Well, good morning. I know this is an overwhelming two-day or day and a half experience for you all, and as I'll say at the end and I'll say at the beginning, you know, you'll probably push the delete buttons in your brain after you leave here, and it's because there's just so much information. But I hope that you'll at least be able to take away a handful of general concepts and at least know that there are resources and folks available in organized neurosurgery to help you once you get out and practice when these various issues come up as you move forward in your careers. One of the things I wanted to amplify after Dr. Streunk is I think we are trying to find a way beyond just the resident involvement in socioeconomic and health policy issues is how do we capture young neurosurgeons who are in maybe that first decade of practice where there's not an obvious place for you to really fit into our current committee structure, and I think that's one thing we're trying to do. And again, the CSNS meets twice a year at both the AANS and CNS meetings and is open to anybody to attend, and I think there are opportunities if you are interested in various healthcare policy matters to get involved as you go up the career path. Before I start, I just wanted to, I'm not going to do a quiz like Dr. Ratliff did yesterday, but I'd just like to see a show of hands of how many of you are actually, have ever heard of the Washington Committee for Neurosurgery or are even aware that we have a Washington office representing neurosurgery in this country? Show of hands. Okay, so pretty much all of you, so that's good. So we don't have to go through all the details on that. I was assigned this daunting task, the future of healthcare. I was going to have this slide and the next slide was going to be a big question mark and then take any questions, because I think the reality is the sands are ever shifting. It's very difficult to predict what is ultimately going to happen. Politics inevitably get involved in all of this, and so whatever the makeup of the Congress and the White House are, always seem to change the direction. Private sector's always out there moving forward. And so there are a lot of moving parts and it's really hard, I think, to predict with any degree of certainty what's going to happen in the future. But I'll give it my best shot, at least to give you sort of a 64,000 foot level. There'll be a little weeds, but I promise you I will not be talking about relative value units in their incremental fashions. So I thought I'd start out with a little bit of background information on a couple of key topics and then move to a little bit more what may be coming down the pike, current status and going forward. So in the good old days, and this was way before your time, I think there are a few people in this audience, sadly, who are above the 50-year-old mark, who remember the good old days where a neurosurgeon could just go and perform a procedure, see a patient on a consult, submit a bill, and that bill would be paid, largely whatever it was you charged. And things were good. There wasn't a lot of micromanagement of your practice, how much you got paid, how you got paid, what you did in order to earn that money. You just did the procedure, saw the patient, submitted a bill, and got paid. That has led, among other things, to one element of the explosive growth in health care expenditures. The estimated total expenditures for health care in 2014 are roughly just under $3 trillion. I mean, that is a lot of money. And while physicians only take up about 18 to 20 percent of that pie, physicians direct almost all of the spending that happens in health care. You are the ones that decide whether a patient gets a test, or whether that patient gets admitted to the hospital, or whether that patient goes to a skilled nursing facility, or gets home health, or gets a DME, or the like. And so really, physicians are really at the core of, in some respects, the explosion of health care expenditures, pharmaceutical sort of aside. And it's not sustainable. Just the federal programs alone, Medicare and Medicaid, are going to account in the future for an ever-increasing amount of our federal budget and percentage of the gross domestic product. There's nothing inherently wrong with that. However, if health care is taking up all of the money that we have to spend, that means bridges and roads aren't fixed. It means school and education are not supported. I mean, all of these other, the military, all of these other spending priorities we have in our country are going to have to be ratcheted down in order to address the ever-increasing growth of health care expenditures. There's also been, you know, perceived real or perceived sometimes as a matter of opinion, but there have been a number of studies that have had a great deal of influence on health care policy, suggesting that there are huge gaps in both the quality of care provided by physicians as well as the resources and health care spending variations across the country. So, in certain areas, there's a whole lot of spine surgery being done or a whole lot of C-sections being performed, other areas, more conservative therapy, and the like. And so, this has caused policymakers to really be concerned