Latest / Behind The Knife: The Surgery Podcast / The RVU Shake-Up: Why CMS Is Cutting Surgical Pay—and What It Means for You
Transcript
- CMS Rate Cuts === [00:00:00] Hello and thanks for listening to Behind the Knife. This is Patrick, Georgia, acute care surgeon at Duke University. Starting on January 1st of the new year, the Centers for Medicare and Medicaid Services, A-K-A-C-M-S are going to implement a 2.5% reduction in work RVs for all non time-based CPT codes, and they plan to have repeat efficiency assessments every three years. Now, CMS has decided that we as surgeons are all more efficient and we're spending less time in the operating room and therefore. Our work, RVU should be adjusted and reallocated. Now there's a problem with that. Uh, we actually aren't more efficient. In fact, our cases are slightly longer and more complex. And it is important to understand that these proposed changes apply to nearly all surgical procedures and that this represents billions of dollars in spending. As most hospital employed and private practice comp plans peg their pay to the work RVs, these changes have the potential to be [00:01:00] very disruptive. Thankfully, we have two very well-versed guests to help us understand what's going on here. First we have Dr. Chris Childers. Dr. Childers is an HPB surgical oncologist at the University of Washington. He holds a PhD in health policy and conducts research in healthcare finance. With a focus on physician compensation and the physician fee schedule, Dr. Childers serves on the American College of Surgeons General Surgery Coding and Reimbursement Committee, and acts as an advisor to the a MA Relative Value Scale update Committee, which is the organization that helps develop the RVU valuations we all know so well. Next we have Christian Sheen, who is the Senior Vice President of advocacy and healthcare policy for the American College of Surgeons. Christian has worked for the a CS for over 25 years and is head of the American College of Surgeons Washington office. He has a broad set of knowledge, , in regards to a variety of issues, many of which we're talking about today, including Medicare quality improvement and legislative and regulatory efforts. So welcome [00:02:00] both Christian and Christopher. Thanks for joining us. Thanks so much for having me. All right, Chris. We're all active. Surgeons busy, and most folks are probably like me where we don't really fully understand how we get paid, especially when it comes to the federal allocation of funds through CMS. Can you enlighten us all? Yeah, absolutely. So I think this is something that we don't get enough education about as we're students and trainees, and so hopefully I can spell it out, uh, as clearly as possible. But essentially everything that you do as a surgeon, whether it's seeing a patient in the office, whether it's taking out their appendix, or in my case, a pancreas has a code associated with it. It has a CPT code. Uh, those codes are generated by the a MA and updated annually, and that's how you describe to payers, whether that's Medicare, medicaid, private insurance, what you did. And then the question is, how does that actually get [00:03:00] translated into a dollar value, , that gets paid to your institution? And now the way that this has been set up it starts back in about 1992. CMS generated, uh, with the help of some investigators out of Harvard, a work RVU system or an RVU system, uh, more broadly, that assigns a numerical value to each one of those codes. So an appendectomy is somewhere around, you know, nine to 10, a Whipple procedures around 50, seeing somebody in the clinics, two or three. Those numbers are all supposed to be what we call relative values. Essentially, what is the relative amount of resources that go into taking care of that patient. Now, there's a lot of nuances and subtleties and, and I happy to dive into all of these things later on, but essentially you take those numbers, you multiply it by what's called a conversion [00:04:00] factor. That conversion factor is generated by CMS each year. It's updated based on some balance budgeting that they do, and that number then gets multiplied with the dollar value and you spit out how many dollars you get paid for that service. Another couple of things I just wanna mention, just 'cause I'm sure we'll talk about them a little bit later on in the podcast today. Surgical procedures, generally speaking are paid based on what's called a global period. So most of our major surgical procedures have a 90 day global period. And so this means that all of the care that you provide as a surgeon for that patient starting the day before surgery to 90 days after the surgery in the hospital, out of the hospital is all bundled into that number. For the appendectomy or the Whipple procedure. Things like office visits do not have global periods. Those are just billed based on how many office visits you have at any given day or week. And so the rvu, that [00:05:00] number that I was talking about is a really important number for surgeons across the board, no matter what model that you work in. So if you work at a hospital. Most likely you are paid in