I see our participant number going up, so I'm just going to wait a couple more seconds and then we'll go ahead and get going. Kind of like sitting at the back of the room in a live presentation, everybody waits till the last minute to come on. We won't wait until it's longer. All right. Let's go ahead and get started. Good afternoon. Welcome to the webinar today on the 2023 Cardiovascular Provider Compensation and Projection Trends. And we're going to focus on some subspecialty information. I am Karen Wilson, I'm the Vice President of Member Services. And with me is Joel Sauer, who is the Executive Vice President for Consulting, and a well-known name when it comes to MedAxiom's compensation report. Last year, we celebrated the 10th anniversary of the report, so this year makes number 11. And we're glad that you joined us for today's webinar. A couple of Zoom hints, just as we're navigating and getting started, if you were interested in seeing the presentation slides or downloading those slides, those are going to be available in the chat box in Zoom. And if you have any questions for us as we go through, we're going to try to leave some time at the end to answer those questions. So please put any questions in the Q&A box inside Zoom, and Ari is going to help us with those so that we can answer those at the end. So if you haven't done so already, we encourage you to download the full report at the link shown here on the screen. This publication is probably the most requested and the most downloaded publication that MedAxiom produces each year. That being said, it truly is a team effort. You see Joel and myself here, but this project would not happen without our colleagues on the IT team. They're the ones that do all the behind-the-scenes work with MedAccess, our data benchmarking system, which is the source of this information, and then our marketing team who make all the data and analyses look good and help keep us on track for getting the report published. So a huge thank you to them and to our members. This report would not be possible if our members did not submit data. So Jerry Blackwell frequently refers to MedAxiom as the member services organization that is driven by data, and this survey might be one of the best examples of that. It is stronger as more and more members participate. So if you haven't done so yet, join us and have your data included in next year's survey. So our agenda for today, I'm going to start with some survey highlights, just high-level trends that we saw. I'm going to go over some of the demographics so you know who is actually included in the data samples. Then I'll move into the cardiology general overview for compensation and production. I'm going to turn it over to Joel, who's going to do the super subspecialty findings, as well as the surgery overview and some information on ADPs. So starting with the survey highlights, every year when we begin to analyze the data for this report, we wonder what the big story will be. So when Joel and I first met to review the initial findings, and he said, what's the big story? My answer was that the big story is there's really no big story. The data was very consistent between 21 and 22 with just some minor ups and downs depending on subspecialty, ownership, and region. Overall, you'll see here that cardiology compensation increased 3% while RBUs decreased a little more than 1%. So what was interesting was that the changes in production were not really a predictor of the changes in compensation overall or between subspecialties. Hopefully, the consistency of the year-to-year data is good news, reflecting some stability after some rocky years. But the consistency also led us to dig for a story, something unique we could bring to the report this year, which led us to dive into the data around super subspecialties, something that many of our members have been asking for and Joel is going to cover today. So then total compensation, the total compensation difference between our private and integrated cardiologists widened in 2022. Last year, we had commented about the narrowing of this gap to its closest point yet. But this year, that gap grew again with physicians in integrated programs earning about $57,000 more than private cardiologists. The median compensation for integrated cardiologists was the highest in the history of this annual report, slightly ahead of where it was in 2019. Total new patient volumes per cardiologist inched up to their highest level recorded in the annual report. The average number of patients per physician or the patient panel also inched up in 2022, literally about 10 patients. It's not the highest on record, but that 2019 number there might be somewhat of an anomaly. And then there were really no significant increases in imaging or procedural volumes per patient panel across the board. I went ahead and pulled the cardiology strongholds into one graph to demonstrate this. So year over year, very consistent. In fact, the strongholds of ECHOs, NUCs, CAFs, they actually all dropped slightly with PCIs remaining the same. And the final highlight, the ratio of APPs to physicians continues to increase along with APP production and compensation, which Joel will cover. And now about 92% of the programs submitting data have APPs as part of their care teams. So some demographics. I want to review a few of these, not the most interesting data in the report, but definitely important so that you will know who's included in the data, as well as how those demographics compare to overall membership. And then we brought in some national statistics