Well, so this is a very interactive session. We know that RVUs are an important part of compensation in many institutions, sometimes at a small, mid, or senior level. We know that there are pros and there are cons related to the use thereof, and we have two very distinguished faculty folks who are going to debate each other and beat each other up. But before we get started, I want to ask just a very simple question. Forget about all the nitty-gritty, intricate details, but just tell me, do you think RVUs have value as at least a component of compensation? If your answer is yes, I think it does have some value, raise your hand. Okay, so probably about 50, 60%. So that's where we're starting, and at the end of the debate, there will be another poll, and we'll see. And of course, if you want to stack the deck, you can text all your friends who align with you to come and vote accordingly. Okay, I guess our first speaker is going to be, I mean, Anish from Ohio Heart and Vascular, and you're taking the point of view that they are very useful. You are the protagonist. You got it. Well, thank you so much, Dr. Doering, for the kind invitation, and I don't know how vigorous the debate will be because Amit and I are pretty close friends, but we'll do our best here. You can see the disclosures. We're just waiting for the slides to load here. All right. So yes, RVUs are great for electrophysiologists, and let's go into why. So despite what Amit is going to try to tell you, this is not what RVUs stand for, and if anybody is familiar with the reference from office space, although people come around and ask me all the time, like, what exactly do you do around here? While it can be measured by RVUs, it's not solely measured by RVUs. This is not some bureaucratic form that we fill out that has no meaning, that has no potential, that has no ability to drive the work that we do. This comes from a, you know, distant evaluation by a pretty famous healthcare economist, William Masayo, with the intent to change what was previously a billing cycle that was based on these three parameters, usual, customary, and reasonable mechanisms to bill for the care that we provide. The idea was to say, listen, in this world where we have asymmetric information, where there's price insensitivity because of the payer model, we should look to an evaluation that values resource input costs, helps us understand what it is that we are putting as not only clinicians, but as a healthcare delivery system into delivering care for patients. So how did they come up with the formula? This is the formula right here. If we break this down a little bit further, what this means is that the total work, the work that we do, based upon knowledge, psychological stress, technical skill, our general perception of how complex the work is, needs to be combined with the specialty practice costs, the operational lift for us to deliver care, along with the amortized cost of becoming more and more and or less and less specialized. So this was the idea, that we would say, the work that we put in needs to be measured, it needs to be balanced by the operational cost, and we also have to consider how hard it is for us to actually attain the specialty training that's required to understand the diagnosis and treatment. And as I mentioned, when we think about what is easy to understand, operational costs are easy to understand, we can go through tax forms for practices and understand what average operational costs are. We have to estimate opportunity costs. We do that by looking at training patterns, essentially saying, gosh, to be a CT surgeon it takes seven years, to be an EP it takes eight, to be an interventional cardiologist you can probably do that overnight. But each one of these has an opportunity cost. The hard part is understanding what we, as clinicians, have to go through to deliver the care. It's broken down into these six subsets, knowledge, judgment, diagnostic acumen, technical skill set, the psychological and physical stress, and we put all this together and we say, yep, this is an RVU. What this assessment did, and what I want to point out, and this didn't reflect perfectly, but in essence what this was trying to do is to say, if we were to understand what geographic disparity looked like, if you asked me as an electrophysiologist, if you asked one of my partners, Dr. Bedina, as an electrophysiologist, if you asked Dr. Okabe, who's sitting there in the audience, in various geographies, do we align with an assessment of how hard we're working? The answer is yes. So this goes back to 1988, 1989, 1990. This formed the foundation of us putting all this together. The intention was that we would break down the usual customary and reasonable practice of billing. We would break down the geographic disparity in access. We would break down the asymmetry in information that patients are receiving because payers would then have an opportunity to influence the system in such a way that we could manage healthcare resources. So if we fast forward, what has happened? Well, this is what has happened. If you looked at 2023 expenditures in healthcare, you can see that physicians, clinical support, this includes advanced practice providers, represents about 20% of healthcare expenditures. And if you were to take a Kauffman impression, what they would say is that while physician and clinician productivity continues to increase, the overall contribution reimbursement for that productivity is on the decline, and we have to find ways to optimize care. Amit is going to tell us that, listen, we've done this to ourselves. Our views tell us to do more, and we were getting paid less. The reality is we haven't done this to ourselves. Consolidation in the healthcare industry is evident over the last 20 years. This is a description of what has happened between private practice and integrated and employed models. This is from the MedAxium database from 2024. Most of us are in actually blended models, salaried models, not pure productivity models. And so while our measure of productivity has gone up with RVUs, our compensation has not necessarily been following along directly because of the RVU. The RVU is, in fact, intended to optimize the healthcare delivery. So these two graphics are coming on at the same time, but access, efficiency, and quality are what Amit is going to talk about. These are narratives that he's posing to us as a way to make us succumb to administrative efforts and reduce our value because we're not actually shifting the value. The reality is this. We are living in a highly matrix world as far as logistics go. That's the input on the left-hand side of the screen. That includes the logistics of supply chain. That includes the logistics of InfoSec, workforce, research, finance, marketing, and the education that we have to provide to the next generation of clinicians. We