Cecilia Saffold: 0:22

Hello and good afternoon. Thank you for joining us for this important conversation on shaping the future of primary care through the CMS 2026, Medicare Physician Fee Schedule, proposed rule and the Shared Savings Program proposal at Health TeamWorks, we are passionate about advancing sustainable, responsive and Person Centered Primary Care. So today we're going to explore how those proposed changes could affect primary care delivery, prevention and chronic disease management. We're going to start with a very high level overview of several proposed changes that are that have been highlighted as relevant to primary care, followed by introductions of our distinguished panelists. Then we'll dive into a moderated conversation with some prepared questions, but we're going to leave plenty of time for your questions and an end of session Q and A as they arise to you. If you have seen any questions on your mind at the very start, please drop them in the chat. We're going to share your questions through the chat box, and we'll be fielding those questions at the end of the session and throughout. So please feel free to add them in the chat. If you want to come off mute and share your question, please make that known in the chat as well. So with no further ado, I'm Cecilia Saffold, CEO of Health TeamWorks. Little think everyone knows how to do this, but if you want to send a question or comment added in the chat at the bottom of your screen, just wanted to run through some of the selected elements of the proposed rule that have come up in numerous conversations over the past couple weeks related to primary care. There are elements that roll out some payment updates and some changes to the conversion factors. There are elements related to site of service reforms. There are some changes in terms of the telehealth flexibilities that we are accustomed to, some additional remote monitoring codes or self patient self monitoring codes that are proposed, some expanded digital mental health coverage items as well, some adjustments to the MIPS value pathways and how quality is kind of tracked under MIPS shifts in the ACO to Shared Savings Program and some RFI questions that are incorporated that are all related to adequate prevention support as it relates to primary care and and beyond. And we're going to talk about many of those elements today. If there are other elements of the proposed rule that you'd like us to highlight or really emphasize, please add those in the chat as well. So moving right along, I would like to introduce our three panelists. First, we are honored to be with Dr Russell Kohl today. He's the Chief Medical Officer and Chief Operating Officer at the tml, TMF Health Quality institutes. Russell is a family physician in Stillwell, Kansas. And at TMF, which is a Medicare Quality Improvement Organization, they support assorted CMMI programs by directly supporting the quality of care in Medicare. They support those beneficiaries in Louisiana, Texas, New Mexico, Oklahoma and Arkansas. Russell cares for patients with the nonprofit care beyond the boulevard as a street medicine physician, he provides direct medical care to those living in homeless encampments throughout the Kansas City Metro Area. He's also a colonel, chief flight surgeon and state air surgeon within the Missouri Air National Guard, and is the current speaker of the Congress of delegates for the American Academy of Family Physicians. Thank you for joining us. Russell. Next, we have Kristi Bohling-DaMetz, who's the director of aging and adult services at Mid America Regional Council or mark, with more than 30 years of combined experience in clinical care, organizational development, community engagement and executive leadership, Kristi is the director of aging and adult services at the Mid America Regional Council, a metropolitan planning organization in Kansas City. Mark is the Area Agency on Aging for the Kansas City region, and leads the BI State Community Support Network, a nationally recognized Community Care hub model. Other programs that Mark include food is medicine community health workers and communities for all ages. Additionally, Kristi is president of the Missouri association of. Area Agencies on Aging. Next, I welcome Larry McNeely. Larry is PCCs Director of Policy. He helps to shape and advance a policy agenda aimed at building a comprehensive team based and patient centered primary care system. He coordinates PCC policy and advocacy, community and behavioral health integration work group. Mister mcnealy's career includes policy roles at the American Diabetes Association, where he guided its diabetes prevention and health equity policy advocacy and the Maryland Department of Health from 11 2011 to 2017 as policy director at the National Coalition on health care, Larry led that diverse, multi stakeholder coalition's policy development and advocacy efforts. Previously, Larry guided us Public Interest Research groups campaign to secure federal health reform. Thank you for joining us, Larry, so no further ado, I would like to pose a question to get us kicked off to Dr Kohl. Could you share with us your overall perspective on the proposed rule and implications for primary care?

