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Otherwise, we'll likely hold on answering those questions to the end, but we'd love to see them come through throughout the presentation. So as I mentioned, today's webinar is really about value-based care, and if there's anything in the last 20 years of my time in cardiology that has experienced fits and starts, it's value-based care. This has not been a quick transition or something that's been grasped the first time, and it's because to make that transition, there's so much that's required to do so, including models that make sense for folks, making sure that we have data to target performance improvement, collaboration with payers in a real trusted environment, solid relationships with payers, and certainly a willingness to take risk. And I think we're all willing to take risk in our lives when we're confident that we could be successful at creating a better outcome for all. That level of risk-taking seems like a no-brainer when we have that confidence, but to get that confidence, to be willing to take that risk, we've got to tackle those issues. We need to have the tools, we need to have the intelligence, and we need to have the support that emboldened us to be confident in a value-based care model to usher in the future. And today's presentation is about providing that intelligence, that support, and what it takes to be successful in value-based care. So our three speakers today, we have Dan Blumenthal. Dr. Blumenthal is the Chief Quality Officer of CVA USA. We have Catherine Evans, who's the President of the Novocardia and Novolink Division, which is the value-based care division of CVA USA. And we have Dr. Greg Sanders, who's the Founder and CEO of an organization called HybridChart, which is a supporting tool that can really help folks to be successful in value-based care. So excited that you've been able to join us. Thank you in advance to our three speakers, and I will turn it over to you, Catherine, to take us away. Thanks, Joe, appreciate it. I think we quickly have some disclosures, which is the same disclosure for all three of us, which is that we own equity in Cardiovascular Associates of America, and that Dr. Sanders has equity in HybridChart. So what is value-based care? I think we get this question a lot. What does it mean? How is it different than traditional fee-for-service? And the way I like to think about this is fee-for-service is exactly what it sounds like. You get paid a fee for a service that you provide, and it really rewards service delivery. Value-based care is really more of a fee-for-value. So the care delivery model is based upon, and the reimbursement model, are based upon managing specific quality and cost-related conditions. And the reimbursement models are rewarded when you achieve those quality and cost-related outcomes. So it's really value of the health outcome over the cost to achieve it. So the U.S. healthcare system is moving toward this value-based care model more and more, and there's very good reasons why, which we've outlined here. The national healthcare expenditures, over $4 trillion, accounting for nearly 20% of the GDP. Medicare is expected to grow from 64 million to 80 million beneficiaries by 2030. A cardiovascular disease is accounting for one-sixth of the dollars spent in healthcare, or $320 billion in direct medical spend, and that's today. So already, we have a huge opportunity in terms of just the volume that we deliver in cardiology care in order to have a true impact in the healthcare system. Annual cardiovascular-related direct medical spend is predicted to grow to 750 billion by 2035. And because of this, CMS is really looking hard, of course, at where are all these dollars going, how are they being spent, and how can we provide the best possible care and the best possible quality? And through that, they are looking at all of these fee-for-service Medicare beneficiaries and saying, how can we get them all into value-based relationships? And they have set a goal of that happening by 2030, which is just five short years from now. So what does this look like in practice? How is value-based care different? How would you manage a patient differently? And then how does that reimbursement look different to you as a practice or a clinician? So this is a case example where you have a patient with heart failure, and he's gained 10 pounds over the past 12 days. He's short of breath when climbing the stairs. And at 9 a.m., he calls his doctor's office and says, I'm short of breath, I don't feel well. What am I gonna do? Well, by the time the message comes to the cardiologist at 6 p.m., so he's been here all day, he's short of breath, and so the physician says, go ahead, double your diuretic, go to the ER if your symptoms worsen, and then we're gonna get you an office visit to come back and see us. But guess what, we're really busy, so it's gonna be three or four weeks before we can see you. So two nights later, Mr. Jones gets short of breath. He calls 911, and he goes to the ER and gets admitted. I think we're all very familiar with this story, and it happens every day in this country. And it's just, frankly, the way our system is designed and the way we are incentivized. There's not a right or wrong answer here. This is just how things are working for us today. In a value-based approach, when Mr. Jones has this shortness of breath, we've actually identified Mr. Jones early on as somebody who may be getting short of breath through a risk stratification model. And we think that Mr. Jones is high-risk, and he gets enrolled in a heart failure program. So we're monitoring him on a regular basis. He has remote patient monitoring tools in his home. He's working with a nurse practitioner, a health coach, a medical assistant, a really strong interdisciplinary team. And through all of these interventions, they identify that he's gained four pounds. And so we're able to get him out of the hospital and we're able to bring him into the clinic in the same day. He's seen by a nurse practitioner. They order some labs. They do a physical exam, administer IV diuretics in the infusion area, and plan for a virtual follow-up the following day. And with that virtual follow-up the following day, and through the RPM, we identify the patient is feeling lighter, he's feeling better, his medications are adjusted, and he schedules his follow-up to continue to support his heart failure education, and he's working with a health