So, with that, I'm going to turn it over to Afnan, and he actually, as I said, is a member of the SC&I Government Relations Committee, also has a background in law. He doesn't put his JD on his signature line, but he has that experience as well. And he's going to talk to us a little bit more about the getting beyond fee for service and exploring innovative payment strategies. Go ahead. Thank you, Brendan. It's been a pleasure working with you on the Government Relations Committee, and yes, I put the, I buried the JD in here, otherwise other physicians are hesitant to talk to you. But it's a, you know, it's a pleasure to be part of this conversation. I think this is a really important conversation to have. As we go forward, we know that the current system has been non-sustainable for some time, and CMS has been exploring innovative payment strategies, and therefore, it is incumbent upon us as interventional cardiologists to be familiar with what they're exploring and to look forward to the horizon. As Linda was talking about, the fee for service model is the one that most of us are most familiar with. And with that, we have a procedure with the CPT code, which is assigned a value, a relative value unit, which is then put through a geographical price index, a conversion factor, and many other factors that then result in a payment. And that's what we're familiar with. So, on the fee for service model, you are paid quite literally for your time and effort. And it is, if you are not putting forward the time and effort, there is no payment. This can lead, or it is believed that at times, the incentives can not necessarily be aligned with long-term health for all of our patients, and so value-based care models have been posited as really being patient-centered and patient-first. And the focus here is that a better outcome for your patients leads to savings, which is a savings and a payment that can then come to the providers that are enabled in it. I think that most of us who are up for board renewals or different aspects understand very, you know, what the onus is upon cardiologists really to have a focus on value-based care and preventive care, even as interventional cardiologists. A significant portion of our practice is devoted to general cardiology and to preventive cardiology. While you may have one event, you're often trying to prevent the next. So, CMS has many, many different models, and I know that we'll go through a bunch of them in detail, but the two primary models which have existed for some time and have some traction, particularly across cardiology, are accountable care organizations and bundled payments. And a very, very high-level overview of accountable care organizations are accountable care organizations are a group of healthcare providers who establish a mechanism for shared governance. It's really about care coordination here. And when you have the care coordination, this group of healthcare providers agrees to be held accountable for the design and for the overall care of those beneficiaries assigned to them. If you look at the traditional payer, whether it's through a health system, an IPA, or a group practice ACO, they take on the burden of payment oftentimes for fee-for-service models. And this becomes relevant for interventional cardiologists who take fee-for-service models, but will take referrals from accountable care organizations. As interventional cardiologists, we can help become part of the payment process. As interventional cardiologists, we can help become part of the conversation on redesigning the care processes such that we are driving forward that coordination of care across accountable care organizations. So, the general principles are an ACO is formed, patients are enrolled in an ACO, and there are a number of reporting requirements and geographical density requirements around forming an ACO and being responsible for the overall cost of care and not just an episode. And that's a distinction I think you'll hear over and over again as we go forward. But as patients receive care, the hospital physicians and other providers are paid fee-for-service. The total cost of care for these patients are compared to the overall target. And really importantly, quality metrics are assessed. And this is where ACOs really have a number of quality measures. I think some people may have read that paper from Johns Hopkins a couple months ago, where they said it was about $6 million spent on quality measure reporting annually at Johns Hopkins Hospital. And this is something that is important in ACOs, so they administer for the population. With bundled payments, for those of us who have participated in this, whether for MI or for TAVR, if a patient, if a group is enrolled in a bundled payment program, you will be paid for the bundle at a certain time period afterwards. And your cost will be compared to the overall target, your geographical index, quality metrics will assess. And penalties or payments are administered per episode. This is an established model that's established across many procedural specialties, including orthopedic surgery and others. And it's something that is familiar with interventional cardiology. So when looking at an accountable care organization, it's really important because we often think that we just do procedures and we get out of the room. And I think that is a minority of the membership at this point. And interventional cardiologists do fit in this paradigm because we require increased collaboration. When you look at your cath lab measures, data reporting is incumbent upon every measure that you have, and cost containment is a part of every conversation. So those transitions in care from interventional cardiology, whether you'll be the one following the patient longitudinally after the MI, after stenting, or you're transitioning care to a colleague, the emphasis is on secondary prevention. And whether that is for an ACO or BPCI, or whether it's for another alternative payment model, that is a consideration that is of paramount importance. And why does this matter? Well, as an interventional cardiologist, this gets you access to more patients through greater networks. And that's hugely important to have access to more patients, and patients get access to you. Patient access is really always very important. The other important thing is that with decreasing fee-for-service payments, every year that Medicare conversion factor actually goes down despite the rate of inflation going up. So because of budget neutrality requirements from CMS, that is the status quo. And therefore, this is a way to maintain income and generate passive income for doing the right thing for patients, right? The important thing is here, it's patient-centered. You can get better care for patients. There are a number of quality measures that are really important here. And I think some providers will be familiar with the MIPS payment system. There are different payment systems and many more that are there for ACOs. But outcomes are only a small portion. A lot of these are process measures, including interoperability, improvement activities, and quality measures, which are passively collected EMR requirements. And these make up a significant portion of the overall measures. Now, the outcomes measures, when you go through the calculations, are often double or triply weighted. So therefore, the patient still is the center. But it is believed by calculating these measures, that's how you're going to have better reporting, have better performance scores, and then either have incentives through shared savings or through downside risk, which I think will be spoken about later. So the challenges for interventional cardiologists in value-based care is, how are the patients enrolled? Who's responsible? The attribution for interventional cardiology is really a challenge. So who's responsible for taking care of these patients? Who's responsible for their improved outcome? Where do these patients have other choices? And what are the patients responsible for? Coordination is really important here. Outcomes, we spoke a lot about the measures, but how to define those. How long do you measure those? Whether it's a bundled payment, whether it's longitudinal calendar year ACOs, whether it's over the lifetime of the patient, how is it reported? How do you monetize an outcome? And this will be, I think, spoken about further. There are many different models here, whether that's shared upside, downside risk, and who gets credit there in attribution. And then the savings of, if you can prevent an event, how much is that worth? And who gets the payment? How is it divided? So I think we have a lot of really important things to talk about. To me, it's a very exciting conversation. It's a very necessary conversation. And I'm excited to hear what everybody else has to say today. Thank you.

innovative payment strategies

interventional cardiologists

accountable care organizations

bundled payments

value-based care