some way, shape, or form based on rvu. You're gonna have a target, maybe it's 6,000, 7,000 RVU that you need to generate in order to make your salary. You might have some incentive to go over that salary, a certain number of dollars to RVU or pool that you can draw from. But your compensation, what you take home, is entirely related to the number of RVU that you generate as a surgeon. What is unique, and I think what is, so Im important to discuss about this efficiency adjustment that CMS has finalized at this point for 2026 is, it's the first time that I know of that they've come after the [00:06:00] RBU's. Historically, they've always gone after that conversion factor, that dollar value that it gets assigned to work RVs. And while that matters for some surgeons, it probably matters to a surgeons in private practice who are dependent upon actually balancing the books of the dollars coming in and the dollars coming out. It probably doesn't matter quite as much to employed surgeons, people that work at hospitals, people that work for other entities, because most of the time I'm just given a target. I'm given 6,000 rvu. And my RVU were never affected in the past. The CMS efficiency adjustment for the first time has said, you're getting more efficient. We're not just gonna drop your dollars, we're gonna drop your RVU as well. And so you do the exact same work, Patrick, this year. As you do next year, you're gonna get paid two and a half percent less if your comp model doesn't change. And that's a big deal for people that are not used to, seeing dollar values change in any given year. So I think that's, uh, hopefully that provides a kind of a simple overview [00:07:00] of how we translate kind of codes into dollars and why this efficiency modifier, uh, is such a big deal for us. Yeah, that's, uh, one of the most clear explanations I've heard. I've got a lot of extra questions on conversion, uh, of rates and, and RVU that maybe we'll have to have you back on to, to break those down farther. But sticking with the topic at hand here Christian, you know, what's the goal here? Some people may kind of have a knee jerk to say, well, this is cost savings, right? Cost savings for our healthcare system, but these funds are actually being reallocated. Is that correct? It absolutely, it is correct. In terms of, they started this conversation back in July. By talking about efficiency and where they're at now is the money doesn't leave the system. These cuts doesn't leave the system, it just gets reallocated. So a robbing Peter to pay Paul is really sort of a, uh, is a good analogy here. This doesn't make a whole lot of sense as far as sort of how they're going about doing this. Really, it's not about saving money in the healthcare system. It, it's [00:08:00] strictly about sort of making cuts and shifting those dollar figures into other areas within the healthcare system. Yeah, so explain to me the difference then in terms of pr, actual practitioners, right? Surgeons or non-surgeons, especially when it comes to non-time, time-based DPT codes versus time-based codes and how those funds are gonna be shifted. So CMS makes the argument that the non-time based codes are being done more efficiently, and so thus there should be a cut of 2.5% of the work RVs. They take that and then translate that into the conversion factor as Dr. Chow has mentioned earlier in terms of there's a dollar figure that they attach this whole thing to called the conversion factor. Well, they increase the conversion factor by some small amount, but that goes across primary care and all the other sort of non a time-based codes as well. So, that's really where, so there's been a small increase right across the board, but then this allocation of this 2.5% cut from s, we'll call it surgeon [00:09:00] RVs, right? Non-time based codes, your appendectomy or Whipple, and shifting it over to time-based codes, which tend to be more to oversimplify medicine based. Uh, non procedural based interactions perhaps clinic visits, et cetera. And that's where that 2.5% is going correct? Exactly. That's exactly what it's, so how unusual is this then, Christian we've never seen 'em go after the work. Rvu, as Dr. Childers said, . What they usually go after is the conversion factor and going after these work RVs has been, uh, a first time that I've seen in the 25 years that I've been at the college. Okay. And so this all hinges on this idea of efficiency. We keep mentioning that surgeons are more efficient, therefore, you're spending less time in the or therefore you should be paid less RVs per case you do, uh, which to some degree it makes sense, but we don't know that's true in fact. Dr. Childers, you published a paper, uh, with some of your colleagues showing the opposite, right? And so the title is Longitudinal Trends in Efficiency and Complexity of Surgical [00:10:00] Procedures Analysis of 1.7 million Operations Between 2019 and 2023. And this was published in Jack's just a week or two ago, in November. So you found the opposite, right? So what's, missing here in terms of the rationale for this Cut. Yeah. Yeah. Uh, one, one quick thing I did wanna just add to the conversation that we were having just a second ago about conversion factors. And, and this is the part that makes my blood boil a little bit as somebody that's been in this space for a while, so you've probably seen every single year. The college sends out an email every time we go through this whole process saying conversion factors are going down, we need the conversion factor to be indexed to inflation. Right, right. We've said that over and over and over again. 