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On Demand: 2024 Provider Compensation & Production ...
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Hello. Thank you for joining us for today's webinar. We're just going to give another minute or so to let folks join in. So we'll be starting in just a minute. All right, so thank you for joining us for today's webinar. We're going to go ahead and get started. I'm Karen Wilson, Vice President of Member Services for MedAxiom, and I'm joined by Joel Sauer, Executive Vice President for Consulting with MedAxiom, and today we're going to do an overview of the 2024 Cardiovascular Provider Compensation and Production Survey. Okay, just some housekeeping. If you're familiar with Zoom and the various buttons that you can use to communicate with us, our Academy team is going to put a link to the presentation slides that we're showing today. Those are going to be available in the chat section, and if you have any questions that you would like to ask Joel or myself, if you could please type those into the Q&A section, we will try to address those as many as we can at the end of today's webinar. And if you haven't already, please go into the website and download the full version of the comp report. The address is there to pull that report so you can have a full copy for yourself. And then just as a reminder, MedAxiom publishes a companion report to the comp report that we are reviewing today. That is the Cardiovascular APP Compensation and Utilization Survey. This report goes beyond the basic comp and production that we're going to present today, and it dives deeper into APP utilization, but that is only possible with our members' participation in the survey linked here. So the survey will remain open until October 28th, so please complete that survey if you haven't done so already. So our agenda for today, I'm going to start and I'm going to go over some demographics, both of survey participants, and compare some of those demographics to our MedAxiom membership. Joel's going to review cardiology compensation and production, then I'm going to go over some of the key volumes for cardiology, turn it over to Joel to cover surgery, and we'll conclude with APPs and then time for questions. So looking at demographics, at the time that we pulled data for this report, there were 202 programs that had submitted 2023 data. So those are the data that are reported in the 24 survey. That is two percent more programs than last year, and for all of those that participated, thank you. These data and this report would not be possible without our members' participation, so we greatly appreciate you submitting data. The 202 programs represent 5,633 total providers, which is actually 2.5 percent fewer providers than last year's report. The total physician count, so full-time and part-time physicians, is 180 fewer this year compared to last, whereas the total APP count is higher this year, but only by 40. So this supports the national trend of fewer physicians with a growing presence of APPs on the care team. Looking at the percentage split of providers included in the report by by CV service, these have remained fairly steady for the last couple of years. So 85 percent in cardiology, 10 percent cardiac surgery, 5 percent vascular surgery. And then looking at program size, the percentages of various program sizes, these are determined by the number of CV physicians. They have remained pretty steady over the last several years. So those with 10 or fewer physicians represent more than half of survey participants. If we compare this to the MedAxia membership, there are programs with less than 10 physicians represent 41 percent membership, so slightly more than half in the survey, slightly less than half overall membership. So these percentages suggest that this cohort with 10 or fewer physicians is over-represented in the survey compared to some larger member programs. And what that means, Karen, sorry to interject, we're missing our integrated larger groups from submission, so if you're attending this webcast and you haven't submitted, please urge your organization to do so. Our data are only as good as the return rate we get, so we really need your support on that. As Karen showed you earlier, we're at about, what, 200 out of 550 members. We'd love to see that notch up to over half. Absolutely. And, you know, if you need help with that, I'll just put a plug in. You just need to reach out to membership at medaxiam.com and we will get you connected for submitting data. Just of note, the programs with that 11 to 20 physicians are actually the least represented in the survey compared to MedAxiam program members by size. So looking specifically at cardiology programs, the median size of programs responding to the survey this year was 10.4 FTE physicians, which was a decrease of about one full-time physician from last year's survey. This makes that first demographic slide make sense with that decrease in providers, increase in programs. The number of physicians in private practices actually, though, increased from 19.1 physicians last year to 19.8 this year, but the number of physicians in integrated programs decreased from 9.3 to 8.5, and the integrated programs, as we'll show in a minute, represent a much larger portion of survey respondents. So the private practice size is nearly double of what the integrated size is. Cardiac and vascular surgery programs are much smaller. Their medians are 2.0 for cardiac and 1.5 for vascular, and these decreased just slightly from last year's survey, but like I said, they're pretty small to begin with at the median. So the South continues to be the most represented region in the survey, but it is also the most represented region in MedAxian membership, just at a smaller percentage. So 49% of