Welcome to today's webinar. I'm Dr. Ludmila Lipetskaya, the moderator for today's webinar. Before we begin, I'd like to share that we will take questions at the end of the webinar, 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 titled Value-Based Care and is being presented by Dr. Rebecca Rogers. Dr. Rogers came to Dell Medical School from University of New Mexico, where she was a Regents Professor of Obstetrics and Gynecology, Chief of the Division of Urogynecology and Vice Chair for Research. She began her career as a math teacher in the Peace Corps in Swaziland, Africa. From there, she was trained in experiential learning as an assistant instructor for outboard bomb. She received her medical degree from Harvard University and completed her residency in OB-GYN and fellowship in urogyne at University of New Mexico. After her training, she joined the faculty at the University of New Mexico, where she established the ACGME-credited urogyne fellowship program, a very successful one, and Division of Urogynecology. Under her leadership, the Division of Urogynecology brought together a multi-specialty group of physicians, midwives, physical therapists, nurses, and the research and administrative staffers to bring high-quality care to patients with pelvic floor disorders. Most recently, Dr. Rogers was recruited to the University of Texas, Austin, to start the Women's Health Institute. In this role, she has been tasked with designing and starting an innovative clinic focused on increasing the value of urogyne care. Please welcome Dr. Rogers. Thank you very much for those nice comments. So, today we're going to talk about value-based care, and I think I look forward to your questions as we go along. Is that me? Okay, so these are my disclosures. I receive loyalties from UpToDate. I do receive stipend and travel from iUGA, ACOG, and ABOG for various things I do for those societies. So, I think that to start off our discussion about value-based care, we can start with a question about who doesn't really appreciate a bargain. I mean, most of our patients are bargain seekers. They want the best operation with the fewest risk. They certainly, as insurance plans are changing and co-insurance and co-payments are changing, sometimes they're seeking environments where those charges will be less. So, people, everybody kind of enjoys a bargain. We want things to be high quality and low cost. This is also happening in healthcare. So, particularly in our field, women's healthcare demands continue to increase. Most of our services will increase for women over time, and the greatest growth will be among Hispanic women. We also know that the aging population is also increasing. We have individuals 65 and older represents currently about 12% of the population, and that's going to expand to nearly 20% of the population for 2030. There will definitely be more elderly women than men, and they are going to need our services. So, the future is bright for urogynecology. We're going to be busy as things go along. Not me. I'll be done by then, but you guys will be taking care of all these folks. Now, if we put this in the backdrop of what's happening to U.S. healthcare spending, this is a graph that's often put up in these talks. Starting within the 1960s, the percentage of the GDP was about 5%, and now it's somewhere close to 18% in 2010 and even higher now, and this is expected to continue to increase. Obviously, we cannot continue to spend what we're spending on healthcare forever with this trajectory. So, this is where the government has come in and says we need to figure out a way to still offer high-quality care, but at a lower cost. So, this has engendered a plethora of legislation and initiatives. Some of you may have been aware of from your clinical work, the Affordable Care Act, so that more insurance is available to those with preconditions, and the idea was at lower cost. Skip measures, value-based efforts at individual institutions and nationally, and then trying to look at patient satisfaction. So, our quality of care measured by those, you know, would you recommend this physician to someone else, and is this physician in the top 10% of doctors that you've had experience with, and whether you agree or not with those kinds of measurements, they're here to stay. Newer ones include MIPS, where we have to meet certain quality measures. Those quality measures travel with the individual physician and don't stick necessarily just with the institution. So, the government, through legislation, is trying to move us to a more value-based care model. In OBGYN, what have we done? Well, when I started my career, women were admitted to the hospital the night before their surgery. We did this so we could do a brow prep, and they would also get to know the nurses on the floor, and I remember rounding on these women. They would be shuffling around in their bathrobes and slippers, you know, waiting for undergoing their miserable bowel preps, and waiting for their surgery the next day. Obviously, not a value-based decision, but it was what we thought was right at the time. Now, we're shifting more and more to ambulatory-based care, and I rarely keep patients even overnight after major surgery. We have to pay attention to value, and in this equation, it includes both quality and cost, and we know that high-volume providers and institutions are more likely to provide high-quality care. Another good thing for the forecast of our