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PTAC Meeting Day 1_UNMHSC


ALL RIGHT. WE’RE GOING TO GET STARTED. GOOD AFTERNOON. WELCOME TO THE MEETING OF THE PHYSICIAN FOCUSED
PAYMENT MODEL TECHNICAL ADVISORY COMMITTEE, PTAC. WELCOME TO MEMBERS OF THE PUBLIC WHO ARE ABLE
TO ATTEND IN PERSON AND WELCOME TO ALL OF YOU PARTICIPATING OVER THE PHONE OR OVER LIVE
STREAM. THANK YOU ALL FOR YOUR INTEREST IN THIS MEETING. WE EXTEND A SPECIAL THANK YOU TO THE STAKEHOLDERS
WHO HAVE SUBMITTED PROPOSALS, ESPECIALLY THOSE WHO ARE PARTICIPATING IN TODAY’S MEETING. THE PTAC’S NINTH MEETING, THAT INCLUDES DELIBERATIONS,
VOTING ON PROPOSED MEDICARE PHYSICIAN FOCUSED PAYMENT MODELS SUBMITTED BY MEMBERS OF THE
PUBLIC. IN JUNE WE DELIBERATED AND VOTED ON CAPABLE
PROVIDER FOCUSED PAYMENT MODEL PROPOSAL, WHICH WAS SUBMITTED BY THE JOHNS HOPKINS SCHOOL
OF NURSING AND STANFORD CLINICAL EXCELLENCE RESEARCH CENTER. LAST WEEK WE SENT A REPORT CONTAINING OUR
COMMENTS AND RECOMMENDATIONS ON THIS PROPOSAL TO THE SECRETARY. PRELIMINARY REVIEW TEAMS HAVE BEEN WORKING,
ONE WE’RE WORKING ON TODAY, THE ORDER OF ACTIVITIES FOR THE PROPOSALS ARE AS FOLLOWS. FIRST, PTAC MEMBERS WILL MAKE DISCLOSURES
OF ANY POTENTIAL CONFLICTS OF INTEREST, WE WILL THEN ANNOUNCE COMMITTEE MEMBERS NOT VOTING
ON A PARTICULAR PROPOSAL. SECOND, DISCUSSIONS OF EACH PROPOSALS WILL
BEGIN WITH A PRESENTATION FROM THE PRELIMINARY REVIEW TEAM, OR PRT. CHARGED WITH CONDUCTING A PRELIMINARY REVIEW
OF THE PROPOSAL. AFTER THE PRT PRESENTATION AND INITIAL QUESTIONS
FROM PTAC MEMBERS, THE COMMITTEE LOOKS FORWARD TO HEARING COMMENTS FROM THE PROPOSAL SUBMITTER,
SUBMITTERS, AND THE PUBLIC. THE COMMITTEE WILL THEN DELIBERATE ON THE
PROPOSAL. AS DELIBERATIONS CONCLUDE, I WILL ASK THE
COMMITTEE WHETHER THEY ARE READY TO VOTE ON THE PROPOSAL. IF THE COMMITTEE IS READY, EACH WILL VOTE
ELECTRONICALLY ON WHETHER THE PROPOSAL MEETS THE SECRETARY’S TEN CRITERIA. AFTER VOTING ON EACH CRITERION WILL VOTE ON
AN OVERALL RECOMMENDATION. I WILL ASK PTAC MEMBERS TO PROVIDE GUIDANCE
TO ASK THE STAFF ON KEY COMMENTS THEY WOULD LIKE TO INCLUDE ON THE PTAC REPORT TO THE
SECRETARY. BEFORE WE BEGIN, A FEW REMINDERS, QUESTIONS,
PLEASE REACH OUT THROUGH THROUGH [email protected] EMAIL. WE HAVE ESTABLISHED THIS PROCESS IN THE INTEREST
OF CONSISTENCY AND RESPONDING TO COMMITTERS, AND MEMBERS OF THE PUBLIC AND APPRECIATE EVERYBODY’S
COOPERATION USING IT. I ALSO WANT TO UNDERSCORE THREE THINGS. THE PRT REPORTS ARE REPORTS FROM THREE PTAC
MEMBERS TO THE FULL PTAC, AND DO NOT REPRESENT THE CONSENSUS OR THE POSITION OF THE PTAC. THE PRT REPORTS ARE NOT BINDING. THE FULL PTAC MAY REACH DIFFERENT CONCLUSIONS
FROM THOSE CONTAINED IN THE PRT REPORT. FINALLY THE PRT REPORT IS NOT A REPORT TO
THE SECRETARY OF HEALTH AND HUMAN SERVICES. AFTER THIS MEETING PTAC WILL WRITE A NEW REPORT
THAT REFLECTS PTAC’S DELIBERATIONS AND DECISIONS TODAY, WHICH WILL THEN BE SENT TO THE SECRETARY. PTAC’S JOB IS TO PROVIDE THE BEST POSSIBLE
COMMENTS AND RECOMMENDATIONS TO THE SECRETARY AND I EXPECT THAT OUR DISCUSSIONS TODAY WILL
ACCOMPLISH THIS GOAL. I’D LIKE TO THANK MY PTAC COLLEAGUES, ALL
OF WHOM GIVE COUNTLESS HOURS, TO CAREFUL AND EXPERT REVIEW OF THE PROPOSALS WE RECEIVE. I ALSO WANT TO THANK YOU AGAIN FOR YOUR WORK,
AND THANK YOU TO THE PUBLIC FOR PARTICIPATING IN TODAY’S MEETING VIA LIVE STREAM, AND BY
PHONE. BEFORE WE GET STARTED, I JUST WANT TO MAKE
A PERSONAL ACKNOWLEDGMENT OF DR. TIM FERRIS, WHO HAS BEEN ON THE COMMITTEE
SINCE ITS INCEPTION, FOUR YEARS AGO. DR. FERRIS IS THE CEO OF THE MASSACHUSETTS GENERAL
MEDICAL GROUP, WE’RE VERY PROUD AND PRIVILEGED TO HAVE HIM ON THE COMMITTEE, AND WE WILL
MISS HIM DEARLY. HIS LAST MEETING IS TODAY. HOPEFULLY, TIM, YOU’LL CONTINUE TO MAKE A
CONTRIBUTION TODAY SO YOU’LL BE MEMORIALIZED FOREVER GOING FORWARD. SO THANK YOU. THE PROPOSAL WE DISCUSS TODAY IS ACCESS TELEMEDICINE,
ALTERNATIVE HEALTH CARE DELIVERY MODEL FOR RURAL CEREBRAL EMERGENCIES, PROPOSAL SUBMITTED
BY UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER. PTAC MEMBERS, LET’S INTRODUCE OURSELVES AND
READING DISCLOSURES. I’LL START WITH MYSELF, DR. JEFF BAILET, NOW WITH ALTEUS, NOTHING TO DISCLOSE.>>TIM FERRIS, MASS GENERAL PHYSICIANS ORGANIZATION,
I HAVE NOTHING TO DISCLOSE.>>KAVITA PATEL, JOHNS HOPKINS AND BROOKINGS. I’VE BEEN IN CONTACT WITH THE TEAM FROM THE
UNIVERSITY OF NEW MEXICO AROUND THEIR PROGRAM, PROJECT ECHO, WHICH HAS SIMILAR FEATURES. I WAS EMPLOYED WORKING FULL TIME, WE DID A
REPORT HIGHLIGHTING THE ECHO MODEL.>>I’M LEN NICHOLS, ECONOMIST IN GEORGE MASON
UNIVERSITY, NOTHING TO DISCLOSE.>>GRACE TERRELL, CEO OF ENVISION GENOMICS,
ALSO DO WORK WITH KILOS GENETICS, INTERNIST AT WAKE FOREST BAPTIST HEALTH SYSTEM, AND
SENIOR ADVISER TO OLIVER WYMAN HEALTH INNOVATION CENTER, NOTHING TO DISCLOSE.>>BRUCE STEINWALD, HEALTH ECONOMIST IN WASHINGTON,
D.C., NOTHING TO DISCLOSE.>>PAUL CASALE, NEW YORK PRESBYTERIAN, NOTHING
TO DISCLOSE.>>JENNIFER WILER, PROFESSOR OF EMERGENCY
MEDICINE AND BUSINESS AT THE UNIVERSITY OF COLORADO, ALSO FOUNDER AND EXECUTIVE MEDICAL
DIRECTOR OF UC HEALTH CARE INNOVATION CENTER, NOTHING TO DISCLOSE.>>DR. ANGELO SINOPOLI, PRISM, SOUTH CAROLINA, CEO
OF CARE COORDINATION INSTITUTE, NOTHING TO DISCLOSE.>>WE HAVE TWO OF OUR MEMBERS ON THE PHONE. RHONDA MEDOWS, DR. MEDOWS, AND HAROLD MILLER. RHONDA, DO YOU WANT TO INTRODUCE YOURSELF?>>SURE. DR. RHONDA MEDOWS, POPULATION HEALTH AT PROVIDENCE
HEALTH, NO DISCLOSURES.>>HAROLD MILLER, I’M SORRY I COULDN’T BE
THERE IN PERSON TODAY. I HAVE NO CONFLICTS OR DISCLOSURES ON THE
PROPOSAL.>>THANK YOU, HAROLD AND RHONDA. WE’LL BE SURE TO MAKE SURE YOU GET AIR TIME
IF YOU NEED TO MAKE COMMENTS. I’D LIKE TO TURN IT OVER TO LEN NICHOLS TO
PRESENT FINDINGS. WE’LL ADVANCE YOUR SLIDES FOR YOU.>>OKAY, GREAT. YEAH, SIMPLER. IT’S HARD TO KEEP UP WITH MY SOUTHERN ACCENT. THANK YOU. THANK YOU. SO THIS IS AN AMAZING TEAM. I HAD THE PRIVILEGE OF LEADING, YOU KNOW,
THEY HAD THE RULE YOU HAD TO HAVE AT LEAST ONE DOC ON THE COMMITTEES, THEY GAVE ME TWO,
SO IT WAS A LOT OF FUN. ANYWAY, DR. TERRELL AND DR. MEDOWS BOTH WERE QUITE ENTHUSIASTIC AND YOU’LL
SEE WHY. SO AS JEFF TOLD YOU, THE WAY THE WORLD WORKS,
PROPOSALS COME IN, THE STAFF REVIEWS FOR COMPLETENESS, THE CHAIR OR VICE CHAIR SELECTS THE PRT, COMPOSITION,
TALK ABOUT OVERVIEW, SUMMARY OF OUR REVIEW, KEY ISSUES AND THEN THE SPECIFIC CRITERIA
BY WHICH WE EVALUATE EVERY PROPOSAL. YEAH, AFTER THE COMMITTEE REVIEWS THE PROPOSAL
WE DO HAVE A PROCESS WHEREBY WE’RE STAFFED BY REALLY SMART PEOPLE WHO BRING US FACTS
WE SHOULD BE AWARE OF AND WE ASK QUESTIONS OF THE APPLICANTS. THEY SUBMIT RESPONSES AND THEY CAN DO THAT
ALONG THE WAY, AND I THINK THEY SENT US SOMETHING LAST WEEK IN FACT TO CLARIFY SOME THINGS. THAT PROCESS CONTINUES THROUGH TODAY AND AS
JEFF SAID IT’S VERY IMPORTANT TO MAKE CLEAR THE PRT REPORT IS THE REPORT OF THE PRT, NOT
THE JUDGMENT OF THE PTAC AND ALL OF US MAY CHANGE OUR MIND BEFORE IT’S DONE. THIS IS A PROPOSAL BASED UPON A PILOT STUDY
DONE UNDER THE AUSPICES OF THE HEALTH CARE INNOVATION AWARDS, AND ESSENTIALLY THE IDEA
IS TO ADDRESS WHAT IS PERCEIVED AS APPARENTLY CLEARLY IS AN UNMET NEED FOR CEREBRAL EMERGENT
CARE MANAGEMENT IN RURAL HOSPITALS. AND IT’S PRETTY CLEAR THAT THERE’S NOT A FINANCIAL
RESOURCES TO SUPPORT THIS SORT OF THING NOR A PAYMENT MODEL AT THE MOMENT THAT CAN SUCCESSFULLY
MAKE IT WORTHWHILE. WHAT ACCESS DOES IS AIMS TO EXPAND ESSENTIALLY
ACCESS TO EXPERTISE OF NEUROLOGICAL AND NEUROSURGICAL NATURE TO DOCS IN RURAL HOSPITALS, SO THAT
THEY COULD MAKE MORE TIMELY AND MAYBE MORE ACCURATE JUDGMENTS ABOUT THE NEED FOR HOSPITALIZATION
AND VERY COSTLY AND SOMETIMES RISKY TRANSFER OF PATIENTS TO HOSPITAL. THE IDEA IS TO REDUCE UNNECESSARY UTILIZATION
AT THE REGIONAL REFERRAL CENTERS BY EQUIPPING THEM WITH THIS ACCESS TO TELEMEDICINE EXPERTISE. THE APM ENTITY WOULD BE THE RURAL HOSPITAL
BECAUSE PAYMENT WOULD GO TO THEM. IT USES THIS TWO WAY AUDIO/VISUAL PROGRAM
TO CONNECT PROVIDERS IN THE RURAL UNDERSERVED AREAS TO EXPERTS IN THE TEACHING HOSPITALS,
THE RURAL PROVIDERS WOULD REQUEST A CONSULTATION WITH AVAILABLE SPECIALIST, WHO CONSULTS WITH
THEM USING THIS PLATFORM. AND THE CONSULTING PHYSICIAN PROVIDES RECOMMENDATIONS
ON TREATMENT TO THE REQUESTING PROVIDER, WHO ULTIMATELY ALWAYS HAS CONTROL OF THE PATIENT
AND THE COURSE OF ACTION. THE SUBMITTER IN THIS IDEA PROPOSES THAT A
BUNDLED PAYMENT BE MADE TO THE RURAL HOSPITAL, NOT TO THE ENTITY THAT’S DELIVERING THE TELEMEDICINE
SERVICES BUT TO THE RURAL HOSPITAL ITSELF SO THAT IN A SENSE YOU PAY THE HOSPITAL AND
THEN THAT RURAL HOSPITAL DECIDES WHAT TO DO WITH THE MONEY, AND OF COURSE THE MONEY WOULD
FLOW BACK UPSTREAM TO THE DELIVERER OF THE CONSULTING SERVICES. THE PAYMENT INCLUDES AN ELEMENT FOR THE CONSULTING
ITSELF, FOR THE TECHNOLOGY, AND FOR ENSURING PROVIDER AVAILABILITY AND I WOULD ARGUE STAFF
EDUCATION, PROGRAM ADMINISTRATION AND QUALITY ASSURANCE, THE KINDS OF, IF YOU WILL, INFRASTRUCTURE
STUFF THAT IS NOT TYPICALLY PAID FOR IN IN THE CONTEXT, PARTLY WHY THE BUNDLE WAS SEEN
AS A NECESSARY PRECONDITION FOR ENABLING THESE SERVICES TO BE PROVIDED AS FREQUENTLY AS THEY
SHOULD BE. THE PAYMENT COVERS THE FOLLOW UP CONSULTATION
ON THE SAME CASE WITHIN 24 HOURS SO THEY CAN CALL THEM BACK, AND THE RURAL HOSPITAL IS
RESPONSIBLE FOR PAYING THE DISTANT SITE NEUROLOGIST OR NEUROSURGEON AND TECHNOLOGY PLATFORM PROVIDER. HERE IS A NICE CHART WHICH SOMEBODY MADE,
PROBABLY Y’ALL MADE IT ORIGINALLY AND ASPE MADE IT PRETTY. HERE IS HOW THE BUNDLE BREAKS DOWN. FIRST OF ALL, WHAT YOU WANT TO PAY ATTENTION
TO PROBABLY, ALL SPECIALISTS IN THE ROOM ALREADY HAVE, THE NEUROLOGIST IS PAID DIFFERENTLY
THAN THE NEUROSURGEON, AND THEN THERE’S A PAYMENT TO THE CONSULTING PHYSICIAN RIGHT
THERE, TECHNICAL CHARGE IS THE SAME REGARDLESS OF WHO DOES THE SERVICE, THERE’S A RESIDUAL
