PTAC | Reducing Barriers Public Comments | Mar 4, 2025 | 8/8

DR. MILLS: Welcome back. At this time, we'll have our public comment period. Currently, we have the pleasure of Ms. Florence Fee, Executive Director of NHMH, in person and present. If you'd like to go ahead and give your public comment. MS. FEE: Hello, my name is Florence Fee. I'm executive director of NHMH which stands for No Health without Mental Health. Thank you for allowing me to make a brief statement. So I represent the part of the public that encompasses mental health patients, families, caregivers and mental health advocates, and we believe mental health policymakers as well. My main message to you this morning is that there's a critical need to reform our U.S. healthcare system to allow for the integration of behavioral healthcare as an essential, foundational component of high-quality accountable care relationships, including population-based total cost of care models. If you have any doubt about this, just look at CMMI's record of the past seven, eight years where they've progressed from the CPC+ -- these are all primary care models -- from the CPC+ model to the Primary Care First model to the Making Care Primary to the IBH model, all moving closer and closer to optional, then mandatory behavioral health integration. Currently, our healthcare system is living with a 40-year-old outdated anachronistic carve out feature which separates mental healthcare from medical care in terms of care delivery, provider payment, and provider networks into completely separate independent systems. This may have made sense 40 years ago. But today, in today's world with the prevalence of mental healthcare -- mental health needs as we have it -- is so high, 50 percent of the American -- U.S. adult population has a mental health condition. And half of them get no mental healthcare at all. So this carve-out system makes no sense. It's hurting us terribly on an individual patient level and certainly at a population and societal level. It's resulting in poor medical and behavioral health outcomes for Americans, greatly increased total healthcare cost and frustrated, burnt-out providers as well as dissatisfied, sicker patients. And yet in its October 2024 RFI to identifying a path to maximizing participation in PB-TCOC model, there was not a single reference to the essential critical role of the integration of behavioral health in Medicare, primary care, accountable care relationships, hence why I'm here today. The field of science medicine and clinical care has over the past 30 years developed proven effective med/psych integration care delivery interventions. But they are not widely implemented or disseminated. What we need right now are increased financial incentives for practices that require accountability in order to build integrated care delivery into existing value-based payment models. Secondly, we need consensus quality measures on behavioral health and behavioral health integration, including predictability and stability of these quality measures. Moreover, we need to involve patients, caregivers, and clinicians in the design of new behavioral health integration and care delivery models and in the monitoring of their outcomes. For instance, behavioral health integration models will need to be modified for different health systems and different health populations. And we have repeatedly learned from past studies in model development that nothing is going to work unless patients, caregivers, and frontline providers are involved in the future. So this is not an aspirational vision for the future. It's an urgent, critical, present need. We are living in the midst of a national mental health crisis where there is a lack of access to mental health, evidence-based mental healthcare, a grossly inadequate mental health workforce, and skyrocketing total healthcare costs due in large measure to the fact that there are so much untreated behavioral health conditions which thereby prevent or impede the improvement of chronic medical conditions and thereby escalating medical expenditures and hence total cost of care. So finally, I'd just like to say that multiple healthcare systems as you well know across the country have moved towards patient centered primary care homes, ACOs, and prevention of 30-day hospital readmissions. As they do so, they are realizing many of their highest cost patients have med/psych comorbidity and that these health systems will have to integrate mental healthcare in order to be successful in the world of value-based care and accountable care. So the ACA helped push the American healthcare system in the right direction. However, it's a bit like turning around the Titanic. There are always vested interests that will fight these changes. However, the time for healthcare leadership, including amongst this group, for action, for reform and modernization of our national healthcare system to include the integration of behavioral health in medical settings is now. Thank you very much. DR. MILLS: Thank you very much. Appreciate your time, Florence. Now I will check in and just confirm. No other – there are no one else signed up to give a public comment. Is anyone else here present interested in public comment? No. Okay. Hearing