We've heard loud and clear from you over the last year or so as we've asked you for feedback that you're interested and you have a clear desire in connecting with your fellow certificants and learning more from them. And so we've tried to provide some opportunities for you to do so this year through our coffee chats and through our 4HMDCs by HMDCs webinar in town hall series. So we appreciate you being with us today. Appreciate those of you who are going to be watching this later as a recording. We appreciate your interest as well. But today we had more than 150 registrants for the event showing the excitement that everyone has to hear from our great panel today. And we're really appreciative of you all being with us. I wanted to take just a moment to share with you on the next slide, some upcoming events that we have for HMDCs. We have a December coffee chat happening as well as a webinar that will be coming up in December. So we look forward hopefully to having you at those events as well. And then our 2022 initial application opens in January. So if you know folks who aren't yet certified and think they should be, please make sure to encourage them to become certified starting in our January initial application window. I'd also like to take a real quick moment to thank our sponsors for our HMDC webinar in town hall series this year, Kindred at Home and Bluegrass Care Navigators. We really appreciate their investment in HMDCB. And we'd love to talk to anybody else who'd be interested in sponsoring our 2022 series. We're creating that right now and we'd love to talk to anybody. So please reach out to us if you're interested or your company is interested. With that shameless plug, I will turn it over to our moderator, our newly titled moderator. He's our former secretary treasurer for HMDCB's board. And after our recent board meeting, he became the president elect of HMDCB. So interested and excited to welcome Dr. David Wentzel to be our moderator for today's session. So Dave, take it away. Well, thank you, Bruce, so much. And thanks everyone for joining. I am really excited about the panel we have today. And I know the discussion is gonna be awesome. I just wanna let you know, if you have questions, please type them in the box. Gina will be monitoring those and get them over to us. If we don't have time to answer them all, we're gonna compile a quick list of them and try to answer them and send the information out to everyone or at least provide links to some of the information that you're asking for. So we'll try to get to all of them, but we have a great panel today. So I'm looking forward to this and I'm sure you'll get a lot out of this. So thanks for joining us. Well, the first thing I'm gonna do is have our panelists just introduce themselves and specifically touch on their role and the organizations they're representing today in this panel discussion. And we will start with Balu. Thank you, Balu. Thanks, Dave. I'm Balu Natarajan. I am the Chief Medical Officer with Seasons Hospice and Palliative Care, now part of the Accent Care Group. I've been with Seasons as a local part-timer since the year 2000, and then as a national person since 2005, full-time since 2010. So I have had the opportunity and responsibility to herd cats coast to coast for a very long time. Originally, internal medicine by background, and I have taken both the, I've maintained the ABIM HPM boards as well as HMDCB, took the first one in 2014, and I'm now certified until 2026. Awesome. Thanks, Balu. Next, Carl, if you could introduce yourself and tell us a little bit about your organization. Sure, hi, I'm Carl Steinberg, and I'm a family physician by training, and I've been a hospice medical director for a small nonprofit hospice here in San Diego County called Hospice by the Sea since 1995. So I like to say, you know, before it was fashionable. I grandfathered in with the hospice boards. I did not do a fellowship. I think I got the old boards in 2004, and then the first year that the hospice boards were available through ABMS in 08, I took that, and I've recertified in that, and I'm, you know, I'm a baby boomer. I like taking, you know, I like getting certifications and stuff. I like this young generation, and so when HMDC came available, I took that the first year also, and I mostly do nursing home work, so I'm a nursing home medical director also, and CMO for a couple of small nursing home chains, and I feel like there's sometimes there's a little bit of a tension between hospice and skilled nursing facilities, but right now I'm president of AMDA, which is the old American Medical Directors Association, now called AMDA, the Society for Post-Acute and Long-Term Care Medicine, you know, rolls right off the tongue, so anyway, that's me. Thank you so much. Joe, can you introduce yourself, please? Well, hi, friends. I'm Joe Rotella. I'm the chief medical officer for the American Academy of Hospice and Palliative Medicine. I'm in my seventh year in that role, and that really gives me a hand in our policy and our education, including our educational materials for hospice medical directors and hospice physicians, and in quality, and I spent the bulk of my career as a practicing hospice medical director, chief medical officer for Hospirus in Louisville, Kentucky, and still live in Louisville, and I have to say, I have a tremendous appreciation for the role of the hospice medical director. I think it's underappreciated. It is a very challenging role. It's hard to think of another role where we have to do more balancing. We have a duty to our patients. We want to do absolutely everything that's best for them. We have a duty to the government because it's our medical judgment on prognosis that is the gatekeeper for access to the Medicare hospice benefit, and we have to be obedient to that structure, and we know