Good afternoon now my name is outreach to sac and delighted to be here as part of the program I haven't had a chance to participate in any of the sessions but it really looks like it's just an awesome opportunity for a lot of people from a lot of different perspectives for some really terrific terrific ideas to get together and learn a lot just a little bit about me briefly by way of context for the the comments that I'll have to hopefully put things in will be a Perspective I'm a physician radiologist by training actually a diagnostic radiologist So for those of you who really don't know some of the weeds of health care a lot of C.T. M.R.I. ultrasound kinds of things and in my dishes subspecialty training is an interventional radiology So I'm sort of one of those people the puts catheters and wires and stents and all those types of things in all sorts of parts of the body there's probably very few places in the body with great imaging as it exists today that through the skin you can't get a needle into the challenge of course is to do it and keep the patient alive that becomes a little bit more tricky and really becomes in the space of on some of the cool innovation that's out there but I'm going to be talking about the complicated reimbursement landscape for emerging technology and sort of you say well who's this doc in you know how did you get involved in this space so just a little bit about me with those is sort of an areas of subspecialty training you know some of the most high tech and from the perspective of the payer some of the most expensive services that are out there I actually for a long time was involved in the payment advocacy efforts of the American College of Radiology I headed up the Medicare carrier advisory committee for the society of interventional radiology back in the day when we were trying to get coverage cover payers start paying for things like stents in the legs and whatnot that's now sort of like DAW everybody does that and as well I was very involved in American College of Radiology as. It's advisor it's representative to C.P.T. current procedural terminology it's one of the coding systems we'll be talking about today and in that capacity was really the advocate for the specialty in trying to get new codes for new technologies out there and start some of the payment chain again that I'll be talking with you about today as well in that capacity learned a lot as with doing any new things and you're all in that space as well we make a lot of mistakes that we say gosh we could have done this better hopefully we'll have some stories to share with you there on how to a lot of opportunities to work with a lot of partners from other physician specialties and that's one of the challenges for innovators in the space working with us crazy docs we're not always the easiest breed to work with and we'll have some perspectives there and as well have worked with a lot of innovators a lot of folks in industry some of them have been in great collaborative types of arrangements where everybody was on the same page and we're working together and there's a number of stories and some of them you know I can't share necessarily all the painful details with each and every story where we were at odds with each other and I must admit as as a physician who's really interested in seeing reimbursement systems not be an impediment to the development of new technology I've been labeled by some of those people as you know he wants to stymie new technology when in reality the situation in almost all those stories wound up being these people didn't have a clue as to what the system was and sometimes that was sort of just blissful ignorance and in a number of situations they had gotten bad bad advice and were actually paying for it and so it is a rocky road to get to where you want in reimbursement and hopefully some of the things that I've learned on the trails over the last twenty years I can share with you in the forty five minutes I have left here so it's going to be a little bit tough but I try to do my best to at least paint some broad pay. Sure's for folks and I know there is a very different mix of folks in the audience some of you a lot of the stuff will be more familiar some of you this is all new and hopefully can you know spend maybe a half hour or so get everybody on the same page and hopefully have some good conversation at that point here and so I like to keep things really simple in these spaces again knowing I'm talking to a mixed audience and I'm going to keep coming back to my four rules of advice here people say you know all the policy makers the players they saw it's not about the money you know we all know the story they say it's not about the money it is about the money on and we do need to realize that and the monetary the financial concerns of propriety of different stakeholders is very very different so I would encourage you in a system that is very been very volume oriented in health care were you know the fat days of insurance companies just paying for everything or over you really do need to drill down what your value proposition is what your story is what you're selling and you've got a lot of different stakeholders you're going to have to sell that message to the docs the hospitals the payers I mean all those different people that are out there really encourage you to hone down your story and focus on that because we're in an environment of absolutely intense scrutiny for any new technology to move forward because the payers see new technology equals and bleeding money and you're going to have to overcome that and that's a huge challenge number three you don't always need a code whether it's a C.P.T. code or any of the other types of codes that are out there but you do need to make a determination early along whether you do need a code and if you do need it you don't want to get caught with your pants down later on because the cycle from a concept to a code is sometimes as long as a year and a half two years and that's if you do it right on so you do need to make that decision on the front end if you need a code we'll talk about some things there and finally my piece of advice which I'll sound like a broken record and just for the record here I'm so busy. Anymore doing some of my other our research and other things I'm no longer in the consulting business so this is not a shameless plug for me as a consultant that's out there but I would encourage you not to do all this stuff alone on you know if you start realizing that you're treading in some uncharted territory it's probably time to step back and buy a map or hire a navigator here. And so you do need to remember the context here and again I'm wearing the perspective of somebody who's more from an advocacy role to a policy perspective it's C.P.T. I now sit on the editorial panel so I'm one of those seventeen evil people that votes on codes and that gets all