coach. So you can see the cost differential here, right? In a value-based approach and a fee-for-service. The total cost is $15,000 for this admission, less than $1,000 for a value-based approach, a better quality experience. Someone didn't have to suffer a hospitalization. As we all know, during a hospitalization, that $15,000 can rise very rapidly with a nosocomial infection or some other type of complication or other decompensation. So it's truly just a different approach, moving care upstream, providing more resources in the outpatient setting so that we can avoid that inpatient care. So this is really what we think of as a classic example of how a value-based care management looks different. So our specialty is very dependent upon public funding. As we mentioned, it is quickly focused, quickly shifting to value-based models. I will tell you, CMS is really looking hard, as we've seen, not just at value-based care for primary care providers, also for specialists, right? We've seen models coming out around CKC, so really thinking about end-stage kidney disease as well as musculoskeletal, and I think we're in oncology, right? And so really, CMS is starting to take a look, again, at cardiology. And as we know, 70% of cardiology patients are Medicare beneficiaries. So of those beneficiaries that you're managing, about 70% of those are in Medicare Advantage or ACOs. So again, moving that to that 100% is going to continue. That momentum is not slowing down. And I think that independent entrepreneurial cardiologists have a huge opportunity here and an enormous comparative advantage because of the way that our practices are designed to be separate from a health system. We really are at the forefront and the driver's seat in order to take advantage of this shift to value. And certainly with prioritization in this, we can be very successful in this world. So this is a question we get a lot around, what is value-based care? How does it look? How do I contract? What does it mean? How am I reimbursed? So I really want to show this slide because I think it really demonstrates the importance of showing how value-based care lives on a continuum. It's not just one thing. It's not just one model. There's a lot of different ways to think about participation in value-based care. So if you start on the left and really kind of those emerging models, direct contracting is one place, fee-for-service with quality kickers, this is something you've all probably seen in your practices pretty regularly. A payer comes to you and says, if you are able to close these gaps in care, if you better manage hypertension, if you better manage lipids, then you will then get this quality bonus down the line. So that's what we think of as really the emerging value-based care and moving into the space. Then we start thinking about bundled payments. Again, I'm sure all of you are very familiar with bundled arrangements and these really help to reduce unnecessary costs. This is where you really start to see some of this additional support coming to patients and where we start to think a little bit differently about management when we have these bundles in place to shift side of service, managing patients a little more carefully in the office so those bundles are successful. So that's, as we think about that, they generally also have quality kickers associated with bundles as well. And then we get into that more maturing value-based care. So this is where we think about shared savings arrangements. So ACOs are an example here as well. So this is upside only, meaning you're sharing in the savings with a payer, whether that's CMS or a Medicare Advantage payer or commercial payer. And you're able to do that because you are reducing unnecessary costs. It is where a benchmark is set and you are providing costs at a lower than the benchmark that was set previously. So essentially, if cost of care per patient was $1,000 in 2024, and in 2025, you provided that care for $900, that $100 is savings and you share in that savings with the payer, give a 50-50 arrangement, that is $50 to you, $50 to the payer. And if you have a large enough population, those types of arrangements can become very significant in terms of the savings that come back to you. And when we say upside only, that means that if for some reason the costs go up, you don't lose anything. You're not paying out of pocket for that, right? If you're a winner, you win, but you're really not necessarily a loser. You're not going to necessarily have to pay back dollars to the payer. But as we get into more mature arrangements, that's where you start seeing things like upside and downside. So taking downside means you are willing to take a risk, meaning if you do not save those dollars, then you are going to have to pay dollars back. The flip side of that is if you save dollars, you get a lot more savings back to your pocket. So higher risk, higher reward, right? So that's how, as you move down the continuum, value-based care begins to work. This is where you really have to start leveraging data and having a platform. And you have to have true interdisciplinary teams that are really managing this population that you know exactly who these people are in your practice, and you're able to manage them carefully. So this is where you have to start thinking a lot differently if you're going to be moving into this upside-downside arrangement. And then as we get to the end, we think about really full capitation or managing total cost of care. And there's a lot of ways this can look contractually, but essentially this is where you're responsible for the whole pie for this patient. And you have to have a lot of focus on preventative care services. You're getting a bucket of dollars from the payer that you're responsible for, and you're really needing to risk stratify that population and ensure you're absolutely covering those high-risk, high-cost populations. So as you think about this continuum, and as you start to think about, can I do this? Can I operationalize this? The way I encourage people is to really start thinking about the left-hand side of this slide and start thinking about how can I start participating in value-based care and creating that foundational opportunity for myself so that I know how these programs work. I start to get a feel for how savings are delivered. I find good partners that I know I can work with that can help educate me, help provide the right data for me. And then over