membership compared to 60% in the survey. So again, a plug for programs. Not that we don't want the South, we definitely want the South, but a plug for other programs from other regions as well. The Midwest actually has the lowest representation in the survey compared to MedAxian membership. So 17% in the survey compared to 23% of membership. And then the compensation model is another important demographic for understanding the physician compensation and production. The percentage splits for compensation models are fairly consistent between cardiology and surgery programs here. The percentage splits the productivity percentage actually decreased for a second year in a row, both for cardiology and surgery with the increase going to a blended model. We will probably say this a few times during the webinar today, but this is one of those shifts that may be more due to survey bias than a major shift in compensation models. So as a reminder, MedAccess, like all compensation surveys are voluntary and the same programs don't necessarily submit data year after year. So this is important to keep in mind when we are talking about trends. And just a comment there, because it came up at our Denver CVT meeting this past week. We don't know what's in that blended. It could be a 20, 80 equal productivity split, or it could be an 80, 20 equal productivity split. They all get lumped in there. One thing we're considering doing in 2025 is some kind of deeper dive into that bucket so we can get a better understanding of what it looks like. So I mentioned integrated being larger. For the first time in the 12 years of this report, the percentage of groups integrated with hospitals or health systems actually declined. It's not a statistically significant change by any means, but it is noteworthy. So time will tell if this is the start of a trend or due to the survey bias I just mentioned. But of the 12% private programs, half of those, so 6% of survey participants were also part of a private equity portfolio. Just a few years ago, that percentage was zero. So these percentages for survey participants are close to the integrated and private split for MedAxian membership, which is 84% integrated and 16% private. Almost half of the private practice MedAxian members are now in a private equity arrangement. So that represents about 7% of our membership, which is actually very close to the 6% represented here in the survey. So the final demographic I'm going to share is the percent mix for cardiology subspecialties. Private groups definitely skew more heavily toward interventional physicians, while integrated programs lean toward more general non-invasive physicians. It's interesting that the interventional to general non-invasive physician percentages are nearly the mirror image of each other. So 29.2% being the same for interventional physicians in integrated groups and general non-invasive physicians in private groups. The percent splits for EP and invasive are nearly the same. So very few private groups reported heart failure physicians this year. So we were unable to report their compensation and production out separately. And with that, I'll turn it to Joel for compensation and production. Great. Thank you, Karen. So for compensation, both the private and integrated cohorts ticked up. And in fact, both reported their highest median total compensation in the history of our survey. So as you all know, it's difficult to find cardiologists in today's market and the compensation reflects that. We're going to talk about productivity coming up. So we'll show you how compensation relates to productivity in just a bit. When you break it down by the subspecialty categories and remember, Karen just showed you private groups skew towards the procedural list because they are higher generation of revenue, which is really important when you don't have any financial backing from a hospital or health system. And you can see that here in the numbers, what was an anomaly in 2023 is both the private and integrated reported invasive cardiologists as the highest earners for this year's survey. When you consider at the median, keep in mind that in both ownership categories, that is a relatively small and actually shrinking N because we're seeing fewer and fewer invasive non-interventional physicians in our workforces. But it was interesting to note. And as usual, EP and interventional were the top two earners separate from invasive and then advanced heart failure, the lowest earner. But of note, look at the gap between heart failure and general non-invasive that has closed tremendously. A few years ago, that was greater than $150,000 per FTE. And it's now within a spitting distance of each other. So that's also a reflection of the challenge in recruitment. As you can also see from this slide, and then I'll move on each at category, integrated physicians still out earn those private doctors. Next. And then this is the trend over time and all subspecialties ticked up in 2023. We'll go to the next one. The South was the top earner. This is a fairly consistent, if not a hundred percent consistent with our past surveys. I think the South has always been on top with the Northeast on the bottom. And before you think maybe the South are doing more to their patients, if you go to the next slide. Oh, sorry. One more. The productivity in the South is also very high, as you can see here and the Northeast low. So these are in the exact same order as compensation, which obviously means that there is a strong relationship between total compensation and total productivity, which we have known for some time. And now I will make my point about the South. Notice that these are in descending order. So they changed on you. The South is no longer on the left-hand side. So pay attention to that. But when you look at