On the nose, let's get this started. Welcome I'm Joe Gettler, your moderator. This is concurrent session C. I did ask Dr. Toth, my boss, if we could have beer and she said there was no funding for it. So current session C, times they are a change in. Prepare your practice. Over the next 60 minutes or so, we'll explore the nuances, the challenges, and perhaps the opportunities that can arise out of those challenges if we play it right. I'd like to thank our presenters, speakers, Christian Payon, Jocelyn Whitstein, Brian Cole, and Richard Mather. And now to kick things off, we're gonna have Dr. Payon. He's gonna tell us about the importance of determining SDOH and acting on them. And basically just you guys know what we're gonna do is we're gonna have two 10-minute talks, then we want to make it real didactic, a real Q&A, back and forth, 10-minute session, two more talks, 10-minute session. So let's kick it off. Doc, love it. All right, good afternoon everyone. I'm actually an orthopedic trauma surgeon at Duke University School of Medicine, also a core faculty member at our Policy Center. And one thing that I am tasked with talking to you all about is the social drivers of health and why they matter. And I actually have some slides here to preempt my talk. There are many mandates coming out that are indicative of us shifting from fee-for-service to value-based care. We all know about the patient-reported outcome measure mandate. Social drivers of health are also mandated to be screened for by all major hospitals. The goal for Centers for Medicare and Medicaid Services is to transition 100% of their members to value-based care models. And you know I always say, if you follow the money, the number of Medicare lives covered by value-based care entities is going up and up. The investment in value-based care enabler models is going up and up. Meanwhile, our reimbursements are going down, and we're being asked to do more with less. So my message to all of you is that I think that the future of orthopedics is value-based, it's health equity focused, and technology enabled. And what does that mean? I'll jump into my talk here and talk to you a little bit more in depth about the social drivers of health and why I think that they are key to making that transition. My relevant disclosures are online. I am going to talk a little bit about a technology that I have a stake in, and I'll be sure to disclose that. To level set, the social drivers of health, what are they? We're talking about the tangible factors that impact the environmental and physical health of your patients. Food insecurity, transportation access, housing instability, the neighborhood that you live in. And I had shown this slide before. These are the factors that we have to start collecting in our patients. Why? Because if we look at orthopedic surgery and we think about the equation of value-based care, value is quality of outcome divided by cost. Well, you know, I'm always thinking about where I want to make the biggest difference, right? And if I'm a payer, I'm thinking about where the biggest delta is. On this slide, you can see as a patient's area deprivation index goes up, as their social drivers are more prevalent, they're less likely to show up to their appointments. The disparity between black patients and white patients is stark. Our payers want us to start focusing on these factors of patient care because if we impact them, we can make a big difference in the spend of care. I mean, you know, these numbers are tremendous if we look at the amount of expenditures that are attributed to the disparities of outcomes. You know, I think a lot of us, when we hear about these issues facing our patients, we kind of harken back to this quote, God grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference. I think increasingly we need to start realizing that we can make a difference here. And just to give you more fuel to the fire on why this is so important, the new mandatory bundles that are on the horizon for 2026. On page two of this sheet that they put out, health equity strategy. Fee-for-service incentives. In order for you to connect your patients with information regarding social drivers of health. I like this quote from James Baldwin, anyone who's ever struggled with poverty knows how extremely expensive it is to be poor. I think we went over all that just now, right? If you're a patient and you just had your rotator cuff surgery or, you know, for a lot of my patients who got an ankle fracture, hip fracture, your post-operative care is already challenging for anybody, for Dr. Whitstein up here, you know, made it up to the stage with crutches. You know, you can only imagine how much that post-op journey is compounded by not knowing where you're gonna get groceries, not being able to get a ride to your next appointment. I also like this quote from Edwards Demings, in God we trust, all others must bring data. So here's some data. We had conducted a large study out of the Margolis Policy Institute looking at Medicare claims data. We tracked the area deprivation index decile linearly and compared that to readmission rates and cost. As area deprivation index goes up, costs go up in total joint arthroplasty patients, readmissions go up as well. In the sports world, social drivers of health are directly correlated with the access to surgery for patients, and rotator cuff patients who have lower education levels, low income, and live in underserved areas are more likely to have worse outcomes after their surgery. Even if you were a practitioner who's not taking care of a large Medicaid patient population, dual eligible patient, you know, you're Surgeon of the Stars and you've got a lot of commercial patients, this still applies to you. This was a great study that looked at the social drivers of health in the commercially insured patient population. Again, in those patients who lived in those lower area deprivation index decile regions, there was a 3x increased rate of return to the emergency room compared to their high income area deprivation index counterparts. And why are we pushing for addressing these factors of health specifically? It works. This was a study out of North Carolina's Blue Cross Blue Shield research arm. They gave patients who reported food insecurity $60 worth of groceries throughout the course of their care, and they saw a $139 reduction in the per member per month cost for those patients. They just were giving out checks. If you said you have food insecurity, here's how you get groceries, and that decreased the cost. They extrapolated that that would be an 8.5 to 13 million dollar savings in their patient population. So this is really, in my opinion, the core of how we drive towards population health. And candidly, I always say that this is a moral mandate, but it's also an economic imperative because when we look at those charts earlier, our reimbursements are going down, but there's tremendous return on investment and, candidly, a very compelling argument to be made that we should be driving musculoskeletal population health. And in some of these shared savings arrangements with payers, if you successfully do this, you can make tremendous money for your practice and reinvest that into the things that we care about. At Duke, the way that we've done this is over the last 10 years or so, we've rolled out social drivers of health screening, and we found that 16% of our patient population had at least one social driver of health impacting them. In my orthopedic trauma clinic, that rate is higher, 30-40%, incredibly high, and this was a very rigorous process where I've had somebody at the front desk implementing some screening, we've got an epic build, and my last message of today, I would say, is that I'm not asking people in the room to increase the number of clicks that they spend on the computer. I'm saying that the people in this room should be the ones setting the system in place that captures these factors and addresses them because there's a ton of incentive to do it. And now, I think that there is a true opportunity in technology to automate a lot of these processes. The bottleneck in so much of population health is the number of people that we have accessible. Staffing needs are extremely high, it's very hard to employ nurses, surgical techs, etc., and I think that with, in particular, large language models, there's this opportunity to automate so much of that process. And one program that we're piloting now is pairing those clinical needs with social needs, where patients get screened automatically, they start receiving SMS based messages, and through a partner, zip code-specific social needs resources in that patient's neighborhood are sent to that patient. I'm not going to show this demo of how realistic it sounds to be deploying an AI voice agent that's collecting this information for your practice, but here's a transcript from an interaction back and forth with that AI voice agent and a patient, and that transcript automatically ended up getting transcribed to a structured note. So you can apply this across the board, and what I would say is that as we're starting to tackle the needs and mandates that everyone throughout today's discussion is going to be addressing, think about how you can lead and combine some of this emerging technology to move the needle on these patients. Lastly, what I'll say is, if you want to make a big difference for your patients, hopefully what I've brought across to you is that you have to be busting the bummock. We're just at the tip of the iceberg, everything that we do in the operating room and afterwards. 