Well, by my clock, it's 1 o'clock Eastern Time, which is our scheduled starting time. So, I'm going to go ahead and get us started here. Welcome, everyone, from the MedAxium community to our highlights from the 2022 MedAxium Annual Survey. For those of you who don't know, my name is Joel Sauer. I'm the Executive Vice President for Consulting, and I'm joined today by Kevin Mayer and Karen Wilson. So, the three of us will be providing you what we consider an hour's worth of highlights from this year's comp survey, which, by the way, you can download from the MedAxium website. Before we get started, though, just a quick housekeeping. If you want to download the slides from today's presentation, you can do that through the chat box. We will place a PDF copy of the slides there. And if you have any questions, you don't have to wait until the end of the webcast. You can type those into the Q&A panel. You should have a screen or a Zoom layout that looks similar to what you see on the screen here. You can also ask any technical questions. If you're having difficulty with audio or visual or anything at all, you can type it in there, and we do have MedAxium team members standing by to help. What we're going to cover today is this is our 10th anniversary, which is a big deal, and we're celebrating that. So, Karen is going to take us through some 10-year trends and kind of show you the difference between those two decades' worth of data changes. Then she'll take us through the demographics, turn it over to Kevin for a look at compensation, everybody's favorite topic, and then I'll close this out with productivity metrics and some key volumes out of the cardiology database. And like I said, you can download the entire survey. It's free. It may not always be, but it is as of now. You can download that survey by going to our website and then go to the slash comp survey site. So, with that, I'm going to turn it over to Karen to take us through some of the 10-year anniversary data. Karen. Thanks, Joel. Like Joel said, when we heard that it was the 10th anniversary of the compensation production report, we went back into the archives to that first published report of 2012, which reported 2011 data, and then we compared that to the 2021 data that was reported in this year's report. And we weren't really surprised by the directional trends, but some of the raw numbers and some of the percentage changes since 2011 were fascinating, at least for us data people. So, I'm going to take you through a few of those, starting with compensation. These trends that I'm going to share for this section of the report are for cardiology only. Since surgery data wasn't reported in that first 2012 report, so we went back and looked at cardiology. Clearly, compensation increased since that first report with the 2011 data. Private cardiology compensation increased 32% in that time period, whereas integrated compensation increased 13%. But if we apply an average cost of living increase of about 2.4% each year, the compensation for integrated cardiologists actually didn't keep up with inflation. It would have needed to be closer to 695,000 to keep up with that inflation rate. But the compensation for our private cardiologists, it actually exceeded the inflation rate by approximately 25,000. But what's most notable, we think, is probably the closing of that compensation gap between the private and integrated programs. And I know that's something that Kevin is going to touch on in the compensation part. So, next. So, it's important also to look at the number of cardiologists that are included in those two cohorts over this time as well. We're happy that in our 2022 report, we had compensation for more than 2,000 full-time cardiologists. But what's really fascinating is when you look at the raw numbers. So, the raw numbers of integrated and private cardiologists represented in these reports, they were nearly equal in 2011 to obviously predominantly integrated in 2021. And for this particular one, I wanted to show it year by year. So, the next slide. So, you'll see that 2012 report, which has that 2011 data, that was really the turning point where the integrated and private mix was nearly 50-50. If we trace that data back a little bit farther to 2008, that was pretty much the mirror reflection of 2021 with a 90-10 split of the groups and the integrated and private models. So, in about 13 years, they have swapped places. So, that integrated percentage to 89%, that's a little bit higher than what we estimate for MedAx in membership overall, which is closer to 82%. Next. So, production. Production is measured as RVUs, obviously has also increased with 10 years of reporting, which makes sense with the compensation numbers we looked at. However, here, the private cardiologists are on top of this graph. They've outproduced their integrated cohorts each year, increasing RVUs about 16% since 2011, whereas the integrated cardiologists increased RVUs about 4%, both at the median level. So, at that median level, a private cardiologist generates nearly 2,000 more RVUs than an integrated cardiologist. Next. So, APPs. One of the most significant changes since our first compensation report is the increase in APPs as part of the cardiology care team. It's up 67% in 10 years of reporting. Programs have shifted from one APP per three cardiologists to about three APPs per five cardiologists at the median. Next. So, imaging. I wanted to put a couple of them on here for contrast. So, the most dramatic percentage increase that we saw by far is the increase in advanced imaging volume per cardiologist. So, this is going to include CTA, MRI, and PET, which together