have to deliver a highly matrix outcome. That outcome is patient satisfaction, cost, quality, culture, retention, and alignment. How are we going to do this? We can't just say we're going to go get quality. We can't say we're going to go manage outcomes. We can't say that we want to focus on patient satisfaction because these things are all intertwined together. We know that we are working harder than ever. These are the number of procedures that electrophysiologists are doing over the last several years. You can see it's on the rise. I mentioned that the RVU total is increasing. You can see that we're actually getting paid more. The RVU is our metric to align complex delivery systems against complex outcomes. It helps us flatten disparity. This is a description of what happens for call versus no call. How do we transition RVUs and pay female versus male pay schemes? It is actually helping us change the disparities that are occurring in our practices. We're doing the work. These are two examples from our own center about how we develop quality programs, care pathways, value-based pathways. This along with think about 3PH that Jose has put together where communities are coming together to do the work that's not driven by procedures but driven by the patient experience. We're doing this already. It is in fact driven by the RVU. The RVU is a metric and we can use any metric to pull these two things together. Typically when you have complex inputs and complex outputs, we have to rely on culture which is flexible. As people transition in and out, the culture changes and equity which is durable. Our focus should be on understanding what the RVU can do, understanding how the RVU has been manipulated for us and trying to incentivize us to do things in the outliers that we perceive as being inconsistent with the type of care we want to deliver and try to be vocal advocates for using a metric-driven system to combine complex inputs to get complex outputs. Amit, good luck. Our antagonist is Amit Thasani and he's going to tell us why they're ridiculous and very unhelpful. Thanks, Christine. Thanks, Tom. I appreciate the opportunity to speak on something that I've thought about probably 24 hours a day for the last 15 years. In my role as one of the leads of our program, and I'm happy to share that Dr. Silverstein and Belden are here and can corroborate what I'm about to say, I think that we have an opportunity to rethink how we approach our day-to-day and how it's evaluated. I actually think it's an exciting time to be able to rethink and bring back some of the autonomy that's, I think, lacking right now in American medicine. So our views are ridiculous. We'll take the extreme point. Anish shared with you one thing that's true is that we probably agree on this more than we disagree, but we'll take the extreme point to make the argument. So I respect and collaborate with Dr. Amin, is my relevant disclosure. Anish brought this up. This is the New England Journal of Medicine paper from 88. So in 86, the work to begin the RBRVS scale began. It was commissioned by the federal government through this team at Harvard. Ned Becker, the lead author, is actually a good friend of mine. And Anish went through the methodology. I talked to Ned in preparation for this debate. And I asked Ned, I said, listen, tell me about where things were in 86. RBRVS was implemented under the George Bush administration in 92. What do you think about what's come of your work? And I think the intention was to create a reproducible model to compare the inputs to our work. And here's what Ned told me. We certainly didn't know all the consequences of RBRVS, especially with compensation and how widely this would be used. And we didn't anticipate the consequences of volume-driven decision-making with respect to certain scales that were measured against that are unique to medicine, MGMA, metaxium, et cetera, targets and physician burnout. So while the intention was to make sure that there was some equity, particularly for government pay across geographies and across specialties, the way that this has been adopted, I think, is not commensurate with the way that modern medicine is practiced. So here are my arguments. Number one, RVUs are products of a system, not of a physician. Number two, RVUs undervalue cognitive labor, risk, and technical intensity of our work. Number three, RVUs distort clinical priorities, valuing quantity over quality. And number four, RVUs do not represent a stable currency to link to our compensation. So let's see if I can make sense of these arguments for you. And number one, let me ask you a question. Anybody have staffing shortages in their health systems? Are your RVUs adjusted for those staffing shortages? Do you have control over those staffing shortages? No, but you're still expected to produce the same target. So Dr. Silverstein did a lot more RVUs in Columbus than he does in our system. We've had work to do to make our place more efficient or, as I say, better patient care excellence. The same provider moving from Columbus to Pittsburgh is generating less RVUs. He's the same person. He's got the same qualities. He's got the same talents. It's a system, not just you, but you individually are charged for that RVU target. You're not the owner of your health system. You don't have control over all these things. It's an important point. I think this is actually incredibly important because I see us moving toward more of a partnership model of medicine rather than pure employment, different point we can debate later. Number two, RVUs undervalue cognitive labor, risk, and technical intensity of our work. One of my GI colleagues said something profound to me that I've had to think about. He said this, the heart gets a lot of cardiac output. And while we're good at what we do, when things go wrong with what we do, bad things can happen. And we take that risk every day. I walk into the hospital every day knowing that I can kill someone. We normalize this life that we live that is not normal. It is an incredibly complex field. We should be acknowledging that. We should stop talking about how fast we do things. That's not the point. It takes a very skilled, very technically competent, compassionate, highly trained person to do the work that we do. Can you call your attorney at any point in the night to get advice? We do that for our patients all the time. We're not compensated for it. And that's okay in the current model, but I think we need to think differently about what the future should be. RVUs distort clinical priorities, value in quantity over quality. We all know this, right? This is the, I think, the real fundamental crux of the argument. And here's the challenge. I'm on the Health Policy Committee. I've learned a lot in the last year. When we do more in the era of budget neutrality, okay, EP volume and procedures