the hate mail after words in the letters from the lawyers for the last three almost four years I've sat on the executive committee of that body which is the first pathway by which all pretty much every appeal comes through and so everybody's you know venting propositions and stories from their attorneys wind up coming across my inbox and so I've seen a lot of that but I think you do need to remember whether it's a year of the rock or these other things is that everybody is acutely aware we're on an unsustainable trajectory in our economy for health care spending I mean if you look at the percentage of G.D.P. that is going to health care spending I mean we're on an approach of collapse right now and you know we could have a whole separate conversation about where we're going and where we should be going and all those types of things but everybody has to be acutely aware dollars dollars dollars I mean that's the thing nobody wants to pay for anything unless you prove that there's going to be value back for them and again my perspective why I'm hopefully sensitive to this audience is needs as people that are innovators out there when you look at this is an article from The New England Journal of Medicine back in two thousand and nine when you look at this unsustainable from the interval growth in various specialties and areas that are out there looking at the top at the sort of bleeding edge if you will of this it's met. Imaging you know we've slowed down a lot for a lot of the pressures with this but your concerns are ones that you know I've lived my specialty has lived as well and so when I talk about some of our challenges while they may not apply to you as individuals or to your teams hopefully some of the messages will resonate with some of the challenges that you have here so again come back to that first piece it is always about the money nobody wants to spend anything else not another penny and in fact they want to cut money and so you do need to be acutely aware of that regardless of what it is that you're trying to bring to market here. Now the folks across campus for me at the Rollins School public health I mean you know people can go out there and get their master's in health policy and all these types of things and spend all this time doing it I'm going to tell you sort of the Dummy's Guide to that here on health care policy makers see more spending and there's only two ways you fix spending you cut the price or you cut the volume or actually three ways your cup oath of on there and to some extent while you can get into all the want the theory behind all this most people that you're going to be out there trying to get through the reimbursement process this is all I care about is the spending piece and I sound you know immediately pessimistic about this but I think if you realize that that's the reality you're going to be much more successful in putting your stress sales pitch back to all these people and to get wins at all the various levels that you need to be there and some of the problem behind our current system is here is we've got this system of structured fee for service and this is a bunch of people lined up at your Wal-Mart to buy things at the cash register but this might as well be the way we as physicians get paid a bunch of people wind up in the outpatient center over it Emory University or any other radiology department in town here lined up to get the chest X. rays of their outpatient CAT scans we leave people waiting and then basically we as the docs have this magical machine the electronic medical record we dictate into and somehow behind the end of the thing at the. End of the month APEC paycheck shows up and so there's a lot of. Incomplete information by physicians like a lot of other stakeholders and how we actually get paid but the piece here is that right now our fate payment system for right or for wrong and a lot of it is wrong is we get paid for the volume of the services we delivered not necessarily the quality of those services and so let me give you a few examples again I know this is sort of Radiology focus but hopefully some of the messages are here and so this is a report of a really good chest X. ray report this is a portable chest X. ray we do lots of these in critical care hospitals like ours it's thoughtful it's meaningful it's got a whole bunch of you know really good information that's actionable for referring physicians and hopefully of value and the details are as important as hopefully you can take away it's structured it's long it's got a lot of information Medicare and national average pays radiologists or any physicians to read these eight dollars and eighty five cents for that interpretation which is interpreted that making the phone calls on all those other things associated with in reality how many radiologist do you think to actually take that you know seven minutes to dictate a report like that what almost none of them in fact this is the most relative value in a productive partner in my old private practice in Memphis here I mean he would crank them out and this is just illegible you know this is just voice recognition gone bad lines in tubes hardier So I mean I don't even know what it means and I do this for a living here. How much does he get paid for that report eight dollars and eighty five cents there and so this is the challenge under fee for service you want to come for some new stuff by golly you know if I'm a payer I'm saying I've been ripped off people been taking advantage of me here you need to prove that people aren't going to abuse your technology views the codes and all the other things there's a lot of skepticism and it's rightfully so and so you know I think increasingly as well and we're all aware I certainly am that the patients deductibles and our health plans is going up and up first dollar for health care delivery services are. I mean for me you all rather than this mysterious insurance company that's out there and so you know the additional complexity of this new environment here is you know patient eight dollars and eighty five cents gets two of these and I only have nine bucks to write a check this month who I'm going to send the dollars to on and I'll hopefully some of those concepts work to you as well there that you know if I'm going to have to actually choose with my own money I need to see the value of this service and so again I'm talking big picture won't be kinds of stuff here but hopefully provide some context for where we're going this is sort of a chart of over time on the X. axis here in viability and performance which really is you know for most health care systems for most providers that's dollars That's how much money I made and I came out in radiology I started my residency in one thousand nine hundred before we were computerized I mean I was getting paper cuts from hanging film and dictating into cassette tapes and you know three days