increased 311% between 2011 and 2021, and this actually only represents those studies read and billed by cardiologists, since that's the data that MedAxiom collects. So, contrast that with the graph below. ECHO, our imaging staple, did increase 22% in 10 years. It's now over 900 studies per cardiologist at the median level. But nuclear and stress ECHO, different story. Stress ECHOs are actually down 68% and nuclear down 32% in that same time period. Aaron, just a quick comment on the advanced imaging. From Medicare claims data, we do know that the vast majority of cardiac advanced imaging is both ordered by and interpreted by cardiologists. So, even though we only represent the cardiology look, we know from claims data that the other population is relatively small, comparatively. Good. Thanks. So, finally, ending with a decrease. The largest decrease since our first report was hospital discharges. It clearly demonstrates that cardiologists are much less likely to be the discharging physician for hospital patients. And it's interesting, while year-over-year data points for a lot of our measures, they kind of bounce back and forth over time. This one, this trend line has been consistently sloping downward. So, it really highlights the role of hospitalists and the shift for many of our cardiology groups to be in a more consultative role. So, I'm going to transition over to demographics, just to give you an idea of the providers that are going to be represented in the measures that Kevin and Joel are going to talk about for the 2021 data from our 2022 report. So, this year, we're pleased we had 198 programs respond to the survey, representing over 5,600 cardiovascular providers. This is actually the highest number of providers ever represented in a compensation and production report, which is great. We'd even like more. Obviously, the more providers that are represented, the stronger the data is. These numbers actually represent a 13% increase in providers over last year's report. And for most of the measures that Kevin and Joel are going to share following, the data reflects our full-time providers, and MedAxiom defines a full-time physician and a full-time APP as a 0.8 FTE and higher. So, those 5,600 providers, the mix is about 85% cardiology, 6% cardiac surgery, 9% vascular surgery. It's interesting. I went back and looked last year, cardiac surgery was actually at 9% and vascular surgery was at 4%. So, we did see a pretty significant increase in the number of vascular providers represented in this year's survey. And then going to program size, on the left is the program size as defined by the number of cardiovascular physicians for survey participants, and on the right is the program size for MedAxiom membership overall. So, there is a higher percentage of smaller programs represented in the survey than in the MedAxiom membership overall. So, keep that in mind as we look at the data, but that median size is interesting. The median size for all program types are shown below, and they all actually increased over the median program size as reported last year. The biggest increase was for the private cardiology groups. Last year, actually, it was at 13, and this year, it jumped to 20. So, we don't think the private groups went out and hired a lot more physicians. It really just represents the groups that participated in the survey this year, which isn't always necessarily the same from year to year. So, that's another thing to keep in mind, but it was interesting to see that increase. I think another interpretation, Karen, and, you know, you just brought it up, and to our listeners, this is a voluntary survey. So, we don't necessarily get the same programs participating year to year, but that's any volunteer survey, which all of the national bigs are. And so, doing those comparisons from year to year is not a perfect science. So, we would encourage you to use the data directionally. And one of the directional take-homes from what Karen just mentioned about the private group size is that it probably takes some substantial size in order to maintain that private status. Most of those smaller groups are part of that now 90% that would be integrated with a hospital or health system. Right. All right. So, subspecialty mix. So, we get asked about this a lot. So, what's the mix of subspecialties within cardiology programs? So, we show that here. There are really two main differences, heart failure and interventional cardiologists. The private programs didn't report enough heart failure physicians to include. There was a couple, but not enough to include in the data, whereas the percentage for integrated programs actually continues to tick up a little bit since we started collecting this back a few years ago. It's now nearly at 4%. For private programs, the interventional cardiologists make up more than 4 in 10 of their total physicians versus 3 in 10 for the integrated programs. And then look at the percent of general non-invasive cardiologists. It's nearly identical for the two ownership models. And then finally, region of the country. The south, very well represented in the survey with more than 50% of the providers practicing in southern states. But the south is also very well represented in our membership. So, you can see those numbers there on the right side. The midwest and west are slightly maybe underrepresented in the survey when you look at those percentages as compared to the overall membership. But really, not too much difference. So, fairly good representation of our membership, even though it is very heavy in the south. So, with that, do you have a comment about heart failure in the south? I was going