time, you can move down that continuum of risk. So this is just one way to think about it. And I think as you start to think, is this something I'm capable of doing? This is something that's a really critical piece is to understand how far down the continuum are you jumping in and are you ready? Thank you. Thank you, Catherine. So I'm gonna talk a little bit about Cardiovascular Associates of America and who we are as an organization. Our mission is to empower cardiovascular specialists to transform patient care. And value-based care is really a critically important piece of our mission, an important piece of that transformation process. And from an organizational standpoint, was deeply embedded kind of in the foundation of the organization. And we are very transparent with all of our physicians, all of the groups that we work with about the fact that this is critical to our mission and that they need to understand if they join the organization, that it will be in there, a part of what they do and that a responsibility of theirs is to learn about value-based care and to understand the critical levers of success within value-based care, several of which Catherine just talked about. I think also core to that mission are several other elements, including a commitment to quality, which is critically important for value-based care, commitment to innovation and a commitment to entrepreneurship and finding ways to support, excuse me, the network and our physicians to deliver better care at lower cost in a completely autonomous way. And autonomy is critically important, as I mentioned, to our mission. Next slide. So, you know, just kind of some details about who we are as an organization. We work with 27 partner practices that have 160 locations across eight states. And those practices employ over 570 cardiovascular specialists and we serve 1.2 plus million unique patients per year. You know, our practices deliver a tremendous amount of patients, deliver a comprehensive suite of cardiovascular care services, ranging from general outpatient cardiology to inpatient cardiology, to electrophysiology, interventional, peripheral, structural cardiology services. And we have a very large network of ambulatory surgery centers and office-based cath labs as well, which really function as an important element of value proposition because we're able to shift appropriate services from more expensive sites, typically hospital-based sites, either in the inpatient setting or the outpatient setting at a hospital, to an ambulatory surgery center or an office-based lab. And so I think that's important to recognize. We also are able to really coordinate well the management of patients from the inpatient to the outpatient setting. All of our practices and the physicians in those practices and nurse practitioners and physician assistants are involved in delivering hospital-based care. And so as we think about how you can manage care between sites of service and ensure that you're delivering care efficiently in a patient-centered way, focused on avoiding unnecessary care, managing those transitions of care, both into the hospital and out of the hospital, becomes a very important lever for driving additional value for patients and improving the patient experience, generally driving better health at lower costs. Next slide. So there are several, in addition to kind of our core focus on value-based care, there are several elements, I think, which reinforce that commitment. First, and I think most importantly, is that our organization is led and owned by the physicians who practice in those 27 practices. Every single one of those physicians is an owner in Cardiovascular Associates of America. And they're not just owners, they're leaders of the organization. They set the priorities for the organization. So value-based care was a core priority of our medical leadership board, which is comprised of two to three physicians from each of our practices. And those leaders of each practice get together three times a year to talk about priorities for the organization and to review our progress towards completing or achieving those priorities. And having that leadership, having that commitment from the ground up and having that kind of ground-level commitment drive how the organization functions and where we focus our time and efforts is really critically important to achieving success and motivating the ship to move in the same direction in a coordinated way. And so when Catherine and I go and talk to practices and work with practices to educate them about our value-based care work, to educate them about the opportunities to improve quality and reduce costs of care, there's a broad understanding that this is critically important to the mission of the organization and the mission of and our broader commitment to patients that we serve. And I think that's really, really important for driving transformation. And so I think I wanted to really highlight that. The commitment to quality and innovation is also, I think, complementary and core to our value-based care mission and to our work in value-based care. So I spend a lot of my time focused on quality improvement, which complements and really enables a lot of the efforts that Catherine has focused on related to driving those value-based care arrangements and making them successful. We have implemented a safety management system across our network, a safety reporting system. We have implemented a culture of safety survey. We have created quality standards. We have a very strong MIPS program, which includes education about MIPS and support for MIPS performance. And those elements really are critically important to supporting broader efforts to improve quality and reduce costs. We have a group of experts at the National Support Office, which is our kind of central office which supports our practices, who are experts in different areas of practice management, value-based care, quality improvement, services delivery. And those individuals also play a really important role in enabling the mission of the organization. And then finally, value-based care and kind of achievement of our broader efforts to transform care delivery don't happen overnight. And so we talk a lot about and focus a lot on what we are building with respect to kind of sustainability, long-term success, ensuring that we have an organization that is built to last. And I think that is also very important for setting expectations around value-based