80% of care is attributed to the social drivers of health, and we have a unique opportunity because of policy tailwinds and technology to make a difference for those patients. So I'll leave you with one last quote here from James Baldwin, not everything that is faced can be changed, but nothing can be changed until it is faced. I'm asking all of us here today to take up the mantle and face the challenge, because our patients are depending on us to do it, and things are changing in a way that such that if we're not at the table making these decisions, we're gonna be on the menu. And I don't know about you all, but I'm not interested in being dessert, so thank you. Thanks Christian, that app looks cool. Feel free to ask him about it afterwards. And now we have Dr. Wittstein, who's going to talk to us about automating PRO collection in your practice. I have a much drier, less passionate talk than I just followed, but all right. So disclosures are available there. So my title is, you know, times are changing, PROs and your practice, how to automate this. But I kind of would say the subtitle to this topic is PROs are not just for research anymore. They're used for many, many other reasons. Some of these include, you know, patient-reported outcomes are useful for point-of-care data. When you're meeting a patient for the first time, you might want to be looking at their PROMIS scores or something like an OSPRO score to kind of help you with shared decision-making or what kind of treatment path you want to take with that patient. They're of course used in research, you know, our orthopedic research is no longer just objective data. It's subjective and subjective data paired together oftentimes. Quality improvement could be for your own practice, could be benchmarks for your division or your department. And now patient-reported outcomes are really also becoming insurance data. And some of this isn't as directly impactful to many sports medicine providers, but there are many people in this organization that also do total knees, probably less than those doing total hips. But this is a really big change that came through Medicare this year, and this will, I would predict, spread to other types of insurances like many changes do. But the new CMS requirements are that for total hips and total knees, inpatient Medicare patients over the age of 65, pre- and post-operative HOOS and COOS scores have to be collected along with PROMIS global health, very specific CMS questions that relate to pain in other joints and back-related pain, as well as provider-assessed opioid use in the last 90 days. And this has to be collected at least a 50% rate for all eligible patients, and that 50% has to be collected pre-op as well as post-op. So for example, if you have 10 eligible surgeries and only eight people complete the questionnaires pre-operatively, you still need to report on... So let's say you get five of those post-op, that's only five of the eight, so that's giving you a... Even if 50% of them complete it, your ratio only comes out of those that completed it pre-operatively. So this is kind of a challenging metric to meet. A strategy would be to maximize how many people are completing these pre-operatively so that you can actually get closer to a post-operative 50% completion rate. But there are real financial penalties coming for institutions at this time, not the individual providers, but essentially loss in the increase in CMS reimbursement is going to happen for organizations that do not meet this PRO requirement. So this is where PROs are now becoming insurance data. So there are many mechanisms by which you could collect patient report outcomes. I'll tell you when I started practice, I was doing this on paper. My rotator cuffs got ASES on the work score, my ACLs got IKDC and COOS, and we were batching them at the end of every month. Who's due for 12 months? Who's due for 24 months? That is a very non-scalable thing to do. You really need to do this in an automated way, particularly in a larger practice. And there are multiple ways to do this. So this could be through vendors. This is not an exhaustive list, of course, but companies like Patient IQ or OBERD, which I have no relationship to, Qualtrics. I am in an Epic-based system. By a show of hands, how many people have Epic where they work? So it is the majority, that's what I suspected, for good or for bad. So there's a lot of information in here on Epic because I am working within an Epic system, but many of these third-party services provide similar capabilities. And sometimes better. So in the Epic-based system or an EMR-based system, you can do encounter-based PRO collections. So every time your patient comes into clinic, if they have, say, shoulder or arm in their scheduling notes, that person could be scheduled to automatically, for instance, get an ASES score at their visits. That would be an encounter-based visit, or where I work, we do PROMIS scores. And that just happens when they check in. That can be done through EMR. And then there's a type of questionnaire called series, which is based on a certain time point from an event. A surgery. So you can set it up, so rotator cuff repair, 29827. You post that case, that person automatically gets a pre-op ASES, and they can get a post-op ASES at whatever intervals you set. That can be done through your EMR, through Epic, or it can be done through these commercial vendors. So any of these companies that provide these services, or within Epic, it's called Epic Foundations, if you want to set this up within your Epic, if you use Epic. Epic Foundations includes almost all of the surveys you would typically use that are validated for certain types of procedures. Rarely would you need to build a survey. The one caveat I would say is for our sarcoma group, I've had to actually build surveys for our organization and get them set up to be distributed through Epic. What we collect is PROMIS computer-adaptive testing for pain interference, physical function, and depression at encounters for our patients. And if they haven't completed it within the last seven days, if they come in for a visit, they get it again. So it's kind of for that point-of-care interaction. And then we use series-based questionnaires that are triggered essentially by scheduling surgery. So it's the CPT code is paired to the PRO. So for instance, our shoulder procedures get ASES and SANE scores preoperatively six months, one and two years post-op with a plus or minus two-month interval, and you can set that up within your EMR. And for knees, we do IKDC and SANE, elbow, wrist, and hand, quick dash, foot and ankle, hip, post-junior, and PROMIS global health. And you have to be mindful of not overburdening your patients with surveys. So would I like to have the work survey with rotator cuffs? Yes, but we've kind of pared it down to what we think are sort of critical PROs. So how do you collect these? Again, if you're trying to do this with an Epic system, there are some advantages of this. One is that everyone can see the data. Primary care is orthophysical therapists, not just the registered users of, say, a third-party vendor, potentially. You don't have additional fees of using an outside vendor, but you have to work with your IT group