how many RVUs are generated per 1000 active patients, it's very, very consistent with the exception of the Northeast who does fewer. Remember that was the smallest sample size or the smallest return rate of our surveys this year. So we had a relatively small end, which makes it more volatile. But you can see the South doesn't do any more per patient. They just have more patients per position than other geographic categories. It's also remarkable how close those first three are. I mean, they're just, they're so close to each other when you use that panel as the denominator. Just a couple of percentage points. Yeah. Next. And then when you take that to a compensation per work RVU, and I will do this until I die, I'm going to remind you what this is, because this does not mean what they are paid on a contractual rate. This is simply taking their total compensation and dividing it by their total work RVU production to give us a ratio of compensation per work RVU. And you can see here, the South actually is the lowest paid on that per unit basis because of their high productivity. And the West goes from the lowest in total comp to the highest in terms of compensation per work RVU. When you look at the productivity at each of the subspecialty levels, and then broken down between ownership categories with dark blue representing private groups and lighter blue integrated, you can see at every subspecialty level, private physicians generate more work RVUs per physician than their integrated peers. And as Karen pointed out earlier, we didn't have, I think we just had a couple of advanced heart failure physicians in those private settings, which was not enough to report. And so you see the absence of a bar there. And in terms of being the king EP, despite some of the significant cuts to EP procedures a couple of years ago, they're still at the top of the heap when it comes to productivity. And then trending that over time, we're blending now the ownership cohort. So we're looking at all cardiologists by subspecialty. Everybody ticked up with the exception of advanced heart failure, which basically remained flat. And then when you take that both in terms of compensation and productivity, the dark blue bar is the change in compensation. The lighter blue is the change in productivity from last year to this year. It reflects what I just said, but you can see invasive cardiologists jumped up considerably because of our in-depth knowledge of the industry. We doubt that is a real phenomenon that all of a sudden invasive cardiologists suddenly got busier. Our guess is this was a phenomenon of the responses we have, as Karen pointed out, called survey bias. But then when you look over at heart failure only, as I mentioned in the last slide, only heart failure kind of lost ground, but it was very, very modest. And then compensation per work RVU at the subspecialty levels, advanced heart failure is by far the highest paid on a per RVU basis. We often see them carved out of compensation models in integrated practices. And keep in mind, that's all we're reporting here is integrated for the heart failure category. We often see them put on like straight salaries or a salary plus an incentive to keep them from being, quote, competition to the other physicians in the practice. And because they live in a very heavy E&M world, they are going to earn less if they were paid on work RVUs. So if we put them up at that 620 per physician, like you saw in the total compensation, and then they're only generating 5,000, 6,000 RVUs, that's where you see this result. What's interesting, at least across the integrated is, look how close, they are the lighter blue bars, but look at how close all the subspecialties. There were just a few years ago where there was a pretty wide delta between subspecialties, particularly EP. That has narrowed considerably. And then you can see that at each of the levels, the private physicians earn substantially less on a per work RVU basis. Remember, they earned more than our integrated partners, but they produced more when you do that math, they are going to fall then on this metric. And then the trend over time, what these data show us is we're flat. This has not changed for quite some time. There really is very little statistical difference between these. And it would be hard to say they're either up or down, they're just simply flat. That being said, we have seen continued increases in total productivity. So our physicians by some strategies are finding ways to produce more work RVUs year after year. Switching gears now, now we're not talking about compensation or productivity, we're talking about the age distribution within cardiology. You can see that here, 26%, so just over one in four are age 61 and over. And where that matters is if we go to the next slide, there is definitely a relationship between age and productivity. And as a result, because as I mentioned earlier, there's such a strong relationship between productivity and total compensation. You can see here that a physician kind of hits their peak in that 51 to 60 category and then starts to tail off. And by age 70 plus it drops considerably, but so does their work RVU production. So they are relatively commensurate as you see between the two bars. Next. Here's a good one and we'll see how this impacts that previous graphic. Our prediction is going to be that you're going to see those younger age cohorts start to tighten up with that middle 51 to 60, which has been historically our top earning category because right now, new physicians, those under age 35. And the reason we do that, by the way, is because often there are perversions in a brand new hire, such as signing bonuses, incentives, and other things that may inflate that first year salary. So we do it as an age category because not only