care and the transformations that take place or need to take place in order to enable the organization to be successful in value-based care. Next slide. Well, welcome, everyone. Thank you. So I'm here to talk to you a little bit about the practicalities. If you do decide to embark upon a value-based care initiative, and hopefully the slides have reassured you that it's possible, but make no mistake, it's not easy. And I think Catherine and Dr. Blumenthal get a lot of credit for the program they put together. The first overarching theme, and I'm going to talk to you a little bit more about the practicalities of how do you really roll this out. And the first, first theme is you're going to need partners. So if you think you can do this all by yourself, you can't. You're going to need partners. And I want to talk to you about two little areas within the partnership side of it of how to fill in the gaps and make it actually execute and happen. So doctors are the first piece I want to talk to you about because doctors in general want to help. The problem doctors have is they're too busy. They don't have any bandwidth. And their bandwidth issues leads to two fundamental issues when you want to do value-based care efficiently. One is a consistency problem. So if you have, if you need the doctor to be able to collect data, or if you need the doctor to be able to alert the system that we have a problem with a patient or participate in making sure a patient doesn't get admitted to the hospital, they are going to function very well when they have bandwidth and very poorly when they don't. And we're not looking for inconsistency. We're looking for consistency. The other problem is a timeliness issue. If for value-based care to work effectively, things need to happen in real time or as close to real time as possible. And if you work with a bandwidth issue, you're going to have a problem where by the time they get to it, it's a little too late. And so great data. Thanks for everything. But unfortunately, too late. Next slide, please. So if you're going to start embedding a VBC into a current workflow, the first theme I want everyone to focus on is you got to make it easy for the docs. They want to help, but you have to make it easy. How do you do that? And this is partly why I'm here talking to you. The first thing I would recommend doing is leveraging some of the existing processes you already have. So let's not create brand-new processes. Let's piggyback onto ones that we already have and you're already using. For instance, rounding at the hospital, doing charge capture. That's part of every independent practices model that has an office and also rounds at the hospital. You might as well jump on top of that process and leverage it to help you do VBC. The second concept is to embrace automation. Remember, everybody gets scared of automation because you lose a little bit of control. In this case, you want automation. You want the system to be able to read what's happening and pull out the data without asking the doctor to please push this button, please check this box. Remember, we already talked on the previous slide. We're not going to do it consistently. If the system that you bring in has the business intelligence to be able to grab information for you and feed it to your VBC network, and remember, this is only one little slice of it, well, then all of a sudden it becomes easier for the doctors. Last but not least is try to use something that works for fee-for-service also. If you're bringing in initiatives and processes that only feed the VBC side, that's good, but it's much better when this new process actually helps fee-for-service also. You're going to get better adoption, and you'll get, like, probably more return on investment for whatever you're doing. Next slide, please. The other concept, so the first one is make it easy. The other concept is connect the silos. There's a lot of moving parts with VBC. There's a lot of things that need to happen to take care of patients, and there's a lot on the line because you've taken on, as Catherine explained to you, you're taking on potential upside and downside risks. This is one example of some of the silos. So if you look at the inpatient and outpatient world, this is one great example of where you can make a difference. Patients are coming out of the hospital. They're there with heart failure. They're there with a STEMI, and how do we make sure they get cared for very efficiently and don't end up back in the hospital? That's when costs are going to rise. Obviously, there's a whole other side of this, which is how do you make sure they never get in the hospital in the first place? I love that part, but let's just focus for a quick second on this part. Throughout the connection between the inpatient and outpatient, which, by the way, is a massive gap, and this is where a lot of mistakes happen. It's where patients get lost in the shuffle despite everybody's good efforts. You've got transitional care medicine trying to help. You have office visits. You have urgent cares. You have specialty clinics. You have IV infusion centers. All of these different practices are doing weekend hours, urgent care clinics that are specially designed for cardiology, all great ideas. Unfortunately, they're all not talking to each other. Go to the next slide, and I'm going to walk you through a few examples of how we can help. In this particular instance, you have a patient that is in the ER. This patient's in the ER, and they're short of breath. They're about to get admitted with congestive heart failure because if you're going to an ER in America holding your chest saying you're short of breath and you have a history of CHF, you're going in the hospital. So the question is, how do we prevent that from happening because that's expensive? Well, in this particular case, and we're going to use hybrid chart as an example, the hospital has an ADT feed that feeds the command center, which CVA USA maintains and runs. That ADT feed, admission discharge transfer feed, for those of you who don't know what ADT stands for, will basically say, hey, Bob Smith's in the ER. The command center runs an analysis and says, wait a second. Bob Smith's one of our VBC patients that we're tracking. Uh-oh. We've got a big problem. So now the challenge is, how do you mobilize your workforce? How do you get people in the ER right now to make sure they run down and don't admit Bob Smith? Don't worry. We're