'cause , right now we have conversion factor that for the most part stays stagnant year after year after year, which is a real cut when you think about inflation adjusted dollars. And so we've been [00:11:00] asking for years. To get the conversion factor index to something called the MEI, the medical economic index. And here's the part that makes my blood boil, is that CMS said, okay, we're gonna take, there's actually two components to the MEI. There's a component that describes inflation. There's also a component that describes efficiency. The idea that manufacturing, for example, should get more efficient over time. They said, we're not gonna get, we're not gonna do anything with the inflation component. We're not gonna increase the conversion factor. We're gonna take that efficiency component. We're gonna sum it up over the last five years, and we're gonna apply that. Depreciate all of the work RVs for non-time based codes. So we got our MEI update. It was just not exactly the one, not exactly what you're looking for. Huh? And I bring that up because in the final rule. They said we're gonna use, we're gonna go back five years. In theory, they could have gone back 20 years and depreciated all of our work. RVU used [00:12:00] by even higher. So I, I guess that's one other way to look at this, but they said, we're gonna go back five years. And so we decided, when we learned about, I gotcha. This efficiency adjustment going live, they proposed it over the summer. I said I think I can do a quick analysis. We have a robust. Database that we all have access to. If you work at a, at a hospital that has NS quip I'm gonna go back five years and look and see whether or not our operating operations have actually got more efficient. We looked at over 200 different CPT codes. These are high volume codes. They're not just general surgery. We're including things ENT, neurosurgery, orthopedics, general surgery. And so we looked at over 200 different procedures. And we looked at our operating room times, and these are measured skin to skin times. They're abstracted by a or a registered nurse that's doing it prospectively. Are they actually getting any faster over time? And when we compare 2019 to 2023, we actually saw the [00:13:00] opposite. On average, our operative times are getting a little bit longer. And actually when you look at it by procedure, it was 90% of procedures. Are the same, if not a little bit longer than they were in 2019. And so the question that then followed from that, and we did a few preliminary analysis to look at that, is why, why Yeah. Is that happening? And so what we did was we looked at some basic measures of surgical complexity and the patients that were taking care of, and it's pretty clear from the data the patients are getting older. They're getting sicker. We're just doing more complex operations over time as the population evolves and as we expand the breadth of operations that we offer to patients. And so we found the opposite. We said we don't see any evidence that we're getting more efficient over time, and we have a pretty convincing argument with pretty robust data that it may actually be the opposite. We summarized that data. We got it [00:14:00] published in js. And we've been disseminating that as widely as we can. The a MA was bought in and started using it in their materials as they fought back against the efficiency adjustments. So we submitted a very detailed report to CMS that anybody can do. And then we had to wait. And we found out on Halloween. They published the Final Rule late in the afternoon on a Friday. We're publishing it anyways. We're finalizing it as it's written. And if you read through the language in the final rule, they acknowledged that they got the paper, that they read the paper, and they basically said, we don't care. We view your surgical procedures as being maybe not more efficient over the last five years, but we still think they're overvalued, so we're gonna cut them anyways. I think the only, the only final thing that I think is really important to mention that we haven't mentioned so far yet today is it's affecting surgeons, don't get me [00:15:00] wrong, but this is affecting a very broad swath of physicians. We're talking, I think, something like 7,000 codes that are getting impacted by this. 