as well. So when we pulled the data for the report in early summer, there were 198 programs included, which was the exact same number of programs as when we pulled the data for last year's report. There was a slight increase, 2.3% in the number of providers represented by those 198 programs. You'll see here, the pie chart shows the split of providers between specialties, obviously primarily cardiology, but we have seen an increase in the number of surgeons participating. And just to note, you'll see on a lot of these graphs, we've kept the figured numbers from the report. So if you want to go back and reference those to the full report, you can do so that way. The median group size for programs participating in the survey is 11.6. And so we were wondering how that might compare nationally. So we use data from the ACC, as well as 2022 Medicare claims data to estimate that the average cardiology group size is just under 11 physicians. So really very close to the MedAxium medium, but interesting for private programs in the survey, the median is actually 19 physicians, twice as big as the median number of physicians for integrated programs. So this means that for private cardiology groups, MedAxium's data are skewed heavily to larger groups. The median group size for cardiac and vascular programs are both around two physicians. So then when we compare the MedAxium membership to our survey participants, programs with one to 10 physicians are actually overrepresented in the survey. So 43% of membership, but 57% in the survey. And then interesting, programs with 11 to 20 physicians are actually underrepresented. So 22% of membership, but just 13% in the survey. Membership model, very key demographic, and one we use frequently to compare data in the report. As we know and see in the trend lines here, there has been a steady decline in percent of private programs, and those private programs represented in the survey is what these percentages represent here, but percentages from last year held for 2022. So no change in that percent split in the survey respondents. This suggests that the much discussed impact of private equity on cardiology ownership for groups, especially those employed by a health system, really has not yet shown in a meaningful reversion of integrated practices back to private practice, at least amongst MedAxium membership and those submitting data. Karen, it's worth noting, though, that at our Austin meeting, the CBT meeting, it's a big topic of conversation, and the private equity firms have clearly now set their sights on integrated practices, with some success noted, by the way. So it'll be interesting to, we'll keep tracking that trend line and see if and when it changes. So at the provider level, there was a slight uptick in the number of private physicians and APs reporting this year compared to last. So 16% providers for cardiology compared to 18% this year, and it was actually 2% private surgery physicians and APPs last year, and this year it was 7%. Then another important demographic we used to filter data is geography. So this graph compares survey participants, that top line, as well as MedAxium membership, and then we did some research into some national numbers as well. So the South is always well represented in the survey, as well as in MedAxium membership. The South and Northeast are actually a little over-represented in the survey compared to overall membership, which you can see there in those top two lines, but we wanted to dig a little bit deeper and see how MedAxium membership compares to national numbers. So a study by KFM Polling used state licensing information to count cardiologists by state, and then we grouped those states to our regions, and those percentages are shown in the bottom below. So the national numbers do show that MedAxium membership is Southern heavy, and with the Northeast, even with an uptick we've seen in the last couple of years, we've had some new members join us from the Northeast. Even with that, our membership is half of the national percentage for that part of the country. Then compensation. There was a shift in the percentages of compensation models this year. The productivity percentage, which has been the long time leader for some time, dropped to below 50% for both cardiology and for surgery, and the increase, the resulting increase, was seen in the salary plus bonus category. That being said, it's important to note that participating in MedAxis is voluntary, and while we would love, as I mentioned at the beginning, for all members to participate, and certainly encourage all to do so, it's not required. So this means that sometimes that year-over-year shifts like this could be more likely due to a survey bias, different members with different demographics completing the survey from year-to-year than they are due to a major shift, in this case, compensation models. So just something to keep in mind with a voluntary survey. Then the final important demographic, one we use a lot, is subspecialty. This shows the percentage subspecialty mix for integrated and private programs in the comparison of those two. The largest difference has traditionally been with interventional physicians, but this difference did narrow a bit this year with the private percentage dropping from 39% to 35% interventionalists. The increase there was seen in the private general non-invasive cardiologists, and the numbers of non-invasive, non-interventional physicians for both ownership models does continue to drop. This is actually the first year that the private heart failure specialists