about figuring out how we can, as a nation, sort of flatten that out so that there's less variation in both spending and quality across the country. There is no question that, you know, the current fee-for-service system in many respects is leading, again, to this increase in cost. You do a procedure, you get paid, there's, you know, a kind of perverse incentive for you to, you know, the more you do, the more you get paid, and there's really no global mechanism for addressing whether or not what you're doing is actually providing any value to the patient, and it's leading to a very, you know, expensive health care system. So, when we look at, so those things need to be addressed, I think. I think there's nobody in the country, by and large, who thinks that we're on a sustainable path and that we can't do something to make some change to do better. In terms of just, you know, the evolution, there have been a lot of events along the way, even going back to, you know, FDR times in terms of health insurance discussions and how to deal with the health care in this country. But there are a few key physician landmarks over time that have dealt with the physician payment side. So, I just wanted to give you a brief timeline on that, and then we'll talk about some of these in more detail. Obviously, the big landmark back in 1965 was when Medicare was passed and President Johnson signed it into law. Back then, the AMA was vehemently opposed to the government getting involved in health care, probably very prescient, but because they knew that was just the first step in the government controlling your lives, and it has turned out certainly to be the case. You can go back. There was a marvelous speech that one of the past AMA presidents made when this law was first being discussed when President Kennedy was in office, where the AMA purchased a half hour of time on NBC. They rented out the entire Madison Square Garden, which came the day after the president had made this big speech about the need to pass Medicare. The president of the AMA spoke to an empty audience, basically giving a speech for 30 minutes on why this was bad, and you can watch that, and you can fast forward to 2010 and the Affordable Care Act, and you can really see the parallels. It's actually quite fascinating, but I digress. So, Medicare passed. It turned out that it was actually a boon for physicians because, again, you did a service, you wrote a check, or the government paid you a check, and didn't ask any questions, so the good times were there. All of a sudden, Medicare starts going up. The Nixon administration and health care costs were going up a little bit. Nixon administration put in place a few things, price controls, passed the HMO, Health Maintenance Organization Act, and people were focusing on the high cost. Things sort of percolated. There were a number of activities in the early 80s directed towards hospitals. That's when the DRG payment system came into effect, but the real seminal event for physician payment was in 1989 when Congress passed OBRA, the Omnibus Budget Reconciliation Act, which is what started the move towards this RBRBS, which you heard yesterday, Resource-Based Relative Value Scale. This also put in place, for the first time, a system that was going to establish a fixed pot of money for physician reimbursement, which would increase incrementally over time based on a number of factors, but it was largely creating a system where there would be an internal food fight among physicians for this fixed pot of money, and that has probably been, I think, the singular most destructive thing that's happened in medicine because now doctors don't view each other as collaborators. They view each other as competitors for these dollars. This has set up a really unfortunate schism between primary care and the specialty care, and it's just always the battle about who's going to pick whose pocket to get that ever-shrinking money, so that went into effect technically in 1992, but it was passed in 1989. Then you also had this period in the 90s, which, again, was sort of the predictor of what's happening now. They call it different names now, but of managed care, where companies and health insurance companies were trying to, in a fixed pot, have physicians do a better job at managing the cost of care. Patients revolted because they had limited choice, their gatekeeper system. They couldn't see the doctor they wanted. They couldn't go to the hospital they wanted to, and so that whole system blew up, and as a result, costs went up again. Congress came back in in 1997 with OBRA 97, which was a mechanism, again, to take slash Medicare across the board. Hospitals took it on the chin, home health, skilled nursing facilities, and physicians, and what physicians got with that great bargain was something called the Sustainable Growth Rate Formula, or the SGR, which you've heard a little bit about. And then finally, as cost—none of these things have ever worked, which is interesting. I mean, none of them are really market-based. They're all kind of government, top-down approaches. But then the Affordable Care Act came in and has a whole lot of provisions in there related to physician payment. So I'm going to focus a little bit on the Medicare side, and