'cause it's very few codes, it's less than 10% of the fee schedule that has time based codes. Most of the fee schedule is non-time based codes. And so this is impacting cardiologists and gastroenterologists and a lot of other specialists. And so there was pretty uniform opposition to this, but CMS just said, we don't care. So, , how did you argue to policymakers that. Your findings, uh, are not supported by the actions here. Yeah, it's, it's, it's a real challenge. You know, I think that we were all hopeful, optimistic that we were, we were finally bringing some solid data and that in a world where data is driving decision making, but that should [00:16:00] matter. Um, and unfortunately we didn't get that in this situation, which is why. We're still working hard, but it's through different avenues. Apparently data is not enough for this administration, and so, and I know Christian's gonna talk about this a little bit later, but the college is still gonna keep fighting. We just have to work on, on different mechanisms. Right. So is there, Christian evidence that surgeons have been overvalued or overpaid in the past? You mentioned robbing Peter to pay Paul when it comes to. Reallocating funds away from non-time based codes. No, I don't think there is evidence that says surgeons are overvalued at all in terms of they are providing lifesaving care for patients at 3:00 AM And and so I don't think it's a matter of whether or not they're overvalued. I, you can argue that, primary care should be paid more. And there's a valid argument for that. But the reality is, is cutting surgeons and other physicians in order to pay for that increase , doesn't make it right. And [00:17:00] it's gonna have an impact on the healthcare system as a whole. So we have argued Don't cut, don't rob Peter to pay Paul here. I think one thing that a lot of folks don't appreciate about the physician fee schedule, which is kind of a ridiculousness of the physician fee schedule. Is the fact that it has this balanced budget provision built into it. And so every dollar that goes to another specialty is by definition required to come out of another specialty's pocket, right? Just say that one more time in terms of the balanced budget portion of all this we talk about healthcare costs ballooning, and , we're trying to save money. And so one might say, that we are hopefully being thoughtful about that. But this is physician pay that has to be balanced each year, not the other portions of these budgets. Correct. There's a statute built into law that has existed for Christian, you know, better than I do, at least 30 years. That says if you expect a $20 million increase, this $20 million by the way hasn't changed over 30 [00:18:00] years, despite the fact that $20 million has changed in value a lot over the 30 years. That if you expect that anybody's gonna get a pay raise or a pay decrease by that amount, that you have to adjust the fee schedule so that it all ends up balancing. So they do that every single year. And no other sector of healthcare, hospital pay, ambulatory surgery center pay has that provision. And so hospitals every year will get a little bump in their inpatient and their outpatient prospective payment systems based on inflation. 'cause it's built into law. We've never had that for physician fee schedule. And by definition that means we end up having to compete against other specialties in these decisions. I don't think there's anybody who disagrees with the idea that. Primary care should get paid more for the work that they do. Mm-hmm. I think the problem is that we've created a system and we are stuck in a system that by definition means that you have to rob Peter and pay Paul. And the other thing that I think is really [00:19:00] important, so primary care is a large part of, of. The health system, I think something about 40% or so of physicians are in primary care fields and they rely on a very narrow set of CPT codes in order to be able to take care of patients. They basically have office visits and, and things associated with office visits. When you look at the fee schedule, and in order to allocate even a small amount of money to those few codes, you have to steal from 7,000 other codes in order to have a small increase. To those larger codes, and it's just, it's an untenable system that pits everybody against each other. Now we're talking about CMS here. How does this relate, to private insurance? Yeah. So I think that is again the part that makes this so novel and so challenging and disturbing frankly. In the past, , private insurers have their own kind of way of doing finances, but they don't have a balanced budget If they pay a little bit more to surgeons that year, it [00:20:00] just, it ends up being what it is. What makes this challenging is that they're decreasing work RVs and private payers. Also rely upon work rvu, right? Most surgeons are shielded from their payer mix, and the fact that you take care of somebody that doesn't have insurance or Medicaid and Medicare and private pay doesn't really matter to you. You take care of those patients nonetheless because you're getting your work rvu. It's a way of leveling the playing field, but suddenly this policy is gonna drop all of those work reviews, so it's gonna impact every surgeon across every payer. That's what is unprecedented about this and why we really are in uncharted territory. So explain to me what's gonna happen Christian on January 1st, 2026, if you're gonna get a payment from Blue Cross or another private entity. Are they going to automatically match and adjust according