Good evening, everybody. My name's Michael Lloyd. I'm a vice chair of the Digital Education Committee of the Heart Rhythm Society. And welcome to episode 12 of The Beat. This evening, we're gonna talk about physician compensation plans. With us tonight are Nicole Knight and Joel Sauer. Both are executive vice presidents of consulting with the MedAxiom Company, which is an ACC company. And our host, Dr. David Slotweiner at New York Presbyterian, a member of the Health Policy Committee of the Heart Rhythm Society. David, take it away. Before you do, please remember that the questions and answers, we will try to address as many as possible, but please use the Q&A tab at the bottom of Zoom. David. Terrific, thank you, Michael. As Michael mentioned, I am on the Health Policy Committee at the Heart Rhythm Society, a long-time member, Chief of Cardiology here at New York Presbyterian, Queens, and a long interest in health policy. I'm the alternate representative from HRS to the AMA RUC. And it's my pleasure on behalf of the Health Policy Committee to bring this webinar to you tonight. This is the fourth in a series of webinars developed by the Health Policy Committee to try to help educate members of the Heart Rhythm Society and to help build our bench for physicians interested in participating and volunteering with the Health Policy Committee. The three previous webinars, I encourage you to check out, they're on the beat. The first was, A Seat at the Table, Understanding the CPT and RUC Processes. Our second webinar was Understanding the Evolution of the Centers for Medicare and Medicaid. And the third was Understanding the FDA's Role in Regulating Medical Devices and the Role of Practicing Physicians in the Device Surveillance Process. Tonight, I'm delighted and excited to be able to present to you Nicole and Joel's presentation on Physician Compensation Plans, something I think all of us are very aware of and really delighted to have both of you here, highly skilled in expertise in this topic. So thank you all. Turn it over to both of you. Great, thank you everybody. Appreciate it and thanks for joining us this evening and taking some probably personal time to be here with us. Just a quick introduction of who we are MedAxium. As Dr. Lloyd mentioned, we are a wholly owned subsidiary of the American College of Cardiology. In its 75 year history, the ACC has only made one acquisition and that was us. And they did that because our focus, unlike the ACC's which focuses on individual professionals, we focus on the organizations they work for. So we like to say we take their science and quality and we embed it in the organizations and we take it that last mile to the bedside. So our focus is on those organizations. Nicole and I are both consultants on the MedAxium team. We have both been here for a very long time and in the industry for a very long time. I used to be able to hide that fact, I cannot any longer. And then Nicole heads up our revenue cycle services, which is an entire division of MedAxium. And we do a lot of EP coding and documentation support. And then I am the lead author of our annual physician compensation and productivity report which comes out late in the summer each year. And so that just gives you a few of our bona fides to say why we are here talking to you this evening. We all show this slide at almost every presentation we give because it has been created over decades of consultant travel and experience across the country. We're not smarter than anybody else, but we get to see a lot more cardiology and cardiovascular programs in a single year than most people do by virtue of our jobs. And we kept noticing that there are certain attributes that make some places successful. And when they're missing, they seem to be a lot less successful. And so we catalog those and put them on this hierarchy that you see here. And you can see that economic alignment, getting our comp models right is important. It's one of those attributes that is critically important. Cardiology is very different than nearly any other specialty. A lot of hospital administrators and others get tired of hearing how special it is, but you have so many moving parts. It's not only delivered in multiple care settings such as the hospital, the procedure area and the ambulatory setting, but you have all this deep subspecialization including electrophysiology. So managing that is challenging and it takes some thought. You all probably live this, but this is the ownership trend back to 2008. You can see that was the year before all the big cuts to the imaging reimbursement happened. And at that time, the vast majority, 90% of physicians were employed by private groups. They were in the private group model and the percentage that wasn't were academics. Lo and behold, Medicare started making cuts to reimbursement and the reaction was pretty swift. Now it's completely flip-flopped. Nearly 90% of cardiologists are now practicing in an employed model with a hospital or health system. And only 11% are in those private groups. Here's data from that report, the annual report I mentioned. This is median subspecialty compensation. These are annual amounts per full-time physician for EP invasive, general non-invasive interventional and then advanced heart failure. And you can see we split it by that ownership model, private groups being the dark blue bar and integrated or employed being the dark red bar. Keep in mind, our private subset has gotten so small. It's now representing only about 10%. Those data are more vulnerable to a smaller sample size. And so they swing pretty heavily, but you can see pretty much across the board. Although the gap has closed or narrowed over time, the employed physicians earn more on a FT full-time basis than those who are in private groups. There are currently or certainly exceptions to that rule, but that's a general overall statement. You'll also notice that EP is the highest earners of the cardiology subspecialties. And that is regardless of ownership model. When you turn over to productivity and the vast majority of productivity in this country is measured by work relative value units or work RVUs. That is also what we use. Those are established by Medicare. And I don't have to tell EP physicians that Medicare tinkers with how the RVU schedule for certain activities. That is how ultimately they reimburse all physician services. It is based on the full relative value unit of which the work RVU is a component. But commercial carriers tend to