PTAC | Reducing Barriers Presentation | Mar 3, 2025 | 1/8

DR. MILLS: Good morning, and welcome to this meeting of the Physician Focused Payment Model Technical Advisory Committee, known as PTAC. My name is Lee Mills, and I'm one of the co chairs of PTAC, along with Chinni Pulluru. Since 2020, the PTAC has been exploring themes that have emerged from stakeholder submitted proposals over the years. Previous PTAC theme based discussions have included maximizing participation in population-based total cost of care models, addressing the needs of patients with complex health conditions or serious illnesses, developing and implementing performance based measures, encouraging rural participation, improving management of care transitions, and improving care delivery and specialty integration, particularly within population based total cost of care models. At this public meeting, we've brought together various subject matter experts to gain perspective on reducing barriers to the participation of population based total cost of care models and in supporting primary and specialty care transformation. How do we effectively reduce the barriers for different kinds of provider organizations and move towards the goal of maximizing participation in total cost of care models? For today's agenda, we will explore a wide range of topics on reducing those barriers to participation in population based total cost of care models and supporting primary and specialty care transformation that includes understanding factors that affect different kinds of organizations' business decisions about participating, approaches for streamlined models, improving the predictability of benchmarks and incentivizing the participation of different kinds of organizations in PB-TCOC models. And specific incentives for improving clinical integration and supporting primary and specialty care transformation in different kinds of organizations that are participating in value based care and enhancing the sustainability and competitiveness of population based total cost of care models. The background materials for the public meeting, including the environmental scan, are posted online on the ASPE PTAC website's meeting page. Over the next two days, we will hear from many esteemed experts with a variety of perspectives, including previous PTAC members. We will begin our day tomorrow with opening remarks from Mr. Abe Sutton, the Director of the Center for Medicare and Medicaid Innovation and Deputy Administrator for the Center of Medicare and Medicare Services. I want to mention that tomorrow afternoon will include a public comment period. Public comments will be limited to three minutes each. If you would like to give an oral public comment tomorrow but have not yet registered, please email [email protected]. Again, that's [email protected]. The discussion, materials, and public comments from the March PTAC public meeting will all inform a report to the Secretary of HHS on reducing barriers to participation in population based total cost of care models and supporting primary and specialty care transformation. Over the next two days, the committee will discuss and shape our comments that will go to the Secretary. In February, we posted a request for input on the ASPE PTAC website to give stakeholders an opportunity to provide written comments to the committee on reducing barriers to PB-TCOC models and supporting primary and specialty transformation. To date, we have received two responses that the committee may consider in their discussion today. The request for input will remain open for public comment following this meeting and is posted on the ASPE PTAC website. Responses received after today's meeting will help to inform future PTAC public meetings. Lastly, I'll note that, as always, the committee is ready to receive proposals on possible innovative approaches and solutions related to care delivery, payment, or other policy issues from the public on a rolling basis. We offer two proposal submission tracks for submitters, allowing for flexibility depending on the level of detail of the payment methodology proposed. You can find information about submitting a proposal on the ASPE PTAC website. * PTAC Member Introductions At this time, I'd like to invite my fellow PTAC members to please introduce themselves, please share your name and organization, and if you like, feel free to describe any experiences you have with our topic. First, we'll go around the table and then I'll ask our members joining remotely to introduce themselves as well. I will start. My name is Lee Mills, I'm a family physician. I am Chief Medical Officer of Aetna Better Health of Oklahoma, one of the contracted Medicaid plans in the state of Oklahoma. Before that, I was Chief Medical Officer for a provider owned health plan in the ACA Advantage, Medicare Advantage and commercial space, and before that, a medical group and health system leader operating in practice transformation, in which I have helped implement and lead five CMMI models over the years. I'll turn to my right, Chinni. DR. PULLURU: Good morning, I'm Chinni Pulluru, I'm a family physician by trade. I've spent 20 years in the value based care implementation space running clinical operations. Currently, I'm Fractional Chief Medical Officer of