PAYMENT WHICH IS THE DIFFERENCE. THE IDEA BEHIND THE DEFERENTIAL PAYMENT IS
THESE PEOPLE COST DIFFERENT AMOUNTS OF MONEY IN REAL LIFE, HOWEVER, THIS IS A DEVIATION
AS YOU’LL SEE FROM WHAT MEDICARE HAS ALWAYS DONE. THAT DOESN’T MEAN IT’S A BAD IDEA, JUST IT’S
A DEVIATION FROM WHAT MEDICARE HAS ALWAYS DONE. THE OTHER THING I WANT TO CALL YOUR ATTENTION
TO IS COST DOES COVER THE PAYMENT FOR THE TECHNOLOGY, AND INCLUDES THIS ON CALL AVAILABILITY
NOTION OF KEEPING FOLKS AVAILABLE. THE HCIA EVALUATION CONCLUDED THERE WEREN’T
ENOUGH PEOPLE IN THE EXPERIMENT TO DELIVER STATISTICALLY VALID RIGOROUS IMPACT ANALYSIS,
AND THAT WAS DISAPPOINTING. AND OBVIOUSLY A FACT WE HAD TO TAKE INTO ACCOUNT. THE EVALUATION THAT WAS DONE DID REPORT ANECDOTAL
EVIDENCE THAT SUGGESTED ALL THE GOOD STUFF, AND I’LL JUST SAY, I CAN’T REALLY PRONOUNCE
THAT, BUT THE POINT IS THAT THAT THING, THAT TTA, CLEARLY IS A GOOD IDEA TO GET THAT SORT
OF STUFF QUICKLY. TIMING IS EVERYTHING, I BELIEVE THE PHRASE
I HEARD ON THE PHONE WAS “TIME IS BRAIN,” SO I DID LEARN THAT. AND THEN WHAT HAPPENED WAS BECAUSE THE HCIA
EVALUATION WAS NOT ABLE TO DO WHAT WE LIKE TO SEE IN SORT OF STATISTICAL CONTROL GROUP
ANALYSES, THE SUBMITTER MADE AVAILABLE TO US A NUMBER OF DIFFERENT MODELING EXERCISES,
BASED UPON REAL DATA THAT SUGGESTED THE KINDS OF SAVINGS THAT YOU SEE HERE, AND THERE ARE
SOME UNPUBLISHED COST ANALYSES FROM THE SUBMITTER THAT ESTIMATES QUITE ALARM SAVINGS OVER TIME,
ALL OF WHICH IN OUR VIEW IS PLAUSIBLE BUT COULD NOT BE PROVEN STATISTICALLY AT THE TIME. SO, THIS IS THE SUMMARY CHART. AND YOU CAN SEE IF YOU JUST TAKE A SECOND,
IT’S UNUSUAL IN THAT WE REALLY LIKE THIS ONE. IN FACT, WE LIKED EVERY DIMENSION OF IT, AND
THREE OF THEM MEETS AND DESERVES PRIORITY CONSIDERATION, WHICH MIGHT BE A RECORD. BUT ANYWAY, UNANIMOUS ACROSS THE BOARD. LET’S GO THROUGH IT. WE BASICALLY THINK THIS IS ABSOLUTELY A VALUE
ADD TO THE MEDICAL DELIVERY SYSTEM. PRECISELY BECAUSE IT MAKES THIS SPECIFIC EXPERTISE
AVAILABLE IN REAL TIME, WHERE TIME IS BRAIN. AND WE BELIEVE THAT THE PROGRAM HAS POTENTIAL
TO IMPROVE QUALITY AND OUTCOMES FOR PATIENTS WHALE SAVING MEDICARE MONEY AND REDUCING FAMILY
STRESS, IT’S KIND OF A WIN WIN WIN. THE PROPOSAL IS INNOVATIVE. IT IS AN INNOVATIVE CARE DELIVERY MODEL, IN
ADDITION TO INNOVATIVE PAYMENT MODEL. AND IT WOULD IN MANY WAYS BOLSTER THE ABILITY
OF RURAL HOSPITALS TO CONTINUE TO BE VIABLE AND ALL THOSE ARE DESIRABLE THINGS. AS I MENTIONED EARLIER, MEDICARE HAS NOT TRADITIONALLY
PAID FOR THIS INFRASTRUCTURE STUFF, EDUCATION, TRAINING, KEEPING THE PROVIDER AVAILABLE,
ET CETERA. THE PAYMENTS ARE MADE TO THE ORIGINATING SITE
WHICH IS A LITTLE DIFFERENT THAN PAYING THE PEOPLE WHO DELIVER THE SERVICES, AND WE WENT
THROUGH THIS. I’M AN ECONOMIST, MY JOB IS TO BE SKEPTICAL. AT FIRST I THOUGHT IT WAS ODD, NOW I THINK
IT MAKES SENSE. THAT’S OUR EVOLUTION AS WE THOUGHT ABOUT THIS
PROBLEM. WE THINK THE FAIR MARKET VALUE, WHICH WAS
THE METHODOLOGY USED TO DETERMINE THE PRICE OF THE NEUROSURGEON VERSUS THE NEUROLOGIST,
PROBABLY REASONABLE, BUT THERE WASN’T A GREAT DEAL OF INFORMATION ABOUT EXACTLY HOW THAT
WAS DONE. I MEAN, IT DOES HAVE KIND OF AN IMPLICATION. SO IT COULD BE THAT MEDICARE WILL WANT TO
LOOK A LITTLE MORE DEEPLY INTO HOW THAT MIGHT BE DONE AND MAYBE IT SHOULD BE DIFFERENT IN
DIFFERENT PARTS OF THE COUNTRY. SO THE CRITERION, WE START WITH SCOPE WHICH
ASKS DOES IT REACH PATIENTS THAT HAVE NOT BEEN REACHED BEFORE OR PROVIDERS WHO HAVE
NOT BEEN REACHED BEFORE IN A SCALE THAT’S BIG ENOUGH TO MAKE A DIFFERENCE ESSENTIALLY? WE SAID NOT ONLY IS IT UNANIMOUSLY YES BUT
MEETS CRITERION AND DESERVES PRIORITY CONSIDERATION, PRECISELY BECAUSE OF THE RURAL HOSPITAL NEXUS
WITH THE STROKE PATIENTS. AND SO THERE’S NO QUESTION HERE. QUALITY AND COST, AGAIN, WHILE THE HCIA EVIDENCE
WASN’T TREMENDOUSLY CONVINCING, THE TOTALITY OF THE EVIDENCE PRESENTED LED US TO BELIEVE
THAT IT WAS QUITE REASONABLE TO CONCLUDE IT WILL INDEED LOWER COSTS AND IMPROVE QUALITY,
SO, AGAIN, WE THINK DESERVES PRIORITY CONSIDERATION. THE PAYMENT METHODOLOGY LIKE I SAID WE DID
HAVE A COUPLE QUESTIONS HERE. WE’RE NOT QUITE SURE THAT THE FAIR MARKET
VALUE CALCULATION WAS CLEAR ENOUGH TO SATISFY CMS’S NORMAL HEALTHY SKEPTICISM SO WE THINK
SOME OF THAT WILL HAVE TO BE CLARIFIED. AND THERE IS NO EXPLICIT RISK SHARING ALTHOUGH
ALMOST BY CONSTRUCTION A BUNDLE INVOLVES SOME DOWNSIDE RISK SHARING BUT IN ANY EVENT WE
THOUGHT THIS DID IMMEDIATE THE CRITERION AND NOT DESERVES PRIORITY CONSIDERATION. VALUE OVER VOLUME, AGAIN, WE HAD NO DOUBT
THAT THIS WAS MOVING IN THE RIGHT DIRECTION AND WE THOUGHT IT WAS SUFFICIENTLY IMPACTFUL
POTENTIALLY TO DESERVE PRIORITY CONSIDERATION IN THAT WAY. WE CERTAINLY THINK THE FLEX� ONE GREAT THING
ABOUT PAYING THE RURAL HOSPITAL IS THEY HAVE FLEXIBILITY ABOUT WHAT TO DO WITH THIS MONEY
AND HOW TO CONTRACT WITH THE SERVICES AND SO FORTH, AND SO WE THOUGHT THAT ABSOLUTELY
GAVE THE RIGHT AMOUNT OF FLEXIBILITY CLINICALLY. NO QUESTION THAT THERE’S A QUESTION ABOUT
COMING UP WITH A CONTROL GROUP, BUT WE’RE PRETTY SURE THERE’S ENOUGH PATIENTS OUT THERE
TO FIND ONE IN REAL LIFE AND IF YOU TAKE IT TO SCALE LIKE THEY ARE PROPOSING IT SHOULD
BE MUCH EASIER TO GENERATE A SAMPLE SIZE LARGE ENOUGH TO GET STATISTICAL VALIDITY. SO WE THINK IT ABSOLUTELY IS ABLE TO BE EVALUATED. CARE COORDINATION, THE WHOLE POINT IS TO BETTER
COORDINATE CARE OF THESE COMPLEX PATIENTS IN REAL TIME AND WE’RE CONVINCED THAT THIS
APPLICATION OF TECHNOLOGY AND SERVICES WOULD DO THAT. PATIENT CHOICES IS ABSOLUTELY RESPECTED BY
GRANTING THAT THE LOCAL RURAL HOSPITAL PHYSICIAN HAVE CONTROL OVER THE BASICALLY PLAN OF CARE,
SORT OF GUARANTEES THAT PATIENT CONVERSATION GOES ON THE RIGHT WAY. PATIENT SAFETY, I WILL SAY THAT THERE’S CONCERN
ABOUT THAT, BUT ALMOST BY CONSTRUCTION THIS IS BETTER THAN THE STATUS QUO AND THEREFORE
IT’S ENHANCING THE SAFETY ENVIRONMENT THAT WE HAVE TODAY AND OF COURSE IT USES SOPHISTICATED
TECHNOLOGY TO MAKE ALL THIS HAPPEN. SO FOR ALL THOSE REASONS, MR. CHAIRMAN, WE CONCLUDED THAT THIS PROPOSAL
MEETS ALL THE CRITERIA THE SECRETARY LAID OUT. LET ME STOP NOW AND ALLOW MY PHYSICIAN COLLEAGUES,
RHONDA IS ON THE PHONE. WE MIGHT WANT TO START WITH HER ON THE PHONE
AND GRACE TO SEE WHAT I LEFT OUT OR SHOULD HAVE SAID BETTER.>>SO, LEN, I DON’T THINK YOU LEFT ANYTHING
OUT. YOU’VE DONE A FANTASTIC JOB DESCRIBING WHAT
I THOUGHT WAS ONE OF THE BEST PREPARED PROPOSALS WE HAVE SEEN AS A COMMITTEE. QUITE FRANKLY I THOUGHT THEY ADDRESSED A SCOPE
AND SPAN OF NEED THAT WAS NOT ADDRESSED PREVIOUSLY. POPULATION OF NEED, DID A GREAT JOB DESCRIBING
BOTH HOW THEY WOULD ACTUALLY MEASURE AND MONITOR QUALITY. PATIENT SAFETY, PATIENT OUTREACH AND ENGAGEMENT,
AS WELL AS HOW THEY WOULD ACTUALLY GET COORDINATION TO OCCUR AMONGST A SIGNIFICANT GROUP OF PROVIDERS
FOR THIS MUCH NEEDED SERVICE. I THINK YOU DID A GREAT JOB. I DON’T HAVE ANYTHING ELSE TO ADD OTHER THAN
THANK YOU FOR REPRESENTING THE PRT.>>THANK YOU, RHONDA.>>SO, I FORGOT TO SAY EARLIER WHEN I WAS
STATING SOME THINGS I DO THAT FOR THE LAST SEVERAL MONTHS I’VE BEEN DOING SOME TELEMEDICINE
WORK FOR A TELEMEDICINE COMPANY, A VERY DIFFERENT SITUATION THAN THIS, BUT WHAT I’VE LEARNED
FROM THAT EXPERIENCE HAVING DONE ABOUT 4100 TELEMEDICINE CONSULTS OVER THE LAST SIX MONTHS,
IS THAT THERE IS A MAJOR ACCESS PROBLEM IN RURAL AREAS, AT LEAST IN THE TWO STATES THAT
I DO THAT IN, WHICH IS NORTH CAROLINA AND ALABAMA. EVEN THOUGH YOU THINK OF A STATE LIKE NEW
MEXICO, GEOGRAPHICALLY SPEAKING, THERE IS A VERY DIFFERENT SORT OF STRUCTURE. I THINK THAT THE NEED FOR THIS IS GOING TO
BE UNIVERSAL. AND THAT THIS COULD BE A VERY, VERY GOOD AND
EFFECTIVE WAY TO REALLY SOLVE MAJOR STRUCTURAL PROBLEMS IN THE U.S. HEALTHCARE SYSTEM, NAMELY
THOSE IN RURAL AREAS, AS WELL, QUITE FRANKLY, MAKING THE EXPERTISE AND EXPERIENCE OF ACADEMIC
MEDICAL CENTERS HAVE AN OUTREACH THAT SOMETIMES IN THE PAST HAS BEEN CONSTRICTED BY GEOGRAPHY. SO I WOULD AGREE WITH BOTH OF MY COLLEAGUES
AND JUST WANT TO TALK ABOUT THE EXPERIENCE THAT I’VE HAD ACTUALLY SINCE THE REVIEW PROCESS
STARTED THAT WOULD JUST CONFIRM THE ENTHUSIASM I HAVE FOR THE WORK THEY HAVE DONE AROUND
THIS.>>GREAT. THANK YOU. BEFORE WE HAVE THE SUBMITTERS COME TO THE
TABLE, IT’S NOW TIME IF WE HAD CLARIFYING QUESTIONS THAT THE COMMITTEE WOULD LIKE TO
ASK OF THE PRT. WE’LL START WITH YOU, BRUCE, AND THEN TIM.>>THE ELEMENTS OF THE PAYMENT, PAYMENTS TO
CONSULTING PHYSICIAN, BUT THEN THE OTHER PAYMENTS SEEM TO BE COVERING THE COST OF MONEY WHICH
MIGHT BE FIXED COSTS, WONDERING IF YOU HAD DISCUSSION ABOUT THAT AND IF THE VOLUME WASN’T
HIGH, ABILITY TO COVER FIXED COSTS MIGHT BE LIMITED.>>GOOD YES. THAT’S WHAT I MEANT BY INFRASTRUCTURE. THERE’S A LOT OF STUFF THAT IS FIXED. THAT’S WHAT I MEANT WHEN I SAID CMS MIGHT
WANT TO KICK THE TIRES MORE ABOUT HOW TO THINK ABOUT THIS. THEY MADE A SET OF PRICE RECOMMENDATIONS BASED
UPON ANTICIPATED VOLUME. AND I THINK YOU MIGHT WANT TO BE ABLE TO ADJUST
THAT IF THE VOLUME TURNED OUT NOT TO BE THERE, I THINK THAT’S RIGHT. AGAIN, I THINK WHAT WOULD HAPPEN IF IT GOES
THROUGH THE PROCESS IS CMS TO BRING DATA TO GET A PRECISE ESTIMATE BUT THE NOTION IS IT’S
A FIXED COST YOU’RE SPREADING OVER THAT.>>TIM?>>MY QUESTION HAD TO DO WITH THE RURAL VERSUS
EVERYWHERE ELSE. AND THE EXPERTISE NECESSARY TO MAKE A DECISION
TO PRESCRIBE IN REAL TIME A HIGHLY LETHAL POTENTIALLY LETHAL DRUG IN ORDER TO PREVENT
STROKE OR EXTENSION OF THE STROKE. IT’S NOT COMMONLY FOUND IN SUBURBAN COMMUNITY
HOSPITALS EITHER. SO I WAS UNCLEAR WHETHER OR NOT THE PAYMENT
MODEL AS PROPOSED RESTRICTED THE SITE OF CARE TO RURAL AS HOWEVER DEFINED, OR WAS IT JUST
A PAYMENT MODEL THAT HAPPENED TO BE PARTICULARLY BENEFICIAL FOR RURAL BUT COULD BE APPLIED
ANYWHERE, THAT’S THE FIRST HALF OF THE QUESTION.>>I DON’T REMEMBER THAT RURAL WAS A REQUIREMENT. I THINK IT’S MORE THE WAY IT WAS DESCRIBED
