So I'm going to talk a little bit about how we as electrophysiologists get paid. And you just heard in the last talk, Eric mentioned that you could get paid anywhere between $8 and $800 to put in a pacemaker. And it's nice to kind of know what that looks like, where did those numbers come from. So we're going to talk a little bit about basic payment structures. And we're not going to get too much into the weeds of this, but hopefully this will at least provide you some insight. And when you're looking at jobs and job contracts and those kinds of things, you'll see a lot of this terminology in these contracts. And it's important to kind of know what these terms mean, what people mean when they talk about an RVU and benchmarks and productivity. And I will say to echo Eric's point, I mean, I'm at Emory now, I was an EP fellow at Emory. Basically, I took the job that was offered to me, they handed me a contract, so we've got a job for you. And I signed and there wasn't a whole lot of negotiation, I wasn't nearly as savvy as I could have been. And fortunately, it's worked out, I'm happy where I am. But I think I would have been a better consumer or would have been a more savvy job finder if I had known some of these things. So we'll talk a little bit about productivity. And so you're going to hear the term RVU put a lot. And we're going to talk a little bit about what an RVU is. But we'll come back to the RVU. But basically, an RVU is a work metric that is defined by CMS for sort of equalizing the types of work that people do. Most, I think, jobs currently in EP use some variation of an RVU. There are some practice, I don't know anybody who's still collections based, but what collections based means is basically the money that the hospital or your practice collects on your behalf from payers, that's what you get paid based upon. The problem with collection space is that if you in a setting where you're doing a lot of indigent care, people are uninsured, your hospital, your practice may not be able to collect any money from those folks. And so you're at your salaries at risk because of the type of patients that you're taking care of. And that's not ideal, right? You want to be able to take care of people without worrying so much about that. And then gross charges are basically what the hospital charges. So you know, you see these wild statements where people will get a bill in the mail for a pacemaker and the bills for $50,000. Well, no insurance company, no payer is actually going to pay $50,000. That gross charge is really mythical. And I don't think anybody measures productivity based on gross charges. And by and large, it's going to be based on some variation of an RVU. And you'll see a lot of in the contracts. And when you ask people about how they get paid in productivity, you'll see people refer to benchmarks, meaning there'll be benchmarks that you have to hit in order to get bonuses, there'll be benchmarks that you'll have to hit for various metrics. And a lot of those benchmarks are based on MGMA. And we're going to show some of the data from MGMA in this talk. So let's talk a little bit about what an RVU is. It's a relative value unit. And as I said, it's a standard that CMS uses for reimbursement. And there are three components to an RVU. There's the physician work RVU, or work RVU as it's called. And that's basically the compensation for the individual physician's work. And if you're seeing somebody in clinic, if you see a patient in clinic for a follow up visit, there's a certain amount of RVUs associated with that. If you see a new patient in clinic, there are RVUs associated with that. And the number of RVUs you get for seeing patients varies based on acuity. If you see a higher acuity patient, more complicated, more comorbidities, you get a higher number of RVUs for that. So the RVU integrates time and acuity and is based on CPT codes or current procedural codes. But we'll go through some of the RVUs that are relevant to EP. There's a practice expense RVU, which basically goes to your practice or to your hospital. And that's the amount that you get reimbursed basically for overhead, for keeping the lights on, for all the expenses that go into medical care that aren't specifically reimbursing the physician. And then there's a small component that's the malpractice RVU. But if you take those three components of the RVU, and then there's a geographic factor because the amount that you get reimbursed varies based on geography and cost of living and other metrics. But if you put all of those components together, basically what you get is a work RVU and you multiply that by the geographic factor, the practice expense RVU, multiply that by geographic factor, and then the malpractice and multiply that by geographic factor. And that's how you come up with the total RVU that you get reimbursed for doing something. And then you've got to somehow convert the RVUs to dollars. And so there's a conversion factor, which is used to actually convert the RVUs into the number of dollars you make. So the number that Eric threw out about 800 is based on this sort of calculus of the RVUs and the conversion factors. And we're going to come back to this conversion factor in a bit, but this year CMS pays $34.89 per RVU. And that's down from $36.09 last year. And unfortunately, we'll be going back down to $33.59 in next year. And so these conversion factors can change over time. But this is a sample. This is probably good. This is for 2021. This is a little bit outdated now, but just to give you a sense for the number of RVUs that work generates. If you do an AV node ablation, and this is physician work RVUs, you get about 10 RVUs for an AV node ablation, which can be a pretty straightforward procedure. A