Russell Kohl, MD, FAAFP: 6:17

Sure. Happy to thanks, Cecilia, and thank you to Health TeamWorks for convening this, this discussion today. You know, I spent a lot of my time at that intersection of where policy hits practice, and as I look at the 2026, Medicare Physician Fee Schedule, I really have to say, you know, my my feelings are best described as cautiously optimistic. You know, let's be honest, the next year is going to be really hard for healthcare. As we look at the impacts of the HR one reconciliation bill, how that's going to affect Medicaid, we look at things happening at the ACIP, the US permanent Services Task Force, there are a lot of challenges that folks will be facing, but I really do see a few glimmers of hope for rural medicine and primary care. You know, if you look at the Rural Health Transformation Grant Program, or look at this physician fee schedule, you know, I think there are some reasons for optimism. We all know that the devil's in the details and how the rules get implemented, but, but I do think there is cause for optimism. You know, kind of big picture start off, you know, there's a fairly welcome shift in tone and direction. I think he can see some real support for office based primary care over that facility focused direction that we've seen in the past. But we have to be realistic and view that with the caveat that, you know, the landscape of medicine really has changed. We know that over 75% of Family Physicians now are employed, and many of those physicians are employed by facilities who could be seeing reductions based upon the way the fee schedule is laid out. I'm really excited about the expanded behavioral health integration and the efforts to finally put some value on the time that we spend with patients managing their chronic disease. I think these are all. These are all positive things on on the other hand, you know the the financial bump that is proposed in 2026 comes with an expiration date. If there is not a longer term solution, we will be back to the days of SGR, where every year we're having a debate about what's the financial solvency and what does that financial brinksmanship look like for Medicare, I think there's some great positives around telemedicine, particularly for rural health clinics and FQHCs. I'm a little bit worried about the rollback of the virtual supervision aspects for teaching physicians that are outside of rural areas. And you know, does that put us at risk of moving backwards on areas like team based care and access to care for vulnerable populations? So it's a lot easier overall, to focus on the areas where you disagree and and want to fight about things. But I think it's really critical that we also look for the areas where perhaps CMS got it right, and I think it's important to support those so that we can continue to evolve the environment that actually delivers on that goal around, you know, the long term vision of sustainable Person Centered equitable care, which is what we're really trying to get to primary care. So cautiously optimistic is the is the short version,

Cecilia Saffold: 9:21

Thank you, Dr Kohl, you raised a couple points around some behavioral health elements that that are raised. And I'd like to pivot to Larry and ask, you know, from your perspective, doing a lot of work around expanded, integrated care, behavioral health and primary care, what does this proposed rule mean for that,

Larry McNeely, MPA: 9:41

Sure, I appreciate it. Cecilia, appreciate the question, and it's great to be on here with Health TeamWorks and Kristi and Russell the I think, firstly, the reality is the kind of care that. Not physician like Russell, a nurse like Kristi, involved in wanting to deliver care for patients is really in primary care is unique, because you can really think about how to take care of that whole human being that you have in front of you and I'd agree that there's some glimmers of hope here, more than glimmers, almost the contours of a path that's beginning to appear, where, last year, under different administration, they set up something called The advanced primary care management service. For the first time, there could be a not in the model, not in a demonstration in traditional Medicare monthly payment to take care of your regular patients if you have advanced primary care capabilities. And what they're proposing this year is an add on code very similar to the existing collaborative care and general behavioral health integration payments, right, but without some of the burdensome time tracking. Now, if we can get collectively as a primary care community behind the idea that more comprehensive care should get additional resources and more burden reduction, folks, I think that's something we can run with more than a few times in the coming years. So

Cecilia Saffold: 11:39

you touched on the the idea of a reduced burden, and also really providing truly comprehensive care. And Kristi and your role leading an area and an area agency on aging, I know that you see on a regular basis what those elements are that truly allow patients to to access and engage in care fully. And would love your perspective, as this proposed rule does directly call out a request for best practices related to area agent Agencies on Aging, what? What's your take on that? What are, what are the things that we really need to elevate?

Kristi Bohling-DaMetz, RN, BSN, MBA: 12:19

Yeah, I think that the community clinical linkage and by the way, thank you as well to Health TeamWorks for hosting us, Dr Kohl and Larry, I'm honored to participate in this with you. But yes, the community clinical linkages is something that I think we've got to keep our eye on. And for a number of reasons, I'm trying to change my language from aging to longevity. Because we're aging every day, no matter how old we are, and aging is not a it shouldn't be an ism so it shouldn't be something we set aside as different from who we are today and the needs that evolve every year we have a birthday. So I think we've got to talk not only about that clinical setting, but we've got to talk about how we seamlessly connect primary care with the community. Dr Kohl, I love that you're doing street medicine because it places you in the community firsthand, but that infrastructure of services in the community is sometimes invisible and yet absolutely foundational to folks getting to their doctor's appointment to their ability to afford medication, or even have medication delivered where that's not available, in some parts of of my region in particular. So those two have got to continue to work together. And I think, I think the Physician Fee Schedule leaves room for that and ask some very key questions, as you said, around area agencies on aging that are already operating essentially as Community Care hubs, but then expanding to that community care hub approach, which is all ages, things like those medically tailored meals. It's hard to control diabetes if you're only coming at it with medications, but you're not talking about diet transportation, as we said, to get to those appointments and supportive services, like being able to pay for utilities to get through a gap. So unless we're connecting all of those dots, it makes it really difficult for either one of us on our own to achieve good outcomes for folks, especially as we age and become more expensive,

Cecilia Saffold: 14:20

Really, um, some of the things that we see in the Shared Savings Program proposal is a shift away from some of the elements related to health equity and assessing for social determinants. Do you have any sort of thoughts about how we might achieve more robust prevention and addressing those social needs if we're not screening for them or paying measuring them proactively.