going to take care of it. We're going to diurese him. We'll put him in our clinic. We'll do all those other things. So the command center pings hybrid chart with all the necessary information. Hybrid chart sends out a push notification real-time to all providers at that facility. It's not always the same practice. It can be multiple practices that happen to overlap at a facility. It could even be a patient being followed in Florida that's visiting in New Jersey and happens to hit a hospital ER in New Jersey. Now you want the group that's covering that hospital in New Jersey to run down to the ER. The guys in Florida can't do it. That happens in real-time. And now, you know, now there requires some coordination at the doctor level or APP level to jump in and figure out who's going down to the ER to make sure that that patient gets adequate follow-up and adequate care and does not get admitted. Sometimes they are going to get admitted. That's the reality of real quality-based medicine. But if there's an opportunity to manage it as an outpatient, we want that opportunity. Next slide, please. Last slide. Okay. So now the patient, let's just say, is in the hospital and they're coming out of the hospital. Here's again where you want to piggyback on existing processes and connect the silos and make it easy for the doctors. So as the patient's being removed from the rounding list, wouldn't it be fantastic if the software you're using for rounding and charge capture automatically connected all the silos for you? First, flag them as a high-risk patient. So now everybody knows we've got a high-risk patient. Plug and play with TCM. Plug and play with office follow-ups. Plug and play with telemedicine. Automation. Piggyback on the existing workflow. And this works for fee-for-service also. You're going to have fee-for-service patients coming out of the hospital that are going to need close care also, even if they're not enrolled in a VBC program. So I highlighted these as several examples of how tools of the trade can help support your VBC initiatives. You are going to need partners. When you get down to the nitty-gritty of execution, you're going to find problems you didn't know you had. And so these are some practical ways for you to try to solve them. Thank you. Great. I'm going to talk a little bit about MIPS versus value-based care and then also talk a little bit about kind of how we measure success of value-based care. So, you know, I think first to kind of take a step back, value-based care, as Catherine noted, is really a care model where you are aligning how you pay for care with health, the delivery of some set of benefits for patients. Right? Health outcomes as opposed to just paying for additional services. And so it's not monolithic. There are lots of different types of value-based care models. And broadly speaking, a model where you're paying for quality has many, which is what MIPS is for the most part, has many elements of kind of an early or less sophisticated value-based care in it as part of the construct. Broadly speaking, MIPS is a quality bonus program. It does have elements of pay for performance. It does have elements of episode payments or bundles in it. There's a cost section which accounts for 30% of your MIPS score, which really is a reward for how well you are performing at managing risk-adjusted costs of care for pre-specified episodes of care. There are three other elements that comprise your MIPS score. There are three elements that comprise your MIPS performance. There are cost, which is what I mentioned, and the three others are quality, which accounts for 30% of your score, and that's really a quality bonus program. There's an improvement activity section where you choose one to two improvement activities or now one to two improvement activities used to be up to four. And execute against those. And execute against those and then attest to having executed against them. And then there's a set of electronic health records and care coordination-related performance measures, which are broadly categorized into promoting interoperability, which is 25% of your score. So again, quality bonuses with pay for performance and some episode payments. In more advanced value-based care models, you are being rewarded or penalized for managing whole person health, broadly speaking. So not just specific quality books, quality performance measures or specific episodes, but longitudinally managing a patient's chronic conditions and managing the spending associated with those conditions and either sharing in the savings and potentially also sharing in some of the downside risk if you spend more than you are given to manage the patient's conditions. So again, we think about MIPS as having some elements of more basic value-based care and being really otherwise focused on quality management and putting the structural elements of quality management in place. Value-based care really focused on, advanced value-based care really focused on managing whole person health, taking on downside risk for financial risk in addition to upside financial bonuses or benefits from managing that spending efficiently and the care efficiently. And in general, those more advanced value-based care models require somewhat more advanced care models and data to support them. Next slide, please. So, you know, I think there's been a lot of conversation both in the public literature and in conferences and, you know, in government about whether or not value-based care works and how we can show that it works. How do we prove that it's actually a superior model or where it's superior, where it needs to be improved. I think first we have to kind of align on what working means. And so broadly speaking, when I think of working, whether value-based care works, I define that as the model having to either reduce costs while maintaining quality constant or reduce or maintain costs and improve quality. So there needs to be an increase in value kind of harkening back to that equation that Catherine showed on one of her initial slides about the definition of value. We do have evidence from published papers, from, you know, studies done by the Commonwealth Fund, studies done by CMS, which show that accountable care organizations, which are, you know, one of the major forms of value-based care, those are Medicare's and Medicaid's ACOs, have successfully achieved that increase in value, meaning that they have either reduced costs and maintained quality