later it would get transcribed I mean it was just a terrible delivery system but it was the best we had back then we've enjoyed these amazing efficiencies and I can read studies three or four times as fast voice recognition send out a report that's literally instantaneously in our medical records soon as it hits line on my P.C. and so we've done great under that fee for service environment not nest and this is assuming you're providing good quality not sending out those crappy reports Europe on but we've been more efficient and so you know our specialty like a lot of other technology based specialties where maybe the pointers I mean you know one nine hundred ninety I came out and we sort of hit this point around two thousand and seven for the specialty I mean it was just a great great ride to be you know young guy paying off your medical student debts and your mortgage and all that kind of stuff but scrutiny is on us I mean we're getting whacked after that I go heart graph that I showed you a New England Journal guess who had every bull's eye painted on his or her back it's every radiologist that's out there in a lot of other specialties as well and so this sort of old volume paradigm is falling apart and we could get into a whole bunch of the synonyms that are out. Or Accountable Care Organizations patient centered home but basically all these types of things that you're hearing about in the media really are value based care where we're saying you know what we can't just spend spend spend we want to spend for results that are out there and so I think the huge opportunities are going to be the people who can shift from some curve A to curve B. keep that horizontal arrow keep that vertical arrow short as possible I mean really good sort of through that gap of the interveners dilemma it's a how do I just pivot into this new market space in which really a very perverse payment system that we have right now and that's a huge huge challenge here I don't have all the solutions but at least I can point out some of the potential problems on and so again I hear lots of people that come to us and you know I'm preparing now the agenda for the C.P.T. editorial panel meeting for October I've got like sixty five Co change proposals to review and guess what you know a whole bunch of them that are out there you know I read into it me me me me and you know if there's a way you want to turn off seventeen people who have a fiduciary responsibility for looking after at least part of your health care spending that's it and so you know the ones that in their initials talking points their thirty second elevator pitch have the value piece that's out there they're the ones that are at least going to get the most fair due diligence by all the people and this isn't just the bias of me as an individual this is talking with people that I know that are in that whole system that I'll talk with you about in a moment here now how to providers get paid what I wish were only so easy so this is sort of I made a fictitious letter to the president of Blue Cross Blue Shield of Georgia you know I do most of my clinical time at Emory St Josephs you know Mr John Doe came into my emergency department with abdominal pain and I interpreted a C.T. scan please send me five hundred dollars I mean maybe you know twenty fifty years ago that's how it works but basically each of these things I mean you send them a letter it just goes in the circular file that's out there each of these buzz words that I have been here translates into a variety of different codes that are out there this place of service codes there's I.C.D. nine codes there C.P.T. codes. And by the way I only get paid sixty five dollars for that I wish I could get five hundred dollars otherwise I'd be retired off in the islands right now so this is the reality of the system and this is the paper claim version but the computer version is pretty much identical these are the claim forms that are billing operations that are billing operations are huge I mean the amount of support staff time they could spend to support and we've got pretty much you know a half F.T.E. to support every doctor I mean that's that's how much sort of stuff that goes in the back end of this if you look at all the lines of filled in on the paper form and nobody submit a paper but the electronic equivalent there's no space for words everything's got to be a code that's out there and I think this is a critical piece to get out there is that if you can't get your box your product to be filling in those codes then and you're going to payer and you may not be going to a payer for your payment here then it does not compute it just doesn't go into their data system and the whole chain downstream falls apart at that point and so I'm going to illustrate for you some of the ranchman's in which you do need codes or think about that you may need codes that are out there there's a lot of series where you don't need codes at all but if you do need a code you do need to be thinking about those things sooner rather than later because if you're ready to go to market but I don't have a code to be able to bill for as a provider guess what I can find your product there because I am doing this for free and I think that's the harsh reality of this environment and so the it all starts with the codes for a lot of these and again in a not for your individual products so if you're selling your information technology services to a hospital you probably don't need a code we'll talk about a few scenarios here if you're out there developing some new device a stent or a catheter or something like that we're likely than not you will need a code here and you do need to do that just consider that as part of your due diligence now there's this I.C.D. nine code that's out there or you know we're lagging behind the rest of the world as we do with America with a lot of things everybody else is on ten or eleven version but this is an international classification of diseases this is diagnoses. Why a large you don't need to be worrying about this whole lot where you need to think about whether you need to be in the spaces current procedural terminology does your procedure have a code to describe what it is if you don't and you need one to get paid guess what you know you've hit your obstacle point there at that point on the other hand evaluate your technology it may come in just sort of taking like the F.D.A. approach you know the equivalent of sort of a five ten K. if somebody has already got something out there you may be able to fall under a descriptor that's great an alternative technology and be just fine but you do need to be thinking about that and so back when I was an advocate do a lot of back and advocacy volunteer work for the American College of Radiology I gets a whack a do a radiologist call me up every week and say I'm not getting paid for this you know why can't you just get