All right, so let's get this session underway. So welcome to Health Policy and the session that's titled Why You Should Care About Health Policy at HRS. So we're always trying to get more people to care, and so it's my pleasure to welcome you. I'm Chris Liu. I'm an electrophysiology physician at Cornell Medical Center in New York, and along with my co-chair, Scott Greenberg. So if you've not already done, hopefully you've already done downloading the app, and you can use that to ask questions. You can scan the QR code on the screen to access the questions Q&A, and also log in with your HRS credentials. Please note that visual reproduction of Heart Rhythm 2025, either by video or still photography, is strictly prohibited. All right, great. So this session, we're going to talk about some of the basics and advanced concepts in care. Thank you, Chris. So thank you for inviting me to give an overview of the AMA CBT and RUC process as no conflicts. I just wanted to start by saying for those of you who are interested in a deeper dive into the AMA CBT and RUC process, we have done a webinar, which is online at The Beat episode 5. So I definitely encourage you to check that out. It goes into more detail than I can possibly do in 12 minutes. By way of background, the AMA has been working with CMS collaboratively since about 1992 to develop what's called the Resource-Based Relative Value Scale. The AMA is not contracted with CMS. It's really just an organization representing physicians using their First Amendment free speech rights. But it's worked out to be very productive for both sides overall. And the objective of the collaboration is really quite simple. It was to come up with a scheme, first of all, to identify with a code all the procedures that we do across the House of Medicine, and then come up with a way to value the work across the House of Medicine. So there's a way to compare what pediatricians do to what electrophysiologists do to what neurosurgeons do, et cetera. And the components of the work are described below. But the main component is really called the physician work component, which comprises time, physical effort, and mental effort. And we'll go into how these are evaluated in more detail. The AMA has two components. The first is the Common Procedural Terminology Committee, or CPT Committee, which is the group that develops the terminology and code descriptors. I'm sure you're all familiar with the CPT codes. I'm going to spend most of the time talking about the RUC process, because I think that's probably what more of you are interested in. But we're definitely going to talk about the CPT as well. Every CPT code also has to have a relative value, a resource-based relative value. And that is done by the AMA RUC Committee. Now, when are codes valued? Well, they're all valued, of course, when they're first created. Any new code has to be assigned a work value. So any code created by the CPT Committee goes to the RUC for a value. And when there's a modification to the work of a code, that may also trigger another revaluation of the work. But there are many other reasons codes can get valued. If there's a rapid increase in utilization of a code, if there's new technology, for example, if codes suddenly start to be built frequently together, then it seems like it may be one procedure rather than two separate ones. That, of course, happened with AFib ablation and 3D mapping. And if codes have a very high practice expense, or if the site of service changes, or if they haven't been valued for a long time, they may come up. And then there are always other reasons as well. But there are multiple reasons that codes may be valued or revalued. Now, the process at a 30,000-foot level starts when the AMA RUC decides that a code has to be revalued. And then they contact the societies that represent physicians who perform those procedures. For electrophysiologists, that generally means not only us, but also the ACC and sometimes SCI as well if there's overlap. We then create a survey, which I'll talk more about in a moment, and then send that out to members. Once the results come back, we compile those results and we present those to the RUC committee. More to come on that. And once we reach a mutually acceptable recommendation on a work value, those go back to the overall RUC, and that goes to CMS. CMS doesn't have to accept that. It's just an advisory role. They usually do, although increasingly that's been less consistent. And then they're published in the Medicare fee schedule. That's the high-level view. Now I want to dive into the survey a little bit more, because I think that is something that a lot of people have questions about, and that's where most clinicians come into contact with the RUC. There are very specific parts to the survey, and the RUC has given us very little flexibility on how to design the survey. So those components are first the code descriptor. And again, I'll go into more of these in detail on the next slide. So the code descriptor, then identify a reference procedure. So we'll give some similar procedures and ask you to compare it to that, then estimate the time you think it takes to do the procedure being surveyed, compare it to the reference procedures, work RVUs, and then you're asked to give an estimate of how many RVUs you think that procedure being surveyed should be valued at. Now each one of those we'll go into a little bit more. The code descriptor, here is the actual code descriptor for afib ablation. 62-year-old male with a history of hypertension and recurrent atrial fibrillation. Despite rate and rhythm control with antibiotic drugs, he remains symptomatic. A comprehensive EP study with transeptal catheterization and PVI is ordered. Now what I want to point out about that descriptor is it's very, very minimal. There's very little detail. And that's not by accident. We are not allowed to give any additional factors that might paint the picture of a patient who has a more complicated scenario. And we have to get approval for that code descriptor before the survey can go out. It needs to be accurately describing more than 50% of patients who come for the procedure. And as you take the survey, you'll be asked if you think that is a typical case. If respondents indicate they don't think it's a typical case, that could make the results of the survey difficult for us to defend when we bring the values to the RUC committee. Now here I put together an idealized reference service list that you would like to see when you're taking a survey, for example, for afib ablation. Because these are all things we do, right? We know ECGs. We know diagnostic EP studies, pacemakers, SVT ablation, afib, and VT. And so it's pretty easy for us to estimate where the work of an afib ablation falls in this list. For those of you who have taken the surveys, they don't look like this. And the reason is there are a lot of reasons we cannot use particular codes on the reference service list. For example, we wouldn't put ECGs there because it's too low. All the EP studies also are part of the same family as the afib ablation. So often those are being evaluated at the same time, which prevents us from putting them on the survey. But also there are strategic reasons why we might think it's dangerous to put them on the survey. If they're not