go up, demand is going up, we're able to provide more therapeutic options for patients. The total number, the total budget has to stay the same. So tallest blade of grass gets cut. And we keep running on this treadmill. Each of you are working harder and harder, okay? Your RVUs are going to be cut. It's coming. It's coming. There are many revaluations coming. It's inevitable. Where does it stop? Where does it stop? I think it's an important thing to think about. And argument number four, we have linked RVUs as a currency to compensation. If you are personally on a model that is RVU-dominated, my apologies and sympathies, I don't think it's sustainable in the future. We've all lived through what happened in 23. To drive, I should look for in the finance market, is there a comparable level of cut that happened in 2023? The answer is yes. The currency of Ethiopia was devalued about the same as EPRVUs. And last I checked, the currency of Ethiopia is not used in the world market in any sort of exchange in a meaningful way. I think this is an important point to think through. This is not what it was meant for necessarily as a dominant to our compensation. And here's the truth, okay? This is from the AMA. Physician RBRVS is not adjusted for inflation, okay? And over the last 20 or so years, if you adjust for inflation, that scale has gone down about 22% while hospital payments have gone up, okay? We are primarily employed. I think that the right solution is to find a line somewhere in between where we're actually partners working together for the betterment of patient care, not employees generating financial returns just for hospitals that we don't have full control over. It needs to be more of a partnership. And I think that the RVU system prevents us from having that discussion. It's all about patient care, okay? Excellence, safety, quality, and outcomes matter, not just volume. And while RVUs provide a common language that we've come to understand, which I think is of questionable value, they do not center the patient or the physician, okay? And here's the other important point. Other models exist. If you don't believe me, come talk to me, okay? Other models exist. I actually think Tom is a plug for next year, probably should be the source of a discussion. How do we take this? We all know the concerns about RVUs. What's actually happening in the community now that we can teach each other to take home to our institutions when we leave HRS about how to put together a better process? Thank you. Okay. So the session is now open for questions, and then we'll have the rebuttal afterwards. So if you want to scan the QR code and enter them, we can see them, but also please come up to the mic. All right. First participant. Thank you. Mark Gerski. I'm from Los Angeles. My disclosure is I'm one of the 14% in private practice. I don't understand RVUs. I guess my question to both of you is how would you explain RVU to a fellow in training that has a lot of stress about getting certification and training and then has to get a job? Is there a path to it? Because I get a lot of questions, and I say, I don't know RVUs. I know dollars. I think you're right. I think we go through medical training where we're spending time on understanding the clinical aspects and understanding coding and documentation is never really brought up, understanding how we're reimbursed is not really brought up. Even beyond the RVU because, I mean, you know this, like we can create models that a physician compensation that go beyond just the clinical productivity that acknowledge administrative time, that acknowledge value propositions and bonus structures around quality and outcomes. I think ultimately if we say we want a metric that helps us drive operational efficiency, part of what we need to train our colleagues about is that we need to understand, we need to document risk, we need to understand that the work that we're doing does have reward and is compensated at some level and we need to be consistent with how we're applying our knowledge. So I look at, in our own practice, I look at things like Epic and I say, this is great. It's a great way for us to copy and paste notes on daily inpatient rounds, but it is not a good tool for us to write quick notes and not get rewarded or another word would be recognized for the evaluation that we're doing that day because we are not actually generating any type of numerical recognition for us. I know we all agree that, gosh, we really shouldn't be held to this standard that says we want to count nickels and dimes as we take care of patients and I think that's a very lofty goal and when you're somebody like Amit, since we're in the middle of a debate and he's got all these leadership positions and talking about Ethiopian currency and finance and all this kind of stuff in a high-minded way, like for the rest of us in a mediocre Midwestern electrophysiology practice, we all know that we're trying to treat patients. We do have to have some underlying commitment to saying, here's what we're doing, here's how we're describing the complexity of care, doesn't have to be the RV, it can be anything, but a metric does drive us to be better. I think you're asking a great question and I think it's a hard answer because what you tell your fellow today is not going to be true in a year, right? And I think that's the point, so I think two points, one, Tom has put together the last two years of business of EP session at HRS, which I think is fabulous and I frankly think everyone should attend to understand it's an important part of our continuing education that is not part of our training and fellowship and I'm 15 years out of training now and I've spent more time thinking about this probably than just about anything else and I've made plenty of mistakes and fortunately now there's a lot more structure I think at a society level to help understand this. I think number two, for those of you that are interested, get involved in the policy side of this and understand the process for how these assignments are made and re-evaluated and I think it's an important point for us to understand particularly now with PFA and everything else, we're bragging about left atrial dwell times, we're cutting our own throats. And I would say to this, it's not just about getting paid more, I don't think that's the point, I think Rob Califf yesterday, if you heard his comments, I think said something quite profound. Nobody's feeling bad about EP compensation, we're all doing okay on the whole. I think the question is what is your day-to-day stress going to be? Is it chasing a target that somebody else is putting on you or are we going to talk about partnership and valuing other components of all the complex work that we do beyond just the RVU? That's the point. I think Anish showed you a nice slide where he and I happen to agree. I'm happy