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Innovations in Neurosurgical Practice, Part I: Co-Management Models with Hospital

Dong H Kim

February 09, 2018

Transcript

- Hello, ladies and gentlemen and thank you for joining us for another session of the AANS Grand Rounds. Today, we have Dr. Dong Kim, he's the Chairman of Neurosurgery at University of Texas, Houston and Director of the Mischer Neuroscience Institute. He's going to talk to us about two topics of extreme importance. The first one is a discussion regarding financial relationships and core agreements with the hospital in terms of improving the collaboration for the hospital system and the neurosurgical group. And the second topic would be related to quality control, including service line management, as well as core management agreement with the hospital, as well as ACOs, more cutting edge models for providing neurosurgical care. I look forward to your expert comments.

- Thank you so much, Aaron. I appreciate the opportunity to do this and you've developed such a excellent webinar series that it'll be a pleasure to add to it. Today I'm going to go over very briefly, this is my financial disclosures, the backdrop and why we've made some of the changes we have here and then explain what's happened in our program and then hope to give you real life examples of what we did that you might find useful. Now I'm gonna have a fair amount of information in these slides and because this is a webinar and you can stop it at any time, I'm not gonna go through all of that and some of that you can look at on your own. So there's a cycle of assumptions that's driving healthcare change in the US and the main one involves the thought that healthcare is too expensive and it's low value. As a result, there's a need to measure the quality of care, there is a lot of variation when that care is measured and the assumptions that we're living under now is it if the care is standardized and positions incentives change and both the quality and cost while improve. Now, whether these assumptions are true or not, the policymakers believe that they are true. And as a result, we have major shifts happening in our healthcare system. A large one is that more patients are going off to capitation or restricted networks, free for service remains, but reimbursements are dropping and it's especially worse when you factor in inflation. More and more, our compensation is tied to quality data or salary in hospitals and administrative and regulatory challenges are increasing. Finally, there are more and more large entities forming. And a lot of this is putting stress on our practices. Now it's true that the country is very heterogeneous and different things are happening in different places, but those are really major trends. So the result is that our practices are under stress. One thing I would contend is that increasingly it's very hard for us to just live on professional fees. The quality and value of our work is being judged by more and more people. And the big question is how do we manage that and get ahead of that, so that's helpful to us. Small providers and small systems lack leverage increasingly. So what can you do if you're a solo practitioner? And more and more people are under pressure to be on one team. The doctor that used to go to many hospitals, it's harder to maintain that now. So the result is that all kinds of practices are changing, but the main one is this solo and small groups are disappearing and that our autonomy is threatened. Of course, for us we always have to think about how do we maintain our research and education mission in this environment. So in this presentation I want to tell you briefly what's happening in our program and go over real world changed new initiatives that we've done to adjust. And I'm hopeful that that will be helpful to you. And we try in this environment to maintain our core values to patients education and research. So this is the Texas Medical Center in the foreground with downtown Houston in the background. And I wanted to give you a little backdrop about Houston, because of course, most things are local. Now, Houston is still a small group dominated referral driven market, just quit unlike, say Boston, where I came from previously, and many hospital systems, all insurance companies are here and physician still by and large determine referrals and that's been a big advantage for us, but more and more employers are looking for a one entity, one contract in our restrictive networks. So things are changing here too. Over the last nine years here, when I took over in October, 10 years now, 2007, I had a different job than the typical UT Chair, 'cause I was asked to try to develop neurosciences for the whole system at Memorial Hermann. That probably changed my thinking and approach and it was 11 hospitals, that it's a 16 hospital system that has about 25% Houston market share. It was a small department at that time. Our biggest issues were probably that we had no residency, which made recruiting difficult and there's very little teaching, very little research or quality initiatives. And our program at that time was at our Texas Medical Center or TMC location only and no other place. So over 10 years, this is what our program looks like now. We have 63 clinical faculty, all told I've recruited about 100 faculty, and we have many different specialists financially in our group, research faculty residents, and so on. So it's been a fair amount of growth and we're in 22 different locations across the City of Houston. And we've also had a significant program expansion. And I want to kind of explain to you how that happened here and some of the things that might help you. So this is the change in our case volume over that time. More recently, we've been growing just as quickly outside the TMC, as within and both programs have become very