being surveyed at the same time, we might be asked to then do another survey to survey all of them. And every time you survey codes, the value goes down. So we have to be very strategic. And dual-chamber pacemakers, we can't put on it because they have a different global period. They have a 90-day global period. So we can't compare it to afib ablations that have a zero-day global period. So that's why you're more likely to see a reference service list that looks something like this, where we're comparing afib ablation to a hernia repair or a craniotomy. Now, that's a bit extreme. We try not to do that. But the reason we are often forced to do that is because we have to match the global period of the code being surveyed. We need to come up. We need to bracket that code that we're surveying. So we think that the work value for the references for that code will fall somewhere in the middle. But it's not just the work value. The times have to also be consistent. Because if the times are off, then we won't be able to defend the recommended work value from the survey. And to make it even more complicated, the RUC has certain codes they really like that they think are particularly well-valued and accurate. So we have to choose some of those to put on the list. So that's why you'll often see a list that looks frustratingly unfamiliar. But we do it because we're trying to get the best value and the most accurate value. So for example, for that particular list there, these are what we're looking at behind the screen. So hernia has these are the times. So the intra-service time is really the most important. The hernia is 45 minutes intra-service. A craniotomy to remove a brain tumor is 200 minutes. So right now, AFib is about 180 minutes. So we want to fall somewhere in the middle. Same with those work RVU values. We need to bracket it. So next, you're asked to estimate the time. I'm just looking, thinking of time. I guess I'm not on a timer. I don't see a timer. OK. Yeah. OK. Just grab a cane if I go way over. So when you're asked to estimate the time it takes you to do a procedure, there are three components, the pre-service, intra-service, and post-service. Pre-service refers to just addressing, scrubbing, and positioning. Intra-service is skin to skin. That's the really important one, of course. And then there's post-service, which is just speaking with the family, and post-operative assessment. And then, ultimately, you're asked to compare the service code being surveyed to the one you think is most similar. And you have to choose one. So then you have to compare the time pre-intra-post. Then you have to estimate the time post-post. Then you have to estimate the mental effort and judgment. So that's the quantity of clinical data you're considering, the fund of knowledge needed to do the procedure, the range of possible decisions, the degree of complexity and other factors, and then the technical skills. But in reality, unfortunately, it really comes down to the intra-service time. Everything else is really just icing on the cake. And then the last component on the survey is to estimate a work value. And I want to just actually go back on the time. People may try to game the time. You want to brag at how fast you do procedures or how long it takes you. Both of those are not a good idea. The best way to do it is to go right in the middle, because they end up throwing out the outliers. And obviously, we don't want to brag how quickly we do procedures when we're getting valued on how long they take. So estimate what you think is really a fair work value. Next, we present it to the RUC committee. And the RUC committee is actually much larger than this committee. And there are representatives from the entire House of Medicine. Each area that I've listed here has one seat with an alternate individual in the background. And we present the results of the survey, go back and forth, and try to come up with a value that we agree is reasonable. Now, an important thing to understand is that when we present an EP code or any cardiology code, cardiology cannot vote on that code. So ACC holds the AMA RUC seat. HRS has never had a seat and never will have a seat. We're too small. But cardiology has to step back when there's any code being valued with cardiology. And same for all the other specialties. And it's in our interest to come up with a recommendation that we can all agree on. Because if we can't agree on it and we go to CMS on our own, we're much less likely to be listened to. So then at the presentation, we'll give the vignette. We'll be asked if it's accurate. We usually present either the 25th or 50th percentile value from the survey. That's about the highest we can ever expect to get accepted. And then, as I mentioned, we negotiate. And while there are many factors that we can consider, the time of the procedure relative to the other times on the reference service list and across the entire CPT codebook is really the most important. After the meeting, then the values get sent to CMS. CMS has no obligation to accept them. The role of AMA is just to voice our First Amendment rights to free speech. There is no contractual obligation. They typically will, but not always. And we only find out whether they've accepted it when they publish the proposed fee schedule sometime over the summer. When the proposed fee schedule is issued, we have a chance to rebut if we are not pleased or if they haven't accepted it. And then we find out the final rule in, I guess, the end of November, typically, which starts in January. That's the process. It's far from perfect. There are plenty of flaws, but if you're not at the table, you are on the menu. And I think I'll leave it there. Thank you. David is one of our representatives at the RUC, so thank you for your service, David. We're going to keep the questions to the end so that we have a dedicated time. Our next presenter will be Amit Tasani, who will be talking about how I work with hospital administration as an EP leader. Thanks, Scott, Chris, for allowing me to talk. I care about health policy because it affects my day-to-day practice. And I'm going to try to give a little bit of discussion about philosophy more than policy. You have a bunch of policy experts here, and I've been working with this group for a year on the Health Policy Committee. I'm going to try to put some context to some of what you'll hear today and relate it to what you're going to go home to. Which one is it? Okay. All right, so I'm gonna focus on two words in the title. This is a loaded title, so for my team that's sitting out there, don't worry. I'm gonna give the PG version of this talk. So I'm gonna focus on the how and the I work with hospital administrators as an EP leader. My relevant disclosures, I'm an advocate for our team and our patients like all of you. These are my opinions. They may not be correct, and they may not be a fit for you and your practice environment, but I'll at least share with you my experience as a hospital administrative liaison for 14 to 15 years now. And as I learned before I traveled to San Diego, Wednesday the 23rd of April was National Administrators Day, which my administrator told me, I didn't know that. So with that said, here's my perspective. It's all about the patients. I think all of us who practice feel this