to say, Kevin, I'm glad you have to follow Karen, not me. Thank you, Joel. Awesome, awesome job, though, because Karen is one of my favorite people. But yeah, definitely hard to follow. So, I have the exciting part of compensation to go through with the group today. Thank you, everyone, again, for joining the call. Next. In this first graph here, we're showing the total compensation by full prime equivalent cardiologists and by ownership model as well. So, as you can see, from the going back since pre-pandemic levels for both integrated and private groups, compensation has gone up. Really, as Karen has mentioned, too, very and extremely exciting for me just seeing this, too, as I remember the, I'm not sure if we named it, Joel and Karen, back in 2010 and 11, the great integration. A lot of the driving force behind that was the decline in compensation that was happening. And to see the private programs now only 3% lower than integrated programs is quite interesting to see. So, from the, and over the last five years as well, it has been a substantial increase from the private group setting as well. So, you can see the 126% increase from 2017. So, they went from a 480K up to 605 in 2021. Next. Thank you. In this bar chart, it depicts the median total comp per FT by subspecialty and ownership. So, again, breaking down private and integrated groups, but also breaking it up into each of the subspecialties, EP invasives, interventional, and in general, noninvasive. Do want to call out again, as Karen mentioned, an overall year of advanced heart failure. We're very excited to see this part being collected now, a rapidly growing subspecialty within our groups right now. And just want to point out too, I'll start and work my way back. The advanced heart failure salary has lagged from a subspecialty standpoint. And we know this because most groups are highly compensated from a work-review productivity standpoint. And since the advanced heart failure programs are heavily E&M codes, they are behind the other subspecialties. Another key area to point out too is the EP interventional, highest paid from an integrated group standpoint. And in the integrated programs, EP and interventional are the highest paid. Again, we think a lot of that has to do from the comp models that are out there that are heavily weighted towards work-review production. And those are the procedure lists. Next. Just a quick comment, Kevin, on the heart failure. We have seen those salaries though. Part of it, I think, is data normalization. Whenever you enter a new measure, the N is so small and now it's getting substantially larger, but we're seeing that compensation increase. Likely a market condition, supply and demand. We were up to 80 heart failure physicians with the data this year. So in this graph, in the- Did I go too far? Sorry. No, you're next. You're fine. OK. We definitely want to show the pre and post pandemic. So we're in 4% plus or minus for compensation. So this is just showing from subspecialty again, just where we were in 2019 and 2021. And really, we've climbed right back up from pre-pandemic. So good story there. Next. Compensation by region. So as Karen stated too, the South wins again, and this has been a constant for the last five years too. So sector of the South is Midwest. And important to note that this has been consistent for the last five years with the South being the highest paid region in here. May not come as a surprise, but the South is also the highest productivity region of the country when we look at RBUs. Yes. So from a total compensation standpoint in relation to work RV production, the graph shows a strong correlation between productivity. Again, not surprising since most groups, over half the groups are paid on a productivity model. One important note I want to show here too, the EP is the highest producing subspecialty and interventionalists being the highest paid subspecialty. And a quick call on that too is going through the data, it looks like from a call burden standpoint for interventionalists is what's triggering the higher paid and interventional standpoint and EP being higher because of the procedures. It'll be interesting to watch the EP number for next year because EP's RVUs got tinkered with I'll say, this year. Joe, I'm glad you said it Joe, not me that that's a hard year and a lot of hard boardroom talks across the country there. Next. Thank you. So, I actually, next slide is the one I actually took out, next. So from a compensation and call relation to, this is definitely showing that when you, compensation has reduced in half when there's no call. So you can see from a partial call standpoint too, so the trend line is exactly where the importance of call across the programs and as we dive in a little bit more on the age demographics within the groups to see the importance of how call is known and how it will continually be in the future too. We've heard groups that have 50% of compensation tied to call participation. That's how onerous it can be, particularly in the interventional world. Next slide. Yes, so with that said too, so total comp by worker review by age. So in our, we know we've been numerous talks that one in four cardiologists are above the age of 60. And we like to say, Karen is much younger than Joel and I, we like to say that in our prime years from 40 to 60 is our prime years and highest producing time. And as you can see from the graph here, that productivity is definitely correlating with your compensation because you can only do, but so much as time goes on here. So this slide and this topic, it is a constant in all of our CBTs, it's a constant topic in the cardiology