constant or reduced costs or maintained costs and improved quality such that they have improved that value equation. Those are generally models that are focused on enabling and empowering primary care first. We have also in this country undertaken some specialty risk models, including, as Catherine mentioned, the kidney care choices model and then an alternative payment model for cancer care and bundles. And those risk models are generally less well-studied. They have been around for less time. And therefore, we have less data about them. Medicare did recently publish its first-year evaluation of the kidney care choices model, and that analysis was favorable. It showed a slight reduction in spending for certain elements of kidney care. It also showed a benefit in terms of reduced, improved transitions to dialysis and increases in transplants for patients with end-stage renal disease, which we know is a desirable outcome. So the early evidence from this demonstration is favorable, but it hasn't been around long enough for us to evaluate it comprehensively. And we at CVA USA, I should say, are really committed to undertaking evaluations of the value-based care models that we are working on, and so that work is ongoing. In terms of study designs, you know, randomization is really hard in care model and, excuse me, contracting model design interventions because you can't blind participants to those interventions. They certainly can be done. They're really well done studies that look at, that are implementation science focused, that look at different care models and randomized sites to one or another. They're just more challenging than kind of our placebo controlled pharmaceutical studies or device studies. Often observational study designs are kind of what we rely on. And there are some ways to use those and really structure them to infer causality. And so difference in difference models are one important structural study design that we use. The other, one other that I have seen used and that we think about is using an instrumental variable. And so these are two approaches that I think, we have seen used in studying interventions for value-based care, for other quality improvement interventions and that we will likely continue to see used as we move forward in this journey with value-based care. That's next slide. Thank you. Thank you. Well, thank you, Dr. Sanders, Blumenthal and Evans. I appreciate that so much. I think you just took three days in a conference room and whittled it down to 45 minutes and gave us just enough to get us excited instead of the entire textbook, but holy moly. And this is a textbook that we're writing as we go. So, you know, I really appreciate it. We've had some questions come in before I read off even the first question. I wanna remind everybody at the lower right center of your screen will be the Q&A button and feel free to enter some questions now and we will make sure that we get those answered for you. I appreciate how much time that you guys have left for questions today and I think we're gonna use it. So I wanna start with a question that's come in here and it's about how you collaborate with the inpatient side of the house. And so the question is, have you began to work with hospitals to incorporate into the collaboration for providing value-based care and reducing costs obviously on the hospital side as well as on the clinic side? So whoever would like to jump on that grenade, feel free. Yeah, I think there's a couple of ways to think about that. And certainly you have to consider your hospital partnership, what that looks like, what your relationship is with the hospital system and then what your value-based care relationship looks like. And many hospitals are participating in ACOs and other value-based care relationships and absolutely that's a great way to begin to get involved in value-based care and understand how it works because the hospital systems that work with value-based care tend to have great data, understand their populations very well and can help you get acclimated to that. We do work closely with the health systems when we're in a value-based arrangement and we think about that from several areas, right? You wanna understand any of your patients that are in a value-based arrangement when they're in the hospital, circling back with that care management team that's on the ground, making sure that you're collaborating. As Dr. Sanders mentioned, all of that TCM process is important. And any nurse will tell you that discharge begins at admission. So you want that discharge planning to be smooth and that starts from the moment that person hits the ER. So the more we can plug into that process and be part of it, the better the outcome is ultimately going to be for that patient. And ideally, we then also avoid a readmission as well. So there's a lot of ways to think about that. The ADT and HIE feeds is one, as we talked about getting those feeds and knowing who's in there when. The other is just a day, if you're a part of that hospital system, looking at that daily census, really understanding who these patients are. Are they part of any value-based arrangement? And do you want to take some additional or extra steps in the process because of that? Perfect. Any additions? It's a great answer. Nobody wants to touch it. I don't blame you. I think that was perfectly said. I am going to ask a question as a follow-up to that. Being that CVA USA has independent groups that you're a capital partner for, and they're not employed by the health system directly. So my question is, what kind of resources and support do you get from your health system partner? You're driving a ton of value on that side, readmissions reduction, admissions reduction. As you work with that, you talked about the ADT feed. And so there's some collaboration there that you're getting a piece of. Is there any other resources or support that they provide when you undertake these efforts? Yeah, so one thing that we have done with some of our, obviously we want to always continue to be great partners with the health systems that we work with them, right? So that always remains at the forefront and thinking about how we can continue to work well together with that partnership. Some things we've done, I mean, one example is having the ability for our physicians to access very quickly those patients in the ER or who were recently admitted who were part of a value-based arrangement. So getting that average