Business of Electrophysiology. My name is Thomas Dearing, I'm from Atlanta, Georgia, and I'm joined with my co-host here, Melissa Middeldorp, from Adelaide and a multitude of other places. This is a session program that we put on for the first time last year, and we wanted to address issues related to the business of electrophysiology, knowing that most of the issues at this meeting are purely scientific and clinical in nature, but we also realize that this is an important and evolving concept in how we manage patients and how we function in our lives. So we have three sessions here today. The first is going to focus on general things that everybody needs to do and know about in the business of delivering electrophysiologic care. The second will bring up issues of some of the new elect funding components, ASCs and independent private equity firms and how they would interface. And then the third will be about innovation and how we can go forward. We have an excellent faculty, and we're gonna get into a lot of discussions. We have time at the end for Q and A, and we want you to step up to identify yourself and to give us good questions and good thoughts. With that, I'm gonna hand it over to my colleague, Melissa, to introduce the first speaker. Thanks, Tom. So yeah, I'm Melissa from the University of Adelaide in Australia, and I'm gonna introduce our first speaker, who is Brynne Decker-Crooks. She's gonna speak to us today on improving the efficiency of EP care by building a champion and broad-based allied professional team. So also a champion in the allied professional space. Welcome, Brynne. And just as an FYI, we are gonna keep the speakers on time, so when they hit that 10-minute mark, we may actually pull out a weapon. I can't wait for that. There we go. Great, thank you so much for inviting me to be here, Dr. Dearing and Melissa. I was very impressed with last year's sessions, and are we going forward? There we go. And I'm excited to continue the discussion this year. I come today with a unique perspective. First of all, I'm a pediatric person. I'm also a nurse practitioner. I do have over 20 years of experience, and I manage nearly 40 pediatric advanced practice providers. I've doubled our team over the last five years, and that's mostly because our trainees today, or our learners, are not able to do what they used to do. So the allied professionals and the advanced practice providers are really filling in those gaps. We'll be focusing on improving efficiency of EP care by building a champion and broad-based allied professional team. So as any good Michigan girl would do, I have to recognize one of our greatest coaches in college football, Bo Schembechler. And the idea of his 1983 pre-Big Ten Championship speech was that if you focus on the team, your team will win. And I think we'll hear a lot about that with Dr. Abrams' talk next. There's a lot of similarities between sports and health care. First of all, you can't have a team of all quarterbacks, right, you have to have a team that's broad-based. In my world, this is why I don't have a voice, you can't have a track and field team with no one running the longer distance or doing the field events. So I think you have to focus on making sure that your team is broad-based and diverse and they all have different responsibilities. You want your team to focus on outcomes, you want them to be efficient, lifelong learners, performing at the top of their scope, and you need good leadership in order to do this. And we'll talk about each one of these points later on. As we have it, Dr. Dearing did a study in 2010 looking at the work hours of physicians back at that time. And we know there's a projected deficit of basically up to 65,000 physicians in non-primary care subspecialties by 2032, so we will not have enough physicians to manage these patients in heart rhythm care. Dr. Dearing's study showed that the median work hours at that time for physicians was 60 hours. And we know that volume of work has increased, and it's not even increased with patient care, it's increased with administrative responsibilities, documentation, all that kind of stuff. And at that time, physicians recognized the need for skilled allied professionals in EP care. So who are the allied professionals? Heart Rhythm Society is home to more than 2,000 allied professionals, which is about 30% of the membership. This list may not be exhaustive, and you may not work with each one of these types of allied professional, but I'll kind of go through what they do. Advanced practice providers are nurse practitioners or PAs. They provide care. They can provide care collaboratively or independently. They manage medical problems, surgical procedures, and they treat, and they are required to have a master's or doctorate. NRN provides care in collaboration with physicians and advanced practice providers. They are very good at patient education, coordination of care, and they are required to have a bachelor's of nursing or associate's degree. In electrophysiology or CRM tech assists in the diagnosis and treatment. They're often providing technical support in the EP lab or EKG lab, and they do have a state licensure that they must pass, and most of them have gone to some sort of training program. Pharmacists prepares and dispenses medications. They provide medication education. They sometimes can actually run their own medication clinic, and they're required to have a PharmD to practice. And then genetic counselors also assist in the diagnosis. They interpret genetic testing. They provide support and counseling, and they are required to have a master's in genetic counseling. So these are some of the different allied professionals that you may work with in your practice, and you may not have them all, or you may have even additional allied professionals that you work with. So as a manager and recruiter to many allied professionals, I have learned what to look for, and I go beyond the typical education and years of experience. I want more from my recruits, and to start building your team, you need to attract and recruit good talent. So what I think you need to do is look for someone who has better attitude than aptitude. I feel that you can teach anyone anything, and so if you bring a team member on that you're able to coach and mentor, you're gonna have a better team than if you picked the top of the class, and they may be the same person. You wanna look for someone who's team-oriented, who's accountable, who's innovative, and we'll go into a little bit more detail on this later, flexible, and who is performance-based. So they wanna do what's right for the team, and they want to put their best foot forward every single day. What are the benefits of a good AP team? First in this era, we wanna increase revenue. We will talk a lot about that today, and you can increase revenue in several ways. One, by being efficient. The faster you can turn over the lab, the faster you can see patients, the more you can see and the more you can do, and allied professionals can really help you do that. They can also help you add services, so remote monitoring is often something that allied professionals will do, seeing patients in outreach sites. All of these will help bring more money into your program. They can improve patient satisfaction. They're often the front line. They're able to connect with patients, usually, not all the time, but sometimes even better than physicians can, because physicians are very much limited on the time that they can spend with patients. They provide education. They expand access to care, which is very important in many areas of the U.S. They improve patient safety, so they're often the people that are calling your patients and letting them know the lab values, changing the doses, things like that. They can triage any important calls that come in on whether a patient needs to go to the emergency room. They can also share the workload by monitoring, by doing inpatient