follow suit. So where Medicare goes, pretty much the world goes. You can see EP is also one of our highest producers across the board. And regardless of ownership, you'll notice this very large blue bar for interventional physicians in private groups. As I mentioned, that smaller sample size is subject to swings. This is from our 2022 data published in 2023, which is the most recent we have available. But you'll also not in our slides, but I will tell you that private groups tend to be very procedural heavy and more interventional per capita than the integrated and more EP per capita as well. So when you do the calculation of compensation per work RVU, you can see how much wider the Delta gets between the private cohort and the employed or integrated because they earn less, but generate more work RVUs when you do the math. And that's all this is. This is not representative of what a contract says. This is simply taking total compensation and dividing it by work RVUs. This is the product comp per work RVU. So you can see EP is one of our lower earners on a work RVU per work RVU basis with heart failure being one of the higher earners. Now, again, I can't stress this enough because over and over we get questions that make us realize that we're not comprehending this. This is not a contractual rate. This is not how much the hospital or health system or even a private group is paying. It is simply looking retrospectively and taking total compensation and dividing it by work RVUs. So if a physician or if a practice, and we're gonna talk about these different models, has a heavy equal split, that is gonna change dramatically. That calculation for this metric from a group who had identical performance, but is 100% productivity based. Important to keep in mind. Here's a trend for work RVUs over time. We went back five years and hopefully you can see this, but it's the 25th, 50th, 75th and 90th percentile from the bottom going up. And these are for full-time EP physicians. So even though Medicare made some significant reductions in EP work RVU values, they have not translated in significant decreases. We had a year of pause, but all activity is up again in 2023. And this is the trend around comp. Similar to work RVUs over all each of these quartiles has, we took a year off on the increase, but back in from 2022 to 2023, compensation ticked upwards. And then the comp per work RVU, it doesn't really necessarily make sense to trend it over time, but it is because of that calculation aspect. But you can see it's relatively flat over this time period. The scale starts at $40. I wanna point that out. So it makes the variations more dramatic, but I would say a more accurate reflection is it's been pretty flat over time. Okay, as I move into talking about compensation plans, I need to kind of set the context with a little bit of definitions because even in private groups, but particularly in integrated or employed, you often have two models. You have how a pool gets funded. That may be by contract. It may be by revenue versus expense or minus expense in a private group. It then goes through some sort of pool or a model that then pays it down to the individual physicians. So for instance, a group may have a cardiology compensation pool that is created entirely by work RVUs. It's 100% productivity base, but the physicians have chosen to distribute it 50% equally and 50% by work RVU productivity. And that's their internal distribution plan. I use that just as a frame of reference or as an example, but it helps delineate. The hospital is paying 100% based on work RVUs, but the physicians have chosen a different model. Two thirds of the, these are more MedAxium data, two thirds of the employed cardiology groups out there have a, even though they're employed, they have a distribution model that is different than how the funding happens. In other words, they have a significant say in how the money drills down to the individual doctors. So when we look at, this is looking at physician compensation plans across all cardiology groups, you have 48%, and these got pretty small, I apologize for that, but almost half of the groups pay predominantly on a productivity model with 32% who pay on some blended version of both productivity and some equal, and then only 6% of cardiology groups out there are 100% equal. They still exist, that number has gone down significantly over time, which is interesting as we are theoretically transitioning to a more value-based reimbursement system. We're moving heavier and heavier into productivity models as a compensation plans. And then you have this yellow wedge 14% that are a salary plus. Tends to be a lot of academics in that slice mostly integrated practices that would be there as well, not so much in private. When you talk about a base or salary, oftentimes we will call it a guarantee, but when you dig into the language of the contract, it's really only guaranteed for 12 months and then it can reset based on whatever that prior year's productivity was. That's more like a draw in my definition or in my perspective. However, we often hear that called a guarantee, but that is a portion of compensation that stays fixed through the year. It doesn't ebb and flow with productivity or with vacation time. It's a part of your paycheck that you can count on. Then production, nine out of 10 times, groups are measuring productivity by work RBUs. They tend to like those because they are agnostic to the payment and the payment source. So there is no motivation or demotivation based on the patient's ability to pay or the payer type. They also are maintained by a third party. You can like that or hate that. That third party is the American Medical Association and Medicare, but they keep it maintained, which time value units that you see on the bottom, we see those in a few groups. And I like to call the groups that like time value units, they are like Subaru owners. Their enthusiasm is more than it should be probably based on the product, but man, you cannot talk them out of loving their TBUs. Same as Subarus. And then private groups will often go straight to the money, which is cash receipts, because that's what they live on. They live on that revenue minus expense because there is no safety net of somebody else funding it. So those are just some examples of productivity. Then equal share sometimes gets called pooling. But one thing to note, when you talk about a pool, that does not mean 100% equal share across the board. That just means