have made it to the chart with 1.4% in the mix. And just wanted to add, last year we added a measure in MedAccess, which allows you to compare your program subspecialty mix by percent, and also by patient panels. So, for example, how many EPs per 1,000 active patients would you have compared to other members within MedAxiom? So, very helpful tool that's relatively new to MedAccess, if you haven't tried it out yet. So, cardiology is going through a general overview. Again, we'll not cover every single category that we cover in the report. So, cardiology is going through a general overview. Again, we'll not cover every single category that we cover in the report, but just some highlights here. Looking at all full-time cardiologists by subspecialty, this time not ownership. EP and interventional, those two dark blue lines there at the top, have been kind of neck and neck for several years. Interesting that in 2022, EP took back its spot for the highest compensation after being edged out last year. And then if you look at the other end of those lines, for the last three years, general non-invasive and heart failure physicians have also been nearly the same. So, there's only a 1% to 2% difference between compensation for those specialties at the top of the graph, and then 1% to 2% difference between the ones at the lower end of this graph, with those invasive physicians pretty much in the middle. Also interesting is that compensation for all subspecialties, except for heart failure, increased pretty much nearly at the same rate from 21 to 22. So now, adding in ownership by subspecialty. For all the subspecialties, the median compensation for integrated cardiologists is higher than that for private counterparts. The compensation differences between ownership model are around 20%, definitely the greatest for the more office-based specialties for the general non-invasive and the heart failure physicians. And the rank order for the two ownership models are nearly identical with that slight swap between EP and interventional. But when we look at production, it's the exact opposite. So here, private cardiologists outproduce integrated cardiologists at the median across all subspecialties. The largest disparities are definitely with interventional and heart failure physicians. Regionally, so now bringing in that geography, the South continued its run on the top. Interesting that the West snuck above the Midwest in 2022 and was the most dramatic increase as visible here on the graph. Again, this could be survey bias, different programs, smaller number of physicians represented in that Western region. The median compensation for the physicians in the South was actually 150,000 more than the Northeast. And we just talked about the Northeast, a segment that we've already mentioned might be underrepresented within MedAxian membership as well as overall numbers. So something to keep in mind there as well. Looking at production by region, important to note that 44% of all private groups responding to the survey are in the South. And we already looked at the higher productivity for the private groups. So that potentially partially explains the South's higher production totals. Where the West snuck ahead of the Midwest in compensation, the Midwest held that second place for production. So putting compensation and production together shows that very tight relationship between the two. For every subspecialty, the rank of median total compensation is in the exact same order as the median WRVU production. And let's go back to what I mentioned in the highlights. The changes in RVUs was not a predictor of compensation changes in 2020, 2022. All the subspecialties saw an increase of compensation at the median, but three of the subspecialties shown here saw a decrease in production with a fourth being basically flat. So again, going back to that RVU change was not a predictor of that compensation change for all subspecialties. So this leads us to the total compensation per WRVU measure. And as a reminder, this measure is a calculation. It is not a physician's contractual production rate, but it is purely a mathematical total compensation divided by total WRVUs. So with the graphs leading up to this point, higher compensation for integrated subspecialists and higher WRVU for private subspecialists, these amounts on this graph are really not a surprise. And Joel will talk more about the difference there for heart failure. And then over time, the delta in compensation per WRVU between private and integrated cardiologists has remained mostly unchanged. That narrower compensation gap that I mentioned for 2021 shows here as well. But overall, the delta suggests relative stability of this metric despite some significant changes to some RBU values over the years, for example, E&M changes in 2021. So I put this in here almost as a placeholder. So there is an entire section in the report on call, gender, and age. And that topic could be a webinar in and of itself. And hopefully, it will be. We're going to redo the call survey we did in 2022 and early 2024. So be able to pull in all of the information that participants give to that call survey. Hopefully, mesh it with some of the Med Access data as well and give a more comprehensive overview of call. You'll see here, I mean, absolute direct correlation between call and compensation and RBUs. So just a whole section. Definitely take a look at it in the report if you're interested. And then also volumes. There are many pages in the report with data related to cardiology volumes, E&M visits, testing, procedures, EP. I've