none, I'll say that the period of public comment has ended and pass the baton to Jay. * Committee Discussion DR. FELDSTEIN: Thank you, Lee. As you know, PTAC will issue a report to the Secretary of HHS that will describe our key findings from this public meeting on reducing barriers to participation in population-based total cost of care models and supporting primary and specialty care transformation. We now have time for the committee to reflect on what we have learned from our sessions today and yesterday. So committee members, I'm going to ask you to find the potential topics for deliberation document tucked in the left upper pocket of your binder. And also, we know what to do if you have a comment. Just raise your nameplate or raise your hand. And then I know -- do we have our individuals? I can't see anybody on this screen. Josh is on? Okay. Oh, there we go. Great. So who wants to go first? And if nobody raises their hand or placard, I'll just call on you. So Josh, do you got a minute? DR. LIAO: I have 60. No, yeah, I have a minute. I continue to extend kind of some of the things I said yesterday. I'll just carry them forward and maybe layer on some of the things I've heard from our subject matter experts today. I think what I described yesterday about really not maybe -- addressing barriers is not to maximize necessarily participation as much as it is I called it optimize. I think today we heard about things like competition and really the goal being success versus competitiveness. I think those are related. I think you're not going to be competitive if you're not successful or have the prospects of that. But I continue just to double click and underline that point that I think what we want to do is remove barriers to make this a viable option as a choice for Medicare beneficiaries, Medicaid beneficiaries, commercial beneficiaries, et cetera, across the country. So I think that just, to me, the conversation today underscored that. The second point I appreciated is some of the -- the other point that I made yesterday about some of the tradeoffs, the real ones we need to make today. We heard from a few speakers about how you can go into the market level and do primary care pretty similarly in those markets. But it's very hard to do that for a specialty, right? So I hope we as a committee and others in the community grapple with this idea that if we want to scale and integrate, how can we do that with simplicity and avoiding complexity? Or do we want to embrace in times of complexity because that's actually a requisite to get some more specialists engaged. And I just think probably the only bad outcome here is to kind of not see any tradeoff on the horizon. There's probably three that I see that are pretty big. And I'll just cede the times the rest of the committee members, I'm happy to maybe have a discussion about what I think those three would be. But I think today's conversations helped to kind of brightline that for me. And so I hope in future conversations about especially integration, about multi-payer, about scale up, again, within or across payers and purchasers that we keep these tradeoffs kind of front and center. DR. FELDSTEIN: Thanks. Larry. DR. KOSINSKI: Well, in addition to what I said yesterday, probably the biggest thing that's going around in my mind permeated most of our discussions today. And I keep asking myself a question. It's clear that CMS doesn't really want the financial responsibility to continue the way it has. But who does it want to bear it, insurance companies or providers? I think the theme that came out earlier today was you have a Medicare Advantage. Well, that's insurance plans that are bearing the responsibility for the financing of care and treating the providers the same way they do in commercial plans on fee-for-service. Or do we want MSSP with provider organizations that are actually bearing the financial risk? Or do we want both? Is that the new world that we're going to have both of those, no traditional Medicare but providers bearing risk or insurance companies continuing to bear risk? And we were formed in the first place hoping that there would be a groundswell of providers coming up with value-based models. So I'm wrestling with this because I think if we want this to happen, then certain things have to be set into motion to make sure they happen. I want to say I'm very impressed with Josh's comment that came out at the end yesterday and he brought it up again today about complexity. That is something that should permeate our decision-making as well. If we want everybody on board, it can't be complex. It's got to be one size fits all which means some simplicity. I love Josh. That was fantastic. One of the other takeaways I have is that we still don't have effective models, even from our best SMEs, nesting specialists into total cost of care models. We're still scratching the surface of this. We still don't have a way -- at least someone who has already implemented successfully chronic evaluation and management services for chronic disease performed by specialists in total cost of care models. So that's still something that needs to be worked out. I said most of my other stuff yesterday. But those are my takeaways from today. DR. FELDSTEIN: Well, and the only thing I want everybody to think about is -- and we'll get the written documentation of the entire session. What recommendations do we want to make to the Secretary to move this forward? So just keep that in the back of your mind as we go around the room. And after maybe everybody does their initial impressions, we can come back to that if we want to. I think we're good till, like, 2:20, 2:30. So Krishna? MR. RAMACHANDRAN: Yeah, thanks. A few things, I think my one takeaway for the first session was I think just us having to define competitiveness better because it felt like people are interpreting as competition being traditional, MA and Medicare versus -- sometimes physician versus hospital. So I think, like, what are we actually trying to get a point on I think would be helpful, I think, for us to define. I assume it's largely a market-based competition, so sort of more MA was my initial definition when I heard about, like, be more competitive as opposed to competing between MA and fee-for-service providers, so just define an opportunity for us. From an inside perspective, I liked when the panelists on, like for giving our value-based care during graduate medical education. I thought that was interesting -- like, how we make that the new model of education or at least include early in the process. I thought it was fascinating there. And then from a smaller ACO, the sort of financial hurdle, making sure that's lowered as well because we obviously want more participation from independent providers. So those are the things that stood out for me. Thank you. DR. FELDSTEIN: We'll go to Lee and then Walter. DR. MILLS: Okay. These are just points that struck me throughout the two great conversations we had today. I'll try to put them together in a way that makes sense and kind of holds together. But first, I really appreciated the comment early this morning just about MSSP is the mechanism. Maybe seeing my pilots are where we learn new things and test out theories. But MSSP is the chassis we're driving value-based care on. And that was, I think, powerfully said. We did hear about -- there are ways we should think about making MSSP a bit more simple. There's the simplicity idea, whether it's possible or not. But at least make MSSP to those trying to operate within it perhaps more simple. But then I was struck by that it's blurred with MIPS. We need to get back to the idea of making MIPS much less palatable and MSSP more palatable as an option to tip over to that magic 40 or 50 percent number that we've heard today. We did hear that regarding the comparison of MSSP and MA, each has two significant flaws that could be fixed with policy choices that would make them stronger, first of all, for MA. We want to fix the Stars bonus issues and the risk adjustment issues particularly that could be gained. And that goes towards leveling the playing field. And then for MSSP, we want to fix the constant ratcheting and regressing to the mean that takes away your savings. We need to address the 4 percent clawback to make that just more reasonable and then allow practices within MSSP ACO structure to spin their savings in ways that make them more competitive to MA like reduced deductibles or additional added benefits. I think those are all really smart. I heard one of the speakers say -- while we're making policy choices, we're 20 years after American Board of Internal Medicine initiative. We should just not stop paying for low value care, right? There is some care that shouldn't be delivered in certain combination and just make the decision not to cover it. I did appreciate the comment about -- from Sean about where we are in the adoption -- the Gartner adoption curve that we've gotten the early innovators and the early adopters. That truly means we have to change fundamentally how we're thinking about it, the words we use to describe it, the messaging, what the incentives are. That changes completely from early adopters to first half mainstream adopters. And I think that's really well pointed for CMMI to think as they go about their work and build initiatives. We heard about -- again, about democratization and transparency of data. But that's not the goal. That's to enable more active choices so that we have more of an actual functioning free market health system that we don't have now. I thought that was powerful. And then I really appreciated hearing -- two more comments and I'll end. But just hearing a good example of how a specialty conditioned-based model can nest within a total cost of care model. That was a great example and well thought out, and it's really got my wheels spinning. I'm still not sure since in all honesty except for some MA plans that are full cap at risk and probably a small number of MSSP contracts that are similarly full cap at risk. There aren't many total cost of care models operating today that can do that model. So I think we need to think more on how can that work inside an MSSP model that's not full cap at risk. And then lastly, the brilliant idea someone mentioned about a model, the next best population to move to value-based care would be those in GME training and in how to build a model. And people that run GME training associations really hate how the