that the judgment calls we make have a major impact on the health of our organization, that in many ways, the decisions we make can affect the financial stability and also the well-being of our staff, so I think it's a very challenging role, and I'm very glad that we have a way of signaling that a person has done that extra education to really do it well, so I don't work directly with a hospice right now. I'm on a board for the palliative care services of Hospirus in Louisville, and, of course, I work with the Academy on all those different kinds of products and support, and I recertified for the first time last year, so I guess that tells you when I certified the first time. Thank you. Thanks, Joe, and Ada, would you introduce yourself? Thank you. Yes, thank you so very much. I'm Ada Stewart, and I currently serve as board chair of the American Academy of Family Physicians and immediate past chair. I've had the honor of representing 133,500 family physicians, residents, and students, and I just want to say that I initially certified in May 2015, and this coming Friday, please pray for me, I'm recertifying for the first time for my hospice medical director certification. The one thing I just want to make note of is family physicians, we care for individuals of all ages, from the beginning of life to the end of life, and we provide comprehensive as well as coordinated care in addition to prevention and caring for those acute and chronic illnesses, but we have a special relationship with our patients, with the community, and we see how our population is truly aging, and so family physicians have a unique position and a unique opportunity to be able to guide our patients in decision-making as we look towards end of life care, as we look towards palliation, and so being a hospice medical director has been very important for me to be able to have those conversations with my patients, to talk about advanced care planning, to have the knowledge that is necessary to be able to communicate with them on a different level, and so it's been a great opportunity for me. I'm not currently working with a hospice right now due to my many other jobs that I'm holding in addition to being an officer of our AAFP, but I tell you, it's been a great experience, and it just provides me that extra, I guess, the added qualifications and to be able to even educate my fellow colleagues on what is necessary to be able to care for our communities, our patients that I see and encounter every day, so thank you again for this opportunity. Thank you, Ada, and I appreciate all of your commitments, all of you, to the hospice medical director certification and that you're all certified. Thank you for that. So now we're gonna turn to some questions. So the first question I have, and we'll keep the same order, is if you wouldn't mind, just provide a high-level overview of what trends your organization that you're representing is seeing or focusing on in medicine hospice care. In other words, where do you see the strengths, sort of weaknesses, opportunities, and maybe threats with your organizations? And Baloo, we'll start with you if that's okay. So for us at Seasons and now having come together with Accent Care, we've actually had a lot of opportunity to answer that question, and we're answering that both internally and externally because Accent Care sizably increased by 60% just with us joining them. And so it's a lot of what we've been trying to sort out, but our strengths really are, we've been doing complex care for a very long time. We take care of a lot of inpatients across the country. We do work with large institutions such as Christiana and Beth Israel Deaconess and Cedars-Sinai, so we're not afraid of that. And we've gotten many, many years, decades, really under our belt of taking care of that complicated care. But on the other hand, because of, to some degree, the complexity of care that we take care of, our patient stay is shorter. And where that reflects is CAHPS responses. We don't get a lot of responses back, right? And so that's something that is very much an area of weakness. And if anybody sees those scores, the lower your percentage rate, the higher the likelihood, right, of extreme responses. You don't get middle of the road responses and that's publicly reported. And so that's definitely a weakness. Our opportunity now, and I think for all of us in the industry, the opportunity is for various reasons of awareness and particularly economics, we have the opportunity to serve patients upstream. We have hospitals actually inviting us in instead of barring the door. And we've also got health plans that are very interested in working with hospices and certainly working with palliative care. And so we have tremendous opportunity there where we were never invited in. But that also brings with it a threat. There's a whole bunch of maneuvering that's been going on trying to get a piece of this, what is really an end of life pie, but folks will call it a post-acute pie, right? And with direct contracting entities and the like, it is very possible for any institution to get boxed out. Right, if there is somebody who's only giving out four contracts, then the fifth and sixth provider won't have as much work to do, even if they are really good at doing meaningful work. So I've just described what is relevant to our organization, but I suspect that that's gonna be, those sorts of things are impactful to the vast majority of people on this call. Thank you for that, Baloo. Carl, what would you see from your perspective in your organization with those questions? Sure, I mean, there's so much going on lately, a lot of it due to the pandemic, but also just some longstanding trends. I know we'll be talking about telemedicine later, so I won't, I'll just mention that that's been a big, I think a big improvement. Nobody