given a few of those here. Joel will cover some more during his sections with super subspecialties. But I had to include office visits. Both new and return visits hit their all-time high in the history of the annual report, although not a huge increase. But they are at an all-time high compared to other years. Also on this graph is the percent of total of new office patients to total office visits. So what percentage of new patients are you seeing in the office? At Med Accent, we often affectionately call this the access measure. We recommend 20% as a means to have enough new patient slots available to ensure healthy growth in a practice. It's interesting. If you look at the benchmark graph, Med Accent members about at the 75th percentile are at that 20% rate. We aren't there yet as a median. But a plug, at CBT, we did a talk on our new access insight that we have now put into the Med Access system. And it's a custom set, including these measures and others that are pre-populated with denominators that you need to take a look at when you're measuring access. So just such a key metric and something definitely to take advantage of within Med Access. With that, I'm going to turn it over to Joel for super subspecialties. Thank you, Karen. If you want to go to the next slide, please. One of the areas that we kind of expanded in this year's survey was on the super subspecialties to dig a little deeper. We're often asked by our membership, particularly around compensation for people who focus in an area like structural heart, how that should differ from interventional cardiologists in the circumstance of structural heart. But it might be general non-invasive versus heart failure when you're talking about advanced heart failure physicians. So we wanted to get a little bit deeper into the data and then publish that so that our valuation consultants, those that are out there doing fair market testing, et cetera, have more data at their disposal to make good decisions. So as you can see here for structural heart, this is showing the percentiles of their work RVUs. So those physicians who perform structural heart procedures, what percentage of the work RVUs came from those procedures? And you can say at the median, just 10% of a, quote, structural heart physicians' work RVUs come from structural heart procedures, where you have to go all the way to the top 10% or the 90th percentile in order to get near a quarter of a physician's RVUs coming from those. Next. And when we looked at compensation, what we determined is there's really nothing we can distinguish from an interventional cardiologist versus a structural heart physician. To orient you to this graph, the quartile 1 through 4 go from the lowest percentage of work RVUs coming from structural heart to the highest percentage. So quartile 4 is the top 25% in terms of their percentage of total work RVUs coming from structural heart procedures. And you can sort of see, although the data are a little less robust than to say this is statistically relevant, but you can see a physician who does a high percentage of work RVUs in the structural heart actually, at the median, performs less total work RVUs than a physician who does less structural heart. And maybe that's intuitive for some of you in the audience, but it's not necessarily intuitive for me and Julie or Karen. And I don't think it would necessarily be intuitive to our evaluators. And then you can see the other quartiles there as well. So what we have determined, what conclusion we can draw is the super subspecialties are pretty heterogeneous. And we're going to see that theme as we go forward into some of the others. Next, please. These are TAVR volumes now per physician who performs TAVRs. And you can see the trend is up on a per physician basis. So for those operators who are doing TAVRs, the median now sits at 42 or did in 2022. And when you look at the lighter blue line, you can see the incidence of utilization of TAVR is also increasing when you look at it on a per 1,000 active patients. And that patient panel or those active patients, we feel is a better indicator of utilization patterns than looking at it on a per physician basis. And both those denominators are available to you in the system at access. You can filter down and change those denominators. Next. All right, so here's more evidence just to show you how disparate this group of physicians is. These are interventional cardiologists. I realize that's different than structural heart, but these are the physician pool where structural heart physicians come from. And you can see on the right just the very wide range of work RVUs from activities other than interventional services, including structural heart. So a big, wide variety of the work being performed by these physicians and how that impacts their overall productivity. So this is very important information for our evaluators to understand you really can't draw a bright line around what is a structural heart physician, what is an interventional cardiologist. When you've seen one, you've seen one, they can be very different from program to program. And even within the same program. Next. I'll draw your attention. This is more kind of the advanced interventional procedures. And you can see TAVR is included on this, the second line from the bottom. And you can see at the median, a physician who performs TAVR is doing about 42 of those a year. And it's only the top 10% that are getting close to 100 per year. One of the things we hear regularly from our members is as they are recruiting, they are often