they pool and they separate by some model that the physicians have a say in. And then non-clinical incentives. Often we see patient satisfaction, not our favorite as MedAxium, because you're talking about hundreds of a percent difference between 25th and 75th percentile performance. That gets really hard to motivate anybody around. But then also quality and outcome measures such as registry, citizenship, which I'll go into a little bit deeper coming up, and then other value, which could be payer performance scorecards, outreach, things like that. So the whole kind of negotiation around a comp model design is moving the knobs. Do you make these buckets equal? Do you make them predominantly one over another? That's where the kind of the rubber meets the road. When we do compensation consulting work, it's all about trying to manage different expectations and desires and where you want the incentives to be. And there's no magic way to get there. You kind of have to arbitrate, or I hate the word negotiate, but you mediate that within your group, following your group's culture and what your organization needs from a strategic perspective. So this is, again, where we're trying to figure out where you put the needle. And I'm not suggesting that there's only these two polar ends that it's all productivity or all equal. There's a lot of different models that can be employed. In fact, there's an adage in cardiology that says when you've seen one needle, there's an adage in cardiology that says when you've seen one physician comp model, you've seen one because everyone is like a snowflake and has a little bit of difference. And that is true, but we do see that almost all of them include these kind of big buckets of productivity, equal split, and some form of incentives. New physicians typically start out on some sort of guarantee that allows them to ramp up their productivity. We're seeing new physicians starting salaries creep up, and I shouldn't even say creep. They have leapt up over the past five years. They are now approaching similar salaries to what a fully matured physician is earning. The market is incredibly competitive. There's a shortage of cardiologists. We have done the math on that as an organization and presented it elsewhere. We're losing cardiologists each year through retirement, productivity slowdown, coming off call, et cetera. And yet our demand for cardiovascular services just increases every year. So that net delta is being felt, and we're seeing it in both the compensation figures. I showed you how those are trending up and in the wages for our new fellows coming out of training. Usually there's also some form of productivity incentive that is placed on top of those to kind of keep everybody's eye on the productivity ball. Night and weekend call, speaking as a recovering healthcare executive, we are loath to pay separately for a call because it is seen as a Pandora's box. If I open it in cardiology, I'm gonna get asked to pay for it everywhere by all employed physicians. However, we still see it paid separately in some instances, but most often it's baked into whatever the compensation model or plan is. And by the way, we did a survey of our membership in 2022. And regardless of the size of the group, EP participated in general call more than half the time. Physician compensation valuing non-clinical time. This is another hot topic or something that comes up frequently when we're talking about developing cardiology compensation plans. There's the old tried and true timesheet where you have to fill out exactly what you did and how long it took, and then you get a payment per hour. Not loved by either side, physicians hate it because it's kind of like getting paid hourly at a McDonald's, hospitals hate it too because they have to manage it and it's kind of a pain. There's also the FTE allocation. We see this a lot in academic institutions where I might be a 0.25 academic role and a 0.75 clinical. My clinical may be paid under one model and then I have more of an FTE based fixed amount for that 0.25 or quarter FTE. Another popular strategy is phantom RVUs, particularly in models where the physicians are paid by work RVUs. You see these with activities like outreach. If I am a traveling cardiologist that has to cover an outreach site, you have both the car time and then you have the usually lower productivity that happens when I'm in an office setting in a remote area. So some organizations will assign RVUs to those activities and they will track them through the practice management or billing system, just like they do CPT activities. And we'll even create some phantom CBT codes for those. And then you have the value incentive. This is becoming more popular or has become more popular where there is a fixed pool of incentive dollars available. And then there each year, a set of metrics that have to be achieved in order to earn that money. And it's tracked throughout the year. It's gotta be set in advance. It's gotta be in the contract. It's gotta be very well-defined, but each of the physicians then has this list that they are expected to achieve. And by doing that, they can earn that extra pool of money. I mentioned citizenship earlier and this one can get controversial, but it is intended to reward the physician who always says yes, because not everybody does the non-clinical, that work that needs to be done that nobody wants to. For instance, when a recruit comes to town and you're trying to hire them, everybody wants to go home at the end of their day. But if we're holding a recruitment dinner, it sure makes a better statement to that potential hire if there are future partners show up. Well, citizenship might be a way that you would reward that as opposed to trying to allocate phantom RVUs or things like that. The thing with citizenship is there's no revenue behind it. So it is a redistribution of the current comp pool, but it does tend to provide some incentive for the physician who is always the one that everybody goes to because they know he or she will say yes. And it gives them some sort of remuneration for that activity. All right, I'm gonna turn it over to Nicole now to take us into the exciting world of compliance, the law. Yes, yes, absolutely. Thanks, Joel. One thing, just a disclaimer, and Joel and I often do these presentations and work in this space. Medaxium as a consultant team, we do remind everyone, we're not attorneys. We're making comments, generally no legal advice. So you always wanna consult your legal