way. And I think that's terrific, and I think it's our job to advocate for our patients, which is why understanding everything that affects them, including policy matters, is important for all of us to understand. But here's the rub. Your administrators may not care, okay? And that's the truth. Your priorities in practice may not be the priorities of your administration, and we are often on different timelines. We're trying to build practices and careers that last decades or longer. And your average administrator may be in his or her position for three to five years. You have to bridge that temporal divide and take this privilege and responsibility as a leader to advance your team, to advance patient care, and take all the national level policy matters into the context of the day-to-day challenges of your practice environment and try to figure out this whole process to get your practice moving forward and generate that professional satisfaction that all of us crave and deserve. So let's talk about the I and how I work with hospital administrators. Here's how I think about this. I'm not an employee, even though I receive a W-2 form. I am a partner, as I see it, in shared success of my program, my practice, my health system. We all took an oath to center the patient in our professional activities, both clinical and administrative. I think that's unique to us, and I think it's part of the value of the folks that are sitting to my left here when they represent us at national and other organizations advocating for our patients. I am inevitably a patient, like all of us, on borrowed time, and I'm committed to the power of working together with my hospital team to build something special, the type of program we want for our loved ones. And I think, ultimately, at least for me and I think for all of you, at the end of your practice, I want to be proud of what we've done together and leave something behind that didn't exist before for the betterment of patient care. So how do you do this in your practice environment? That sounds like a lot of lofty stuff. My business is to know my administrator's business, okay? And so you'll hear today and at this meeting a number of sessions helping us educate ourselves about the impact of EP services beyond our views, okay? And I think that when you contextualize what it is that we do, you need to understand reputation, satisfaction for patients, financial impact of everything that we do in our profession. I think it's important to ask the question of what our team, what your team in EP means to your hospital and to your health system. I think this is critically important. I know this is a partial violation of things I'm not supposed to talk about, but have a general idea of what the financial impact of what you do is to your health system. You don't need to know the exact numbers. You don't need to violate the star clock. But I think it's important to understand the scale of your practice and what it means to your program. Understand then, taking all of that and what you're gonna learn today, the pressures facing your hospital administrators. They don't have the same priorities as you in many cases, okay, and what you can do though is offer to help, figure out some common ground, execute a plan and share that data. And sometimes you can do this without them, okay? And that's an important point, I think, to start to take all the other pressures that you're gonna hear about today from the RUC and RVU readjustments, et cetera, into your practice state. So a little bit about the how. Okay, so I'm gonna talk through how I think about my approach. I spend an inordinate amount of time, as I'm sure many of you as leaders do, thinking about how to execute all that goes into building a practice. And so here are my points. Be my guest, be a self-starter. Focus on patient care excellence, which leads to growth. Know the important data. Find your friends. Anticipate shifts in the landscape. Read your emails that Chris Liu sends you. Learn about leadership. All right, so as far as please be my guest, I think it's very important that your administrative team spends at least a half day with you at some point in their journey in your lab. They have to see you behind the red line. And I think it's really important to contextualize the spreadsheets and the finances they look at all day and understand that there's patients behind each of those numbers. And that's part of what I do. It's part of, I think, all of our jobs as leaders is to make it come to life, to understand that we're not moving widgets, we're taking care of human beings. We come to the boardroom. We usually do it after hours and evenings and dinners and all this time that we dedicate to trying to build beyond our clinical work. But to understand each other, your administrative partners have to see you in your natural environment, which is not necessarily the boardroom. And then when you have that sort of, at least cultural exchange, is when you take some of the things that you'll learn at this meeting and from our policy experts and the folks who advocate for us at the HRS level to educate your administrative team about each of these factors that have affected us recently and will continue to affect us into the future. So how do you do this? How do you offer to help? My team is sitting out here, Josh Silverstein's sitting here and has led a bunch of these efforts for us. You don't need an administrator to make your practice better. You don't need an administrator for a lot of those things to make your practice better. But if you can do so, do it for yourself and do it for your patients and then share the data with your administrators and let them take credit for it. Make them part of the process. Right? This is something we presented at this meeting last year, looking at overtime utilization. Okay, so this is growth of about six to 700 cases over three years and a 50% reduction in overtime utilization by showing up on time, turning labs over and asking our docs to show up when the patient's in the room. Okay, we take this to our administrators. We prove to them that this is something we can do. Look, we did it without you. Okay, but you should be part of this and it creates this synergy and everyone wants to be part of a winning team. And I think we then can translate some of the pressures that we have to making our administrators our partners instead of our adversaries. Patient care excellence is our professional joint responsibility, but growth is your administrative currency. And I don't care how you cut it, but this is the language that I think any health system speaks, no matter if you're academic, private, or somewhere in between. You have to show growth and you have to be growth minded. Chris showed this slide yesterday in the business of EP talk and I think it's important to understand this. You have to know the data when you talk to your administrative counterparts, okay? And so while physician payments, this black line here, have stayed relatively flat over the course of the last 20 years or so, hospital payments have gone up. And I think that when you demonstrate to your hospital team and your administrators that you understand this disparity, understand then that we're not employees, we're partners, and we have a shared success that we have to get right to make