important. And about halfway in our market share had increased significantly above what the hospital was doing. These are data from the Texas Hospital Association we hit just under 30%, but now in this last year we had almost 40% Houston market share for neurosurgery. Our education programs have expanded quite a bit. We were approved to go to a one-year program in 2008. And then we were approved to go to a two-year program in 2010. And currently we're matching three residents a year. Dr. Arthur Day came as Program Director in 2010 and has done a great job. We're now part of a surgery rotation, as well as a neurology rotation, and recently we have fellowships. So the result is that the education program went from very little to a lot of activity and this is the heart of our clinical enterprise is to teach the next generation. And similarly, we've had a very large expansion of laboratories, clinical trials, grants and in 2017 our research budget is going to be about $7 million when we finish up the year. I would say that keys to us was partnership and support from both the medical school and the hospital. And I'll explain how we set that up and why that was possible. We also have a unique financial and governance structure for our physician group. The approval of the residency and fellowship program and the enhanced research enterprise is very important to recruiting the best people and building our programs. But we did have these specific projects that I will go over with you that helped us tremendously. So what about hospital physician relationships and what are the different things that are possible? So I'm going to go through a brief overview of the legal background and what's different now. There are a variety of relationships that neurosurgeons have with hospitals and what regulates it has almost entirely been two laws, the Stark and Anti-Kickback Statute. And then more recently the Affordable Care Act and the ACO has affected this. You can read this, I don't need to go over it. But the main thing that as you all probably know already is that hospitals can not pay physicians for referrals or bringing patients. And they also can not be involved in any kind of profit sharing. And that severely limits the kind of financial relationships that neurosurgeons can have with hospitals. Now, more recently, there is an exception to this and that's under the umbrella of the ACO and the Medicare Shared Savings Plan. These relationships even affect academic groups, like medical schools that are date specific set of differences called the academic exception, which I don't need to go into too much detail. But when they started trying to do the Medicare Shared Savings Program, which I'll describe later, well, the idea is if the healthcare entity or an ACO can save money for CMS, they will split those savings with a doctor or healthcare entity. That went directly against the concepts embedded in Stark and AKS. Therefore there has been a specific waiver that the federal government has cut out that ACO programs structured in the lightweight are exempt. And that is a important regulatory distinction that I will describe to you later and can be very useful. So these are the different options and the main legal element that defines a relationship or ownership of the physician and his clinical time and practice is the taxpayer ID. Whose taxpayer ID one bills under has a lot of ramifications. So we'll go through that as we describe these relationships. Everybody is familiar with the independent practitioner. You run your own practice, you bill with your taxpayer ID, you have complete autonomy and that's it. Now on top of that, there can be a physician service agreements, those are copay, those are specific agreements of a hospital paying you to do something, it's gotta be evaluated and that's a very common approach. And within that rubric, co-management agreements were possible. Now we ran a co-management agreement and I'll talk about that later, but largely that's been superseded by the ACO legislation. Hospital, I'm gonna spend a little bit of time on the CIN or this is an IPA, this is a hospitals sponsored clinically integrated network. The idea is that the hospital provides organization EMR services to integrate the practice of an independent physician or group of independent physicians who would have their own taxpayer ID, but can work with a hospital to improve quality, for example, or reduce length of stay. Now regulatorily, if you do that and form a CIN, you can easily contract together as one entity, which means all these different practitioners with different taxpayer ID can band together and negotiate one contract, because one of the big issues of private practice is the lack of leverage with insurers. The problem with this is that while it is allowed that you can contract together, there's no mandate that the insurer has to contract with you. So many IPAs have fail because insurance companies will not do a single contract as is to their detriment often. And so it really depends on the political leverage of each individual CIN or IPA. Position employment is the ultimate integration because you are fully, you use the hospital's taxpayer ID. And as an employee is what's called a bonafide exception to Stark and Anti-Kickback. So you one financial entity, therefore you can't be referring cases to yourself. Now, this gives a lot of flexibility and legal protection, but raises the question of autonomy, who are you reporting to and who's making the decisions. So the last part is an interesting concept, which some of you may have heard of which we have used extensively. And this is a concept called leasing. In a lease a physician can retain their practice or their assets or their name or their staff, even their clinic if they own it, but their clinical time, only their clinical time can be leased to another entity like a hospital. When