Stellar Health, a value based care enablement company, as well as consult with organizations large and small in that transformation space. Prior to that, was at Walmart Health and scaling health and wellness operations, and prior to that, led a large multi specialty independent medical group in suburban Chicago. Thank you. Now, I'm going to hand over to Lindsay. DR. BOTSFORD: Thanks, Chinni. Good morning, I'm Lindsay Botsford. I'm a family physician in Houston, Texas, where I also serve as a regional medical director with One Medical. I'm the chair of our ACO REACH governing body within the organization. Prior to that, came through the Iora Health Network. I currently still see patients, in addition to managing our practices across the Midwest and Texas. DR. BHANSALI: Hi, good morning, everyone. My name is Henish Bhansali, and I'm a primary care internal medicine doctor by training. I serve as the Chief Medical Officer for Medical Home Network. Medical Home Network works with federally qualified health centers or community health centers across the country to help transition them into value based care. Prior to that, I was Senior Vice President for Value Based Care, Medicare Advantage, at a multi specialty group, the same as Dr. Pulluru in Chicago. Prior to that, I was at Oak Street Health as their VP and National Medical Director for Care Navigation, really helping patients across the country find the best specialty and other ancillary services. I was in academics before that. Pleasure to be here. DR. FELDSTEIN: Good morning, my name is Jay Feldstein. I'm currently the President of Philadelphia College of Osteopathic Medicine. I was originally trained as an emergency medicine physician and practiced that for 10 years, and then I spent 15 years in the health insurance world working in both commercial and government plans with a lot of value based purchasing, which in those days was called full risk capitation. MR. RAMACHANDRAN: Good morning, I'm Krishna Ramachandran, Senior Vice President of Health Transformation at Blue Shield of California leading our value based care efforts. Previously was at Healthcare Service Corporation, HCSC, and then prior to that worked for Duly Health and Care as Chief Administrative Officer, a large multi specialty group. And then before that spent about eight years at Epic, so installing, optimizing EHR software for health systems across the country. Good to be here. DR. KOSINSKI: I'm Dr. Larry Kosinski, I'm a retired gastroenterologist. I practiced for 35 years in the Chicagoland area and built one of the largest GI practices in the country. For the last 10 years, I've been involved with value based care, and it actually started with a project that became the first PTAC recommended physician focused payment model, which was Project Sonar, that led to the formation of SonarMD, a value based care company that's focused on chronic disease in the GI space. Currently, I'm also Chief Medical Officer of Jona, an AI platform company that is focused on the fecal microbiome. I've been on the committee for three years. DR. LIN: Good morning. I'm Walter Lin, founder of Generation Clinical Partners. We are a small, independent practice based in St. Louis focused on caring for the frail elderly in nursing homes and assisted living buildings. We have been involved with a number of different value based programs, including institutional special needs plans, PACE programs, home based medical care for the seriously ill, as well as bundled payments. Most recently I took the position as Clinical Strategy Officer of LTCACO. MS. HARDIN: Good morning. I'm Lauren Hardin. I'm a nurse by training and Chief Integration Officer for HC2 Strategies. We work with high cost, high needs populations in partnership with states, communities, payers, and multi state health systems, really focusing on innovation and developing connected communities of care. I spent multiple years leading care management innovation in all of the ACOs, including everything from Pioneer, all the way to BPCI, and then spent eight years at the Camden Coalition as part of the team that started the National Center for Complex Health and Social Needs, where I partnered with projects in more than 30 states, designing innovation for complex, high cost, high needs populations. DR. WALTON: Hi, good morning. My name is Jim Walton. I've been a member of PTAC for two and a half years. I'm a part time healthcare consultant, retired physician executive, and internal medicine primary care physician from Dallas, Texas. Over my career, I practiced primary care first in Ellis County, Texas, and then in Dallas. I led the community medicine and health equity improvement strategy for a large health system before shifting to value based care development for a physician led IPA in Dallas. That IPA contracted with CMS and commercial insurers for practicing independent physicians in and around Dallas Fort Worth and North Texas for commercial Medicare Advantage, MSSP, and Medicaid ACOs. DR. MILLS: Thank you. Let's go to our PTAC members joining us on Zoom. Josh, please go ahead. No, Josh. All right. We will proceed. Let's move to our first presentation. Four PTAC members served on the Preliminary Comment Development Team, or PCDT, which has collaborated closely with staff