would that capture their salary, but it would capture any incentives that they might earn. We are using that as our surrogate for a new physician. And that age group now earns 90% of what the median is for the overall cardiology workforce. Just a few years ago, that was more like 40%. So you can see the tightening of the market has definitely factored into the starting salaries you are all paying to attract cardiologists. And by the way, this is a point of consternation on our list serve. If you're not part of our list serves, I would encourage you to get on there because there's some really great dialogue amongst our member programs on there. Next. You can see here that by age, not surprisingly, although it is maybe surprising to some of you that already in that age 40 and under, we have 15% of cardiologists not taking call. And that is also one of the things that was just chatted about on our list serve. These physicians coming straight out of fellowship and asking for no-call positions in organizations. But you can see it holds pretty steady with the vast majority taking call until about 60, and then it starts to taper off. And by age 70 plus, we're down to less than 40%. So that also factors into compensation and productivity because there's usually when you're stopped taking call, those physicians are typically also curtailing daytime activities. This is also a topic that's often on the list serves, looking for some kind of creative compensation models or different ways of doing things. It was also a topic during Pod A, I know during our CV transform, just looking for ideas because this is what some physicians are looking for now. For sure. And then when you look at the relationship between taking call and not taking call, it has a very, very substantial impact on both productivity and on compensation, more on compensation though, than on productivity. Yes. Most physicians, and I would say 99%, it's kind of like the dentist who recommends sugar gum to their patient. There's that 1% that for some reason does. Most physicians will say call is the worst part of the job and therefore they ascribe a very high value of compensation to it. And it is generally not productive time. Being on call, the burden of it is far exceeds the number of work RV use you can generate or the amount of revenue you can generate during that time. And you will see that reflected a physician taking full call earns about 700,000 at the median that drops by not quite half, but it's 40% when they go to partial call. And that is not the dip in production. They are 70 to 80% as productive as the full person, but they're earning only 60%. That is like the epitome illustration of the value of call. We have heard, and we did a separate call survey in 2022, we have heard values all the way up to 50% of total compensation, depending on the region and the number of facilities, et cetera. And then when you look at no call, it really drops. Now we're down below 450,000. On those call surveys. And we did another one in 24, the most common was between 30 and 40%. So that's matching what is shown here in this graph. We often get called into groups to do slow down projects. And most of our, I'm pointing now mostly at the integrated practices, but most practices don't recognize call in their normal model. It's only when a physician comes out that they quickly have to say, okay, well, if you're not going to take call you, because we have actually seen physicians pulling out of call and their work RVUs go up. If you simply pay them on a work RVU basis, most groups would say it is egregious that a physician not taking call could earn more than a physician taking call. That just is untenable for most places. All right. Here's the subspecialists who participate in general call. This was pulled from that survey that Karen just referenced. So great segue. Almost a hundred percent of general non-invasive physicians participate in their general call, but you can see only about 30% of advanced heart failure. They are typically then in their own call group. Interesting and surprising to us was that almost 60% of EP physicians out there also participate in general call. We hear a lot and not surprisingly from EP physicians saying nobody in EP takes general call. Our survey data would beg to differ. It being more than half and almost 60% of interventional physicians are still taking general call. And here you see the frequency, the sweet spot. If you look in the middle of one in four, one in five call, and this is for interventional, more than half are in either one in five or one in four. If you are less than that, that is from all accounts that tends to be burdensome and considered more than a sustainable model. And you can see very few programs are in that one in two, one in three. The other thing we get asked to do a lot is talk about program building. That last slide is one of the kind of the costs of doing business. If you are going to be a STEMI program, even if your volume can only support two physicians, you're likely going to have to either hire three full-time physicians in order to make the call burden tolerable, or you're going to have to provide relief through locums or other expensive means. And that is often overlooked by our administrators in health systems. They just look at the volume as being one-dimensional and kind of make their judgment on staffing around that. And that translates over to your cath lab teams as well. They have to take call too, and we're seeing shortages across the board. So, sorry, now we can go on. In terms of taking call and separating it by gender, there really is no difference, so there was no story here. But there was a story in terms of male-female total compensation, but as you can also see on this same slide, there's a pretty proportional difference in