to see that most of us are moving toward a hybrid model and I think Tom, this is what we probably need to move as a next step to educate our membership. Thank you. Thank you very much. There is one question here that came in electronically and again, if you want to and you don't want to get up to the speaker, which we encourage, just scan the QR code and we'll be glad to address it. For both of you, what EP specific features do you think would help with RVU or other type of reimbursements using EPIC as a model? Don't jump in at once. I think in the most recent commentary from Brad Knight in EP Lab Digest, he talked about how for the first time, outcomes around arrhythmia management are going to be included in U.S. News and World Report and we can talk about whether that's a valuable metric or not, but certainly acknowledging the fact that arrhythmia related outcomes should share equal footing with surgical outcomes, PCI outcomes, TAVR outcomes is a good first step in transitioning us to a model where we do have commitment from healthcare organizations to help us manage the tenets of our practice, access, quality, and ultimately longitudinal outcomes. I have a little bit of a different opinion on this because we're part of a vertically integrated system and owned by a payer and I think that the future is going to be whether we like it or not, there's going to be some level of population-based management that we're going to be held to and I think that if you look at right now, our clinical trial endpoints, which in the AF world, as an example, have to do with recurrence based on 30 seconds of atrial fibrillation detected by some monitoring in a post-procedural setting, that's really nice, but what really matters is how that patient's doing and what their healthcare utilization is at a societal level and I think we will be held to that at some point. We could debate about whether that's right or wrong, but I think that sort of gets to better defining what the value is that we do and I would say, if that sounds scary to anyone, I wouldn't be scared about it. I think that the work that we do dramatically changes people's quality of life as just one outcome and I think we should be confident about standing behind what we provide as a society to our patients because I think that we are, quite frankly, a unique field in terms of what we can do for people and the fact that what we do does improve quality of life and give people that sense of well-being back and I think we should stand behind it and not be afraid of it. You may get to this at some point because you alluded to it a couple times, this sort of getting the compensation blended with the institutional compensation and one of the things that I always hear when I start talking about that is the Stark Law and how you can't benefit from referring for yourself and what are your thoughts about how you do that at an institutional level or if you're going to talk about that in your rebuttal, you can. I'm not, but it's a terrific question and it's something I think about quite a bit, I'm sure Aneesh does as well. So here's what I would say, I actually spoke about this yesterday. We can't speak to the finances that we bring into the hospital systems, okay, but you in your role can have a good sense of what the impact is of your program to your health system at large, okay, and I think it's an important thing for you to know if you're building or you're in a leadership role because if you are told, which we are told often that we lose money, we're a cost center, that's a bunch of nonsense, okay, and to me that's part of the discussion about being viewed as an employee versus being viewed as a partner in shared success, which is what we are to our health systems. I'm not advocating for an antagonistic relationship with your health system, that's nonproductive, but we do have a responsibility to take the knowledge from these sorts of sessions back to our home institutions and move the needle forward for our groups and our patients, and it's all about those patients, right, and this is an important part, I think, of advocacy that each of us has a responsibility for, and more and more I think that that responsibility is falling on us, and I can tell you that being part of a payer system, the physicians are, and our APPs and extenders are sort of the last line of defense for patient advocacy. I think that's a very important point there, I mean, you know, we are in partnership with our institutions, and if we have an antagonistic relationship, we're not going to be able to advance the needle to improve the quality of care delivery, so we need to really bring down those barriers, so we're sitting at the table. We will have disagreements, and the alignment isn't always going to be uniform, but at least if we can open the discussions and try to come to some meeting of the mind, we'd be better off. Did you want to make a comment? I was going to say, like, I 100% agree with the comments. We are shy about asking, and I think in many cases, the institutions that we work with are not transparent with us about what the NOI on our programs is, and so I was pulling up our 2023 NOI, which includes salaries, wages for physicians, lab staff, drugs as a supply, purchase services, the depreciation on our capital equipment, the rent, the overall operating expense, the variable cost attributed to our global program where I work at Ohio Health, and I can tell you, like, hey, year on year, I'm running, I don't have a fancy lapel pin to acknowledge that I'm running, but, you know, we're running a $75 million program, and we have to acknowledge that, like, we are bringing significant revenue to the health system, and we have to demand the access to those numbers if we want to be partners. If we want to be partners, then folks have to give us the ability to manage the P&L. No, I think that's an important point, and that's why it's really clear and, in my opinion, important that individual physicians and leadership positions understand all the ability to manage, understand, re-portfolios, you know, prepare, proformas, and stuff like that. I mean, when our administrators sit down and they say, oh, but look at the overhead assignment. Well, all the fixed overhead that has nothing to do with us really doesn't influence whether we're truly profitable or not, because you're not going to fire that cleaner, you know, because one less EP procedure was done. So I think we have to look at it from a purely good economic perspective, because we will often be given data that is fixed to make the argument that we don't think is right. And, of course, the highest revenue segments of the hospital or of the institution get the majority of the costs attributed, so the more revenue you make, the more costs assigned. And getting back to Christine's question, there's no other business in which the P&L is