at your organization, which, depending on your IT group, can be good or bad. The data is easily intertwined with other data that's within your EMR. And you can theoretically increase patient engagement within your patient portal, because everything is going through that site. Disadvantages, it's probably less nimble than working with an outside company. The Epic and IT staff may be less responsive to your needs than the third-party service providers that you're paying for. And data extraction can require some more effort and assistance from your IT folks, although it may be able to be more detailed and more customizable, because they can access everything within your EMR, not just what's going into that third-party vendor. So as a glossary for people, again, who are using an Epic-based system, remember, encounter-based PROs are those assigned at clinic. It is linked to that encounter. The series-based are linked to a surgical event or an in-clinic procedure event, just something that has a CPT code, basically. And you have to define your intervals, you have to define what dates you want to collect and what range you want to collect in. It can't be like a forever open thing, it has to have an endpoint. And these surveys have no relation directly to the clinic visits. However, if a person happens to be in a clinic visit at the time that one of these surveys is due, you could have them complete it by setting that up through your Epic technology, such that it can migrate to a tablet or something at check-in. The way that this is done, if you are relying on an Epic-based system, is something called procedure pass. And that is kind of that whole pathway of linking your CPT codes to the specific PROs and setting your data collection windows. Communication methods. How do we communicate to patients that they have a survey to complete? Email is really clearly built into Epic's infrastructure, so it requires a little setup. The patients can get an email that they have a survey waiting for them, essentially, and use a link to get to it. MyChart messaging is a little bit trickier to set up, but it can be set up and gives them, again, a direct link to go to their surveys that they are to complete. And Epic can also send MyChart app push reminders that come across as a banner on a phone. I think the welcome tablets are critical because you're going to have people that just ignore reminders and don't do these things, but if they happen to be in your clinic at six months or one year, having that survey migrate to their check-in tablet is really helpful. And what I've been pushing for at our institution is actually to have welcome tablets at surgical check-in because if you have that patient that didn't do their preoperative PRO and it populates their tablet at surgical check-in, that's your last chance to catch them while they're still pre-op because they're never going to be pre-op again. So if you're going to set this up, I would encourage people to get your institutions to have tablets at preoperative check-in. So this is a patient-facing communication tool, which I really like. This is called the Trend Dashboard. This is part of Epic, but again, these third parties have similar trend dashboards that can be visualized, but the patient can see this in their MyChart. So it's called the Trend Dashboard. I've recently been seeing my own trend dashboard in Epic, but you can see this is a patient that had a lateral meniscus repair in late March, and then you can see they've kind of gone from moderate dysfunction in their promised physical function and pain interference to normalizing, and it actually gives the patient like a patient-facing explanation, much like these radiology reports that are patient-facing and sort of simplify the outcomes for them. This – I put this slide in here, and it's in the handout that I put. For anyone who wants to take this back to an IT professional that works with Epic, it's in the PDF that was in the handouts. These are the actual terms that your IT Epic builder person needs to set up procedure paths. Some of these actually don't mean anything to me, like INI, LQW, but I promise you they mean something to the Epic builders. So if you just want to take that slide back, or if someone wants to reach out to me directly, I would be happy to help you with this, but these are kind of the elements that are needed for your Epic builder to set up a procedure path if you want to automate things to be distributed to your EMR, or you may decide you don't want to do it that way and use a vendor. Slicer Dicer is the specific name of the Epic tool that allows you to extract data. This is just an example. These are just bars of – like you can see in 2023, we distributed 6,422 ASES questionnaires across our whole network. So you can say how many of each questionnaire have we distributed. You can visualize it this way. You can see the actual data. So this is what an actual extract looks like. This is QuickDash, it's a bunch of patients, it shows their surgical date, the anchor date, date of questionnaire completion, the side, all the details. You can display the actual results. So this is ASES scores. We do bilateral, so this is right, left, and we do ASES and Sane for Shoulders. You can see the actual numbers, the actual scores. And you can actually ask it to display the actual answers that then lead to the calculation. So there's like a ton of information that you can actually just display through Slicer Dicer, which is an Epic-based tool. For your patient-based interactions, the Synopsis View is very helpful. This is something within Epic which shows you all of the scores that they've completed. So I do think if you talk to your patients about this in clinic, you probably increase your likelihood of them completing their 6-month or 12-month or 24-months. If you never talk about these PROs or don't tell your patients they're going to get them, they're just going to ignore them and be very disinterested in them. So I would encourage you to like tell your patients if you're going to use PROs and actually show them the results if you're able to during clinic. This can be helpful because, you know, point of pure decision-making. You can kind of look at someone and say, is this a patient that has a lot of pain and dysfunction but with little pathology? Is this a person with little pain and dysfunction but requesting a very large surgery? So think of a person who's promised pain and physical function scores are very normal. And maybe they're, you know, 68 and they have a non-repairable cuff tear but they want to reverse. Like, you can take that information to the patient and say, hey, do you really want to reverse? Like, it seems like you're doing pretty okay. So just, you know, ways to engage in your shared decision-making. This is a patient of mine, for instance, someone who's had a shoulder stabilization. They started out with poor physical function. Pain scores on Promise Cat, SANE score 48, ASES 50. They're there for the six-month follow-up. Hey, look, your ASES and SANE scores are now 100. Your Promise pain and physical function have normalized. This is good feedback for patients. And you show them these numbers. You know, I do think if you share that with the patient, they may be more likely to complete their 12- and 24-month survey. So in summary, there are many third-party vendors. You do not have to do things through your EMR. If cost and other barriers are an issue for you, there are EMR-based ways to do this. Unfortunately, the only experience I can share with you is through Epic, and that sounds like a lot of you do use Epic, so I'm happy to answer questions regarding that. Remember, PROs can guide point-of-care decision-making, aid in tracking patient progress, can be helpful in QI and research. And these are likely to be increasingly utilized by insurance companies, so thank you. All right, so we have some time for Q&A. We'd like to make this as didactic as possible. If you have a question and you're on this side, probably either just speak loud or come up to the mic. And over on that side, I don't see a mic, so just speak up. We'll probably be able to hear you. So questions for our first two speakers? We have a mic. Two mics. Just no questions. What's that? I said just no questions. Okay. I'll warm up the room. Okay. Oh, there we go. Yeah, response rates are, of course, what everyone wants, and they kind of are, I would say we're hovering around 