finding physicians who want to do a lot of structural heart. And what we've heard is there just isn't the bandwidth or the capacity demand to give them the kind of expectations that are coming out. So this number is creeping up, as I showed earlier. But at the median, 42 a year, not necessarily what the expectation is of some of the fellows coming out of training. Next, please. Now turning to advanced imaging, this is another one of the super subspecialties that is kind of on the growth curve. I will say this. Unlike in both cases, structural heart and advanced imaging, these are not specific designations within MedAxiom's data. They are not yet recognized from a taxonomy standpoint by Medicare. That's when we start to break them out. By contrast, advanced heart failure is now recognized as a separate specialty by Medicare. We created these data by finding those physicians who do these procedures. And for advanced imaging, we define that as cardiac CT, cardiac MR, and PET CT. So those are the advanced imaging procedures. We narrowed the search down to those physicians who are reading those studies and have then labeled them in this presentation as advanced imagers. It's not perfect, and we acknowledge that. But it is better than no data at all for those of you who are hiring and creating these advanced imaging procedures and then need to work with your legal and compliance consultants on determining work RVU expectations and compensation. So here again, what you see is a physician who only generated 1% of their total work RVUs from advanced imaging procedures was the midpoint in our data of all of those who do advanced imaging. Translation, this is still very much a growing super subspecialty, and we need the data to flesh out in order to get more meaningful comparisons. The 10th and 25th percentiles weren't really zero. They were simply rounded down to zero because they were less than a half a percent. So you can see why disparity. At the top 10%, less than 10% of those physicians, so they were the top performers in our database, the top 10% performers, but they were still doing less than 10% of their total RVUs from advanced imaging. I can tell you, you can't see it on that slide, but we did have some physicians where more than 50% of their work RVUs were coming from advanced imaging. So even within that top 10%, there was a very wide disparity. General non-invasive physicians, which is where the majority of advanced imagers, you're not typically seeing, for instance, an EP who also is an advanced imager or an interventionalist who is an advanced imager. That typically comes out of the general non-invasive pool. So we wanted to compare to that subspecialty. And you can see, again, big disparity of where their work RVUs come from. In this case, we're accounting E&M, evaluation and management work RVUs. That's seeing patients in the office, seeing patients in the hospital, new patients, and follow-up visits. And you can see at the median, a general non-invasive physician generates 63% of their work RVUs from E&M codes. Try to put a pin in that and remember that, because I'm going to show you then for advanced heart failure what that looks like coming up. And you'll see that it's pretty high as well. Over on the right, you see the range was dramatic from as low as 3% all the way up to almost 100%. So there are physicians who are simply being office-based and doing nearly all of their work in the E&M spectrum. Next. ECHO and NUC, I realize, are not advanced imaging procedures, but we wanted to show you where those were at in terms of panel production and where they've gone over the last five years. You can see ECHO has been relatively flat or entirely flat. NUC has actually inched downward. If I had extended that graph for 10 years, you would see that NUC had inched down year after year after year for that entire decade. The impact of cardiac CT is pulling that number down more. 2020, I would predict that we're going to see nuclear spec numbers continue to go down in the subsequent years as CT programs are ramping up. It takes a while. Those are expensive machines. It's not easy to increase that capacity. Even though the clinical indications have been expanded, it takes a while for that capacity increase to hit our provider community. But I would predict you're going to see that number continue to fall. Next, please. Now, looking at the three advanced imaging procedures, you can see that total cardiac PET is kind of a little bit of a mixed bag. We had that kind of a bubble in 2020 and 2021. And I'm going to show a little more data on that because the number of programs who offer PET is very, very small as compared to cardiac CT. A little less dramatic than cardiac MR, but still more programs offer cardiac MR as well. And you can see the cardiac CT, which is the lighter blue bar, is on the increase. MR has languished. It has not found a foothold in cardiology as it was expected perhaps 15 years ago. We did a deep dive into that a few months ago and found that programs find it challenging from a throughput perspective. Those are harder interpretations. And they're expensive machines as well, and they're pretty specialized. And not everybody has an interest in that. So it just has had its troubles getting any kind of traction within the cardiovascular community. Next. So here's what I was talking about earlier. If you look at cardiac PET, in this case, cardiac PET is the kind of bright green line. And you can see only in 2022 of our responding programs, only 17% even offered cardiac PET. That compares to 93% who are offering