outpatient management, especially why a physician may be in the EP lab. They can be out doing other things. So I'm gonna speak a little bit about measuring patient outcomes, and I'm basically gonna skip over this slide. I think everyone knows what patient outcomes are, and that's length of stay, waiting times, adverse events, all those types of things. We know this, but what I wanna focus on is measuring employee outcomes, and that is employee satisfaction. Are they happy? Have they been in the position a long time? What their retention rate is? Are they absent? What about their productivity, their quality of work? Are they able to execute what you're asking them to do, and are they meeting their goals? Financial performance is very important. Again, we'll talk about this over the next three sessions. So are you getting return on investment with your allied professional team? Are they able to bill? How can you enhance that? And then, to keep them long-term, you want them to progress in their career. You want them to become experts. You want them to be involved in research and stay engaged in your team. And lastly, the thing I wanna talk about is innovation. I think this is the most important goal. You want your team to be innovative by looking at QI initiatives, generating ideas, and implementing new ideas. If you can imagine, if you had a team of someone who can't be flexible and can't implement things, then you'll never grow. And so I think this is one of the most important points that I make today. So in order to have a champion AP team, you need to support education and training by allowing time in purchasing the tools. Luckily, Heart Rhythm has a lot of education on the 365 platform. And so that's the first thing that I would stress is allow time for continued education for your team. Purchase the education tools. Like I said, Heart Rhythm 365 has many different platforms dedicated to allied professionals. Review our educational competencies that were published in Heart Rhythm 02 in 2022. It's very helpful. Development of education for your team. At the University of Michigan, every week, we have something called EP Club. That's for all of our team. It's techs, trainees, physicians, genetic counselors. We come together and we talk about education, we talk about patients, journal clubs, all that type of stuff. But really, it's team building. It's not just education, it's team building. And then promote certification. So IBRI is what we have now. That's very important. LEAP, Melissa and I were in the same LEAP class several years ago, and that's another program through Heart Rhythm Society. So encourage your allied professionals to apply for this. It's leadership and education for allied professionals, and that is how you're gonna get top-notch allied professionals in your program. Mentorship is one of the most important things that you can offer your team. It will enhance workforce performance, and I am lucky to have several incredible mentors in my life, several in this room. It is a bi-directional process, and it benefits both parties. It often focuses on coaching and education, but also can influence personal and career development. It requires a lot of time, so that's what we wanna put in, put in the time to your team, and it can really make a difference. Their performance and efficiency will really increase with good mentorship. Top of the scope, and that's something that we use a lot in the allied professional world, refers to limits of a health professional's knowledge, skills, and expertise, and reflects all tasks and activities that they undertake within the context of their professional role. There are state and national regulatory guidelines, those are things that are out of our control, but I do think that we can also support our allied professionals by performing at the top of their scope, by clearly delineating what you are asking them to do. It can't be vague. They have to know what they're asked to do, so they can meet the outcomes that you're expecting. Understand that there's overlaps between different roles. We all know that. We do different things at different times to help others out. Clarity and essential functions. Collaboration with the team. Promoting autonomy as much as possible. I think it's very important, as much as you can. Trusting your allied professional. And then recognize the barriers that could lead to not performing at the top of the scope. We have focused so far on employees, but as a leader, we can make a difference. In order to have a good team, you need to have a good leader and this leadership concept comes from a famous Ann Arbor business owner named Ari Weinswig. For any of you in this room who have been to Ann Arbor, my guess is you've been to Zingerman's Deli. Even President Obama went there several years ago. He owns several very successful businesses and always has a champion team. And his model is, instead of walking around on a busy night in a restaurant and asking the customers about their experience, he's the guy that's pouring your water. You would never recognize him. He always wears a black Zingerman's t-shirt, but he's a gajillionaire and he is the person, that's how he leads the team. He said he gets to know his employees much better by doing this instead of having staff meetings and he really leads by, or manages by, pouring water. So in summary, put time into building your champion AP team and you will win the AP Super Bowl. Right on time, right? Thank you. Thank you, Brennan, you were right on time. So we do appreciate you getting us off to the right start. That was an excellent summary. And we are gonna have an opportunity for Q&A, which we're gonna extend to the end because we wanna get through the presentations first. So our next presenter is Dominic Abrams, who actually is from the hospital where I was born, Boston Children's Hospital. And he's gonna be speaking about optimizing performance and mental skills in a multidisciplinary care team. So thank you for joining us. Thank you, and thank you very much for the invitation. It's a pleasure to be here. There we go. So when I saw the title of this session, I was very excited because, as Brennan already told you, it marries healthcare and sport. And this was something I started to think about six or seven years ago and started to look back over my own career, both in healthcare and formally in sport. When you start to do that, it's probably a sign you're getting older. But what were the good teams I'd been in, be it healthcare or be it sport? Why were those teams so good? And often when you think about great teams, you've all been in, I'm sure, it's very difficult to define exactly what it is. But if we can start to dig deeper, if we can start to define it, understand it, then can we replicate it and use that to drive teams forward and drive teams to be better? So this was something I was thinking about a lot. I had the opportunity to spend some time at MIT. And it sort of became something I was increasingly interested in. But then it was this book that sort of cemented everything together for me. This is a book by a guy called Owen Eastwood. He's a former lawyer and now a performance coach. And Belonging is his just fantastic book. I can't recommend it highly enough. But all of a sudden, I had this anchor on this one word that belonging is such a fundamental human need. We need to belong. And really sort of a lot of the stuff he talks about was very, really spoke to me and brought all these things together that I'd been thinking about. And through Owen, I've met this guy Aaron Walsh, he's also a performance coach. He works a lot in sport, but also in the corporate world. And he and I have been working together for the last two or three years. We put together a program to sort of really bring this into healthcare. And we're gonna hopefully launch that later this year. So what I'm gonna tell you today is a lot of the sort of the background and the thinking around