I've got time for some questions from the audience. Yes, and could you speak to the microphone? Okay, so first of all, Dr. Pelka, thank you so much for coming. We appreciate your time and your story about, you know, changing over that hospital system was pretty interesting. So I was wondering, could you tell me what the three, in priority order, what your three top priorities are at the American College, and do you have solutions for them? And if you do, could you tell us just briefly what they might be? I don't know that we've labeled them one, two, three, but the top three areas that I spend most of my time on, number one is currently reducing regulatory burden. We've got a spreadsheet of regulatory burden on surgeons, and we're always hammering at, how are you gonna reduce this reg? How can we reduce this reg? It's just a bunch of things that influence you every day, like the documentation guidelines. How do I reduce the documentation guidelines? It's silly in the modern era. Number two is alternative payment models. So we have built an alternative payment model that's an all-payer, all-physician alternative payment model that CMS just isn't acting on, just because it's not in their vein, but we're turning it into a public utility for all payers, and we're getting a lot of payer response where we want the physician community to control defining an episode of care. It shouldn't be defined by Blue Cross or United or Aetna. We'll have 20 different episode definitions for a spine case. We don't need that. We need one, or two, or three, but they should be defined by the industry. So we're working on that. And the third is this whole concept of the digital health system and interoperability. We are looking right now to build the ability for all the different specialties of medicine, including surgery, to be able to have web services that meet your patients. That are the kinds of things surgeons say, I do this every day. If I'm taking a patient to the OR, why isn't there an application used in every EHR that does a critical med list, critical disease evaluation, and get this patient ready for surgery? Why are we doing this onesie twosie at every different place? In a digital world, that makes no sense anymore. So we are building the infrastructure to do that. Those are massive projects. They're not small by any means, but we spend an awful lot of time building a standards environment to move the infrastructure. It's almost as if I'm working on building the highway so that you who are building the high-speed racecar will have a road to put it on. Yes, sir. Thank you for your talk. I was wondering if you could give us any hints on the best way to access the appropriate level of decision makers, you know, to influence policy, and how do you identify the best entry points for those type of efforts? So, great question. A lot of this is where are they in terms of are they ready for an issue. If they're not ready for an issue, we got to prep, if you will, prep the field and get them, get the issue to bubble up. So interoperability is a good one. They were looking at EHRs, and all they were doing was talking to Epic and talking to Cerner and talking to Epic and talking to Cerner, and I was spending time talking to the engineers at Google and Apple, and they're all saying, what are you talking to them for? They're just gonna take money from you. This isn't how you solve the problem. So we had to go in and educate ONC. We had to find the right people inside ONC, and then once we could create the demand, you can identify who's going to be the touch point. Your comment letters that you write, they're very important. They're very, very important. By writing those comment letters, you're starting to reach those people. If all of us say the same thing in our comment letter but in our own words, that's going to hit somebody inside the agency that you want, whether that agency is CMS, ONC, AHRQ, FDA. It's coming together and hitting them with 10 different specialties who are saying the same thing in different words. That gets their attention. Oftentimes we have to go to the hill and say, CMS isn't paying attention to us. Would you write a letter? Somebody like a Senator Cassidy from Louisiana, I need you to write a letter to do this. We got to convince Cassidy. We convince Cassidy. His team will write the letter. It goes to CMS. CMS doesn't want to keep getting dragged down the hill to testify on all this stuff. So they're going to come back and say, can we have a meeting? Can we have a group? Can we sit down and talk about this? The conveners that are there that help us the most are the college as the big convener, the AMA as another big convener. If ACP, Family Medicine, the College, AMA, Cardiology come together, the big five, we'll get the attention of any agency. That's a huge lift to get all five of us to agree on something. If all five of us said there's burdensome regulations that are hitting everybody that you've got to stop, those five will have an enormous voice. CMS does not want that voice to go to the hill. They'd rather address it right away. The other thing is this White House has been pretty open. It doesn't sound like that the way the press plays it, but I've probably had one trip to the White House in eight years of Obama, and I've probably had five trips to this White House, where we sit in and the White House chief strategic officer is sitting at the table listening and taking notes while we are having a dialogue. That hadn't happened before. Thanks for coming, Dr. Pelka. Would you amplify a little bit how the College, we're in neurosurgery coming around to, we're still sort of circling around, rather than being reactive and or trying to fit what we what we would like to see as defined by quality and some of the reporting and some of the alternative payment model approaches into the sandbox that CMS has created, saying, you