counsel. These are what we would say from a compliance consideration, the three that cover most of our federal programs. So the Stark Law, the Anti-Kickback Statute, and the False Claims Act. So we're gonna talk just a little bit about that, not to put you to sleep tonight, but just hit a couple of points. Next slide, Joel. All right, so on this one, this is the Stark Law. Stark Law, so I think we lost our titles on these. Yeah, somehow the titles got cut out. You're trying to trick me. Joel's setting me up now. She's testing me. So the Stark Law dates back to the 90s, and this is around prohibiting payment for volume or value of referrals. So this mostly, when you're dealing with compensation, you'll hear designated health services. It's around mainly our diagnostic testing services, ECHO, Nuclear Spec, CTMR Lab for cardiology. The violations do not have to be intentional. We have a little box there, no jail time. However, you do have some penalties, and it can trigger the False Claims Act liability, and then you get the per service violation, and you have to refund the claim. So there's some penalties there, but most of this you'll hear around designated health services and referrals around the Stark Law. The scariest thing about the Stark Law is that it almost always triggers the False Claim Act, and it doesn't have to be knowing. So that makes it really scary. Yes. All right. So now this is the anti-kickback. Yeah, anti-kickback statute. So this one is, it may not be knowingly either, and willingly offering, pay, solicit, or receive any remuneration to induce or reward referrals. The examples are around material gifts, providing free or reduced services, I think are some of the common ones, around rent, those types of things. The penalties are severe here. They can be criminal or civil. They also trigger the False Claims Act, and there are fines per occurrence, and include that imprisonment or felony conviction when we talk about that anti-kickback statute. So our False Claims Act, as we said, the others contribute, can trigger this because it is the catch-all law. These are and covers all knowingly submitted false claims that go well beyond referrals. This is where our whistleblower claims or participation in rewards, they also fall within that False Claims Act. Some examples around up-coding or over-coding unnecessary services or double billing, significant fines and penalties per claim, and also that prison time. These are some other considerations. When you're going through compensation negotiations, they're going to look at fair market value. Joel's word of negotiation, so this is some bonafide negotiation by the informed parties. It's not influenced by the ability to generate or refer business, and can't consider referrals. Some examples of when they're looking at fair market value Some examples of when they're looking at fair market value, are you looking at, is it below market lease rates? Is it work RVU rate well above market? What are some of those things that could put you at risk based on fair market value? And does your compensation plan meet those guardrails around that? We often get asked, you know, where is the discomfort? It really is organizationally focused and it's dependent on your legal review. That said, and speaking generally, anytime like total compensation or comp per work RVU goes above the 75th percentile, that's usually when you get an extra level of scrutiny. All right, so some others, what's fair and reasonable? I think that's supposed to say commercially reasonable, a sensible, prudent business agreement from the perspective of parties. So settling services at a loss, like in a PSA where you may be setting up services for your institution and putting them at a lower price, renting equipment full time when it's only used infrequently, those types of things. So commercially reasonableness comes into play on what is fair. Joel, any particulars in this area that you often see? I do see some health systems, they have a loathing for PSAs that include the non-professional side, like, you know, the office itself, the nurses, the medical assistants, and it gets legally, I'm not saying their interpretation is right, I'm saying we see this often where they say, there is no commercially reasonable reason we wouldn't do those things ourselves because we employ 700 other doctors and other specialties, and we have all those, we know how to do it and we have all those things. So why would we rent them from some third party? And that's why you'll hear, I'll do a PSA with the physicians, but all of the support services need to come over to the hospital. Good point. All right, some revenue cycle considerations, and I know Dr. Sotweiner mentioned y'all had went through some of the RUC and those types of examples, just a couple of things to consider on that revenue cycle side. You know, we focus a lot on work RVUs, they are used beyond physician compensation. So you may get, and there's a lot of our, the ACC and HRS both have put out information about surveys you may receive, and this may have been covered in that RUC process, but they're also used to calculate the time intensity and cost of care. So when you're looking at these, they're used to support physician reimbursement and they are assigned that work relative unit, but they also are based on other calculations that support that resource-based relative value scale. Next slide, please, Jill. The language of coding. So we talk about CPT. CPT is our professional billing services, and it's also used for outpatient facility services, but that's the common language of the AMA. And this is where we get our RVUs. So our work RVUs, practice RVUs, they are assigned per those CPT procedural codes, which also include our visit services. When we talk about ICD-10 and the professional physician space, those are our diagnosis codes to support medical necessity. And one category that comes up often is called HCPCS, which are our procedural code systems. These are services, and mainly where this comes into play is when there's new technology, these are created by the AMA as part of that process for it to become a CPT code. And they may not have work RVU or relative value units of the actual expense, all of that assigned to it or including payment, but they also are considerations in your comp plan. And we'll talk about some tips around that and some of the things we've seen as we go through the rest of the slides. For professional reimbursement, so how is a physician reimbursed? So