I'm going to focus a little bit on the Affordable Care Act, give you some background on those things, and then we'll go from there. And please make sure you interrupt me if at any point you have a question. Dr. Ratliff showed you a much more complicated mathematical equation. I cannot do algebra or whatever that was. I can do simple mathematics, pluses, minuses, and subtraction and addition. But again, basically, you are paid under Medicare based on three aspects of your work, your practice expense costs, and your malpractice. Those give you a total relative value unit, which is multiplied by a monetary conversion factor, which gives you your fee. And the SGR, the sustainable growth rate formula, is what determines what that monetary dollar conversion factor is. And what the SGR is, is essentially an annual expenditure target, global expenditure target for Medicare physician services. And there's a number of elements that go into that. Notably, it's been tied, growth has been tied to the GDP. So when you had economic downturns in the economy, even if physician costs were going up, reimbursement would be tied to GDP, and that's led to negative updates. Basically, for a couple, three, or four, or five years, physicians didn't bust the target. But then since 2002, and ever since, physicians have not met that spending target. And so cuts have increased. The magnitude of those cuts over time have increased, because it's a compounding formula. Here you can see that since 2000, the rate of inflation has gone up as far as Medicare, the way Medicare tracks the cost of health costs for physicians, nearly 60 percent over these past couple decades. And your reimbursement has either been flat, and a cut is predicted of 21 percent next April if Congress fails to act. Now, Congress has not failed to act ever since the first cut went into effect in 2002. And every year, we go through this ritual of going up to Congress and begging for crumbs that say, please don't cut us, please don't cut us. They heap on a whole lot of other bad stuff just to make sure that we don't get cut. But it's largely been a flat reimbursement system. So when you hear about the SGR, you know, what we're trying to do is get rid of this payment formula, close that gap between expenses gone up and what the predicted cuts are going to be, and try and reset, essentially, the fee schedule or the payment schedule for physicians so we can get around for this. So what does it mean at a per-unit basis? These are some back-of-the-envelope calculations from last year. But you can see that, you know, a 20-25 percent cut for these procedures that you do is not insubstantial on a per-service basis. You're going to take, you know, aneurysm, that's $1,000 loss if a 25 percent cut went into effect. You know, $100 here, $200 there. You multiply that by the number of procedures you're doing, and you're talking about real money. This is Medicare only. It's important to note that most third-party payers, whether it's United or Blue Cross, all the private sector payers, all follow Medicare. So they start with Medicare, and you negotiate based on what Medicare's paying. So if Medicare keeps ratcheting down, so, too, will all the rest of your reimbursements. You know, globally, you know, it's about a $45,000 hit annually, just this SGR-related. But there are other cuts that we'll talk about on the quality of reporting side of the equation, and even just, you know, coverage policies that third-party payers implement to say we're not going to pay for lumbar disc fusion or lumbar fusion anymore for degenerative disc disease. What does that mean to neurosurgeons who were doing that a lot of money? Maybe they shouldn't have been doing that in the first place. But it's these are some of the challenges that we're facing. Switching gears just a little bit, give you some background about the Affordable Care Act, otherwise known as Obamacare. It used to be a derisive statement. Then he embraced it. Then he didn't. You know, I'm not sure if it's a positive or a negative thing to call it Obamacare, but that's what it's otherwise known as. The Affordable Care Act was actually originally, it's two laws. Back in 2009, the Senate passed what was called the Patient Protection and Affordable Care Act, or PPACA. That passed completely along party lines on Christmas Eve by a margin of 60 to whatever, 40 or 39, I can't remember exactly who was there. In the Senate, it's important to remember that you need basically 60 votes in the Senate in order to prevent a filibuster, subject to a few exceptions. Right now, the Senate doesn't have, there's not 60 in the majority party at this point. It's hard to get things done. Nothing is getting done, as a matter of fact. They passed this. Senator Kennedy died. The folks that were opposing the Affordable Care Act were cheering in the streets because they thought, oh, surely this is dead. It's still got to go back to the House. The House of Representatives, which was controlled by the Democrats at the time, wanted to make some changes to the Senate version of the bill. They didn't like it in some respects. But if they made any changes, it would have had to go back to the Senate, and they had lost a key proponent of this law in the form of Senator Kennedy. He