this and how we're hoping to do it with some evidence to support why we're doing it. So when we think about a team, one actually is a team with lots of academic definitions. Katzenbach and Smith wrote this paper 20 odd years ago, defining as a team of those with complementary skills, committed to a purpose that they all share, and they hold themselves accountable for their outcomes. Perhaps the sort of one of the best definitions and one of the nicest, cleanest, is this guy, Richard Hackman, who's sadly no longer with us, but also at HBS, who said teams must be real. So that means a team is brought together for a purpose, not because they all happen to work on the third floor or they work on a Tuesday. Have compelling direction and enabling structure with the team to do exactly what Brin just said, allow everyone to perform at their best. Organizational support I think is fundamental, particularly in healthcare, and then coaching from an external source who's an expert in what you're trying to do. So those are sort of the five things he came to over about 30 years of research in terms of how does a team become successful. When we think about the world we are working now, academic and other medical centers are very complex. There's multiple teams interacting in different ways and interrelating often multiple times a day. So when we're thinking about performance in healthcare, what do we often look to? The first thing we often look to is the processes that we go through. We've got six MRI scanners. We've got 12 EP labs. We've got all these amazing things that must surely elevate the performance that we're able to achieve. But ultimately, I put it to you that it's about the people as much as the process that are driving this, and it's fundamental that we focus on the people getting that right, creating the teams that are there to do the job that they are being asked to do and making sure they have that enabling structure around them. And this was a very nice quote that really speaks to that. If we spend as much time working on the people who actually do the work as we do on the process, then we probably significantly elevate our performance. And of course, that is one of the backbones of what they do in professional sport, is really focus on the people who are gonna drive the team performance forward. So when we think about the fundamental pillars of performance, we can divide it into these four basic groups. The first is the environment, the environment that we all work in. There are multiple studies from Harvard, the British Olympic Association. You can pick one of many that really have shown that between 60 and 80% of the performance that we can measure is attributed to the environment in which we work. The cornerstone of that is belonging. So when we think about belonging in any environment, it's are you connected to your role in that team? Are you connected to your teammates? And are you connected to a purpose that's higher than yourself? So belonging really drives this instinctive and confident behavior. And you know if you've been in a scenario where you really feel you belong, you will really sort of work productively, you'll just do things instinctively, and you really sort of feel part of that team. Leadership is obviously key, but must be challenging and supportive. So you want people to challenge you, to push you, but you need that scaffold around you to help you build and help you develop. When I was a very junior attending in London, electrophysiologist, I remember walking with my boss at the time, we were going down between the EP labs, and he put his arm around me and said, we really need to get you out of your comfort zone. I remember thinking to him, no, no, I'm actually really quite happy in my comfort zone, I'll stay here for six months and then we can regroup maybe. But I knew full well he was gonna push me because it was good for me and it was good for everyone else, it was good for the team around me. But I also knew 100% that he was gonna be there to support me in anything I needed, and that absolutely played out. So leadership that is challenging and supportive. And then thinking about how do we define success? We're very incentivized to define individual success in medicine. Papers, grants, all these kind of things. But maybe we should think a little bit more intrinsically and think about what is the process that we're conducting here, and what is the sort of longer term view on success that we wanna think about. When we're integrating this process, so obviously into healthcare, it has to be very contextual. You can't take a playbook from a sports team or a great orchestra, dump it into healthcare and expect it's just gonna work as it is. So it's gotta be contextualized, it's gotta be specified for the environment in which you're working. And that could be very different in an orthopedic group compared to a cardiology group. So really understanding the specific needs and what that team's all about. What we're talking about here largely is the top 10% of performance. So we're thinking about can we use these skills to get us from 94 to 96%, 93 to 98%, whatever it is. And you may say those are very minor gains, what difference does that make? Well this is the sort of a theory of marginal gains that was championed by Dave Brailsford who was the manager of the cycling team in the UK for many years. And he recognized that with a professional team you're not gonna be able to improve it by 10%, that just doesn't exist. But if you can improve 10 things by 1%, your overall net gain may be significant. So thinking about making small incremental changes in what we're doing and building things slowly from there. Key to this is it has to be integrated, this process has to be part of the environment in which we all work. I'm sure you've all been on away days, it sounds great, you hear great talks and then you go back to work the next day and it's forgotten about and you just carry on doing what you were doing before. So if you have this as part of your team and it's gonna significantly improve things. This is Dan Carter, he's a New Zealand All Black, he played about 100 times for the All Blacks, was one of their great players ever. And he said in 2005 if you went to see the performance coach people thought there was something wrong with you. In 2015 if you didn't go and see the performance coach they thought there was something wrong with you. So it just shows that how that's been adopted over 10 years in sport and now I really believe we need to do this in healthcare, but also unless you have that integrated into the system people can't benefit from it and can't improve their performance. And then finally understanding your origin story. What is the story of us? Where do we come from? Who are we? Who are the people who went before us and who are the people who are coming after us? Now is our time, you can create the narrative now, this is your opportunity to drive that and leave a legacy for people that are coming after you. So this is where I used to work in London, this is St. Bartholomew's Hospital, that is St. Bartholomew who was skinned alive by the Romans, he's holding his skin here in his hand with a scalpel. So there's a very long origin story there, but it doesn't matter if you're just starting from fresh, you can create that from the beginning. In terms of the mental skills, what do we mean? Well if you're here and you want to be here, how do you bridge that gap? So we can think about that in three ways, how do you grow yourself? Do you have a personal strategy? Who are your supporters? Who may be your detractors? Do you have people around you? Do you have that scaffolding? What is your mindset like when you approach a difficult situation? Are you thinking, I can add value here, I can bring something, or are you thinking, this is going to go wrong and it's going to be all my fault so I might as well just resign now? And pressure. Pressure is universal in