AND THE WAY THE HCIA THING PLAYED OUT. IN FACT, I THINK THEY SAID ANY HOSPITAL THAT
DIDN’T HAVE THE EXPERTISE SHOULD BE ABLE TO CONNECT AND THEY ARE NODDING SO I THINK THAT’S
TRUE.>>OKAY.>>YES.>>ALL RIGHT.>>IT AIN’T RURAL PER SE. IT’S RURAL LIKE.>>RURAL LIKE. OKAY. MY SECOND QUESTION HAD TO DO WITH DID THEY
MAYBE I’LL ADDRESS IT TO THEM WHEN THEY COME UP, BUT DID THEY ADDRESS THE ISSUE OF STATE
BORDERS? SO THE LICENSING REQUIREMENTS ASSOCIATED WITH
PHYSICIANS DELIVERING RECOMMENDED CARE ACROSS STATE BORDERS HAS BEEN LET’S JUST SAY A BIT
OF A CONUNDRUM, AND WHILE SOME STATES ARE MOVING TOWARD RECIPROCAL AGREEMENTS, USUALLY
ADJOINING STATES, WE’RE STILL A LONG WAY AWAY FROM THAT AS A COUNTRY. AND IT IS A BIG BARRIER TO THESE KINDS OF
TELEMEDICINE SERVICES, AND I JUST WONDERED IF THERE WAS ANY REFLECTION ON THAT IN THE
PROPOSAL.>>OKAY. I’LL ASK OUR SUBMITTERS.>>JEN AND THEN
>>THANK YOU. I WANT TO MAKE SURE I UNDERSTAND. SO THE EPISODE STARTS WITH THE REQUEST FOR
CONSULTATION FOR AN EMERGENT WHAT I WOULD DESCRIBE AS STROKE CONSULT, RULE IN, RULE
OUT, AND DECISION AROUND ADMINISTRATION OF tPA, AND ENDS AT TRANSFER OF THE PATIENT TO
A FACILITY OR WITHIN 24 HOURS IF THE PATIENT STAYS WITHIN THE RURAL LOCATION, IS THAT CORRECT?>>I THINK SO. SO MY QUESTION, WAS THERE ANY CONVERSATION
ABOUT WHY TRANSPORTATION COSTS WITH EMS, WHICH CAN BE COSTLY, WEREN’T INCLUDED IN THE BUNDLE? OR RADIOLOGY? BECAUSE IN THE RURAL FACILITIES GETTING EMERGENT
READS, SCANS, WHICH COULD BE DONE BY A CONSULTATION EXPERT IN NEUROLOGY OR NEUROSURGERY BUT AT
LEAST AT MY COMPREHENSIVE STROKE CENTER THAT WE ACTUALLY HAVE NEURORADIOLOGY READING THOSE,
AND ALSO THEN THE HOSPITALIST CARE, WHOEVER IS PROVIDING IN HOSPITAL CONSULTATIVE SERVICES
DURING THE POST 24 HOURS, WHY THOSE WEREN’T INCLUDED IN THE BUNDLE?>>AS I UNDERSTAND IT, AND GRACE, I LOOK TO
YOU AND RHONDA TO WEIGH IN HERE, THE FUNDAMENTAL PROBLEM THAT WAS ATTEMPTED TO BE ADDRESSED
HERE WAS OVERLY CONSERVATIVE REFERRAL TO THE REGIONAL HOSPITAL CENTER. SO, THE EXPERTISE WAS THOUGHT TO ESSENTIALLY,
AND PART OF THE TRAINING AS WELL, WAS ESSENTIALLY DESIGNED TO ENABLE THE LOCAL PHYSICIAN TO
FEEL MORE COMFORTABLE ABOUT KEEPING THAT PATIENT IN THEIR OWN HOSPITAL. AND EVERYTHING ELSE JUST DESCRIBED IS SORT
OF AFTER THAT. IF THEY ARE GOING TO KEEP ‘EM, THEY FEEL GOOD
WITH WHAT THEY HAVE GOT. IF THEY ARE GOING TO TRANSFER THEM THEY DON’T,
COMPARED TO WHAT THE PATIENT NEEDS, THAT’S THE EXPERTISE THEIR TRYING TO BRING TO HELP
THEM BEAR. THE THE REST OF IT IS ALL PAID FOR, AS I UNDERSTAND
IT. SO I DON’T THINK IT’S RELEVANT TO THE BUNDLE,
PER SE. THE BUNDLE IS TO BUY THE EXPERTISE.>>ANGELO?>>FIRST OF ALL, I LIKE THE IDEA THE RULE
HOSPITALS ARE THE OUTLYING COMMUNITY HOSPITALS OWN THIS PAYMENT. JUST A COUPLE QUESTIONS, MORE CURIOSITY. SO, IT WAS CLEAR IN THE PROPOSAL THAT IT STARTED
WITH THE EVENT AND THERE WAS SOME PAYMENT FOR THE 24 HOUR COVERAGE. IT WASN’T CLEAR WHETHER THERE WAS PAYMENT
FOR ON CALL AVAILABILITY TO BE AVAILABLE WHEN AN EVENT OCCURRED? WAS THAT DISCUSSED, PART OF THE PAYMENT, AND
AS PART OF THAT AS A RURAL HOSPITAL HAS THE EVENTS AND SEES THEIR NEEDS, IN THE COMMUNITY
THAT MAY HAVE SEVERAL HOSPITALS THAT DO THIS TYPE OF INTERVENTION, CAN THEY ON A GIVEN
DAY OR WEEK CHOOSE CARIOUS HOSPITAL, ARE YOU LOOKING THIS AS BEING EXCLUSIVE CONTRACT WITH
A TERTIARY CARE CENTER THAT DOES THAT?>>IT WASN’T, TO MY UNDERSTANDING, LOOKED
AT AS A BUNDLE OF REALLY GREAT QUESTION A BUNDLE OF ONE PAYMENT THAT DIFFERENT HOSPITALS
WOULD SHARE IF YOU’RE TALKING ABOUT. IT REALLY WAS ABOUT COVERING THE COST AT THE
UNIT LEVEL OF THE RURAL HOSPITAL. I MEAN, THIS MAY BE CLARIFICATION THAT MIGHT
WANT TO BE WHEN TALK TO SUBMITTERS WITH RESPECT TO HCIA AWARD BECAUSE THEY WERE COVERING MORE
THAN ONE HOSPITAL AT A TIME.>>ALL RIGHT. PAUL?>>JUST TO ADD FURTHER TO JENNIFER’S QUESTION,
WHICH AGAIN I THINK THE SUBMITTERS COULD PROBABLY FURTHER ELUCIDATE, BUT SO PART OF IT WAS AROUND
DO YOU TRANSFER OR NOT BUT IF YOU GIVE THE tPA YOU STILL NEED A NEUROLOGIST AND EXPERTISE,
WHO IS PROVIDING THIS, IF THEY HAVE A NEUROLOGIST ON SITE WOULDN’T NECESSARILY NEED THE TELEMEDICINE
NEUROLOGIST SO I’M TRYING TO UNDERSTAND TO JENNIFER’S POINT ABOUT THAT ONGOING CARE AND
IS THAT WHY NOT INCLUDE THAT IN THE BUNDLE OR IS THERE A SEPARATE FEE FOR THAT ONGOING
TELEMEDICAL MEDICINE CARE?>>WE SHOULD ASK THE PROFESSIONALS. I WOULD JUST OBSERVE WHAT THEY ARE BUYING
IS THE EXTRA EXPERTISE FOR THE DECISION MAKING. THE MONITORING NEUROLOGY OF INPATIENT IN THE
RURAL HOSPITAL WOULD EITHER BE PAID FOR THROUGH NORMAL MEDICARE CHANNELS OR NOT. I MEAN, THAT’S A CONSULT.>>ANGELO? OH, AND JENNIFER.>>I PREEMPTED THE DISCUSSION WITH THE PRESENTERS,
WHY NOT ADD THIS TO THE FEE SCHEDULE IN SOME WAYS, EXAMPLES OF WHERE THESE SPECIALIZED
CONSULTATION SERVICES MIGHT HAVE BEEN ADDED, WHY THAT’S NOT POSSIBLE AND WHY AN APM WOULD
BE BETTER WOULD BE A WELCOME DISCUSSION.>>I WANT TO MAKE SURE, CHECK IN WITH RHONDA
AND HAROLD BEFORE WE OPEN UP TO THE SUBMITTERS. DO YOU GUYS HAVE QUESTIONS FOR THE COMMITTEE?>>I DO NOT.
AND I’M ON THE COMMITTEE.>>I DO NOT. I HAVE QUESTIONS FOR THE SUBMITTER BUT NOT
THE PRT.>>THANK YOU. LET’S GO AHEAD AND HAVE THE PROPOSAL SUBMITTERS
COME UP TO THE TABLE. WE HAVE ONE PERSON ON THE PHONE, SUSIE SALVA
WENDT PARTICIPATING BY CONFERENCE LINE. INTRODUCE YOURSELVES. YOU WANT TO MAKE OPENING COMMENTS WHICH WE
LIMIT TO TEN MINUTES AND WE’LL OPEN FOR QUESTIONS. THANK YOU GUYS FOR BEING HERE.>>I’M RYAN STEVENS, ADMINISTRATOR WITH UNM
SCHOOL OF MEDICINE, JOINING ME IS CONSULTING NEUROLOGIST AND USERS OF THE PLATFORM. WE THANK YOU FOR YOUR TIME AND CONSIDERATION
OF OUR PROPOSAL FOR ACCESS MODEL OF DELIVERING SPECIALTY TELEMEDICINE CONSULTATION IN URGENT
AND EMERGENT SETTINGS. IT’S FULFILLING PERSONALLY AND PROFESSIONAL
TO DISCUSS WITH YOU TODAY A SERVICE THAT HAS DEMONSTRATED TREMENDOUS VALUE AND IS POTENTIALLY
A SPRINGBOARD FOR ELIMINATING HEALTH DISPARITIES DRIVEN BY BENEFICIARY ZIP CODE THAN SOCIOECONOMIC
OR MEDICAL VARIABLE. I WANT TO TAKE A MOMENT TO THANK THE MEMBERS
OF THE ACCESS TEAM ON THE PHONE, AND PARTICULARLY DR. HOWARD YONUS, WHOSE VISION MADE POSSIBLE THIS
PROGRAM NOW DELIVERED OVER 6000 CONSULTS. WE SENT YOU UPSTATED STATISTICS BUILT ON THE
DATA COLLECTED DURING THE CMMI GRANT, DEMONSTRATING POSITIVE IMPACT OF THE ACCESS MODEL FOR PATIENTS,
FAMILY, EMERGENCY PHYSICIANS, FACILITIES LACKING SPECIALTY COVERAGE, THEIR COMMUNITIES, PAYERS
AND REFERRAL CENTERS. IT’S DIFFICULT IN TODAY’S HEALTH CARE ARENA
TO IDENTIFY SELF SUSTAINING PROGRAMS AND SERVICES WITH SOY MANY BIG STAKEHOLDERS BENEFITING
SO MUCH, YET STILL WITH THE PURITY OF PURPOSE THAT ALIGNS EVERYONE FOR THE BENEFIT OF PATIENT. THE ACCESS PROGRAM HAS GARNERED SUPPORT FROM
HOSPITAL, LOCAL PAYERS AND STATE OF NEW MEXICO BASED ON VALUE PROPOSITION DEMONSTRATED BY
THE GRANT AND PERPETUATED INTO A SUSTAINABLE AND EVER EVOLVE POST GRANT PERIOD. SEVERAL UNIQUE ASPECTS CONTRIBUTED TO CURRENT
LEVEL OF SUPPORT, I’LL LIST THOSE OFF. FIRST HOSPITALS ONLY PAY FOR SPECIALIST SERVICES
AS NEEDED. THIS ENTIRELY VARIABLE COST STRUCTURE IS PARTICULARLY
FAVORABLE FOR CEREBELLAR EMERGENCIES. WE
PROPOSE REIMBURSEMENT FOR PHYSICIAN SERVICES, IF THE SPECIALIST IS NOT REQUIRED TO BILL
INSURER OR PATIENTS FOR SERVICES RENDERED. PROGRAM RESOURCES REQUIRED FOR BILLING INFORMATION
ARE BETTER SPENT ON EDUCATION AND QUALITY ASSURANCE. THIRD, EDUCATION COMPONENT IS A CRITICAL ELEMENT
OF SUCCESS. THERE’S FAR GREATER AS DIFFERENTIATOR FROM
MANY TELEMEDICINE PROGRAMS, IT’S ONE THING TO RECEIVE A RECOMMENDATION FROM A SPECIAL
ITS AND ANOTHER TO BE COMFORTABLE IMPLEMENTING IT. WE BELIEVE THE CHANGE IN EMERGENCY PROVIDER
AROUND FACILITY BEHAVIOR FROM 90% TRANSFER TO 15% TRANSFER FOR THESE CONDITIONS IS A
RULED OF RESULT OF COMBINING AVAILABILITY. ANOTHER INITIATOR IS INTENT. ACCESS WAS SET UP WITH THE GOAL OF KEEPING
PATIENTS IN THEIR HOME COMMUNITIES. NOT TO CAPTURE CASES FOR REFERRAL CENTER. AND WE LEFT THE DECISION FOR TRANSFER AS TO
WHERE TO TRANSFER UP TO THE LOCAL FACILITY. WHILE WE’RE CONFIDENT IN POSITIVE RESULTS
WE ACKNOWLEDGE THERE ARE MULTIPLE ASPECTS OF THIS MODEL THAT CHALLENGE EXISTING CMS
PHYSICIAN PATIENT PARADIGMS AND LOOK FORWARD TO PARTICIPATING IN A LIVELY DISCUSSION TODAY
AMONG EXPERTS ON HOW BEST TO MEET THOSE CHALLENGES. I’LL CALL FOUR CHALLENGES OUT NOW. OUTCOMES VALIDATION, SO UNFULFILLED PROMISE
OF INTEROPERABILITY, WITH SAVINGS IMPACT BEYOND tPA ADMINISTRATION IN
STROKE, WELL STUDIED, AND TRANSPORT AVOIDANCE. DURING THIS PROGRAM NEARLY $100 MILLION IN
TRANSPORT CHARGES HAVE BEEN AVOIDED BUT WE KNOW EVEN MORE BENEFIT ACCRUED VIA IMPROVED
TIMELINESS OF TREATMENT DELIVERED TO PATIENTS EXPERIENCING A TIME SENSITIVE CLINICAL EVENT. INTERESTINGLY, THE MAJORITY OF CONSULTATION
REQUESTS ARE FOR NEUROLOGICAL CONDITIONS OTHER THAN STROKE. STROKE CONSULTATIONS THERE’S GOOD EVIDENCE
IN THE LITERATURE TO SUPPORT FINDINGS OF IMPROVEMENT IN LIFETIME QUALITY ADJUSTED LIFE YEARS OF
2.8, AND SAVINGS OF $35,761. HOWEVER, OTHER THAN TRANSPORT AVOIDANCY WE
HAVE LESS EVIDENCE FOR NON STRUCK CONSULTATION, WITH A ROBUST HIE TO ASSESS CLINICAL OUTCOMES. WE NEED TO ACQUIRE A CONTROL POPULATION FROM
GEOGRAPHY THAT DIDN’T HAVE ACCESS. THIRD, FROM THE FOCUS OF RAPID DELIVERY TO
MANAGEMENT OF THE EPISODE OF CARE INITIATED AT THE TIME OF CONSULTATION. EPISODE MANAGEMENT REQUIRES A DEGREE OF COORDINATION
THAT EXCEEDED THE SCOPE. THIRD THING, VARIABLE REIMBURSEMENT, WE INTRODUCED
IN THE PLATFORM A MODEL TO WORK FOR FRONTIER, RURAL, UNDERSERVED, EVEN URBAN HOSPITALS WITH
EACH ENTITY ONLY PAYING WHEN THE SERVICE ISSUES. EACH PARTICIPATING HOSPITAL HAS ACCESS TO
CLINICAL EDUCATION QUALITY REPORTING, OTHER RESOURCES PART OF ACCESS BUT WE INTRODUCED
IN THIS MODEL THE MARKET DRIVEN REALITY OF COST OF A SPECIALIST ON DEMAND 24/7 COVERAGE
AND VARIABILITY. NEUROSURGERY COSTS MORE TO MAKE AVAILABLE