careers, because we are a subspecialist, we tend to be higher-volume surgeons for operative care. So, why is women's healthcare a key in this? Well, women's are gatekeepers for not only themselves, but their families, but also often are in charge of family budgets, and decide where healthcare money will be spent, and these things are critical to both our departments and our institutions. So, where are we now? Lots of things are changing fast. Many of our chronic problems are still chronic, and ease of access and coordination is challenging. So, how does trying to increase value in healthcare affect providers? Well, in general, it has evolved into we're trying to see more patients, do more procedures, generate more RVs, and spend more time documenting. So, as if payments go down, one solution would be to just produce more widgets. This is not something that is sustainable in the long run. I don't know a provider that I interact with who doesn't feel overburdened by the amount of care that they need to provide, and the pressure to perform and generate billing units. So, let's change the focus and now talk about value. So, the typical equation for value is quality, which would be, in my opinion, outcomes that measures to patients, divided by the cost of providing that quality care. Some folks have suggested that we should also include a piece that looks at what kind of service the patient is giving, which is a little bit different than quality, or could be wrapped up in quality. So, how do we increase value? Well, if we look at our equation, we can either increase quality or decrease costs. Those are the two methods that we really could change things. So, we can certainly decrease waste. We can decrease duplicate services. We can have people work at the top of their skill sets, and we can ensure that our providers have the tools to be successful. Now, I would challenge you all to think about your last day in clinic and whether there was any waste that happened in that clinic. Was there any duplicate ordering? I know routinely in my clinic, we struggle to get lab results and or test results from other clinical venues, and if we don't have them, but we need them to coordinate our care plan, we sometimes repeat them, even though the patient may have undergone this testing relatively recently. We all have experience working at the bottom of our skill set. This would, in my mind, include talking to people about avoiding diaries, talking to them about how to manage your constipation, and we all have struggled with not having all the tools we'd like to have to be able to do our job well. So, it seems that we could address value with this fairly easily. So, like I said, if we're going to focus on value, there's really two ways we can improve quality, and one of that is improve underuse. So, there are some things that save us money that we don't do well regularly. We can also reduce overuse. So, we know that there's lots of waste. The Institute of Medicine report states that almost 750 billion dollars in healthcare waste occurs yearly. So, there's lots of opportunity in here. So, if we look at this, this is from a JAMA article, if we look at that exponential growth of healthcare costs over time and the percentage of our GDP that's devoted to it, there is fraud and abuse. I'm not going to talk about that. That's hard to fix, and it's a small sliver there at the bottom. Pricing failures, that's pretty tough for me to fix. Administrative complexity, I may be able to do some things about that. Overtreatment, failure of care coordination, and failure of care delivery, those three, I think, are where we have the most opportunity to really make some difference in value. So, I'm going to shift gears here and now talk a little bit more about the design and development of what are called integrated practice units, which is our approach to addressing value-based care. So, Michael Porter and Elizabeth Teasburg published a volume called Value-Based Care, and in it, they described an approach to care delivery and a way of doing the accounting around that care delivery, which really focused on increasing the quality and decreasing the cost of providing that care, but not just costs that incurred on the clinical side, also taking into account the cost to the patient of receiving that care. So, in an integrated practice unit, the care is organized around the patient, and the idea is that we're providing the full cycle of care for a particular condition. So, just like many of us have multidisciplinary clinics where we may have physical therapy, we may have nursing, we may have social work, or others in our clinic, or we may work closely with a cadre of folks, the idea is to bring all the types of care that patient may need for their condition in a single co-located place. It is a team-based care, and this is where I think it very much differs from multidisciplinary care. At the University of New Mexico, we had multidisciplinary care. We had people who were pest responders, we had physical therapists, and we were co-located, but we really didn't discuss patients in a very concerted way as a team and come up with care plans that were really team-based. In the IPU, we have a single administrative and scheduling structure. There typically is a physician team captain and a care manager, and the team meets formally and informally as a group and in subgroups on a regular basis. Key to this is to measure outcomes that are important, not