landscape because we have so many cardiologists above the age of 60 and the need, the demand is higher than what is coming out of schools right now. Joel, Karen, any points you wanna make? I know you made them well. Sorry, I thought I saw. Okay. And now this graph is showing all the new fellows coming out, so age 35 and under. Very interesting to point out too, again, back to that supply and demand. You know, I remember in back in 2014, salaries actually doubled for new cardiologists coming into the workforce here today. So it's definitely more expensive to recruit cardiologists now, and also productivity is not the exact same what it once was too, but newer cardiologists. Next slide. And we do realize that this is not a perfect indication of what starting salaries are, but cause not all fellows are 35 and under, but it is likely a close surrogate for that. Next. So now we're gonna jump into surgery compensation. Great story here for surgeons. So the last five years, a significant increase for our cardiac surgeons and increase for our vascular surgeons, but definitely most notably in our cardiac surgery space. Again, because of a supply and demand issue that we've seen in the last five years too, there is a huge need for cardiac surgeons, and there are definitely less, there's even some programs that have stopped producing, stopped their surgery programs too, so there's less coming out of school as well. So as you can see a 60% increase and 30% increase for cardiac and vascular surgeons respectively here. Next. Anecdotally from travels around the country as a consultant, there are a lot of one surgeon programs out there. And when you're the only surgeon in town and that call burden, that is, call is a big deal for cardiac surgery as well. And I think that's reflected in these numbers where we're approaching a median of almost a million dollars which is not an unusual number to the MedAxiom team when we travel around and hear what, in order to attract that very scarce resource as Kevin mentioned, you have to pay for it. Yes, highly competitive arena. And so from a median total comp per work hour view here too, so you can see from a just pre-pandemic standpoint, surgery remained roughly flat from pre-pandemic, but interesting to note that the vascular surgery has seen a dip in their per work RV dollar amount from a median standpoint to tune of about $7 here. So there's been a decline in their compensation. I will point out, and I'm not conflicting with Kevin's statement at all, our vascular surgery and sample size is relatively small. And anytime we have a small sample size, it makes the data more volatile year to year. So whether this is real reflection of the market, we'll see, because you can't look at one year and call it a trend. We'll have to see a few more before we know where we're at. Great point. So jumping into compensation for our APPs, next. So over the last five years, there's definitely been an increase and the APP compensation, just to make sure that everyone is seeing that top line is our cardiac surgery, APPs. Green in the middle there is our vascular and the dark blue down there, it's cardiology. And there has been a increase over the years, but most notably in the last two, the increase in APP compensation. As we travel the country too, as we suggest and see more sophisticated care team, I'm sorry, people are showing the importance and want to recruit the right talent in their APPs because they have really shown a great benefit to programs, especially with the national shortage in cardiologists. I would say too, going back to Karen's 10-year trend and the doubling of the utilization of APPs in cardiology, quite candidly, I'm a little surprised that the wages haven't escalated even more dramatically than this. Because this, if you do the math on that, it's probably in line with the cost of living adjustment over that same time period. We must, the supply side of APPs must have proportionally increased, or I think you would see a much more inflated compensation trend here. Another point too, is that this year we started collecting APPs enabled to do that full-time split. So that 2021 data is only representing the full-time, whereas some of the previous year would have had that combined. So we'll have to be able to look at it with just the full-time in the next coming years as well, now that we created that ability. And by the way, we do also separate, you can see APPs for general versus EP for heart failure for our members who can go into the database live. Yes. Next slide. But to your point too with, this actually refers from cardiologists. So the highest paid are in the West and Northeast for APP. So cost of living possibly there, but to your point, I think there is still a lag behind, especially with the importance of their QRT models now. Next slide. Okay. I think I'm gonna take over from Kevin now and go into productivity. And we're gonna start where Kevin left off, which is with those APP resources. And one of the things that is the take-home point or the main take-home point here, I believe, is the spike in, or the upward trend in workers RVUs produced by our cardiology APPs. Cause the other two cohorts, surgery cohorts are relatively flat over time, even though the graph may look like it's bouncing around, those are actually relatively static from a statistical standpoint. But cardiology is definitely trending upward. And as many of you on the webcast are well aware, many of the work RVUs or the work generated by our APPs in cardiology is actually showing up under our physicians tally, not our APPs because of the way we bill for services and the way we are organizing. But