Kristi Bohling-DaMetz, RN, BSN, MBA: 14:53

Yeah, I'm hopeful that they continue. I hope that it's baked in enough now and as it refers to the social determinants of health. Screenings that used to be another billing opportunity. Now it's being rolled up into the EM codes, for example, but they still need to be done, and I think it's short sighted, probably, if we're not doing that at some level, even if it's a few questions to make sure that when they leave the office, they're able to be engaged in their health and complete the things that they're being asked to do to have good outcomes. So I'm hoping that it's baked in enough we know that it's really hard to say it's the right thing to do, and that that motivates everyone, but hopefully as they shift from those lead measures or process measures to do the screening and focus more heavily now on lag measures or outcome measures, are we getting those healthcare outcomes? They'll know that this is an incredible building block that has to be there. Larry, please expand.

Larry McNeely, MPA: 15:53

You know, I don't want to interrupt the flow here, but I think it's also worth saying that they seem to be continuing on this path of trying to move towards more comprehensive payment to match more comprehensive practice. If CMS continues down the path we were just talking about, if we build on a PCM and start moving towards more hybrid payment options, whether it's an ACOs or not an ACOs that I think under those constructs, it creates a rationale for doing exactly what quality clinical care which might require, which is knowing whether the patient with diabetes Has stable housing with the refrigerator for insulin, you know, that's, that's just good quality care. And, you know, I think finding ways to make sure that that continues to be supportive is going to be key. But, you know, it is unfortunate, and I think the pullback from that terminology.

Russell Kohl, MD, FAAFP: 17:05

And if I could kind of add on, you know, it always struck me odd that it's the advanced primary care, because I think if you went back and asked Barbara Starfield, she would say it's actual primary care is what we're actually asking people to live up to. And so, you know, when you think about it from that perspective, and yeah, they do away with the health equity benchmark adjustment, but they then put in a population adjustment. And so this is one of those areas where the devil's in the details. So what will that population adjustment look like? Will it still take into account? And you know, from the reality of of the the care of patients. I don't really care what you call the adjustment. If you're taking into account the things that are affecting my patient's health, and whether or not I'm aware of those things and doing things to try and make them better for them, then that's what we're looking for. And so I think watching the population adjustment, and certainly that's an area where these are the proposed rules. These are not the final rules. They are still in comment period for another month or so. That's probably a great area for folks to look do you agree with this discussion of what the population adjustment is going to be, and get that feedback back into CMS. Use the comment period to tell them the things that, hey, I think you got it right here, or I think you're overlooking this. This is why this is an important thing to include back into that population adjustment.

Cecilia Saffold: 18:30

One, one, excellent point, Russell, and one of the things that is very salient to me is that most of the people and most physicians are not going to have time to dive into the entire proposed rule. Can you give us sort of a Cliff's Notes pay attention to these areas so that folks can dive in and start to develop their own feedback to CMS on some some really key points.

Russell Kohl, MD, FAAFP: 19:00

I heard a joke the other day that in the modern world, you take one sentence, ask chat GPT to turn it into an outline, then ask chat GPT to make it a narrative that's then 50 pages long that someone then loads into chat GPT and says, boil this down to give me a one sentence Summary of so it's it's challenging. It's an 1800 page document. You know, the couple of things that I would really throw out for folks that I think, Hey, these are, these are the big the big rocks that jumped out to me. One's the conversion factor, and what that's going to be in the future. Is there sustainability, or is this a one time bump? I think that's a big deal. I think the practice expense, RVU methodology is huge. I think this is something that could very easily fall into, oh, that's a policy wonk sort of discussion, but it may be, but it is. Also probably the thing that has the largest implications for the future of physician payment. You know, they are specifically ignoring the 2026 survey data from the AMA the physician practice information. They gave a long explanation of why they didn't think it was valid and why they weren't going to follow it. That's a notable historical break for CMS to make that break, and that has very real implications for the future. Once you have made that break, if they sustain it, then the question of how physicians should be paid, what it should be based upon, and all that is important. We spoke a little bit about the efficiency adjustments and building that in. That's a really interesting perspective. The idea that I, as a family doc who is seeing a patient in a time based encounter, I don't make that better over time. I'm not necessarily able to more quickly pull out someone's heartache psychological distress, and more quickly counsel them in a way that makes them feel better. That being said, I can tie sutures a whole lot faster than I could when I was an intern. And so that efficiency adjustment that looks at all of the different codes and says, okay, the cognitive or time based codes are what they are, but these procedural skills, it's only reasonable to assume that over time, you get better and more efficient at a procedure. And so when this procedure starts, it's paid at x value. But we're going to have efficiency adjustments in the future that reduce the value of those procedures. Not because we're saying that the procedure is no longer valuable, but we're saying you've had three years to figure out how to do this better, faster and more appropriate. And so it shouldn't pay the same as it did before. I think those are some really big things for people to look at that have a lot of implications. And so that's where I would focus. If I didn't have the time to look at a whole 1800 pages, I would look at what are the implications for the future. And I think the RUC aspect, the efficiency adjustments in that practice, RVU calculation is going to be where the real discussions lie three years down the road.