only to the bottom line for the institution, which is what is always measured at most of our facilities in terms of billings and collections, but looking at whether the patient is better. Now, as an illustration of how off-base billings and collections can be, or some of our compliance measures in terms of outcomes following surgery, you could do a stress incontinent surgery on a patient that failed completely. The patient remained completely incontinent. However, she didn't get a urinary tract infection, she didn't go back to the OR, she didn't have a blood clot, she didn't get pneumonia. So, she would check all those boxes of not having a complicated surgery, and the surgery could conceivably be deemed a success, but clearly it's not a success. So, this team tries to measure outcomes that are important to pay for patients, and as I have lectured previously, this is very tricky to figure out, but we're still working on it. And then the team accepts accountability for the patient's outcomes and what we're spending to achieve those outcomes. So, this is this then diagram of the overlap between outcomes and cost. The idea is if patients attend clinics where care providers are co-located, there will be greater provider and team efficiency because we won't have to be waiting for the referral note or calling somebody. We can talk to our teammates in the clinical setting. We feel that this leads to better utilization of facilities, and it should hopefully streamline administrative costs. In terms of outcomes, because the team has input, this should result in better decisions in terms of diagnosis, execution of treatment, faster cycle time, improved patient compliance because they're not running around to a million places, hopefully results in improved engagement of care and greater patient convenience. So, what we do conceptually is we define a medical condition, which is an interrelated set of medical circumstances that can be addressed in an integrated way. The medical condition is the unit of value creation in healthcare delivery, and then we look at our outcomes. This is very simplistically the life cycle of treatment in an integrated practice unit. Now, as I said, IPUs are inherently different than multi-specialty practice, and these are the key differences. Shared decision making, weekly case conferences where patient care is discussed, facilities tailored for shared clinical space and integration, and then how do we decide how we're going to treat the patient? Well, one of the things that we do is create care pathways for specific conditions as a team. So, for example, we have pathways for the initial treatment of patients with urinary incontinence, and I'll show you an example of a pathway for anal incontinence a little bit later on, but if we were to create a pathway for urinary incontinence, that pathway would estimate how much time we would need to evaluate the patient at their first visit, what kind of testing might be necessary, and clearly not all the testing we do is necessary, what kinds of things we might offer them as first-line therapy, and then how we might move on to more surgical therapy. So, it's a structured pathway of care through the IPU. So, at UTHA, we have a women's health integrated practice unit. We have three of them, and we focus on complex gynecological care. So, we focused on complex gynecological conditions, including pelvic floor disorders, which we're all familiar with, vulvar disorders, and chronic pelvic pain. The reason that we chose these three areas to create integrated practice unit is because their treatments are often complex and intersecting. So, they need a broad, they may need care from multiple individuals. The clear diagnosis, path for diagnosis and treatment may be lacking. At least in the Austin area, provider and supportive services with subspecialty expertise, particularly in vulvar disorders and chronic pelvic pain, was lacking, and all three of these conditions have some stigma associated with them. So, for pelvic floor disorders, I'm preaching to the choir. We know that lots of women don't seek help. Reasons they don't seek help is because they're embarrassed. They believe that their condition is unavoidable to the age, and they may have lack of understanding or knowledge of the availability of effective treatment options. Particularly for some patients with some insurance types, they may think that the only option available to them may be a surgical option, which was the case with our safety net population before we started the IPU. We could not access physical therapists to work with our underinsured population, and many insurances would not allow us to refer them to individuals so they could seek more conservative care, even if they did have insurance. We all know that patients with chronic pelvic pain can be challenging, yet this is a huge consumer of health care dollars. Less than two-thirds of women with chronic pelvic pain receive a diagnosis as to the cause of their pain, and only 70 percent of those that are even given the diagnosis of chronic pelvic pain end up with the diagnosis and a coherent treatment plan. A lot of patients with chronic pelvic pain develop chronic pain syndrome, and we've all experienced this in our clinic, where it's really difficult to unravel and make their quality of life better. Now, I will admit that I did not have a tremendous amount of experience with vulvar disorders, although it does overlap clearly with