to this new CMS rule? Or is that something that [00:21:00] we'll have to watch and wait? So most private payers pay based off of the Medicare fee schedule. They might pay 5% more. They might pay 10% less. Whatever is sort of negotiated from that. But as we're seeing these cuts that are happening, the private payers would pay less as well. So whatever that contract is that's been negotiated for 2026 by the private practice surgeon's practice with the Blue Cross or Aetna or whomever, they are going to see a decrease because their contract is tied to the Medicare rates. What is interesting also here is the fact that this is not just your private practice surgeons who care about this, many surgeons who are employed. Most surgeons who are employed, their contracts are connected to work RVs in some sort of a productivity adjustment. So they are looking and saying if all of a sudden you were paid, as we talked about earlier, you were paid for [00:22:00] 5,000 work RVs in the course of a year. Now you're gonna take a 2.5% cut. Well, your contract is done most likely for 2026 at this point. So this is gonna have an impact both on the private practice surgeons and the employed surgeons. If our workforce is, roughly 40% primary care, does that mean they're gonna be paid more starting in the new year as proceduralist based RVU go down. So that's a really interesting question. And there, there is actually some empiric data on what happens when RVs change. There was a, a National Bureau of Economic Research paper that came out a couple of years ago that basically said that RVU changes, and this is, this is kind of some rough back of the envelope kind of math, but basically says that if you change RVU, that it actually changes pay by about 10% of those values. It goes in the same direction. Like if your RVU go up by a hundred, then your pay goes up by, by a hundred percent. Then [00:23:00] your pay goes up by 10%. So it goes in the same direction, but it's not a one for one match. And so I think the, the reason that's important is that CMS assumes when they make these decisions that there's going to be a windfall. To some specialties and not to other ones, but physician compensation is extremely complicated. Sure. And there's a lot of things that go into it, whether it's payer mix, whether it's a practice ownership, supply, demand, region, state, there's a lot that goes into physician compensation. And the RVU system is ma what my interpretation of it is actually, maybe the RVU system's not the best way to lever that, but CMS assumes that it does, and they've been acting for years now, including this latest effort, that this is the way to, to pay primary care more, um, and [00:24:00] make it a windfall for primary care. And that's gonna fix the entire healthcare system. Is there a clear argument on their behalf to say that we're getting right here to some degree based on these. Changes. Changes? Or is it again, more of a wash based on what you just described? They see a pay increase and they're happy to see a pay increase. But I think it's that issue of, uh, robbing Peter to pay Paul, and that doesn't work within the healthcare system. And the healthcare system is broken in that way. Are physicians an important part of the problem when it comes to ballooning healthcare costs? That same paper that I was referring to a minute ago says the physician's salaries are about 8% of spending. In the United States, it's not, and that's, that's on par, if not a little bit lower than many other countries. So if you think that we're spending twice as much in this country than other countries, it's probably not largely being contributed to by position salaries. But what I will [00:25:00] say is that as physicians, we do contribute to healthcare costs a lot. Maybe not necessarily through our own salaries. But things that we do are very expensive, right? The surgeries that we do are very expensive. Not money that's going into our own pockets, but money that is going into hospitals and other organizations. And ironically, one of the things that I think is maybe a little bit shortsighted by CMS in this whole process is they have a little bit of a math problem. So let's just say, let's just work through this. Let's say that you do 7,000 RVU a year and next year you do the exact same number of operations you're gonna do. I just did the math 170. You're gonna get 175 fewer work RDUs next year if you do the exact same amount of work. Let's just say for the sake of argument that you're in a compensation model that pays based on rvu. You might be incentivized to [00:26:00] increase your volume a little bit. You might need to make up those 175 work RVU in some way, shape or form. And so how does that happen? It happens by doing more surgery or seeing more patients. And what does that do? That costs the health system a whole lot of money. When I do another 175 RVU way more money than the two and a half percent, they're saving on my physician payment. So I think there's some math that. Is not gonna end up adding up in the long term. I think they're doing my honest opinions, I think they're doing this as a political win to try to say that they're robbing