reviewed with you without the P, and that's where we are. You should all understand that. When you talk to your hospital about budgetary matters, you're told you're a cost center and you're losing, because we can't talk about the other side because of Stark Law violation. Okay? So understand the truth. You're not being told the truth sometimes. Josh, you had a question or two? Yeah. So Josh Silverstein, for those who don't know me, I know everyone up there knows me. I'm the one that RVUs are plummeting, despite working harder and being more skilled than I was three and a half years ago. And the question I have, which I know probably both of your viewpoints, but I think it's important that we share them with everyone, is how do we get credit for doing the difficult work, for fixing someone else's mistakes that took all day, and I get 30 RVUs, and the person whose mistakes I fix got 100 RVUs the same day, creating the same mess, so I can go fix it again? That's part of the reason the RVUs are down in our institution. And so the quality, how do we help administrators understand this so that I don't get that report every month telling me how little I'm valued, and my RVUs are down every month, year-to-year, despite working harder and doing higher-quality work? So full disclosure, Josh and I talk about this stuff all day and night, but so a couple things about the RVU. One, if you go to an attorney, let's take an analogy, and you go to, my wife's an attorney, if you go to a senior partner in a firm for some legal consultation, there's a higher fee that you will pay for that experience than somebody that's a year out of law school. And we can debate the merits of that, that's not true in medicine. So yes, we can say that's egalitarian, some people think it's Marxist, whatever side of the debate you're on, that's the truth. Number two, a procedure is a procedure. So Josh took care of a horrible complication from somebody that had a terrible outcome during a VT ablation, that he saved the patient's life, and it was incredibly taxing in an eight-and-a-half hour procedure that very few people are skilled to do the way he is, and it's the same RVU as the operator who left that patient in a worse spot. So I think that for each of us that are in different practice settings, if you are part of a quaternary care center getting those complex referrals, understand that it's not valued the same way. And in fact, there's an opportunity cost to doing those complex circulatory supported VT ablations versus somebody who's putting in three or four devices, and then we can have that debate about whether that's fair. Now, that level of care still needs to happen, which is part of the reason we've been mindful as a group about setting up our structure the way it is to defray some of that risk as a team. And I think this gets back to a lot of the point that I feel very strongly about, which is that EP is a team sport, and if we allow our hospital systems to put us on individual contracts without acknowledging the interconnectedness of all this type of complex work, we're kidding ourselves. We're in for trouble. And I think I'm heartened to hear, actually I've heard from a bunch of folks at this meeting, that more people are moving toward that model. Chinmaya is sitting in the audience, and we talked about this yesterday. So I do think that the needle is going to have to change, and I think it's probably something that we need to speak to next year. Let me ask two... Oh, you go ahead first. Hello, everybody. Thank you so much for this talk. My name is Nnamdi. I'm a first-year EP fellow. I'm just trying to understand, with these RVUs, is there like, let's say, countrywide, a certain target that is put for all institutions, or do institutions have different RVU targets? And in the next couple of months, I'm probably going to be wading the waters of nowadays. What are your advice for us young ones as to what to watch out for as you look at all this, your contracts, as you come in? Thank you. It's a great question. So some of the data that I showed was from a MedAxium survey, and once you get out in the practice, a common term you'll hear is fair market value. Fair market value is a way for compliance officers, in essence, to help grade where compensation is going to fall for physicians, recognizing that in certain geographies, in at-risk areas, there needs to be an uplift on compensation relative to the measured productivity. And because the RVU forms the basis of how we're judged across the country for the quote unquote work that we're doing, that becomes the root metric and conversion to help us understand, gosh, if you're working in rural Idaho versus New York City, how do we equate dollar per RVU to make sure that compensation stays reasonably fair? So fair market value becomes this broadly applied metric or slogan that says, this is what we can compensate individuals. In essence, most people are using three primary surveys. They're using MGMA, they're using MedAxium, they're using Sullivan. And depending on which one they're using, they're going to come up with a different RVU target, and they're going to come up with a different salary that kind of goes along with it. All of it is rooted back to a dollar per RVU. You can adjust all that stuff a little bit by saying, we're doing a little bit of administrative work, we're doing this, we're doing that, et cetera, to get you to the compensation you want or the compensation that we deserve. But it gets back to some of what Amita was talking about, which is that ultimately when we think about the RVU and the way that we're measuring ourselves, there are two components. One is the individual component, and that generally hits close to home because it's tied to our compensation. The other is the team component. So we have to balance those in some way, and we have to figure out how we put the two together. Here's what I would say. First of all, I'm glad you're going into EP. I think it's important that we have really talented people and the best of the best go into our field. I'm a product of Mark Josephson. This is something that he and I talked about as he was dying and something I take very seriously. I worry about running on this treadmill. Where does it stop? I think it's an important question we have to ask ourselves, and I've spoken to more than a few colleagues who are contemporaries of mine at this meeting who've told me they're burned out, one of whom went on a meditation retreat for a couple of weeks to try to figure this out. I think that when you get to the point of the end of your career, you're going to look back and you're not going to share with anyone how many RVUs you made. No one cares. You're not going to look back for the most part and say, well, I made X number of dollars. We're fortunate and privileged folks. We're reasonably comfortable in the big scale of