wants it to be overutilized, but it also, it can be a lot more efficient. And certainly I've found that it's been surprisingly good at getting all family members into a Zoom room or something like that. There's this sort of recent, not so recent, but recently upped attack on advanced care planning. To the extent that all of us can be advocates for coverage of advanced care planning way upstream before they get to us in hospice, I think it's unfortunate. I'm not sure what's behind it, but I don't need a research study to tell me that, the conversation I have at the bedside in a nursing home that prevents somebody from getting sent to the hospital and put in the ICU when they don't want it, it has a value whether your research study says it had a value or not, and that's advanced care planning. And I'd have a lot more to say about that if I had more time. One thing I did want to mention that I think is relevant to HMDCB is that AMDA has had a board for nursing home medical directors, a CMD certificate for many years now. And I think we've had, I don't know, six or 7,000 people take it. California just passed a law that is going to mandate all nursing homes to only hire medical directors who have that CMD certificate. So even though it's not ABMS recognized, I think that the gaps in care, in post-acute and long-term care were so obvious that this thing sailed through the California Senate and Assembly without a single no vote. People want improved quality. You know, hospice is a little bit of a different basket, right? But we want to give the best care possible to people. So I think the patina of having an additional certification is really of value. And if that's something that could be pushed legislatively or even just with big organizations saying, we only want hospice medical directors who are certified, I think that would be a good avenue for this organization. Thank you so much for that. So, Joe, we'll turn to you from your seat on the, especially with the AHPM, working on a national perspective, what do you see as the answers to some of these questions? Sure, well, so we have a strategic plan that's in effect for these three years, this year and the next couple. And it turns out it's right on target. We're focused on a number of things that the pandemic and also this sort of increasing awareness of health inequities and the need to remedy those, you know, would indicate we've been on the right path and we need to double down. I would say initially, one thing we recognize is there's an increasing need for professionals to be able to connect with each other in a meaningful way, in a safe environment, where they can actually share best practices, questions, even provide, you know, some emotional support. And I know we're gonna talk about the pandemic and specifically, but even before that, you need a place where you can talk to your colleagues who get it and where you can pose questions and not worry about as an attorney listening, or is this gonna be in the New York Times tomorrow or something like that? So, you know, we really have been pushing our Connect platform for our members, which is, you know, a moderated chat forum where people can have exchanges. And we've been holding a whole lot of virtual meetings now where we can have town halls or special interest group meetings. But secondly, what we knew we need to commit to is quality. And, you know, hospice and palliative care is just now having a moment where the payers and the quality machine is actually paying attention to us. I don't know how long it's going to last, but we need to get as far as we can during this time. So on the quality side, the Academy actually was able to secure a grant from Medicare using MACRA funds to create two new quality measures for use in palliative care. And these are patient experience measures. Did you feel heard and understood? Did you get the help you wanted with pain? This moves the field forward. And we've just wrapped up a three-year, again, federally funded project to develop these measures. Also launched a quality registry, the first unified quality registry for our field called the Palliative Care Quality Collaborative or PCQC. On the policy side, we already knew we need payment reform, because you know that community-based palliative care is needed, not just the hospice benefit, and that traditional fee-for-service doesn't cover that interdisciplinary team, and that's key to making this work. And so we've been working on alternative payment model reform, and I'm happy to say that over the years, we've become regular friends with the CMMI crew, and I'm still optimistic that they may be working on something right now that might come out in the next year that would actually really make a difference. On the workforce side, we have our landmark legislation we've been pushing for at least a decade called PACHETA, the Palliative Care Hospice Education and Training Act, which would actually increase, would be a federal program that would increase not only specialty training, but sort of primary or generalist training in palliative care, not just for physicians and nurses, but for all the different members of the interdisciplinary team. It hasn't been introduced in this latest Congress, but there is an effort to maybe get some funding for it in the reconciliation package you've heard about, so it is moving. Things are happening there. And so, you know, there's a, and then I would say, you know, we had already made a commitment to diversity, equity, and inclusion. And I'd say now we'll go a step further and say justice and anti-racism, and that this isn't, again, a moment when we can do more. And so at the Academy, we've actually got a number of things going on. We hired a new manager of DEI. We have retained a consultant to do a complete assessment for us. And then we also joined a new