you can see in the data that is changing. And that is one thing that MedAxiom is keeping a very strong eye on. And we are strong advocates for top of licensure deployment of these resources. As Kevin mentioned, care teams are, you know, they're expanding, they're getting more sophisticated. And while APPs are significantly less expensive than cardiologists, they're still one of our most expensive non-physician staff member. And we need to use them in a highly effective fashion. Now, there's also a lot of differences in work done in the hospital versus work done in the ambulatory setting. And when our APPs are predominantly deployed in, I'm not saying they are, but when they are predominantly deployed in the hospital, often those are split shared visits. And they, again, will endure to the total of the physicians work RVUs, not the APPs. So you can't look at these numbers and say, this is how hard my APP is working. And that may seem very obvious, but it is surprising how many times we are hearing pressure from leadership about that exact disconnect that we have to correct or push back against. Sorry, trying to maintain two screens with Zoom and click, and it gets a little challenging. Probably not for many, but I'm getting old, as Kevin called me earlier. So now we're looking at just the percentiles. And again, I just want to point out the, you can see we have APPs in cardiology, only 10%, I get it, but that are generating in excess of 4,000 RVUs. And I actually went into the data, the granular data, and we even have APPs in around 8,000, 9,000 RVUs. So when they are acting in a very independent fashion and they are getting credit for the billing 100%, they are nearly as productive as a general non-invasive cardiologist, or it can be, I should say. They're not, those are the exception, not the rule, but we're seeing much more sophisticated utilization of these resources. Surgery is a different animal because a lot of surgery is global build. And so it really doesn't matter who renders the care because it's all covered as part of that global surgical code. So we did have always seen these resources. It's kind of almost like a natural alignment of incentives for surgery and APPs and their deployment. And so they've traditionally been ahead of the curve in terms of their utilization of these resources. I mean, you have APPs, particularly PAs that are going right into the ORs and opening and closing cases and things. Okay, now turning to surgery production, and this will go fast because we don't have a whole ton of data around the surgeons, but you can see cardiac surgery is a median of about 11 and a half thousand RVUs compared to about 10,000 for vascular surgery. Part of the reason our sample size in vascular surgery is so small and vascular surgery is so small is a lot of that community tends to still be in private groups. And a lot of their work is done in ambulatory settings and particular office-based labs and ASCs, which are on the increase, as you all are aware. And we don't necessarily have great penetration into that community. If I have any vascular surgery programs on this webcast and you did not give data, we would love to get it because we would love to get that sample size doubled or tripled even. And then when you look at compensation per work RVU, I think Kevin even covered this one already, but quite robust for those cardiac surgeons. All right, now I'm gonna go into productivity for cardiology. And does anybody remember a pandemic? 2020 was quite the unusual year. These are month-to-month data and you can see the big dip that happened in April. Whereas for the most part, 2021 was quite a stable year in terms of work RVUs. And it has largely caught up to pre-pandemic levels when you look at it year-to-year. However, something to note, and we know it, E&Ms had a significant increase in 2021. So, you know, for most cardiology practices, just that E&M increase, the average was about a 7% bump in work RVU, doing exactly the same work from the year before. So if you do that math, we are probably still below some of the previous years work RVU thresholds normalized for those changes. I do have to point out, because I'm sure somebody in the audience is going through their head, well, why don't you guys normalize? You have to remember CMS tinkers with the work RVU schedule every single year. It just happened that E&M change was more significant than most. And I know some of your programs probably struggled with that because they were paying a lot more to cardiologists through those work RVU models that Kevin mentioned, but there really was not the corollary revenue coming in to offset those new expenses. And that was a big deal and kind of came out of nowhere for most programs. And suddenly they were dealing with that phenomenon. When you look by subspecialty, EP in the private setting is over 15,000 work RVUs at the median, which is pretty incredible. Again, we'll probably see those numbers come back in 2023 based on 2022 data, because of some of the changes to the work RVU schedule in EP. And then as Kevin pointed out, interventional cardiologists were the second highest paid. They're also the second highest producers. One of the big take-homes is the difference between the generalists in a private setting versus generalists in an integrated setting, a 20% gap. That was the widest gap of any of the subspecialties on a percentage basis. They don't necessarily have a good explanation for that based on data, but I would say our generalists in private settings, which private groups live off of revenue minus expense, it's that simple. They tend to probably generate more imaging volumes and some