was replaced by a Republican, Scott Brown. And so people were thinking, oh, Obamacare is going to die before it ever gets passed. Well, there was this little procedural trick called the Reconciliation Act, which allows, the Budget Reconciliation Act, which allows Congress on spending bills, on budget bills, to actually only need a simple majority to pass it. So they cooked up this deal with the House, where they'd make a few changes in this second bill, called the Health Care and Education Reconciliation Bill. The House passed the Senate version of PPACA, as was. They both passed this other fix-it bill that also had a whole bunch of stuff related to education by 50, you know, just by a simple majority in both houses. And off it went to the president, who signed it into law in March, I think March 20th or thereabouts, in 2010. You also might remember famously that, you know, then-Speaker Pelosi announced that we have to pass the bill before we find out what's in it. I mean, it was a 2,000-page document, and then some, with all this extra stuff added on. But there was a lot of stuff in there. It wasn't just about expanding coverage to people who didn't have insurance and regulating bad behaviors of insurance companies. It was a much bigger deal, and this is what it now looks like. You note that there are approximately 160 new agencies, committees, and other governmental entities that were created or expanded by this law. That is a lot of bureaucracy. And once in place, bureaucrats don't go away. It's very difficult to undo once it's done. You will also note that the physicians are at one side of this, and the patients are at the other. And look how much is in between that. And at the center of the universe is now the Secretary of Health and Human Services. You know, the IRS is looming large, and some other, you know, scary agencies, like the Office of Inspector General and the Department of Justice and the Federal Bureau of Investigation. You know, you heard a little bit about that yesterday. You'll hear more today. But it really has, you know, in many respects taken the doctor-patient relationship and blown it up. A 2,000-page law has turned also into 20,000 pages of regulations. And this is an actual stack of the regulations printed out and put into, you know, a dolly. And you just see it. This is now what physicians and other health care providers, employers, patients, I mean, everybody now is having to sort through all this to figure out what the actual impact of the health care reform law is going to be. So the basics, just briefly. It expands coverage. Ideally, it was geared to expand coverage to 32 million people, dealt with a number of insurance issues, like prohibiting preexisting condition exclusions and the like. There are, that's about one-third of the bill. Another one-third of the bill or the law deals with various cost containment, delivery reforms. And then about a third of the bill was geared towards improving primary care and preventive services. There is a school of thought, I'm not sure how folks in this room feel, I know how some feel about it, but that if only we had better preventive services and primary care, more primary care physicians, we could fix everything in the health care system. And so there's been a big movement to shift money and resources from specialty care, surgical care, hospitals to primary preventive medicine. And that is going to somehow improve quality and reduce costs. That remains to be seen. For us, the real, for neurosurgery and the physicians, most of the issues that are of concern to us come within this cost containment health delivery reform. So some of the issues that are in there, cost containment, the law set up something called the Independent Payment Advisory Board, otherwise known as IPAB, not IPAD. It's a bad thing, not a good thing. In contrast, 15 members appointed solely to cut Medicare. And they have pretty much unfettered discretion to do it however they want. It has not yet been constituted, but it looms large. A little bit, you know, this again, a little bit in the weeds, you heard about the ROC, well, it requires CMS, Center for Medicare and Medicaid Services, which administers Medicare, to basically look at all physician services and determine whether or not they're misvalued. That is, that's not undervalued, that means overvalued. And they're not looking at primary care, they're looking at specialty care, especially the surgical services, which Dr. Ratliff talked about yesterday. Also, there are a number of other things, reducing reimbursement for imaging, requiring comparative effectiveness research and the like. Another way that the Affordable Care Act aims to deal with cost containment is by increasing transparency and enhancing sort of the patient in this, so there's going to be public reporting, you know, all this whole alphabet soup of quality, which I'll talk a little bit about, the Physician Quality Reporting System, or PQRS, which is something that you're gonna need to know about. The Center for Medicare and Medicaid Innovation, which is testing all of these different new models of healthcare delivery, patient-centered medical home, the patient-centered medical neighborhood, and I joke, you know, the patient-centered vacation home, which