initiative called Equity Matters. And my friend Ada Stewart is in the same cohort. She's also doing Equity Matters, which is a curriculum that's going to help us all understand what associations can do to actually make a difference. So we'll talk a little bit more about what's changed since the pandemic. But boy, you know, it's been about connecting people, advancing quality, advancing payment, taking care of the workforce. Those things have never been more important. And of course, educating, giving you the resources and knowledge that you need. Thanks. Yeah, thanks. Thanks so much, Joe. And yes, Ada, you're up next. Could you just tell us a little bit from the AASP's perspective, what you see is, again, some of the strengths, maybe weaknesses or opportunities for AASP? Yes. So thank you. And thank you, Joe, for kind of helping me to lead into this. So we all saw the, and we're seeing the impact of the pandemic right now. And especially as the Academy of Family Physicians, we recognize that we had a flawed fee-for-service payment system. And in that, we saw that as individuals lost patients due to patients not being able to be seen or being fearful for coming into the offices. And a lot of practices and people end up either retiring early or closing down their practices. And it gave us the opportunity to, again, talk about the value of a value-based payment and how primary care can really kind of transform the way we are paid, recognizing that an increased investment in primary care would be so much beneficial to the health of our nation and to the health of our communities. And that's something that we were able to look at. And I always say, with crisis comes opportunity. And so, again, this crisis gave us the opportunity to, again, to continue to advocate for value-based payment reform, alternative payment models, as Joe previously mentioned. And with that, also addressing the issue of burnout. For us, as hospice medical directors and as family physicians, we see how the workforce is diminishing. We need to get more individuals within that workforce so that they can do the job that we need them to be able to do. To have those conversations with our patients as we try to address advanced care planning and getting patients into hospice and palliative medicine early on in their disease trajectory instead of later. Recognizing the importance of great outcomes and not necessarily at lower cost and not necessarily just seeing patients and having procedures and things such as that. Recognizing the importance of having the funds to be able to pay, having the funds to be able to pay your staff as far as looking at those interdisciplinary teams that we all need to be able to do the great jobs that we really want to do and continue to do. So, if we are able to impact our payment models, change to value-based payment, we can see improvement. We can see more individuals looking to the specialty of family medicine and thereby becoming hospice medical directors. And if not, at least being able to be that referral source, having that education piece and having the time. You have to have the time to be able to talk to your patients, to establish those relationships that we value so much. Those are things that are, I guess, opportunities for us to improve where we're going and to truly transform health care as we really want to do as we move towards the future. Thank you, Ada, for that. And thank you, all of you, for the responses. So, yes, now I want to step into and ask the question about how do you think the role of the hospice medical director has changed from your perspective due to the pandemic and any other variables that you think have impacted that role? And again, we'll start with Baloo. How do you think that's impacted the hospice medical director's role? Well, I think being a physician in this line of work is incredibly rewarding. And you only know it if you've actually tried it. On the other hand, there are times when it can be a no-win situation. And for me last year, I mean, I got more wishing you well, hope you're doing OK than ever before. I also got more, who do you think you are? I can't believe you're trying to kill us sorts of messages, which I have not gotten in 20 years of doing this sort of work. But people really thinking that we were putting them at harm's way when we were trying to find ways to get folks through the bedside. So fear is a very powerful thing. I still vividly remember a Sunday morning when my hospice CEO was emailing me and saying, we have 10 minutes to decide. Are we going to spend $425,000 on 100,000 KN95s that I can get? And the HMDCB blueprint doesn't really tell us how we're supposed to answer that question. And so I would say that there is a lot of uncertainty associated with our roles these days. But I think that most of us have, along with our colleagues across company lines, but also with our colleagues within each of our institutions, have figured out at least a framework as to how to navigate all this, just like the rest of the world did. And I think there's some really good things that came out of it. I know that we'll probably wind up talking about virtual visits and other creative ways of getting to bedsides later on. But I think that it's an exciting time to be in this role because we actually gave people the latitude to think outside of the proverbial box. So I think in summary, I would just say that it is different. It is way outside most of our comfort zones. And it's really exciting because it's way outside most of our comfort zones. Thank you for that. Yes. So Carl, from your perspective, especially with AMDA, how do you see the role of not just hospice medical director, but maybe even the nursing home medical director, their role has shifted, changed with COVID and the pandemic? Yeah, thank you. I think one of the biggest things, especially