Cecilia Saffold: 22:34

Larry, I want to pose the same question to you, are there elements that Russell didn't raise that you would you would urge people to really dig into?

Larry McNeely, MPA: 22:50

I have to underscore what Russell said. You know, the the reality is dating back to mid 2000s we had Medpac reports talking about some of the imbalances and how we were paying for care and the fee schedule. We had the American Academy of Family Physicians championing reform early in the 2010s Health TeamWorks has been at the table at PCC, where we not only have primary care clinical organizations societies, but we also have consumer organizations and payers. And we've been talking about this for several years the National Academies, and the fact that CMS is talking about taking aim at some of the systemic flaws and how we've undervalued primary care over time. Yeah, it's a really big deal. And the real story is that either we as a community come together, not only to tell them, yeah, we're glad you're looking at these problems and help them get it right. Either we do that or knowing how Washington works, honest to goodness. I mean, it might be decades before they're willing to touch these issues again. So I think it's really important that folks care about this way. Kristi How do you work with Area Agencies on Aging? You know, are there forms of payment that could allow you to bring somebody onto your team? Do you need to have a relationship? Relationship with external folks to help deliver that for your patients. What needs to happen? And that's a real open ended door that we should walk through, because if we're not addressing the whole healthy human being, like, like was said, that's, that's just good primary care. It's not advanced. It's what Starfield would have said, is good primary care. Thanks.

Cecilia Saffold: 25:22

Kristi, building on on that point. Um, what things do you do you think primary care and health systems in general need to adopt or adapt to better work with and better engage with area agencies on longevity,

Kristi Bohling-DaMetz, RN, BSN, MBA: 25:40

Longevity, and I want to make sure that we're talking about community care hubs as part of this as well, because area agencies on aging are kind of a subset of that, although, again, it's the same model, just different funding mechanisms. I think there are things that are already starting to bridge that gap from a structural standpoint, things like the Community Health Integration codes, some community care hubs are working with healthcare entities around transitional care, coding and billing to follow somebody for 30 days within the community once they get home, and ensure that there's not a readmission. So but I think we have an opportunity to take some of those things that CMS is putting out there, and figure out, how do we use those in the transition from clinical to community? And hope to get to the point where that's not a stark line where folks don't see themselves either in primary care, seeing their physician or in the community, but feeling like they are the center part of that whole person care, surrounded by their primary care team and the folks in the community that will see them all those other hours that they're not in a clinical setting.

Cecilia Saffold: 26:50

Kristi, I'm gonna kind of rest here for just a second, because I think that looking across our audience, I see a lot of familiar faces, and many of these folks work in in primary care. And I'd love if you could just give us a little bit more about what a community care hub is,

Kristi Bohling-DaMetz, RN, BSN, MBA: 27:09

Sure. So Community Care hub is a it really rests on that social infrastructure I was talking about. We it's easy for us to think about physical infrastructure, roads and buildings and tangible things, but we don't think a lot about the human services infrastructure in communities. We kind of take for granted that there will be services there when we refer folks to get them coming from the clinical side. I know that we used to work with practices to have a list of community resources, but we never talked about, how are those services going to be funded? How does the funding follow that person to those services? And so Community Care hubs work with a network of often nonprofit, community based organizations that deliver a variety of services, but they provide a hub or backbone organization that does the contract negotiation, that does the it, the data security, the invoicing support, which is not always easy on the clinical side, if you're working with a commercial insurance company, for example, they may want you to build encounters, which is very foreign to nonprofits in the community. So it's a way to if you think about an IPA, independent physician Association, it's a similar model, but community based. So I do think that healthcare has they benefit from that. If it can be viewed as an investment to again, for large health systems that have hospitals reduce readmissions or cost avoidance opportunities, then certainly there are opportunities to work financially together to support that infrastructure. My greatest fear, as I've said to you, Cecilia before, is that we don't see it quickly enough that we take it for granted. We think it's there. It will always be there. It's mysteriously funded, but through this uncertain time, that funding is weakening. So I give you the example oftentimes, of last year, AAA alone served over 600,000 meals, home delivered meals. We could easily double that in pretty short order with the infrastructure that's in place today. But if the funding continues to weaken and those nonprofits aren't able to expand or be agile or even exist, then it makes really, really difficult for us to stand that up again or recreate it.

