Tuesday, September 6, 2022 | Joel Sauer
This year marks a decade of publishing MedAxiom’s Cardiovascular Provider Compensation and Production Survey. Be on the lookout for the 2022 report, which will be published in the coming days. As the primary author of the survey, I can honestly say it’s been a labor of love for the MedAxiom team. The feedback on the value of the data we get from our membership keeps us motivated and energized.
Given the significance of the milestone, I thought it would be both interesting and entertaining to look at some of the dramatic changes that have occurred over this 10-year period. Because MedAxiom did not begin publishing surgical data until 2013, this lookback will show comparisons for cardiology only.
The most dramatic change in cardiology over the past decade has been the explosion of advanced imaging – defined as coronary computed tomography angiography (CCTA), cardiac magnetic resonance (MR) and cardiac positron emission tomography (PET) – which collectively rocketed up 311% in that time (Figure 1). However, not all modalities flourished with both stress echos and nuclear SPECT experiencing declines in numbers (68% and 32% respectively) during the decade (Figure 2). Since 2011 the volume of non-stress echo, the imaging staple, increased 22% per FTE cardiologist, now topping 900 per physician.
Practice Setting Trends
When you look back a decade, there was nearly an equal number of cardiology practices in private programs and integrated models (employed or in a professional services agreement with a hospital or health system) (Figure 3). In fact, for those of us old enough to remember the decade preceding this illustration, those two ownership cohorts have effectively switched places. Private programs used to be 90-plus percent of the reporting programs and now barely make up 10%. The decline of imaging revenue was a significant factor in this migration, as private programs were hit with a double-whammy: reimbursement per study dropped precipitously and, in the case of nuclear SPECT, volumes also plummeted.
Another interesting trend is the raw number of physicians from each ownership model participating in MedAxiom’s annual survey (Figure 4). Like the cardiovascular programs themselves, in 2011 the number of cardiologists in each of these cohorts was nearly identical, and now those in integrated models dwarf their private peers. A huge shoutout to the MedAxiom membership for helping us grow participation overall and reach the milestone of 2,000 physicians in 2021.
Hospital Discharge Trends
Over the past decade the role of hospitalists in the hospital has mushroomed. This has in part caused a conscious shift by many cardiologists to move to a more consultative role. This has been in many ways a mere survival transition given the shortage of cardiologists against an expanding cardiovascular patient population. This point is made abundantly clear by Figure 5 that shows median hospital discharges per FTE cardiologist have plummeted 75% since 2011, now at only 18 discharges per physician compared to 73 to years ago.
OK, OK, you’ve waited long enough. Now on to compensation and production developments over the last decade. Median cardiology compensation has increased regardless of ownership model (Figure 6). Private cardiology compensation has expanded by 32% to a median of $604,652 per FTE, while integrated cardiology income has increased by 13% to $621,596 per FTE since 2011.
While these gains seem significant – and may be when compared to other professions, at least for the integrated physicians – compensation has failed to keep up with overall cost of living, as measured by the Consumer Price Index (CPI). You’ll have to allow me some liberties in making that statement since there are so many variables that can impact compensation, particularly over such a long time period. For instance, changes to the work relative value unit (wRVU) schedule and reimbursement happen annually and – like we saw in 2020 with a big bump to Evaluation and Management (E/M) codes – can have profound effects on compensation.
This being noted, on average the CPI has increased 2.36% per year over the past decade. Thus, all things being equal (which they are admittedly not), this would mean that the “average” integrated physician earning $549,999 in 2011 would need to top $695,000 in total compensation in 2021 to keep pace with inflation. The reported median of $621,596 is obviously well below this threshold. Faring better, a private physician earning the median of $457,661 in 2011 would need to earn $578,000 in 2021 to have the equivalent spending power – which was exceeded by some $25,000 per cardiologist for 2021 ($604,652).
Turning now to production, private cardiologists have really stepped on the gas and pushed per-FTE production up 16% since 2011, while their integrated peers have expanded by 4% (Figure 7). This imbalance in gains has widened the gap between these ownership cohorts; now at the median a private cardiologist is generating nearly 2,000 more wRVUs annually than her integrated analog. This delta is likely at least part of why a private program has remained independent.
Perhaps assisting in the reported increase in wRVU production is the 67% increase in advanced practice professionals (APPs) per cardiologist witnessed since 2011. This ratio has grown from around one APP per three cardiologists in 2011, to three in five in 2021 (Figure 8). The expansion of these professionals allows programs to manage more active cardiology patients (panel), which in turn allows for more new patient volumes. As Figure 9 shows, new ambulatory cardiology patients increased 22% from 2011 to 2021.
The past decade has brought many interesting and revealing changes to the practice of cardiology. From procedure shifts and the mix of cardiologists to the production and compensation alterations that result, it has been a dynamic 10 years. While no one can predict the future, the beauty of surveys is their ability to measure the past. MedAxiom is looking forward to the next 10 years of cardiology surveys to provide the community with invaluable data and peer comparisons.
No doubt the next decade will also provide profound changes to cardiovascular medicine, and there are bound to be some surprises along the way. While no one can predict the future, the beauty of surveys is their ability to measure the past. MedAxiom is looking forward to the next 10 years of cardiology surveys to provide the community with invaluable data and peer comparisons.
Stay tuned for the mid-September release of the 2022 Cardiovascular Provider Compensation and Production Survey revealing additional insights from the past decade and the full 2021 data review.
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Illustration: Lee Sauer
Joel Sauer, MBA, is Executive Vice President of MedAxiom Consulting. Joel consults around the country in the area of value-oriented physician/hospital partnerships preparing health organizations for the value economy. His work includes vision and strategy setting, creating and implementing effective governance and leadership structures, co-management development, joint venture and other innovative partnerships, and provider compensation plan design. Beyond the above, Joel has a wealth of experience in service line development, clinical strategy development, provider workforce planning; including care team creation and physician slow-down policies, MACRA and bundled payment planning, and operational assessments.
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