during the peak of the pandemic, was just the not being physically present. And I don't know, probably a lot of the people on this call, the physical presence, being invited into a person's home, this sort of magic that happens there, the trust, you lose that to some extent when you're doing virtual visits, the hugs, right? I hope at some point we'll be able to get back to that. But so that was a big adjustment. It's been a very big adjustment. On the other hand, there are efficiencies that come with that, right? And I think I'm proud of the way our hospice made that work, the way the nursing homes were able to manage family visits and clinician visits during the pandemic. I also think the pandemic has shed more light on inequities. And I think that is something that all of our organizations need to be working on in an intentional way, not just putting something in the mission statement or policies and procedures, but really doing things about it. And I think that is one blessing that we'll take out of this pandemic and the other things that happened during the pandemic, like George Floyd. So, yeah, I think it's been a tremendous growth experience. And I hope it sort of pushes things toward more value-based, less fee-for-service, and figure out creative ways of getting people services maybe before they're ready to forego all curative treatment and that sort of thing, like some of the pilot programs that have been out there. How do you actually make that work financially? So anyway, that's it. Thank you, Carl. Joe, we'll turn to you now. And from your position with AHPM, when you're out and about and speaking to people on a national level, how have you seen the pandemic affect the role of hospice medical directors? Well, I'm going to agree with Carl that it's been a growth experience and agree with Balu that it's been actually, in many ways, very painful and difficult as people have clearly been thrust into new roles. And I'll say I saw, I actively mentor a couple of hospice medical directors, so I got to experience secondhand what they were going through. And I would say hospice medical directors have really responded to a very challenging situation where they've had to completely retool the way that they provide care because of the need to go to telehealth in some cases or the limitation in visitations and that sort of thing. And while this is happening, they've had to deal with increasing staffing shortages and with increasing levels of burnout among their staff. They've found on top of all their usual responsibilities, now they're in a room with people planning for crisis standards of care. Maybe they were heading up an ethics committee before. Now they're actually helping write the policy for who's going to get a ventilator or not get a ventilator. That's maybe not something we signed up for. Sometimes they find themselves becoming the employee health doctor. They're actually the person doing the contact tracing on their fellow employees because of new policies that have been put into place. And all of this means that hospice medical directors have been learning as quickly as they can, but it also means that it's really been hard. And I think most of them have never worked harder in their lives, and they've legitimately experienced moral distress and in some cases, significant burnout. And so I think we do have to acknowledge that. I think it's one thing to be seen as a hero. You're working super hard. You've worn yourself out. You can't find another ounce to give, but at least people say you're a hero. But when you do that and they say, I think you're trying to kill me. Why are you making me have a vaccine? You add that insult to injury and it's very painful. So I did have a hospice medical director tell me that after she communicated to her entire staff the new policy that they would be mandating vaccinations, that she had a longtime colleague and team member accuse her of being Hitler. So I mean, that is painful. Yeah, thank you. Thank you for that. And I think it's great that we acknowledge that out loud. We acknowledge that and call it what it is. So thank you for that. Ada, from your perspective, from the AASP and the family physician who's got sometimes three full time jobs and a hospice medical director, how have you seen the pandemic affect that group of folks that you represent? Yes, sir. So it's been really eye opening. You know, we already know that family physicians are over overworked, excessive burden. We talk about administrative burden, but just the burden of the pandemic upon, you know, piled on top of all the administrative things that we have to do and recognizing as hospice medical directors right now during the pandemic, how important it is for us to have these conversations. But not having the time has been a true, true burden upon myself and many others. You know, we're trying to deal with issues of mistrust and distrust of the health care system. And prior to the pandemic, we had to deal with that where we talked about, you know, hospice and palliative medicine and talked about, you know, the advanced care plannings with our patients, you know, recognizing how important it is to have those conversations, but recognizing that how hard it was even to have these conversations. And even with the pandemic, we now have a more difficult time to have it. And I can tell you that even for myself and for many of my colleagues, not having the conversation as much as they would like to because of the fear for, you know, not being trusted anymore within their community or not being trusted anymore within their populations. But, you know, and so you have to find that fine balance. And it's been a tough time for many of us, especially for those who are, you know, not only hospice medical directors, but also family physicians or running the nursing homes or, you