other things that would allow them or require them to produce those higher work RVUs. Oh, and to make my point, you'll notice there is zero bar for heart failure physicians in private group settings, because those physicians, as you can see, the median is almost only 60% that of a generalist. It's tough for a private group to support a physician with that low of work RVU and corollary revenue total. All of our submissions were for integrated heart failure physicians. And then when you compare kind of pre and post pandemic, everybody was up. And as I mentioned with the heart failure salaries, we've also seen heart failure work RVU productivity climb each year that we've included them in the survey. I'm now gonna turn to some key volumes. These are out of cardiology only, just because we don't have good data around surgery and well, around surgery, because of the way the billing and these are based on claims, CPT codes from a volume standpoint. But when you look at new patients, we are up to pre pandemic levels. The dark blue bars are the total new patients. And then the light blue line is patient panel. MedAxiom is the only survey that is tracking patient panel, active cardiology patients from the survey standpoint. And you can see it has largely 2019, whether that 1800 median was kind of a statistical blip in the radar or something real. We don't know and won't probably for several years, but you can see that we are now well past 2020 for both new patients and patient panel. As we dig a level deeper, sorry, when we look at new patients, what we as MedAxiom consider the health of a cardiology practice or program is not necessarily the total, but what comes in through the office. And although not on this graph, if I would have showed you the trend for office, new patients, it too has recovered from pre pandemic levels. And I believe was at a, if not an all time high, was at one of the highest points it's ever been. As Karen mentioned, discharges has been a perpetual slide. Cardiologists don't wanna do the admission because then they don't wanna have, also have to be responsible for that discharge. So as she mentioned, they have largely moved to a consultative role. We have seen a pretty level five years for hospital visits, those follow-up visits, and pretty steady inpatient consult work as well. You guys are living it. I don't need to tell you, but we are obviously in the transition from moving patients away from the hospital and into ambulatory care settings more and more. That is likely part of the flat trend we see. Because while at the same time we're hearing about that transition, we are also hearing from our programs of how bed-challenged they are. So, you know, trying to reconcile that. One thing we do know that's factoring into that, two things I'll mention. One is as we transition the less sick people to the ambulatory setting, that means we're keeping the more sick, more concentrated. That means greater lengths of stay, which leads to bed capacity issues. A 10% increase in length of stay, which I would argue is not significant when you're talking about this transition being made, can have like an 80-bed impact on a 400-bed hospital, which is not a large hospital in today's vernacular. So it is a big deal. And then the second phenomenon that's out there is we're seeing a lot of the rural hospitals either contract or even close, which is pushing more care into our tertiary quaternary facility. So those two factors are really impacting the hospital work being done by our cardiovascular programs. Thank you. Karen covered this in the 10-year trends, but ECHOs have actually weathered the imaging transition. The advent of CTA and some of the more advanced have not had a bad effect on ECHOs, but nuclear continues its downward trend. And based on just reading tea leaves, that trend will likely continue as programs are ramping up alternative testing to the nuclear spec. Advanced imaging, significant increases year to year, particularly for cardiac PET. Have to take these bars with a little bit of a grain of salt because not all programs offer these and the PET population of programs is much smaller than for instance, even a CTA. So considering that, and in fact, here's that graphic only 25% of programs, or I'm sorry. Again, we don't necessarily have the same groups responding year after year. So these changes may be more of a statistical phenomenon related to who completed the survey than what the community, but you can see the vast majority of programs offer ECHOs and NUC. It goes down considerably when you talk about those advanced imaging modalities with less than one in four offering PET and only about one in four offering cardiac MRI. I will predict and probably be wrong or most likely be wrong that that cardiac percentage, cardiac CTA percentage will amp up over time, particularly since the guidelines were changed this past year. Cardiac cath rates have stayed very, very flat over even a longer period of time than what I'm showing you on this graph. And the PCI volume has also remained relatively flat, which means then the ratio of PCI to cardiac cath has also remained relatively static over time. There are, it will be interesting to watch that green line over time with the advances in CTA and heart flow and clearly and some of these other technologies that are really helping us identify who needs to go to the cath lab for interventions and who doesn't. So again, very uninformed clinical opinion, but a prediction would be that that percentage will tick up over time. I have heard from our programs that are heavy utilizers of CTA and some of those more advanced functional flow that their percentages