is what we might be, because you only wanna see us maybe, you know, if you have to see us for a couple days, not for a long time. So these are things that are being tested now, but are not yet, that we don't know whether or not they're gonna work. Again, things like the shared savings programs, accountable care organizations, bundling, all of these are new systems that the government is trying to test to see if they will work to hold down cost and improve quality. On the quality front, I mean, explosion of so-called quality measurements that most of which, in fact, almost all of which, are absolutely irrelevant for specialists and neurosurgeons in particular, which is a problem if you're gonna get penalized for not following measures that are not relevant for you. We're turning quality now, instead of a bonus incentive program, to try and enhance and improve quality to a penalty system, and so that's, I'll talk a little bit more about that. And Dr. Ratliff alluded to this idea that we're gonna also pay physicians based on the value of their care provided. That is to say, are they delivering quality care at a reduced cost? So Medicare is now going to be evaluating the resources that you utilize. Are you ordering too many tests? Are you doing too many procedures against some sort of benchmark mean or average? And you will be given money if you're doing well, and you will have money taken away if you are not. The totality of the impact of this, and I apologize, this is totally not uplifting talk, but I never, you know, I always had to deliver the bad news, but just to be prepared. But going forward in the next decade, the amount of cuts that physicians, and this is writ large, so it's not just neurosurgeons, can potentially expect is upwards of 80%, and it's sort of death by 1,000 cuts in some of these programs. Again, if you're not doing electronic health records, you're not doing quality reporting, you are going to get a penalty, at least in Medicare. Transparency, we talked a little bit about some of these things related to conflict of interest. It bans physician-owned hospitals, which used to be one way physicians could derive some ancillary revenue to make up for what they were losing on their professional fees. They could get facility fee reimbursement. Dr. Woens might talk a little bit about surgery centers, which still is an option. Sunshine Act, we talked about yesterday. And also, if you join a practice that owns its own in-office ancillary imaging services, you now have to give patients a list of other places they could go, not just you. There are a number of problems related to, right now, concerns about do we have enough physicians and other providers to take care of this big influx of patients? A number of provisions in the law were aimed at trying to address some of that. That's a work in progress. In fact, next week, the Institute of Medicine is gonna be putting out what, I don't know if it'll be a seminal report, but it'll be a report on graduate medical education and workforce issues, and calling for making changes in those systems. We're waiting to see what they're gonna do. And two big items that were not addressed in the healthcare reform law was the sustainable growth rate formula problem, and there was no medical liability reform. And I think the thing that we've seen with effective liability reforms, and at least the theory goes, is that not only is that gonna reduce the premiums that doctors pay, but ultimately, it'll provide you with enough protection and confidence that you don't have to order that extra MRI, or do that extra test to cover your rear end in case you are going to be sued. So what's the future look like? On the ACA front, implementation is a long process. We're about midway through. There was a few of the insurance reforms went into effect. In 2012, folks were looking to the Supreme Court to basically rule the individual mandate to buy health insurance unconstitutional. It didn't happen, so things are continuing to plug along. In 2013, all the taxes that are being collected to pay for the expanded reform, access to health insurance came online. And this year was the, you've seen, just the implementation of actually expanding insurance, whether it's Medicaid for those individuals who are below the poverty, 133% below the poverty line, or these healthcare exchanges. So all of those, access to health insurance, for the most part, came online. The mandate for employers to offer insurance has been delayed by the White House until next year, may even be further delayed. But for us, again, penalty programs are all coming to home to roost next year. So this, for providers next year, will be probably the biggest impact. And then going forward, we'll see how it goes. There was a lot, in terms of this year, a lot of, I think most people were aware of the colossal failure of at least the initial rollout of the healthcare exchanges last year and the problems that patients faced actually enrolling online, the computer glitches and the like. Despite all of that, and the Obama administration had set a goal of enrolling seven million people in this first round, this first year of implementation, they ended up actually exceeding that goal. And about a little over eight million individuals