Russell Kohl, MD, FAAFP: 29:30

If I could add there, Cecilia, you know, going back to medical school for me, which was a lot longer ago than I'd like to admit. Now, you know, the the big discussion then was about that transition away from the idea of the physician centered health care and the physician centered payment, physician centered everything you know the reality of what Kristi's describing and what we can see in the fee schedule here is the actual application of that patient care. Your team that the physician alone can't do it. You've got to have a broader team. I think what's incorporated in the fee schedule, as you look at some of the health coaching aspects, all of those sorts of things, the apcm for behavioral health integration, I think you're finally seeing the payment model potentially catch up a little bit with that theory that says, Okay, we recognize not only is it not just the physician, it's the healthcare team, but the whole healthcare team may not be in the same building with the physician. There are things that improve this person's healthcare that are outside of a hospital, outside of the clinic, but are still coordinated in their overall primary care. And those are equally valuable, and we need to be thinking about how we pay for those. The greatest irony of the whole thing is we're getting to have the debate that has happened in medicine for a long time now about, well, this is basically a zero sum game. So if you're going to pay for more prevention, you're going to pay for more of these services. Where does that come from? I think what's a really interesting aspect in this physician fee schedule is it's coming from high paid specialty care. We're saying we simply, as a society, we're not going to be able to afford that ongoing, and we want to invest that money differently. And so I think, from my perspective, that's a huge shift in thought process, if it survives the comment period and makes it into the final rule.

Cecilia Saffold: 31:32

Larry, did you have a thought to add there? I saw you come off mute.

Larry McNeely, MPA: 31:35

I had a beautiful and incredible thought, and then I got lost in Russell's thoughts,

Cecilia Saffold: 31:41

I don't know that's excellent. It's easy to do, right? You touched on a lot of key points, both Kristi and Russell on things that need to shift in practice and the way that we're practicing currently to be successful under the proposed rule as it stands again, proposal and room for change. I'm really curious on how these changes might impact smaller, more independent practices differently than larger, system based practices as they stand, and if there's any kind of light at the end of the tunnel for a slowing and consolidation if this proposed rule proceeds, open to anyone,

Larry McNeely, MPA: 32:29

if I can, and then Dr Kohl may have his thoughts if somebody's been doing the thing in Clinical Practice this site of service differentials, what they're calling the shift in how they're accounting for it's called practice expense. If you Bill, you know what that is, or a policy wonk, if you don't, you probably don't. But how we account for that in payment and shifting it from facility based services to other community based care. That's substantial movement that would take effect, according to proposal next year, so that would be real resources in the fee schedule, if you're billing fee schedule for a small practice and a rural town like I grew up in in West Virginia, or independent practice that might be dependent on Medicare and Medicaid, and a suburb like I'm living In today that's got high high social need burden. But what I think the go forward here is, how do we help those practices transform and become the question from their accountant has to be. Well, how many more shouldn't be? How many more patients can you see next month? It should be. How can you help your patients? How can you deliver the best care and help those patients, you know, have the best health that they can and, you know, I think the hope was that the advanced primary care management service might be the beginning of that for somebody who's not in an ACO as an independent practice, because it's available in the fee schedule. But again, I think we've got to work these work these proposals, so that it's actually digestible and there's actually support for those small, independent, rural, underserved practices that are the backbone of primary care in this country.

Russell Kohl, MD, FAAFP: 34:50

Yeah, building on Larry's comments, you know, the challenge is, you know, and having been you know, a rural primary care doc, you. Suspect that the vast majority of them are not particularly aware of the proposed Medicare Physician Fee Schedule. They absolutely have not read it, and they're just trying to get through their day. They're trying to take care of their patients and trying to take care of their communities. And so while there are some positive things in here, you know, the as Larry said, the differential site payment, the advanced primary care, with the behavioral health integration aspect, looking at a lot of those factors in the RFI, around chronic disease management, all the things that you do as a small town rural doc, because that's your community, and it's just the way that you take care of people that have never been reimbursed in the past. They're in here now, the risk, though, is that they won't know it, and so the implementation of this is going to be the hard part. You can change ENM codes and those sorts of things, and a large system that has a billing department will recognize those immediately, will make the changes and will make sure that you're billing the new code that gets you additional funds when the coding department is you know, in my case, your wife in the evening, in the background of the EHR, that may or may not happen really quickly. And so I think a really important aspect of this, when you think about it from the small practice perspective, is who's going to actually do that education part make sure that they know and provide them the support that they need to make those changes in their practices to actually take advantage of these and let's not forget, you know, it's it's great to be somewhat optimistic about the physician fee schedule. Let's not forget the entire milieu of their life that this is going to fit into. This is going to be at the same time that they're looking at significant cuts to Medicaid payments, which, for most rural practices, is a very large portion. There's not going to be a whole lot of money on the side to hire consultants or those sorts of things. It's going to be really critical for associations, be it, you know, state chapters, the National Associations of like AFP and that to be able to get these messages out to our members, because, if not, the only way that they're going to find out about it is when a a targeted consultant wishes to help them capture 75% of the increased funding that was aimed for them for a mere 25% fee to pay for their own services.