the organization move forward. And I think that's the mentality that I take into my discussions with my administrative team, and I'm sure a number of you do as well. I do think that we need to see the pendulum swing more toward a partnership situation rather than a pure employment situation. I think that we as physicians are wired to make things better. We are hard-driving patient advocates. Not all of our administrative partners feel that way, but you will find ones that do, and the ones that you do find that do, you hold onto them, and you keep going back to them and make sure that they help generate some of that bandwagon that you need to keep that momentum going. If I've learned anything important in where I've made my mistakes in my career is this. Trying to do this on your own, you can't do it. That's when I've made sort of my missteps. You need to find your friends and have a community to support you through this. There's enough challenge in your practice locally with staffing and everything else that goes into running a day-to-day practice, and then you add on top of it all the policy issues that come at us from a federal, state, regional, local level, and then it's a mix for a really complicated situation. So working with administrators to build a program requires like-minded partners. Not everyone is going to see eye-to-eye with you. It's okay. It's frustrating, but it's okay, okay? So you've got to find your friends in nursing, anesthesia, supply chain, perioperative services, your division chiefs, your C-suite executives. Tell your story and what you're trying to do for patients to as many people as you can. Doing this in the long haul with everything else that you have to do in your life, clinical, professional, and personal, requires some degree of insanity, but also a supportive network of EP colleagues. You have to have friends to bounce ideas off, and chances are if you're dealing with a problem with, let's say, recent RVU cuts, you know, I called a bunch of folks on this panel to ask, hey, listen, how are you guys handling this? What are you seeing that's working in your practices? How should I approach this? You don't have to reinvent the wheel. Part of learning about policy is the anticipating shifts in the landscape. Everyone knows what we've lived through recently with RVU cuts, but know that there's plenty more coming. Okay, and I think that's really the important part of this session and yesterday's business of EP sessions. Read those emails and stay abreast of what's about to happen, because it's going to affect you, whether you like it or not, usually in a shorter time frame than you'd like. And last point is this. Becoming a leader, mastering policy matters and regulatory matters and practice matters, it's not a natural thing. You have to spend time to learn how to do it, and I think it's a privilege to do because it lets you build a program that you can be proud of, and obviously that's what we're all after professionally, but I think we also need to acknowledge the fact that leadership has costs, right? It's not easy to do. There's plenty to do already, and I think it's part of the reason why being part of a community and learning from folks who are experts in these areas and all the areas that affect our practice is super critically important as you get older and move through your career. I'd like to thank my team who's sitting here at four o'clock on a Friday for their patience dealing with me. This is, we've been on a 14-year process of trying to build something special. I think we have, and with that, I'll stop and appreciate the opportunity to speak. Thank you. Thank you. Great. Thank you, Chris. I would like to thank the Heart Rhythm Society and our chairpeople for the invitation to speak today. The business of electrophysiology is something that I've talked about for nearly 20 years, and I'm really thrilled that HRS is really starting to embrace this as a pillar of the scientific sessions. So let's dive in. We are very lucky in the field of electrophysiology to be in a very dynamic and changing field. There are new technologies, new procedures, new techniques that come out every year, and that's not the case in many medical specialties. If I look at my own career, there's been a tremendous amount of innovation that's occurred in the last 15 to 20 years, and I expect if we fast-forward to the next 15 years, it's going to be even greater. So if we look just at the landscape over the last 15 years, these are all new technologies. It's a limited list, an abridged list of everything that actually has come to pass, but if you look at it, subcutaneous ICD, this didn't exist when I was a fellow, left atrial appendage closure, force-sensing catheters, renal denervation, quadrupler leads, leadless basing, cryo-bloom, cardiomyems, pulse field ablation, CCM, EVICD. These are all new technologies that we're excited and happy to use, but at some point you need to figure out a strategy to bring them into your hospital. So earlier than you imagine in your career, if you're just starting out, you're going to be faced with the challenges of incorporating these new technologies and techniques into your practice, and the question arises, how are you going to do so? How are you going to incorporate these new technologies? Are you going to be an early adopter? So are you going to be the first in your hospital, the first in your region, the first in the country to adopt a new technology? Are you going to wait for more evidence, large published studies before you kind of go down this path? Are you going to actually just wait for some of your colleagues and friends to try something out and then use their experience in your own before you incorporate something into your own practice? Or are you just going to say, I don't want to adopt this, I'm going to actually hire a new partner and I'm going to have them learn this new technique and let them figure it out? And then the question is, how will you justify these technologies to your practice or your hospital, and will reimbursement make a difference? So the first four things on this, that's up to you. You need to have some introspection to see where do you fall on this spectrum of adoption. But these last two, these last two points are the things that I want to talk about today. So let's focus on understanding the costs and the revenue from procedures. So just a one slide primer on billing. So as a physician, you're going to submit a bill for any services that you provide. So this could be office visits, consults, procedures, and from that, you will derive some financial revenue from the payer. And that will either go directly to you or to your practice, whoever does your collections. If you're an employed physician, you're also going to pay some attention to a relative value unit or RVU. You'll hear that a lot in your future careers. Separately, the hospital is going to submit a bill for that procedure. And that's going to be grouped into one of two things, either something called an ambulatory payment classification or APC, if it's an outpatient procedure, or a diagnosis related group or DRG, if it's an inpatient procedure. So let me walk you through some examples here. So this is AFib ablation. So if you look, what is the national payment for Medicare for an AFib ablation in the United