any site of service, you're gonna assign a CPT code and a diagnosis code to support the medical necessity for that service, regardless of where it's performed. Of course, you're gonna have the documentation to support that service, and then you're paid under the Medicare physician fee schedule. Next slide, please. For our facility services or hospital services, and this is for both inpatient and outpatient, they do use ICD-10 codes, both diagnosis and procedure codes for our inpatient services. And those roll into a DRG payment for the facility. And then when we talk about outpatient hospital services, as an example, our diagnostic services, if those are done in an outpatient hospital setting, those are billed with CPT or HCPCS codes and the ICD-10-CM diagnosis codes. And those are paid to the facility under an APC payment, both of which are under the Medicare perspective payment system. So it's a little different on how facilities are paid and how physicians are paid for their professional services, but a lot of the coding language translates both to that professional and that facility side. When we're talking about how compensation intersects with the revenue cycle process, when you go into your program, practice, organization that you're gonna work with, you're gonna see where that CPT code that has the WorkRVU value, if you're using that in your compensation calculation, it drives that authorization process and it definitely drives that middle revenue cycle piece around clinical documentation, charge capture, are you capturing all of the services that you're performing? Are you coding correctly to level that meets the specificity? And then is there a charge reconciliation process or revenue integrity process to ensure that we're capturing all of those services documentation to support what we're billing? And on the backend, of course, as we get to that middle and backend, we have the denials. Usually when you're billing your services and denials can come into play for your cost of collections, your comp to collections, those types of things. So are we having the correct information on the front end that's gonna support that? And then do you have that downstream communication and education feedback that you have confidence in those revenue cycle processes and how that's supporting your compensation plan? Because unfortunately in our volume driven world, we spend a lot of time trying to determine are we capturing all of our charges, which in turn is are we capturing all of our work RVUs? How do we know that? How do we have communication on that? But also are we being reimbursed for those services that are being provided? So some considerations with your comp plans as we start wrapping up and we can take a couple of questions. How are your providers reimbursed for new technology? Remember I mentioned those T codes or temporary codes that are assigned as HCPCS code. Those are not assigned work value units. So we often see when you're looking at compensation, how will new technology be used? How will new technology services be brought into your organization? How are physicians compensated for those procedures? If you're looking at the work RVU and being compensated on work RVUs, what does that look like? Do you have a solid charge capture and code and reconciliation process so you have confidence in the fact that those services are being captured? What are the impacts of some of the modifiers that reduce payments? So every code is assigned to work RVU, but we also have modifiers that could be applied when there's multiple surgeons, when there's multiple procedures and that does impact payment. So how does that within your comp plan impact if you're on a volume driven comp plan of work RVUs? I always have to remind everyone documentation is that overarching criteria. So you wanna be responsible and have the documentation to support the medical necessity when you look at your comp plans and Joel can comment on, is there a variable for comp two collections? Meaning, even if you bill for all the services, is there some type of calculation on how that's considered in your comp plan? And then of course, coding is a team sport and does require that participation, collaboration and communication, both to make the revenue cycle process, reimbursement, collection of our data and compliance, but also to support that compensation plan because we do know when we're still in this volume driven world, it does go back to are we capturing all of our services and getting credit for that. So Joel, do you have any comments on the comp two collections variable and how that is sometimes calculated into some of the compensation plans? I know I get asked about that a lot. Like I can bill for my services, but it doesn't necessarily matter if we're getting paid on the backend, but we do see that variable in some plans. Yeah, it's actually gotten more vogue from a fair market calculation standpoint. Our valuator community has looked at that more heavily now. Which you could argue is unfair because the physicians really don't control how well the backend functions are working to collect that money. But there is concern when, especially because some physician specialties, the physician's compensation can be nearly the same if not even higher than what they bring in in annual direct revenue. And that's where the heartburn comes from. It doesn't help to hear my opinion. I think that's kind of bogus because it's, we all know there's other revenue that comes in for hospitals and health systems that is not directly tied to the professional services of the physician. In EP, when you do an ablation in the hospital, they are definitely collecting revenue for the hospital side of that procedure. But that is not recognized in the physician enterprise where we pay the physician and that's where we do the fair market calculation. So it's a troubled calculation, I'll put it that way, but it's not something that you control or that MedAxium controls. It's coming from our evaluator community. I will say this, the more that we can push that community and we can do that through advisory opinions, asking for guidance and saying, hey, look, this is what we wanna do. Is this a problem? There's clearly risk in that and I'm not suggesting there isn't, but often one of our regular attorney friends who presents at MedAxium on a regular basis, he said much of what the valuation industry is doing, he can't find any code, any law or any regulation that supports it. It's almost like