Larry McNeely, MPA: 37:47

You know, I'll just underscore, if I can the, I think the points you're raising there, Dr Kohl, I think mean that this debate one CMS has to follow through and get some of the details right on what they put forward. But two to the point raised earlier, there's some work that only Congress can do right. Congress has to look at even broader payment reform that puts primary care at the center. You know, we could do something called physician payment reform in DC. That doesn't really help that small rural doc, right? That doesn't help primary care. And you know, that'll unfold over the next couple of years, but that's going to be important as well.

Cecilia Saffold: 38:43

All great, great points and kind of building on the idea of payment reform, one of the areas of payment that's performed in this proposed rule is how shared savings works, specifically some ACO items. And would welcome from anyone on the panel, just kind of a summary of what that shift looks like. And is this one of those things, Dr Kohl, you think we can agree on, or is this one of those things that we should be sending some recommendations back to CMS on adjustments?

Russell Kohl, MD, FAAFP: 39:19

Yeah, so I would suppose that the thing you're actually mentioning is the So, the number of years around an MSSP, ACO, in the one sided. So if you're in the basic track one sided only upside risk, historically, that has been seven years, and they propose to move that down to five. Truthfully, I think this is an area that doesn't matter. If we look at the practical aspect of it, we know historically the third year is realistically, where you know how this is going to go. And so by. Moving past that third year, going to five, I don't think puts a real risk on the vast majority of groups. Five, I think still gives you time to make the changes you think you're going to need. Have a relatively low, rapid cycle. PDSA, of you know, what do we need to change? Can we get the answers back? Where do we need to go? You'll have that answer in five years. So I think this is actually one where you can say, Yeah, that's fine, because what it does is open up actuarially funds that can be used for other things. By saying we're willing to let the last two years go, cut it at five that allows us to move funds to other programs that will make positive advances for us. So it doesn't strike me as a realistic danger to primary care to move that from seven to five.

Larry McNeely, MPA: 41:00

Kristi, do you want to pop in? If not, I have got a little you know, one of the things, in addition to what they propose, I think that's a change. I agree with the assessment. There's a change to adjust the threshold. You can get kicked out of the program if you fall slightly below 5000 attributed beneficiaries or assigned beneficiaries, they're flexing that up a little bit. Might be good for the smaller practices might want to get together form an ACO. But the reason why it's important, and frankly this is one area where this administration's Medicare officials, I think, are in continuity with past practice here. There is really strong evidence, and we put a we had a report last year at PCC with the AFP Robert Graham Center that showed that primary care centric ACOs were delivering, they're all important, all work, but they were delivering higher levels of savings against the benchmark than most other type of practices, because they're They're not trying to put heads in beds and still doing superior quality results. This administration is really interested in how to expand it, and I think that's continuity with the last administration that launched ACO Primary Care flex at the urging of many of our organizations, and they've actually gone ahead and continued that. But there are bolder steps. There's an RFI in here, how to support more primary care ACOs. There are bolder steps they could take. They could say any ACO, right? If you want to get off the pay and chase model of billing. We will give you a upfront, prospective population, pain based payment for your regular beneficiaries. Here you go, and fee for service for the other beneficiaries. And you know, not for everybody, but that should be an option for every ACO right? They are steps they could do to expand a second cohort within that ACO Primary Care flex that actually increases dollars going to primary care ACOs, and only the smaller ACOs can participate, no system affiliated in that or, sorry, no high revenue ACOs in that program. So I think there's some real targeted ways to build on what is working in MSSP for some primary care practices

Cecilia Saffold: 43:57

and everyone Larry shared that report in the chat, if you would like to access that and download it. It's on the PCC site. One of the elements that drew my attention in the proposed rule was an emphasis on, you know, increasing and kind of motivating practices and providers to do use more tools that promote patient self monitoring overall, CMS seems to be leaning towards, you know, more emphasis on technology. Some rules about AI use the Wiser model as one of the innovation models, the first model to be targeting software and technology providers that came out this year. So just welcome your perspective. And I'll start with you. Kristi on how valuable tools for patient self monitoring could be, and you know what the impact might be with CMS. putting greater emphasis on this area.