urogynecological care. We see patients with vulvodynia and vulvar dermatoses. Vulvodynia and dermatoses are highly underdiagnosed, and it's very unclear about the origins of vulvar pain. Lots of patients with vulvodynia choose not to be treated, and those who do choose to be treated often go from doctor to doctor without relief. Vulvar disorders increase the risk of sexual dysfunction and diminished quality of life, and delay in diagnosis is linked to lack of training, and I would have to include myself in this cohort of specialists who may be seeing this patient. So, these were the conditions that we decided to focus on. Three conditions. Chronic pelvic pain, pelvic floor disorders, and vulvar disorders, and we wanted to provide high-quality, value-based care that is designed around those specific wants and needs of the women we served. So, we designed a team-based model of care. Patients enter care through associate providers. There are two reasons for this. One is that it decreased cost. The second is that it is encouraging people to work at the top of their license. So, most associate providers can initiate conservative therapy for patients, talk to them about the range of options that they have, and then see their response to conservative management if they choose that. If the patient chooses not to pursue conservative therapy, then the associate provider will pass them on to one of the faculty who are, for the most part, surgeons. We do have patients complete a variety of patient-reported outcomes. These include for pelvic floor disorders, the PFDI, as well as the PGII. We also have patients list goals for their therapy so that we can find whether they are able to achieve their goals or not. We do have case conferences weekly. The initial goal of those case conferences was to increase the education and knowledge of the group for each other's disciplines. So, at the case conference, there will be physical therapists, there will be a nutritionist, there will be a nutritionist, there will be a social worker, there will be physicians, there will be associate providers, and all of us talk about particular patients. We would talk about patients that we've had success with, as well as patients that we're having challenges with. In the case conference, we document a care plan and a care pathway for the patient to follow. Now, here is another concept that is a little bit foreign to many folks in their clinical setting, and that is graduating patients who meet their clinical care goals. Lots of folks in subspecialty clinics will see a patient initially, treat them, they no longer have incontinence, they no longer have prolapse, but they come back year after year just in case or for an evaluation or because they've turned into your friends and you'd like to visit with them. Part of our design and the way we help to bring value is to graduate patients once they have achieved their care goals. Now there are a subset of patients who will need continued care over a long period of time. But what we are trying to do is to return our patients to their primary care providers with a care plan for their continued treatment so that they can continue on their pathway. And of course, they are welcomed back if they have a relapse of their symptoms or new symptoms. This does two things. One, it opens up the clinical schedule for access. A lot of those return visits, although they make you very busy, don't block the availability of appointments for new patients. So graduating patients helps to keep the practice alive, increases value, and brings in new patients to care. The last thing is we really try, as I said, to have everybody working at the top of their license. So, and being co-located, we have our personnel and facilities to provide that care. So the way we developed our IPUs is that we identified providers with expertise in clinical gynecology, in particular in these three areas. We did develop evidence-based pathways, and again, I'll show you one in a moment. And then we had reviews of those pathways with clinical experts. Those pathways are living documents and are modified periodically as new evidence emerges, but it also provides the framework around which the whole team operates. We also, in the development of our pathways, interviewed patients to see what their experience with treatments were before, and what kind of challenges they faced to their point of diagnosis. We identified through these interviews opportunities to improve our care delivery. And then finally, and I would say that this is the area that may have had the most difficulty and took the longest to develop, was how we were gonna measure outcomes. Most of the measurement tools that we have are unwieldy, long, and patients don't really like filling them out. I know that I certainly have had patients fill out questionnaires that I have not looked at. We have been working to integrate our patient-reported outcomes into the electronic medical records so that they're presented just as a lab test would be presented. So we can see if a patient, for example, with a PGII says, yes, I'm doing better, or no, really not much better over the course of my treatment. We did also do some analysis to see what our market needed through a Truven database. And we also analyzed claims data from the CCC, which is our safety net care provider in Central Texas. Then what we did, we assigned a cost to each element of the care pathway and estimates about how many folks