the world. What you are going to look back and look at, and this is something I think about a lot, have we done good for our patients? Are you professionally satisfied with what you've left behind? When you walk away from your practice, which currently in an employment model means that I'm gone. When you walk away from your practice, is your team, the people that you've cared about that are helping care for your community going to be better off than when you started? That to me is what this career is about for me, and I think hopefully for you as you progress through your training, we figure out some of the metrics and systems to make that rewarded and not something that you look at as a burden. A quick question for both of you. I know you probably have more areas of agreement than in reality you have disagreement, but I'm going to push each of you on the topics that you talked about. If you could first address to us, because you said RVUs are the greatest thing since sliced bread or maybe since fire. Well, how do you compensate people for doing quality-based things and for doing other important activities like academics, teaching, publication, adhering to the guidelines, getting everybody who needs it on an OAC, making sure complications are lower? Then I'm going to push you a little bit too. What do you do with the person who basically doesn't ... I mean, they're a good doc, they do the right thing, but they just don't work hard or want to work hard. How do you address those issues? Because those are real world situations that are operative in many organizations. So go for it. Yeah, so we're a large group. We have docs that encompass both ends of the spectrum that you described. And to get into the rebuttal a little bit, if we talk about healthcare as a team, I reference things, people will reference major sports franchises, right? And we'll say, gosh, healthcare is not a sport. Okay, fine. Justine and I are aligned on the sport team. Yeah, exactly. So I am. So I know that, so that's why I'm gonna choose a different sport. So I've got a 10 year old who loves Formula One. So you can't think of a more intricate sport. It involves 10 teams, 20 drivers, global logistical elements to move the entire franchise across the globe. And these 20 drivers have one goal, which is to amass points, win constructor's cups, or win a world championship on an individual level, much like what we're talking about, right? Like we wanna be compensated, but we have to help our team. The point system, our version of an RVU, is intended to align these two things together. So you say, how do we get drivers to work together on a team so that everybody gets rewarded, and at the end, constructors win the championship? Where you finish, one to 10, determines how much revenue you share. And there are limitations. There are resource limitations, much like a salary cap, how much you can spend, et cetera. You have to manage all of that. And if you wanna be successful, that metric to go after those points helps you optimize operational efficiency and say, okay, we gotta manage all this stuff. Here's how we gotta do it. These are the set number of dollars. This is our team, hundreds of people in many cases. That is not that dissimilar to what we're talking about with RVUs. So if I were to say, hey, this is what we're doing. We're figuring out a metric. We're saying, yep, we gotta all push to that metric. In this particular situation, Amit, he's working at an ivory tower like Ferrari. I'm working at McLaren. And if you wanna Google who's winning, it's McLaren. McLaren is winning because they understand that the metric drives team success. I mean, we need to get to the rebuttal, so if you can make a very quick comment. Anish needs to come visit our place because he'll see that the tower is definitely not ivory. But Tom, to get to your question, what do you do with people who are not sort of keeping up with the group, the decided upon group metrics? And I'm gonna say this. Partnership is not just the good, it's also the bad. So we have to be responsible for sharing and success, but also the downside risk. And I would rather that be, if one of us is not keeping up with where we need to be, even though it's a headache and not pleasant to deal with, I'd rather that be my issue because I'm going to come to you from a place of love than your administrator who's gonna come to you from a cut and dried, I'm gonna cut your salary based on your contract terms. I would rather take that responsibility and that headache as a leader than outsource that to somebody else because it's easier to do that, but the right way to do it is that we have to care for each other and deal with those things. And I think part of that, and actually, we're gonna be talking about this in my team after HRS, as we grow and expand, those things need to be clear and we have to manage to it the way that CEOs do. It's not fun, okay, but when everyone knows sort of outrightly what the expectations are, you don't meet them, there have to be consequences. Well, we have to have access. Thank you, I mean, you just defined what characterizes, or one of the characteristics of a great leader. Do you wanna make one very quick comment then we've gotta move to the remote? You're supposed to be moderating. You're taking time here. You're taking time here. We'll talk afterwards. No, no, no, I was just gonna say, transparency helps achieve all these outcomes that Amit is talking about, right? Like, if we don't have transparency from our healthcare institution, we can't drive our teams for change. Right. Okay, yeah, so we'll start with the rebuttal. And again, our first is gonna be our prior protagonist, Amit Dasani, Malakini Health. It's me first. Oh, I'm sorry. It's Amit. Yeah, it is. It's Amit? Yeah, I read it wrong. Yeah, it's Amit. I mean, we just basically did it. It has to be the other way around, but you guys decide. You decide. No worries. So, it's been a great conversation, and I think we all recognize that we really do need partnerships in order for us to have not only satisfaction for our own careers, but also to achieve the metrics that we want for patient care. And I think you're right, Amit, that we are blessed to be working in this field. I firmly believe that until we have transparency in what the P&L is for the global programs, until we have equity, real equity in those programs, we're not gonna be able to get the seat at the table that we need to manage this. One thing that we did not talk about is the RUC survey. So, when we, the intention of the resource-based value unit was for physicians to be in the driver's seat about the work that we're doing. It was to fill out the RUC survey in an accurate way. If we don't participate, this was the form of self-governance, then somebody's gonna take that governance from us. So, my message generally is to say that the RUC survey, at