they invented it as part of their own processes and now it's become so gold standard that everybody accepts it and everybody's doing it. That's the kind of thing I think we need to push back on. So could you just repeat that one more time? You lost me there at the very last moment. Well, so if I am one of the big evaluator companies out there and I start doing a certain calculation and I did it because I thought of it, but I really can't trace it back to any of the, Nicole showed the big three. I can't really trace it back to any of those big three in terms of where does it say what you just calculated? Where are you coming up with that interpretation that that's a problem? But if everybody else starts going, hmm, they're doing it, maybe I need to do that too, pretty soon all of a sudden it becomes accepted as if it's truth and it's not necessarily true. Got it, got it. Thank you. And I think that's a great end point. Thank you, Joel and Nicole, that was superb. We're getting a lot of questions from different sources, not just through the chat. So I'm gonna try to synthesize them. And the first one is really start with questions about these surveys of compensation. I think there's a lot of concern about the quality of these surveys and the methodology. And that leads to other questions that I wanna get to down the road. But could you talk about the survey methodology, which physicians are served, how many and how robust they are? Yes, I can only speak for the MedAxiom survey. I can talk generally about some of the other ones that are predominantly used in valuation work, but I'm not an expert inside them like I am with MedAxiom. So all of the large surveys that are done around cardiology are volunteer surveys, as is MedAxiums. We don't, we can't control who responds. We cajole, we solicit, we plead, but we can't ultimately force anybody to provide data. That's how the other MGMA, the large group survey, formerly the AMGA and Sullivan-Cotter, they're all the same way. They depend on people providing them data. And if you're cynical or you're a little skeptical of survey data, you should be, because we also, we can do quality control to a point, but at some level, we're trusting that we're getting what we ask for, and we're getting accurate information. The other thing with surveys, with all surveys, is the larger you can get your sample size, the more it would even out any craziness in the data from individuals. So our survey includes thousands of cardiologists from across the country, so it's pretty big, and we think it is fairly representative of the community and of the market. However, it's not an exact science, and that is why valuators never say, here is fair market for an EP physician. They always say, here is a range of what we believe to be fair market for EP physicians, and the art of negotiation is within that range. So I hope that explained it. We do our survey once a year. We, our collection tool is a data collection worksheet, but again, we're relying on both the accuracy of the information that they're sending us. We can do some spot testing. We can do some things that are like algorithmic-based checks and balances, but we can't know if you met 600,000 and you sent us 500,000. We just wouldn't know that. Okay, yeah, I think that's the concern, which leads to the next question, which is how to break the cycle. If, you know, with the ablation cuts, there are many interventional cardiologists that get more dollars per RVU, and that's reflected in these surveys, and people are asking, if that's what the surveys are showing, that's what's being used to create the reimbursement models, how can that cycle be broken? Yeah, it's a good question and a tough question. So, Nicole, what year was the E&M code big change? Was that 2001? Or 2021? 21, 21. Yeah, so when the E&M code, Medicare dramatically increased, in one year, they dramatically increased the value of E&M work, ostensibly to promote more people going into primary care and to more reward kind of the cerebral side of, not the cerebral, but the office seeing patients in the office side of the ambulatory. However, cardiologists do a fair amount of their work spectrum is E&M, and we had programs that were calling us with this, oh crap moment, because if you employed 40 cardiologists, all of a sudden their work RVU production was gonna go up by seven, sometimes 10% without any change in revenue to the organization, all of that would have come straight out of the bottom line of these hospitals. And in some cases that was $2 million. So, I shouldn't say that specific, but it was millions of dollars. It wasn't inconsequential. That was because they had these fixed work RVU contracts and the rates and kind of the floor fell out from under it in terms of the revenue that they would generate. Likewise, with the question on EP, okay, so all of a sudden those work RVUs in that spectrum of work went down. If my work RVU, my per work RVU payment is fixed, I'm suddenly generating fewer work RVUs, I'm gonna get paid less, or I have to generate more work RVUs, do more work to earn the same as I did last year. And then is that fair in the context of my interventional brother or sister right next to me didn't have that. So, how to mitigate it? One way is to have a pooled model where there is some sharing where that put is absorbed by more than just the EP physicians. I realize that has risk because now I'm sharing some of my income with others and the higher producers, the higher earners tend to share more down. There's not as much lift up from the lower producers, but it is a team sport in cardiology and there's some safety in that pooling. So, that's one way. I'm not sure how you do it in the negotiations. I mean, there's risks if you fix that rate multiple years because maybe it goes the other way. Maybe you miss out then on an opportunity for the upside, but that's kind of like your investment portfolio. You got to manage that risk to your tolerance levels and how you do it. I'm sorry, I don't have a more concise and really easy answer. It's just not that kind of question. Yeah, no, I understand. I think a lot of these questions are coming from our health policy members who think about this a lot and I understand there may not be a good answer. It's just, I think you're hearing their frustration. Let me move on to another related question, which is- Can I make a comment, David? I'm sorry. Because Nicole brought it up. You make sure Medicare sends the surveys when they're going to change