to prepare for this meeting. Jim Walton was the PCDT lead, with participation from Larry Kosinski, Henish Bhansali, and Walter Lin. We are very thankful and grateful for the time and effort they put into organizing today's agenda and preparatory information. The PCDT will share some of the findings from their analysis to set the stage and goals for the meeting. PTAC members, you'll have the opportunity to ask follow up questions afterwards, please. And now we'll turn it over to Dr. Walton. * PCDT Presentation - Reducing Barriers to Participation in PB TCOC Models and Supporting Primary and Specialty Care Transformation DR. WALTON: Thanks, Lee. Our title, as already mentioned, Reducing Barriers to Participation and Supporting Primary and Specialty Care Transformation in Population Based Total Cost of Care Models. I first want to say thanks to Walter, Larry, and Henish for their great help in producing that presentation. And, of course, we couldn't do it without ASPE and NORC's research and support in developing the slides. So thank you all for that. You know, as I prepared for the presentation, it occurred to me that PTAC, CMS, and many others are following in a long line of visionaries and reformers since Medicare's inception in 1965. Over the last 60 years, we've all been working to continually improve Medicare's social contract with America. Today and tomorrow, we continue in that tradition as subject matter experts, practicing front line providers and administrators, and policy experts work to help uncover barriers to participation in APMs, alternative payment models, accountable care, and MSSP as we find new ways to support primary and specialty care delivery transformation. In this, our objectives for our meeting, as Lee identified, first is this discovery of barriers to participation in population based total cost of care and other APMs. Second was to discuss the idea of participation pathways and the creation of participation pathways to help reduce key barriers. Third is to discuss ideas for better supporting primary and specialty care transformation to drive more value and help grow participation in accountable care and alternative payment models. And, lastly, discuss opportunities for enhancing both sustainability and competitiveness in the population based total cost of care models. Ideas discussed over the next couple of days, as Lee mentioned, will greatly assist PTAC in the work, so we encourage lots of discussion. We would develop a report for the secretary of this discussion and hopefully will help our colleagues in CMMI as well. So here's kind of an outline of the presentation that we're going to try to go through. So let's go to the next slide. We start with the first three slides being some basic working definitions. The first one being the accountable care relationship, which is, in short, a relationship between a provider and patient that establishes the provider as accountable for quality and cost for all of a patient's covered healthcare services. The next is our population based total cost of care model working definition as an alternative payment model, or APM, in which participating entities or organizations assume accountability for quality and total cost of care and receive payments for all covered healthcare costs. This last working definition is one that we developed for the healthcare business model, and it follows that a viable healthcare business model is one that allows a healthcare entity to provide healthcare services that meet the patient's needs and delivers value while ensuring a sustainable return to continue so that they would continue in the business of operations over time. After these definitions, we wanted to review some of the findings of ASPE's research, and you can find this on the ASPE website. There's a number of issue briefs, and one we want to elevate here is a study that was done between the years 2012 and 2022, effectively the first 10 years of MSSP and CMMI's work. And we see here in some of the results that CMMI models had gross savings between $7 and $11 billion over that decade. MSSP also had savings of around $23 to $31 billion. So it illustrates that the CMMI models were successful in reducing spending, and it was noted that it was best in those counties with high penetration and participation, and we'll spend more time looking at those elements for this meeting. This suggests to me that the likelihood of even greater savings potential in the future if barriers to participation could be identified and mitigated for more participation, especially in low penetration regions where Medicare beneficiaries have not had the access to participating providers. But beyond the savings, the research also showed both CMMI and MSSP models delivered more care coordination services, more coordination of care, and improved quality to Medicare beneficiaries. Next, we're going to take a more detailed look at some of the participation data for alternative payment models, both CMMI and MSSP models over the first 10 years. Here we summarize the data through the lens of a few key trends during the rollout of APMs. First would be that the participation has plateaued, and this is also true for all payers. Hospital and integrated delivery system participation has declined. Physician led