funding is done and feel constantly straightjacketed. So, it may be a sweet alignment of forces that model offering value-based. It would fundamentally change the culture of those being trained and allow for more or better funding for the types of physicians the community needs, where that's done. So I thought that was a great comment. DR. FELDSTEIN: Walter. DR. LIN: Thank you, Jay. So I also have a lot of thoughts. But I'll just make three hopefully somewhat brief comments about my impressions from today and actually one comment from yesterday that I didn't get to. So, first comment, we've all heard for a long time now how unfair the playing field is between Medicare Advantage and traditional Medicare. I think today's first session just really highlighted that and made me understand how much worse it is. And it really is, how much more unfair it is, and it really is. And so, I just think there are things that MA can do through not only benefiting from the savings they achieve but the subsidies they get that traditional Medicare can't even under population-based total cost of care models. I think Dr. Pena made that very clear in his remarks today. And I just hope that we can continue to keep that top of mind because unless there are ways to level the playing field, it's pretty clear to me at least where all this is probably heading. Second point, one thing that I just would like to highlight about Dr. Shetty's comments from today is the care model that he -- Humana has developed through CenterWell that supports the payment model. So this committee is so focused on payment models as we should be. But it's a good reminder how in order to succeed in population-based total cost of care payment models, there needs to be strong underlying care model to support that. And in CenterWell, he described the numerous high access clinics, the home health services they provide as well as the pharmacy that all kind of come together to provide the kind of care needed to succeed under PB-TCOC payment models. And the last comment I'll make is around specialty care transformation and integration. One of the kind of aha moments I had during yesterday's afternoon session was from Dr. Frank Opelka who mentioned this idea of episode compare, right? And so we're all probably familiar with hospital compare, CMS' website, CMS' website on nursing home compare in my world. But this idea of episode compare or maybe bundled payment compare, bundles compare I think is fascinating. You know I think one way to engage specialists in value-based care is to have some sort of episode compare type idea out there where referring physicians can log on and see the value of care that their specialists in the area provide. I know -- I'm still a practicing physician. One of the frustrating aspects of my practice is not knowing which specialist in my market are high value specialists. And to have something like that would be really fascinating. And I just wanted to highlight that. So hopefully it gets into the report for the Secretary. DR. FELDSTEIN: Jim and then we'll go back to Josh. DR. WALTON: You know, I think we've made a couple of -- multiple times in the last couple days, I've heard this perspective that this is the physician advisory committee around technical models. And I can't help but kind of reflect on the comments that some of the physicians that were on the front lines made. And it kind of strikes me over and over again, like, a lot of the doctors that are still practicing and what I remember when I was practicing was this notion of a social contract that we had with our patients and this idea of Medicare existing to do the most good for the most people. And I think I agree that I think Josh calls us this question of simplicity versus complexity and can we get there from here with an aspiration of being simple. And the first thing I take away from this is that a lot of our colleagues that are trying to do this really important work of transforming the healthcare system in their lifetimes, over the practice lifetimes are really doing a lot of work around portfolio management of the payer sources that they get in order to stay in business. And this is kind of how we got started with this meeting which is to get our heads in the game around what the business models are for providers who are caring for the -- or front line caring for the patients. And the second component that seems to kind of play on this for me is competition and choice. The idea that our consumers, our patients need to be making active choices. We heard that today, and they need choices. And so hence, we have MSSP which is the ACO for the fee-for-service population. And then we have Medicare Advantage which is de facto the ACO for the non-fee-for-service population. But to me, that's going to land in this larger economic issue which is the global budgets, a healthcare budget from a -- how much can the population be willing to pay for Medicare patients to get healthcare? So, I think that's going to be a global budget, whether that's for MSSP or for Medicare Advantage. So, I think the products -- the way I'm thinking about it, the products for accountable care, value-based care, population-based total cost of care are kind of be both MSSP and Medicare