that's done, you have to use the hospital's taxpayer ID or a taxpayer ID owned by the hospital. And on legal terms what that means is you are financially one entity with the hospital. So it's like being employed, except that you can maintain a separate identity. It can be an intermediate step between a fully independent practice or an appointment. This was largely used for a private practice physicians who are thinking about joining the hospital. You can therefore go into a lease agreement, see how it works. If it doesn't work well, you can go back to your practice. You would have to then re-contract with an insurer. And that's where the concept originated. Our use of a lease was a little different. We did use this exact model for some of our physicians, but we may have been the first and still only academic group to use the lease to integrate with the hospital. So here's just a summary of the relationships. Before I talk about our specific model. In private practice, as you can see you own everything, but things like billing who owns the assets, IT staff, private practice, you own all of them. For an IPA or a CIN, you own most of it, but in a leased employment model, you still have to bill through the hospital like full employment but you can own your own assets and name hence that can be separate. So there are issues with all of these different practice situations. There's nothing that's perfect. In private practice we mentioned already that contracting leverage, but it's becoming increasingly difficult to meet regulatory burdens for a small start up. With CIN, all these different independent physicians governing themselves and moving in one direction can be different. Academic practice often has issues with supporting less viable departments in the medical school and how much autonomy each chair is granted can be variable. And with an employment model, often you're working with an administrator and not another neurosurgeon and the way they choose to pay you can be very difficult and they'll usually hire people and at a higher salary and that can get degraded over time. So nothing is perfect. And in our situation, we tried to create, nine years ago, a model that would give us a lot of the benefits of each system and try to minimize some of the drawbacks. So we created this entity called Mischer Financial Associates. It's a subsidiary of the hospital. So the Memorial Hermann Hospital System owns the taxpayer ID, but it's a separate taxpayer that we have for ourselves. And we set it up with a separate governance board and set to be run by myself and an administrative leader. We then have the option of coming into the MNA in three different ways. The main that we started was to lease all the UT neurosurgeons into the MNA. So while we were hired through the university, we are full faculty members and we get our paychecks through the university. Our clinical time is leased into the MNA. In addition, as our program has grown, we've been able to hire physicians directly into the MNA, that's the hospital employment model, but they work with us as our partners 100% and they're administered through a self-governing position group and not really reporting to hospital administrators. And finally, I have recently allowed good private practice groups that want to leave for solo situation, how the benefits of joining our group, lease their clinical times and their time, but maintain their own practices and their own identity. So those are the three different ways physicians join us. And the result is that currently about 40% of our faculty are full-time UT, about 40% are directly employed to the MNA and have about 20% private entities. We had to get approval from the UT regions for this. So this is not something you can just do and the President and Dean of the Medical School is very supportive of this now. And that's why, when I showed you this slide earlier about all the different specialists in our group, they all have come in under this kind of model. Now, what are the advantages for us? I think the big one is that we are as much as possible. Of course, I have a boss, we have to get approval from the hospital system for certain things, but we are self-governed. And we run as a lot of physician and administrative engagement. We see ourselves as partners, we have a separate board that really helps us maintain independence and autonomy. We do remain the core UT Department of Neurosurgery with all the resources and protection of the university. And we need that for our academic mission. We also pay a reasonable Dean's tax, which we should as good citizens of the school, but this also allows non-academic physicians, and I have brought on some neurosurgeons who had bad experiences at other medical schools, and specifically did not want to be in the medical school setting, come in as a hospital employed physician but still be in our group. And then private practice, good private practitioners, covering mainly neurologist. Now, you might ask, why would they wanna join us? On Houston right now our contracts are probably 30 to 40% better than the contracts they have in a small group. So when they join, they automatically get bump in revenue for the same work. Plus we provide a lot of administrative and IT support. It takes a lot of things they don't want to do off their hands and they are able to maintain their practice, including their own name they like. We also have the benefit of professional managers, all of our managers are 100% involved with us and work as one team. And the result has been that we've been able to recruit a lot of great people with high retention and satisfaction, and we can move in one direction quickly without the silos or interdepartmental fighting and I'll be talking about that motivator. And finally, I think this is a win, win, win type situation. So Aaron, I'd like to stop there and get your thoughts and...