50%, but if you get out much beyond one year, they get lower. So for research purposes, I still think the most critical thing is to collect the preoperative time point. And so I think you would like to have automation with high response rates at one and two years, of course. And we're working on ways to optimize that. I think giving patients more feedback on what their scores are and making more things patient facing will be helpful. But at least if you get your preoperative rate up, you can always go back and survey people later. But yeah, we would like to have higher response rates. That's a constant battle. I mean, some of that depends on how you define it. What response rate are you talking about? Well, it depends how you collect it. So the reason we moved to encounter-based collection is it's easy to track, easy to do, and we have great encounter-based collections. Yeah, I should say, the encounter-based ones are over 88. They're like around 90%. Yeah. Yeah. Very impressive. I wanted to highlight that. I think that's great. And some of our clinics at 98%. And that's it. The other piece of that is that's how you measure compliance. The series-based are really hard to figure out, should they be getting it then? What's the dominator? But if you're collecting at every visit, it's pretty easy to know what that response rate is. The issue, of course, is a lot of people are not back in your office at two years. Dr. Cole. I have two questions, but first is Christian, right? So tell me about what is the economic impact? What is CMS expecting of us specifically? So it's a lot like MIPS and some of the other things early on. This sort of reminds me of that. So just, you know, what's the take-home message from an economic perspective, and how do we execute to make sure that we can take advantage of the economic driver for the new requirements? Well, it's huge. It's very similar to some of the fee-for-service reimbursement cuts that we're going to get with PROs. Not reaching that level of social driver of health screening, and they haven't set the metrics yet for that, will probably be 1% to 2% or 3% of all of your Medicare reimbursements, similar to what it will be with Medicaid. I think, like, the point that I would drive home is that the economic impact is going to be felt more strongly when we're transitioning over to these value-based care models, where you're responsible for the whole 30-day spend of these patients, and there's downside risk that you are obligated to take, meaning those patients that have exorbitant expenditures within the first 30 days of surgery, who disproportionately are patients who have social drivers of health impacting them, whilst those patients with social drivers of health also are the ones less likely to answer their patient-reported outcome measures. So if you don't concentrate the care on those patients, I think that the economic impact can be millions and millions and millions of dollars for us. So to get it done, though, at a practice level, I assume this will be modules, it'll be macros, it'll be something that all of us will be able to do, whether or not we're paying attention to it or not. And that's what I'm encouraging, is I think that nobody wants, I don't want any clinician to start having to click into Epic to collect the social driver of health from their patients. I think we need to lead to implement systems, and there are a ton of technology-based solutions. Epic does a pretty good job of screening. It's the closed loop that I think there are more and more value-based care enablers out there that are starting to automate that process. And I just want to make a comment on PRO. So you did a really nice job, and you were sort of agnostic to all the systems that are out there. We started on paper. We converted to consolidating forms. We went through at least three or four different companies, and the bigger challenges have been integrating with the existing EHRs. Right now, we've gravitated towards patient IQ. There's other solutions out there, but no matter what system you have, it's not a passive process. What we're doing now is we're dividing it by specialists and procedures. We're literally assigning clinicians to be responsible for various pathways, and every month we meet and we have dashboards for compliance to basically humiliate people to get it done. Even if it's a push through SMS or what have you, it still doesn't meet your compliance expectations. The bar is pretty low from a CMS perspective and so forth, but if you're trying to publish, you need considerable follow-up at the 75 percent level. Really hard to achieve, but having something passive that goes out to the patients is helpful. You can't do this without FTEs, in my opinion. You have to have people that are paying attention to it to get it done, independent of any system you're using. That's just been our experience. We were in the 30 percent range, despite very motivated people, but now our research assistants, many of us who have research, and the problem is this isn't scalable at the level you really want to do. It's just not scalable for the traditional private practitioners, and there's a real cost involved to do it. I think the take-home is having someone assigned to it and being accountable is what makes the difference. I agree. It cannot be a completely passive process. I think without technology to at least automate the distribution, though. Otherwise, it's this impossible manual task of rolling it out. At least having it automated so you have your data collection windows and your time points, but it can't be entirely passive. You can't break into those higher collection rates. I agree with you. One more thing I was going to say. We developed a video for our patients that everyone gets pushed on why we're collecting PROs and how important it is, and we continue to try to resend that to them just to have how it has an impact on their care, the impact that they have on future care for them and for others and so forth, just to demonstrate the importance of it. We're always looking for tricks to maintain patient engagement. We have a video like that, too, on patient digital health. I'm not sure how effective it is. You just keep hitting them. Just got to keep telling them, yeah, it's important. For Jocelyn or Brian or anyone, if somebody in the office is part of a small private practice, they're interested in implementing a PRO in their practice, and certainly you would find a vendor that works with your EMR, I guess the next question would be, from my standpoint, would be, how many humans would you expect to have to hire to implement the system? Say you're a 10-person group heavy on sports. How many extra full-time FTEs would that be? I don't even know how to answer that, but you'd have to have, like, IT. I can't imagine utilizing the procedure pass through Epic in a private practice without significant IT support from an institution. But as far as the, you need more than one. Yeah. So it depends on how ambitious you are. I mean, we've identified, look, you can do natural history studies, amazing natural history studies that are non-surgical. We tend to focus at least out of the gates on surgical procedures, and we pick the procedures that we're really going to focus on. So we have a cartilage database. We have a rotary cuff database. We have an instability. We have an arthroplasty. So on the sports side, we just pick the ones that are important to us, and then we have accountability. So it actually, you can't just do it with one unless you're just going to track the basic stuff. It has to be automated, but you're going to need a couple of people, and I don't know how you get out from under that to be honest. Yes, sir. Yeah, Doug, I was just going to piggyback on that. Kind of the same question about, I don't know if you were there from the beginning of your push for these PROs and stuff, but how much of an upfront cost was it, and what was the value proposition? Who were you talking to in order to kind of push that along? I think that's, for a lot of us, that's probably a yes. Yeah, I mean, I would say in the last five years, there's probably been a million dollars spent between salaries of people, and I'm thinking about like, this is mostly people's salaries on this. We were the first department to do it, and I know, you know, if you look at some other institutions, peer institutions, they've done a lot of theirs through the entire