ACOs are growing, and specialty care physicians are less likely to participate in ACOs. To illustrate these trends, the next few slides were published by one of tomorrow's SMEs, and the key point in this particular slide is to illustrate the continuous growth of physician led ACOs over the first 10 years. This next slide illustrates the plateauing of covered lives at around 36 million by 2021, and the number of ACOs plateauing around 900 to 1,000 in the same period of time. From the same study by Muhlestein, we see a graphic illustration of ACO growth plateauing across all lines of business a provider holds in their portfolio, commercial, Medicare, and Medicaid between the years 2010 and 2021. Again, this graph adds to the evidence illustrating the deceleration of new entrants entering alternative payment models, and as well a suggestion of acceleration of exits of participating entities in the ACO market. Here we see the information differently presented by market potential for growth for both physician and hospital system provider entities. As you can see, the low 6 percent penetration of physicians and 28 percent for hospital and integrated delivery system highlights a remarkable size of opportunity for participation to increase. The key point of this last graphic from the study assesses the provider adoption of Medicare advanced APMs, revealed that about 50 percent of primary care doctors and 70 percent of specialty care physicians have opportunities to join in participation in the future. The trends of participation and the magnitude of the market opportunity for participation of all providers and the entities they are aligned with is noted in this slide and is combined with the benefits. And when we combine that with the benefits to both quality and cost for both beneficiaries and CMS, has led us to want to take a closer look at the unique barriers hospital and integrated delivery systems confront when considering alternative payment model participation. This is best emphasized with data showing the increasing number of physicians and hospitals aligned with corporate entities and healthcare systems. We noted both market share and resource capabilities of integrated delivery systems enables them to provide high value and well coordinated care. So we wanted to know the trends of integrated delivery system participation. So the next few slides try to answer a couple of key questions concerning integrated delivery system participation. First question was, has there been a decrease in the number of integrated delivery system led ACOs, and the second question, are physicians and hospitals able to participate in accountable care if the entity they are affiliated with is not participating as the lead organization? The analysis to answer these two questions attract ACO participation among large integrated delivery systems for the years 2016, 2018, '20, and '22, and for the Medicare alternative payment models, MSSP, Pioneer, Next Generation, Global and Professional Direct Model, and ACO Reach. The data suggests the answer to question number one, the Pioneer model had 62 percent integrated delivery system leadership in the ACO in 2016. By the Next Gen model, had a falling percentage of delivery system leadership in the ACO. It dropped from 56 percent in 2016 to 39 percent in '20. And then finally, the Global and Professional Direct Model had only 23 percent integrated delivery system leadership by 2022. To answer the second question, the data showed on this slide attempts to answer kind of the second question. 90 percent of large and 70 percent of small Medicare integrated delivery systems had partially participated in alternative payment models each year of the analysis, 2016 through '22. In those that participated, however, a relatively small proportion of the integrated delivery systems hospitals and physicians participated. The graphic highlights the degree of penetration divided by large and small to medium integrated delivery systems. Other findings were noted that around 25 percent of large integrated delivery systems participated in more than one ACO, and around 50 percent of the large integrated delivery systems participating in Medicare ACOs spanned multiple states. So, key takeaways. We next turn to addressing the organization's -- let's see, I'm sorry. The key takeaways, the percentage of CMMI ACO models led by ADS, IDS has declined over time. Despite the large integrated delivery systems high rate of participation in Medicare ACO models, the percent of its providers' participation has been relatively low. So we're next going to turn to addressing the organization's characteristics that may be factors affecting both organizational participation and profitability in alternative payment models. This slide highlights the first three characteristics that we wanted to discuss during the next couple of days. The first is the organizational characteristics by type, and you see where we've grouped them together by ownership types over to the left of the slide with physician ownership, hospital ownership, and insurer ownership or payer ownership groupings to illustrate how we might organize this work. The second table there is organizational characteristics. Examples are management approaches, governance, clinical integration, EHR