healthcare. We're all going to face it. We all see it every day so we have to learn to live with it. You can't avoid it so we might as well embrace it, make the most of it and use it to propel our performance forward. Those are sort of the mental skills. Obviously that's a very quick synopsis of what is a very long journey. Quickly, just to finish, in terms of evidence, what evidence is there out there? This is a really nice study done by Amy Edmondson 15 years ago. I'm sure many of you now have heard of her. And what she demonstrated in an emergency department, I assume in Boston, but she doesn't specifically say but that's where she works, is by creating small teams in an emergency room just for 12-hour shifts. So this is a team who came in and worked for 12 hours and then went home again and then went home again. They improved the throughput by 40%. So a massive improvement just by this teaming structure, creating teams and you can see there, there's a quote that says this sense of belonging to the team increased the camaraderie and broke down the barriers to communication that were driven by hierarchy. Perhaps more pertinent to us in the cardiac world, she did another study a few years before in how quickly a cardiac surgical team could adopt a new procedure. And what they showed was that when the team was designed for learning, people were brought in the team for specific reasons and told why they were part of that team and creating psychological safety, they were able to adopt that procedure far quicker. And that was typically smaller hospitals with a younger surgeon who wanted to create a team around him to build this. And then many people will say, well this is all great but ultimately we're running a business and I've got to adjust, I've got to account for the bottom line and of course we all have to do that in life. This is a fascinating story. This is the Microsoft story and in 2014, someone drew this corporate structure diagram of the different tech firms in the West Coast at the time and you can see Microsoft in the middle on the right. A series of factions who were all just ultimately trying to destroy each other and that was very much the culture in Microsoft at the time. Satya Nadella took over, he drove this whole new concept of how they were going to work. They were going to be really focused on what they were trying to do with their customers. A concept of one Microsoft were all in this together, supporting each other and helping each other and then bringing a wide range of opinions and views to the point. So if your focus is the bottom line, that's what their share price has done over since Nadella's been in charge and I left off the last few weeks for obvious reasons. But anyway, so there's been a very significant improvement in growth from 2014 demonstrating that these things can also help with the bottom line. So I'm just going to leave you with a quote to conclude. It's one of my favourites. It's a guy called Wayne Smith who's also a New Zealander from the rugby world but again, this was adopted by Phil Jackson has been adopted by the Seahawks as well. This sort of real concept of having a spiritual purpose to the team that you're building and you've all I'm sure felt that when you've been in fantastic teams and you sort of really sense that cohesion, that belonging that drives performance forward. So thank you very much for your attention and really look forward to some questions at the end. Thank you. Thank you, Dominic. That was very interesting. So we're going to move on to the next speaker which is Christopher Liu from New York who's going to present to us today on navigating the reimbursement landscape, where we came from and where we're going. And I'll also just give everyone a reminder that if you do have questions, you can start feeding them through to the app as well and we will ask them for you on your behalf if you don't want to come up to the microphone. Thank you. All right. Thank you, Melissa and Tom for chairing this session and for inviting me to give this talk. All right. So after a couple of really inspiring talks from Bryn and Dominic, we're going to go into a little bit of math and politics. All right. So navigating the reimbursement landscape. This is an area that I think we electrophysiologists here in America have come to reconcile and really understand that we need to embrace it in one form or another. So here in this short talk, I'm going to go over a little bit of the history of coding and payment for EP procedures in the United States. We'll talk about some basic concepts that are evolving value-based care payment models and then some of the details in terms of how we, as in you, can participate and anticipate future changes in payment for EP practice so that we can preserve a sustainable model for arrhythmia care in the United States and worldwide. So politically and organizationally in the United States, this is the structure of payers and medical societies for electrophysiology. So in the middle there, you see the FDA and CMS as well as commercial payers. These are the regulatory agencies that are responsible for governing medical treatments and indications as well as payment for medical devices procedures. Down below is the American Medical Association that has a house of delegates as well as the CPT and the RUC panels. And these are the methods that physicians and healthcare practitioners have a voice with the United States government and commercial payers. And on the sides, on the left, you see the Heart Rhythm Society. On the right, you see the American College of Cardiology. Each of our medical societies and medical organizations has health policy experts, so the Health Policy and Regulatory Affairs Committee in HRS, the Health Affairs Committee in the ACC. And now there is an advocacy organization, Health Rhythm Advocates in HRS, and there has long been the HeartPAC in ACC. So these are the specialty advocacy organizations that have been developed in order to facilitate these conversations. So each of our respective medical societies has communication channels both with each other and with each of these other organizations. And so let's get into RUC surveys. So this was the first introduction for many electrophysiology practitioners several years ago, and this is because revaluation occurred by way of RUC surveys. So when do these RUC surveys occur and when do revaluations for physician services occur? So they occur in three conditions. When there's high-volume growth, and that's defined by services with utilization increase of 100% or more in a five-year period. The second condition is when CPT services are bundled. So when services are billed together more than 75% of the time, then they become bundled together, and so, of course, that redefines that CPT code that then needs to be revalued. And then the third condition is also somewhat common. When codes, CPT codes, transition from Category 3, where they're considered experimental services in clinical trials, to Category 1, where it becomes standard and widespread utilization, then these codes become valued with a regular RVU value. So this is what has happened with RVUs, for example, in AFib ablation. So in 2008, when I finished training in EP and began practice, these are the codes that you would bill when you did an AFib ablation. So there was the EP study, the CS recording, transeptal puncture, 3D mapping, ice, SVT ablation, and drug infusion stimulation. So altogether, this would gather about 45 RVUs. And in 2013, the AFib ablation code was created. Now, this was forced upon us because we were doing so many ablations, and so a code was created to specifically describe AFib ablation. And so because that then bundled a bunch of services, including the left atrial recording and the transeptal puncture, then you could only do the AFib ablation, 3D mapping, ice, and drug infusion stimulation. That still got you 32, 33 RVUs. And then, of course, in 2023, with the next