might use various treatments along that pathway and the cost associated with it. So then we came up with a way of deriving the cost of care through a cycle of care for a given condition. So many of you may have heard about bundle-based care provisions where insurers would provide, let's say, some capitated amount for the care of the patient, and the provider would assume some of the risks that if the patient required more care than the allotted amount that they would lose money. But if they didn't spend the allotted amount that they would make money, and that this would somehow help incentivize us to be more quality and cost conscious. So we, although this has been talked about a lot, bundle-based care payments have not really taken complete hold, even in Central Texas with our care. So we had the opportunity with our safety net insurer to work in tandem with them in building a bundled payment for the cost of care for a patient through a cycle for pelvic floor disorders. Now, the estimation of what we would need to take care of a patient without the facility fees for surgery was about $1,000 for a year. And we are still modifying that amount over time and learning about whether our estimations were correct or not. Under this model, where we were getting bundled payments, we have served over 800 individuals. We also see quite a few patients with commercial insurance who access the care in our IPU. Where our bundled care patients, they can access any of the treatments that we have available in the clinic, regardless of cost, because we're just providing a lump sum for their care. And we decide where they are on their pathways and what they will assess. For our insured patients, they also have services co-located, but some of their uptake of some of the ancillary services may be limited by their coverage with their insurance. So this is an example of a pathway for anal incontinence. On the left-hand side, you can see that the patient enters, there's a physical exam, and there's an estimation of the amount of time it would take to perform a particular task. So instead of saying, well, it's a level four visit, 99204 for a new patient, we're estimating how much time we think that it would take an associate provider to do the exam, gather the history. And then in that black box, the first black box is a variety of treatment options that the patient may or may not choose to have. And then they would choose, we would talk about the different options available to them, physical therapy, bulking agents, some medications, et cetera. And then they move through their pathway and we decide, okay, is the little triangle on the right-hand side, is the patient, I mean, the diamond on the right-hand side, is the patient met their treatment calls? If they have, they move on to graduation where we send them back to their original provider with a care treatment plan. And if they are not, and we've exhausted our various options, they may choose to have say neuromodulation or some other therapy for their fecal incontinence such as sphincterplasty. So that's an example of a pathway. As I said, some of our pathways, all of our pathways have been revised multiple times, some of them more than others, depending on what happens in the literature. So we are an office-based clinical practice. We do have an office-based procedure suite. So we try to move things into our procedure suite instead of in an inpatient or even an ambulatory surgery center. We have expertise in gynecology, female pelvic medicine reconstructive surgery. We have MIG surgeons, we have dermatology and psychiatry. We have pelvic floor physical therapy, nutrition. We have advanced practitioners, care coordinators and behavioral health. And I can't overemphasize the utility of the behavioral health, physical therapy and nutrition services within the clinical setting, particularly for things like anal incontinence where dietary manipulation really can make a huge difference. I had never really had easy access to those individuals in the past, but having them available has been really a game changer as has the social worker, because patients, as we all know, may be depressed, may be challenged in some way. And regardless of what we do for their underlying condition, if they're still depressed, more likely than not, their condition might not improve. So let's move on to patient reported outcomes. So we are very committed to this patient-centered care model and understanding how the patient is doing and how we create and measure value for our patients. We do have research going on around this and trying to create some measures that would be more applicable to measure their care experience. Right now, as I said, we measure symptoms related to their condition, functional capabilities and the patient goals. In our unit, I think our team finds the patient goals to be one of the most useful portions of information that we gather. We do follow patients. We try not to bring patients back for visits just in case and do as much of our follow-up by telephone as we can. We do reach out to them at six months and a year to see if their condition remains improved, or if not, we need them to come back. So this is a graphical example of a distribution of patients' responses to the PGII. And the cool colors to the left show that the patients are either, as in the gray, unchanged, or the blue, better, a little better, a lot better, or very much better. And the orange shows that