladder injury at the time of a prolapse procedure reported within 30 days, proportion of bowel injury, and proportion of ureteral injury. And I think that these are important measures to look at. They're easy measures, right? They're binary, yes, no. They're in a very short time frame, so they're easy to collect. They don't require too much burden on the part of the physician. You don't really have to ask the patient questions. So, you know, all of those things make them easy. But they're also pretty limited. So I think if you have a low rate, it's quality care. But, you know, I could score perfectly on these and do the worst prolapse procedure ever, right? So this isn't really what we want to be, where we want to be. I just wanted to mention the AUGS Quality Improvement and Outcomes Research Network. And I think Blair is the only person who works in this network. But they've developed a lot of measures, not necessarily outcomes measures yet, but they've done a lot of work, like the value trial, where they looked at quality measures associated with, or outcomes associated with, hysterectomy done for prolapse. And we were able to create some measures based on that, things like cystoscopy at the time of hysterectomy, things like apical suspension at the time of hysterectomy for prolapse. And there's a lot more. These two other additional studies that they're working on at this point in time, quality in prolapse surgery, quality in anti-incontinence surgery, where it's a multi-site retrospective study looking at different quality measures with these different surgeries. So looking at length of surgery, looking at length of stay in the hospital, looking at different surgeon variables, training, whether you're a high-volume surgeon, low-volume surgeon, just all different kinds of factors that could be impacting the quality of care, and then looking at what measures we can develop from that. So I'm just going to talk a little bit now about patient-reported outcome measures. So the initial MACRA legislation really pushed patient-reported outcome measures, and physicians, as you might expect, were pretty resistant, kind of speaking to what Bob spoke to before. We don't like change at all. Nobody likes change. And these were their initial concerns, right? We don't use them, and we don't know what they do. So why should we use them now? Because they really were not widespreadly used in clinical practice, and we didn't know how they represented our performance, especially for a health care entity. So the National Quality Forum did a lot of research on this and looked at it, and they created an algorithm about how you should create patient-reported outcome measures. And this is something that is gaining a lot of popularity at this point in time. So some of this may seem like common sense, but you have to identify the quality performance issue or problem, right? What are you looking at? Identify the outcomes that are meaningful to the target population and are amenable to change. And this means talking to patients as well as the providers, because sometimes what patients think are important and what we think are important aren't necessarily the same thing. And then determine whether asking the patient is really the best way to get at this data. Is there a different way to do it, or is this what we really think is the best? So once you've kind of identified the outcome you're looking at, then you can look at the way to assess it. So are there any measurement tools for assessing the outcome in the population at interest? So are there surveys out there? Are there things that you can use? And if there is something that you think you can use, is it suitable, right? Is it reliable? Is it valid? Is it responsible? Is it feasible, right? I mean, sometimes when we talk about measures, we come up with things that really aren't feasible or practical. And then can it be used in a real-world setting with the intended target population? A lot of our surveys are research surveys, right? So can you use them in clinical practice, and does that make sense? And then once you have all of that identified, you can specify the outcome performance measure, right? So how are you going to use that survey? Are you looking at average change? Are you looking at percentage improved? Are you looking at meeting a benchmark? And then you have to test it. And this is why developing these measures take a long time. Developing any measure takes a long time. But you have to test it for reliability, validity, and threats to validity, right? So do patients fill it out correctly? Can you give it to 100 percent of patients? What does that look like? But developing these outcome measures is becoming more and more popular, and it's starting to be done on a small scale. So one of the places that people are starting to use these are with knee – with joint replacements, so with knee and hip replacements. And they're not all – they haven't all been developed into measures yet, but they've been working on automating the process and asking patients the surveys. So this is an example of the knee injury and osteoarthritis outcome score. The higher your score, the more pain-free you are, right? And so when you look at this, you can tell that patients have a considerable amount of pain before surgery. This line is their surgery. And then after surgery, they feel better, right? And so this is becoming, you know, kind of a new measurement standard. And you can also envision how you – you know, with appropriate testing, you could determine cutoff points, what percent of improvement and what percent of patients is what you would expect and what would be a good benchmark. And I just wanted to include this quote. So this is from Neil Wagle, who's from Brigham and Women's Hospital, and they've started using a lot of surveys as part of their quality measurement. And what he said is, you know, patient-reported outcome measures are precisely the missing link in defining a good outcome. They capture quality-of-life issues that are the very reasons that most patients seek care. And I think this, you know, speaks a lot to what we do as well, and we can see how these measures could be very beneficial for us and for our patients. That's it. Thank you.

healthcare changes

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cost

incentives