the work RVUs. And when you look at compensation per work RVU, which I believe is the next slide, oh, no, sorry. So, here's the story on that previous slide, which if you look at it in a vacuum, you could think, oh, this is more of the gender bias of the United States and the way we pay. But here you can see the productivity differences are in large part driven by the subspecialty choices and those differences between male and female. Right in the middle of this graph, you can see almost twice as many female general noninvasive physicians as men. And when you look at the higher productivity subspecialties of both interventional and EP, it's almost half as many women choose those two categories as men. So, those there show you that big difference on the previous slide between men and women in terms of their productivity. It's likely, although we can't say definitively, it's likely not how hard they choose to work. It's the subspecialties they choose that creates that difference. And then when you look at those subspecialties and what percent of the physician's total work RVUs come from E&M evaluation and management codes, those are the codes that are face-to-face in most cases or 99% of the time. We're seeing a little more virtual, but likely not enough. But those specialties that generate a lot more of their total work from E&M, like advanced heart failure on the far right and general noninvasive in the middle, that tends to be harder work RVU generation than, for instance, doing procedures, which both interventional and EP do. And ergo, they rise to the top of the productivity and advanced heart failure is at the bottom. And then compensation per work RVU, as you went back to that total compensation and work RVU, it's actually the female population that gets paid more per unit than the men. Although whether this is statistically significant or not is likely a no, but it does demonstrate that it's likely not a gender bias issue. It's other factors that are at play. Next. Karen, take it away. I'm going to move into some key cardiology volumes. There are a lot more that are in the report, but we picked a few to share with you today, starting with total new patients and patient panels. So this kind of sets the stage for a lot of the other ones that we'll talk about. Both total new patient visits, so that's new patients in the office and in the hospital and patient panel sizes. They've definitely rebounded since 2020 and hit all-time highs in the history of the med access surveys. The median number of new patient visits per physician is at 680 and patient panel is now about 1800, a little bit more per full-time equivalent physician. So this is a sign of increasing demand for cardiology services in the U.S. like we talk about. As a reminder, patient panel is a unique patient count we collected at the program level. It counts each patient seen face-to-face for an E&M visit by a physician or APP, counts each patient one time, no matter how many CV providers they saw or how many visits that patient had in an 18-month period. So many of the volume metrics shown today and in the report, we use patient panel as a denominator. If you've heard Joel and myself speak before, we are both big proponents for using patient panel as a possibly better means to benchmark how your program overall is managing patient care and utilization, especially for various tests and procedures. So looking at office visits, both new and return office visits broke records in 2023 with 384 new patient office visits per physician and more than 2,000 return office visits per physician FTE. This is at the median. This is the first time we've hit that 2,000 mark. So the green line there is that metric we often refer to as an access measure, which shows the percentage of new to total office visits. This percentage actually dropped in 23 from 16.5 in 22 to 15.9 percent in 23. And when MedAxiom does access studies with our members, our care transformation team typically recommends that percent be at 20 percent as the goal for new patient visits in order to provide a healthy funnel of new patients into the program. Last year was interesting. Programs had to be at the 75th percentile to reach that 20 percent goal. This year, programs achieving that 20 percent were closer to the 90th percentile, suggesting that patient access continues to be a challenge with fewer physicians like we've been talking about and larger patient panels. And I'm going to talk a little bit more about that when I talk on the APP section. In the hospital, initial care and consults also continued with that all-time high record with visits at 283 per FTE cardiologist. But subsequent hospital visits didn't reach that high. The high was actually in 2019. So we haven't quite made it to that level yet. What MedAxiom hears is that more cardiology groups are shifting to a consultative only service. So it'll be interesting to see if this metric trends, how it'll trend in the future. Another sign of that move to more reliance on hospitalists and other house staff is in that discharge trend. It's been on a steady decline, and that metric hit an all-time low at just 16 per cardiologist FTE in 23. So transitioning to testing. With changes in technology and clinical guidelines, the role of advanced cardiac imaging is definitely changing, as reflected here in the ratio of advanced imaging studies to total caths. So in this metric, PET, CT, and MRI volumes are all added together to contribute to that advanced imaging volume number. So in just five years, the median has nearly doubled, and the average grew to a strong 73%. So just a note, when we see median and average trend lines with significant gaps in between them, reflects disparity in the program submitting data. So in this case, there is a significant, there's a segment of MedAxiom