Advantage because that enables choice. That satisfied that one requirement. And then the second, though, is that what we saw with the great research that our folks at ASPE and NORC did was that there was a disparity -- a geographic disparity in participation and penetration of ACO work in different regions of the country. And some reasons were not getting the benefit of value-based care. And some regions were getting more benefit. So, I think that kind of addresses this issue of quality. And so, when we think about cost and quality and the value proposition, I think that it's important for us to at least nod to this idea that there is geographic disparities in the penetration of participation. And I think that does lead to low versus high value care. I think there is a distinction there. And I think that the evidence being shown as we heard earlier today that physicians -- and we heard this yesterday too that physicians are willing to change their clinical care model because it's more gratifying to practice medicine. And I think that is satisfying that itch around the social contract. And we heard that younger physicians and providers, non-physician providers, are moving in that direction. And they're satisfied -- or more satisfied with the healthcare delivery because they're working in a different care model. So policy options have to be on the table as far as what we recommend to the Secretary. And I think, Lee, you identified some. I thought our last speaker of the public around integrating behavioral health has got to be one of the things that we write to the Secretary. That's got to be part of a policy option, whether that's incentivizing somehow that gets integrated. So I won't reiterate the policy options that need to be kind of considered for strengthening MSSP which is our purview here. So I think that's -- the last thing I'll point out is that one thing I picked up with regard to quality is that we heard yesterday around patient goal attainment being one of the really key innovations that we might consider as a quality measure that's shared between all payers as we consider what makes a quality accountable care organization or a provider network. So I'll leave it there. DR. FELDSTEIN: Lindsey. DR. BOTSFORD: Yeah, thanks, Jay. I was reflecting, I think, on Lee's comments from yesterday around diffusion of innovation. It was interesting to see some of those themes picked up in our presentation today around taking a look at where we are in innovation and what population are we targeting. The early adopters have all adopted and we're trying to move a different group now. I think in our previous meeting, the concept of building within the MSSP to allow the continuation of programs below the surface. And that resonated again today around you know we've heard themes around stability and the timeline of innovative programs. But I'm wondering whether the frame shift is more around building on MSSP and having the innovation take place there as opposed to expecting people to come up with standalone models outside of that. If you look at even the proposals submitted to this committee that have not materialized over the last few years, I do wonder if it speaks to a dwindling number of people interested in separate payment models outside of the MSSP space and whether we've kind of tapped the well, so to speak. So I think the affirmed commitment that MSSP is where some of the innovation will happen and that accountable care models will be tested in that space might be the answer to some of what we've heard in previous presenters around the need for stability and certainty for planning for the future. I think to Sean's points from today, that might also be one of the hurdles for attracting providers that aren't actually looking for major innovation. They're looking for the new status quo or the new normal as was referenced today. And maybe that also addresses some of Josh's concerns around complexity and not creating too many other programs and really just focusing and narrowing as opposed to continuing to expand. We wouldn't want to lose track of the opportunity to innovate within the MSSP space and continue to solve problems that were raised and highlighted again today which I won't be -- so I do think the quality measures, some already spoke to. But I would just highlight continuing to move away from process measures, even in the MSSP space. As we start to see more downside risk, will reduce some of the burden and I think decrease the barriers to the later adopters wanting to participate. Thanks. DR. FELDSTEIN: Josh. DR. LIAO: Yeah, when Jay says, come on, give us recommendations, I try to step to it. No, it's a great reminder, Jay. And I think just actually getting a chance to hear the other committee members reflect, I mean, I go back to that idea of we heard from an SME today about how you can think of population-based total cost of care models doing different things. But it's probably a better tool for certain things than others, right, lowering spending for an allocation under a fixed price or a fixed amount of spending. And so I kind of take that analogy and I think, what is the role here? And another SME I think I very much agree with kind of notes that there's this tradeoff between accessing