they're worse. And thankfully, most people are getting better. So this is one of the things we've been working with to try to figure out how our patients are doing. Graduation is key in this, as I said, because if we do not graduate patients from our clinics, then as our clinics mature, we'll just end up with a lot of our friends in our clinic rather than patients who really need our ongoing care. So thinking ahead, some of the challenges, I certainly don't wanna make this sound like it's all worked out. We need a process to continually monitor and graduate patients from our clinic and back to either their primary care provider or their primary gynecological provider. We have worked to build some capacity in our safety net population through our FQHCs so that they have more capacity to manage pessaries or recurrent UTIs, because really I don't think once we've done an initial evaluation workup and recommendations that we really are adding much value by keeping them in our care. So at this point, what I'd like to do is talk about a few examples that might be relevant to your practice or not about how we might control some issues around waste. So for example, let's talk for a moment about preoperative laboratory evaluations. Now I was taught to send pre-op labs on everybody, a type and screen, a CBC, usually a urine, and maybe either a metabolic panel just in case, and then postoperatively, and then hematic, a CBC, and then postoperatively check the CBC. Well, what's the value of all this laboratory testing? Certainly it carries costs. Well, Kim Kenton's group in Northwestern looked at this. They had 836 patients. Their distribution of patients kind of looks like the patients we see with hypertension, diabetes, kidney disease, and CHS. Lots of patients had laboratory values. They had six abnormalities, and some had elevated creatinine, and none of the surgeries were postponed or changed. They also did a whole bunch of types of screens and no patients were transfused. So routine lab ordering, I think, is an area that's ripe for us to change our practice and decrease waste. That is one example. Let's move on to another example. So you're looking at your clinic schedule for the next day, and I posed to you this question. What would you rather have in your clinic? Six new patients with prolapse and or stress incontinence, or two new patients and a whole bunch of follow-up patients who are following up for their medication checks or had an operation six months or a year ago, or two new patients and the rest had bladder pain? Well, certainly don't want the last one, but, and probably the second one, option B, is somewhat like my old clinic schedule would sometimes look. I can tell you in our new schedule because the associate providers act as a funnel, my clinic schedule may have five or six patients on it, but they're all high acuity, highly complex patients, and or surgical consults. So even though the volume is much lower, I'm pretty busy in clinic with that small load because patients with other problems who could be treated conservatively have already been seen by the APs. Here's another example. So another way we might bring value. When, as I described, I started my career, we discharged patients, we brought patients in the day before their surgery, and routinely they stayed until they had a biome event. So hospital stays could be anywhere from three to five days. Crazy, it seems almost impossible that we were doing that. Then we started discharging patients post-op day one. That felt pretty comfortable, although a little scary at first. And then as I transitioned here, we now routinely discharge patients home on the same day. And I have found that our expectations and expectation setting with patients really plays a key role in this. Trying to, talking to patients about, I don't want them to be in the hospital unless they're sick, and we're going to do everything we can to avoid them being ill is a key part of this process. But we also have to commit to communicating with them once they return home in a little bit different way. So keeping them in a hospital may or may not be convenient in terms of keeping an eye on them, but it does expose them to increased risk of harms and problems. So we now, like I said, routinely discharge all of our patients on the same day. There is occasionally a patient who's not quite ready to go. We explain to them that we'll keep them if they're not, of course, but our goal is for them to be in the comfort of their own home. So these are some examples of value that you might apply to your own practices. This is a journey of looking at waste and utilization and trying to make evidence-based decisions about how to approach care for patients. So I don't know if you have any questions for me, but I would be happy to answer them. Thank you. Thank you, Dr. Rogers, for a wonderful presentation. And as a reminder, you still can enter questions in the boxes on your left-hand side, but I have a question for you. So can you comment on your institutional support on this project? The reason why I'm asking, and I think if people listen, they probably agree with me a lot of time, Uruguay, and if you try to bring it to your, that kind of a model of the patient care, which sounds wonderful, to the CSU, the people, they would say that Uruguay doesn't have a lot of margins. We have no interest to grow that. And is it some, so can you just provide some broad comments on that? So the question