members who are heavy adopters of advanced imaging, and they're influencing this average. So that's one reason you're seeing that gap there. So kind of going on that same theme, programs in the top decile, so that 90th percentile and above for advanced imaging studies performed 119 studies per 1,000 active patients, while at the bottom, that 25th percentile performed just five. So even the median, 23 studies per 1,000 active patients, is just 20% of the volumes of that top decile program. So just illustrating the difference between our membership there and the adoption of advanced imaging. And Karen, that also speaks to just how challenging it is to take new guidelines and get them implemented across the entire country. I've heard estimates of anywhere from 10 to 14 years to get those kinds of technologies up and running across, which is where MedAxiom lives. Most cardiologists you would talk to from a science perspective would say, yes, I should be doing advanced imaging, but they don't have the technology available or the access available. And this shows that by modality. So this is showing the median trend for the various modalities included in that advanced imaging total. So CTA has seen the most steady increase, now topping at 19 studies per 1000 patients in 23. Interesting, PET has dropped over the last couple of years, MRI pretty constant, but definitely not at the utilization of some of the other modalities. Another thing to note, and I don't know if this is influencing what Joel just said too, but these data are through the lens of cardiology programs because the cardiology programs are the one that submit data into MedAccess. So radiology based and red services are not factored into this data. So if a study was ordered by a cardiologist, but performed in red by a radiologist, those aren't reflected here because we don't have a way to get that data since our members are the cardiology programs. So moving on to the cath lab, the cath volumes per 1000 active patients, fairly steady over the last several years, same with PCI volumes. That, however, that ratio of PCIs to caths, it hit its lowest level actually in MedAccess data at 37%. So this drop is somewhat expected with the more definitive studies demonstrated like the CTAs that we've been talking about in previous slides. And then looking at who's doing those procedures at the median, full-time interventional cardiologists perform more than two and a half times the number of caths as invasive cardiologists. So this is interesting when you think about the comp and the production that we talked about previously. And this figure, not only does it show the volume differences between those two subspecialties, but it also demonstrates the significant difference between your lower and higher volume physicians in the cath lab. And then TAVR, after several years of seeing those TAVR volumes increase, both per physician and per patient panel, TAVR volume may have plateaued with both per physician and per patient panel volumes matching the numbers from 22. But from what we hear based on MedAxiom's work and our insights into this market, this plateau could be as much to do with facility and staffing capacity as it does with actually patient demand. So it's gonna be interesting to see what the data shows when we collect 2024 data. And then we looked at the percent of interventional cardiologists performing TAVR and some of the other advanced procedures. A quarter of interventionalists perform TAVR and PFO, 95% perform PCI, and just half perform the chronic total occlusion PCI. And finally, some EP volumes. Both ICD procedures and pacemaker implants have remained pretty flat over the last several years, looking at those here by panel. Ablations, on the other hand, have increased from 10 to 15 per 1,000 patients. So if you had a patient panel of 25,000 patients, this would be an increase of from 250 to 375 ablations. So 125 additional ablations over five years. And we're likely to see that number go up again because we have both opened up and expanded the indications for ablation and those procedures have gotten shorter. And so we're able to do more in the same capacity of labs. And this is showing those numbers this time by physician. So looking at these by electrophysiologists, again, the ablation growth there are now at 150 per electrophysiologist at the median. And similar to the panel numbers, the median volumes per EP for the ICDs and pacemakers are relatively flat. I'm gonna turn it over to Joel to talk about surgery. All right, this section will be relatively quick because as Karen pointed out in the demographics section, surgery is quite a small portion of the overall survey results. And as she talked about, here is the size of those programs in terms of both physicians, the dark blue, and then the lighter blue being total providers, which would count in the APPs. Surgery has always been ahead of cardiology in terms of its APP deployment in large part. Our belief is because there was total alignment because you were paid globally. So there was a very strong motivation for the physicians. They didn't get additional work RVUs to see patients in the return office visits themselves. They had a very strong motivation to shed those off to APPs. And that's why you see that ratio being so significant. And then if you go to the next slide, surgeons continue to be hard to find and very well-paid. Remember the median in the MedAx cardiologist was around 680, 700. It's over 900 for cardiac surgeons, even though the work RVUs have remained relatively flat over time. And then over at the vascular side, same kind of trend. You have median compensation over 650. It does look like the RVUs are trending upward, but we don't have enough years under our belt yet to see if that's gonna hold true or if it would go