quality and cost. I think you see that in the fee-for-service versus MA markets. So, to an early point from a committee member, I think about competitiveness in that broader sense, not within a certain segment, I think across. And if I were to kind of say this directly, population-based total cost of care models to me represent an intermediate point between that, those things, right? The original entitlement of traditional Medicare is an open network, right? It's a uniform benefit structure. You can go anywhere you want. The benefits of MA, supplemental benefits, but yet there are restrictions, network effects, prior authorizations, et cetera, et cetera. So that's a continuum, right? And I think population-based total cost of care models bridge that in some way. So the real question for us is, do we think an intermediate offering, if you kind of pick up what I'm putting down here, is useful, I tend to think so. That would be a recommendation I would consider to make, that there is an intermediate that we need. And that intermediate needs to be based on the right goal and have the right value. But if those things are both true, check, check, then we need to make sure it's competitive, right? We can't ratchet people down. We can't have a rebase. And we can't do all these things. We need to preserve that intermediate offering. And I'm not even saying there's three. This may be another thing to recommend that maybe there's work that we can do to kind of feather out, is it four, is it five? Someone made a -- or is three? Someone made a comment about MIPS. While I appreciate that MIPS is flawed in certain ways and you know I think the comment was about blending, isn't that in some ways what we want with a glide path, though, or a transition or a pathways or a step up to value? We want that in some ways, right? So, I think what we need to do, I think, for something like MIPS is we're using that tool for too many things. We're using it for rate adjustments for everybody in the fee schedule. But then we're also using it for, like, non-advanced APMs. I think we need to adjust some technical pieces there. But is there a fee-for-service? Is there a MIPS fee-for-service? Is there an APM built on the chassis of MSSP, the very specific, complex, but narrowly focused at market level, especially integration models? And is there MA? And is that world something we think we could do? I'll just leave that for the committee's consideration. But one final thing I'll say is what that requires us to do is not try to overfit. So, I think Jay actually had a comment about maybe this model is not right for some rural. I tend to agree. I think there are probably segments where we should not try to pull population-based total cost of care models over it because it's not the right tool for the job. I don't think that's a defect in our system. I think that's a feature. And so those would be things I think we could maybe consider for recommendations to the Secretary. DR. FELDSTEIN: Thanks, Josh. Chinni. * DR. PULLURU: A couple of things that I wanted to sort of add to the conversation was you know I agree that during the course of these two days, in particular this morning, MSSP or traditional Medicare is not competitive with MA in so many ways. And the point of which is to create patient choice, particularly if that choice comes through MSSP or Medicare Advantage. How do we think about that choice in empowering patients? So, one of the quotes that I found really elucidating was not what we pay -- there's two things. There's what do we pay for and the other thing is what do we spend it on. So, you think about the financial model with the operational model. And in a lot of ways, yes, MA wins in the financial model. But to be honest, it wins in the operational model, right, because there's creativity that can have a physician like Dr. Shetty and his organization be able to do what they did and reinvent the care design. And so and that's much harder to do, whether it be utilization or other things in traditional Medicare. And so that's even when you're taking risk. That's one of the issues. The other thing that struck me was Dr. Shortell talking about low value care being about 100 billion, possibly 300 billion. What it tells you is that as much as we struggle to find the pennies at the end of the trail, there's still money that is low value care. And that's a lot of money. A hundred billion is a lot of money. Three hundred billion is a lot of money. And so I think it's important to pull ourself back and say we're fighting really hard to sort of find these pennies in these margins for patients who are very high -- very sick and high acute care. But there's still a lot of money spent on low value care. And then lastly, I'll say one of the coolest things was Dr. Koenig talking about orthopedics and some of the redesign he's doing and coming from a multi-specialty group where a lot of that was done in value-based care. The ability to maybe use the chassis we have and find a way to include specialists in -- and one of the things that struck me about that was we've all talked about there's obviously the bundles. And we've talked about nested models. But having flexibility regionally or pushing that sort of flexibility down to