THAN NEUROLOGY, FOR EXAMPLE. CURRENT TELEMEDICINE FEE SCHEDULES DO NOT
TAKE INTO ACCOUNT SIGNIFICANT COST VARIABILITY BETWEEN SPECIALIST NOR CHALLENGES OF DELIVERING
SERVICES AT ALL HOURS OF THE DAY INSTEAD OF SCHEDULED VISITS. THE HOSPITAL CRITERIA FOR ELIGIBILITY FOR
ACCESS SERVICES IS CONCEPTUALLY QUITE SIMPLE. DOES THE FACILITY NEED THE SERVICE? THAT DOES NOT CORRELATE TO A POPULATION BASED
RATIO OF SPECIALISTS NOR TO HRSA AND RURAL STATUS REFLECT INDIVIDUAL SPECIALTY AVAILABILITY. THROUGH MEDICAID COLLABORATION WE CONTINUE
TO DEVELOP PROCESSES TO VALIDATE THE PRESENCE OF PROGRAM ELEMENTS AND OUTCOMES DATA, AND
WE’VE PROPOSED THE FOCUS BE ON DEVELOPING A PROCESS OF VALIDATING FULFILLMENT OF OBJECTIVES
AND NOT UPON CREATION OF FACILITY ELIGIBILITY CRITERIA FOR PARTICIPATION. SO, WE GREATLY APPRECIATE THE OPPORTUNITY
TO COLLABORATE WITH CMS AND CONTINUE THE DISCUSSION OF HOW TO TAKE ACCESS MODEL TO THE NEXT LEVEL,
AND OTHER AREAS OF THE REGION AND SPECIALTIES, I’LL CONCLUDE WITH A STORY. DURING THE CMMI GRANT WE COLLECTED MANY STORIES
HOW ACCESS AFFECTED PATIENTS AND FAMILIES. SEVERAL WERE EXTRAORDINARILY ILLUSTRATIVE
OF THE BENEFIT OF TIMELY SPECIALIST AVAILABILITY. SUCH AS THAT OF A WOMAN WHO SUFFERED A HEMORRHAGIC
STROKE IN RURAL NEW MEXICO AND REQUESTED A CONSULTATION. THE PRE ACCESS EVIDENCE EXPERIENCE AND CMMI
DATA BOTH CONFIRM THIS WOMAN WITH GREAT PROBABILITY WOULD HAVE BEEN TRANSFERRED 300 MILES TO REFERRAL
CENTER LIKELY IN ANOTHER STATE, AND WITH HER PROGNOSIS WOULD HAVE CERTAINLY DIED IN SPITE
OF THE HEROIC EFFORTS OF HER FLIGHT CREW. INSTEAD DR. YANIS HAD THE NURSE TURN THE CART TO THE FAMILY,
EXPLAIN THE PROGNOSIS, THE WOMAN PASSED WITH DIGNITILY SURROUNDED BY THOSE SHE LOVE. WE PROPOSE WORKING TO CONTINUE DEVELOPING
A PHYSICIAN FOCUSED PAYMENT MODEL THAT ENABLES HUMAN AND FISCAL BENEFITS. THAT CONCLUDES MY PREPARED REMARKS. THANK YOU.>>THANK YOU. WE’LL HAVE A DISCUSSION, RIGHT? BUT I WANTED TO TURN IT OVER TO BOTH RHONDA
FIRST AND THEN HAROLD, BECAUSE THEY HAVE ALREADY SIGNALED THEY HAD QUESTIONS AND THEY ARE ON
THE PHONE AND WE’LL OPEN UP TO COMMITTEE MEMBERS IN THE ROOM.>>I ACTUALLY DON’T HAVE QUESTIONS.>>I DO HAVE QUESTIONS.>>GO AHEAD.>>THANK YOU, JEFF. FIRST OF ALL, I’M SORRY I COULDN’T BE THERE
IN PERSON. I WANT TO COMMEND YOU FOR THIS PROJECT WHICH
I THINK IS AN EXCELLENT SERVICE THAT CLEARLY HAS HAD VERY GOOD RESULTS. I’M VERY FAMILIAR WITH THE NEED FOR THIS KIND
OF SERVICE IN A VARIETY OF RURAL HOSPITALS. BUT I DID WANT TO TALK TO YOU ABOUT MORE DETAIL
ABOUT THE PAYMENT MODEL, AND I HAD THREE QUESTIONS. FIRST OF ALL, I’M INTERESTED TO KNOW HOW THE
CRITICAL ACCESS HOSPITALS IN NEW MEXICO HAVE DEALT WITH THIS SINCE THEY WOULD THEORETICALLY
BE ABLE TO COUNT THE CHARGE, YOUR CHARGE AS A COST, AND RECEIVE COST BASED REIMBURSEMENT
FROM MEDICARE FOR THAT. OTHER CRITICAL ACCESS HOSPITALS HAVE TRIED
TO PUT THESE SERVICES IN PLACE, HAD THE CHALLENGE MEDICARE CAN BASICALLY COVER COST FOR MEDICARE
PATIENT BUT NOT MEDICAID AND COMMERCIAL PATIENTS. IN NEW MEXICO YOU NOW HAVE A PAYMENT FOR MEDICAID. SO I COULD THINK THAT THE CRITICAL ACCESS
HOSPITALS WOULD ACTUALLY BE ABLE TO SUPPORT THIS THAT WAY. I’M WONDERING WHAT EXPERIENCE YOU’VE HAD DIFFERENTLY
WITH THE WAY ARE THEY IN FACT BILLING THIS SERVICE TO MEDICARE NOW?>>NOT THAT I’M AWARE OF. THEY DO HAVE SUSIE, ARE YOU ON THE LINE?>>YES, I AM.>>YEAH, SUSIE CAN SPEAK BETTER TO THE HOSPITALS
THAT EXPERIENCE WITH BILLING MEDICAID.>>AS OF RIGHT NOW, OUR CRITICAL ACCESS HOSPITALS
HAVE NOT BEGUN BILLING MEDICAID. WE’RE IN THE PROCESS OF DEVELOPING THAT PROCESS,
AND AS THEY SEE IT, THEY BELIEVE THAT THEIR BILLING WOULD BE THE SAME AS THE OTHER HOSPITALS,
AS THE BENEFIT THAT THEY SEE IS THE SAME. SO WE DO NOT ANTICIPATE ISSUES WITH THE CRITICAL
ACCESS HOSPITALS, OTHER THAN THEY DURING THE GRANT WE WERE SUPPORTING, AND SO THAT’S WHY
THERE HASN’T BEEN A CRUCIAL INCENTIVE FOR THEM TO BILL UNTIL NOW THAT WE’RE OFF THE
GRANTS.>>OKAY. THANK YOU. BUT THEY WOULD BE ABLE TO COUNT THIS AS A
COST, AND RECEIVE BASICALLY 99% REIMBURSEMENT FROM CMS AS A COST, AS A PORTION TO THE INSTANCE
YOU’RE CHARGING THEM ON A PATIENT BY PATIENT BASIS, THEY WOULD BE ABLE TO RECOVER THAT. THE TWO QUESTIONS I HAVE REALLY ARE ABOUT
THE OTHER QUESTIONS ABOUT THE PAYMENT APPROACH, AND I UNDERSTAND WHY YOUR STRUCTURE, WHEN
YOU’RE CHARGING FOR THE SERVICE, WOULD BE TO HAVE THE HOSPITAL PAY YOU ON A PATIENT
BY PATIENT BASIS, THAT MAKES PERFECT SENSE. THE THING I’M PERPLEXED BY IS THE NOTION THAT
IF MEDICARE WERE PAYING FOR IT, THAT THE RURAL HOSPITAL WOULD BE BILLING MEDICARE FOR A SERVICE
THAT YOU ARE PROVIDING. TYPICALLY IN VIRTUALLY ALL PAYMENTS MEDICARE
MAKES, MEDICARE PAYMENT GOES TO THE ENTITY THAT PROVIDES THE MAJORITY OF THE SERVICE. BUT WHAT YOU’RE HAVING MEDICARE PAY FOR HERE
IS A SERVICE THAT IS PROVIDED BY YOU, THE REMOTE PROVIDER, WITH A VARIETY OF THINGS
THAT YOU PROVIDE AS PART OF THAT, NOT ONLY PHYSICIAN CONSULTATION BUT AS YOU MENTION,
THE BACKUP STAND BY SERVICE FROM SPECIALIST, ET CETERA. AND SO I DON’T UNDERSTAND WHY IT WOULDN’T
BE YOU THAT WOULD BE BILLING MEDICARE FOR THE INDIVIDUAL SERVICE, YOU WOULD ONLY BILL
MEDICARE FOR THE INDIVIDUAL SERVICE WHEN AN INDIVIDUAL HOSPITAL ACTUALLY USED IT. THAT PART WOULD MAKE SENSE. BUT MEDICARE WOULD PRESUMABLY CMS WOULD WANT
TO KNOW THAT IN FACT THE SERVICE WAS BEING DELIVERED APPROPRIATELY, THAT THERE WAS HIGH
QUALITY STANDARD ASSOCIATED WITH IT, THAT THE SPECIALISTS WERE IN FACT AVAILABLE AND
RESPONSIVE AND HAD THE APPROPRIATE QUALIFICATIONS. AND IT WOULD BE VERY DIFFICULT FOR THE RURAL
HOSPITAL TO DO THAT, WHEREAS IT WOULD BE FAR EASIER AND MORE APPROPRIATE FOR YOU THE SERVICE
PROVIDER TO ACTUALLY DO THAT. CAN YOU EXPLAIN WHY IT WOULD MAKE SENSE FOR
A RURAL HOSPITAL TO BILL MEDICARE AND THEN HAVE TO SOMEHOW JUSTIFY IT TO MEDICARE THAT
THE THING IT WAS DELIVERING IN RETURN FOR THAT PAYMENT MET ALL THOSE KIND OF QUALITY
AND APPROPRIATENESS STANDARDS?>>I’M GOING TO LET DR. DEBAY SPEAK TO THAT.>>TYPICALLY, THEY GET CONSULTED ON A STROKE
PATIENT OR NEUROLOGICAL EMERGENCY, WHICH REACHED THE E.D., WE PROVIDE CONSULTATION WITHIN A
VERY SPECIFIED PERIOD OF TIME FRAME, 30 MINUTES, AND WE DISCUSS WITH E.D. PHYSICIAN. AND WE ARE AVAILABLE FOR THE SAME CONSULTATION
WITHIN 24 HOURS, BUT NO EXTRA CHARGE, AND IF THEY APPROACH US AGAIN AFTER 24 HOUR PERIOD
THERE’S AN EXTRA CHARGE I BELIEVE. SO, THE SERVICE IS SO GOOD BECAUSE WE GET
APPROACHED NUMEROUS TIMES ABOUT THE SAME PATIENTS IN 24 HOURS, CRITICAL TIME PERIOD WHEN YOU
SEE A PATIENT. AND I THINK IT’S EASIER FOR HOSPITALS TO BILL
RATHER THAN PHYSICIAN BILLING FOR THE SERVICES OVER AND OVER AGAIN AND ADDING ADMINISTRATIVE
COST TO IT.>>I’M NOT SUGGESTING THAT THE PHYSICIAN BILL
FOR THE SERVICE BECAUSE THIS SERVICE IS NOT BEING DELIVERED BY INDIVIDUAL PHYSICIAN. IT’S BEING DELIVERED BY YOU AS A PROGRAM THAT
ORGANIZES A SET OF PHYSICIANS AND HAS PHYSICIANS ON STAND BY SO THAT YOU CAN DELIVER THE SERVICES
IN A TIMELY FASHION. NO INDIVIDUAL PHYSICIAN COULD DO THAT. AND WHAT YOU’RE OFFERING IS NOT JUST THAT
INDIVIDUAL PHYSICIAN CONSULTATION. IT’S THAT WHOLE BACKUP PROGRAM. SO YOU’RE THE ONE THAT’S DELIVERING THAT SERVICE,
SO IT SEEMS TO ME THAT YOU WOULD BE THE PERSON THAT WOULD BE BILLING MEDICARE. LET ME ASK PART 2 OF THE QUESTION BECAUSE
THESE TWO ARE RELATED. AS I READ THE PROPOSAL, YOU DID NOT INCLUDE
ANY KIND OF ACCOUNTABILITY FOR RESULTS OR QUALITY IN THE PAYMENT, THE PAYMENT GETS BILLED
IF THE SERVICE IS DELIVERED, ESSENTIALLY REGARDLESS OF WHAT THE QUALITY IS. YOU HAVE THE MEASURE YOU DEFINE THAT WOULD
BE REVIEWED THROUGH AN EVALUATION PROCESS. BUT I’M CURIOUS AGAIN AS TO WHY MOST MODELS
WE REVIEW AND CALLED FOR IN OUR GUIDELINES HAVE SOME KIND OF WHERE THE PAYMENT IS BASED
IN SOME FASHION ON THE QUALITY OF THE SERVICE DELIVERED. SO IN FACT IF YOU WERE NOT DELIVERING SERVICE
IN A TIMELY FASHION, THE PAYMENT WOULD BE LOWER. IF YOU WERE MAKING BAD RECOMMENDATIONS THE
PAYMENT WOULD BE LOWER, ET CETERA. AND SO I GUESS I’M INTERESTED IN WHY YOU DIDN’T
INCLUDE ANY ACCOUNTABILITY LIKE THAT. BUT TO RELATE THIS TO PART 1 OF THE QUESTION
IS IF THERE WERE SOME ACCOUNTABILITY, THE ACCOUNTABILITY WOULD REALLY BE AT THE PART
OF YOUR PROGRAM, NOT THE INDIVIDUAL HOSPITAL, BECAUSE YOUR PROGRAM IS THE ONE ASSURING TIMELY
RESPONSE AND GOOD RECOMMENDATIONS, ET CETERA, AND YOU WOULD NEED TO BE ACCOUNTABLE FOR THAT
QUALITY.>>CAN I INTERVENE? THIS IS SUSIE. AND SO SINCE I WAS ON THE INCEPTION OF 2010
WHEN WE STARTED WORKING ON TELEMEDICINE, OUR WHOLE POINT WAS TO KEEP THE LOCAL RURAL UNDERSERVED
HOSPITAL CONTROL OF THEIR PATIENT. AND SO TO DO THAT, WE FELT IT WAS BENEFICIAL
THAT THEY CONTROLLED THE BILLING, BECAUSE OUR PURPOSE WAS TO PROVIDE THE CONSULT. AND THE EDUCATION AND SOME QUALITY OBJECTIVES
THAT WE DO AS PART OF THEM BEING PART OF THE ACCESS TEAM OF HOSPITALS. SO, WE THOUGHT ABOUT THIS, IN THE BEGINNING,
VERY INTENSELY, WHY DON’T WE BILL? WELL, BECAUSE THEN WE BECOME THAT PATIENT’S
DOCTOR, WHICH WE’RE NOT PREPARED TO DO. WHEN PATIENTS GO TO RURAL HOSPITALS OR UNDERSERVED,
MOST TIMES THEY KNOW THOSE DOCTORS. THEY HAVE A RELATIONSHIP. WHEN IT COMES TO BILLING, IT’S THE PATIENT
CAN ACTUALLY GO TO THE HOSPITAL AND UNDERSTAND THE BILLING PROCESS, AND WORK WITH THAT HOSPITAL. WE’LL REALLY WANTED THE HOSPITALS TO BE THE
ANCHOR INSTITUTIONS, AND NOT HAVE US, THE UNIVERSITY, BEING THE BIG GUY DEFINING THE
BILLING, ALL OF THAT. WE WANTED TO PUT ALL OF THIS IN THE RURAL
HOSPITALS SO THEY COULD BUILD UPON THEIR FINANCIAL STABILITY, AND THEY COULD CONTROL WHAT HAPPENED
TO THE PATIENT CLINICALLY AND THROUGH THE REIMBURSEMENT PROCESS.>>EXPLAIN HOW IF ONE WANTED TO TIE THE PAYMENT
TO THE QUALITY OF THE SERVICE BEING DELIVERED, HOW THAT MIGHT BE DONE?>>I’LL MAKE A POINT TO THAT. EACH OF US DOES CONSULTATION IN DIFFERENT