Peter to give Paul, but also I think that they want to take the power out of the AMA a little bit because they have been critical to the valuation process for. Uh, RVU for a number of years now, and they want to kind of say that we're gonna reign in that process and, and have some [00:27:00] oversight of that process. And so I think that's what their goals are. Um, and they stated as much in a lot of their documentation, but I think it's pretty shortsighted and we really don't know how this is gonna impact things. We're not gonna know for years, we're not gonna have data on what happens to surgical care. We're not gonna know how many people drop Medicare. We're not gonna know how many people increase their volume. We're not gonna know if quality deteriorated, if patients were getting kicked outta the hospital faster. If you were doing operations quicker, we're not gonna know any of that for years. Um, and unfortunately, CMS. Has made a decision in the absence of data. 'cause there is no data to guide them as to what is gonna happen downstream from this effort. Yeah. And you had mentioned RVU is just now and earlier, how does that line up with what we do on a daily basis as surgeons? The vast majority of us work extremely hard and. What we do is complex but there's a lot of other [00:28:00] providers working very hard too. So what is the relative value of what we do and help folks like myself understand, what it means to be a surgeon. And what we're being assigned for RVU is Really good question. If we had all day, I could dive really into imagine the needs on these things. Um, and I would be happy to do so at any time. But very superficially RVU system was created. Back in 1992, they created this list of RBU's for the codes that existed at that time, and they've been updated ever since then. And very broadly, how does that process work if you're updating a code or if you're getting a new code? Well, it goes in front of. This a MA housed committee called the Relative Value Scale Update Committee, the ruck. All of our assess societies, including the college, have representatives there in order to advocate and, and discuss the work that goes into that new code. All specialties are represented roughly equally, or you know accordingly? Yes. Okay. Probably represented based on number of physicians in that specialty. But we don't have an even [00:29:00] distribution, as you can imagine, of specialists versus primary care doctors. So for example, sitting around the A MA rec table, you will never have a majority surgeons just 'cause there are not that many surgeons in the United States. So we're always gonna be in the minority. But very high level if you're reevaluating a code or creating a new code. Currently the process is a survey goes out to people that perform that procedure. They are asked to generate a relative value compared to other things that they do, um, and compared to other things in other disciplines. The details of that process I could dive into and, and talk to you about all day. But essentially that is the basics is that a survey goes out and you're asked to generate a relative value. And so it actually brings up a really important point though, is that. When CMS decided to do this efficiency adjustment, they were assuming that our operative times are getting shorter and so therefore all of your work RVs need to go down. Mm-hmm. Well, that kind of assumes that there's [00:30:00] some like calculation going on in this process that like every minute in the operating room is equal to six rvu, and that's not how RVs are generated at all. And I think that's something that CMS really a big disconnect is missing the boat on. It's a, it's a real big disconnect. You're assessing the overall value of that procedure in terms of the overall work in the 90 days for taking care of a surgical patient, getting a Whipple versus an appendectomy, right? And sure is an appendectomy one sixth of the time in the operating room. I mean, you could, you can mess with all of that, but the only people that can really assess the relative value of that are people that actually. Do those procedures. And that's why this survey process has been so instrumental to this, , effort over the last 33 years and why nothing has come up that's better than this. I understand that CMS can then look at individual numbers that go into it and have problems with individual numbers, but it's missing the way that this is actually getting generated. Alright, so most [00:31:00] importantly, are these. Changes going to impact patient access to surgical care. Chris, you had talked about this earlier, we will probably have to wait and see is there a chance that this has a negative impact on our patients? Yeah, I do think there's a chance., I think that every surgeon wakes up and tries to do their best in any given day and really does try to take good care of their patients. But I don't think we really fully understand how these. Subtle incentives change surgical care over time, over the different practices, will it change surgical decision making? I don't know. Maybe would you maybe not do as much non-operative management of appendicitis over time because