Kristi Bohling-DaMetz, RN, BSN, MBA: 45:02

I think it's just one more connection with community and acknowledging that that's where folks live, is in community, and not in those vitals checks once a month, once every three months. So I think it's absolutely wonderful. Accessibility is going to be the question, comfort with privacy questions, I think is important to acknowledge and talk through and not just assume we can put devices in your home and watch your your health measures, and you'll be real happy about that. I think we It doesn't replace our interactions and communications and honoring of individuals. So I think the other thing that that we didn't quite touch on with the ACO, but is also applicable here, is, is the acknowledgement of caregivers. I'm an old pediatric oncology nurse, and so you didn't do pediatrics unless you knew how to work with families. And as we age, that caregiver becomes more and more important, as important, really, as the older adult, and yet we're we're approaching this caregiver crisis. I was really pleased that CMS acknowledges caregiver measures, things like the guide model that came out recently for caregiver navigation, especially for folks with dementia, and the ability, again, to work between clinical and community settings. In that piece of if a patient is coming to you and there's somebody there at the appointment with them, likely that is the caregiver. So then, how do you work with the community to make sure that caregiver is getting respite support in the community, that they are they have other wraparound services available to them that they have the knowledge and understanding that they need to make sure those remote patient monitoring steps are happening and that accurate measures are being taken. So another opportunity to connect dots, I think.

Cecilia Saffold: 46:57

Larry, you have anything to add on?

Larry McNeely, MPA: 47:01

Just to reflect that. You know, as somebody who grew up with a physician who gave me allergy shots with the PA, who was a saw more often than not, who ended up delivering my sister in the maternity ward who took care of my grandparents, you know, as somebody who has that kind of experience with primary care, that's the superpower of Primary Care and everything in this rule, or any future rule that pulls in a new tool, be it a technology based tool, a new member of the team, a different dimension of care, a new way to pay. That can be important. But the real question we've got to ask is, is that app or that new approach going to be to Kristi's earlier points, fully integrated, or designed to support and inform the partnership between A patient, their caregiver and the primary care team. That's got to be a one of the North Stars for policy making here, because if you don't have that, you're, you're, you're missing all those 4c that Barbara Starfield talked about, and you're not going to get the outcomes you want. And I think that's going to be real important for CMS to hear from us. I think there are a lot of folks in their ear saying, Hey, we can do this. We can do this. Well, you can do this. We got to make sure we don't fragment care.

Unknown: 48:55

Yeah, at Medicare Quality Conference this year, the main thing that you heard over and over again was the role of technology, the role of technology, of AI and machine learning and all those sorts of things. I think the key to success in that is not confusing data with information. And you know, I'd be remiss if I didn't share a quick story. So as a first year medical student, I attended the National Conference Family Medicine medical students. And there was this really old doctor there named Bruce Bagley, who was giving a talk. And Dr Bagley, in his talk, was talking about that if you looked at the future, the future was all family medicine. And he based this upon Star Trek, because if you look at Star Trek, they had all the information they could ever need out of a tricorder, but the tricorder still couldn't fix it, because you needed the doctor who understood why this particular crew member with this particular species in this particular situation, why this all applied to them. And. So, you know, I think that's the thing we have got to keep in mind. With regards to technology. Technology can do great things. People are producing more data than they can even imagine right now, but how do we turn that data into information, and then how do we put that information in the hands of somebody whose job is to make sense of it for this particular patient, and that's what a family doctor does, and that's what a primary care doctor does. And so we just, I think it's great to pay for these things and it's great to expand the use of them, but we can't lose sight of the fact that it's not technology for technology's sake. It's to give that family physician a tad bit more information than they would have had otherwise about what it takes for this person to be able to achieve their health goals.

Larry McNeely, MPA: 50:51

I knew there was a reason why my folks raised me on Star Trek and Dr Bagley, I see it now bearing fruit in the policy work I do, I think to your point, Dr Kohl, is it's important to think about those remote patient monitoring tools and technology and data that hopefully results in information as another piece of wraparound services for folks to age in their homes or in the location of their choosing. We know the aging population is growing exponentially. All of the baby baby boomers are in the 60 plus group as of last year. And so in Missouri alone, we will have more folks over 65 than under 18 by the year 2030 so it's changing dramatically, and we certainly don't have enough assisted living, nursing home, types of organizations to take care of folks, so we have to have those wraparound services, and some of that is just the visibility to how someone's Health is faring when they're not under someone's care.