consolidation, and similar ideas of organization. And the third is the market characteristics would be urban or rural geographic locations, the area deprivation index of markets that are served by the organizations that want to participate, the degree of Medicare advantage penetration could all affect participation and profitability. When we considered the fourth key organizational characteristic, the business model characteristics, we felt the need to highlight important revenue concepts related to alternative payment model and accountable care. And the first point is the size of total annual revenue has a large contribution to the business model and its participation decisions in accountable care. The second consideration for revenue would be the mix of revenue sources for a particular entity. And the third item is the revenue of ACO participants compared to the total spending for the assigned beneficiaries dividing into low versus high revenue ACO definitions. For example, a large group primary care practice accountable for total cost of care may have high total annual revenues but may control a relatively small share of the total spending for the population. This would be defined as a low revenue ACO. In this slide, the revenue concepts related to ACO participation are represented. We identified business model characteristics as a key fourth organizational characteristic to consider as a factor impacting participation decisions. The key point of the slide is that ACO revenues as a share of total cost of care may significantly impact participation decisions. For example, as improvements in care delivery and overall health status could shift demand for some organizations who provide these services. Example would be inpatient care for a large integrated delivery system. When we looked at annual revenues, the size of the revenue for a particular organization may also influence decision, impacting the ability to invest in value-based care infrastructure and or their ability to or willingness to assume financial risk. And another example would be revenue sources could impact decision making, as the degree of the diversification of revenue portfolios may impact risk tolerance within an organization. In the next section, the subcommittee worked with ASPE staff to create an initial framework for linking the four organizational characteristic areas with participation pathway development for maximizing participation in accountable care and alternative payment models. Here, we particularly wanted to focus this idea on identifying pathways for increasing population-based total cost of care models. Our definition for this population-based total cost of care is a pathway may be considered as a grouping of healthcare delivery organizations treated similarly with regard to benchmarks, two-sided risk, and how performance measures affect payment when choosing to participate. This will evolve over time with this meeting. So, putting this all together, a picture is worth a thousand words. And here we see the various inputs that we conceptualized entering into the participation pathway creation with provider types and operational characteristics feeding into the organizational types along with market and business revenue characteristics all feeding into the participation pathway created for like groups of provider entities. The pathways produced have unique features and incentive structures potentially incorporated into existing alternative payment models with the ultimate outcome of maximizing accountable care mix of entities. We suspect organizational business model characteristics are useful for pathway development because they help explain why organizations may or may not participate in alternative payment models. As such, key business model characteristics like revenue, revenue source, management control, could serve as the pathway building blocks for grouping-like entities into pathways that best fit their business characteristics and where it's reasonable to apply similar payment approaches such as benchmarks, two-sided risk, and performance measures in the pathway for those entities. Additional considerations for discussion around developing participation pathways include that pathways may take into consideration certain factors that affect outcomes that are not easily modifiable by the organization, like area deprivation index or the geographic location that an organization is operating in. Conversely, pathways may not recognize factors affecting outcomes that are more modifiable and consistent with accountable care vision, like primary care and specialty care integration and clinical integration. Importantly, we all agree that the factors incorporated into pathways, future pathways, should avoid increasing complexity of administering contracts by both participants and CMS. Finally, given the rising influence of value-based care aggregators, for example, it's expected that they might manage 19 million beneficiaries by 2028, we may want to consider a different pathway for this type of entity. In this slide we illustrate some of the complexity connected to alternative payment model and pathways for various types of organizations. This slide attempts to illustrate this complexity, the total cost of care payment models within the