daily census, knowing who is in that census. If somebody's in the ER, having the ER physicians calling us quickly. So we've been able to do things like that where we have relationships in the ED with ED physicians. And we're able to avoid those admissions by having that tight relationship with those providers that are in the health system and just creating new and different workloads as we think about how that can come together. Dan, did you want to add anything there? Well, I mean, I think having, just having kind of service line collaborations is also really important once patients are in the hospital because as you mentioned, the discharge preparation process, not, we are caring for, our groups are caring for a lot of their patients in the hospital, right, when they are admitted and therefore have control over their hospital course and discharge planning. And we can work with case management teams in the hospital directly, certainly for our community hospitals that we work at and collaborate with. And then I think that was the major addition that I wanted to make. I mean, I do have a few comments. I think also the word gets out very quickly and this is goes for BBC and for fee for service, it's all your models. You know, the ERs and the HUCs and the discharge managers, they don't necessarily need to have directive from top down. When the ER gets wind of the fact that you have processes in place to see a patient same day or see if that spreads like wildfire throughout the ER, they're always looking for ways, you know? And so the second you start showing up with processes in place, everybody gravitates to it. And even internally amongst their departments, it's amazing how quickly the word gets out. And so they'll help drive the process even though they're not necessarily, you know, attending board meetings and being told by the upper management, this is what you need to do. They just do it because naturally it makes sense. There's an add-on to that question and it says, do you staff an on-call physician to deploy to the ER in each market or how do you make availability to deploy based on the ADT alerts? So in our network, all of our practices have hospital relationships. So we have privileges and we're staffed at hospitals in all of our markets. So we leverage those relationships and then also leveraging partner relationships as well as we think about where some of our patients may be going that are tied to some of our close partners, either primary care or other health systems as well. Now, this question came in, I've got another question. Thank you for that, Catherine, for that answer. It came in during your portion of the presentation, Dr. Sanders, and that question is, how does this data get into the EHR at the hospital and physician practices? So if you wanna talk about how hybrid chart interfaces, I think is the real question. Well, and I don't think it's unique to a hybrid chart thing. You're bringing up a point, which is the disconnection between a lot of our data analytic systems and electronic records. And an ADT feed is only gonna get you so far, and so this is a big challenge. If you look at CVA USA, there are not everyone's using the same EHR. And if you look at the hospitals that they round up, not everyone's using Epic or Cerner or whatever, and even if they are, there are different instances of the same software. So it's a big mess. Yes, hybrid chart can connect to pretty much every EHR, but most of that is in the patient sampling and charge capture realm. I think the success to what CVA USA has been doing is by centralizing the data. So CVA USA invested a lot in creating a command center that serves as sort of the data lake and the hub of where all the data can flow into. And then they've worked very hard and meticulously to try to make sure that the right data gets back into the EHR. So sometimes the idea of, hey, let's push everything into the EHR so that we can get the right data back into the EHR, sounds great until you get this tidal wave of useless data that pours in there and cloudies the picture even further. So you have to be selective. And the best way to do that, in my opinion, is to have a command center that is receiving data from multiple spokes and multiple data points, figures out what data is relevant, and then works on channels of, and it's not always through a company like ours. Sometimes it is through CVA USA working directly with an EHR to make sure that the data gets back in there. I think that's the best answer, especially for a model like CVA USA that has multiple practices under their umbrella. If you're just one practice trying to do this alone, I think the answer may be slightly different. Gotcha. Okay. I think, Craig, you bring up a good point, which is if you are a smaller practice or a smaller group of physicians and you're thinking about that work, it is important to think about what tools you choose, what your EHR is. A lot of EHRs have existing integrations with certain tools. So those are important questions to ask. And then also, are there added costs if you do choose to integrate with your EHR? Because there's sometimes that will exist either upfront or ongoing. But as you think about, do I want to engage in this work and what tools do I need? That's a really important thing to ask as you look at vendor partners. Yeah. And we'll go ahead then. No, I think the other point is just the ability to have access to the people who are doing the analytical work, right? Because a lot of the analytical work, the data that you get in is going to need to be restructured and customized. And then you're going to want to make sure that you have some kind of direct line of sight into, and ideally some control over and direct interaction with the people who are running the analysis so that you can work with those people to make sure that they're relevant for you and when you get into a value-based care arrangement to your arrangement, right? Because while there are standard metrics, there are some times where those standard metrics for quality cost control do get modified based on the structure of the arrangement that you ultimately sign with a partner. No, those are good points. I was going to bring up two points. One is every process we've talked about today has been internal. And there is another angle which is the direct patient communication angle of what kind of tools are you putting in place so that you can communicate directly with your patient, right? And