rates, they send the surveys to individual physicians, not to where you work. And they often get thrown away. That means a very small sample of returns is driving Medicare decisions, which is terrifying. I don't know that it would have made a difference in this case, because the truth is those services, you go back 10 years ago and we had four-hour ablations. It's very rare that we run into that today. And the work RVU productivity was on an upward trend. Medicare sees those data. They have them just like anybody else because they have a huge volume of claims. So I don't know, it could have been avoided, but we often see physicians not participating in those surveys and they're critically important. Yeah, that's a great point. I've never received one, but that's something we can certainly emphasize to the health policy members and the membership. Let me move on to a related question, which is the hospital reimbursement. One question from Scott Greenberg is when sometimes people try to mention the hospital reimbursement as a potential component of their reimbursement or to support their salaries, they often get shut down saying it could be a stark law violation or kickback. Is that true? Could you explain that? Well, there's truth in it, but at the same time, it's one of the silliest things in our industry is that we're, why else are hospitals employing physicians? There is truth to it. And we have some places that will go to such extremes that they won't even share any of the hospital financial performance, period. But then we have others who interpret it completely differently. And they do share that with their physicians because they want the physicians involved in the financial performance of the hospital as well. This is another one. I'm not gonna have a great answer for you. I'm not a lawyer, nor is Nicole. We see it on both sides. It's a matter of the individual legal interpretation of that hospital or health system, which is frustrating. I mean, we're getting asked to kind of narrow our standards in medicine, wish they would do that in the law. So what I hear in Indiana is completely different than what I'll hear in Florida. I could even say I could hear something completely different across the same city. Well, on a related note, another question in the chat is with the possibility of more Medicare payment codes for ACSs, ambulatory surgical centers, is there a model to pay physicians as a percentage of the facility fee? A little bit contrasting the previous question, but I think it's out there. Anything you know on that topic? Well, we know that ASCs are getting bigger and more prevalent, and that's only gonna grow. I think the question is around physician compensation from activities in an ASC, right? Yes, like job ownership models of the facility fees. Is there a way to get a percentage of those facility fees from a physician comp model? Right, exactly. Once again, we're not attorneys. However, you wouldn't wanna do it based on your volumes, anything that even smelled like your volumes in the ASC. But as Nicole mentioned, if you are an owner in the ASC, you will, by virtue of that ownership, participate in the facility side of it. And it is very legal for physicians to own ambulatory surgery centers. You would, particularly EP, because you guys do a lot of the procedures that are now reimbursed in an ASC model. So the safest legal way, and I'm a little over my skis here because I'm not a lawyer, but if you are an owner, that is your safest participation in that facility. Anything else gets a little, I would think would make some lawyers uncomfortable because it could smell like you are getting paid for volumes. Okay. Even though your ownership interest will go up if you do more cases, somehow that gets a pass, but other models can get targeted. Yeah, yeah, frustrating. Another question, can you, the value incentives, are they linked to bonuses received from Medicare quality reporting programs? We certainly see that, like the- MIPS, I guess. Yeah, well, MIPS is a big one. Yeah, we do see that as an incentive or the, like reducing failure readmissions. Yeah. Is that- NCDR metrics, any type of- NCDR metrics. And are the, but are they physician bonuses, I guess, often linked to those incentives? Are they linked to those incentive programs? The outcomes, I think, is the question. I wouldn't use the word often, but we, it's not uncommon to see it, but out of 100, it's probably only 30 that have those types of incentives. Most are a pretty one-dimensional comp plan, quite honestly. Okay. Which personally, we're not big fans of because we don't think it rewards some of the other things that physicians, the value they contribute. Joel and Nicole, a recurring theme to affect reimbursement has been these surveys and the lack of response. Can you, for our audience, tell us what we should not click as spam and what we should actually pay attention to? What are the actual senders of these emails? Because it's very easy. They don't look like legitimate emails. What sources will they be for the audience? Yeah, we can actually provide you with the email address. It is from like a third party bogus looking email, as you said, but we have the actual address and we have had institutions who've had to unblock that from getting hit in their spam filter and not coming to the physician. So we'd be happy to provide you with the address. It is super long. I can't even memorize it, but we would be happy to provide that. And that can be something we can share after the webcast, but it is a particular address. The other thing is you can also find out what email address you were registered under with the AMA. So we've seen like these Gmails, we've seen AOL emails that have been gone for a long time, or even addresses, Hotmail, those types of things where these go. And then the physician may not even have access to that email any longer. So you can check your profile with the AMA as to where they're sending those, because that's where they get the information from as well. But we'd be happy to share that address with you. And I think that is important to look at, and then your personal emails. And if you have old registered emails, to be sure that those are updated. I think we may be talking about two different surveys, and I just want to make sure we're all on the same page. Joel, are you talking about the surveys of reimbursement or the AMA RUC surveys or both? Well, we have our survey, which individuals don't participate in, organizations do. What Nicole