Cecilia Saffold: 52:03

Thank you so much for that. I want to give some space and time for questions from the audience. I've been watching the chat and haven't seen any questions come in. But welcome anyone to either come off mute or share your question in the chat. If you have a question for any of our panelists, you Dr Bagley, please, and you're welcome to come off mute.

Bruce Bagley, MD: 52:27

I'm as a representative of the longevity generation, I have to speak up and tell you how strangely familiar this whole conversation is. Keep I mean, just a couple of things. Keep in mind that whether it's regular old EMR or AI or whatever it is, it's a platform for the team to be able to do better work. It's not a solution in itself, and that the team based care is a flag we've been waving for a long time, and find it slowly coming along. But if you're paying only one member of the team, and if you're dealing in a visit or procedure based economy, it's going to be tough to do what you want to do. A cardiologist needs certain tools and tests and machines, and the hospital gets paid for those so that don't You don't pay the cardiologist to buy the machines. Why don't we pay primary care to build the infrastructure, instead of worrying about individual physicians or pas or actors getting more money? So I guess you know Russell, you probably have more current statistics than I do, but my understanding is that as much as we've moved towards quality incentives and efficiency incentives, that the majority of people are working on a fee for service like I'd say, 90% of what gets doled out to the actors at the end of the game is fee for service. It may be a little lower than that, but it's in that range, and until we do something about that, you're going to get more. Do more, get more medicine. I don't mean to be a downer, but you know, I think that focus on the infrastructure to support the care teams that really are effective for chronic disease management is the key.

Cecilia Saffold: 54:24

Thank you so much. Dr Bagley, always insightful.

Russell Kohl, MD, FAAFP: 54:31

Yep, Bruce I would, I would say the one of the interesting side effects of more family physicians becoming employed is how are they getting paid? And the vast majority of them are getting paid on an RVU compensation model. So even if we move things to a more holistic payment model, and the system gets paid on a more holistic way, the system. Still forcing them to capture codes, collect RV use and pay them along those lines. So, you know, I think that you are right to be cautious, and that's where my cautious optimism is around. This is that this is a baby step towards what we think it ought to be. But I would re emphasize one of the points that you made there, which is incentives must make it to the people you are hoping to incentivize in order for them to actually be an incentive. And there's nothing in the Medicare Physician Fee Schedule that necessarily does that. It the incentives make it to the system that is billing. And so, you know, how do we, how do we make those changes? I think is, is kind of a next step, sort of continued conclusion, although I would, I would throw in one other thing, just because we haven't talked about it at all, but it is in the physician fee schedule, and that's the ambulatory specialty model, I have to tell you, as a family doc, this is one of the funniest things I've ever heard, that if we would just pay cardiologists and orthopedists differently, they might do a better job at congestive heart failure and low back pain. The good news is, all they need to do is ask their family physician colleagues and we have a few recommendations about how the rest of the person's body and life might actually contribute to the problem that they think is caused by a single organ system. So it's in there. It'll be great to see the results. It'll be interesting to see what happens when you expect specialists to act as a holistic physician for a few years and see what the outcomes become,

Larry McNeely, MPA: 56:45

when and if I can Dr Bagley, when the Primary Care Collaborative got together with a number of organizations and said, Hey, we need a different payment model that can work with ACOs, but has to really focus on primary care within ACOs, we had two of the big messages we had was, well, you know, if you're going to give a substantial value based in this case, remember per month payment to an ACO. You know, you need to think that that ACO is not just paying RV use downstream, right? And they've at least tried to make that happen with a small model called ACO Primary Care flex. I don't know how we're going to see how well that works, but the second thing is that there's actually a question specifically about this in the RFI, and the rule it asks about the advanced primary care management. How about if we paid an ACO this apcm upfront, and that they then would pay participating practices again, those dollars have to reach the practice. And I think there needs to be, and this is a message we should all be conveying. There needs to be some transparency as to whether those resources are reaching the point of care or getting how much is getting captured at other levels. And I think a message on transparency have a certain purchase in this environment. So I filibustered over to you. Cecilia,

Cecilia Saffold: 58:27

Thank you, Larry, thank you everyone. We have one more question from Sue. I'm going to have to table your question because we're right at time, but we will get you a response offline. We'll send that out to you. I want to thank like very sincerely, thank Dr Kohl, Kristi and Larry. Thank you all for taking the time out of your your more than a day. It took plenty of time to prepare and to really understand the proposed rule that just thank you for being here with us today. I urge everyone to please dive into those pieces and parts of the proposed rule that you've learned about today that are very applicable to your work, your practice, your experience of care, and send feedback to CMS in those areas that are pertinent, that you feel strongly about. They need to hear from, from all of us in terms of what what they did well and what needs improvement. I welcome Larry to share in the chat. PCC is continuing this conversation on the eighth this week, and there is a link to that opportunity to join, and I urge you to complete our survey.