me a new coat and most of the time the problem wasn't new but here I mean codes are necessary but not sufficient for payment but you do need to understand the role of the codes that are out there to get paid most of the time it was because his dictation was crappy and his coders didn't know was going on or he didn't hire coders or a variety of the other things that are out there but there are some legitimate circumstances where you will in fact need coats on and so as I talk about things here and I'm going to walk you through very briefly this sort of spoke will approach of getting from C.P.T. to RB R.V.S. to coverage to payment policy to physician payment and if that all sounds dizzying in part is intended to be so here hopefully to give you a broad overview of things but leave you also a little bit intimidated by the system because if you're not intimidated by the system and I still am after twenty or so years of living in it you're going to fail that's out there I mean it's just it's a scary scary landscape and I think the important thing to remember with the central spoke here is health care costs in the center of this everybody all those bodies there has a fiduciary responsibility or at least believes they do to help solve part of this cost crisis that we have here and so each of these spokes in the wheel here is an opportunity potentially for people to squeeze things and make things difficult and so the. The challenge is much more formidable than it has been in the past of working your way through this we'll now I know there's other folks on the faculty in the program that are spending a lot more time talking about these types of concepts than I but I would encourage you when you're thinking about the reimbursement landscape to think about a couple things here number one Who's your customer and it sounds like this course is designed to help you all do that a lot also think about who's paying for it because the consumer of your technology or your services or your device may not be the person who's paying for it so I think that's really important part of your due diligence to realize that you've got different stakeholders involved so and then there's a few pieces in this is just on the Medicare side private payers have their own set of rules and guess what they're proprietary they won't tell us what they are that are out there so is as daunting as you think Medicare is at least Medicare is required by law to be pseudo transparent that's out there so there's a variety of different ways that I as a physician get paid you will potentially use device manufacturers and other people get paid here and so if you want to sell a device to a physician by and large you need to make sure that that service shows up and is somehow compensated under the Medicare physician fee schedule to get onto the Medicare physician fee schedule you need to C.P.T. code or there's an equivalent sort of Medicare version of Hicks' picks code that's out there but you know what as a general rule docs don't just sort of practice medicine on the street corners there are a lot of our services are provided in the physician office setting and so you know if there's a technical component to this a gizmo that I need to buy here and I'm using it in my office I will get paid for that under the Medicare physician fee schedule that's out there if I'm and there may be some things that I can do in that pass through space and that's a whole black box to me I still don't understand it other than there are some really good people that may help you identify whether you get some extra bucks to harder and harder to get but if I'm providing that service in a hospital outpatient setting guess what you still need to figure out a way to get the doctor Pedo the Medicare physician fee schedule because otherwise he or she is not going to provide that service we don't like to do a whole lot of stuff for free. That's out there but the hospital's going to need to get paid now you're going to hold different group of people at C.M.S. here the ambulatory people payment classification group the hops the hospital outpatient perspective payment system so you need to sell to those people as well get them to understand your services and get on their feet schedule and what if it's a service that you provide in the inpatient setting Well you need to figure out a way to to which which diagnosis related group this gets bundled into because that's how Hospital in patient services get paid and all of these potentially are passed through as well and again the context of this is that the insurance company meaning Medicare is paying for it but you still need to step back and say is Medicare or another insurer going to pay for this as at all and so really that's the same question is the question of do I need a coat the key thing from a reimbursement perspective and admittedly I'm simplifying this but that's sort of my goal here is to try to make some simplicity of this very complex environment here is who do you want to pay you know you've got customers that are out there you need to figure that out who's going to pay who wears the check coming into your company here is going to be a provider to pay meaning me or my hospital then you don't need a code you need to sell a value proposition back to me that Rich you're already getting a bundle payment for radiology services that are out there and my gizmo my software my Whatever your cell and there will hope you do it quicker faster better or get paid more for it there and in those situations you don't need a code I've seen a lot of people try to get codes for that kind of stuff waste of time completely but if you want to assure to pay you know you've got some new catheter drew into somebody's brain or you want to put a stent in somebody's whatever kind of thing by and large are talking about a device some of those are bundled in but most of the time you're talking about an insurer paying for those services and so I think this is a critical question for you not just who who's going to be the consumer of your services but who's paying for it and a very admittedly simplistic way provider insurer very different pathways because if it's a provider again you don't need a code you. To sell to me if it's an insurer you need to sell the insurance company going to have to go through this whole silly coverage pathway that I'll be talking about in a moment. So again don't get caught without a code again message yes or no. Is all. That's fine. Yes so so sort of niches if you're going out of market or out of network in these scenarios so why I again said it's sort of the simplistic approach there are exceptions and those are the exceptions where you may sell directly to the consumer to the provider of the employer whoever is insuring down in those situations there are some reasons to get codes there's reasons not to get codes or some people who strategically decided not to get a