round of bundling and revaluation, there was bundling of the 3D mapping and the ice into the AFib ablation, and now you could only bill AFib ablation and drug infusion stimulation, and so the RVUs dropped when they were revalued after the bundling. And so now we're getting about 18 RVUs for these services. And that, combined with the conversion factor for each year, which in 2025 was about $32.35 per RVU, then nets you the summed physician payment for the procedure, which is about $897 for the total RVUs. So now that's for physician payment, and, of course, in the United States, we have two components, the physician payment and the facility or hospital payment where these procedures are performed. This is a figure I adapted from my friend Amit Tosani's talk where the AMA presented this information that physician payment you see on the bottom there has essentially stayed relatively flat over time, and this is due to a law called budget neutrality. So the Medicare physician fee schedule is subject to a law called budget neutrality where there is no adjustment for inflation and any additional utilization needs to be accounted for by reduction in other services for physician fees. And so when you account for the fact that there is inflation in the, for example, consumer price index, then essentially physician reimbursement has, in fact, declined over time, okay, when adjusted for inflation by about 26% from 2001 to 2023, whereas hospital or facility payment is not subject to budget neutrality and is built with inflation adjustment so that the hospital administration, the hospital facility payments, as you see on the upper curves, have gone up and essentially have gone up by about 60% in the same time period. So this is part of the disparity that we're seeing in physician and facility payments. Now, overall, how are physicians doing? So it turns out that EP physicians are actually doing okay. So this is according to the 2024 MedAxiom cardiovascular provider compensation surveys. You can see that in the years from 2019 to 2023, in fact, physician RVUs have not dropped for EP, have gone up slightly, and this is, of course, because even though the procedure RVUs per procedure have dropped, the procedure volume has increased per physician. And so commensurate with that, physician compensation has actually not dropped for EPs. The median physician compensation is still quite high for electrophysiology. So physicians are doing okay, but that is despite a drop in the per procedure fees. So now let's have a quick tour of value-based care and alternative payment models. So I put in the acronyms because when we talk about these parts of healthcare economics, it's always an alphabet soup. So I want to give you a flavor of what we deal with in this environment. So there's fee-for-service, which has been around for many years. It's a simple model, but there's no role for quality, and, of course, we know that this incentivizes overuse. So we talked about budget neutrality. It's been a law since 1989. And so that any anticipated increase in the Medicare physician fee schedule where the spending with a threshold of $20 million increase must be offset elsewhere, and this is usually done by reducing the conversion factor per RVU. So this fee schedule was subject to this SGR, sustainable growth rate, until 2015, and this was something that tied growth in physician spending to the overall health of the economy, but due to the design flaws, every year, this SGR thing required an act of Congress to manually adjust up. And so this, of course, was subject to politics every year. So in 2015, the MACRA legislation was passed, and that repealed SGR and instituted this quality payment program, the QPP, where there were two options, the merit-based incentive payment system and the advanced APMs, and so these systems incentivize care based on quality, cost, and effective EHR use, but these are systems that most PEPs are actually not part of. So both of these systems are being innovated by the CMS Innovation Center that was established in 2010 to test some of these APMs. Here I listed just a few of the current challenges, and it's a small sample. I won't go through them, and this is part of why President Trump said, who knew healthcare could be so complicated? But in fact, physicians in EP actually have a very difficult time participating in some of these incentive payment systems. So now, ambulatory surgical centers, one of our next sessions in the business of EP will actually be dedicated to ASCs. This in many ways could be the next frontier in EP, where there's a focus on efficiency and reduced cost to both payers and to patients and hopefully an improved patient experience. There is overall a growth in ASCs, now accounting for over 65% of surgeries in the U.S., and there's an opportunity for physicians to own or partner with hospitals and possibly could swing the pendulum back toward physician empowerment. There are at the same time some concerns that will be discussed, safety, quality, availability of technologies, viability of hospitals that are vulnerable, and this issue and possibility of site-neutral payments that really could devastate hospitals. So what can we, and that means each of you, do to help? So focus on quality and not speed. Patients and communities care about quality. Administrators care about speed and efficiency, but then they often will reset expectations and expect more productivity still over time, and so there's a hamster wheel effect. The payers will reduce payment if they see procedures take less effort, which is equal to time. We all need to be good stewards of resources. Everyone needs to understand what's happening at CPT in terms of new procedures, new technologies, as well as RUC. So make sure you respond to those surveys and do not under-report effort, which primarily is now intra-procedural time. This is how our views are determined. We know that innovation is expensive, but each of us needs to practice fiscal responsibility because ultimately all of us in society bear the cost of health care. We need to exercise judgment when speaking for industry because industry is paying you for the use of your credibility. So when you speak for industry, understand that they're paying for something. And read those emails from HRS and HRA, and those things are archived. So I'll leave you with this quote, be the change that you wish to see from government. Thank you. Thank you very much, Chris, for that very interesting presentation. I'm sure we'll have an ample opportunity to discuss the changes in reimbursement as we get to the Q&A and to the panel discussion and for your work on the Health Policy Committee that you chair for HRS. So I'm moving on to our final speaker, Dr. Victor Cotton, who, and I have to apologize, you'll soon find out that he is very soft-spoken, lacking in energy, and unable to engage the audience. But we shall soon hear thereupon. Negotiation with all the different partners, whether they be payers or whether they be administrators, at our institution is key. So he's going to talk about the art of negotiation and how you prove your worth. Thank you, sir. Dr. Dering, thank you for the opportunity to come back. I want to talk about how you can negotiate in a way that establishes your worth and ultimately makes you more successful. I'm going to start with three simple points, and then we'll see where they take us. Point number one says, your clinical activities as an electrophysiologist produce substantial profit for your hospital and your health care system. This is a universal phenomenon which is unarguable. All the procedures you do generate tremendous downstream revenue. That was demonstrated on the graph showing the hospital income relative to your income. That's what we're talking about here. It's a universal phenomenon. In fact, you're one of only three reliable profit centers for most health systems. Most health systems pay the bills with orthopedics, oncology, and