know, just, you know, family physicians are everywhere. And that's the one unique thing about our specialty. And during this pandemic, you know, we had to deploy in many other areas that we weren't quite used to, but, you know, willing and able to do so. And so it's been quite a daunting task for us as a specialty. And again, you know, as I talk about burnout, you know, recognizing that many of us are burned out and it's not just, you know, the clinicians, physicians, but our nursing staff, our front desk staff, our social workers, you know, everyone has just been totally overworked. And, you know, just, you know, we have to find a way to be able to help not only our patients as we do every day, but help our clinicians, help our medical professionals that help us to do our jobs that we do every day. And if that's, you know, finding increase as far as payment reform or, you know, just finding a way to decrease some of the other administrative burdens that we have to deal with as far as, you know, prior authorizations, et cetera, et cetera. I think those things would at least provide some help and guidance for those who are trying to do this job that we really need to do. And that is, you know, caring for our patients and making sure they have the best quality of life as they transition or, you know, go towards the end of life and deal with their end of life care. So those are just issues that, you know, I can think of personally that I've dealt with and have seen within our specialty. Yeah. Thank you so much for that, Ada. So the next thing I want to turn to is a little bit of something that Joe mentioned and started to talk about a little bit with the AHCM strategic plan. But I want to hear from each of you, how do you feel hospice medical directors can be part of the solution to improve equitable access to hospice services, because all of you have spoken to this and talked about it, that there still is a big disparity in terms of access and how short many patients' lengths of stays are, and so, Balou, I would ask you to start to answer this question as we go around. How do you feel like your role as a hospice medical director and the people that work for your organization, how can we be part of that solution? Yeah, one of the biggest things we try to make sure happens is that our local medical directors, our team docs, anybody who's on the receiving end of a, hey, may I admit this patient, right, doesn't say no without actually speaking with someone who knows this patient. There is still a tendency to say, send me the clinicals, and then they're waiting for an 80-page fax, and our continued reminder and admonition is, can you please talk to someone who knows this patient, right? Like, you don't get from 80 pages of Epic or Cerner Millennium what you can get from that individual saying, this is why I think they're dying, or at least a few probing questions might be able to tell us a lot. You know, no matter what we've done with health information exchange, that one-on-one conversation is still incredibly powerful, and I think it is becoming progressively underrated. So, I think that that single commitment will make a huge difference in building bridges, and I think all it takes is one or two such conversations to really then create that flywheel effect, and I think we, in many cases, used to do more of that, and we need to really double down on that. I'll keep it that simple and leave it at that for the rest of the group. Thanks. Thank you, Balu. Carl, how would you see the role of Hospice Medical Director being pivotal in one of the solutions to improve equitable access? Yeah, I think Balu hit it really well as far as kind of the micro-individual level. Looking at kind of more of a macro level, and I rely on our organizations like AHPM, you know, there are sort of systemic issues where some populations are reluctant to consider hospice. There's this deep mistrust of the healthcare system, and so, you know, as an individual Hospice Medical Director, all I can do is, you know, touch people's lives one life at a time, but I think sometimes engaging the faith community can be really helpful. There's a lot more trust of somebody, you know, a fellow parishioner or clergy as far as saying, yeah, these are not the people that are trying to kill you or, you know, somehow get money out of killing you, which doesn't make any sense. But so I think we could probably benefit from trying to engage more with faith communities, with other community organizations and so on. And that, I hope, would move the needle a little bit in some of these inequities. Thank you, Carl. And Joe, you spoke about this a little bit about the strategic plan for AHPM, but talk, if you would, specifically about your experience as a Hospice Medical Director, those that you're mentoring, how you feel like we can be part of the solution to improve equitable access. Yeah, thank you. Well, so there's so many different levels at which you can engage in this work, the personal level, the level of your team, the level of the leadership of your organization, and then the bigger policy or national level concerns. I'm just going to start at the personal. You know, if you acknowledge that the judgment call of the Hospice Medical Director has a big impact on people's access to service, you know, whether you deem them eligible, whether you deem a treatment medically necessary and appropriate and covered, then I would say if I have bias, I'm going to the odds are it's contributing to the lack of access or the inequities that we see. So I should have curiosity about my own biases. And if you're interested, you can go to a website and you can take the Harvard, I don't know what it's called. It's called like, you know, the implicit bias something test, right? You can take it. And I did. But don't take it unless you're ready to find out