the region when it comes to things like cardiology, orthopedics, or high specialties because specialty care is very regionally mediated in competition, right? Some places like Chicago, there's five different cardiology groups with 40 cardiologists and each that one can pick from. You go to rural areas, there's two cardiologists and they belong to the same group and you can't really pick. So how do you make that work in value-based care? And so do you bundle that? I think that kind of flexibility that goes more regionally is really important when it comes to specialty care. And I feel like that's one of the things he highlighted. And that's what also allows -- and then I'll end with one other thing is access. One of the things that comes from home health or telehealth and we speak about parity and we speak about the ability to do that. That flexibility exists in Medicare. But oftentimes in the programs we're talking about, we don't assign a value to access. Time of first appointment, same day appointment, time of return appointment, time to specialty appointment, there should be a financial value in the delivery system that is assigned to access. And I gathered that from some of what the presenters earlier said. DR. FELDSTEIN: Thank you, Chinni. Henish. DR. BHANSALI: So I'll pull down maybe a little bit of what I've heard Josh say as well Chinni is to have that middle model from the fee-for-service to the fully total cost of care, Medicare Advantage, something in the middle. You know we want that model to be viable and strong and minimize as many flaws as there are in that model to really enable better outcomes. We also heard that the next addressable market is the remainder of the primary care docs. We also heard that there's a 13 to 1 ROI and investment in primary care. So this may sound simplistic and maybe it is. But if there are folks in one of the middle models, ACO, MSSP, et cetera, whatever it is, then can that fee structure be changed to increase the amount of money that goes to primary care, so on the fee-for-service chassis which is still within that construct? Because just by doing that, there will be an increased interest in participating in these models. And then there are also multiple different conversations around conveners being a part of how a model like this can actually be adopted by the middle market. So not necessarily the early adopters but the middle adopter group, the next addressable market. And I think one of the SMEs spoke about how there was two to three percent participation early on, and then now it's up to 30 percent participation through the convener enabler. There was someone -- another SME yesterday that talked about the vital role of enabler. And if enablers are working with both Medicare Advantage as well as some of the middle products and they have a good amount of flexibility on how they can repurpose the monies that they're receiving, then you can actually put those two things together. Improve the fee schedule which -- just by the nature of it will increase the amount of engagement with PCPs. Potentially have outcomes that are structured much more around -- or metrics that are structured much more around outcomes like utilization outcomes. All though if it's total cost of care, then it's not as necessary. And then given that it'll create higher adoption having these conveners be able to structure payment, et cetera, to incentivize the right behavior to then drive those outcomes, that can create a competitiveness of this product while still creating a lot of the -- or still resulting a lot of the outcomes that we want and increase primary care investment and uptake. So that's at least how I'm finding some of the things of what I've heard together. DR. FELDSTEIN: Anybody else have any final comments before I turn it back to Lee? Okay. DR. MILLS: All right. Thank you so much, Committee. Amazing meeting. We heard some really incredible and innovative thoughts and insights. And I think we've served up rich grist for the report to the Secretary I'm looking forward to helping craft. I want to check with staff to see if there's any clarifying questions or other issues for the committee. Okay. Seeing none, I want to thank everyone for participating today, expert presenters, panelists, my PTAC colleagues, and all those listening in on the livestream. We explored many different topics regarding reducing barriers to participation and population-based total cost of care models in supporting primary and specialty care transformation today. A special thanks to my colleagues on PTAC. There was a lot of information packed in the two days, and I appreciate everybody's active participation and thoughtful comments as always. We will continue to gather information on our theme through a request for input on our topic. The RFI is currently posted on the ASPE PTAC website. And you can offer additional input to the questions we posed in that RFI up to the deadline of March 28th. The committee will work on our report to the Secretary with our recommendations and the public input we receive. * And with that, one final thank you to the committee and all the expert presenters for joining us and making this a memorable PTAC public meeting. I announce the meeting is adjourned.