are significantly higher than this. TAVR volumes, they were nearly pandemic proof because they even, in terms of who was getting a TAVR out of our patient populations, it went up from 19 to 20 and is held static in 2021 while the median has actually bumped up. So TAVR volumes are increasing and I think that's probably your experience in most of your programs as well. In terms of who's doing these cases, and this is looking at patient panel, who's doing those advanced procedures that you can see on the table here. Most interventionalists, most programs are trying to consolidate those higher end interventions, if you'll accept that term. But you can see actually for PCI-AMI only, that volume has actually gone down per interventional cardiologists from a median standpoint. And you can see the relatively small volumes for procedures for those other advanced services. Kind of like Kevin brought up the issue of physician slowdown and the consternation that causes in groups, this is another one, trying to consolidate volumes to a smaller population of operators. It's both a challenge professionally, but it's also can be a challenge from our comp model standpoint, depending on how we pay our physicians and distribute work RVUs, et cetera. So this is a topic that we have as MedAxiom been involved in at multiple programs, trying to say we can't have five interventionalists all doing TAVRs for instance, or these advanced procedures. To it, only about half of the interventional cardiologists are performing CTOs and less than one in four are performing TAVRs. So we are seeing some of that clinical strategy focusing those procedures to a smaller population of physicians. Turning now to EP, relatively flat volumes except for over time, except for ablations. Even though this looks like only an increase of one, that's about a 10% increase from 2021 to 2020 comparatively. And what we know is that we are doing more ablations out of our active patient panels as this graph illustrates. So continuing to do more and more ablations. And I know that one of the reasons Medicare adjusted the work RVUs around ablations is because the more of these we have done, the better we're getting. Our technologies have improved, our mapping has improved. We hear programs reporting that those times for those procedures have come down pretty significantly. And unfortunately, so did MedPAC, they heard that and they adjusted the work RVUs accordingly. Maybe too much, depending on your opinion or point of view. But again, Medicare does that annually. It's like taxes, it happens every year. In terms of procedures per EP physician, the median at each of these levels ticked up. Although if you look at the ICD numbers, that trend is actually down, but up for both permanent pacemakers and for ablations. I believe, Karen, keep me honest here, but we could actually run these volumes for non-EP physicians, because we know a lot of groups are having non-EP physicians do pacemaker inserts, for instance, and we could get that out of the database. We can. Yeah. So if, again, a plug for our membership, which has access then to these data in our web-based format, which allows you more filters and ways to slice and dice than I can count, you can get into a much more granular level of look at the data. Kevin brought this up, but, you know, call is onerous and is reflected in our compensation numbers and in our productivity. One comment I will make, just because I've done a lot of work in this space with programs on physician slowdown plans, the most, I shouldn't say that, but many times when a physician comes off call, they are also adjusting their daytime schedules, and that is why you see such a kind of straight line impact to both work RVUs and compensation. So it's a very, very important thing to both work RVUs and compensation. So it's rare that they just do one thing, or it's common that they will do more than one thing. They would both slow down from a call standpoint and adjust their daytime activities as well. Some programs actually mandate that as part of their slowdown policy. If you come off call, then you also come out of the cath lab entirely. Obviously, if you have a rule like that, that's going to impact work RVU productivity as well. When you look at participation in call by age group, it really isn't until you get age 71 and above, and believe it or not, we have a fair number of cardiologists in that age spectrum still, where it really goes down substantially. I mean, you still at age between age 61 and 70, you still have three quarters of cardiologists participating fully in call. So I was actually surprised by that a little bit. I thought that percentage would be lower. Although when you look at the impact it has on income, maybe that's the reason everybody's staying in, so they don't have to weather that cut. There are differences in terms of both productivity and compensation by age group. And I'm going to skip over this because Kevin already covered that. Hey, Joel, just real quick, because I know we're almost at the end and we did have a question related to this. So since the slides are back up, I'm going to throw it in there now. And the question was, how do you separate the effects of lower productivity and lower call in those greater than 70 years old? It looks like comp per RVU in over 70 year old cardiologists is similar despite taking much less call. That's a great question. And my experience anecdotally is that's not what I hear reflected in the communities and in particular in the programs that I've worked with on slow down. For the very reason I think the question is being asked, that doesn't seem, I don't like to use the