back to some of the previous years. And then compensation per work RVU, just like cardiology is relatively flat. What we see more often, especially with cardiac surgery is the volume of the program is much less a driver of compensation than simply needing the number of cardiac surgeons that a program needs to stay open. Even small volume programs need more than one surgeon for call coverage and just for redundancy, because if you only have one surgeon, you're one away from none and your program shuts down. And we've actually seen that quite a bit out in the market, unfortunately, just the nature of life, I suppose. But much more than the productivity or the volumes of the center, it is all about keeping the program open. And you can see that reflected in how the compensation number versus the productivity. All right. So I'm gonna talk about APPs to end us here during this webinar. But again, that plug to complete that survey, because that will go into much more depth than what I'm gonna show here. But for the first time in many years, and Joel already talked about this a little bit, but the number of APPs per cardiac surgeon fell, decreasing to 1.5 APPs per surgeon. It's interesting. Last year, I looked back at the report. We actually predicted that if the APP to cardiac surgeon trend continued, the median would surpass two APPs per cardiac surgeon by 2025. That obviously didn't play out this year in the data. So we'll have to see if this drop is an exception given the shortage of surgeons or if this ratio has started to plateau. The ratio of APPs to vascular surgeon have continued. They're fairly steady trend of nearly one-to-one. And the ratio of cardiology APPs to cardiologists continue to climb now at 0.67 APP FTEs per cardiologist. There were many predictions, by the way, at the CVT and RPOD that we'll see that in excess of one-to-one in a very short amount of time. For cardiologists. For cardiologists, sorry, yeah. Well, going back a little bit, if you recall from the demographic section, I said the median number of cardiologists in private practices increased. So here we see that the ratio of APPs to cardiologists in private practice programs actually decreased slightly from 0.57 in 22 to 0.54 per cardiologist in 23. The median number of cardiologists in integrated programs decreased, but the number of APPs per cardiologist increased for the integrated programs from 0.63 to 0.68 per cardiologist. So seeing those play together there. Also discussed earlier was the increase in patient panel sizes per physician for cardiology program. So this graph, this figure is actually the flip side of the number of patients per cardiologist. This is showing the provider FTEs caring for a thousand active patients. So trend lines show fewer provider FTEs caring for a thousand active patients, 0.84 FTEs in 23 compared to a 0.92 in 2020. So while patient panel per cardiologist increased 6% from 22 to 23, the median provider FTE, that combination of physician and APPs per 1000 active patients fell nearly 10%. So the data is suggesting that provider numbers are not growing at the same rate as patient panels. And by the way, that's almost like a critical mathematical must because we are seeing an increase in demand through the age distribution in the US, the rise of chronic conditions and heart disease, unfortunately, and the number of fellows coming out of training is just not sufficient. So this is a good thing that our programs are figuring out ways to see more active patients and manage more active patients with fewer physicians. So I'm gonna go back to that 25,000 patient panel size example. So at a median of 0.23 APPs per 1000 patients, a group with 25,000 patients would have had 5.8 APPs in 2014. With the increase in APPs per physician, that same group for the same patient panel size would have added three APPs for a total of 8.8, again, for that 25,000 patients in 2023, but that group would have fewer physicians than they did in 2014. So looking at some compensation for our APPs, median compensation per full-time APP continued its upward climb in 2023 across all three cardiovascular segments, similar to our physicians. Cardiac surgery APPs continue to be the highest paid of the three. Historically, cardiology APPs had a slight lead over vascular surgery APPs in total compensation, but in 23, the median compensation for vascular surgery APPs increased 11% over a comp in 22, and that took him 8% higher than the median comp for the cardiology APPs. Again, maybe likely at least partially due to survey bias mentioned previously, also vascular surgery APPs represent a smaller sample size in our data. And then looking closer at compensation for cardiology APPs, the ownership model has much less impact on total compensation for APPs than it does for physicians. In 22, the median compensation was nearly identical for private and integrated APPs, but in 23, compensation for private practice APPs pulled ahead of the integrated APPs for the first time in our report's history, now at 126 plus thousand. And then MedAxiom has collected data now by cardiology APP subspecialty for three years, so we can start to report some of those trends. Subspecialty does impact compensation, but not significantly. And do notice that the graph here starts at 100,000 just so we can make those lines a little bit easier to read. In previous years, compensation for cardiology APPs followed the same hierarchy as compensation for cardiologists of the same subspecialty. With comp for EP, APPs leading the pack. But in 23, compensation for heart failure APPs jumped 11% to 129 plus thousand, which took our APPs working for, quote, our lowest paid cardiology subspecialty to the top of APP compensation. Again, possibly survey bias and heart failure APPs represent just 6.1% of the cardiology APPs in