that you have very strong biases that you wish you didn't. But, you know, so you take it and you find out that yes, I didn't, I don't want to be biased, but I do have biases. It's good to know that, particularly since your judgment calls are so key. At the team level, you can express curiosity for every one of your patients and families, whatever culture or background they come from. And I would say in particular, if the team wants to discharge somebody for cause, that's a great opportunity to say, are we looking at the whole picture? Because in many cases that discharge for cause might be driven by actually cultural issues or social determinants of health, or stigma or bias on our part. So you can actually on the team level really try to model this care for everyone that should be receiving your service. At the leadership level, you could challenge your organization to actually acknowledge the differences in access that are there. If you measure it, they're there. And then you could set goals, you could challenge them to set goals to begin to bridge those gaps. Then on a national level, there are all kinds of things we can do, including, you know, starting to gather democratic demographic data in a consistent way. Looking at what are the biases that occur in algorithms and artificial intelligence and machine learning that we apply now, like it's infallible, you know, and, and really, I think you've heard actually, the current administration of Medicare has put out their strategy recently. And they're saying the equity lens is going to be front and center in everything we do. So let's align with that. I think there are so many things you can do. But you know, just on a personal level, be curious. Explore this. Don't be afraid to learn more about it. Thank you so much, Joe. That's so pivotal and right on. Ada, I'm also interested in hearing from your perspective with AFP, how you see the hospice medical director's role being one of the solutions and pivotal to improve equitable access to end of life care. Oh, my goodness. So you know, it's really important as with hospice medical directors, you know, they have a lot of the education that is needed to be able to identify patients who would normally be eligible for hospice care. And, you know, with that education comes an opportunity. Family physicians, we know our patients, we know the communities, we're out there, we're able to be that trusted resource, we are the ones that are, that our patients come to for for help and for guidance. And then having that extra opportunity as a hospice medical director to know who would normally be eligible under, you know, to be admitted for hospice, you know, just really helps us to have that connection. I also go out to the communities and do presentations, talk about hospice on both the family medicine side, and also as a hospice medical director. And that helps the community to recognize the trust that you have. As an organization, you know, we continue to talk about everything that we were doing, we have to do it through an equity lens. We also look at and make sure that we address and talk about racism, and the impact that it has on the healthcare of our communities on our nation. And that's something that as a organization we've been doing, we have our Center for Diversity and Health Equity that was founded in 2017. So we were ahead of the game as far as looking at health equity as a organization. And so we continue to work to address equity and making sure that our patients obtain equitable, affordable healthcare. And it helps us to not only be able to care for our patients who don't otherwise may not even know the opportunities that they can have as far as quality of life, being under hospice care, and just having that opportunity to teach as hospice medical directors. That's the one thing that we don't give ourselves enough credit for is that education piece, educating our communities, educating our fellow physicians and clinicians as far as what hospice is all about. So look forward to, you know, continuing work, addressing access, because we need to make sure especially during this time that we no longer have anyone who would normally be eligible under hospice miss out on this opportunity to gain quality care. Thank you so much, Ada. And I just want to remind those who are on the call here that you can post questions in the chat box. And if we don't get to them today, which we may not be able to, we will compile them and send out a response to them from the panelists. So we're going to keep those questions. And the questions we're moving into now as the last couple of questions came from people submitting them prior to the panel discussion. So I'm going to continue that. The next question I want to get into is one that each of you have kind of touched on a little bit in terms of just talking about how we might go forward to try to preserve the reimbursement for audio video visits or tele visits or continue to, from your perspective, how do you see that working in your organization? And what can we do to to sort of get CMS to continue that? Balou, I'll start with you again. So how is your organization using that? And what do you think we can do with it? We've certainly been able to use virtual visits to support access, right? So admissions sooner, the ability of a doctor to get to a face-to-face much more readily or a nurse practitioner to do the same. And I think what that really parlays into, right, we all know, there just aren't enough practitioners who can do hospice, who can do palliative medicine. There is a dearth of folks in this. And so what this really allows is if it's done correctly and done in a reasonably economically viable way, right, that it opens the door for the same practitioners to do more complex care as opposed to purely administrative care. There's a lot of