is about the institutional support for this model of care and the fact that traditionally, urogynecology does not have a high margin. So why would we want to grow that care anyways? Well, I do have the privilege of working in an institution that is committed to rethinking the way we deliver healthcare and with a firm commitment to providing value-based care. On the other hand, I have to exist in the fee-for-service world. And although bundled care payments have been discussed broadly, very few of the insurance providers have really made the leap into that model of payment reimbursement. So like I said, I've been privileged to be in a place that is committed to do this. Our safety net insurer was spending quite a bit of money on caring for these patients in a traditional model. And having bills where patients with recurring UTIs were going to the ED, et cetera. So we felt that we could make an argument that we could provide better care at a lower cost than what they were already spending, or at least an equivalent cost. So that at least resonated enough with them for them to finance this model. About 30% of our population comes under this bundled care payment. In terms of the fee-for-service, I think patients really like this kind of care. One of the things to remember is that I said that the entry to care is through the associate providers. So our FTE for physician time within the clinic when we first started was 1.3 FTEs. So it's a very tiny amount because our physicians were mostly, their time was allotted to, or our surgeons were mostly allotted to doing surgery and less time in clinic. So if you're in a model where your reimbursement is really linked to the number of procedures than you do, which most of us are, then if I can get you out of clinic and into the OR, you're more likely to make money. And that may be a way to argue with your administration. Did that answer your question? Yeah, thank you. And we are surely hoping you will share your results and the awards so we can bring your experience as a positive to our institutional leaders. So is there a plan on doing that at some point? So we did publish a paper in the New England Journal Catalyst, which is a, I don't know, somewhere in the New England Journal family of documents that describes the integrated practice units that we have developed. In terms of outcome data, we did present a number of abstracts at OGS last year. One was on how we created the bundle care payment model. We have a document or a manuscript that we're in the process of writing right now and hopefully will be publishing within the next year. We also looked at the difference of uptake of ancillary services between those women who were under the bundle care payment model and those who were privately insured to see if these services were available at no cost, would there be more uptake than if they were under their insurer? We didn't find a difference in the uptake of ancillary services, and that paper is also under, we're writing it. So our hope is to eventually publish these results. We have integrated practice units also in other areas of medicine within UT Health Austin. Particularly, we have a musculoskeletal program, and they have published a number of things about their experience with this model of care as well. Thank you. And the other question would be about how you assemble your team. I mean, definitely as a physician, you play a role, but it's a bunch of ancillary providers you need to train and bring on the same page. Sounds like the conferences play the major role in that, but initial process. Yeah, so that's a great question. So the question is, how do you build your team? So we are continuing to build our team. We were fortunate to recruit four associate providers who had experience in a variety of things. One did actually a fair amount of obstetrics and some gynecology. Two of them had worked in your gynecology clinics, and one of them had worked in a vulvar clinic. So they brought a lot of expertise to the table, but it was clear to me that we really needed to make sure that we focused on educating our team. Certainly, I needed a lot of education in vulvar, although that's not my primary focus in the clinic. And so the care conferences, you're absolutely correct, have really, I think, elevated everybody in the care of patients. So because we have pathways, it makes it easier for us to have structured conversations about care pathways and treatment plans for patients, and also for us to learn about the approach to care for some of these disorders that we may be less familiar with. So the APs, the ones with more urogyne experience have learned a lot about vulvar and chronic pelvic pain, and the vulvar folks have learned lots about urogynecological disorders, et cetera. So I think we have all risen and we share what we know so that we can all do a better job. And you're absolutely right. It doesn't really rely fully on the physician. So really, it's team-led rather than physician-led. And I think that that has also been a key part of this journey. On behalf of the OXA Educational Committee, I'd like to thank Dr. Rogers and everyone for joining us today. Our next webinar is going to be on retropubic anatomy and non-mesh SUI procedures, and will be presented on February 12th.

Value-Based Care

Dr. Rebecca Rogers

Women's Healthcare

Pelvic Floor Disorders

Vulvar Disorders

Chronic Pelvic Pain

Integrated Practice Unit

Patient-Centered Care

Cost Reduction