coat because they can get paid better so I'm admittedly painting with broad brushes and there are some there's going to be unique niches of exceptions that are out there but yes some people are doing and if you're marketing to you know a device that may be more cosmetic in a physician audit office setting you know who's paying well in that case the sort of insurer is the patient him her house or herself I mean you know if you're paying for cosmetic you know you've got some cosmetic surgical gig there you probably don't need a code So these are Mastercard I mean to the patients the worried well so again different markets there but no you're spot on lots of exceptions here and my point here again is you don't necessarily need a code but you need to decide if you need a code because if you need a code you don't got one who Boy you got to you just last two years of time so you do need to be thinking about this early here and so I'll share with you some of my perspectives again and this is a whole bunch of imaging studies just to remind you that I am a radio. Just in my stories we'll be radiology based here so in a we'll through this very quickly the goal here is not to get you to understand all these pieces but just to realize how complex and dizzying this is and again sort of each of these steps here related to health care costs that are out there on that so let me walk you through here the piece with this is if this is dizzying you don't understand it but you do realize that that sounds like it could be me on you do need to do some more due diligence in that space rather than say I'll deal with it later because a lot of these things take forever to get to and it's probably better addressed sooner rather than later here so let's talk about coding that's the space in which I live on current procedural terminology so this is on you know those of us in the editorial panel were appointed by the A.M.A. board of trustees the copyright holder held by the A.M.A. under the HIPAA legislation in the C.B.D. codes that was designated by Congress as a HIPAA compliant code set in is pretty much you know sort of the the law of the land although there are some exceptions that are out there and importantly the C.P.T. codes that describe what service was rendered and so this is again it's not the diagnosis it's the what because a lot of your stuff is going to be what for this group here where you do need to be thinking about C.P.T. a whole lot of sort of goofy stuff I mean there are these five digit code some are surgery some are radiology I mean there's sort of a nomenclature in the point here is not to know this other than to know this is sort of the Dewey decimal system that's been out there for thirty years and got a lot of people the audience for I don't know what the Dewey Decimal System had to memorize that kind of crap in grade school but it's a classification system I'm showing my age here and so a lot of these are very specific again in my space you know the nuances here seventy one zero two zero You know did probably forty of those yesterday to you chest X. ray Well guess what if it's a one of your chest ranks right it's a seven one one zero different code different reimbursement got to get it right there if you're selling pick lines which is a central catheter in an adult this is the code that's going to get your provider paid for that service if it's in a kiddie it's going to be seven or three six five six eight. They're so very specific and you know what there's not a whole lot of consistency from Code family to code family there you're really going to have some expert sort of tell you do I fit under an existing code or not everybody sort of golden ring to go for in this arena is a category one code some people refer to as real C B T codes by and large these are the ones that move through the editorial panel they go on to Medicare they and large good value huge literature burden huge proof of concept I mean I'm I'm cheering right now a literature review workgroup for C.P.T. to revisit this as to how many trials you need how many studies U.S. populations non US What happens if you've got an orphan technology here the burden to get to Category one is high but if it's if you know you think huge market potential you do want to be thinking about that the alternative as well though and these were disturbed when they came along with these Category three emerging technology codes on and if you have a consultant immediately dismisses these types of codes I would encourage you to just sit back and ask why in the old days these things never got paid but you know we're doing some work right now in the radiology space that you know for some category three codes I mean they're getting paid two thirds of the time it's not one hundred percent there but it's not bad here so this isn't necessarily the kiss of death that it used to be it's a complicated process here you know you individual society vendor you've got to do a bunch of paperwork with the American Medical Association staff it goes out to all the C.B.C. advisory group which is one hundred twenty physician organizations talk about herding cats and a lot of dysfunction that's out there a lot of different opinions they all way and those of us and yet a Tory Pownall review and vote on these things on the disgruntled people come back to us on the executive committee and you know we made moving forward or you know it may go back and say start it go back into the start line again here. So it is a pretty complicated process by a large For right or for wrong the physician specialty societies sort of have a lot of input into the process and if you can it all work with physician societies you would be well advised to do so particular. If you can find that your interests are aligned with hers because basically you know you're going to have somebody that's really experienced knows the process navigate you through that process and guess what do it for free because if their interests are aligned with yours they're your consultants I tell a lot of vendors hand things over work with them be the silent partner of the societies here they don't have to disclose anything financially you sort of help them to work with them and it winds up being a when the people who do it in the face of subspecialties society opposition run into a lot of troubles now there's a couple reasons you can have some specialty society opposition you threaten your turf you know what and turf you know money will motivate stocks that are out there but a lot of times again I've shared some stories or this or some anecdotes there that you know sometimes it's just you don't need a code in the first place don't do this you're wasting your time and so you do need to be careful with the reaction that you get here and yet a total panel is made up by a bunch of practicing docs like me some payers out there I won't go into all the details but you know on average