payment ecosystem for all provider types, recognizing the reality of revenue source portfolio management at play. Moving from left to right we see an example of moving from fee for service, a pure fee-for-service payment system, to a full total cost of care risk-based payments in the brown or reddish boxes. In the blue ovals we illustrate the various CMS, CMMI alternative payment model payment policy options where participation pathways may be applied. In the green boxes at the bottom we see illustrated the various entity types that may be attracted to participate in different offerings available based on organizational business characteristics and alternative payment model pathways that have been developed. To end this part of the presentation we illustrate how the concept of participation pathways along the Y axis would intersect with pathway payment considerations along the X axis. This is the work ahead of us, taking the discussion and feedback of this meeting into consideration as we move to fill out the different elements of the different pathways for different groups of entities we desire to have participate. Next, I wanted to briefly touch on the topic of supporting primary and specialty care transformation to kind of start the conversation for some of our discussions later on today. Specifically focused on primary and specialty care transformation, acknowledging the first decade of accountable care's difficulty with increasing specialty participation. This slide highlights a couple of ideas previously discussed in earlier PTAC theme-based discussions, and the first point here is the importance of support for sharing patient data as being a key opportunity for improving care transformation. And the second point is the creation of nested specialty episodes that may be another key opportunity to encourage collaboration between primary care and specialty care physicians. For emphasis, this slide calls out two different potential approaches for nested specialty episodes. The first recognizes the opportunity for low-cost variation specialty services such as GI, gastroenterology, and the treatment of polyps or gastritis as a nested total cost of care model. The second idea around this, it recognizes the opportunity to nest specialty condition-based payments in total cost of care models as well. Finally, to conclude this presentation, we want to introduce some ideas around maximizing the competitiveness and sustainability of population-based total cost of care models. The main point here is that regardless of the number of pathways, there are policies that can also help make APMs and accountable care more flexible and competitive. Policy areas, considerations that might be considered relevant to improving competitiveness would be ideas that address consolidation of the marketplace, the impact of prevailing socioeconomic conditions and low penetration markets, the degree of Medicare advantage penetration, waiver participation incentives, beneficiary engagement incentives, and specialty care nested episode incentives. So now as I finish the presentation, we turn back toward the focus areas for this meeting, reducing organizational level barriers, affecting participation in population-based total cost of care models, supporting primary and specialty care transformation, enhancing the ability of population-based total cost of care models to be competitive, and how to maximize participation of beneficiaries in accountable care and improve the sustainability of effective population-based total cost of care models. So thank you and I look forward to the discussion. DR. MILLS: Jim, thank you and the PCDT for that rich discussion of some important topics. Before we open it up to the full committee, other PCDT members have any additional comments to add? DR. KOSINSKI: First of all, great job. It's a very complex subject and you presented it and organized it quite well. Three points. Number one, I think one of the main issues we wrestled with at the PCDT was this concept of low revenue, high revenue systems. How much of an organization's revenue is at risk from the APM? The more of an entity's revenue that's at risk, the more likely they are going to be to be full participants and maintain their participation over time. What we're seeing is that it's probably not high enough. Secondly, the data sharing issues are always an issue, especially outside of the integrated delivery systems where you have specialty networks that are not on the same EHR with the primary care base. This is a major challenge. And the third thing is the inertia built into the system itself in converting entities from fee for service to value-based care and maintaining them in that value-based care environment. The business model of the entity has to be considered in this transition because the if the transition to value-based care is not good for the business model of the provider entity, you're not going to have sustained adoption over time. So, major challenges. I hope we learn from our SMEs over the next two days. DR. MILLS: Other PCDT members, comments? Okay. We will open it up to the full committee. If you have a comment or question, just raise your table tent or your hand online if you're on Zoom. Committee. Okay. Well, I will take personal privilege