institution, and that tends to, you have a little more wind at your back than we did. We were the only department doing it, but we persevered. Mainly it was just talking to administrators, talking about the, I mean, these things that we see coming down the line in terms of PROs and that affecting reimbursements and things like that. Those are the conversations that mainly drove it. Yeah, that's what's driving it now. We were pushing it now. I think we have to move on to the next speaker, but yeah, it's being driven now that it's being required by CMU. We were on a tight ship. We're moving on. All right, Dr. Mather. Sir. He's going to, well, originally he was going to bring it home, but Dr. Cole's going to bring it home. How he sees it, what ensures value in orthopedic practice? Yeah. Well, yeah, hopefully I can share some of what I've learned the last few years working as part of the UnitedHealth Group Enterprise. Let's see here. So a couple of disclaimer type things. The opinions that I express are with the intent of generating progress, not necessarily to be right or wrong, not a reflection of how I think it should be, but how it is, and that demonizing the payer is not necessarily unfounded or inaccurate, but it is counterproductive to moving us forward. So where do these insights come from? This is a highly simplified org structure of UnitedHealth Group. So UnitedHealth Group is made up of UnitedHealth Care, which is a benefits company, insurance company, and then Optum, which is a delivery company. It is a Fortune 5 company. It's about almost as big as the government, and it functions in that way too. So one thing a lot of people don't know is that Optum's biggest customer and client are other insurance companies, small insurance companies like the Blues. So when they can't afford to develop the capabilities to do a lot of things, they need to do like their claims processing. So Optum does a lot of that. So they do a tremendous amount. So in that way, they do serve almost like a layer, almost like you might think of the government. In Optum, there's Optum Insights, which is that data piece. There's OptumRx, the pharma benefit company, and then OptumHealth, which is where I work, and that's the care delivery arm. And within that, there are a lot of entities, but there are things like specialized entities like Behavioral Health and MedExpress, which is an urgent care company. There are what we call our CDOs, our care delivery organizations, which are mostly primary care-based, but some multi-specialty-based like Kelsey Seabold and Reliant Medical Group. And then there's SCA Health, which was traditionally an ASC company, but I have a role there because they're willing to grow into things beyond that, and my role there is to drive value-based care. It's a really super fun place to work because we're involved in 20-plus growing markets, so I get to solve the same or try to solve the same problems with all these different perspectives, so you get to learn a lot about what works, what doesn't, and it's really, really fascinating. So one of the insights that I've gained over that time is, in the corporate world, everything's about simplifying down to the way to message it easily, and so I think a lot about how we have these three levels of the health system. We have the doctor-patient level, which is where care is delivered, it's where we live, it's where I grew up, that's where I like to be, that's my happy place, right? Can't deliver care, though, without supporting institutions or practices or ASCs, hospitals, and health systems, and so on. And we can't serve the needs of the population if we don't have networks, and of course that's where our payers come in. And each of these pieces, these levels of the system have different needs and different frustrations, and problems are created by not recognizing what either of them needs and wants. So, you know, we send from the lower branch, we send problems upstream, they try to get solved, right? And then they send abrasion down to us, down the ground, right? And that's what prior author is, right? That's trying to solve a problem, creates this abrasion. So in the world that I spend a lot of my time in, we talk a lot about reducing abrasion, and that has to do with experience-related things, but it's more about how the process of care. So when we think about the future orthopedic payment, that's a big piece. It's got to minimize this abrasion downstream, but still solve the network problems and effectively engage ourselves with our institutions. One of the biggest examples of that is compensation. One of the hardest things to figure out is how to pay people in these models. It's easy to transfer the money up top, but it's a lot harder to figure out how to distribute it down low, and so that's a good example of that. So a little bit about understanding the payer and their motivation. So, you know, everything starts with a purchaser, that's what we call it, or the employer or taxpayer, and what they care about is their experience and affordability primarily. They then transfer that risk to the payer or an administrator of that, and they care about retention more than anything. Now, they care about affordability too, but they mostly care about retention, about having lots of members, right? That's how they make their money. So when we think about, we have this great bundle program, maybe save like $100, you know, but you're putting a $5,000-a-year patient at risk through abrasion, possible abrasion, yeah, it doesn't sound so attractive. That's one of the reasons why things might seem great to us down below, and that's not attractive up higher up. And these two entities are primarily responsible for affordability or spend, and that's really important because that affects a lot of things, how that hits us. What matters to the patient though, because each of the stakeholders have different things they value. Patients, they value quality, if they can measure it, and if they can't, then they go to these other things, which we feel them choosing because they usually can't tell the difference in quality. I get a lot of questions about, what's value-based care? What is this value-based care? We had our meeting, right? It was good, it was good. She was right. She said, what is this? You know, and made me really think about that a lot, which I appreciated. So ways you maybe haven't heard it defined, the way I think about it is, value-based care is the shifting of the responsibility of affordability. So the pain that we feel from the purchasers is in some ways the price that we pay for not being responsible for affordability prior off, utilization management. Those things are intended to drive affordability. It created a lot of pain for us because we're not having to deal with that. So to solve, the best way to solve those issues would be responsible for affordability. It just transfers the burden, really. Doesn't solve it. So care, it's a little bit of care for what you wish for. It's also a way to solve important health care problems. That's why I do it because, you know, start with affordability, but I think it can solve burnout, solves the prior off problem. It solved whole person musculoskeletal care in the joint health program we built. It solved physician profitability and health equity, which I'm super excited about. And it's also an opportunity to shift market industry dynamics. So when the business model changes, so do the dominant entrants or participants in that market. And the question is, are we going to allow our own Stockholm syndrome as being a beneficiary of the fee-for-service system to steal that opportunity for us? That's a question to stew on. How's that, things that are going on, is it allocation or risk? So for years and years and years, it pretty much was it. This was it. It went to the administrator, that was it. And then it came along a further attribution of that. And so they can either attribute it to primary care, ACOs and so on, or they're non-attributed patients because they can't attribute them. They could contract directly with us, which some do with mental programs and so on. But over the last several years, there has been a huge, huge emphasis on moving toward attributing their risk through primary care, primary care entities, multi-specialty groups, so on, health systems become then the payer effectively. And then they indirectly pass that risk on to us, which we preferred though, to be getting