you know it's about five hundred code changes a year I mean it's a lot of activity that goes on new codes old codes get deleted codes get modified here it's a fast moving process here and if you're coming in slow in the process you're probably going to get left in the dust here so you do need to know what you're doing here and I will go into the details of some of these Category three stories other than some of the doomsday scenarios nude currently standard of care technology and this is the amazing thing you know ten years ago these things didn't exist Cardiacs Cohen our graffiti when they came out as category three codes everybody said we're not going to get paid for it guess what they're now standard care getting paid for every day and so there is going to be a lag from the time you will introduce your technology get your codes until you pay for it and you do need to consider that in your business model here so you've got a code you know I can't walk into Sun Trust and say hey I did fifty seven one zero two O's yesterday and take my withdraw that code has to turn into something and get valued there and that goes through this whole rock process the RB R.V.S. of day. Committee process this is sort of that evil doctor society that you read about in The New York Times I mean they they're they're reporters here it's the rock that's out there and part of the reason for right or for wrong it's a whole lot of physicians societies look society level of interest as a whole doctor vetting process there and the rock simply makes recommendations to C.M.S. S. to here's how we docs think you should split the pot here that's out there but there's a lot of reasons that you know you you annoy the wrong societies in the process you don't work with the right partners that your battles going to be an uphill one on in these spaces here but ultimately you're going to need some more of you some relative value units will talk about minute how they get translated into dollars there's this complex formula that's out there I won't get you into the weeds with that there's a physician work component practice expense malpractise expense I mean all this stuff goes into evaluation of these services if you want to dock to get paid for your service or a hospital to get paid for your service on you may just want to check at the end of it but if you need other people to use your product to get you paid for your service you do need to be sensitive to their various needs and it's a very very complicated process here the whole process if you're successful to go from gee I'm sending in my first application to C.P.T. and some of this depends because this is an annual where you come in on the cycle here until you actually get a valuation from C.M.S. after it comes out of this our view process can take I mean fast process is going to be eighteen months to two years and a lot of it winds up being two to three years so if you do need to be thinking far ahead with these types of processes again who's voting on this this is a compensation of the rock it's a bunch of docs deciding among ourselves I say ourselves are not one of them never participated in the rock care how we're dividing up the physician payment pie and this is important for people says the rock sets the fees the rock does not set the fees they simply say C.M.S. you've got you know X. billion dollars per year we think this code gets you know point zero zero two. Percent of it we're going to sign in our view alternately as I'll talk with you about in the in a minute it's the payer that uses that relativity to determine the payments here but there's a lot of sort of perverse stories here I'll just go very quickly this is your own fibroid embolization a new technology that our specialty came up with about a decade ago we did a laborious physician survey the average doc with the new technology it was taking us about one hundred five minutes to do these cases the RUP wound up assigning us ninety minutes of work for this and again the weeds aren't as important here as to what did they use against us here what they want to be using against us was the literature for some of the trials that are out there be careful if you're trying to oversell your new technology or sell it I shouldn't say that here because everybody wants to say it's the best thing gosh golly we can do these cases really quickly and so what did all the vendors that were working with the investigators in this is based Do they pick these and sent these centers that were just machines these guys could do these cases in fifty six minutes and so in the literature is out there and you know the real docs in the trenches say it took me an hour and a half to do this kind of case to whatever No we've got peer reviewed literature in your journal that says it's fifty six minutes guess which one wins in a resource constrained environment so just be very very careful you don't oversell because overselling will undersell and there's a bunch of stories that are out there so let's go on to coverage policy here so you've got an R.V. you you know your device has been assigned you know to our viewers well what the heck does that mean well first of all is anyone going to even pay for it and so there's two worlds that you need to deal with that are out there on Medicare and on private payers as well that are out there and so this is where diagnosis comes into play again not important for you you're not going to be going after diagnosis codes but you do need to think about the indications for which a parable pay for your service and some of this gets very specific a specific particularly with new technologies are going to have to think about the payers have policies that they're going to cover it are you going to have to work with physician groups local payers Medicare the Nash. A level to sort of say hey I want a diet my C.P.T. code to have a diagnosis that pays for me as well and the concept here is one of medical necessity it's got to you know your diagnosis needs to match the procedure and I could give you some examples but by and large if you want to C.T. scan of your pelvis and you know I put on as the history that the patient had a headache you know maybe somebody is a pain in the whatever but by and large it's not going to get paid for that service so it does need to match here. Private payers much more complicated you know C.M.S. as much as you don't like them at least the system is transparent and go to any Medicare carrier's website find out what the coverage list is private prayers they just say proprietary So how do I find out what a service is a paid I perform and then three weeks later I get the statement back not covered service and you as the patient then gets the not covered service please pay the entirety here and you know in a five thousand dollars deductible environment you know how often you are likely to pay me not too often anymore here so I'm going to