cardiology, especially EP. Everything else is neutral to a loss of revenue. Second point, your hospital and health system, the folks, they absolutely positively know this. It is unarguable. Now, they're not going to tell you this. They're not going to say it out loud. They're not going to send you a periodic thank you card, thank you for paying the bills for the rest of it. That's not going to happen, but it's absolutely true. And believe it or not, it doesn't feel like this, but the system is actually designed, you're actually already rewarded for that impact. Now, I'm not saying the reward is commensurate with what you deserve, but let me show you what I'm talking about here. The system does recognize this. If we look at median compensation per RVU for three groups of physicians, internal med, EP, and oncology, let's suppose they all three see a patient, spend the same amount of time, engage in the same degree of analysis, write the same similar note, that would result in the same number of RVUs. Let's suppose they each have earned two RVUs that day by seeing that patient. They all three send their bills into Medicare, private insurance, whomever it is. They would receive the exact same amount of money. Medicare pays about $34 for every RVU, regardless of who performs it. Private insurance functions in a similar but higher level of payment. So they're all getting the same money. You say, well, fair is fair, if we're all equally appreciated, then we should all get the same amount per RVU. But that's not at all what happens. The internist winds up in a median of about $44. You wind up in a median of about $62. Same work, same methodology, same payers. How are you getting 50% more? This is in recognition of the downstream benefit that your presence is providing. And, of course, oncology, they get more than everybody else put together, OK? Because it is incredibly profitable, and that explains why everybody's building a cancer institute and a cancer hospital. So my point here, the purpose of the first three points is to say what you do is very profitable for any health system in which you're present. Everybody knows that, and the system is already accounting for that, designed to reward the doctors who are the most profitable for this system. So you're thinking, well, based on that, it should be easy. I mean, I should just be able to go in and say I need an extra APP in clinic, I need some new stuff in the lab, and if we can do that, then here's what it's going to do. We're going to have 20% more revenue, and the return on investment is going to be 8 to 1. And it's a no-brainer. They know that it's true. You should be able to go in, it's a five-minute meeting, and walk out with everything you want. It should be easy, but that's not what happens. That's not what happens. You're in there for an hour. You walk out with nothing but a broken heart, OK? What's wrong? What happened? What is going on? How can those things be possible? Let me tell you what's going on. You're making a mistake. You've made a mistake. Here's the mistake you've made. You're assuming the person across the table from you in that meeting has the same mindset that you do. There's a very, very good chance that person does not. What's your mindset? Success, growth, innovation, impact, revenue, personal financial and professional success. I would submit to most of the people in these meetings in the middle 90% of management that most of these institutions, I need to get a drink. Here you go. I would submit to you most of the folks, they're not of that same mindset. What's their mindset? Well, they're not paid. They don't have an RVU bonus structure. If clinic visits go up 20%, what do they get financially? Nothing. What does it do for them? It's 20% more patients. They got to get through here. They got to find scheduling issues. They got staff complaining. We're working too hard. We don't want to work this hard. Why do we have to change? Their mindset is completely different than yours. Now, of course, they all say, yeah, we want to succeed and we want to grow. But deep down inside, that's not really what they're incentivized to do. You see, you come in and you say, I want to talk about the big picture. It's going to be great. And what do they see? And what do they say? They talk about the first obstacle they're going to encounter. They'll actually say in the meeting, let me tell you the first problem we're going to have if we do that. That's a dead giveaway, okay? And that's, they never get past it, okay? You see benefit. They see risk, right? If it goes bad, I'm going to be blamed. What you see as improvement, they see as disruption. And while you seek success, they fear success. Most people in their jobs fear success. Why? Because success involves change, innovation, growth, adaptation. And most people are afraid that that is going to uncloak their inadequacies and their insufficiencies, that they're going to fail. You're making a mistake in your negotiation. You see, you're going in, you got the left side of the slide, and you are ready. And if you knock it dead, you miss the right slide. You don't even know the right half of the slide exists. And as a result of that, you fail. What I want you to realize is most of the people you're encountering in mid and even some of the upper management of most of these health systems, they're not geared like you are, okay? They're geared towards predictability, tranquility, minor changes. I refer to these folks as stewards of the status quo, okay? That's not their official job description, but that's how they function. Again, I'm not knocking them. I'm being constructive here. If you want to succeed in this environment, you have to recognize this. You're probably thinking, why would anyone be a steward of the status quo? Well, think about it. It's easy. It's predictable. It's dependable. It's always there. It doesn't ask anything of you. It doesn't require anything from you. And it will take the blame for almost everything. You can blame the status quo. How does that work? Something bad happens, what do you say? That's just the way it is around here. It's always been that way. It's a wonderful thing to have. Of course they're going to steward the status quo. What you need to realize to be an effective negotiator is one, you want to prove your worth. That's the title of the talk, but I would submit to you, your worth is well established and widely appreciated and unarguable. The reason you're meeting so many impediments is you don't realize the person across the table. So here's four things you need to do when you realize that that's the type of person with whom you're interfacing. One, you have to present your request in a manner that solves a problem for them. You have to give them something of benefit. They're having a problem in the clinic with patient this or that, there's a problem in the lab with, I don't know, turning rooms or whatever it is. Think about like, what is this person, what can I put in the pot for them that gets them excited about doing this? Because otherwise they're just going to see it as more work and more problems for them. You've got to personalize it. A good negotiator doesn't take the same approach every time. A good negotiator tailors the approach to the mindset of the person on the other side of the table. That's the first thing you can do. Second thing you can do, give them credit. Most of these people never get any credit in the course of their day. It's sad, actually. I mean, you feel like, hey, I'm unappreciated, but you actually get a lot of credit. There are patients and families who deeply appreciate what you do, you save their life, they thank you for that. Most of these folks, they never get that. All they ever get is blame, so they become risk averse. Of course, they're not pursuing success, but many of them have never had much success, and they're not going to get credit for it anyway. They're risk averse. Their goal is to avoid blame. Offer