you need a few extra rvu? I don't know. , I like to think that no surgeon is gonna do that overtly, and I really don't think any surgeon would do it. Overtly, but are these subtle influences gonna impact things over time? I think [00:32:00] it's possible. I think there's gonna be surgeons out there who just say, I can't run my private practice with these payments. I can't take Medicare. I need to shift to another practice model. But as I mentioned before, it takes years for these data to become available, right? Medicare's not gonna release 2026 data until 28. Then it's gonna take another year or two for health services researchers to figure out if anything happened. And at that point it'll be 2030. And CMS will already done their second efficiency adjustment, which they're planning on doing every three years, again, based on that MEI that we were hoping to be using for inflation. But now we're getting it for efficiency and then we won't know what the impact is of that. And so, uh. It's frustrating , and it seems like a question that you should know the answer to before you implement a policy of sweeping as this, but, but they didn't makes me sad. So, Christian, how is this going to impact surgeons then so I think your private practice surgeons are going to see a cut in their payments [00:33:00] based on the fact that the work RVU, it generates sort of their total payments for particular procedures. They have faced this year after year with the conversion factor cuts that we have challenged and fought against every year. So the private practice surgeons are saying, once again, CMS is coming at us with cuts to our payment system. What's a little bit different this year, is the fact that they're going after the work RVs. So those surgeons who have their contracts set up for that are paid based on work RVs are for the first time gonna see a cut in their payments potentially going forward. And so I, I think this is generating both an interest both from private practice surgeons and from your employed surgeons as well in whatever model. They are employed. I think we're going to see more and more of that. That's why we've seen thousands of surgeons contacting Congress , and urging Congress to fix this problem. So we're already seeing that, large scale pushback coming [00:34:00] from surgeons from across the country, from all specialties and from all various types of, uh, models. And so how is the American College of Surgeons responding to all this? And, what can. Any given surgeon who's listening to this podcast do Today? So the College of Surgeons is leading a large scale coalition of both surgical and non-surgical organizations in urging Congress to stop these cuts from being implemented on January 1st, we have had thousands of surgeons go to our college's website@facs.org. And email their senators and representatives urging them to pass legislation before January 1st to stop these cuts. College is working very closely on Capitol Hill with legislators looking to get legislation introduced, looking to get this legislation passed before January 1st. But this is a political fight that [00:35:00] we're in and we need. Every surgeon out there contacting their senators and representatives, and you can do so, so easily through the college's website, facs.org, a couple of clicks and you can send an email to your senator and representative. These letters, these emails mean something in these congressional offices. And the more emails and the more tension that we can draw to this issue of these, uh, these efficiency cuts, uh, is going to be, uh, critical to making sure that we can get the stop before January 1st. We'll include those links in the show notes so people who are listening can easily like you said, one click away from sending that information. I've done it already. It is very easy and quick. And so we appreciate obviously the college fighting back against this. Any other thoughts Christian and Chris regarding this topic? Obviously there's a lot to, unfold here, but we appreciate you setting the stage for this and informing all of us. The last thing I would say is just again, urging everybody to get involved in this process. We really need [00:36:00] every surgeon out there talking about these cuts and urging Congress to stop these cuts from occurring. I, I agree wholly with Christian and I, I think that folks should also be having the conversation locally. Uh, if these cuts do go into effect you need to have those conversations with the leaders in your own institutions about how they are going to handle that, right? So a lot of institutions will create benchmarks based on things like double A-M-C-M-G-M-A data. Guess what? That data's not gonna get updated. For years again. And so next year your benchmarks shouldn't be based off of work RVU that no longer exist. Um, and so those conversations also need to happen internally and they need to happen quickly. And hopefully that will also motivate individuals in your own division to also, get involved at a, at a local, state and national level in the advocacy against them. Fantastic. Well, thanks again everyone for listening. Until next time, dominate the [00:37:00] day.