Alex (00:10) So I think I I am highly impressionable and I also have a memory of a frog. But I just finished reading like I Ray Dalio, it would be my book recommendation of the week. Ray Dalio with Principles, like just a brilliant, brilliant guy, incredibly effluent, incredibly successful. But his last book that's just come out is How Countries Go Broke, the big cycle. and and so it it's a systems approach to failure.
Dana (00:20) Love him.
Alex (00:35) On a macro level. So, like the industry, the connections, and if you're gonna apply this to musculoskeletal space and a payment reform, that we we can, I guess, call this episode the how physical therapy goes broke, the big cycle, is applied to systems under pressure that are now starting to actually show vulnerability under this pressure. And without naming names, there there's a significant financial write-off from one of the larger systems.
that is occurring because the the payers and and the financiers are are have having a difficult time continuing to feed these systems when the systems are not generating the expected returns. and so this is not just profit garnishing, this is a organizations under distress. And once they're under distress, like there's a
pretty easy formula to calculate and and and you you can see the trajectory of this distress, especially if you're a student of history and especially if you're a student of system thinking, that this is the first signs of larger level reorganization and restructuring that we're gonna probably see in the next two to three years.
Dana (01:43) I'm gonna point to to something coming up, which is one of my very favorite times of year when the multi-thousand-page physician fee schedule is proposed rules put out,
And we can guess at some of the some of what we might see in it. One of the things I think we might see listening to CMS talk a lot over the past months and years is trying to do more value-based care policy directly in fee for service and not just in alternative payment models. So I'll tell you why this is relevant. Stick with me.
There something was added to the physician fee schedule called the Advanced Primary Care Management Codes a couple of years ago. It was under the Biden administration. And that allows a monthly billable code for a set of services. So think services that kind of wrap around those team-based care services. There's interest in potentially adding to those. So start for listeners, start to think about.
You know, advanced primary care as a concept also becoming a billable service, ad the advanced primary care team being reimbursed directly for a wide swath of services that get that get categorized as primary care. Right now, if we don't insert ourselves, primary care consists of the behavioral health providers.
And then all your medical providers, and then the teams that support them providing things like chronic care management,
If we start to see more and more funding dollars going towards primary care and now starting to define primary care more formally and fund it more directly as a set of services, we've talked to this theme before, that money has to come from somewhere. It's a closed system, right? So that means everyone outside of primary care that bills Medicare Part B
we're gonna see the money move more towards primary care potentially and less to specialty care. And right now we are bucketed really under the specialty care category. There's also, I mean, this is down the line, but the model tests right in accountable care organizations, they're in sort of indirectly, somewhat directly, testing.
How successful quality and cost of care are when we pay a monthly capitated amount to that advanced primary care team. Right? This is a theme, right? We know this, but that is practiced in these innovation center models like ACO REACH and the new LEAD model coming. But then once that's tested, that can be made permanent, but also Congress can directly act on that information and make a permanent change to statute.
So there things that get floated around are things like, let's do a, you know, all primary care services are going to be paid at X rate, a capitated rate of let's say 10 to 15 or more percent as a minimum starting point. Now, nothing like that is ready for prime time, but it if I was predicting the future, I think we are four to six years away.
From seeing Payment in Medicare being a team-based primary care payment and funded at a higher level since we're at a pitiful four per 4 or 5% compared to other countries at 10, 12, 15%.
Alex (05:10) I So to align this to like a larger system approach and and to to align this to the structure from from Ray Dalio's work, right? So so there's two cycles. There's a short term cycle and a long term cycle. And and I I think he's prolific about describing a short term cycle about the banks to leverage the loans.
Dana (05:20) Mm-hmm.