HOSPITALS, HAVE TO GET CREDENTIALED AT THE LOCAL LEVEL, RURAL OR SUBURBAN HOSPITAL. CREDENTIALING PROCESS IS DONE BY EVERY HOSPITAL,
IT’S NOT A UNIFORM PROCESS. THEY LOOK AT YOUR CREDENTIALS AND APPROACH
CREDENTIALS BASED UPON YOUR TRAINING AND YOUR EDUCATION. NOT JUST SORT OF THE QUALITY MEASURE.>>OKAY. THANK YOU.>>THANK YOU, HAROLD. TIM?>>GOING DIRECTLY TO THE POINT OF ASSURANCE
DID YOU THINK ABOUT REQUIRING THE PROVIDER OF THE SERVICE TO BE A CERTIFIED STROKE CENTER? CERTIFIED STROKE CENTERS HAVE TO GO THROUGH
EXTENSIVE EVALUATION ABOUT THEIR ABILITY TO PROVIDE HIGH QUALITY SERVICES, SPECIFICALLY
IN THE TELEMEDICINE CONTEXT. I WONDERED IF THAT MIGHT SERVE AS A PROXY
FOR THERE’S AN EXISTING CERTIFICATION SYSTEM FOR COMPREHENSIVE STROKE CENTERS.>>WE’RE FAMILIAR WITH THE FACT THERE ARE
SEVERAL CERTIFICATIONS, ONE OF THE CHALLENGES WOULD BE LANDING ON WHICH ONE.>>THERE’S JUST SOME THAT ARE AVAILABLE. GRACE?>>WE OFTEN TALK ABOUT PAYMENT MODELS AS BEING
ABOUT VALUE OR ABOUT VOLUME. ONE OF THE THINGS I BELIEVE I JUST HEARD FROM
YOUR COLLEAGUE ON THE PHONE IS THAT THIS IS BOTH, POTENTIALLY AT THE SAME TIME. THE MOTIVATION FOR THE RURAL HOSPITAL WOULD
BE KEEPAGE, ABLE TO KEEP THE PATIENT LOCALLY AND KEEP BEDS FULL AS OPPOSED TO SHIPPING
OUT SOMEBODY IN A WAY THAT MAY BE DANGEROUS, YOU KNOW, FOR THE PATIENT AS WELL AS INCONVENIENT
FOR THEIR FAMILY AND ALSO NOT NECESSARILY THE WAY THINGS WOULD NECESSARILY APPROPRIATELY
BE DONE IF SERVICES COULD BE DONE LOCALLY. SO, WITHIN THAT CONTEXT OF VALUE AND VOLUME,
THE VALUE WOULD SEEM TO BE THE OVERALL LOWER COST OF CARE, SECONDARY TO KEEPING SOMEONE
LOCAL. BUT THE VALUE PROPOSITION FOR THE RURAL HOSPITAL
IS ACTUALLY INCREASED VOLUME BECAUSE IT INCREASES THEIR MEDICAL APPROPRIATENESS. AM I GETTING THE VALUE PROPOSITION FOR THE
RURAL HOSPITAL CORRECT IN THE WAY I’M UNDERSTANDING WHY THEY WOULD BE MOTIVATED TO DO THIS AS
OPPOSED TO JUST SHIPPING THEM OUT BECAUSE OF RISK OR LACK OF RESOURCES?>>YEAH, ABSOLUTELY. IN FACT, WE HAVE A CFO FROM ONE OF THE HOSPITALS
RELIED TO US THIS WAS THE DIFFERENCE BETWEEN THEM SHUTTING DOWN AND STAYING OPEN. 100 PATIENTS THEY WERE ABLE TO RETAIN WAS
THE DIFFERENCE IN THEIR BOTTOM LINE THAT KEPT THEM OPEN.>>THANK YOU. PAUL?>>ANOTHER ASPECT IS THAT WE DO DO WE REVIEW
30% OF THE CONSULTS EVERY MONTH IN A VIGOROUS REVIEW BY SPECIALISTS WHO REVIEW EACH CONSULT
FOR DIAGNOSIS AND APPROPRIATE TREATMENT. WE ALSO, JUST AS AN EXAMPLE AS WE WERE DOING
RESEARCH ON EPILEPSY PATIENTS REALIZED NOT ALL CONSULTANTS WERE UP TO DATE ON TREATMENTS
IN EPILEPSY, WHICH THEN WE WERE ABLE TO SEND OUT TO OUR CONSULTING PHYSICIANS AND DO SOME
MORE EDUCATION, POINTED EDUCATION IN OUR HOSPITALS. SO, THAT’S ANOTHER WAY WHERE WE’RE TRYING
TO MAKE SURE THE QUALITY IS APPROPRIATE, AND THAT THE EDUCATION IS UP TO DATE.>>THANK YOU. PAUL?>>GREAT. SO ONE OF THE WITH BUNDLED PAYMENTS IN GENERAL
THERE’S A QUESTION IF YOU GET PAID FOR A BUNDLE WHAT PREVENTS YOU FROM DOING MORE BUNDLES? IN YOUR LIST, THERE’S A LIST OF DIAGNOSES
THAT CAN TRIGGER THIS. OF COURSE, WHEN PAYMENT IS TIED, THERE’S A
POTENTIAL FOR SOME TO MAYBE TRIGGER A BUNDLE FOR DIAGNOSIS, UNLESS I DIDN’T SEE, IS THERE
A CLEAR LIST OF DIAGNOSES THAT ARE PRESCRIBED? OR IS THERE POTENTIAL FOR SORT OF UNINTENDED
CONSEQUENCES OF OTHERS NEUROLOGIC CONDITIONS LIKE SEVERE HEADACHE OR SOMETHING THAT COULD
SORT OF TRIGGER BUNDLES AND HOW DO YOU ASSURE OR GUARD AGAINST THAT?>>AS YOU CAN SEE IN THE DATA THERE WERE 27%
OF CONSULTS PROVIDERS OF STROKE. A LOT OF TIMES PATIENTS AT THE EMERGENCY ROOM,
THEY ARE CONSIDERED A STROKE PATIENT, IF THEY HAVE SOME KIND OF DEFICIT OR HEADACHE, EXTREME
HEADACHE. IT’S A PROCESS OF RULING IN, RULING OUT. CLEAR CUT STROKES ARE INCLUDED BUT THERE’S
SUCH A GRAY AREA IN MEDICINE SO NEUROLOGICAL EMERGENCIES HAVE TO BE RULED IN OR RULED OUT. THERE’S NOT ONE CONSENSUS OR DIAGNOSIS.>>I UNDERSTAND THAT. DIDN’T KNOW IF THERE WAS A WAY TO GUARD AGAINST,
AGAIN UNINTENDED QUESTIONS OF SOMEONE TRIGGERING MORE BUNDLES POTENTIALLY.>>I THINK IT WOULD BE HARD TO DO SO.>>ALL RIGHT. WE WANT TO THANK YOU FOR COMING. SUSIE, YOU ON THE PHONE. OBVIOUSLY YOU CAN RETURN TO YOUR SEATS AND
WE’LL OPEN UP FOR PUBLIC COMMENTS. WE’VE GOT THREE FOLKS WHO SIGNED UP FOR PUBLIC
COMMENT. AGAIN, DR. DEBAY AND RYAN, APPRECIATE YOUR COMING.>>THANK YOU VERY MUCH.>>SO I WANT TO OPEN IT UP TO MR.DICK KAVATSKI,
CEO OF NET MEDICAL EXPRESS. YOU’RE CALLING IN?>>THANK YOU VERY MUCH. YES, I AM. THANK YOU VERY MUCH. JUST A BRIEF EXPLANATION OF THE TECHNOLOGY
THAT WE DEVELOPED FOR MEDICAL PURPOSES, IN 2001 WE DEVELOPED FDA CLEARED SOFTWARE TO
REMOTELY DIAGNOSE X RAYS. IT’S CALLED K REX. BY 2005 WE WERE EARLY PIONEERS IN TELEMEDICINE
DISCUSSING HOW WE COULD BUILD PRODUCTS FOR X RAYS AND LARGER EXCLUSIONS TO GET HOSPITALS
TO TRANSMIT INFORMATION FROM EMRs. TECHNOLOGY HAD TO UNDERGO INNOVATION TO PROVIDE
SOLUTIONS FOR RADIOLOGY AND 2011, ASSISTING IN CRITICAL CARE AND NEUROSURGERY. WE HAD TO HAVE A WAY TO COMBINE MEDICAL IMAGING
AND VIDEO CONFERENCING TECHNOLOGY TO PLACE A SPECIALIST IN REMOTE LOCATION IN MINUTES
INSTEAD OF PHYSICALLY PLACING THEM IN THE EMERGENCY ROOM. AND OUR AVERAGE TIME TO DO THAT IS ABOUT 17
TO 18 MINUTES. WE HAD TO HAVE A WAY TO COMBINE MEDICAL IMAGING
FOR THE RURAL HOSPITALS BECAUSE WHILE THIS ALL SEEMS COMMONPLACE TODAY, THERE’S STILL
HOSPITALS THAT ARE GRASPING AT HOW TO DO THIS, HOW TO DO TELEMEDICINE. AND WE ALSO HAVE TO DEVELOP LICENSING AND
CREDENTIALING PROGRAMS FOR REMOTE SPECIALISTS, FOR EXAMPLE A CALL CENTER HAD TO BE CREATED,
NOT JUST TO ANSWER THE TELEPHONE. WE NEEDED THE CALL CENTER OPERATORS TO BE
ABLE TO TROUBLE SHOOT THE TECHNOLOGY IF THINGS WENT WRONG WITH CONSULTATIONS AND HAD TO LEARN
HOW TO INTEGRATE INFORMATION BY REMOTE PHYSICIAN WITHOUT SOMEONE TELL THAT SPECIALIST WHAT
WAS HAPPENING TO THE PATIENT. WE SUCCESSFULLY INTEGRATED WITH MULTIPLE EMR
SYSTEMS INCLUDING EPIC, ALL SCRIPTS, NEXT GEN, NOVA SCAN AND MANY SMALLER EMRs. IN ADDITION TO SOFTWARE AND HARDWARE MEDICAL
EMPLOYEES WORK IN CONJUNCTION WITH THE UNIVERSITY SPECIALISTS. THIS IS ABSOLUTELY NECESSARY. HERE IS WHY. IF YOU HAVE SPECIALISTS IN YOUR HOSPITALS,
AND YOU’RE LIMITED TO FIVE, SIX SPECIALISTS, PERHAPS, IN NEUROLOGY, HOW WOULD YOU POPULATE
THOSE SPECIALISTS AT 10, 20 OR 100 HOSPITALS AND TRAIN THEM TO WORK WITH HUNKS OF WORK
FLOWS. YOU HAVE TO CENTRALIZE TECHNOLOGY TO DO TELEMEDICINE. IT GETS MORE COMPLICATED AS YOU INTEGRATE
FDA CLEARED CONDITIONS, SECURITY, HIPAA, MANAGEMENT SOLUTIONS, OPERATE 24/7, 365. SO, OUR TECHNOLOGY IS VERY ADVANCED. IT’S COMPLEX. BUT YET IT’S ALSO IN THE SAME BREATH EASY
TO USE BY THE HOSPITAL CUSTOMERS. WE STRIVE FOR GOOD PATIENT CARE, LIKE PROVIDING
AN OPERATIONAL PROGRAM WITH MANY MODALITIES AND CUSTOMERS. AND THIS IS IMPORTANT, WHAT I’M ABOUT TO SAY,
AND THAT IS WE’RE OPEN TO LICENSE THIS TECHNOLOGY TO OTHERS AS NEEDED BECAUSE EVEN THE BIG EMR
VENDORS HAVE NOT FIGURED OUT HOW TO DO TELEMEDICINE ACROSS MULTIPLE FACILITIES, MULTIPLE MODALITIES
AND SPECIALISTS ALL THE AT THE SAME TIME. IN CONCLUSION WE SUPPORT THE MODEL YOU’RE
REVIEWING BECAUSE IT ALLOWS SMALL BUSINESS AND INDEPENDENT PHYSICIANS TO JOIN A GROUP
TO PROVIDE CLINICAL SERVICES WHERE THAT WERE NONE BEFORE. THANK YOU VERY MUCH.>>THANK YOU. THE NEXT PERSON ON THE PHONE IS DEIDRE KIERNEY,
CLINICAL EDUCATOR FOR UNIVERSITY OF NEW MEXICO.>>GOOD MORNING. I I’D LIKE TO TALK ABOUT THE IMPACT OF CLINICAL
EDUCATION AND QUALITY WITH CHANGE. ONE OF THE INTENTIONS IS TO NOT ONLY DELIVER
HEALTH CARE TECHNOLOGY SUCH AS TELEMEDICINE BUT ENCOURAGED LASTING CHANGE AND PROVIDER
BEHAVIOR AND PRACTICE WITH POSITIVE IMPACT ON HEALTH OUTCOMES, ROOTED IN CLINICAL EDUCATION
AND CLINICAL QUALITY. HOSPITAL STAFF CAN SEE THE CONVENIENCE BUT
REAL LEARNING PARTNERSHIP WITH THE TELEMEDICINE SPECIALIST. A SIGNIFICANT BARRIER TO ADAPTING CHALLENGE,
TECHNOLOGY IS STILL THE APPROACH, CHANGE IS A PROCESS. IT TAKES TIME TO DEVELOP MUTUAL TRUST, RESPECT
AND TREATMENT BETWEEN RURAL PROVIDERS AND SPECIALISTS. PROFESSIONAL RELATIONSHIP IS THE BASIS FOR
A CRITICAL EXCHANGE OF KNOWLEDGE SUCH AS AED, WHEN A PATIENT WITH A DEVASTATING DEFICIT
HAS THE ADVANTAGE OF TWO PHYSICIANS COLLABORATING ON HIS CARE. IT’S ONE THING FOR A SPECIAL ITS TO CONSULT
IN A HEAD INJURY PATIENT IN E.D., TO PROVIDE A PRESUMPTIVE DIAGNOSIS AND TREATMENT PLAN,
AND ANOTHER TO NOW ASK THE RURAL HOSPITAL AND NURSING STAFF TO ADMIT AND TAKE CARE OF
THE PATIENT, CALLS FOR EDUCATIONAL PRIG WHERE KNOWLEDGE IS SHARED TO PROVIDE A COMFORT LEVEL
AND COMPETENCE IN THE CARE. PHYSICAL AS SAYS IS OFFERED ON SITE WITH CLINICAL
STAFF WORKSHOP AND REMOTELY GRAND ROUNDS AND PHYSICIAN TO PHYSICIAN OUTREACH. ACCURACY OF E.D. PRESUMPTIVE DIAGNOSES, APPROPRIATENESS OF
CLINICAL RECOMMENDATIONS, MORE BITTY, LENGTH OF STATE AND FUNCTION, COST AT DISCHARGE. I WOULD LIKE TO CONSIDER A PERSONAL METRIC
OF QUALITY. THAT IS WHAT DOES THE RURAL COMMUNITY, THE
PATIENTS, THE PHYSICIANS, THE NURSES, REALLY SEE AS VALUABLE. HEALTH CARE WAS BEING ADDRESSED, PATIENT SATISFACTION,
HE NOTED NO POINT DIVIDING CLINICALLY EFFECTIVE AND ECONOMICALLY SUFFICIENTLY. THANK YOU FOR THE OPPORTUNITY TO SHARE MY
THOUGHTS.>>THANK YOU. WE HAVE SANDY MARKS, ASSISTANT DIRECTOR FOR
FEDERAL AFFAIRS, AMERICAN MEDICAL ASSOCIATION. SANDY?>>THANK YOU. GOOD AFTERNOON. THE AMA IS VERY ENCOURAGED IN THE LAST SEVERAL
MONTHS THE CENTER FOR MEDICARE AND MEDICAID INNOVATION HAS TAKEN STEPS TO IMPLEMENT SEVERAL
PTAC’S RECOMMENDATIONS. THIS INCLUDES NEW PRIMARY FIRST MODEL FOR
PRIMARY CARE AND PALLIATIVE CARE AND KIDNEY CARE FIRST MODEL, AMA HAS BEEN WORKING CLOSELY
WITH THE PRIMARY CARE SPECIALTY SOCIETIES, CMMI, TO BETTER UNDERSTAND THE DETAILS OF
PRIMARY CARE FIRST, AND PROVIDE FEEDBACK TO THE AGENCY. WE’RE ANXIOUS TO SEE THIS WORK CONTINUE TO
ADVANCE. IT’S BEEN A LONG TIME SINCE PTAC RECOMMENDED