States in 2025? It's $24,532. That's the national average. Now if you look nationally around the country, there's going to be some slight variations. There's a secret formula that Medicare uses to adjust payments based on where you practice, what hospital it is, what city you practice. For APCs, for outpatient procedures, that variation is not tremendous. It's fairly modest. But on the inpatient side, there's a tremendous amount of variation. So that cost, that reimbursement of $24,000, has to pay for all of the costs associated with that procedure for the hospital. This has nothing to do with physician reimbursement. So if you look at this example, and I want you to just take away, this is not hard fast numbers that the reimbursement is, but if you look at the costs, these are just back of envelope estimates. Your hospital will have different costs associated with these procedures. But you got to pay for the catheter that you're using to ablate, ice catheters, diagnostic catheters, steerable sheets, an overnight stay, any medical supplies, medications, gauze, whatever it might be that is used in the case. You have to actually pay for the lab time that you're using and anesthesia costs. So if you look at that $24,000, the hospital may be left with about $7,000 of margin on that AFib ablation. Again, it may be higher, it may be lower, but it's just a quick and you know dirty sort of estimate of where we are. If you look at an SVT ablation or flutter ablation, the average Medicare reimbursement is exactly the same. Again, this is Medicare. So if you're with a private payer, it's gonna be whatever your contracted price is with that, with that, with that private payer. But this is average Medicare price. Same for an AFib ablation, same for an SVT. So now what's the margin on this procedure? Well, you may not use an ice catheter, you may use less diagnostics, you may use, you know, you may not keep them overnight in the hospital. So all of a sudden, the profit to the hospital may be nearly double what it is for an AFib ablation, $14,000 for that procedure. On the outpatient ICD side, the average Medicare reimbursement, the APC, is $32,839. Again, if it was an inpatient ICD, it's gonna be more than the outpatient. So now you've got to pay for the device. Again, I put in $12,000, it may be more, it may be less. You've got to pay for the overnight stay, the medical supplies, the lab time, the anesthesia costs, and the hospital's gonna net $15,000 on that ICD implantation. All right, so now let's shift to bringing in new technology, and I'm gonna give you a couple examples. Some it's old now, some of it's still evolving. So let's talk about subcutaneous ICD. It's an interesting story. Left atrial appendage closure, pulse field ablation, and then something that doesn't necessarily have a financial return on investment, radiation protection for you and your staff. So subcutaneous ICD, it came out about 15 years ago or 2012, so 13 years ago. It rolls up to the exact same APC as a standard transvenous ICD, but the device costs more. Again, just a ballpark figure, $24,000. You've got all of the associated costs, and the profit to the hospital all of a sudden for that subcutaneous ICD, if it's a Medicare patient, is $1,300. Now if you remember back from a couple slides ago, that was $15,000. So when this first came out in 2012 and in 2013, there were many electrophysiologists who were like, this is my new standard. I'm gonna switch virtually every ICD I possibly can to a subcutaneous ICD because it's just better for the patient, less risk of extraction issues, and so on. But what you just did was slash the margins of the hospital by 92%. So you have to pay that attention to what's happening in your landscape. You're not working in a vacuum. So I'm gonna just briefly pivot to the doctor for a moment. So this has all been about hospital billing, but whenever a new technology or procedure comes out, it starts with something called a Category 3 code. This is the CPT code. So when something's under research and development, there's a Category 3 code assigned to it, and at the appropriate time, HRS and other societies petition the AMA CPT committee to convert these to Category 1 codes. So Dr. Liu, who's on stage, and I are the HRS representatives. This is AMA CPT committee. So from 2012 to 2014, when the subcutaneous ICD was first gaining traction in the United States, it only had Category 3 codes. There were no RVUs associated with that procedure, and then eventually it transitioned to a Category 1 code. So if you're a hospital-employed physician dependent on RVUs, don't assume you're receiving RVUs when you start bringing these new technologies in. There will be a payment associated with it, but you may not get any RVUs. So it's just something to be aware of. Let's talk about left atrial appendage closure. So this was approved the United States in 2015. The average DRG at the time, because it was an inpatient-only procedure, was $21,673, and you can see when you add up the costs, the estimates of the costs of the procedure, we're suddenly in a money-losing situation, a negative about $3,000 for an average Medicare patient. How have things changed? It's been 9 years, 10 years since it came out. Well, if you look at this year, there's been a slight increase of about $500 to that DRG, but the hospital still would end up losing about $2,700 on that procedure. What about pulse field ablation? So $24,532, the same as that AFib ablation, but now you've got a more expensive ablation catheter. You've got maybe some savings that you could extract on other parts of the procedure, like maybe less lab time, less anesthesia costs, whatever it might be, but I'm estimating that the profit to the hospital for that procedure is going to be about $5,000, so you've just cut the profit down by about $2,000 for your hospital. Now, maybe you're going to make up for that by a volume, because it's quicker procedures. You know, there's trade-offs here. So how do you justify new technology to your hospital? So first, you want to understand the costs and the revenue, and so I'm just giving you some examples of how that process evolves. How do you want to think about these things? You want to understand what the capital costs would be to bring equipment in, what are disposable costs for catheters and other things that would be necessary to expend. You want to evaluate what options are for purchasing of that capital equipment. Maybe there's a direct purchase option, maybe it's sort of rent to own deals or deals utilizing disposables. You want to understand other things. So there's something called a pass-through payment. I didn't talk about that. It doesn't typically apply to Medicare, but some private payers, like say a Blue Cross or Blue Shield, may say, you know what, if you're doing a left atrial appendage closure device, our contracts can allow you just pass that entire cost to us, so you don't have to worry about that coming out of your bottom line. It doesn't happen often, but it does happen selectively. And then some technologies, actually when they get approved by Medicare, have a new technology add-on payment or an NTAP. So the Evoque total tricuspid valve replacement or renal denervation right now, both have NTAPs associated with them. So it's just something to be aware of as you