word fair, but it doesn't feel consistent if call is worth 30 or 40%. All things being equal, my comp per work RVU should be significantly lower when I come off call. And in fact, that is my experience in real life in the community. However, we do know groups that very rare these days, or I would say pretty rare, that physicians can, because of senior benefits, they can come off call with no impact to compensation. Not recommended, certainly, but they do exist out there. But I mean, the short and honest answer is I can't explain that because I haven't personally witnessed that. And we would have to, these are medians, so keep that in mind. You can't look at those and say they actually correlate with one another. They are simply two metrics that we are showing you the median of each. Any other answer from either Kevin or Karen? Joe, I think you touched on it too. Just also the effects of if you're coming off call too, but a lot of groups we see across, you have to decrease your time in the lab, if not remove yourself from the lab too. Also, we have other groups that don't allow as much reading of echoes and everything. But with all that, again, to deter coming off call and making it fair, but I must say, though, there is an absolute importance to have an interventionalist who is now a full-time office doc in your programs, especially when you look at the shortage in cardiologists. But I've never seen not having a full-time prior interventionalist in the office, increasing your access has always been a success. So I would just want to put that out there too, is that removing them from the program, I think they can still play a vital part of your cardiac programs. Yeah, and to that point, a good segue, when you have 26% of your workforce that is age 61 and above and MedAxium put this slide out two years ago based on 2019 data, we are projecting a net deficit in terms of the number of cardiologists leaving the practice versus those coming in through fellowship. Now, this is absent some major change in our foreign medical grad rates coming into the United States, which is not what it used to be. But in this environment, as Kevin just pointed out, having our slowdown policy so onerous that physicians simply retire in total may not be the smartest thing for us because it's gonna be really hard to replace them based on these numbers and what we're hearing across the country. So finding a balance that allows them to contribute to the practice may make a lot of sense. That said, nobody wants to take call, right? I mean, it's like paying overhead. Nobody wants to pay the overhead, but it has to be paid. The call has to be covered. So there are some real challenges in those slowdown policies, no doubt about it. I'm gonna end with just a quick graph on 87% of our cardiology workforce is male, 13% female. By the way, that's the highest penetration of female cardiologists ever in our database. And there are differences in both productivity and compensation. We are not here to say that these differences are statistically relevant, that there's any kind of bias in them or anything. We didn't do those kinds of analyses. We just pulled the medians and are publishing them, but there are clearly some differences there. Strongly encourage our members to go to MedAccess. That is the live database where these slides were pulled from and where the slicing and dicing that I mentioned earlier can take place. Powerful, powerful data. And we are here to help. If you are struggling with, because it is a beast at times to get to know it, particularly when you start slicing and dicing, we have membership reps like Karen and Willa and myself and Lori and Kevin and any of us can help you with your data. And we'd love to get your data. So if you are sitting in on this webcast and you didn't participate by submitting data, we will very kindly try to shame you next year into sending us your data. Because as Karen mentioned at the outset, the bigger the sample size gets, the more accurate we know it is a reflection of our community. And that's what the data are for. Also want to plug, we will be putting out our APP survey. It goes deep into not just comp and productivity, but how those resources are utilized in our practice, what kind of call they participate in, things like that. So it's a very, very granular report. We started at it several years ago and it's been one of our most popular surveys. It's time again for that one. But there is still time to participate by the way. And then the new normal are, oh, is this the survey again or? No, this is just for help with compensation strategies. This is what I do for a living and I tripped up on what it was, apologize for that. So if you need expert consulting, don't call me apparently. But we do consulting on all aspects of the compensation, productivity, physician slowdown, all of those dicey prickly issues that you all have to deal with on a day-to-day basis. Our consulting team is very experienced with and can help. And I think we're out of time. Were there any other questions, Karen or? I don't see any other in the Q&A. Nope. That means we did such an amazing job of answering the questions that were anticipated through the presentation. All right. Well, we ended right on time. So thank you for joining MedAxiom and Karen and Kevin and myself and the team behind the scenes. We appreciate you very much and look forward to hopefully seeing most of you in Austin, Texas next week, our biannual CVT is in Austin, great place. It will be a great meeting. So adieu until next time.

MedAxim Annual Survey

compensation

productivity

cardiology

surgery

ownership model

subspecialty

age

gender