A NUMBER OF OTHER MODELS TO THE SECRETARY. BUT WE HAVEN’T YET SEEN A RESPONSE. THIS INCLUDES TWO MODELS THAT THE AMA SUPPORTED,
THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS PROPOSAL FOR ACUTE UNSCHEDULED CARE MODEL
AND ONCOLOGY MODEL KNOWN AS MASON, MAKING ACCOUNTABLE SUSTAINABLE ONCOLOGY NETWORKS. TIMELY RESPONSES ARE NEEDED. SO THAT OTHER APPLICANTS WON’T BE CONCERNED
THAT THEY MAY BE WASTING TIME, DEVELOPING PROPOSALS THAT ARE UNLIKELY TO BE IMPLEMENTED. WE WANTED TO COMMENT ON PTAC PROVIDING TECHNICAL
ASSISTANCE TO PROVIDERS. THE BUDGET ACT OF 2018 REGARDING FEEDBACK
DID NOT ACCOMPLISH WHAT WAS NEEDED. IN A JOINT LETTER TO CONGRESSIONAL LEADERS
LAST SPRING THEA.M.A. AND 20 STATE AND NATIONAL MEDICAL SOCIETIES RECOMMENDED THAT CONGRESS
MAKE A NUMBER OF TECHNICAL IMPROVEMENTS TO MACRA INCLUDING PROVIDING AUTHORITY FOR PTAC
TO PROVIDE TECHNICAL ASSISTANCE AND DATA ANALYSES TO STAKEHOLDERS WHO ARE DEVELOPING PROPOSALS. WE’RE CONTINUING TO WORK FOR THESE CHANGES
AND URGE THE PTAC MEMBERS TO SUPPORT THEM. THANK YOU.>>THANK YOU, SANDY. WE ARE I GUESS I’LL CHECK WITH THE OPERATOR. ARE THERE ANY OTHER FOLKS ON THE PHONE WHO
WANTED TO CONTRIBUTE? HEARING NONE, THAT IS THE END OF THE PUBLIC
STATEMENTS. ANY OTHER QUESTIONS TO THE COMMITTEE OR WITH
THE COMMITTEE BEFORE WE WOULD MOVE INTO DELIBERATION? HEARING NONE, ARE WE READY TO VOTE ON THE
TEN CRITERIA? ALL RIGHT. SO, LET’S JUST REVIEW REAL QUICK HOW THE VOTING
WORKS. WE’RE GOING TO ASK THROUGH EACH OF THE TEN
CRITERIA WE’LL HAVE THE COMMITTEE VOTE ELECTRONICALLY AND YOU’LL SEE THE RESULTS HERE AS WE GO THROUGH
THE PROCESS A VOTE ARE 1 OR 2 DOES NOT MEET CRITERIA. VOTE OF 3 OR 4 MEANS MEETS, VOTE OF 5 OR 6
MEANS MEETS AND DESERVES PRIORITY. THERE’S AN ASTERISK ALSO WHICH CAN BE CHOSEN,
WHICH MEANS IT’S NOT APPLICABLE. ONCE WE VOTE ON THE TEN CRITERIA WE’LL PROCEED
TO VOTE ON THE OVERALL RECOMMENDATION TO THE SECRETARY, WE WILL USE THE VOTING CATEGORIES
AND PROCESS THAT WE DEBUTED IN DECEMBER OF 2018, WE DESIGNED THESE MORE DESCRIPTIVE CATEGORIES
TO BETTER REFLECT OUR DELIBERATIONS FOR THE SECRETARY AND I’LL GO THROUGH THOSE CATEGORIES
WHEN WE GET TO THAT POINT. SO, IT’S GOING TO BE A LITTLE MORE CLUMSY
THIS TIME AROUND BECAUSE WE’VE GOT TWO PEOPLE ON THE PHONE WHO HAVE TO SUBMIT, AND THOSE
VOTES HAVE TO BE TALLIED. WE APPRECIATE YOUR PATIENCE AS WE GO THROUGH
THE PROCESS. LET’S GO AHEAD AND START WITH THE FIRST CRITERIA
PLEASE. WHICH IS SCOPE. IT’S A HIGH PRIORITY CRITERIA, AND THE AIM
IS TO DIRECTLY ADDRESS AN ISSUE AND PAYMENT POLICY THAT BROADENS AND EXPANDS THE CMS APM
PORTFOLIO, OR INCLUDE ALTERNATIVE PAYMENT MODEL ENTITY WHOSE OPPORTUNITIES TO PARTICIPATE
IN APMs HAVE BEEN LIMITED. SO LET’S GO AHEAD AND VOTE PLEASE. HANG ON. WE’RE ALMOST THERE. NO, I THINK WE’RE GOOD. GRACE HAS TO TALLY ONE. RHONDA, COULD YOU PLEASE TEXT YOUR VOTE TO
GRACE? GRACE’S CELL, WHICH YOU HAVE. THANK YOU. (INAUDIBLE)
I DON’T THINK SO. CALL HER BACK AND WE’LL HAND THE CLICKER TO
YOU, YOU STAY IN COMMUNICATION AND VOTE FOR HER. COULD YOU PLEASE, AMY? GRACE, GIVE HER ONE OF YOURS. THANK YOU. I DID SAY IT WAS GOING TO BE A LITTLE CLUMSY. AS SOON AS SHE RECORDS IT YOU’LL SEE THE NUMBER
GO FROM 10 TO 11 AND THE TOTALS WILL TALLY AND WE CAN MOVE FORWARD. SHE’S ON? OKAY. SO YOU VOTED. IT HASN’T
>>I GOT IT. DID IT COME THROUGH?>>NO, IT’S GOING TO. HANG ON, GRACE. HERE YOU GO.>>I LOVE TECHNOLOGY.>>IT’S A BEAUTIFUL THING. AUTOMATION AT ITS FINEST. WE’RE READY FOR THE RESULTS. SARAH?>>OKAY. FOUR MEMBERS VOTED 6, MEETS AND DESERVES PRIORITY
CONSIDERATION. 3 MEMBERS VOTED 5, MEETS AND DESERVES PRIORITY
CONSIDERATION. 3 MEMBERS VOTED 4. ONE VOTED 3, MEETS. AND ZERO MEMBERS VOTED 1 OR 2, DOES NOT MEET
AND ZERO MEMBERS VOTED NOT APPLICABLE. A MAJORITY IS EIGHT, SO THE SORRY, I’M THINKING
2/3. IN THIS CASE THE FINDING OF THE COMMITTEE
IS THE CRITERION PROPOSAL MEETS AND DESERVES PRIORITY CONSIDERATION FOR THIS CRITERION.>>NUMBER 2, QUALITY AND COST, ALSO A HIGH
PRIORITY CRITERION. ANTICIPATED TO IMPROVE HEALTH CARE QUALITY
AT NO ADDITIONAL COST, MAINTAIN HEALTH CARE QUALITY, DECREASING COST OR BOTH, IMPROVE
HEALTH CARE QUALITY AND DECREASE COST. COULD WE PLEASE VOTE. ALL RIGHT. VERY GOOD. EVERYBODY REVOTE, JUST HIT YOUR NUMBER ONE
MORE TIME IN CASE IT WASN’T CAPTURED. THERE WE GO. THANK YOU.>>ONE MEMBER VOTES 6, MEETS AND DESERVES
PRIORITY CONSIDERATION. FIVE MEMBERS VOTE 5, MEETS AND DESERVES PRIORITY
CONSIDERATION. THREE MEMBERS VOTE 4, MEETS, TWO MEMBERS VOTE
3, MEETS. ZERO MEMBERS VOTE 1 OR 2, DOES NOT MEET. ZERO MEMBERS VOTE NOT APPLICABLE. THE FINDING IS THE PROPOSAL MEETS AND DESERVES
PRIORITY CONSIDERATION.>>NUMBER THREE, PAYMENT METHODOLOGY, AGAIN
HIGH PRIORITY CRITERION, PAY ALTERNATIVE MODELS WITH PAYMENT METHODOLOGY DESIGNED TO ACHIEVE
GOALS OF THE PFPM, ADDRESSES DETAIL THROUGH METHODOLOGY HOW MEDICARE AND OTHER PAYERS
IF APPLICABLE PAY ALTERNATIVE PAYMENT MODEL ENTITIES HOW PAYMENT METHODOLOGY DIFFERS AND
WHY PHYSICIAN FOCUSED MODEL COULD NOT BE TESTED. PLEASE VOTE. ALL RIGHT. ALL RIGHT. HERE WE GO.>>ZERO VOTE 5 OR 6, MEETS AND DESERVES PRIORITY
CONSIDERATION. THREE MEMBERS VOTE 4, MEETS. SEVEN MEMBERS VOTE 3, MEETS. ZERO MEMBERS VOTE 2, DOES NOT MEET. ONE MEMBER VOTES 1, DOES NOT MEET. ZERO MEMBERS VOTE NOT APPLICABLE, THE FINDING
IS THE PROPOSAL MEETS THIS CRITERION.>>THANK YOU, SARAH. CRITERION NUMBER 4 VALUE OVER VOLUME PROVIDE
INCENTIVES TO PRACTITIONERS TO DELIVER HIGH QUALITY HEALTH CARE. PLEASE VOTE. SARAH?>>ZERO MEMBERS VOTE 6, MEETS AND DESERVES
PRIORITY CONSIDERATION. FOUR MEMBERS VOTE 5, MEETS AND DESERVES PRIORITY
CONSIDERATION. FOUR MEMBERS VOTE 4, MEETS. THREE MEMBERS VOTE 3, MEETS. ZERO MEMBERS VOTE 1 OR 2, DOES NOT MEET. ZERO MEMBERS VOTE NOT APPLICABLE. THE FINDING OF THE COMMITTEE IS THE PROPOSAL
MEETS THIS CRITERION.>>THANK YOU, SARAH. CRITERION 5, FLEXIBILITY, PROVIDE FLEXIBILITY
NEEDED FOR PRACTITIONERS TO DELIVER HIGH QUALITY HEALTH CARE. PLEASE VOTE.>>ZERO MEMBERS VOTE 6, MEETS AND DESERVES
PRIORITY CONSIDERATION. TWO MEMBERS VOTE 5, MEETS AND DESERVES PRIORITY
CONSIDERATION. SEVEN MEMBERS VOTE 4, MEETS. TWO MEMBERS VOTE 3, MEETS. ZERO MEMBERS VOTE 1 OR 2, DOES NOT MEET. ZERO MEMBERS VOTE NOT APPLICABLE. THE FINDING IS THE PROPOSAL MEETS THIS CRITERION.>>THANK YOU, SARAH. NUMBER 6, ABILITY TO BE EVALUATED, HAVE VALUABLE
GOALS FOR QUALITY OF CARE COSTS AND OTHER GOALS OF THE PFPM. PLEASE VOTE. SARAH?>>ZERO MEMBERS VOTE 6, MEETS AND DESERVES
PRIORITY CONSIDERATION. ONE MEMBER VOTES 5, MEETS AND DESERVES PRIORITY
CONSIDERATION. SEVEN MEMBERS VOTE 4, MEETS. THREE MEMBERS VOTE 3, MEETS. ZERO MEMBERS VOTE 1 OR 2, DOES NOT MEET. ZERO MEMBERS VOTE NOT APPLICABLE. THE FINDING IS THE PROPOSAL MEETS THIS CRITERION.>>THANK YOU, SARAH. AND CRITERION NUMBER 7, INTEGRATION AND CARE
CARE COORDINATION AMONG PRACTITIONERS AND ACROSS SETTINGS WHERE MULTIPLE PRACTITIONERS
OR SETTINGS ARE RELEVANT TO DELIVERING CARE TO THE POPULATION TREATED UNDER THE PFPM. PLEASE VOTE.>>TWO MEMBERS VOTE 6, MEETS AND DESERVES
PRIORITY CONSIDERATION. THREE MEMBERS VOTE 5, MEETS AND DESERVES PRIORITY
CONSIDERATION. FIVE MEMBERS VOTE 4, MEETS. ZERO MEMBERS VOTE 3, MEETS. ONE MEMBER VOTES 2, DOES NOT MEET. ZERO MEMBERS VOTE 1, DOES NOT MEET. AND ZERO MEMBERS VOTE NOT APPLICABLE, THE
FINDING IS THE PROPOSAL MEETS THIS CRITERION.>>THANK YOU, SARAH. CRITERION NUMBER 8, PATIENT CHOICE ENCOURAGE
GREATER ATTENTION TO THE HEALTH OF THE POPULATION SERVED WHILE ALSO SUPPORTING THE UNIQUE NEEDS
AND PREFERENCES OF INDIVIDUAL PATIENTS. PLEASE VOTE.>>ZERO MEMBERS VOTE 6, MEETS AND DESERVES
PRIORITY CONSIDERATION. FIVE MEMBERS VOTE 5, MEETS AND DESERVES PRIORS
CONSIDERATION. SIX MEMBERS VOTE 4, MEETS. ZERO MEMBERS VOTE 3, MEETS. ZERO MEMBERS VOTE 1 OR 2, DOES NOT MEET. ZERO MEMBERS VOTE NOT APPLICABLE. THE PROPOSAL MEETS THIS CRITERION.>>THANKS, SARAH. CRITERION NUMBER 9, PATIENT SAFETY, AIM TO
MAINTAIN OR IMPROVE STANDARDS OF PATIENT SAFETY, PLEASE VOTE.>>TWO MEMBERS VOTE 6, MEETS AND DESERVES
PRIORITY CONSIDERATION. THREE MEMBERS VOTE 5, MEETS AND DESERVES PRIORITY
CONSIDERATION. SIX MEMBERS VOTE 4, MEETS. ZERO MEMBERS VOTE 3, MEETS. ZERO MEMBERS VOTE 1 OR 2, DOES NOT MEET. ZERO MEMBERS VOTE NOT APPLICABLE. THE FINDING OF THE PROPOSAL IS THAT FINDING
OF THE COMMITTEE IS THE PROPOSAL MEETS THIS CRITERION.>>ALL RIGHT. NUMBER 10, HEALTH INFORMATION TECHNOLOGY,
ENCOURAGES USE OF HEALTH INFORMATION TECHNOLOGY TO INFORM CARE. PLEASE VOTE.>>FOUR MEMBERS VOTE 6, MEETS AND DESERVES
PRIORITY CONSIDERATION. TWO MEMBERS VOTE 5, MEETS AND DESERVES PRIORITY
CONSIDERATION. THREE MEMBERS VOTE 4, MEETS. TWO MEMBERS VOTE 3, MEETS. ZERO MEMBERS VOTE 1 OR 2, DOES NOT MEET. ZERO MEMBERS VOTE NOT APPLICABLE. THE FINDING OF THE COMMITTEE IS THAT THIS
PROPOSAL MEETS THIS CRITERION AND DESERVES PRIORITY CONSIDERATION BECAUSE OF IT.>>ALL RIGHT. DO YOU WANT TO SUMMARIZE THE VOTING AND THEN
WE’LL GET TO THE NEXT PHASE ON THE TEN CRITERION. I THINK ALL THE CRITERION ARE MET. I KNOW A COUPLE WERE MEET AND DESERVES PRIORITY. SO SCOPE AND QUALITY AND COST, AND HEALTH
INFORMATION TECHNOLOGY.>>GREAT. THANK YOU. SO THE NEXT PART OF OUR VOTING WE’RE GOING
TO AGAIN VOTE ELECTRONICALLY BUT THE THREE CATEGORIES THAT WE’RE GOING TO VOTE ON FIRST
ARE NOT RECOMMENDED FOR IMPLEMENTATION AS A PHYSICIAN FOCUSED PAYMENT MODEL, RECOMMENDED,
AND LASTLY REFERRED FOR OTHER ATTENTION BY HHS. WE NEED TO ACHIEVE A 2/3 MAJORITY OF VOTES
FOR ONE OF THESE THREE CATEGORIES, IF A 2/3 MAJORITY VOTES TO RECOMMEND THE PROPOSAL WE
THEN VOTE ON A SUBSET OF CATEGORIES TO DETERMINE THE FINAL OVERALL RECOMMENDATION TO THE SECRETARY. AND THE SECOND VOTE IS FOR THE FOLLOWING FOUR
CATEGORIES. FIRST, THE PROPOSAL SUBSTANTIALLY MEETS THE
SECRETARY’S CRITERIA FOR PFPM AND PTAC RECOMMENDS IMPLEMENTING AS PAYMENT MODEL. SECOND CATEGORY WE RECOMMEND FURTHER DEVELOPING
AND IMPLEMENTING PROPOSAL AS PAYMENT MODEL AS SPECIFIED IN PTAC COMMENTS. THIRDLY PTAC RECOMMENDS TESTING THE PROPOSAL