enrolled in these healthcare exchanges. There were two or three additional million that came on board as part of the expanded Medicaid expansion. So a fair number, anywhere from 10 to 12 million Americans were given health insurance. Now, not all of those were new people. You might have seen, at the end of last year, a lot of individuals who currently had health insurance were dropped because their plans didn't comply with the new requirements. And so then they had to get on the exchanges and this outfit called PolitiFact did highlight President Obama's pledge, if you like your plan, you can keep it, as the lie of the year, and gave it a pants-on-fire rating. I mean, for geeks like me who watch this stuff every day, this is how the pundits like to measure whether or not politicians are telling the truth or not. There's a lot of pants-on-fire, as you might imagine, ratings out there. Because, you know, they pretty much lie every time they open their mouth, like it's just a joke about that. The other, so there's a lot, you know, so they got eight million people on the exchanges, but already we're starting to see inaccuracies. About three million of those individuals, they have not been able to actually confirm aspects of their enrollment. Importantly, whether they're actually eligible for subsidies for their premiums. And so right now there's a lot of concern that the government's gonna be subsidizing, and that means you and me through our tax dollars, people to have this insurance when they actually don't financially qualify for it. And there's not probably a very good process in place to deal with that. The Government Accountability Office just came out this week with just, I mean, they only took, you know, just a small sample, obviously 12 individuals, but they tried to enroll 12 fake individuals. And of those 12, 11 who had one problem or another, you know, fake social security number, or what have you, got insurance that would have resulted in a government subsidy. Now, if that is a generalizable percentage, I mean, this is a lot of money that's gonna be going out of the Federal Treasury to people who otherwise may not actually be qualified to receive it. The other thing that folks are watching in terms of the Affordable Care Act is whether or not the risk pool is going to be sustainable. So if all you have are old, sick individuals who use, you know, a lot of preexisting conditions, use a lot of healthcare, and you don't have any young, healthy, relatively stingy users of healthcare to balance that insurance risk out, it's going to be explosively expensive. And it's going to, you know, again, run counter to the idea that health reform was supposed to actually reduce cost. In this first go-round, and, you know, these are all just first year numbers, so you can't really tell what's gonna happen trend-wise, but, you know, they expected you need about 40% to make that mix of youngsters, to make that mix work, and the target only hit about 28. So, you know, that may, in fact, cause premiums for next year to go up. Indeed, just looking at 2013 to 2014, while there is substantial variation both in terms of the plans and the parts of the country where you live, on average, premiums were up 50% for individuals in the individual exchange market. That is a huge problem. And many of these individuals, too, who bought, you know, sort of this mid-level, this mid-level plan, they're paying their premium, but they also have big deductibles, upwards of $5,000 and $6,000. So if they're gonna come, you know, to see you, they think they've got an insurance card, and the first thing your front office is gonna say, okay, well, you haven't met your deductible. Well, how much is that? Well, that's $5,000. Well, how much is your surgery? Well, that's $5,000. I need your credit card, please. Because you're gonna be, you're gonna have no insurance company to bill for your services. It's all gonna be out of pocket on the front end. So that is gonna be, I think, something, again, we're gonna have to watch, is people think they have coverage when, in fact, they, you know, may not be so good. So some of the challenges that we're, you know, we're facing going forward with this, and again, these are things that are on the insurance side, but are eventually probably going to have an effect on you and things that are popping up now. So-called narrow networks. This is gonna be one of the key issues to listen to and think about, because health insurance companies are limiting the number of physicians or other providers, hospitals, that they have in their network. In their network, and so patients who've got their little insurance card, you know, they wanna go see, you know, Dr. Bean, only to find out that he's actually in his hospital are not on the allowed list of providers, and they're gonna be all out of pocket and all out of network. So this is something that people are taking a look at now. Premiums are gonna continue to increase. I think, you know, the employers, large employers may start dumping patients off of their insurance into these exchanges, paying their own little penalty, and then, again, you're gonna have a lot more patients that may be on these lesser plans. State exchanges are all, several of them are folding. Oregon