just get won't get too far in the interest of time here on into some of the examples here which again show you some of the ridiculous systems that are out there and let me get into some of these edits that are out there to just illustrate for you some of the complexities and there's a whole alphabet soup here let me just focus on this one this is one the C.M.S. rolled out a couple of years ago and again the perversities of how the government and other people make obstacles for us getting paid so back in two thousand and eleven you know I was in private practice then the morning I interpret a brain C.T. scan Medicare's me pays me one hundred percent of it's a fee schedule for that service the afternoon patient comes back you know inpatient I interpret a domino alter sound examination Medicare pays me one hundred percent of what the fee schedule is for that great two thousand and twelve they change the rules so in the morning on top of the brain C.T. scan in the afternoon patient comes back completely different study I do an abdominal ultrasound down the nation they only pay me seventy five percent because they said Well. There are some efficiencies how we understand efficiency completely different equipment different time you know I don't know but it was sort of where the government we're here to help you kind of rules twenty thirteen it gets even more perverse and again the point here is just to make you sympathetic to who you may be selling these to so you know this morning you know one of my neural radiology partners over to Emory interprets a brain C.T. examination here she's going to get paid one hundred percent for that I go back this afternoon I interpret an abdominal ultrasound for that patient OK I've been here the whole time he's reading it right now how much will I get paid seventy five percent why because I enjoyed some efficiencies that he did that in the morning I mean it's just perverse It makes no sense but again it's the government it's this bizarre system that you're going to have to work with if you're in Health Sciences innovation I mean it's just the reality of the situation on and again I'm focusing on physician payment but a lot of the same stories on the hospital side as well you do need to think about Medicare and private payers have their separate rules for valuing these things by and large Medicare is going to be more transparent you know most people will follow Medicare to some extent but the rules aren't always the same and so again getting into the weeds here isn't as important as the concept that there's all these goofy things that gets back into geographic practice cost indices conversion factors things like that that you may have done everything right to get your service paid and there's just some bizarre legislative initiative that changed the equation here and guess what you know you're out of luck here so it really is a daunting type of process I mean this whole Medicare conversion factor which is sort of the adjustment R.V. use Times conversion factor usually translates into dollars I mean you can see it is exhaust a seesaw here for us and it really does provide a lot of uncertainty for us in planning hiring in our practices or at the hospital now that I were a health care system leadership had you know deciding we're going to buy equipment not I mean lots of uncertainty that's out there and so with pride. Payors I mean it's even more you know bizarre here Medicare at least I know what I get you know I'm with private payers it's all marketing strength and if you're a small little startup and you're trying to sell your device you know you've got a hard time competing with Boston Scientific or barter the big players that are out there and you know that is a challenge here but as I wrap up in my last few minutes here you know hopefully I've illustrated for you and again I'm focusing on the physician side this issues may not be the people that you're worried about but the stories are going to be similar with all the challenges here goes back to health care costs every one of these squeezes over the last decade or so really has been just sort of ratchet down the price in the payment for these types of services and you do need to be aware of that and so you know here's sort of the best picture I have of the reimbursement landscape I mean I think it all depends on how you look at it you know this is someplace where probably there was you know some some river you know ten million years ago I mean it's sort of cool and if you could you know go hiking through there and get up to the top of one of those mountains I mean if you would just be awesome when it be cool that sense of self accomplishment stuff like that but the this is one of those places like yes what you slip and fall you're dead you know you don't bring along water or have a good you know you know a good guide and you break your ankle down in the right ravine you know you're dead you're just dead slower in the process so it is it is a harsh reality that's out there and so you know in wrapping up again I'll bring back to sort of my four pieces it is about the money it really really is even at the doctor level at the hospital level everywhere else the value proposition is right now everybody's going after buy my product is me it's me it's me it's great look about you you the customer but also the person that's paying if you do need a code Get It Now think about it now because otherwise you're going to add two years to your development cycle in getting it out there to market and my final piece is well and it minutely in forty five minutes there's only so much I can tell you about the landscape here but don't go it alone. Some of these points are resonating with you that my gosh I'm vulnerable there that's probably the time to retain the consultant to help you start thinking about those things it's now it's not two years from now because at that point it's really going to slow you down so I've got some time left would be delighted to take any questions of you know specific general whatever and who can have some THANK YOU THANK YOU THANK YOU. Yes to the question is you know where do you go for code first as a general rule on general rule the place where you want to go for a procedure or service code whether it's a molecular genetics testing whether it's for a new stand whether it's for whatever go to C.P. take care of procedural terminology get run through the A.M.A. shop but by and large everybody recognizes C.P.T. for physician professional services I mean there's some niches in the laboratory space where it's going to be unique there because if you can get a C.P.T. code by and large C.M.S. is going to recognize that it pretty much all private payers under the HIPAA mandate are going to recognize that now that being said we've got some quirky rules and C.P.T. there's a long window to get it through and so there are new products particularly if you're