echo services. And then for cardiac MR, less than a quarter. Next. Advanced heart failure. Advanced heart failure is, as I mentioned earlier, an official taxonomy code under Medicare. And so we have broken it out now for about five or six years. As our N, our sample size, has increased, the data have gotten much more normalized. And you noticed in Karen's section, compensation has been on a steady increase. That is likely the maturation of our data set more than it is that the market is really paying a lot more for advanced heart failure physicians than they did five years ago. However, we hear that is one of the toughest searches in the market. And we also know that about half of the specialty, I'm sorry, half of the fellowship slots for advanced heart failure go unfilled each year. And when I've talked very recently to program directors, the reason that those fellowship slots go unfilled is because a lot of physicians look at the extra year of training commensurate to the compensation and say it's not worth it. So this is another example of where we need to really educate our valuation experts. And sometimes I'd love to put quotes around that word. But they need to understand what and who these physicians are in terms of being cardiologists and the amount of training it takes. Because when we have half of a very necessary subspecialty fellowship going unfilled, that's a problem for our industry, for our patients. And it's something that we need to address. I'm done on my soapbox there. So now I'll get back to the data. Advanced heart failure procedures. So there was a question in the Q&A box about a program's experience looking very different than our data in terms of the work RVU production for their heart failure physicians. Like the other super subspecialties, we find a very heterogeneous population of heart failure. You have those that are part of a transplant program and do heavy procedure-based, which generate a lot more RVUs than E&Ms. And then you have medically-based heart failure physicians that live almost entirely in the E&M spectrum, where work RVU generation is more akin to a primary care physician than to a cardiologist. And you can see that represented on the graphic here, where at the median, a heart failure physician will generate 65% of their work RVUs through E&M, but it's down closer to 50% at the 25th, probably because those physicians who are in that bottom quartile are more procedure-based, but out of 10 programs, there's maybe one or two that are offering transplant. So it's still those physicians are more rare and they would be underrepresented in our data. And that's why you see the lower work RVU total than one of our listeners is experiencing. The range here went as low as 40% all the way up to 98% of the heart failure physicians work RVUs coming from E&M activities. When you look at it, the trend in EP, probably not surprising. The rate of ablations is on the increase. You can see that as the dark line, the darkest of the lines on the graph. It was jumped up last year and held steady in 2022 and then pretty flat for both ICDs and permanent pacemakers. Digging into the ladder here on the next slide, oh, I'm sorry. First, the number of procedures done per EP physician, particularly around the ablations is trending up, but you'll notice it is for permanent pacemakers as well. And this is filtered to only EP physicians. And we recognize that not all pacemakers and ICDs are implanted by our EP physicians, but the increase in ablations could mean A, we're consolidating more of those procedures in our programs. And that's why you're seeing it on a per physician or EP physician going up. And it could also be that as we know, Medicare realized that ablations don't take as long as they did five, 10 years ago. They pulled back on the work RVUs for those, but also the time has decreased, which means our EP physicians can do more of those in a day and in a year. Next please. Holter monitors and Holter and event monitors on a per 1000 active patients also on the increase. This is likely to continue as we do a lot more remote patient monitoring and we get really sophisticated tools around performing remote patient monitoring. One of the themes, there were several, but one of the themes at the Austin Cardiovascular Transform was around AI and some of the incredible things that are being developed to expand our ability to remotely monitor patients in a very sophisticated and safe manner. Next. Here's what I was talking about earlier for ICDs, EP physicians performed about 70% of those implants. Whereas for permanent pacemakers that dropped to about half. So about half of the permanent pacemakers are being implanted by non-EP physicians according to the data. Surgery, as Karen mentioned, we were pleased that our surgery sample size increased in the 22 survey. And we would love to see it even get more robust as time goes on. But what we noticed with cardiac surgery, it continues to be a very well-paid specialty. The supply and demand is, and makes that those physicians highly sought after. And in that environment, you're gonna see compensation increase, which it has. It did settle back down in 2022. We believe that is more of the survey bias, as Karen described it earlier, than it is that we really have seen a market deflation of cardiac surgery compensation. There is nothing we're hearing from the membership or anywhere else that would suggest that that is real. So we're expecting that compensation for surgeons has remained robust. Vascular surgery has been on the increase. That one, if you look at the