start to do your financial analysis. So you want to take all that information and evaluate, is this going to help revenue? Is it going to hurt? Just because a new technology doesn't have a favorable financial impact, there are potential other benefits, and you want to look at that when you're evaluating these technologies. So is there a quality improvement opportunity here? Is there marketing opportunities? Is there sort of a halo effect of downstream revenue that could be materialized? Are there efficiencies, like the PFA story, that you could be doing these procedures in a more efficient or faster manner? Is there a patient safety involved? Is there physician safety? And this brings me to the radiation protection idea. So radiation protection is good for us, it's good for our staff, it doesn't really have any financial impact to our to our bottom line of our hospital. In fact, it could be a big expense. So how do you justify the high cost of this to your hospital? Well, one of the things I want to instill upon you is that you're working very hard, very long hours, and you don't want to sacrifice your well-being and safety because a product doesn't have a favorable financial impact. So how do you do this? How do you bring something like this on board? Well, much like Amit was saying, you want to be a good citizen and a partner to your hospital, and I've used this slide for 20 years. Patient care is easy, everything else is about relationships, and it's very important that you not have an adversarial relationship with your hospital. You want to be a partner, you want to get to know your administrators, you want to participate in hospital fundraising events. When you speak to administrators, highlight the successes you're having, minimize complaints, adhere to vendor contracts to keep your costs low, understand the hospital's bottom line, and understand what your EP portfolio entails in its entirety and what the impact is to the hospital. Join committees, and then we all tout this line, if you're not at the table, you're on the menu. Those of you who are sort of younger additions to the electrophysiology community, John Day, at least to me, immortalized this saying about 20 years ago and before he became president. He's always used to say this, and I think we've all sort of taken it on as EP gospel. So if you're not at the table, you're on the menu. So final points. This is really an exciting time in electrophysiology. It's just a wonderful field to be in, and as you embark on your career, start to think about how you're going to advance your skills, embrace technologies in the coming years and decades, and where you are personally on that adoption spectrum that I outlined. Work to have a favorable relationship with your hospital, focus on patient care, that's what this is all about, but invest time in understanding the economics of EP. And I stress this to you because it's not about the money, but it is hard to ablate a fib if you can't turn the lights on in the EP lab. Take care of yourself, and that's where the radiation protection and other things like that really fall into play, because no one else really is going to. Thank you. Excellent talk. Our next speaker is going to be Jonathan Dukes. He's going to be talking about EP and ASCs, the current status and future outlooks. Good afternoon, everyone, and thank you for holding out to join us for this great session here at the end of the day here on Friday. So yes, my name is Jonathan Dukes. I'm the director of cardiac electrophysiology at Community Memorial Hospital in Ventura, California, and I'll be talking about EP in the Ambulatory Surgical Center, what's happening now, and what's the future. Here are my following disclosures. I think the most pertinent disclosure is I do have an ownership stake in an ASC in Ventura, California. So let's talk about the surgical centers. Why should we be using an ASC? There's been a lot of discussion recently about ASCs, particularly as we have been discussing among ourselves, both in the HRS community as well as what's occurring nationally at a federal level, in discussing the benefits of ASCs in the potential cost savings and in improvements in care that can occur if we start to move cases towards an ASC. And what are the pros for this? There are advantages for health care costs. There's efficiency, patient satisfaction, and physician revenue considerations. But what are the disadvantages? The cons are the question of safety, startup costs, contracting considerations, especially for employed physician models, as well as revenue effects on local hospital systems. And so all of these two things come into play and are important as we consider what is the future outlook for ASCs. Now why is this being encouraged for us? Now we shoot ourselves back to 2020. The story for me is that my vascular surgeons that work in an office just below ours, and I'm part of a seven person cardiology group, six general cardiologists, plus myself making up the partnership circle, plus we have an employed electrophysiologist that as a recent relative the recent grad. And we entering into, they approached us in 2019 asking if we wanted to partner with a surgical center that they were then building. They had been doing procedures in an OBL, in an office-based lab, and they wanted to expand and create an ASC because they could see the the changes that were coming to reimbursements on the OBL level. They wanted to know if the cardiologists wanted to be involved. Fast forward one year, then we hit COVID. Hospital shut down and we're not able to put in our devices in our patients because not all devices were considered emergent from the hospital and even emergent cases were not occurring for about two to three months. So as a result we started shifting a lot of a lot of business over to the ASC. At the same time Medicare saw that this was an opportunity to do some testing. And why? Because on average Medicare reimburses ASCs about 58% of the value that they often give to hospitals. And so Medicare was interested, one, because it allowed for care to continue while the hospitals were being overburdened with COVID patients. But two, because it was inherently less expensive for them to perform the procedure at the ASC. What is also quite telling is Kaiser, a Kaiser system in our area, and Kaiser is very attuned for the numbers, they started using a private ASC in the LA Basin even though they had their Woodland Hills Hospital only to five miles away. And they started sending their own physicians to perform GI and orthopedic procedures within that private ASC not owned by Kaiser. They found that it was less expensive to send their own physicians and to pay a facility fee to a private group than have the procedure done in their own own hospital. Which demonstrates that there are significant cost savings that come from the ASCs. And Medicare has noticed this and it has quite, it has significant interest and is encouraging us to go in that direction. They haven't quite allowed us to go for, go for ablation as I'll talk about later, but they are encouraging it from a device standpoint. And so, and if we look, the amount of procedures were formed in ambulatory surgical centers is only, is only increasing as time goes on. This data is a little old, is looking at from 2008 to 2011, but we look at