to say I was struck by some of your early comments, Jim, about the participation in Medicare APMs have plateaued and backed off in many regards and that we're seeing a trend occurring in alternate payment models across lines of business or across types of payers. And that strikes me that that is similar from a Gartner change cycle that we're past the innovators and the early adopters, and we're entering the trough before you get mainstream adoption and later adopters. And what's significant about that to me is it takes different tools, different messaging, different discussion to move through that trough into later mainstream adoption. And I wonder how those concepts apply in this area. Other comments, questions? Josh, thank you. Go ahead online. DR. LIAO: Good morning, everyone. Josh Liao, physician and professor at UT Southwestern in Dallas. A really great PCDT presentation. I was struck by two things. I think the first is that last kind of section about competitiveness. And I think really from my perspective, that's important. I think the idea of maximizing participation is, really, I would kind of maybe just adjust and say, is it maximizing for the organizations and clinicians and patients for whom it makes sense and recognizing there are many different offerings, so to speak, in the market. You know, we want to make it competitive in a way where it's a really nice option for all these groups we're talking about. But I think kind of like a everyone should be, and everyone should not be, you know, loses the nuance, and I think this presentation really gets at. So I just, you know, really encourage us. And I know the PCDT is doing that because I saw all the slides to keep that nuance kind of front and center. So I think that's just my initial reaction, but great presentation. Thank you. DR. MILLS: Other questions or comments from the committee? Okay. Well, I will, again, add one more comment, which is I really appreciated the graphic at the end, which is original work and is starting to link the HCP LAN, you know, conceptual pathway towards increasing value on a value based payment concept, starting to link it to more granular pieces that any business would have to consider of where they start and where they move to. And I think that's really important for operators of many different sizes as they want to get into value based pathways. DR. WALTON: Yes. I wanted to comment on this, that particular slide. It struck me when we were discussing this topic that ultimately led to the slide was the challenges of portfolio management, payer portfolio management for physicians and independent practice or integrated delivery systems and the decision-making process. And I think that gets -- the graphic gets at the heart, to the heart of what in this meeting, we wanted to talk deeper about, which is how is it that given the 10 years of experience, the first 10 years of experience, and given this plateauing that we see of providers of all types in all different opportunities around accountable care, there is this kind of, number one, there's a learning that's taking place, right? There are these lessons. And some of those lessons are very painful, you know, financially painful for physicians and entities. And so one might think that that's kind of a natural -- as you were saying, Lee, a natural sine wave of participation of early adopters and then people kind of consolidating their losses, consolidating their lessons learned. So the thinking here is around asking folks that have been in the trenches for a while, doing this work, and experiencing these wins and losses, how they would maybe re envision the next decade or the next couple of decades of this work, recognizing in the sum total of the work, there has been savings, number one, and there has been improvement in care delivery and the quality of outcomes for Medicare beneficiaries. And I think that that needs to sit there as the centerpiece of what we're really discussing here in the next couple of days. But appreciating, I think, what Larry was saying, which is this business model portfolio management is kind of the rock and the big boulder in the middle of the stream that needs to be discussed and then incorporated, potentially incorporated, in this kind of participation pathway idea. So I think this is going to be a rich conversation in the next couple of days. MS. PULLURU: Just to add my thoughts, thank you, Jim. That was an excellent presentation. And thank you to the entire PCDT team in putting that together, along with NORC and ASPE. When we think about participation, what you very rightfully sort of put together are three levers. There's the financial lever, and we'll hear much more from our CFO panel, how the payment mechanism flows down to various organizations. There's the operational lever, which is how do these organizations operate? Are they interdependent? Who are they owned by? And are they single specialty versus multiple specialties? And then I would say the third lever is really how those two things come together in the percentage of participation, and how can we influence that? And I think that that's an important topic that is going to be fleshed out over the next two days. And I really like how one of the things that was brought up earlier by Larry was the