the survey. You can see the percentages there. So median compensation for EP and general cardiology, they saw similar increases between 22 and 23. Another consideration and possible explanation for the compensation differences are the clinical roles and responsibilities across these APP subspecialties. In addition to leading in comp, heart failure APPs also lead the ratio by far of APPs per physician, and had the most APPs per cardiologist subspecialty at all percentiles. At that 90th percentile, the ratio of heart failure APPs to the heart failure physicians was 3.77, nearly three times what it was for the ratio of APPs to cardiologists for general cardiology and EP. And then switching to production, cardiology APPs consistently report the highest median number of RBUs per full-time APP across all cardiovascular specialties. Of note, much of the work of the surgical APPs, and Joel spoke to this a little bit before, it's bundled into global procedure codes, meaning that those activities don't necessarily generate a new billable event or additional WRBU. So this is different for cardiology where each visit is typically its own billable activity and generates WRBUs for the provider. So for this and other reasons, for example, who is getting credit and billing for the work, the physician or the APP, WRBUs alone definitely are not the most completely accurate way of measuring work for APPs. It is what we have, but we need to keep those things in mind. And with that in mind, WRBUs attributed to APPs are increasing overall. So this figure shows median RBUs per APP by ownership model. Historically, APPs and private practices generated as much as 84% more RBUs than APPs and integrated practices, but that gap is narrowing. In 23, that difference between the median RBUs per APP and private and integrated programs was just 12%. So it'll be interesting to see in the 24 data, it could be that the private APP data from 21 and 22 were the deviations, and maybe that 12% difference is more the norm. So we'll have to see. And then while RBUs for APPs continue to increase overall, the data suggests there is still opportunity to increase independent APP visits. This is something that is not always promoted by physician compensation plans based on individual production. If you didn't see it, I encourage you to view the compensation session from our recent CV transform. Ginger and Joel discussed APP comp models that possibly better align physicians and APPs. So that would fit in here. Compared to the median APP production numbers shared in previous slides, a fully subscribed APP can generate around 5,500 RBUs when billing independently. And I included the table at the top of this graph so you can see how we get to that 5,500 number. So if you compare 5,500 RBUs to the numbers in this figure, figure 72, APPs need to work at the 90th percentile, and that's for the private practices to come close to that fully subscribed level. This is actually the first year that we have seen an RBU benchmark for APPs that exceeded 5,000. So another thing to note, Med Access data, when we collect the data for APPs, those APPs can be working in the office and or the hospital. So RBU numbers here are a blend of those two roles, but cardiology APPs at the 90th percentile are most likely those office-based APPs and closest to reaching their full potential in a true team-based care model. Again, these are the more nuances around that. Those are things that, thanks to the APP survey, we can include in that APP utilization report. So with that, that's the end of our slides. We have a couple of minutes. We left the figure numbers in these presentation slides so you can reference back to the report, and there are full compensation tables at the end of the report and the appendix as well. So Joel, do we have any questions? Just a reminder that the link for our PDF version of the slides is in the chat box. And at this point, Karen, I think we answered every question in real time because there are none. Oh, well, good. Well, you can always reach out to us afterwards if you have a question or as you're going through the report. But thank you for joining us today.
Video Summary
The MedAxiom webinar, led by Karen Wilson and Joel Sauer, provided a comprehensive overview of the 2024 Cardiovascular Provider Compensation and Production Survey. The discussion opened with technical guidance for accessing the presentation materials and a prompt for participants to complete related surveys. Key findings include a notable shift toward APPs amid a decrease in overall provider numbers, reflecting a national trend of fewer physicians and a growing role for Advanced Practice Providers (APPs) in cardiovascular services. The survey indicated a rise in compensation across cardiology specialties, with invasive cardiologists notably earning the highest. Regional discrepancies were noted, with the South paying physicians the most due to higher productivity. The data suggests steady new patient increases, highlighting access challenges. Notably, advanced cardiac imaging adoption is uneven, influenced by various impediments. The role of call duty, gender disparities, and subspecialty choices further distinguish compensation and production patterns. Surgery remains small-scale compared to cardiology, with notable APP involvement. Trends suggest APP usage will continue rising, emphasizing the need for integrated, team-based care models. The session concluded with a reminder for participants to download the webinar slides and submit any further questions.
Keywords
Cardiovascular Provider Compensation
Advanced Practice Providers
Cardiology Specialties
Regional Discrepancies
New Patient Access
Advanced Cardiac Imaging
Gender Disparities
Team-based Care Models
MedAxiom Webinar
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