AS SPECIFIED IN PTAC COMMENTS TO INFORM PAYMENT MODEL DEVELOPMENT. LASTLY PTAC RECOMMENDS IMPLEMENTING PROPOSAL
AS PART OF EXISTING OR PLANNED CMMI MODEL. WE NEED A 2/3 MAJORITY VOTE FOR THESE FOUR
CATEGORIES, BUT NOW LET’S GO AHEAD AND VOTE ON FIRST THREE CATEGORIES, NOT RECOMMENDED,
RECOMMENDED, AND/OR REFERRED FOR OTHER ATTENTION.>>PLEASE VOTE.>>ALL 11 MEMBERS VOTE TO RECOMMEND THE PROPOSAL. WE MOVE INTO THE SECOND STAGE OF VOTING.>>LET’S TAKE A MINUTE TO MAKE SURE WE’RE
ALL SQUARE ON THE CATEGORIES. AND THEN AS YOU’RE READY WE CAN GO AHEAD AND
VOTE. YES, LEN?>>MR. CHAIRMAN, COULD I JUST SAY WHAT I THINK THE
DIFFERENCE BETWEEN 2 AND 3 IS AND SEE IF I GET IT RIGHT? AS I READ 2, IT SAYS YOU PROBABLY ARE GOING
TO NEED ON WORK ON THIS, BUT IT’S SUBSTANTIALLY NOTABLE. WHAT YOU SHOULD DO. CMS HAS DATA, JUST NOT IN THE HANDS OF THE
PEOPLE. NUMBER 3 SAYS WE LIKE IT, THERE’S UNCERTAINTY
HERE, YOU NEED TO TEST IT BEFORE YOU SET PARAMETERS TO DO IT.>>THAT’S MY UNDERSTANDING, YES, I INTERPRET
IT THE SAME WAY. I THINK WE’RE READY TO VOTE. I’M NOT SEEING ANY ACTION HERE. HERE WE GO. HE’S GOT IT ON. HE TURNED IT ON. HE WAS SHUTTING US OUT THERE FOR A SECOND.>>FOUR MEMBERS VOTED TO IMPLEMENT PROPOSAL
AS PAYMENT MODEL. FIVE MEMBERS VOTED FOR FURTHER DEVELOPING
AND IMPLEMENTING PROPOSAL AS A PAYMENT MODEL, WITH PTAC COMMENTS. TWO MEMBERS VOTED TEST PROPOSAL TO INFORM
PAYMENT MODEL DEVELOPMENT. AND ZERO MEMBERS VOTED TO IMPLEMENT THE PROPOSAL
AS PART OF AN EXISTING OR PLANNED CMMI MODEL. SO UNDER THE NEW VOTING CATEGORIES I BELIEVE
UNLIKE THE CRITERION CATEGORIES TO ROLL DOWN, YOU ALL ARE LOOKING FOR 2/3 MAJORITY HERE
WHICH WOULD BE 8. SO RIGHT NOW YOU DON’T HAVE 8 VOTES IN ANY
BUCKET.>>PLEASE, I THINK IT WOULD BE GREAT TO INFORM
OURSELVES WHICH MAY LEAD TO REVOTING. IT WILL HAVE TO. LEN?>>OKAY. SO I VOTED FOR NUMBER 2, BECAUSE IN MY OPINION
IT’S CLOSE. AND WHAT IT NEEDS TO BE FLESHED OUT IS A RICHER
DATASET WHICH I BELIEVE CMS EITHER HAS OR COULD ACQUIRE WITHOUT A GREAT DEAL MORE WORK,
AND THEREFORE YOU COULD TAKE THIS THING TO THE STREET WITH CMS, IF YOU WILL, USING ITS
OWN DATA TO TEST THE PARAMETERS OF THE PAYMENT. IT’S ALL ABOUT THE PARAMETERS OF THE PAYMENT
MODEL. I DIDN’T VOTE FOR NUMBER 1 BECAUSE I DON’T
THINK YOU WANT TO TAKE THOSE NUMBERS IN THAT CHART AND THROW THEM TO THE WORLD. I THINK WE NEED MORE VOLUME CONSIDERATIONS. THERE’S TOO MUCH UNCERTAINTY. IT’S CALLED FAIR MARKET VALUE.>>YOU’RE TALKING ABOUT ECONOMIC NUMBERS.>>THAT’S ALL THAT MATTERS, JEFF.>>SPOKEN LIKE A TRUE ECONOMIST. JENNIFER?>>I’LL MAKE MY LIST OF COMMENTS NOW, AND
SO HAVE LIMITED ONES WHEN WE’RE DONE WITH VOTING. I HAD THE PRIVILEGE OF TAKING CARE OF THREE
ACUTE STROKE PATIENTS ON MY LAST SHIFT WITH MY NEUROLOGY COLLEAGUES. SUBSPECIALTY ACCESS FOR TIME CRITICAL DIAGNOSES
ESPECIALLY WHEN DIAGNOSES AT TIMES ARE CHALLENGING IS CRITICALLY IMPORTANT. AND REGIONAL CENTERS SHOULD LEVERAGE EXPERTISE
BY REMOTE CONSULTATION, SORELY NEEDED IN THE CARE DELIVERY MODELS CURRENTLY. THE REASON FOR THE PROGRAM THAT WE’RE REVIEWING
TODAY WAS A PILOT TO PREVENT UNNECESSARY TRANSFERS, BUT IT’S UNCLEAR TO ME HOW THIS EXAMPLE MAY
SCALE, SPECIFICALLY HOW MANY FACILITIES ARE IN NEED OF THIS UNIQUE LARGE NEED IN THE RURAL
COMMUNITIES WITH ONE ACADEMIC CENTER, AND ALSO THE PRESENTERS DISCUSSED IN THEIR MATERIALS
AN OPPORTUNITY TO SCALE IN THE SUBURBAN/URBAN SPACE, BUT TO ME THAT IS WHY I VOTED FOR MORE
TESTING BECAUSE IT’S UNCLEAR WHAT THAT SCALABILITY LOOKS LIKE. DIGITAL MEDIATED SERVICES ARE DEMONSTRATING
HIGH VALUE TO PATIENT CARE, BUT THERE ARE FIXED COSTS ASSOCIATED WITH IT. THE IMPACT ON COST COULD NOT BE MODELED BECAUSE
SAMPLE SIZE WAS TOO SMALL, THAT’S WHY I THINK THAT TESTING OF THE PILOT NEEDS TO BE DETERMINED
TO SEE IF A PAYMENT MODEL THAT’S BEING RECOMMENDED IS THE RIGHT ONE, IF THE BUNDLE NEEDS TO BE
EXPANDED TO INCLUDE EMS, EMERGENCY CARE PROVIDERS, DRUGS, CLINICAL EDUCATION AS WE HEARD, RADIOLOGY
AND IMAGING SERVICES, OR IF THERE NEEDS TO BE DEFINED QUALITY MEASURES, WHAT IT LOOKS
LIKE IN TERMS OF THE BUNDLE TO ACCESS LONGITUDINAL CONSULTATION, OR MAYBE DEVELOPMENT OF CODES
FOR EMERGENT PATIENT CONSULTATION AND MANAGEMENT SERVICES. IN ADDITION, CMS COULD CONSIDER MEANINGFUL
USE LIKE INFRASTRUCTURE DOLLARS BE PAID FOR THE CREATION OF TELEHEALTH INFRASTRUCTURE
SERVICES, WITHOUT LIMITED FIXED COSTS IN DEVELOPING APMs. THAT’S WHY I RECOMMEND THAT’S WHY I VOTED
FOR 3.>>THANK YOU, JEN. BRUCE?>>I WAS THE OTHER PERSON WHO VOTED 3, LARGELY
BASED ON WHAT LEN SAID BEFORE WE STARTED VOTING WHICH WAS THAT 2 SHOULD BE BASED ON KNOWABLE
INFORMATION THAT’S NOT KNOWN BUT IS KNOWABLE, SO I WASN’T CONFIDENT THAT THAT INFORMATION
WAS IN FACT KNOWABLE, BUT I’M MORE THAN HAPPY TO CHANGE MY VOTE TO A 2, I THINK BASED ON
APPLYING THE STANDARD THAT WE’VE APPLIED TO OTHER PROPOSALS THAT THIS IS PRETTY WELL DEVELOPED,
AS LEN SAID, VERY CLOSE, NEEDS A LITTLE FINE TUNING WITH RESPECT TO VOLUME AND SPECIFIC
PAYMENT NUMBERS. BUT I’M ALSO INFLUENCED BY THE WEIGHT OF THE
SCALE GOING TO THE LEFT AS OPPOSED TO THE RIGHT.>>THANK YOU, BRUCE. TIM?>>SO I JUST WANT TO SAY DR. WEILER’S COMMENTS, I AGREE WITH, THAT’S GOING
TO MOVE MY VOTE FROM THE 1 TO A 2, FOR EXACTLY THE REASONS THAT SHE SAID. I’M ALSO REMINDED OF HAROLD’S POINTING OUT
THE CRITICAL ACCESS HOSPITAL COST BASED REIMBURSEMENT ISSUE. I THINK THAT IS THAT NEEDS TO BE WORKED OUT
HERE AS WELL. THAT’S A REAL ISSUE. AND SO I WILL ON REVOTING WILL BE MOVING MY
VOTE TO A 2.>>THANK YOU, TIM. PAUL?>>YEAH, I VOTED 2, AND, YEAH, I DIDN’T REALLY
HAVE ANY CONCERNS AROUND THE CLINICAL NEED. IT WAS MORE IN LINES WITH LEN AROUND THE PAYMENT
PART NEEDS TO BE WORKED OUT. AND TO JENNIFER’S COMMENTS THAT AMONGST THE
PAYMENT I THINK MAYBE THE BUNDLE COULD BE CONSIDERED MORE BROADLY IN TERMS OF WHAT’S
INCLUDED. AND EVEN BEYOND THE FIRST 24 HOURS SO I THINK
THERE’S OPPORTUNITY FOR DEVELOPMENT THERE BUT I THINK ON THE CLINICAL SIDE THERE’S NO
QUESTION THAT THERE’S A NEED.>>THANKS, PAUL. I JUST WANTED TO MAKE A COUPLE COMMENTS ABOUT
THE MODEL HAVING SUPPORTED INTEGRATED DELIVERY SYSTEM OVER THE STATE OF WISCONSIN AND NORTHERN
ILLINOIS WHERE MANY COMMUNITIES ARE EXTREMELY RURAL TOWNS OF 3000 TO 7000 INDIVIDUALS, GETTING
NEUROLOGY COVERAGE FOR 15 HOSPITALS IN THE SYSTEM WAS CHALLENGING, NEUROLOGY RECRUITMENT
IS A NATIONAL CHALLENGE, GIVEN THE NUMBERS OF AVAILABLE PHYSICIANS. AND WHEN YOU’RE TALKING ABOUT CONDITION WHICH,
AGAIN, HANGS IN THE BALANCE, MEASURED BY MINUTES, IT’S INCREDIBLY IMPORTANT TO BE ABLE TO HAVE
EXPERTS AT YOUR SIDE TO BE ABLE TO HELP YOU IN THESE SMALLER COMMUNITIES WHERE THAT’S
OFTEN A CHALLENGE. THAT SAID, THERE ARE TREMENDOUS NUMBER OF
ELEMENTS OF THE MODEL THAT WOULD NEED TO BE WORKED OUT, NOT THE LEAST OF WHICH IS THE
TECHNOLOGY DEPLOYMENT AND GETTING ALL OF THAT ESTABLISHED AND CONNECTIONS MADE WITH CLINICAL
COMMUNITY. SO MY OVERARCHING POINT MORE WORK TO BE DONE
BUT CLOSE TO THE PIN FOR REASONS ALREADY STATED. THE LAST COMMENT I’LL MAKE IS IT’S NOT ENTIRELY
CLEAR ALTHOUGH I THINK IT’S CLEAR THAT THE TECHNOLOGY IS NOT PROPRIETARY, MULTIPLE SOLUTIONS,
SO HEARING THAT, THAT’S THE END OF MY COMMENTS. GRACE?>>THERE’S THE STATEMENT THAT ONLY CLOSE COUNTS
IN HAND GRENADES AND HORSESHOES. MY FEELING IS CLOSE COUNTS IN SOMETHING BESIDES
HORSESHOES AND HAND GRENADES, I VOTED TO IMPLEMENT. WE WILL NEVER FIND ANYTHING PERFECT ENOUGH,
SOUNDS LIKE CMS IS THE SAME WAY. AND SO IF WE DON’T HAVE THE STANDARD FOR STATING
VOTE TO IMPLEMENT THAT INCLUDES SOMETHING THIS WELL STUDIED, THROUGH THE HCIA AWARD,
DATA BACKING IT UP, RESULTS THEY HAVE, WE’LL NEVER HAVE A NUMBER ONE IN MY OPINION. SO, I WOULD PUT THIS IN THE CATEGORY OF HORSESHOES
AND HAND GRENADES, THAT’S WHY I’M GOING TO NOT CHANGE MY VOTE UNLESS I HAVE TO TO GET
IT TO GO FORWARD.>>I’D LIKE TO POINT OUT GRACE’S MOTHER VOTED
FOR NADIA COMANECI TO GET A 10 WHEN THE FRENCH WOULD NEVER DO THAT.>>WELL, THAT WAS RELEVANT, LEN. OKAY. I THINK IT’S TIME TO REVOTE. I THINK SO. NO, WAIT. RHONDA AND HAROLD, DID YOU HAVE ANY COMMENTS
BEFORE WE VOTE AGAIN?>>WHAT GRACE JUST SAID, I THINK THIS SHOULD
BE IMPLEMENTED AND ON CMS TO DO THE WORK THAT NEEDS TO BE DONE TO GET IT READY, I HONESTLY
DON’T THINK THIS IS A 3. I’M WORRIED ABOUT PUTTING IT IN THE 2 CATEGORY,
AND IT NEVER SEEING THE LIGHT OF DAY. THIS ACTUALLY NEEDS TO MOVE FORWARD. THANK YOU.>>HAROLD?>>I VOTED 2, AND I’M STICKING WITH IT. I THINK THAT THE I THINK THE CLINICAL MODEL
IS BADLY NEEDED. I THINK THAT TRYING TO DO IT ACROSS THE COUNTRY
BROADLY IS NECESSARY BECAUSE MANY PLACES NEED IT AND THE ONLY WAY TO REALLY BE ABLE TO GET
ENOUGH SCALE TO TELL WHAT’S GOING ON IS TO DO IT BROADLY. BUT I DO THINK THIS PARTICULAR PAYMENT MODEL
THAT’S PROPOSED WAS DESIGNED TO WORK FOR THIS PARTICULAR SITUATION, WHERE WE HAVE THE UNIVERSITY
OF NEW MEXICO THAT IS WILLING TO DO THE SERVICE IN THIS PARTICULAR FASHION, AND IN THAT CIRCUMSTANCE,
I THINK IT DOESN’T REALLY MATTER QUITE WHO IS BILLING FOR IT. BUT I DO THINK IF ONE EXTENDED THIS ACROSS
THE COUNTRY THERE WOULD BE REAL ISSUES AS TO WHAT IT IS THAT A PARTICULAR HOSPITAL WAS
USING THE MONEY TO PAY FOR, AND I THINK THAT IT’S PUTTING TRULY AN INAPPROPRIATE BURDEN
ON THE HOSPITAL TO SAY THAT THEY WOULD THEN HAVE TO TRY TO JUSTIFY TO CMS THAT THEY WERE
USING THE SERVICE, USING THE PAYMENT FOR APPROPRIATE SERVICE. I THINK THE SERVICE PROVIDER NEEDED TO DO
THAT. THAT DOES NOT DISAGREE WITH APPLICANT’S PROPOSAL
THIS HAS TO ORIGINATE FROM THE HOSPITAL. I THINK THAT THE CENTRAL PROVIDER SHOULD ONLY
HAVE TO OWN BE ABLE TO BILL IF IN FACT A HOSPITAL, RURAL HOSPITAL, HAS REQUESTED THE SERVICE. BUT THAT’S WHY I PUT IT IN THE CATEGORY 2. I THINK IT NEEDS TO MOVE FORWARD. I THINK IT NEEDS FURTHER DEVELOPMENT. I DON’T THINK IT NEEDS TO BE TESTED. I THINK IT’S BEEN TESTED. I THINK THE PARTICULAR PAYMENT MODEL BEING