data, it feels more real and could be the advent of office-based labs, ASCs, and other potential revenue sources for those vascular surgeons. Next. Work RVUs have remained pretty flat. So if you look at, if you think back to the previous slide, when I was commenting on cardiac surgery income coming down in 2022, notice that the work RVUs did the same. Are they really doing less work RVUs? Most likely not, because even though we had a larger sample size, our surgery population is small compared to cardiology, for instance. That makes the data more volatile to a change in who responds. We believe that that's what we're seeing here and that the market would be somewhere in the middle of those trend lines for cardiac surgery. And then you see vascular surgery nearly neck and neck in terms of annual work RVU production. And then compensation per work RVU. In both cases, the median for cardiac surgery and for vascular surgery are higher than they are for cardiology. So surgeons on a per RVU basis earn more income, substantially more when you talk about cardiac surgery. Next. APPs. As I go into this, please keep in mind, and the link to download the entire survey is available in our chat box, but we are pulling just a fraction of what's available and hopefully keeping you engaged with what we are pulling, but there's many more details that are available in the full report. And as Karen mentioned, there's going to be a companion APP survey devoted just to the APPs coming out early in 2024 that will go into how they are utilized in the practices in terms of their clinical role and their call participation. So I'm just hitting a few highlights here. One being that our cardiac surgery cohort is the heaviest utilizers of APPs, 1.65 FTEs of an APP per surgeon for cardiology, which has been on the increase for the last five years. It's up to 0.62 FTEs per FTE cardiologist. And as Karen pointed out, more than 90% of cardiology programs now utilize APPs. Vascular surgery hovers right around a one-to-one ratio. Next. Here's what I hope you find interesting, but when you look on a per 1,000 active patients, so that per panel, it has been a pretty significant year-over-year increase in the utilization of APPs. Perhaps not surprising, we've been showing for years the mismatch between the number of fellows coming out of training and the number of positions that will be opening up either through retirement slowdown or other reasons to fill that gap. So we don't lose ground from a provider standpoint, we are using APPs. So if you have a group of 25,000, if you are a group with 25,000 patients in your panel in 2014, based on our medians, you would have had just under six APPs. Now you would be up to nine for that exact same patient panel. Next, please. Here's how the APPs break down and mostly just kind of along the lines of our respondents, the vast majority, and sorry, this is looking at just cardiology and how they break down between the subspecialties. The biggest chunk of the pie is general cardiology followed by EP and then heart failure. So the take-home here is our APPs are getting more subspecialized and we will expect to continue to see that as new subspecialties emerge in heart. Now, next. In terms of compensation, cardiac surgery leads the pack just under 150,000 per FTE per year. Cardiology and vascular surgery, both right around 120,000. Those numbers are up, particularly for cardiology, which I've seen that trend be pretty consistently up. You can see for surgery, it's been up the last couple of years now for cardiac surgery. Next, please. There really is no statistical difference between private APPs or APPs in a private group versus those who are employed by a hospital or health system. They're statistically a dead heat. Terms of the compensation between the specialties, there too, likely that differential would not be statistically relevant, so we would call them even. But EP, kind of like the physicians themselves, EP was the highest paid of the cardiology specialties, subspecialties, so are their APPs. Next, please. And then RVU production. If you, when MedAxiom does calculations, we look at a fully utilized APP, either in the hospital or in the office, being able to generate north of 4,000 RVUs. You can see the median here is just under 1,700. Likely those APPs are performing a lot more clinical work than that number would indicate, but the RVUs are showing up under the physician because of a split shared environment, incident to et cetera. And then in cardiac surgery, you have a completely different environment because in cardiology, an APP can bill for their services separate from any of the other activities in cardiology. Cardiac surgery, those procedures are bundled, and so there is no additional billing beyond the global fee for that surgery, which includes all the follow-up care, which is often performed by an APP. And that's why you see such a low number at the median for their annual work RVU production. And then vascular surgery is kind of in between because they do a little bit of both. And then here we do see a difference in the ownership cohort. We're looking now at cardiology, not quite a two to one ratio, but private APPs like their physician counterparts outproduce those in an integrated environment. Hard to know if how much of that is the difference in utilization in a split shared environment versus billing independently, but likely that is part of the explanation behind this difference. Next. And then, as I mentioned, this production has been on a steady increase year over year over year for cardiology with the