marketing to an Asian population who's more preferentially Medicare where you go directly to Medicare and they've got their own sort of C.P.T. if they've got Level two hips picks codes where you may go there where you may be able to get that cycle a lot faster but the problem then is you've got a G. code which Medicare recognizes but the private payers when they see it on the sheet does not compute they want an S. code or C.P.T. code but as a general rule you know you want to be is as as generalizable as possible in your strategy so you don't have to play individual payer games. Yes or. Yes So great great question so the ambulatory payment on classification is to C.M.S. system so it's for Medicare private payers may work in a bundle payment environment they may not and so basically under an A.P.C. system on it's a bundle payment for the technical side of services that are associated with that outpatient counter and it's a similar to an. In-patient encounter where you get a but with a hospital gets a bundle payment for the entire entity so if you come into you know Piedmont Emory wherever with you know with congestive heart failure with X. Y. Z. complications there's one price now you know we get a little premium because we're teaching hospital there's a geographic and you get one price for that which is really the impetus for all the hospitals to say let's reduce or like the state we can get you know if they're paying us based upon a model for five days and I'll come back every three minutes at the concepts are there bundled and I can get you out in four days guess what I freed up that bed and I can flip it to the next patient and that's were too many people now in the perverse incentives have gained it that everybody's talking about readmissions because you know and then if you came back in two days late later because I didn't treat you right in the first place I get paid for an admission again isn't that great no no I own that readmission for thirty days so the ambulatory isn't quite so clunky because the Q.B. care is not there but there's basically one price for the outpatient counter and so if you're coming in for you know a diagnostic colonoscopy because you've got you know hemorrhoids bleeding or whatever they get one price for that by and large at the hospital level for that you come in for a C.T. scan of the abdomen and you know whether I give you you know do it X. Y. Z. ways it's all one bundle price for the hospital there so they've got a bundle for that some of the devices can get passed through above that but not always but we are in the twilight zone and the hospitals in a bundled system but I as a physician I get paid per click So if you're in for five days I do five chest X. rays I get paid more of the longer the hospitals there so if it's confusing you it's because I'm still a little confused if. You know so many about yes or. Yeah so I the in one of my pieces here. I always get good advice and so this is one where I'm I'm treacherously at the periphery of my competence with durable medical equipment kinds of stuff I must have I probably you don't want any advice from me other than it's a different set of rules there on that as much as I can get into the weeds with the physicians side I would be really cautious about giving you bad advice there it's it's equally quirky that's out there but as a general rule for the D.M. me when I'm talking about some of these pass through types of codes those are the types of things you're doing that maybe separately billable aside from the encounter that are out there and so these may be some of the exceptions and you do want to be looking in that space. Yes. Yes So great question about the transparency the C.P.T. process and we have strived over the probably twelve or so years I've been in the C.V.T. process to get increasingly transparent so back in the day where I took over as the advocate or advisor for the American College of Radiology my predecessor said that you know here's the transparency you come in you walk in they say you know Dr promoter come on into the room Here's my buddy that taught me what I knew there you walk in you present your thing you walk out and you get a letter three weeks later it's increasingly going to an open meaning so you can come to one of our meetings you do need to sign a confidentiality. Disclosure on and that's one of the challenges that we're trying to balance in that space so anybody can come and if you can come to meeting you just have to sign a non-disclosure agreement on one of the pieces that we've been exceptionally sensitive to in that is that our requirements for a lot of literature your trial evidence and stuff is asking people to reveal some stuff that may be market proprietary there and so while people may say well you're not transparent Well we do recognizing we're asking people to bear their SOL here you know we want to be transparent but not naked in the process here and so you can come to any of our meetings but you basically can only talk about it in general sort of rules afterwards for somebody who's in the space you know and there are some consultants that are regularly in this space that they just sit there and they attend every meeting they're on they're not allowed to talk about specifics but you retain one of those people who will say Well there was a similar proposal it was sort of in the cardiovascular and here sort of how the panel did that if you want the open sort of summary session of things from C.P.T. that's out there you're going to get a boat the following were discussed and you'll get the answer in the book next year when it comes out and it's not a perfect system but you know we do realize we have to provide some protection just as if you're coming there we don't want you to bare your soul to the whole world that's out there so it's a double edged sword. All you will see it C.P.T. is the book when it comes out the next year here's the stuff that got the code what you don't see from that process is that nobody there's no appendix in the books that here's the people that went down in flames now that being said you can figure that out you go to the open portion of the website you know I've got access to all the weeds behind the scenes where you can go when you can see the sixty five tabs that are on the agenda for October and if you're smart enough you say OK that's on there that should be in the code book for twenty sixteen twenty sixteen the code book comes out which will be in February of two thousand and fifteen they're not who they probably went down in flames but you don't know they may have chose to postpone it they may have chose to voluntarily withdraw you don't know that other than it was on the agenda and it didn't get a code and no dot connecting. Great question you've been thinking about these things sort of heights here sophistication there yes. Anybody else. Will thanks so much pleasure being thank you.