least in the current form, is for us to not put our PRs down in what we're doing as far as procedural time. It's to understand that the RVU that is attributed to a procedure includes the entire spectrum of care. It's the diagnosis, it's the evaluation before the procedure, it's the procedure itself, the post-procedure care. That's what we're intended to define. So, we need to understand how all of these pieces are available to us to influence the metrics that we're being judged against. And I will go back and I will say that we do need a metric. It doesn't matter what the metric is. I know that we're all at, I'll go back to the fact that it's a highly-matrixed input, highly-matrixed output. We need something to drive us all for good. You pick whatever you want. People are gonna disagree, and people should disagree. If you have something that everybody agrees on, it generally means that it's the wrong metric. So, we're living in a world where there's a tremendous amount of change. We need to understand what we can do to influence our lives for the future and for the future generations. Amita, I'll leave it to you. All right, it's Amita. I also wanna thank you for addressing the RUC issue. That was one of the questions that we unfortunately didn't get to. So, you had great insight and realized it was in there. Yeah, Lisa and Anne-Marie are here from HRS. And for those of you who don't know, there are lots of people who spend lots of time advocating for each of us as professionals. You should find these folks and thank them for the work that they do, which is often unrecognized. And with respect to things like the RUC survey and all the policy matters that we deal with in the background for the betterment of each of our practices. I know it can sometimes feel like, well, I'm not part of it. I don't understand what's going on. The time where we can just focus on our practice is gone. We're kidding ourselves. We actually have, in my opinion, a collective responsibility to understand all the factors that affect our practice so that we can work together. We have really smart people in this society and talk to each other about these things to figure out a better way forward. And I would say this, our views are a part of our reality. They always will be, okay, in whatever capacity. I don't think they should be a carrot to chase. I think that they're a reasonable floor to reach, in my opinion, as a group and a team in a team-based environment. But I think there's a huge opportunity for us to define what it is that we want to be measured by that we value because it's valuable to patients. Thanks. Thank you. We still have a little time left, you were very short in your rebuttals, and we appreciate that. If there are any more questions, people, you know, please come to the microphone or submit it, and we'll be glad to address it. Yeah. I work with Anish, and he's my system chief, so, you know, I feel like I'm going to be asking stuff right now, so rather than just asking questions. But anyway, is there a way to actually, just like there was a formula that was put in in what, 88, for RVU, to come up with other metrics of quality, outside of the bonus system and other things, to really tie in into the RVUs? Say, you know, just giving like a random example, like say if you're 10 years out of practice, or if you perform a set of skill sets, or, for example, if your percentage of invasive procedure linked RVUs beyond 60% of the total RVUs that you get, because we all understand that the NII for an invasive procedure for the hospital is different than reading a monitor. Is there a way to tie in those metrics somehow to even, so keep a currency that could be applied easier than going case by case, and then, you know, you say if you reach those, then your RVU value is slightly higher per physician, or has that been tested or tried? There are ways to do this. I would argue right now the number one way for us to do it is to ask, is to think about equity. Yep. But if you look at like, for example, and I'm happy to share this, if you look at the most recent advisory board paper around physician compensation, it outlines ways that you can move beyond the RVU to adjudicate compensation to assure that you've got fair market value. There's no organization that we're going to work with that is going to put our compensation outside of what can be adjudicated against fair market value, and this is an industry in and of itself at this point with metrics that are being driven by these groups to say, no, no, no, it's not just RVUs, but we're going to create a constellation of indices to assign fair market value. So people are trying to do this, but we have to be partners in that. Right. Yeah, we have to be at the table for this conversation, and I think, like it or not, we have the opportunity now to define what that looks like, and it sounds scary because it's not part of our, you know, the things that we're taught, but all of us live this day to day, and I think if we're not the drivers of that, it's going to be, it's not going to work the way that we want it to. I'll say one more thing to speak to something Anish said earlier. I was part of a Sullivan-Cotter process discussion for realigning compensation plans, and when they define us, in case you don't know this, they define cognitive specialties and surgical specialties, and we are listed in surgical specialties, and I took offense to this, and I said, you know, we do a lot of cognitive work. Okay, so we are not a cognitive versus surgical issue. We have to look at the full picture, and I think there's better ways to do it. That's fascinating. That goes back to 1988 when, you know, some of this verbiage came up, and the paper that I put up from the New England Journal of Medicine, interestingly, that's what the New England Journal of Medicine looked like in 1988. It's like a newspaper. But beyond that, we should be offended by the idea that we are not a cognitive specialty or somehow, you know, there's a differentiation in the work that we do when compared to folks who are not doing procedures because, in fact, we are taking significant cognitive risk in making decisions about the procedural care that we're delivering. And often the right thing to do for somebody is to not do anything to them, and that takes more time to help people understand. When they come to you with an expectation, you know, I'm 93, and my cardiologist said I need a left atrial appendage occlusion device, but you have a pacemaker and you're not having any atrial fibrillation, maybe you just don't take anticoagulation. But that's not what my cardiologist said. And that's usually, you know each of these scenarios that we deal with. That's not valued, right? The right thing to do is often not valued. I think it's an important thing we need to think through. And I think that's a very good point that you