it directly. It's another reason to be engaged in it. And so your risk, if you will, is currently being distributed. And so being part of that is important because this is something of value. Somebody has something of value, they don't give it up easily. It's not going to be easy to get from the primary care entities. Another way to look at it is it can be like a distributor, intermediary, and everybody's taking a piece all along. The other insight is that, remember that perception is reality. So I lined up now all of our risk takers over here on this side. And this is how, now remember, they're mostly all primary care doctors that run these institutions. And this is kind of how they think of us. They think like, why would I put my head in the mouth of the tiger? They see us as like, we want to do procedures, that's what we do, and why would I do that? I wouldn't want to do that. And so they've got to think differently about us if we're going to be successful. One of the ways you do that is by incrementally doing things that tell them we're different than who they think we are. That's why we created the Joint Health Program, which is an emphasis on whole person MSK care. And it's like, when you tell them that's what you do, they're like, really? You're an orthopedic surgeon? Yes, yes. I'm a doctor, right? We're doctors. And so I think, but that's where we're starting from, and understanding that that's their perception. And the other piece of that is collaborative market influence. So we think about coming together, having power in the market. That's only effective if we use it smartly to stabilize the network, give them stability, which is what they need. But accepting reality is a two-way street, too. So these are real numbers, and they're powerful things. So patients as consumers is happening, it is a train that's not going to be stopped. We see that in the choice of increasingly choosing PPO plans, and the disconnection of referrals from primary care to the care being delivered. The other big thing, and this is a number I quote more than any other, is that they see us. We are the entry point, and that's part of the consumerism movement. So most patients are seeing us first, and so approaches, what we call specialist avoidance approaches prior to narrow networks, gatekeepers, and the new ones, the digital vendors, all they do is increase abrasion without meaningful savings because the patients still are seeing us. The influence of PCP referrals is also going to wane, and especially in the commercial population where about 50% would not take their PCP's recommendation. So it is going to be increasingly difficult, if not impossible, to narrow the network. And in terms of care delivery, they talk a lot about doing too much of something. The rise in the use of joint placement, which I remind them often is an incredibly efficacious procedure. But the problem is less about what they are getting, or the low value care, and more about what they are not getting, as our first two speakers talked very nicely about. And if we don't manage this well, as an entity we don't manage this well, we will see unprecedented abrasion we have never seen before. The last two insights to kind of finish up with, because I think they are really, really important to communicate, is how valuable, how important it is that we develop a performance measurement system for value-based care. There is increasing urgency to do this. If you think about how we measure fee for service, we have got so many metrics. I mean, it is dizzying how we do it, fee for service. But I mean, can we even come up with a couple of use in practice that are around value-based care? Very few. And so if we don't do that, we won't be able to move this forward. So patients want quality, and narrowing the network is going to be increasingly driven through performance transparency. The lack of an established system is what is holding us back. We need that for compensation, hiring, and referral. We need to engage our professional societies to do that more, and commit to a system that is excellent, responsive, inclusive, not perfect. And then, of course, to find the value for PROMs. And then lastly, there remains tremendous variation. The payers see. They see these numbers. This is a graph of, you know, I will call this like any practice or any market USA. They all look like this. And there is a lot of variation in how we practice. There still is. And they see that. But what is interesting is as we consolidate our practices, that variation moves within the groups, not across them. And so there is a lot of opportunity within our own groups to be able to affect that. And that is why in the future, successful practices and systems will have strong cultures that are able to make decisions as one entity. They will be able to organize around standardization, improvement, just like Brian mentioned. But that is exactly what he was mentioning with the PROMs. Organizing around initiative and be able to execute on that, you know, whether right now it is value-based care or not, will prepare you well for that. So just in summary there, you know, the times are changing. And these value-based care presents an opportunity to solve a number of problems, to encourage everyone to think more in a pragmatic sense, recognizing what is important at the top level of the system, also but still recognizing this is where health care happens, being pragmatic about that and embracing consumerism. And then as practices learning to make decisions as one entity while still prioritizing the individual, not any one individual, not a single person, but the individual itself, organize ourselves to address variation, learning to take on a network perspective and take ownership performance measurement. Thank you. Okay, so we'll just, I'll try to save us some time here so we have time for questions. We're just going to see if this plugs in and works. So at any rate, I'm just going to share with you our journey. So we're a private independent practice in Chicago at Rush with an academic, everyone is on staff, so you have that academic band. So it's a, I'm going to share with you sort of that hybrid approach of how do you maintain a successful independent practice, at the same time blend a symbiotic relationship with a hospital. And that's kind of the goal of the next 10 minutes, but I'll try to cut it down a little bit because I know we're behind. I agree that demonizing the payer is counterproductive, but it is, it's therapeutic. Therapeutic, yes. I was going to say, we could do that in the bar later. There are grievances. So I, too, just so you guys know, I think one of the reasons Dr. Toth picked me to moderate is I started my own private practice in conjunction with Beaumont, so Privademics, with a senior partner about 23 years ago, moved on to grow that, segued into a supergroup where we all came together and now have an interesting hybrid relationship with Beaumont Hospital, which is now Corwell Health. Is there any questions? Use this time to ask questions. Yeah, ask them questions, you guys. Anyone? Is this going to work? Is this going to work through this whole process? You're going to bring it up now? Oh, yeah. I think it is, like, a game changer. I really do. And I didn't get a chance to play that clip. Thank you. Conversational models, especially, and a lot of us have to be at the helm here, like, there's a lot of value that you can bring. You can, you know, this, like, idea of having FTEs to automate, to do this, I think we're going to be able to cut that down big time. And I think we just have to tailor it to the population health models and take ownership of that, 100%. You keep asking questions. Now they say the talk's there. Yeah, if I can expand. I mean, there's, in my, I think, like, I work very closely with Duke AI Health, full disclosure, I'm CEO co-founder of an AI health tech company, and all those, like, all those PE and venture capital funds that are going into this value-based care enabler entities, I have a little bit of, like, I feel like a chip on my shoulder, because, like, you know, you have Sword Health and Hinge Health up there. I kind of feel like a lot of those digital companies are just getting upstream of us and managing patients, and we should be doing it. And I think that if we can train these models the way that we know that they should be to take good care of the patients, there's a tremendous opportunity to automate