median now hitting almost 1700. As I mentioned, we have the CVAPP compensation and utilization report coming out soon. We expect it sometime early in 2024. We will obviously send out announcements to that and it will be downloadable for free through our website for our members and beyond, I believe. And then we wanna plug the Academy and some of the things we keep expanding this list and there will be more coming in 2024, but you can see lots of different areas of focus to provide additional training to your staff and to your executives. If I could just add there, there's a little note there on the bottom. Part of the membership now is you do get a certain number of complimentary courses per your anniversary year for membership, so please use those. Don't leave those on the table. So if you have those to use, just reach out to myself or the membership email address and we'll get it to the right person, but we definitely want you to use those courses that you have coming to you as part of membership. And as we'll continue to do, and you'll get tired of hearing Karen and I plea for your data, but if you have not submitted data, please, please do. As I noted in the chat, you do receive a discount on your membership for doing that and our data becomes much more valuable the more responses that we have. It's more representative of the community, will help us with some of these evaluation issues that I highlighted earlier, and it's very valuable to you from an operational standpoint because we go much deeper than just compensation and work RVUs. And I will say that on, any of the instructions you see, you might see a March deadline because that's our goal, to get as much data in as possible before our spring conference, but we will take data at any point and definitely want you to get it in before the end of the year. So just reach out to membership, membership at medaxium.com and we can help you with that as well. This is our November webinar schedule, also can be found on our website, medaxium.com. And I think that's it. I did see a couple of questions in the Q and A, and if you have more, you can type them in there and we'll have those read to us now. All right, so first question, is there enough volume to pull structural APPs and find their salary range, like as done for EPs, ADHF, any of those? I believe the answer is unfortunately no, but I'm looking at Karen and her video box. I'm not sure we would be able to identify them unless. Yeah, we don't have that, like Joel mentioned for the physicians, we don't have structural heart yet as an option for a subspecialty when you submit your data on the FTE worksheet for physicians. So we don't have that for APPs yet as well, but we are constantly changing those options as we need to, to meet the changes in the field. So not to say it's something we wouldn't do in the future, and it is something that we could do as a separate polling, but it is not available as part of MedAccess today. Keep in mind, as I mentioned earlier, Karen just said it, there's not a structural heart designation. We created that by finding those physicians who did those procedures. We don't have a CPT code for the APPs that would indicate to us that they're structural based. I think this second question might fall under that as well. Another one on structural heart. Is there any data on what is a reasonable RVU target for a structural heart specialist compared to a non-structural interventionalist? The targets we set for our sexual heart specialists are approximately 92% of our expectations for non-structural interventionalists. And it would be nice to know if there's data that either confirms that or disagrees and says, no, it should be X. I think the data that we showed earlier would almost be dead on with that kind of percentage at the physicians who, I think it matters to whoever put that question in, how much structural heart are your structural heart physicians actually doing? But when we looked at the top 10%, they generated about 10% fewer RVUs than a non-structural interventional physicians. So that's right in the ballpark with what you guys are using there. Is that right? I don't know, or we don't know, but that's what our data show. So I think you're in a rational place and that's a total drive-by consultation and should not be used as a surrogate for evaluation. Karen, anything you'd add to that or? No, I think you might have gone into that a little bit more in depth in the report actually. So just on the salaries for the difference between the two. So I would just take a look at that slide, find that figure number, which will take you to that section in the report. Because I think there is some more information there tying salaries to those RVUs as well. Yeah. And if you are a member, you can reach out to your member rep and we can give you even more details offline. Yeah. And if you're not a member, you want to become one. I was a member. I recognize the name. Okay, good. And that's all they keep saying. Looks like we're out of questions and out of time. Perfect. Well, thank you. Thanks for joining us today. Reach out with any questions. Like I said, that membership at medaxiam.com can be your easy button for lots of questions and we will make sure that you get to the right person and thanks for joining us today. Everybody have a great afternoon and we'll see you on the next one.

webinar

2023 Cardiovascular Provider Compensation and Projection Trends report

subspecialty information

compensation trends

APP utilization

super subspecialties

cardiac care

work RVU

emerging subspecialties