not an internal tool that's used behind the scenes. So that's something to consider. You know, and then back to the whole data analytics, you always have to remember that it's a moving target. So the patients that are enrolled in your VBC program are not static. They're going to change. People move. People unfortunately pass away. New people move into the area and become a VBC target. So you have to, it is a data juggling exercise. And that's what I think makes it so hard is that you have to mirror the processes you already have in place without being too disruptive. You have to execute very, very precisely or you're going to lose. You have to coordinate a lot of systems that are not generally talking to each other. And you need a firm grip on the data analytics side of it because it's a moving target. And that I think sort of is the real challenge of why it hasn't happened to date for cardiology, especially until now. Yeah. So I'm going to take us a little bit sideways. Thank you. Thank you for that. I think just pointing out how big of an issue it is to really transition your data and your strategy to be effective in value-based care, it is very difficult to do without a series of partners. And we're all in this together. So it takes teamwork to deliver care and it takes partnerships. And that's why each of these things is an underlying theme of, you got to work with the right people you got to work with the right folks to make it happen. You can't do it on your own. Unless you're a major health system, possibly you can but not even possibly, not even guaranteed. So I'm going to take us in a different direction and see who has the most polished crystal ball and is willing to go out on a limb. The question that's come in is, do you expect CMS to begin reimbursing for health coach sessions in 2026? So proposed rule coming out this summer, do you expect to see health coach sessions on it? I hope so. I don't know. I haven't, I mean, I haven't seen any buzz to indicate that it is, but it would be fantastic. I will say this, I will say the services of a health coach are amazing. And I think that it's a very valuable service. There are ways you can use some other codes to, if you think about it, if you're providing CCM and there's other ways you can think about the time with your patient that you can, if the health coach time can count toward that. But it's, you know, in and of itself that visit is typically not reimbursed. Yeah. I hope that, like Catherine, I hope there will be, I guess I'm not, I don't know. And I'm a little pessimistic that they will go there. But at least in 2026, but I certainly hope they will. Yeah. My take on this is that there's, you know, I apologize for the crass saying, especially on a recorded video, but multiple ways to skin a cat. And so if you don't get health coach reimbursement specifically, are there other billable pathways out there that can be explored that will serve the same function, but maybe through a different method? And I think when we look at all the other areas of medicine, whether that's mental health or whether that's other areas, the question is, are there codes that apply that we can bring into the cardiovascular domain? And I think those explorations will yield some fruit. Yeah. Yeah. And I think today, right, that's, if you think about how do I want to prepare my practice for value-based care using fee-for-service work, RPM, CCM, PCM, those are areas where you can really start to explore how to better provide care coordination in your practice and get reimbursed for that. And there are a lot of great vendor partners that can help you with that. Yeah. And those are available right now, Ms. Katherine. Yeah. That's right. So there's many ways that we can do this. Many ways to do it. Yeah. I'm going to go back to my earlier comment and pose it back to the group maybe as a question now. My comment was, this is very, very hard to do on your own, without a doubt. And I made the comment, if you're a large health system, maybe you can do it. But at what point do you feel a group, a program, has the capacity to do this on their own? And at what point do you feel they need a partner? If I've got three physicians, there's no way I can do this on my own. But if I've got 20, if I have 50, what does it take in terms of resource and in terms of group size to say, this is really right for me, both with or without partnership? What does it take to go down this path? It's very complex. I think the inflection point around size is important. And I think it's probably less important than your ability to access data. And I think that is the piece that's critical is are you able to get the data you need in order to be successful? So do you understand your population? Do you have the teams that can surface this data to you regularly and in front of you? And if you can't access the data, you're not going to be successful. So I think, even if you're a small group, you could outreach to two other small groups, right? You can create some scale with some partnerships in order to participate in programs like this, or you can find a large partner that's doing this work and tap into that work. But I think the big piece, as you think about, am I ready? My answer to that is always, are you going to be able to have the data in order to inform your workflows? Yeah. I didn't even realize, as they say, where does the time go? I've got more questions. Maybe we can follow up with those in the email, but what an incredible webinar. It was full of great information. I hate that we have to bring it to a close, but I want to thank all three of you for lending your time and your expertise to help educate the MedAxium community today. Any final thoughts? Because we are at time and then we'll close out. Dr. Blumenthal. Thanks, Dan. No, this was great. Thank you so much for the opportunity and terrific to be here. All right. Well, we hope to see you all again soon. Thank you again. And thanks to everybody who attended. You will have the opportunity to view this on demand, and we will be sending out the slides and the link to the on-demand content to your email if you've registered. So don't worry, it's coming your way. We greatly appreciate it. This will be the end of the webinar, and everybody have a wonderful afternoon. Bye-bye.

value-based care

cardiologists

fee-for-service

outcomes

data-driven strategies

interdisciplinary teams

MIPS

patient engagement

data integration

financial risk-sharing