- Very impressive, no doubt, I really liked the idea. I have a couple of questions and these are the ones we have challenges with here. Number one is, are you the only department in your university that has this kind of agreement or is there other departments have such? Because there'll be a sense of jealousy almost that why should neurosurgery have that and not the other department?

- Yes, that's a very perceptive question because that is very true and something I deal with quite regularly. We are the only department that has this arrangement. It's possible that as this evolves, this could be a model for other departments. Both the department chair and the school and the hospital have to consent to it. In reality, the only reason this was possible, I believe is because when I was looking to take this position, the department was quite small and surprisingly from a surgery department losing a lot of money at the time. So when I proposed this in and I proposed this as a condition of my coming, because I felt like we needed something special to go full on, meaning, thinking about all the things that were coming in healthcare, it was part of my startup package, so to speak, that I could have this arrangement. That's how it started. We did get Regents' approval for a initial five-year pilot. And then everybody felt that it was successful. So I got an ever agreement renewal, which really helps us, in that you know that it's a solid foundation. Other chairs have wanted it. And I have felt in some instances that we're different, and why are they getting to do this and we're not? But on the other hand, we also take on a lot as you'll see about taking care of neuroscience across the whole system or staffing other hospitals, and a lot of UT teachers don't have to deal with, they are more concentrated at the TMC, so there's positives and negatives to everything, but you're exactly right, that it started as a one-off and it has remained a one-off. And that can provide an inherent credit at some point, if the school or the hospital decided not to carry this forward. But I think that currently lots of things are going on as long as we do well, the physicians are happy that it will be sustainable. The other thing is everybody was brought in under this model, so for us to change it would be a big deal. We have specific compensation plans, structure, all of these things are set up. So I don't think it would be easily disengaged.

- And the other question, which is also very important is obviously you use your leverage. You came into a department that was doing poorly and you used that leverage to be able to create something unique that has been extremely successful. The challenges are two and I say that very bluntly. Number one is there is no doubt there is more profit that can be collected if your entire group is employed by the system, therefore that profit sharing can problematically be an issue the moment your contract has to be renewed. For how long is this contract for by the way?

- The legal basis for all of this is it's been set up as an ever agreement. So we don't have to keep renewing it every year. It's not got a term in it, but the way we work is now, and I started this recently, I set up a governance council that the CEO of the whole hospital system comes, as well as the president of the university. And we quarterly go over what we're doing, what our goals are, how we're functioning. As you can imagine, as I showed you the volume data on our market share growth, we've become quite dominant and a very large source of revenue and contribution margin for the hospital. And we're very happy to provide that because that helps us do what we need to do. And it's been a very sustainable model. So there's lots of things where we are the hospital leaders, and it's not just all about Medicare profitability, quality of results, all of these things. And that's what we'll be talking about some later, but I think that's what makes us the most sustainable and the heart of the issue, which you're kind of getting at is how much control does each institution want over what's happening? And I think in our model, what we've convinced everybody is we want the autonomy but we're gonna do a lot of things for everybody, including ourselves. And I think what's also helped us, Aaron, is that we're only with one hospital and one medical school. I think if we were spanning multiple institutions, it would be much more tricky to do something like this. And the two institutions are already affiliated. So it helps us be in a much easier environment.