percent of revenue at risk for an organization and that threshold. You know, I would encourage, as we listen to our SMEs over the next couple days, is to think through, you know, is that a lever? And could we potentially use the chassis that we already have in order to affect that to encourage participation? And so, you know, maybe affect benchmark to affect participation for various people at different, when they have more at risk. So with that, anyway, thank you. And next, I believe, is Josh and then Walter. DR. LIAO: Yes. This conversation just kind of made me stimulate another thought I want to just mention. I really like Lee's comment about, you know, phase of adoption, early, you know, adopters and innovators versus others. I would also think just, you know, what I really like about the slides is it represents all the different approaches that have been thought about, executed, that have not been executed. And I just, I think we have to just be a little bit careful there, right? It's hard to say people are early adopters or innovators for a model that comes and then it goes again and the model changes. So you're kind of re adopting it and it's not the same, you know, model. You know, if it was the same model all the way through, then you can say, okay, these people have not been in for five years or eight years. And that's part of, I think, really the power, so to speak, of MSSP. It's been around for a while. And so we can see it in its different phases. And I'm sure some of our panel members will kind of elucidate that for us. But, you know, it's hard to really say early, mid adoption when the models have changed a lot. So I think there's an overarching kind of pull to more and new approaches. And I think that's very good. But I think here we don't want to just add, we want to delete and remove as well or avoid certain things so we can have a kind of clear, this is what the offering is. And so we can see who the adopters are and what are the drivers and the barriers as the PCD gets helped us illuminate. DR. LIN: Jim, a great presentation. And thank you for leading the PCDT in this really important topic of reducing barriers to participation in PB-TCOC models. Now, as I've worked with you and the rest of the PCDT, ASPE, NORC, over the last six months on this topic, I think if I were to zoom out, the key takeaway that I have about barriers to participation in these total cost of care models is that there is an alternative, attractive, financially sustainable model that systems who choose not to participate can fall back on, namely fee for service, right? So this is where the business models really come into play because these organizations across the country have built their business models over the last five decades on fee for service, six decades or more. And it's easy to fall back on a model that your organization's built to thrive and succeed under. And as long as that alternative is available, then I think that creates a very big barrier to increasing participation. So I think we've talked about in previous public meetings, the need to make fee for service, as our experts put it, increasingly uncomfortable, but as long as it is a comfortable, profitable place to be, I think that's probably, in my mind, the biggest barrier. DR. MILLS: Henish. DR. BHANSALI: So as we think about fee for service versus population based total cost of care models, there are certain organizations within certain sectors that are delivering outstanding value within the fee for service structure. And, for example, if there are bundle payments with specific components of quality tied to them in addition to that, then we know that there's high value care that's being delivered, albeit in the fee for service structure. And so as we think about moving population based total cost of care, value based care forward, I guess part of the question is where is the lowest value care being delivered, and how do we create models to drive those structures and to create business models that optimize that sector of care delivery into value based care and make the fee for service business model within that sector the least attractive financial model? With the understanding, based on what Josh said earlier as well, is that not everyone over time will be in the value based care models, population based or fee for peer, whatever structure it is, but they'll live in the fee for service sector and yet deliver very high value. DR. MILLS: Other committee comments or questions? Once, twice? MS. PULLURU: I just wanted to kind of go back to the point that filling in that table on the slide that Jim had presented is one of the goals that we have at this meeting is really getting to the point where we could fill in more of that. DR. MILLS: Okay. Well, Jim and whole PCDT, thank you for that wonderful presentation and highlighting some important research and backgrounds. That's really sets the stage well to hear from our next panel, which will be CEOs and CFOs, to talk about barriers to entering value based care and population based total cost of care models. At this time, we will have a break until 10:40 Eastern Time. Please join us as we come back and welcome a group of experts for our first roundtable discussion. Thank you very much. We stand in recess for 10 minutes.