PROPOSED IS NOT ADEQUATE OR APPROPRIATE FOR IMPLEMENTATION ACROSS THE COUNTRY.>>THANK YOU, HAROLD AND JEN HAD ANOTHER COMMENT.>>ALTHOUGH I LOVE SUSPENSE, IT IS TIM’S LAST
MEETING, SO I DIDN’T WANT HIM TO WORRY ABOUT WHICH SIDE OF HORSESHOES OR HAND GRENADES
THAT I WAS ON. SO I’M PERSUADED, I THINK WE’RE SPLITTING
HAIRS PERSONALLY, WE’VE TALKED ABOUT THIS BEFORE WITH OTHER VOTES, BETWEEN 3 AND 2,
TESTING IN MY DEFINITION IS SCALABILITY COMPONENT WHERE FURTHER DEVELOPMENT AND IMPLEMENTATION
AND SCALING I CAN BE PERSUADED, FRANKLY, MEAN THE SAME THING. I’M NOT PERSUADED TO VOTE FOR 1, BUT I WILL
MOVE TO 2.>>ALL RIGHT. BEFORE WE VOTE, THE DFO REMINDED ME THAT KAVITA
AND ANGELO HAVE BEEN RADIO SILENT.>>MORE THAN HAPPY TO SPEAK. SO I’LL REMIND PEOPLE I COME FROM SOUTH CAROLINA,
CAN’T TELL BY MY ACCENT WHICH IS A VERY RURAL STATE, MAYBE THREE CENTERS CAN PROVIDE THIS
NEUROLOGICAL SUPPORT, ALL THE REST OF THE HOSPITALS ACROSS THE ARE SMALL RURAL HOSPITALS,
THEY WIND UP SENDING TONS OF STUFF TO THESE THREE HOSPITALS THAT COULD HAVE STAYED WHERE
THEY WERE. AND/OR SHOULD HAVE GOTTEN INTERVENTION EVEN
IF THEY WERE GOING TO BE TRANSFERRED SO I AGREE WITH GRACE’S COMMENT, THIS ISN’T PERFECT,
BUT IT’S BETTER THAN WHAT WE’VE GOT TODAY AND IF THEY DEVELOP IT AND WE FIND OVER TIME
THIS IS THE DIRECTION WE NEED TO GO, I VOTED 2 TO BEGIN WITH, THAT’S WHAT I’LL VOTE AGAIN
PROBABLY.>>KAVITA?>>I CAN’T BELIEVE YOU’RE ENCOURAGING ME TO
TALK. I HAVEN’T SAID ANYTHING BECAUSE I VOTED 2
MOSTLY FOR EXACT SAME REASONS LEN ARTICULATED. THIS IS PROBABLY OUR BIGGEST CRISIS IN THIS
COUNTRY, NOT JUST RURAL ISSUE BUT THE DIVIDE BETWEEN ACCESS TO RESOURCES, VIS A VIS SUBSPECIALISTS
AND SUPER SPECIALIZED TREATMENT, SO I THINK THIS NEEDS TO BE SOMETHING CMS DOES EVEN IF
PTAC DIDN’T EXIST AND I’M HAPPY THERE’S A MODEL IN FRONT. THE ONLY REASON I DIDN’T PUT IT AS 1, I DON’T
WANT SOMEONE TO TERM WE THINK ECONOMICS TRANSLATE FOR CRITICAL ACCESS. THAT’S IT.>>HAVING HEARD FROM THE FULL BODY, WE’RE
READY TO VOTE ONE MORE TIME WITH FEELING. OOPS, BACK SEAT DRIVING. HOLD THAT THOUGHT. HERE WE GO. WHOA. IS THIS IT? WE’RE GOOD TO GO? ALL RIGHT. HERE WE GO. SARAH?>>SO TWO MEMBERS HAVE VOTED TO IMPLEMENT
PROPOSAL AS PAYMENT MODEL, NINE MEMBERS VOTE TO FURTHER DEVELOP AND IMPLEMENT PROPOSAL
AS PAYMENT MODEL, AND ZERO MEMBERS VOTE TEST PROPOSAL TO INFORM PAYMENT MODEL DEVELOPMENT,
AND ZEROES VOTE IMPLEMENT AS PART OF EXISTING OR PLANNED MODEL, FINDING OF THE COMMITTEE
TO RECOMMEND FURTHER DEVELOPING AND IMPLEMENTING PROPOSAL AS PAYMENT MODEL AS SPECIFIED IN
PTAC COMMENTS.>>THANK YOU, SARAH. AND WE HAVE WHO IS RECORDING THE COMMENTS
FOR THE SECRETARY’S RESPONSE? GREAT. SALLY. SO LET’S JUST MAKE SURE, I KNOW A LOT OF US
MADE SOME PRETTY DIRECT COMMENTS BUT IF THERE ARE ANY COMMENTS, I’LL START WITH YOU, TIM,
THAT YOU WANT TO MAKE SURE GET READ IN.>>NO ADDITIONAL COMMENTS.>>I HAVE NO ADDITIONAL COMMENTS.>>LEN, YOU’RE GOOD?>>WELL, I DON’T KNOW HOW TO SAY THIS BUT
I’LL JUST SAY THE TWO CLINICIANS ON THE PRT VOTED 1, SO THAT’S PRETTY STRONG, I’LL JUST
SAY.>>ONE OF THE SPEAKERS WHO WAS TALKING ABOUT
THE TECHNOLOGY THAT UNDERLIES THIS REALLY TALKED ABOUT IT BEING A UNIQUE SOLUTION TO
THE VIS A VIS CURRENT TECHNOLOGY WITH DISPARATE EMR AND SOLUTIONS. THE POINT WAS MADE, NEEDS TO BE PUT IN THE
COMMENTS, THAT IT’S NOT EXCLUSIVE TO THAT PARTICULAR VENDOR, BUT THE ACTUAL PROBLEMS
THAT THE VENDOR TALKED ABOUT IN THOSE PUBLIC REMARKS, I THINK, WERE GOOD WITH RESPECT TO
THE PORTION THAT’S ON THE HEALTH INFORMATION TECHNOLOGY COMPONENT. IN THE PAST, WE’VE HAD PROPOSALS WHERE THE
H.I.T. WAS ALMOST AN ALSO, AND THIS ONE ACTUALLY
IS HIGHLY DEPENDENT ON IT, AND ACTUALLY THE TECHNOLOGY ITSELF, UNTIL IT WAS DEVELOPED
AND EXISTED, YOU KNOW, THIS TYPE OF THING WOULDN’T BE POSSIBLE. SO I THINK THAT AS WE’RE TALKING, COMMUNICATING
WITH THE SECRETARY IT WOULD BE USEFUL TO LISTEN TO THE COMMENTS THAT WERE THAT THE VENDOR
TALKED ABOUT, PARTICULARLY AS IT RELATES TO THE TYPES OF THINGS, NOT NECESSARILY THEIR
TECHNOLOGY SOLVES FOR THAT PREVIOUSLY HAD NOT BEEN SOLVED FOR.>>THANK YOU, GRACE. THERE’S A SMALL HOUSEKEEPING ISSUE. WE JUST NEED TO KNOW WHO VOTED IN THE 1 CATEGORY,
IT WAS YOU, GRACE, POSSIBLY>>RHONDA AND I.
>>I THOUGHT RHONDA DID. LIKE I SAID, SARAH, I TOLD YOU IT WAS RHONDA
AND GRACE. ALL RIGHT. I HAVE NO ADDITIONAL COMMENTS OTHER THAN THIS
IS A REALLY ELEGANT MODEL AND I WANT TO COMPLIMENT SUBMITTERS FOR YOUR HARD WORK TO MAKE THIS
HAPPEN AND THE IMPACT THAT YOU’RE DESCRIBING IS TREMENDOUS WHEN YOU CAN GO FROM 80% BEING
REFERRED OUT TO ACTUALLY REVERSING THE NUMBERS. IT’S AMAZING. THIS KIND OF APPROACH CAN BE USED FOR LOTS
OF OTHER DISEASE STATES AND, AGAIN, ONCE THESE RURAL HOSPITALS COLLAPSE YOU WILL NEVER HAVE
THEM COME BACK INTO THE COMMUNITY SO THESE ARE ASSETS THAT REALLY WE NEED TO BE VERY
PRUDENT ABOUT TRYING TO PRESERVE, SO I COMPLIMENT YOU AGAIN FOR YOUR EFFORTS. THANK YOU.>>I’D LIKE TO COMPLIMENT, SOMETHING THAT
WASN’T I’D LIKE TO COMPLIMENT YOU FOR USING QUALITY ADJUSTED LIFE YEARS AS A MEASURE OF
IMPACT. I WISH WE WOULD DO THAT MORE OFTEN, THAT OTHERS
WOULD DO IT MORE OFTEN. LAST, SALLY, WHEN YOU WRITE UP THINGS WE’VE
IDENTIFIED NEED TO BE DEVELOPED, PLEASE DO IT IN A VERY POSITIVE WAY. NOT ONLY THAT WE THINK IT’S GOOD THE WAY IT
IS, IT CAN BE MADE A LITTLE BIT BETTER, AND IT’S VERY DOABLE.>>NO COMMENT OTHER THAN TO SAY THIS IS NOT
JUST RURAL WHERE THERE’S A NEED BUT SUBURBAN AND EVEN IN MANHATTAN I CAN SEE A NEED FOR
THIS.>>JEN, ANYTHING ELSE?>>MY LAST COMMENT IS AROUND SCALABILITY TO
OTHER CLINICAL CONDITIONS. I THINK WE SHOULD COMMENT THAT WE SEE THAT
THE OPPORTUNITY AS IS DESCRIBED TO PROVIDE SUBSPECIALTY EXPERTISE IN TWO FACILITIES DOESN’T
EVEN HAVE TO BE REGIONAL OR GEOGRAPHICAL OR BASED ON CENSUS, BUT ACCESS TO FACILITIES
DON’T HAVE RESOURCES WE SHOULD BE THINKING ABOUT PAYMENT MODELS THAT INCENT THAT DELIVERY
OF KNOWLEDGE FOR ALL THE REASONS THAT I LOVE THAT GRACE EXPLAINED WHY THIS IS PATIENT CENTERED.>>THANK YOU.
AND ANGELO?>>AGAIN TO COMPLIMENT THE TEAM, I THINK IT
WAS A GREAT PROPOSAL, SOMETHING THAT USUALLY NEEDED ACROSS THE COUNTRY. AND AT LEAST IN OUR SYSTEMS WE’RE TRYING TO
FIGURE OUT HOW TO DECAN’T OUR TERTIARY CENTERS AND KEEP AS MANY PATIENTS OUT IN THE RURAL
HOSPITALS AND COMMUNITY HOSPITALS AS WE CAN, SO I THINK THIS IS A GOOD FIRST STEP TOWARDS
THAT.>>THANK YOU, ANGELO. HAROLD AND RHONDA?>>RHONDA?>>I WANT TO THANK THE PRESENTERS, THE PERSONS
WHO ACTUALLY CREATED THE PROPOSAL ITSELF, THE CLINICIANS AND CAREGIVERS WHO ARE TAKING
CARE OF A POPULATION THAT IS BOTH VULNERABLE AND IN GREAT NEED. I REALLY, REALLY HOPE THAT THIS DOES NOT GET
BOGGED DOWN, DOES NOT GET LOST, AND THAT EFFORTS ARE MADE TO DO WHATEVER STUDY IS NEEDED TO
GET IT OUT THE DOOR AND ACTUALLY TAKING CARE OF PATIENTS. I THINK EXPANSION TO OTHER AREAS, GEOGRAPHICALLY
AND CLINICALLY WOULD BE A GREAT THING BUT I WOULD HOPE WE WOULD NOT DELAY THE ACTUAL
DELIVERY OF THIS TYPE OF ADVANCED CARE COORDINATION TO THOSE IN RURAL COMMUNITIES TODAY AS THOSE
WHO HAVE TIMELY RESPONSE TO CEREBRAL INJURIES THAT NEED TO BE ADDRESSED NOW. THANKS.>>I WOULD LIKE TO ENDORSE WHAT THIS IS HAROLD
WHAT RHONDA SAID. THIS NEEDS TO MOVE FORWARD QUICKLY. WE’VE NOT HAD A GOOD EXPERIENCE SO FAR IN
TERMS OF PROPOSALS WE’VE RECOMMENDED STRONGLY MOVING FORWARD AND I THINK THIS IS URGENT
FOR CMS TO TAKE ACTION ON. I WANT TO THOUGH EMPHASIZE I THINK THAT MORE
ATTENTION NEEDS TO BE GIVEN TO INCORPORATING THE QUALITY COMPONENT TO THIS, THAT ONE CAN
EVALUATE IT IN THE SHORT RUN AS TO HOW WELL IT WORKS BUT IN THE LONG RUN THERE HAS TO
BE SOME WAY OF ASSURING IT CONTINUES TO DEVELOP QUALITY CARE AND I DON’T THINK THAT SIMPLY
RELYING ON EITHER ACCREDITATION OR CERTIFICATION DOES THAT. I THINK THERE IS THE POTENTIAL FOR HARM FROM
THIS, AS THERE IS WITH ANY SERVICE, AND I THINK IF WE’RE APPROVING A PAYMENT MODEL RATHER
THAN ADDITION TO FEE SCHEDULE THAT THERE NEEDS TO BE SOME COMPONENT AND SPECIFICALLY THAT
TRIES TO ASSURE THERE IS HIGH QUALITY CARE BEING DELIVERED. THAT’S ALL. THANKS.>>AND THIS IS GRACE TERRELL AGAIN. IN RESPONSE WHO WHAT HAROLD SAID ABOUT QUALITY
ONE THING THAT HAPPENS IN THE NON MEDICARE PRIVATE PAYER WORLD IS CONCEPT OF CENTERS
OF EXCELLENCE WHERE THEY HAVE PROVEN EXPERTISE AND EXCELLENCE AROUND A PARTICULAR SET OF
SKILLS FOR WHICH ONLY THEY ARE CONTRACTED, UNTIL SOMETHING BECOMES MORE WIDESPREAD. PERHAPS WE COULD TALK ABOUT IN OUR COMMENTS
TO THE SECRETARY THAT CMMI OR MEDICARE EXPLORE THE CONCEPT OF CENTERS OF EXCELLENCE WITH
RESPECT TO THIS, AS PART OF PAYMENT MODEL, TO ACTUALLY ADDRESS SOME OF THE ISSUES AROUND
QUALITY THAT HAROLD AND OTHERS HAVE BROUGHT UP.>>THANK YOU, GRACE. I’D LIKE TO CHECK IN WITH YOU, SALLY, AND
MAKE SURE THAT YOU DON’T HAVE ANY QUESTIONS FOR THE COMMITTEE BEFORE WE SIGN OFF HERE.>>NO. I THINK THE DISCUSSION AND POINT HAVE BEEN
CLEAR. THERE’S UNANIMOUS ENTHUSIASM GIVEN THE IMPORTANCE
OF THE PROBLEM, THERE’S A LOT OF ENTHUSIASM FOR THE SUBMITTER’S MODEL AS POSSIBLE SOLUTION. I’LL NEED NEED FOR TESTING AND DEVELOPMENT
WITH, TO ASPECTS OF PAYMENT MODEL AMOUNTS, ISSUE OF REPLICABILITY OF ALL THE ISSUES ABOUT
QUALITY AND I’LL MAKE REFERENCE TO CENTERS OF EXCELLENCE. ALSO DEFINITIONS OF THE BUNDLE, AND THEN I
WILL MAKE TWO POINTS IN PARTICULAR, THE VALUE OF THE TECHNOLOGY PLATFORM FOR THIS PARTICULAR
APPLICATION, AND THE POTENTIAL FOR EXTENSIONS TO OTHER AREAS.>>GREAT. THANK YOU, SALLY. THANK YOU FOR YOUR SUPPORT OF THE PRT. I WANT TO THANK EVERYBODY ON THE COMMITTEE
FOR HELPING US GET THROUGH THIS IMPORTANT PROPOSAL REVIEW. AGAIN, MY ACKNOWLEDGMENT OF SUBMITTERS FOR
PUTTING THIS FORWARD, IT’S FANTASTIC, I LOOK FORWARD TO HEARING ABOUT IT AND WILL USE YOUR
BEST EFFORTS TO MAKE SURE THE SECRETARY UNDERSTANDS THE IMPORTANCE OF MOVING FORWARD ON THIS. AGAIN, THANK YOU, EVERYBODY. FOR THAT, WE’RE ADJOURNED.

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