know, screw that. They need to come to us, sort of similar to the to the comments you made and the payers and whatnot, and that we're going to take charge and really try and find what we believe that will be data-driven, and we're going to try and leverage hopefully some tools that we've got through our board and otherwise to really turn things around so that the profession is the one that is driving this, rather than these third parties. But what kind of traction or, I mean, despite all of that, are you getting anywhere with that? Or are you just sort of starting this thinking, or how are you getting these third parties to, you know, if not come to you, I mean, acknowledge that, you know, rather than, you know, that you've got something in the College, you have products, you have ideas, whether it's the Brandeis APM or something else that would be worthwhile and beneficial to all sides, especially the patient, and if you have any wisdom on that that you could share. So, two thoughts on this. First, my first advice on neurosurgery is when it comes to payment, go slow. You're in a good position. You're a very needed specialty. You're very narrow. You're not easily replaced. There's not a competitor. So, from an economist standpoint, just don't go too quickly, and yet at the same time, dip a toe in the water so that you know what your options are, have a backup plan if you have to initiate it. But I would not go too quickly if I were you, because you're in huge demand, and as long as the supply curve is in your favor, you don't need to jump in too deep, too fast. So, stay knowledgeable, but I wouldn't be too proactive. On a quality standpoint, complete opposite, 180 degrees. So, our position from the college is we go back a hundred years now. When the college took shape over a hundred years ago, it took shape because there were just as many hospitals in America over a hundred years ago as there are today, but they were not standardized, small, and they caused a lot of problems. So, we started the College of Surgeons to develop surgical standards. We developed those standards, and in 50 years later, 40 some years later, it became the Joint Commission. Those standards today promote more quality of care than you get from any CMS program. If you look at the CMS programs by surgical discipline, and I have, it's embarrassing to CMS what you are reporting. All the surgical specialties are reporting things like med reconciliation, tobacco cessation, and immunization reports. That's garbage. That's not surgical care, and we've told them this in public, and they're embarrassed, and they hide, and they put their heads down. They know that what they're doing is now foolish, costly, taking your eyes off the patient, and we say this publicly. So, now they're saying give me something. We're going back to those same standards we built when we built the Joint Commission. We built standards in trauma that now make trauma services, trauma level one, trauma level two, trauma level three, and guess what? Trauma care is the best in the world in this country. Those evidence-based standards of care, it's a structural measure, but it drives the best outcome. It allows you to build the best team. Now, the trauma system, I will tell you, has gotten a little bit overly strenuous in terms of the standards. There are too many. It could be cut in half, and I don't think it would influence trauma care, so that needs to be cleaned up, but bariatric surgery five years ago had a mortality rate of 6%. They asked us to come in and set standards on bariatric surgical care, which we did. Two years after the initiation of evidence-based standards in bariatric surgery, the mortality nationwide is now less than 1%, so it works. We know it works. It's worked for a hundred years, so we're saying there should be standards in spine. There should be standards in aneurysm. There should be standards in intracranial tumors. Whatever it is, there are standards that you should say these are the standards of care that should be compliant of a good system. The second part of this is then measure outcomes, so we're measuring patient-reported outcomes, so if you combine evidence-based standards in specific focuses or disciplines of neurosurgery with patient-reported outcomes, you have a very compelling story for real quality. Now, we're still measuring the NISQIP data and claims-based data, but those are tagalongs now. They become second fiddle to real evidence-based standards and PROs, so that's our approach. That's what we're doing, and we believe in it. We believe it's the right thing to do for patients, and we're going to stand by it. And are you being able to monetize that? I don't mean, you know, like, I mean turn those quality improvement initiatives then into performance standards, the reimbursement models, or whatever, to then put it into a payment. Put it into a plan. We put it into a score, a quality score that goes into your payment program. You've got to go do so well on your standards, which we think is more than 50% of your score. Your PROs get you to 90% of your score, and those other things like the traditional outcome registry-based outcomes only add on 10%. So the real focus is having real standards that only your specialty could verify. You would be the verifying body. We can give you the core set. This is what every surgical unit has to have, but I couldn't give you the spine. I couldn't give you the aneurysm. I couldn't give you the intracranial tumor stuff. You would have to do that, and that's who should own the content and the context of evidence-based standards, and we firmly believe that. I'm pushing the clock here. Thank you very much. It was a pleasure. I want to thank Dr. Apelka for a very, very personal presentation that was very meaningful for us.

regulatory burdens

alternative payment model

digital health system

interoperability

patient care