the process, to direct care and engage with patients, 100%. Yeah. Yeah. I mean, there's so much work to do. Yeah. AI's got to make it easier, smarter, target the effort. I hear that a lot. We talk about problems. We combine the two. Yes. Just tell me what I got to say or do, or, you know, if we, these, like you said, like, talk to this person about the outcome they're expecting, because it's mismatched, right, with what they're probably going to get. Great. I can do that. I mean, there's a couple of things to say and don't say. Right? You can do that. You'd be amazed. And the compute cost continues to go down. It's really, I think, a tremendous opportunity that we have to seize. He's ready. All right. Okay. So, again, emphasizing ownership in your clinical practice, and let's see here. Okay. So, the first thing that's, the biggest change we've seen recently is the fact that a couple years ago I was standing up here and telling you that only about 30% of orthopedic practices were hospital-owned physicians. Now it's in excess of 50%. And it's tracking directly with what's happening with reimbursement. Basically, the price to keep the lights on right now matches your professional revenues, and that doesn't account for salary and other compensation and benefits. So, it's becoming increasingly difficult, as you guys are all coming to understand. I'll just give you a, this is really a business case example. You know, four years ago, we have a, it's a 35-year-old entity. We had about 20 to 30 equity partners. We had about 500 employees, 6 clinics, 12 therapy clinics, 5 ASCs. So, you're basically, as I said, the Department of Orthopedics on the university side, but a private independent practice, but we oversee everything, ACGME research and all the collaborative initiatives with the hospital. And there's been a tremendous challenge to, that's been somewhat disruptive, and I think the biggest key indicator was this movement to the ambulatory setting, and if you're in a system where the hospital doesn't control the ambulatory side or the hospital or the facility side, that basically leads to these challenges of where hospitals depend on facility fees, and then once that's lost, the whole economic structure changes. So, it became a little bit of a we versus them mentality. And so, we began to assess our options in this situation, and we looked at all of these things, and four years ago, we gravitated towards PE, and we said, look, maybe this is a good place for us to go, because we have lots of opportunities to mature our governance, to use capital for growth, and so forth. And the thesis was pretty straightforward. It's really an outside entity that directly invests from a private enterprise into another private enterprise, and essentially, it provides an opportunity for you to monetize your compensation, so it allows you to professionalize your operations, and it lets you mature your governance structures, and it only depends on one thing, and that's growth. You can't do this unless you have your eyes on growth moving forward, and you'll hear all these terminologies, such as first bites and second bites and monetization and so forth and scrapes and new terminology that you may never have heard of before, and it's incredibly confusing, but the bottom line is it's an opportunity to monetize your compensation almost like a leveraged buyout, if you will. And the narrative, excuse me, the narrative basically was compelling, at least it was for me at my age at this time in my practice, and it was somewhat opportunistic with the multiples that they were paying on enterprise value were extraordinary, 12 to 13, sometimes higher times on your compensation. We looked at it as a defensive and an offensive strategy. We were looked at as sort of what they call beachhead, another terminology, beachhead practice. We could be a platform to potentially bolt on other practices, and it was a way to sort of de-risk our business enterprise, and at the time, it seemed like a good idea. Everyone was doing it. I would tell you currently, there's probably more than 80 private equity sponsored business enterprises that have been consummated, but there's never today, to my knowledge, been a second bite, which is what a lot of these deals actually depend upon. And the one thing is if you're considering a private equity relationship with a sponsor, it depends upon growth. Nobody does this unless you have your eyes on growth, and that's the first thing, that if you're going to evaluate this, you have to take into consideration all of these things that are required, including entering new markets, new service lines, updating your EHR, have to be data-driven. So there's this maturation of your practice that you'll be expected to undergo. So if you ask PE what they're saying about PE, they'll say, look, today, the demand for orthopedics is still pretty high. There's a lot of merger activity that's happening now, and it's continuing into 2024, but the biggest challenge, as you guys are all aware of, is that the interest rates have risen, and that has really tempered the business opportunities that have been available, because that margin now is gone, given the fact that variable interest rates are hitting 8 to 10%, depending on what the deal is. The other thing that we're seeing in this environment is that the experts are now saying that PE may not be the best thing for healthcare, right? Consolidation concentrates the markets. It may lead to instability. The DOJ is getting involved. They're starting to look at the safe harbor issues and so forth. So PE, at this time, is facing a number of challenges, and it doesn't seem like it's as rosy as it once was, and it's seeing a lot of headwinds. These are some of the headwinds, and I don't want to go in, because we're sort of short on time, so if there's some slides here that you want to take pictures of, just please go ahead and do so. I would just tell you that some of the biggest challenges right now is PE comes in with this vision to increase your value over three to seven years, and some of the major questions that have come up is what comes next, who makes the decisions, what happens if there's an IPO, and really, what does it mean for me, okay? And that's what people are going to be asking themselves. So I'll finish this part of the talk by just telling you how my group viewed private equity. The senior partner would say, look, buy me out, you'll never see me again. They were really the most interested in PE, because you lose that accountability at that point. The mid-level practitioner, someone who has maybe a 15-year run rate, says, look, my practice is mature, and I have a few more years of this. So they have to anticipate some loss of control, they have to place a premium on taking chips off the table, and they want to place a premium on professionalizing operations, and they understand that they need to commit to growth, right? Because if you're valuing the opportunity based on the first bite, it's got to be rich enough because you really have to depend on the fact that a second bite will occur otherwise. So these guys, or these people, have to be in this game for long enough to actually get access to a second bite, otherwise it may not be worthwhile. And then the hardest group, if you're trying to maintain the stability of a group that has younger people, people who have 20-year timelines to sort of have that break-even analysis, you've got to get buy-in from this group. They have to give up near-term income in exchange for ownership in a larger entity, and they want access to multiple events. So if it's purely financial, they've got to be in it for the long haul, and I will tell you that's the most difficult group to persuade to get into this private equity transaction. So how did my group of 30 equity partners view PE? They mostly didn't, okay? So we did this for about two years. We went through various scenarios, and at the end of the day, we said, look, we've got to move on. Let's focus on the practice, focus on value, maintaining independence. What are our options? And the options were to go alone and build value, okay? And that's really where we ended up. So we said, what can we do? We moved into this aggregation strategy. We knew in the Chicago market that we were sort of shrinking because everyone else was actually getting bigger, and we needed both a defensive and an offensive strategy, so we looked at aggregation. And it was a