is the busy one from Oregon here. I mean, that's been the biggest colossal disgrace, where the federal government gave them about $300 million, and they couldn't enroll a single person on their exchange, so they're actually just moving to the federal exchange. But, aha, there's a court challenge now as to whether or not individuals who are enrolled in a federal exchange are entitled to premium subsidies. And two court cases within two hours of each other this week came out. First was the Halbig v. Burwell case, which said, well, as a matter of fact, the law says no, only subsidies from the federal government to help buy insurance only go to those individuals who are in a state-based exchange. Another court in the Fourth Circuit came out with the exact opposite decision, and it is clear that this is going to go to the Supreme Court, when and how fast, and what will happen, we will see. But, again, there's just, you know, these continued challenges to this law make it impossible to predict. And, you know, despite all of this, there are still millions of Americans who do not even have health insurance. So, I mean, it is sort of mystifying that you would pass this huge law and actually not accomplish, which one of the major goals was to cover, you know, most Americans. So will it collapse? Who knows? You know, we'll keep our eyes open, and it's gonna be interesting, and it'll be rocky, but we'll see how it goes. In terms of Medicare physician reimbursement, quickly, we have been, you know, trudging up to Congress year after year after year after year. That's almost, you know, I don't, that's the definition of insanity, I guess. We've had some Lucy and Charlie Brown, you know, football moments. But, so it's hard to see how this is gonna go. But we're working on, we're working on legislation, which was introduced for, I mean, this was actually quite remarkable. Congress, both bodies, the House and the Senate, and the committees that developed this legislation reported out these bills on a bipartisan basis, and without a single person opposing it. Unanimous support on both sides of the aisle. All the physician groups, healthcare providers are all on board trying to figure out how to repeal the SGR. I won't really belabor the details, but basically the overarching theme about this legislation would be to repeal that SGR formula, replace it with something that's a little more predictable in terms of what you'll get in the fee-for-service system, subject to, you know, again, still participating in some of these quality-related programs, but consolidating them so you're, they actually may make more sense. And instead of, and there is an opportunity for you to get dinged and be penalized, but there is also, unlike current law, an opportunity for doctors to also be rewarded for quality. So we organize neurosurgery and others, I won't go through the details, have supported this legislation, and so we'll see. The House of Representatives did pass the bill in March. Unfortunately, as the House of Representatives is known to do, they tied it to a, the budget offset, because this bill would cost about $150 billion over 10 years, so it had to be paid for. The way they paid for that was by delaying the individual mandate to buy health insurance, which also means no subsidies, so the federal government saves on that for five years. The Democrats didn't approve of that, so this went totally along party lines, got, you know, for the most part, a few Democrats voted for it, but it was a political vote, largely. And then Senator Reid, the majority leader in the Senate, wouldn't even allow a vote on it, because he's got a few members in his chamber that are up for re-election in very dicey political situation, and he didn't want to have this bill become a sort of political vote bill, where if someone voted against it, it could be hung around their neck come November. So it's stalled. It's hard to say what the outlook for repeal is gonna be, whether we'll hit it out of the park this year or not. I think most people now are talking about bringing up this bill again in the lame duck session, which is the session of Congress after the November elections. But, you know, people joke, I mean, there's a reason why it's called lame, because it is, and there's not a lot of major legislation that does or should pass in a lame duck session. So, and it's gonna be totally dependent on what happens in the elections. It's really hard to predict what the dynamics will be after that, regardless of whether or not the House or Senate flip parties or whatnot. And there are a lot of, there's gonna be a lot of change, regardless of the November elections next year, at least in the House, and even has been some change in the Senate, in terms of who's in charge of the powerful committees that have the authority to write this bill. And some of those new members that are gonna be new chair, those members that are gonna be new chairman wanna put their own stamp and wanna develop their own bill. So there's a little bit of a tug of war going on there, but we'll keep going. So, you know, fee-for-service and value-based care is the way things are moving to value-based care. I don't think fee-for-service is gonna go away. And I think as you heard a little bit, it's