raise there, and I think, oh, I'm sorry, you have a question over there? Yeah. No, please, please, go right ahead. Okay. It's Kathy Sasson with Boston Scientific, a manager. So my question is on the REC survey, and going back and using it as an example when SICD first came out, and the RVUs were assigned, and as a new employee learning how that happens and why that happens, because they were assigned a lower RVU value than a single-chamber ICD, although the procedure took longer, especially in the beginning, and, you know, that was a big question. Moving forward in time, physicians, it's an impediment to implanting because of the RVUs assigned for some physicians. I'm not getting the same RVUs. It's going to take longer, whatever it is. So my question is, is that ever revisited, and can those be changed? And when I ask our reimbursement department about that, they say the major risk is RVUs are never going to go up. If you revisit it, they're probably going to go down. But it is all based on physicians. And to your point, given your PR, when you're filling out that survey, it's like, this is my absolute best, and I nailed this, versus all the time that it takes, you know, to care for that patient properly. Yeah, and it's a terrific question. So I think the survey process has important implications for innovation and valuation of innovation. You are correct, because of budget neutrality, we live a little bit in fear. We're trying to not be recognized and trigger potentially a reevaluation of our current sort of traditional devices versus new innovative devices that are coming to market. And I think it sets up a conflict, right? So it's one of the challenges of the current RVU system is this. Why should there not be a reward for innovation that makes patient lives better and moves the field forward? So to your point specifically, obviously the penetration of subcutaneous ICD, 10% in the indicated population in the U.S. compared to 80% in Japan, incentives align in Japan for doing what is the quote-unquote right thing, avoiding leads in the right population. The extravascular ICD in Japan has a 15% increased reimbursement against sub-QICD as an innovation, right? New technical skill sets to learn. So we have to be able to understand how we get to the table to talk about continuous education, continuous learning that we're doing to deliver all this care. Here's a discussion I'm having with my health system, is that if we do the right thing, which is the right thing for the patient, which ultimately reduces total cost of care, we should share in that as a team. And I think that discussion is coming with ASC penetration and everything else that's going to happen. So this process of educating ourselves about these things beyond our practice is actually an important foundation for where I think the future of EP is going to go. Thank you. Thank you. And, again, I think your comment about being cognitive and also being procedurally oriented is really key. I would actually argue that cognitive is our foundation, and it's actually the sandwich. It's the top and the bottom. The other is part of it. What I'd like to do is ask my colleague here, my co-chair, Christine, you've been in several very large, reputable institutions. You run the program at Cedars-Sinai. What do you think you've been able to do, and how do you compensate individuals who work at your organization? Because you have a great reputation for, A, clinical work, and, B, for research and for academic publications. How do you balance all that? What do you think works? Yeah, I think we have a really interesting and it works well program where we monitor people's RVUs, but their salary isn't totally dependent on it. And there's a lot of judgment that I'm able to provide regarding how that RVU target is appropriate, really, for that person. And so far, as long as we overall make our targets and our budgets, nobody makes me reduce anyone's salary or do anything like that. The other thing that we do is we often will give a certain percentage of time. So if you are benchmarked at a certain level, you'll get 10% administrative time. So that cuts your RVU target. Because all of my faculty work hard. They're all working hard. And so I think it does take that partnership with the institution. With regards to EP, we're able to see. I'm able to see the hospital outcome of our electrophysiology service. That was one of the things I did was I kind of made that carve out and wanted to see it. And that helps the hospital understand that they do need to invest in EP. They do need to give you the support staff. And so I think it's transparency, it is cooperation with the hospital, and it's protecting your people so that they can do the work that they're supposed to do without fear of this RVU target. I think that's a great summary on how we can better drive the situation forward. I said at the very beginning when we did the mini poll that we would terminate with a poll. So I'm going to ask a very similar but slightly different question. Part one or part two, please vote in one of the two sections. Number one is, I do believe that RVUs should be a component of how compensation takes place. The second voice will be, I really think RVUs have no role whatsoever, and we should get rid of it. So how many favor including, at least in some manner, RVUs as a component of compensation? Please raise your hands. And, Josh, you can't raise two hands. And how many vote on the other? So what do you think, Christine? I do think we need some metric of productivity. I like the idea of group metrics because I do think that, you know, there are people in every group that are your proceduralists that doesn't like to speak to anybody, you know, and then there's the person who speaks to those people, and they all generate the value. So I do think you need a metric. The problem with the RVU is just it is somewhat, when you look at the actual reimbursement for different procedures versus an ILR versus an EKG, it doesn't make a lot of sense. So I wish we had a better metric, but you do need some metric of productivity. I'm not sure it's the RVU, though. Well, first of all, I want to thank my co-chair, you know, Christine, for her assistance on this program. I want to thank our two speakers for engaging in a very interesting debate. And I want to thank all of you for arriving here early in the morning and addressing this topic. So thanks very much. Please let us know what additional topics you would like to hear about so as we continue to develop the program and create the program for next year in Chicago, we have a better ongoing opportunity. So, again, thank you all. Enjoy the rest of the meeting.

Relative Value Units

physician compensation

healthcare industry

operational efficiency

cognitive labor

physician burnout

partnership models

RUC survey

budget neutrality

quality metrics