VT ablation is about 19.7, 20 RVUs. So you can start to see that you can do two AV node ablations a lot of times much more quickly than you can a complex VT ablation. Now that doesn't mean doing complex VT isn't important and that it's important for patients, but just in terms of the amount that you get compensated for your time, you can see that there are big differences depending on the kinds of procedures that you're doing. AFib ablations and VT ablations are somewhere on the 20 RVU range. An AV node ablation is about 10 RVUs. And these tables are all publicly available. You can Google them to find the amount of RVUs that you get for various EP procedures. This is sort of a similar sort of thing for devices. You can see that putting in a dual chamber pacemaker gets you about eight and a half RVUs. CRT gets you a certain number of RVUs. Defibrillator implants get you a certain number of RVUs. But this is how we get reimbursed for what we do. There's a certain amount of work RVUs and then you get paid a certain number of dollars per RVU. And these tables are fixed. So regardless of where you work, a dual chamber pacemaker gets you the same number RVUs. And it's a way of standard standardizing across systems and across geography. So to get a sense for how busy people are in electrophysiology, and these are numbers that I pulled from MedAxiom, which is affiliated with the American College of Cardiology, and they do physician surveys to help people kind of determine what people are doing. Electrophysiology here is in the dark blue. And you see if you're the 50th percentile of an electrophysiologist in this country, you're doing about 12,700, just under 13,000 RVUs per year. The 90th percentile, these people are working a lot harder than I am, are doing about 21,000 RVUs a year. But you can see generally speaking kind of how many RVUs people are generating. And if you're getting contracts that have benchmarks in them, it's important to kind of know, do those benchmarks seem reasonable? Are these benchmarks way at the sort of upper end of what people are generating? But these kinds of numbers are, like I said, they're publicly available on the MedAxiom website, and you can see roughly what people are generating in terms of work RVUs. When you translate those work RVUs into dollars, so we said that is the conversion factor, you can see what on average electrophysiologists are making. And it varies a little bit depending, as Eric said, in private practice, in hospital employed models, academic models, it'll vary a little bit. But your range of dollars here is somewhere between about 550 up to about 680 or so. And these are average, this is median compensation based on the MedAxiom survey. And you can see that it does vary based on geography, not surprisingly. Some parts of the country are more expensive to live in, others are less expensive to live in. But these numbers, like I said, are all publicly available. The MedAxiom PDF is like 60 pages long, it has it broken down by geography, by gender. And you can kind of get a sense for what, you know, if you're being offered a contract, how your contract stacks up to, you know, the average. I did want to mention that, like I said, the conversion factor will be going down by about a dollar per RVU next year. The other thing that is coming that you may have heard a little bit about already is that there are big impending CMS cuts that were just finally approved. To EP procedures, particularly for SVT ablations, up until next year, you got paid a little bit extra. You got a couple extra RVUs if you use 3D mapping. That's now all going to be bundled in. We'll no longer be getting paid extra for 3D mapping for SVT and for AFib ablations. ICE is also going to be bundled, and this kind of bundling reduces the total number of RVUs. So there is going to be a cut to the number of RVUs that we're getting reimbursed for EP procedures next year. And I do want to say that this is one of these things that when we're trainees, when we're fellows, we don't really think about, but this is where professional societies like HRS can really provide a lot of value. HRS has been very active this year in lobbying CMS, trying to get people engaged to advocate for our profession in terms of trying to protect us against some of these cuts. And as you make the transition from a fellowship to being in your first jobs, it's important to really stay engaged with professional societies, ACC, AHA, HRS, because they really advocate on our behalf. And there are voices for a lot of these kinds of things, particularly when it comes to payment, salary, and reimbursement. If you're interested in more than seeing what the HRS has done this year in terms of advocacy on our behalf, you can go to the website and see a lot of the activity that went into trying to fight some of these cuts. Unfortunately, it looks like most of these cuts are going to go into play. So you can see the differences between what we're getting paid currently this year for some of these procedures and what those payments will look like next year after some of the bundling. So there are some cuts coming. This is inevitable and it affects a lot of fields, but these are the kinds of things that I think when we're in training, we don't think about as much. But as you start to look at jobs and think about how you're going to get reimbursed, it's important to start to think a little bit in some of these contexts. So I'm going to leave it there. I just wanted to kind of provide a high-level overview of what our views are, how payment models get put together. If you guys have any questions, you can feel free to reach out to me or to I'm sure any of the faculty.

electrophysiologists

RVUs

compensation

CMS cuts

payment models