still the basis for the behind-the-scenes calculation about how much you get paid, even if you're in some sort of global system. But we definitely are moving to a more value-based model, whether that is gonna look like accountable care organizations or bundled payments or what have you, there's definitely going to be a quality component built into your reimbursement. You no longer will just be able to do a service and bill for it and get paid. There are strings attached. You know, we're going from patients being discharged to being transitioned. I mean, the whole concept of the medical home and the whole concept of these, you know, the post-discharge coordination of care so that you can prevent readmissions and the like. We're, you know, used to be managing disease. Now it's, again, care coordination, where, you know, we're trying to figure out a system that will look, you know, bring everybody to the table and, you know, trying to address health rather than just treating people who are sick. So we're preventing people from going there in the first place. How are we going to try and react to all this and address value in neurosurgery? I think probably the biggest thing that we're doing right now that is, we're doing a lot of little things here and there. Dr. Ratliff is leading the charge on a lot of our quality-related programs. But I think one of the things that we're really gonna try and do to really be able to get at the heart of what's quality in neurosurgery, not as defined by the government, is the NeuroPoint Alliance and the data, clinical data registries projects that are coming out from that. The National Neurosurgery Quality and Outcomes Registry, the N2QOD is the first, you know, bigger, big project on the table. Is anyone familiar with the N2QOD project? And are any of your departments participating? So you have, you know, some of that. So I think, you know, we're really trying to collect, you know, relevant clinical data to evaluate patient outcomes, which will then, you know, lead to, you know, process of care and the like. But in a way where we can really, in a risk-adjusted fashion, decide on the front end when someone comes in and has this, this, this, or the other, whether or not they should get the surgery or not get the surgery. Right now, the N2QOD is the largest collaborative spine registry in the United States. It's now in about 53 sites. There's both lumbar and cervical spine modules. And there's about 10,000 patients who have been enrolled. They're looking at outcomes in, at the 30-day, three-month, and one-year. And so it's also, I think, the largest longitudinal database. But other modules are coming online. They're testing right now in beta test, a cerebrovascular module and tumor. There's a stereotactic radiosurgery collaborative project coming on. So we're really trying to develop a broad array of products so that neurosurgeons, depending on their practice, will be able to actually take a look at their outcomes and, importantly, satisfy requirements for your maintenance or certification once you actually achieve certification, these various quality reporting requirements for payment and the like. You can see, just on this one little snippet of data, how you could, based on, this is the information that's been gleaned from the database, when you take someone who's obese and old and has got a high school degree and compare that to somebody who's healthy, young, active, and has maybe a higher socioeconomic status and predict which one is going to be able to do better with a lumbar fusion if they've got a grade one spondylolisthesis. And you probably are gonna have a different kind of conversation with the patient number two who's 50% likely to fail. Why would you do that surgery if you have data that suggests it's not gonna work? So these are the kinds of things we're trying to do. So keys to your success, obviously, I think, are going to be focusing on the value proposition, patient-centered care, and you're going to have to find yourselves participating actively in these various different innovative payment models. Gone are the days, again, of the fee for service, deliver a service and get a payment. So I know, as I said at the beginning, you're going to push the delete button. There's gonna be a lot of information flying at you today as well. I think the one takeaway, all the takeaways is the government runs your life. I mean, that's not a political statement, that's reality. And so you have got to be involved, you've got to pay attention to both politics and policy development because it does have a direct impact on your financial and personal well-being, whether you're regulated to death or whether you can actually try and take care of your patients. And change is coming. I don't know, it's hard to predict with any degree of certainty what change is gonna look like, but things are changing. So I thank you. I'm always available by email or phone call. So you can find me on the websites or Google my contact information. So I thank you for your indulgence. I know that's a lot of information. Thank you.

Affordable Care Act

challenges for doctors

fee-for-service system

cost containment

healthcare system collapse

value-based care models

insurance exchanges

data registry project