was just referencing was the RUC. Yeah. Right, okay. So yeah, I think that the RUC surveys, they generally will use, in our case at HRS, they have our email addresses from HRS. But I think the ones that we're worried about not getting are the reimbursement surveys. But Joel, are you saying those go to organizations, not individual physicians, the reimbursement surveys? When you say reimbursement, are you talking about physician comp? Yes, physician comp. Those are voluntary, and most organizations will only participate in one. And they have chosen it because they're a member or they are somehow linked to that survey. Okay. So you would talk to your administrators and ask, do we participate in a physician productivity and compensation survey? And if yes, which one? Okay. Yeah. Do those organizations also send surveys to individual physicians or it's pretty much? No. No, okay. All right, so that's helpful. That would be a self-reported survey, and just something not to get too wonky, but as a fair market valuator, you cannot use data that is not publicly available. So if a survey is like members only or is proprietary to some sort of consulting institution, they don't make it public, then it can't be used in fair market calculations. Okay, and I think that gets back to the first question I asked, which I wasn't totally clear on. So that helps at least me understand that there is some guardrails around these surveys. They're not coming from individual people, but they're coming from the organizations. And so they have to be somewhat objective and they're publicly reported. Yeah. That's your story, okay. And so you know their sample size and you know some things about the data when it's public like that. And you can ask your organization, which they participate in. And so that's great. Yeah. A couple more questions coming in here. One, what percentage of claims get reimbursed? I imagine that varies widely, but let me just throw that question out to both of you. Actually, it's published that Medicare reimburses 95% of claims that are submitted and would deny about 5%. But when you get to your commercial payers, guess how much that goes up? It goes up to about 15 to 20%. That are not paid. Right. That are not paid. Yeah, that sounds believable. Yeah. And another question, do you have a list of the groups or hospital systems that offer ASC ownership for EP docs? There is no such list. However, I'll make a general comment again. And there is, regardless of whether you're in a private group or you are employed, there is no law that says a physician can't be an employee of a hospital and own a piece of a surgery center, even if it is the hospital surgery center, or especially if it's the hospital surgery center. We are seeing more and more across the country, particularly in states that do not have strict certificate of need laws. We are seeing more cardiology or cardiac specific surgery centers being built and physicians participating in the ownership. Some, I would call it forward thinking hospitals and health systems see this as a retention method. I can lock my physicians in longer by giving them ownership in a facility. Cause it's a little, you think twice about leaving when you have an ownership interest in something like an ASC. It's also inevitable that reimbursement is going to, eventually somebody is going to go, hey, I'm paying twice as much in this facility than in this facility. We need to normalize that. And ASCs are by far the lower cost alternative and patients love them. So. Before I go on to the next question, I want you both to know that in terms of the health policy webinars, you guys have blown the participation out of the water in terms of participants and questions, they keep coming. So I hope you have a few more minutes. We got a question to clarify, a hospital system can't deny you from buying into an ASC. Is that correct? Well, if they own it, they can. Okay. All right. I think that's fair. Okay. So here, we're a broken record. You're going to have to check with your, if you're employed, most employment contracts have something that says you cannot own a competing facility or you cannot own interest in a competing, you would need to check your language because you could get yourself in legal trouble if you do it, renegade. Right, right. But yeah. Okay. And in fact, some states actually have their own state laws on physician participation in facilities or they say you can't have a cardiac facility. Oh, interesting. Okay. So check that. They're going away because like Mississippi used to have a law like that and they got rid of it. Okay. Or they modified it. Okay. And now back to the publicly available physician compensation. The question is, how is that institutional physician compensator publicly available? Is it through accounting records or you mentioned that they have to be publicly available records or? Yeah. So if you go to medaxium.com, you can find our survey and download it. And where did you get the compensation though? Do you have the- From volunteer organizations who submitted data. We solicited them. We start with the 580 members that we have, program members, but we get responses from that community. And we don't name names. You can't see any identifiable information. It's all aggregated. Okay. So it's you make it publicly available, I guess to people who are participating in ACC or MedAxium without the names. Correct. Okay. Got it. So you'll see like, here's data on 700 EP physicians in 67 groups or 150 groups. I'm making up numbers and it shows you the percentiles. Okay. I think I've reached the end of my question, Michael. Anything? This has been a lot of fantastic information. Yeah. I imagine a lot of our audiences are entering the job market. And I wish I could have heard this as I was entering the job market. I wanna remind everybody that this will be recorded and you can go back and study all of these acronyms that Nicole and Joel have mentioned. It'll be present, but I wanna thank our experts, Nicole Knight and Joel Sauer from MedAxium and especially our host, Dr. David Slotweiner for talking about physician reimbursement and all of its complexity on this episode of The Beat. Thank you so much. Thank you very much. Thank you. Bye-bye.

physician compensation plans

productivity models

work relative value units

compensation per work RVU

fair market valuation

Stark Law compliance

Anti-Kickback Statute compliance

False Claims Act compliance

revenue cycle processes

ASC ownership for EP docs