this, this data from the ASCA shows that there's been a continued increase in number of procedures performed on Medicare beneficiaries with an almost 50%, 15% increase over a three-year time period. What data has not been published would be the interest in seeing what's happened from 2020 through 2025. And our own, our own experience locally in Southern California is that these numbers have only continued to increase. And so, why else should we think considering about in ASC? Well, the EP, what we find is the ASCs are inherently more efficient. Procedures take less time to perform ambulatory surgical centers and costs have also been inherently decreased. And as you look over here, as you look at the outpatient surgical procedure times by facility type, so there, there is a, there is a significant reduction in surgical times for, for, for neurological surgery, general surgery, as well as in the post-operative care. It resulted in a significant reduction in total time in the ASC compared to the hospital use, hospital time periods. You can see that's here on the green is hospital and the red is the ASCs. There is almost a, they're taking a routine surgical procedure, you're looking at an almost 30-minute reduction in time in a procedure, in total time spent about 150 minutes. You also, given this, are seeing significant reduction with time savings. Time is everything, time is money. Reduction in time is, is estimated cost savings. Looking at at least $300,000 per outpatient case reduction just due to the time alone. But there's also additional savings come from both lower capital costs, personnel and facility costs. Since most, particularly in our area, when you compare the, the, the costs of staff compared to a union hospital versus, versus a privately owned ASC, the cost, the differences in reimbursement to the nursing staff is significant. And why else should we be considering this? There also is the patient-physician compensation concerns, and this is the perfect example. We see that there was, between 2021-2022, we see a 34% reduction in total Medicare fees, but this only further increase, further decreased in 2023 to 2024, with a final, with a final, final value is being look at, looked at about $870 on average for affibrillation with, with, with its bundled components. There's also the question of patient satisfaction. This is interesting because it's cited in multiple reviews and in multiple white papers from the Ambulatory Surgical Center. Interesting thing is, I think this is actually an area of what needs to be improved in research. I couldn't find any actual published data backing up the improved patient satisfaction claims that are often made. I can say anecdotally that within our center, with my patients that have gone both to the hospital and to the ASC, prefer to the ASC because there's less time prior to the procedure they need to be present. They often only show up at 45 minutes to 30 minutes before their case, and they're often out faster. So those that have seen the change between the hospital procedure and non-hospital procedures have noticed the difference, but I think this is an area where extra research is needed. It begs the question, though, how safe are they? EP procedures at Ambulatory Surgical Centers have been shown to be safe, and we first started looking at the idea of what about same-day discharge, since a surgical center would require a same-day discharge. And this study published in 2020 showed that when we were first discussing whether same-day discharge for ablations was safe, showed that same-day discharge patients, on average, had a very low rate of post-procedural complications, as well as a bounce back to the hospital. And overall, if you look at the, if you select the patients appropriately, the likelihood for a same-day discharge can be estimated pretty well if you choose patients based on age, as well as comorbid factors. But if you start to look at longer, not longer, case, we found, at least in the hospital admissions, the later the case time, the more likely that the procedure would result in an overnight stay. And so what we've done in our surgical center is just make sure that we don't start cases after 1 p.m. Therefore, we can guarantee that the patient will leave on the same day, and are unlikely to bounce back to the hospital, or be transferred to the ER late in the afternoon if we're having trouble with the bleeding, or need extended stay because of, extend the stay because of post-procedural pain. Overall, though, if we look at overall complications, the odds ratios, if you, again, choose the comorbid conditions correctly, overall are quite low. When you look at EP procedures in ambulatory surgical centers, they also have to consider new technologies. And if we start to consider more performing ablations in the surgical center, which seems to be more of the future based on our surveys, pulse field ablation offers improved safety in addition to increased efficiency. And again, just to emphasize, as we're talking to the broader community, we need to be emphasizing that the increased safety that comes with these new ablation technologies, not so much the efficiency standpoints. And the safety numbers really panned out as we looked at the close-up data. We saw less pulmonary edema in the pulse field ablation arms. We actually saw a low rate of stroke in the ADVENT trial, and we also saw a very low rate, we saw a very low rate of, we had almost zero systemic embolism demonstrating the overall safety of this. If you look at the important numbers, the cardiac tamponade or perforation, those were slightly higher in the pulse field ablation than thermal. But remember that ADVENT was the initial and early trial looking at the fairway system. And the initial, there were some initial in the first couple experiences with in certain centers, there were some perforations, but now that we've had increased experience, especially with better wire management, that has become more of a moot point. So what happened during the pandemic? We have a couple publications that have looked at what happens when AF ablation was performed during the pandemic or just prior to it in states that allowed it on private payers, and what was the safety rate? Overall, we see is the overall major safety events was relatively low at 1.5%. There were seven patients that had to be admitted to an ER for secondary adverse outcomes. One needed intubation because of undiagnosed pre-existing pneumonia. One was bradycardic post-conversion. Two had groin bleeds requiring prolonged care. One radial artery line bleed required surgical intervention. And this can be ameliorated without avoiding radial arterial lines or patients that might require that. So avoid our sickest patients in the surgical center. And two were just slower to awaken from the anesthesia. As we look at another publication just released last month in Heart Rhythm, and this showed a retrospective study of six ASCs and compared their patients, the patient that these same operators took to the ASC and compared it to their own hospitals and looked at the safety data between. You can see if the procedures that were performed, the types of procedures were both TEEs, cardiac device implantations, including both low-voltage and high-voltage devices. A few CCM devices, EP studies, and