Thank you for that overview, and you know, I've alluded to a lot of this has been driven by Medicare. It's not exclusively to Medicare, but it definitely they've been the big driver. So Colin Barker is going to talk to us a little bit about this. He's a member from, as you can see, Vanderbilt, also involved with government relations, and he's going to get us into a little bit more about how Medicare is trying to push alternative payment models. Great. Thank you, Lyndon, and to everybody for the opportunity, and as we were talking about before, we all have learned a lot, and it's important to at least have a grasp of some of these concepts, and with Medicare being one of the larger payers for the population we take care of, it's especially important. And so a lot of what has been designed, as we just heard, for these sort of alternative payment models is based around the primary care model, but Medicare clearly is focused on capitalizing on their success of these shared savings programs, in this quote, and using the lessons learned from value-based care to reach a goal for people in traditional Medicare so that by 2030 everybody would be part of some sort of accountable care organization relationship. The Affordable Care Act of 2010 set forward this goal of transitioning our healthcare from fee-for-service to a value-based system, as we heard, and MIPS, or Merit-Based Incentive Payments, have links to bonuses or penalties directly to fee-for-service payments. And advanced alternative payment models, APMs, were developed, and those include what we'll talk about now, the ACOs, in addition later you'll hear about the bundled payment and disease-based payment models. And so if you're in one of these APMs and you're a qualifying provider or a QP, which you'll see soon, you're actually excluded from the participating or needing to submit MIPS data. There are already over 80 APMs that have been developed, and categorically they have been based either on geography or demographics, but in addition there have been several successfully launched that are disease-specific, event-focused, and procedure-focused, which would apply to interventional cardiologists, as well as payer-based and primary care-focused advanced payment models. The application process is relatively straightforward and laid out, but it is initiated by CMS at a federal level and a state-local level, and then a request for applications for those groups, institutions want to create and form an ACO and submit an application that subsequently gets executed with a contract of agreement, and then you enter into your first performance period and subsequent payment period, which we'll see in a second. The provider payment types are categorized into four different systems, number one being the more traditional fee-for-service, but as we go into categories two and three, the quality and value assessments of care start to become more impactful on payment, and then ultimately category four is more of this population-based payment plan with global capitated budgets. And as you would expect, and one of the consequences here is that our payment is, a bigger portion of our payment is at risk, meaning something that we as an independent provider can't necessarily Whereas there's very little risk in fee-for-service, you get paid for the services you provided regardless of quality, outcomes, need, et cetera. But as you move across the spectrum and begin to incorporate more value and leverage and value-based care and coordination of care, including these event-based models, disease-based, ultimately ACOs, and then full capitation. So at this point, the current breakdown or share of payments made by payment and payment category are seen here from 2018. And when you look at overall across the board, in 2018, fee-for-service care was still a leader and primary driver. But as you look across from fee-for-service on the left and start into the initiating quality care and then APMs that are fee-for-service structured and ultimately APMs that are population-based, you'll see Medicare has really already shifted significantly away, only 10% currently fee-for-service. Most of them are in some sort of quality metric assessed program, which affects compensation. And you would expect commercial players to follow suit soon. This adoption has been already, and some of you may have experienced this, become pretty prominent in the Northeast and the Northwest, as well as the Midwest, but you can see a lot of the more heavily populated areas becoming more involved and participating in ACOs. So in order to become a qualifying participant or this QP, you must receive at least 50% Medicare Part B payments or see at least 35% Medicare patients through an APM during the QP performance period, which is that calendar year, January to August, and then your subsequent payment comes two years later. In addition, with the APM entity, 75% of the practices need to be using certified EMR, which most have transitioned to at this point. And then an alternative is that an eligible clinician in an APM can also become a QP through an all-payer or other-payer option, which is a combination of Medicare and non-Medicare payer arrangements, such as private payers and Medicaid. So the upside of being a qualified participant include exclusion from the MIPS sort of work that has to go into monitoring and reporting. And then for the first five years of the performance years, there was a 5% incentive or bonus. And then for 23 performance year, 3.5%. And then beyond that, as we'll see, it's actually dependent on participation and the physician fee schedule. So here, what you see is that bonus plan that we talked about on the bottom. Again, the performance period and then subsequent, generally two years later, payment year with the bonus incentives expiring at the end of the performance year of 23 and subsequent payment year of 25 and beyond, well, that will be dependent on the physician fee schedule. And those who are qualified participants will get a bonus on top of the or incorporated into their physician fee schedule. So for interventional cardiologists, this presents a lot of challenges as it's really a model that does work well for primary care and coordination of care. However, with it coming, we clearly need to understand it and understand how to participate. The example of myocardial infarction, which we'll hear about, is challenging because as we know, we're one piece of that entire episode of care that can have a lot of other hands in the mix. And other disease processes we manage, which are sort of more end stage, can be very hard to manage chronically in a preventive pattern like PAD. And so APMs are likely to lead to further consolidation and dependence on employment models for interventional cardiologists, which, as we know, does compromise a little bit of our independence and autonomy and ultimately negotiating power. Thank you. Thanks. And I know we're going to have discussion at the end, but one of the points I would want to emphasize is you showed the pathway for becoming a qualifying provider is one that really would be very difficult for an interventional cardiologist to achieve unless they were entirely employed by a large accountable care organization. So I think that there are lots of ways they're trying to increase specialist integration, but that continues to be a big barrier. And then also, I think that slide that I showed in the introduction of the decrease in payments to physicians, that little 0.75% bump that you get for being a qualifying provider does not quite offset that downward dive that we saw on those opening charts. So a little pessimism or discouraging news for us.

Medicare

alternative payment models

value-based care

accountable care organization

APMs