pretty public thing, you know, you go to Becker's and so forth, and you really He does a really nice job of keeping everyone up to date on what's happening on the business side. And we decided to go alone and step away from this private equity concept, and we began the process of aggregation. And we looked to another group that was like-sized. We came together, and we said, how can we come together, but taking into consideration that egos could be threatened, maybe we might want to unwind this. We each value our own sort of cultural identity, and how can we do this and still take advantage of scale? And we created this entity, and it's really not a merger, but it's truly you aggregate. So a merger is really the complete joining of two or more physician groups into a single organization. And you blend everything, name, assets, policies, business, operating protocols, and so forth. But an aggregation, basically, is groups come together under a single tax ID, and each group gets to transition at their own pace. And ultimately, it's sort of a soft way to proceed without losing your identity, and you can sort of still divorce if it doesn't work out. But as you get further along down the process, it gets more and more costly to do so. And the goals of an aggregation were really for preservation, to position ourselves better in a market, and to encourage our local prominence, both locally and actually regionally. And just to sort of solidify this, the goals were really to fortify and enhance physician income and lifestyle, but not a monetization event like with private equity. So it's very different. And it positioned us and an MSO to adapt and take advantage of all these market changes. And if you want to do a private equity path later on, you'd be positioned to do so. If you want to do a stock ownership plan, you could do that later on. It allows minority capital transactions to occur. It improves our alignment in the healthcare system. It allows us to do hospital partnerships and grow and still maintain control. And all at the heart of it is really the MSO. And what you should do on this slide is just focus on the right. And all those things on the right are the kinds of things that you can offload from the group and achieve economies of scale and a reduction in costs that are ongoing year after year. So there's a lot that goes on. If you look at smaller groups, they have the same capital infrastructure as larger groups just to get out of the gates. So that's why you're seeing consolidation in general. So it's the ability to maintain divisional identity and at the same time take advantage of a full-on consolidation. That's really what an aggregation is. And just to give you a sense of what you can do with this type of thing, it creates these class, these various classes. And the divisional entities, you know, Entity 1 and Entity 2 are Class A. Then you can create these care center units. And then you can do things together and take advantage of it but not lose control at the same time. And the big ticket item is the black box. So the black box basically is where you do an analysis of your payers and you say, where can you get a lift? And this is the most serendipitous aspect of our aggregation was that we actually looked at all of our payers. It's a very compliant way to do it and in a blinded fashion. And we saw that once we aggregate into a single tax ID that we were able to take advantage of all the commercial payers and to bring everyone up to the same level and par level. And that was actually our most immediate benefit. So what did that lead to four years later? Okay, so I told you we were about 500 employees. We had seven offices. We had less than a dozen physical therapy centers, a couple of ASCs, right? This is where we are now. We're still a private independent practice. We have over 900 FTEs. We still have about 30 equity partner but about 20 additional physicians. We have seven full service clinics. We have 11 standalone physical therapy clinics, eight MRIs, two CTs, 11 ASCs up from about five. And we now have a new MSO that houses all the business aspects of the practice but we're still maintaining a private independent practice. Where are we as an aggregation? This just gives you a snapshot. So geographically now we cover a much bigger swatch. So what's ahead of us is doing all the obvious things and the things that you're hearing today. Clinically integrated networks, value based care, all the things that we really couldn't do before as a smaller group. So from an offensive position, we can start doing things that we really couldn't do before. But we still have lots of challenge. This hasn't solved all the problems of being a private independent group. We have challenges of getting access to capital. I can tell you we're suffering from C level and physician level bandwidth. We have so much work to do and trying to find the people and the expertise to do it is a big challenge. You know, all these terms, value based care, clinically integrated network, all those buzzwords, it's still very immature in our marketplace. So maybe we'll be the sort of beachhead to do something in that area. I will tell you that when we look at growth, we're learning that growth is not always accretive. Just adding more physicians doesn't mean that it's adding more to the entire market cap of your practice and it may add actually increased challenges. We have a very fragmented ASC ownership, so we're trying to reign that in. So I'm just trying to share with you that it's not all perfect, that we have still lots of work. And what we have shown, and this is what I started out with, is that, look, if you're depending on, depending to make a living, keep the lights on, or professional revenues, it's nearly impossible to do now. So if you don't own the patient journey, then that's a prescription for just working for a hospital, which is just fine for many people. So this isn't a value proposition on what's right or wrong. I will just tell you that it's obligatorily, if you're not part of the patient journey, you have no choice but to be part of the bigger system that owns the other portions of it. If you want to maintain a private independent practice with independent decision making, you have to be part of the patient journey, which is above and beyond seeing someone in the office, doing an injection, prescribing physical therapy to an outside physical therapy agency, and doing surgery. You have to be part of the entire equation, otherwise it just can't work in today's economic. So what are the, I'll finish up here, what are the next steps? It's full on integration, right? So I told you the aggregation is sort of a soft way that takes advantage of egos and cultures and institutional knowledge, and it allows you to progress into something that's a full integration and take advantage of all those offensive strategies that you're hearing about today. So I appreciate your time, and sorry about the snafu and setting up. Thank you. Way to drive it home, brother. Time's up. Why don't we take two quick questions, if anybody has a couple questions. We like things to be didactic. Yes. Hi. Who are the key players, if you had to go back, that were essential for the smoothness of the aggregation? Yes. MBA, and who are the key players? Yeah, so I mean, we used a company called Melvin Brothers. There are probably others out there, but it's the only name that I continue to hear. And at this point, they've probably done at least 60 of these. So when we met them, they had already done 50 of them, and we were in the trenches with private equity, and I could just tell it wasn't working out, but we didn't want to do nothing. So they presented to us, and it just seemed like a really palatable strategy to get bigger, but not lose our independence or our identity. So it was Melvin Brothers, and they were actually fabulous. They delivered everything they said they were going to do, and it was not an expensive process, and we did this in under two years. Anyone else? All right, you all have a great night. Be safe. Have fun. Thank you. Good job.

Christian Pean, MD, MS

Joseph Guettler, MD

Christian A. Pean, MD, MS

Jocelyn Wittstein, MD

Brian Cole, MD, MBA

Richard C. Mather, III, MD, MBA

value-based care

fee-for-service

social drivers of health

patient-reported outcomes

electronic medical records

healthcare costs

private practices

financial pressures

partnerships

technology integration