administrative burden that's been placed on hospices. Anybody who's followed hospice for decades knows that from 1983 to 2013, there was a little bit of regulatory change. And then from 2013 until now, there's just been an avalanche of regulatory change. And so that regulatory burden is where so many of us find ourselves spending our time. And the face-to-face is certainly no exception to that. So I think that it's been written across a lot of industries, right, that we had to figure out in 24 hours what would have taken 24 months or 24 years to pivot as a society. And that's probably much more dramatically true in medicine. So I think now that we have found the merits of it, hopefully CMS will not only hear and appreciate that, but also make sure that those of us who are able to do it can get some remuneration for it so that we can shift the energy of really well-trained folks to the places where it's actually needed. Thank you for that. So Carl, yes, to you next. How do you see us being able to continue that in the way that we're doing it now? And how are you and your organization using it? Sure. Well, both AMDA and I do sit on the Public Policy Committee for AAHPM. We are strongly advocating for this to be preserved. And, you know, nursing homes, I don't know why CMS, there used to only be allowed one visit per 30 days, telemedicine, in a nursing home. So if the object is to prevent a hospitalization, you can do an assessment, but then you can't do a follow-up visit the next day to see how they're doing. It didn't make any sense. Now they've relaxed it a little bit, but it's still, it's not when medically necessary. There's still restrictions on the nursing home side. But I think, for example, for a face-to-face visit, I mean, what possible reason is there to physically have to drive someplace? I mean, probably almost all of us on this call have done virtual face-to-face visits during the pandemic. And while it's not exactly the same as making a home visit or a facility visit, I think it gives you ample information along with everything else you have from your IDG notes to make that call. So I think as individuals, people can comment on proposed rules and so on and advocate in the same way that our organizations do to preserve that ability to do that. And then when we get into more population health, value-based health, where it's not so much, can you actually bill the 99308 or whatever it is as a telemedicine visit, you're doing it because it's the right thing to do, it's efficient, it provides good care, and not have to worry about your paycheck, I think the more we move in that direction, the better. Thank you. And Joe, you mentioned it a little bit in some of your previous comments, but just in follow-up, how do you see us moving forward with this? And from the AHPM's perspective on a national policy level, how are we, what can we do to move that forward? I'm going to go quickly because I want to hear Ada. And I would say, there actually is a bill that has been introduced called the Connect Act. I went ahead and put a link to some information about it in the chat. AHPM supports that as long as, and we also supported all those waivers that we needed in the midst of the pandemic. There are some very basic things like getting rid of this originating site issue that it matters where the patient is when they're getting their telehealth. They should just be wherever they want to be, and that shouldn't have any impact at all. And so, yes, we all want to go there, and I'm going to pass off to Ada now. Okay, thanks, Joe. Ada, yes, especially from the AFP's perspective. Oh my goodness, we have been advocating just strongly for the continuation of telehealth past this pandemic. You know, prior to the pandemic, about 15% of family docs used any form of telehealth. During the pandemic, at least 80%. And many had to get new equipment, innovative technology to be able to do so. And even now, 70% of family physicians want to use some form of telemedicine. We saw how it increased access for those individuals who we could not get into the office. It increased, again, the opportunity to be able to take care of patients. Just this week, I'm going to be advocating with my legislators on behalf of our academy and others, making sure that we talk to CMS and tell them how important it is to, even outside of this pandemic, to continue to have some form of telehealth and to actually make sure that there is some type of sustained reimbursement for the use of that because so many docs had to transform their offices to be able to use it. And we want them to be able to continue to do so. Recognizing that it is not the only modality that we have to be able to access our patients, but it gives us another option to increase our access. And again, as we talk about access and making sure we're able to see our patients and take care of them, this gives us another way to be able to do so. All right. Thank you so much for that. So I think is our time up, Bruce? I think our time is up. So I will turn it back over to you for final comments. But I just want to say thank you to all of our panelists and all of you who joined in today. Again, if you do have a question, please post it in the chat and we'll try to get them answered. So thank you guys so much. And thanks. Thanks, panelists. Yes, I would just close by saying the same thing. Thanks to our panelists. Thanks to all of you for participating and being involved in this event and in the other ones that we've had this year and that will be coming up. We appreciate you. We appreciate your engagement. And please feel free to reach out to us if we can be helpful. Thank you. Have a great rest of the day.

Hospice Medical Directors

equitable access

disparities

eligibility decisions

healthcare organizations

biases

faith communities

telehealth visits

policy changes