- This is very unique, obviously you're extremely innovative. It's been set up effectively, especially the fact that it's now renewable. And it really comes to the heart of the matter that you have a very collaborative, single system environment. And therefore I want our viewers know that this is a very unique arrangement, special catalysts and ingredients have made it possible. That's not necessarily present in every environment. One of the biggest challenges we face is that you started with a good leverage, you created a nice system, it's working well. Unfortunately there is turnover in the CEO of the hospital, the Dean and they can come in with absolutely a new agenda that may actually clash with yours by the fact that you have had a legal backing of not a renewable system or a contract. In other words, it's not dependent on the personnel, but it's dependent on the origin of the project are extremely unique that unfortunately are rare to obtain these days because the administrators of the system are often not flexible to provide such opportunities.

- You're absolutely right. And I think, I didn't even know how important this could become way back when I was setting this up. But I think what helped us was not to think in three or five-year terms or ask for a startup package. I was less interested in that, I was much more interested in creating a ongoing legal framework that can't be changed easily by whoever happens to be running the hospital. So when we set this up as a separate legal entity with the board and taxpayer ID and moved into it, that was in a situation where to change it the board would have to agree to it, for example. And of course we sit on the board. And so I think that's an important type of thing to consider. If you're thinking about joining on a hospital employed practice or any kind of model, I would say again, annexing people get good opening salaries, opening arrangements and then they want to change it a few years later. And it's much more important to try to get an understanding of what the relationship is going to be for the long-term.

- I'm sorry, is there anything else I'm missing besides the fact that this was an initial program that was startup, leveraged very well by your good leadership? Their system had the buy-in, it's a single system where you're not covering multiple competing hospital, where this administrators of UT Houston are not worried about you taking patients from one hospital electively to another. Were there other ingredients that necessarily make this beautiful system you have possible that I'm missing?