to give them credit. Say, hey, if this works, I'll let you take the lead on it. I'll put in a good word for you. If you help me with this, I'll make sure you get some of the credit. Facilitate that. Give them something. A good negotiator gives as well as receives. It's a good principle in life. Second thing is, you want to reassure them it's going to work, because most of these folks get anxious about making decisions. Now, to you, it's obvious. You say, well, I'll show you the data. The data's compelling. Therefore, you're going to do it. Yes, that's how it works at this conference. That's not how most people make decisions. I learned this by watching videos of hospital meetings. You know, these big hospital meetings where a bunch of thousand hospital people get together and talk about hospital stuff. The presentations are not the same as you give here at HRS. They're a different type of presentation. There's a lot of personal stories. There's a lot of anecdotes, examples. There's not the hard scientific deductive process. A lot of it's just relying on that someone else did it and it worked. That's kind of the message. Well, we did it and it worked, so I think you can do it too. Amazingly, that's motivational. That works. You need to do that as well. How do you do that? You say something like, look, in addition to my idea, and I think it's really good, you want to weave this into the conversation. You want to say something like, by the way, they did this at the Mayo Clinic and it was smashingly successful. They did this at the Cleveland Clinic and wow, did it work great. You have to work in some institutional reference to reassure them that it's going to work because most of the time, they don't want to take the leap of faith. They don't want to take the risk. They're not wired like you are in that regard. Now, because I believe in honesty, I think if you're going to say, hey, they did this at the Mayo Clinic, I think they should have done something at the Mayo Clinic similar to that, okay? But the truth is, you have to drop and mix some references in there to other institutions, other people, and you're really assuring them that, hey, it's been done. The concept's been proven. We just have to implement it. And finally, you have to go over their head. If the one, two, and three don't work, you've got to go over their head. And what I'm going to say here is probably going to surprise you. You should have a very low threshold for going over their head. You should. Why? Because ultimately, I believe they sort of want you to do that. Why would they want you to do that? Because it takes the decision off of their hands. They don't have to make a decision. See, the concern is if you're not a confident person, you don't fully understand the entire issue. Making a decision is risky. It's scary. It's frightening. And although you don't want somebody to go over your head, you'd rather be told what to do from above than to make a decision and then be blamed for that. So if one, two, and three don't work, I'd encourage you to have a very low threshold just to go over people's head, go to somebody that can make a decision, and get them to convey the message down. How do you prove your worth? I think your worth's already been proven. What you need to do a better job of is adjusting your message to the person who's across the table. Thanks for listening to me. Thank you very much. That's very exciting. We're going to open up to questions and answers. I will encourage you all to use the app if you don't want to come up to the microphone. I might start early. We do have someone there. I'll start with you if you like. Great. Thank you. First of all, thank you so much for putting this together. It's really great to see a packed room talking about the business of VP at Heart Rhythm. I have two questions slash comments. The first is for Bryn. My name's Joey Sager. I'm an electrophysiologist with a private practice in Chicago, and we joined a private equity platform very early on. And I really liked what you said about attitude being more important than aptitude, which I completely agree with. And I wondered if you have any experience. Our lead EP tech started at the front desk. And so I wonder if you have any experience. Because when you're hiring, if you're hiring for a nurse practitioner, you need someone who has a degree. But for some of these positions, you can sometimes look within or see if there's someone within to train or who may want to take that role. That's absolutely true. I mean, absolutely true. Our EP lab tech, and then became nurse, started in the file room. So I mean, you can find good people within. And definitely, obviously you need to have the proper degree to do the job that you need to be doing. But I do think looking within your team, you know the people that are good, right? I mean, you know the people with good attitude, and you want to mentor them and encourage them. And so sometimes that means they're in one role, and you actually have to put them in another role. And that leaves a deficit when you move them. But that is what they need to progress in their career. So I'd absolutely support continuing to grow within and putting them in positions that challenges them, just like Dominic said. Getting them out of their comfort zone and showing you, you know, showing what they can do. So I agree, looking within your team is always something that is, you know, easy to do. But you just have to find the right person. Yeah, great. Thank you. And then my second quick comment. So the paradigm within which we are all talking focuses on an RVU-based model in which we are employees. And I think we're at an inflection point. We're going to be talking about ASCs. But I do challenge everyone here to start thinking about position as stakeholder. And I think it's really important going forward that we all start to try and change the paradigm. Because I think the best way to solve all the problems that Dr. Liu talked about really nicely is for us all to be stakeholders in some way, shape, or form in revenues as well as quality. Because I think that when we are at the table talking to administrators just about our RVUs, it's inevitably a losing battle. Whereas if we are stakeholders in it, we have a much better chance of winning and taking control of our own destiny. So thank you guys. Thank you for the nice talk. And if each speaker would just identify himself or herself and where you're from. Yes, this is Dr. Esam Beryun, West Virginia. Yeah, so question about using nurse practitioners to improve efficiency. I just wanted to know, I mean, how often do you guys use nurse practitioners for cardioversions, lube implants, closing pockets, things like that? Great question. I think every facility and practice is different. In pediatrics, much less just because of the volume being different. I'm seeing Jill not over here and probably Melissa too. So it just depends on the practice. It also depends on the state. There are state regulatory rules. But in many institutions, nurse practitioners are putting in lubes, taking them out, cardioverting, all those types of things. It doesn't have to be a nurse practitioner. It could be any advanced practice provider. But it is a way to increase your services and also increase revenue and your efficiency. If an APP can do 10 of them in one day and keep someone in the lab getting their 13 RVUs for an afib ablation, 17, sorry, excuse me. I don't want to shortchange you. But yes, I think that is a great way to increase your services and also your efficiency. So it just depends on what practice you're in. And I would work with your state first and then your hospital regulation. But you can absolutely get an APP credentialed for these procedures very easily. John Reiner, physiologist in Asheville, North Carolina. Most of the presentations today focused on human factors for optimizing performance in our work centers. We have to resolve the observations that