- I don't think so, I think you laid it all out. I think that then once we've got the framework, how we run it internally, of course, is another issue. And I think a big key for us is we really see ourselves as a physician run group of partners, even as we brought in neurologists or neuro-oncologists, we've treated them just as well as neurosurgeons. And we have lots of meetings where we collaboratively make decisions. And I think that's very important for the happiness and harmony and success of our group. So I do believe that quality and value programs are very important. And I like to share with you kind of our thoughts on it. True quality is measuring real outcomes. And I think we know that we don't do that well. But there are lots of measures that we have to deal with. And the other point I wanna make is that patients stats is not the same as quality of care, it can be very different 'cause there's so much emphasis on that. But what are we measuring right now? It's what happens in the hospital, utilization, satisfaction, regulatory compliance. And for us, we also measure something called good citizenship, which means are you submitting your bills on time and reasonable behavior and so on. So what are the obstacles to lining a good quality and value program? Well, I think the biggest one is that administrators often put forward inaccurate or incomplete data. And once you see that, then it de-legitimizes the whole exercise, but the second is that it's very difficult to give individual accountability nowadays. We've got multiple teams, a subarachnoid hemorrhage patient comes in, you've got ICU personnel, endovascular people, surgeons, who is responsible for that? And we're really good at dealing with immediate consequences. Like I clipped an aneurysm when we had a stroke, but we're not good at looking at how the team does in the long-term. Finally, we know that looking at outcome data can be contentious and emotional, and nobody wants to feel like we're prioritizing profit over patient care. So there's lots of approaches. You can ask people to do things which generally doesn't work that well, you can offer positive incentives, you can offer negative incentives, but what you really want ultimately is to develop a culture of excellence and an environment of trust. And if you're not doing that well on a certain thing, we are here to help and educate and support you so you can achieve that. So our approach, and we spent a lot of time talking about this is, yes, a lot of this may not be that great, but instead of fighting about it so much, let's just do well as a group and then we can now think about it. We did all have the consensus that every single person has to be involved and that all the leaders of the program are people that actually take care of patients and also are in the program and equally responsible. Trust and transparency, data driven, we've had physicians get involved in the data. So we know that it's accurate protocol and feedback. And most importantly, we just decided as a group that the only way this is gonna work is if there is one captain of the ship and the attending of the record is that captain and everything that happens for that patient is attributed to that. And then finally we set up significant financial incentives because I felt that would be helpful. We ran a position as you'll hear soon of additional income coming in through a Spinal Implant Savings Program. And we decided to pay that out as a quality of wellness. And we work daily toward a culture of excellence. So we started this initially for neurosurgeons. We've now expanded to everybody in our group, including all of our staff, our surgeons can earn up to 20% of their salary, that's a lot, additional for this incentive program. The person answering phone calls for us can get up to 7% and they're tied to specific metrics that affect them. For example, our clinic personnel is tied to patient satisfaction in the clinic. With a surgeon, we tie it to multiple factors that I'll show you, it's not too complicated. And then we have a separate good citizenship program where they get a bonus for doing things we're supposed to do, like turning their charges on time and so on. So if you look at kind of how we weigh, these are some of the metrics that we use. It's pretty common, everybody knows about it, the inpatient metrics and we've had a very good response to our whole program. So this is UHC or Vizient data. You can see, we started out very poorly and now we're at top 10 nationally. Our infection rates have come down quite a bit across the board. Our patient satisfactions have come up. I set this date because FY13 was when we instituted the Staff Bonus Program. And you can see how it had quite a significant effect. Our length of stay has come down quite a bit. And as a result, we became one of the few hospital or the only service in the hospital that became Medicare profitable during this time period. And all of that was driven by length of stay decreased, as I showed this time period, 'cause this is when we introduced the length of stay bonus. And then you can see, we are maintaining that now. And currently our length of stay, get on UHC data, hovers around 0.6 to 0.7. So our Spinal Implant Program, when I came also had eight vendors here and any surgeon could use any vendor that they wanted. The cost of spinal implant was extremely high. So I got all of our doctors to get together and voted to use two vendors working with the hospital system and led to a significant cost saving. Our accumulative savings is over $20 million now. Then we extended the cranial, endovascular, on biologics. And this is a kind of free money for everybody. And you wanna be a good steward to the system. We don't need to be spending so much on implants. So here's the data, this is the annual spend on implants, cervical and thoracolumbar as our case volume has gone up. And as a result, our total intraoperative cost per spinal case has come down dramatically. And we now have these dashboards. This is on our hospital EMR side that you can go to and you can log in and at any time see your data, service data for all of these metrics that we have. So this is my last slide for this part. We've learned several lessons from this quality effort. Measurable improvements and outcome metrics and cost savings are definitely possible if you work at it. For us, we felt like everybody who was leading this had to be taking care of patients themselves and set an example. Most of the work involves buy-in and operational implementation. It's not rocket science, so you know what to do. So all these sharing of best practices, I don't think it's that useful. For us, financial incentives have been hugely helpful, but it doesn't mean that they capped to how some programs that achieve that and it has to be done in a positive way where everybody feels like they're supported and good things can happen. Our accuracy of data, we spend a lot of time working on that. I don't think everything can be measured. So we still have to have qualitative discussions at m&ms and teaching. And you have to kind of do this in a sustained basis. Finally, we've now implemented a program. And I'll talk about later in part two, where we're doing long-term self-reported patient outcome measures up to a year after surgery, which I think will also give us feedback of a different kind. So I think that's it, Aaron. Any questions or comments about that?

- Yeah, two questions I have for you, the first one is the savings you had under spinal implant, were they're shared with your group or were primarily targeted at the hospital?

- Right, so that's a good question. And this comes up a little in part two but I'll talk to you about it now. We set that up as a co-management agreement. So that you can't profit share. And I don't think that's the kind of thing you can do. And we might have been able to, because we are a financial entity and a hospital, I don't know, but it's very easy to do a co-management agreement. Now, the whole idea of a co-management agreement is that you do something to improve something and you get paid something for it. It can count via, if saved $10, we'll give you $2 back and that's not how we set it up. So part of the reason we were able to do this is we you got the hospital to accept up front, to give us as a group pretty significant compensation to improve the quality and reduce costs by doing this Vendor Consolidation Program. Now they didn't know a priority that it was going to be successful, but that's part of having a good relationship. And so then once we started it because all these other vendors were in the hospital, I can tell you the first year, none of the vendors really believed we were gonna do this together. And so they didn't offer much discount and we didn't mandate that they couldn't use other vendors, we just voted as a group we're gonna use two. Turned out after the first year, our vendor compliance was 100%, which nobody predicted. And whatever money the hospital put up for our group in co-management, they saved much more than that in the first year. But it wasn't any sort of two rack, we're gonna share in profits and so on. And that's how co-management agreements are supposed to run as well. After that first year, the vendor discounts started coming really fast and has continued because they now know that if they do get our contract and they are gonna be able to trade volume for discounts, which is what they want. So this turned out to the kind of a win-win-win situation. We've subsequently let the co-management program lapse in lieu of an ACO agreement, which is much easier to run and better. And we'll talk about that in part two, part two and three.

- And the other quick question I have for you, so we can jump to part two as soon as we can is that, what do you think the effect of training colleagues, special sub-specialty and surgeons who do surgery more efficiently, should be given a certain amount of bonus. So if I'm doing an MVD for hemifacial spasm and it takes me an hour, 15 minutes to do it versus another person who takes four hours to do it, is there an incentive for that if the outcomes are similar? Because there's a huge potential to save money there, even more than length of stay, in my opinion, because the resources we use every hour in the hospital are so humongous.

- Well, I couldn't agree more on that. And I do touch on those themes in part two. I mean, I think there is no other profession, let's say in law where you get the top lawyer in the country who's argued in front of the Supreme Court and you get somebody who's chased ambulances and their hourly rate is the same for doing legal work. That's the situation we're in in our CPT based model. I do think that as things are going, the opportunities for physicians and groups that can achieve secure outcomes is much better and it's gonna do, or what's gonna happen just from kind of RDU. I did a case, we get this profit reimbursement aspect. And so I'll tell you in part two specifically how I think that's going to happen. That's already happened for us in our Center of Excellence Program that we started. Think of bundle payment as a discount for volume, but actually we think of it and we're having experiences and it's gonna be the reverse. It's going to be surgeons who can deliver a COE level outcome are gonna be paid much higher for what they're doing in that COE than they would if they're just sit on I will explain to you how that happens.

- Right and I think you're really touching on topic of APMs, alternative payment models and ACOs, which really are gonna be something we're gonna deal with very, very soon and very complex. Many neurosurgeons had avoided cultivating the opportunities there, which I think we should talk about. So Dong again, really innovative, progressive, thoughtful. I think those are the words that describe my impression of what you have done over there. Obviously, as we all say and I've learned in my MBA classes, culture eats strategy for breakfast. Unless you have that culture of collaboration, transparency, not neurosurgeons being after each other for personal agenda and using quality measures just to bring each other to a lower level, you won't be able to accomplish these. And I have to tell you almost all our academic programs have certain amount of historical, I hate to tell you, emotional complexities and you started really from ground zero and cultivated and established a very special culture. And that's very difficult to do where those programs for many years and the attendings that have been there established certain relationships that it's almost extremely difficult to change. Culture change does not come with a leader. Culture change often comes from the team and therefore you can bring the best chairman, the most innovative, progressive one like you to a group that has been going on for many decades. It is gonna be almost impossible to change the culture. Almost you have to bend a fair amount to what they are doing at the time. However, if you come to a fresh program, bring a new vision, employ people who share that vision and culture, then you have something extremely special. So I would say that all that you talked about today come down to culture, leadership, influence, collaboration. Those are very unique, they don't come easy. And the environment plays such an extremely critical role. So with that in mind, I like to go ahead and-

- I agree and thank you for your events.

- With that in mind, let's close this session. We'll go ahead and start the next one, which will focus on quality measures. I'm sure ACOs, those things that unfortunately inescapable at this time, and we're just coming down the pike. So again, thank you, thank you, thank you, Dong. And let's go ahead to the next one.

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