there are a shortage of physicians who do what we do, but I would argue all healthcare providers in our spaces are at a shortage. With the observations that we're more efficient at doing these things, but it creates this hamster wheel phenomenon that was clearly explained. It seems like the solution to that, at least on the short term before we can be full stakeholders, is a form of cream skimming. And I don't mean to be reductive of that with regards to financial issues, but also in terms of the value that we can create within our spaces overall. How can we help people the best? And hopefully the dollars and the value we produce will be aligned. I have been trying to figure out the best way to optimize my practice for some time. I think it needs to be mathematically modeled, and once it's properly modeled, then we can apply machine learning or even rudimentary concepts to try to optimize the work that we do. I'm curious if any of the panelists have managed to model their businesses or anybody else has been able to do that, and if you've been able to leverage that. Yeah, I mean, you know, there is a lot of interest in terms of using AI to model and analyze operations. You know, I'm at an academic center, and we're terribly inefficient, so I can just tell you that. And I'm still not really aware of how AI has been used to actually analyze where clinicians are being used. And of course, you know, in EP specifically, there's such a rapid evolution of how the practice is changing itself. You know, just with now PFA in the past couple of years, that, you know, I think it would be hard to really adjust for all of these factors. And then it's also very difficult, I think, to, you know, generalize one model from, you know, one place to another. Yeah. And I hear what you're saying. I guess that makes some sense to me. I have four labs in my center. We're building a fifth. We're trying to hire another advanced practitioner. We're considering hiring another doctor. I actually don't know how those choices are going to change the big picture of where I work. And within overall health care, I actually think that EP is a more modelable business. We have a smaller scope of service. And these new tools like PFA actually turn our labs into something more akin to a factory than they used to be. So now might be the time to try to leverage that sort of thing. Hi. Thanks. Steve Pieper, St. Louis, Missouri. A question for Esquire Dr. Cotton, I guess, if you will. You showed some RVU numbers for internal medicine, EP, and oncology. I know in our system from a contribution margin standpoint, I think EP may be ahead in those three areas. I'm not sure, but I think it is. And yet the RVU numbers you showed for EP are a fraction of oncology. Do you have any experience in your consulting or in your profession where you've been able to negotiate better RVU rates, even though it is a losing proposition, as you said? I think it is a point of difficulty for us. Yeah. What happens when you go to a discussion about that, you have to be a little careful. So you can't come out and directly say, you know I'm making you money. We both know it. You need to give me some of it. Well, you can, but I'll attest that that's a failing proposition. Okay. So we have to avoid that. So you're right. So that would be asking for a kickback. That's a crime under federal law. So we can't say it that way. So you've got to be gentle. And you have to say, we know we're bringing a lot of value. There's a lot of this. Our compensation isn't commensurate with our contribution. The answer is yes. You can be successful. You have to be persistent. One of the great strategies that I think hospital folks do is they say no to you the first time, knowing that you're busy. It's not your priority. You've got a bunch of patients to be seen, cases to do. You get turned down once, you may not come back for a year and a half. So you have to anticipate that you're going to be rejected. Don't take it personally. Just go back, be persistent, try again, three fashion, all involve other people, go over somebody's head, and you can be successful. But it should be easier than it is. It's just unfortunately the way it is. If I could, a second question, I think it's for Dr. Lauer, if I have the name correct. With your work at Presbyterian or with the RUC committee, any idea when ablation compensation or coding may be moving to an ASC environment? In St. Louis, we've operated and sold two ASCs that were cardiology EP-based only. And revenue-wise, devices were great for that. But the next level is in ablation. Do we know when that's moving to an outpatient environment for codes? Not HOD, but ASC. Thanks. So we don't know when, if or when that's going to happen. We've been from HRS advocating for this since last year. And this year, right now, we're actually working on a document to craft some of the guidelines for how ablation procedures could be done at ASCs. And CMS has heard our arguments. So of course, with the new administration, it's a little hard to know exactly where they would stand on it. But that is something that really could change the calculus. But of course, then if there's site-neutral payments, that really could hurt hospitals significantly. So this is still an area that we're very much in watching very carefully. And just sort of going back to the question about the RVUs, and this is something that Scott Greenberg is sitting here, he's really had an interest in, which is that many of the employers use the current scaled RVUs and the payments per RVU based on surveys. So MGMA and other surveys that essentially put an index on what the different percentile physician payments are per RVU for different specialties. And these are the numbers that EP has landed. But this is obviously also in flux, and this is something that is subject to negotiation. So it's really just about the kind of leverage you can get in terms of the environment that you're in and the group that you're in. Well, I apologize here, but we are actually at the top of the hour. And I know that these questions are good, and I think many of the faculty might stand around to answer the questions. And I do appreciate the engagement. And one thing I've learned is we're going to need to allow more time for the discussion. So if you could hold your questions and we'll have the panel weigh in on it. A 30 second response from you, Victor. We have an online question. I'd like to give people from online an opportunity. They said 90 percent of us are employed by an institution and we're pretty much evaluated and compensated by RVUs. So how do we negotiate to get part of the fiscal benefits that the institution does? Is it by quality? Is it by other things? What are the arguments that you could use there? And given the short time frame, if you could give us a quick response. Yeah, you can try to supplement it with quality and some things like that. I think really the only legally viable way to get at what you're talking about here, which is that graph that keeps going up, the facility revenue, to try to get to that would be a joint venture with the facility for like an ASC or something like that. Those models are out there. I think that's the most viable, legal, easiest pathway would be joint venture for some type of facility that could be co-owned. And that gives you access to that facility revenue. Perfect. I want to thank the faculty for their great engagement. I want to thank all of you for your engagement. Remember, as I mentioned at the beginning, there are two additional sessions. We do have a half an hour break and the next session will begin in this room. So please come up and engage the faculty. And thank you very much for your attendance and for your attention.

Electrophysiology

Healthcare management

Allied professional teams

Team performance

Reimbursement landscape

Value-based care

Negotiation strategies

Ambulatory Surgical Centers

Physician stakeholders

Healthcare ecosystems