catheter ablation procedures, the vast majority of which were RF ablations of atrial fibrillation. And what they found most importantly was they found no significant difference in event rates between those patients that were performed in the ASC versus matched patients that were performed in the hospital, demonstrating that overall event rates are quite low for adverse events and they are comparable to the hospital. And if you look at the overall urgent unplanned admissions, the rates were well less than 1%, and 30-day post-hospital admissions were also quite low. So where does this leave us? In a survey that we did in 2023 as part of this committee, looking at patients that were admitted to the, looking at physicians at HRS in their comfort level with proceeding with ASC procedures, overall, the vast majority of EPs are comfortable with the idea of generator changes performed in the ASC, new ICD and pacemaker implants as well, but dropping off to a smaller percentage of physicians that were comfortable with ICD implantations and particularly with extractions. When it comes to ablation, those patients that are, those physicians that are doing same-day discharge are also fairly comfortable doing the procedures, doing left-sided procedures as AFib in an ASC, approximately 75% of surveyed participants. But when we get to more complex procedures like VT ablation, which also has a significant increase in morbidity associated with these sorts of procedures, you start to see a significant drop off. So the question is, is it safe to do an EP procedure in an ASC? I would say the answer is yes, and it can be done properly in selected patients, but we need to make sure we're choosing our patients carefully and identifying those of most benefit. If by doing so, my personal belief is that we can give benefit to the health system by dropping costs because the lower associated costs for insurance and for Medicare compared to procedures performed in hospital, and we can perform it more efficiently. In this day of PFA where a lot of us were hoping that we would just be getting out early because we're performing procedures more efficiently, we're finding now that we're actually just doing more procedures because more patients are coming through the lab and we're still leaving at the same time. The ASC will provide us additional efficiencies and reduce patient dwell times that I think would allow us to be able to achieve that kind of quality of life goal that I think we're all expecting. The one thing, and as I close, given that my time is gone, I will just give one small antidote just to consider. One of the things about being part of an ASC is some of the things that Sumit was discussing. It's very, you have to be very cognizant of the costs that are involved. A lot of ASCs have failed mostly because the physicians were not willing to be, were not willing to be efficient both in product use as well as not being cognizant about what the associated costs were compared to reimbursement. The important thing is that we don't go cheap on our patients. You don't want to start using products that are either too outdated or not safe just because they're inexpensive. You want to provide our patients with the best quality of care. But their trick is providing the best quality of care while at the same time staying within a reasonable budget. And the nice thing is that the device companies are very willing to work with you and are willing to find this happy medium. We just have to be careful that as we're part of an ASC, not looking at the bottom line as your be-all and end-all. The bottom line is actually taking care of patients but at the same time making sure you can cover your costs. And that can be done and it can be done efficiently but it requires you to be cognizant of everything you're doing. And with that, I will turn the time back over to Dr. Liu and Dr. Greenberg and we will open the time up for any questions. Thank you so much. All right, so we have a few minutes for questions. So Dr. Dukes, first question pertains to what you just talked about. What do you attribute the decrease in case time in ASCs versus hospitals when both sites have incentives to be efficient? It's an excellent question. I think there's a few things. I find that at the ASC, my staff is a little bit more motivated to, I think, make it faster. I don't get, where at my hospital, I get pushback. We got pushback, we try to, I'm sure Mike's working. We got pushback from the nursing staff when we asked them to help with cleaning the room to reduce room turnover time because they said, well, we have EVS to do that and it's not really in our contract. Whereas at the ASC, it was well-established that the nurses will help with cleaning of the room and turnover and that we would, and that there's an incentive for them that can be put in in terms of financial incentives to make sure that they're staying efficient and on task. We also find that there is less steps with the ASC. A check-in involves, ASCs pushing, bringing less patients through than say a standard admitting for a hospital that has like 30 ORs plus 10 cath labs. Since you have three operating rooms and that's it, you have staff that can register the patient into your system, place an IV and be ready in 30 minutes. Whereas it's 30 minutes just going through admitting downstairs plus getting upstairs into the pre-op area and then they're in line because they're trying to get 30 other patients ready at the same time. I think there's just, it's a little bit more bespoke and allows you to be faster. One more question and it's not an easy answer. How do we balance the value of our procedures versus research and how do you show the value of the latter to administrators? That's for Sumeet then. I can. So, the value, again, it all is about relationships. It's give and take. That's how I've always approached this over the many years. As I said, not everything we do is going to have a financial return on investment to the hospital but they have to understand the entire portfolio of everything we do. I've always done that through emphasizing efficiencies, our cost reduction strategies, our partnership, the good work that we're doing, that whole sort of underlying theme of highlighting our successes and not having every encounter I have with administration be a complaint as I've seen some of my co-chairs do where they're always, oh, this isn't working, that's not working. It's not been a successful strategy for them. So, with things like investments in education, investments in research, it really is channeling our other successes to make sure that they're committed to the entire portfolio of what we bring to the table. Yeah, and if I might add, one of the things which when I sold research to our hospital, it's a fairly competitive environment with a number of other nearby hospitals also having EP labs. And the discussion was if we do research, we'll be the first in the area to get XYZ technology. We'll be the first in the area to get the latest PFA technology. We'll be the first in the area to get the next version of the Watchman. And by doing so, they can actually use it as part of a marketing tool that then has actually brought patients in because they're asking for the new technology and they know that this is the only place they can get it. And so, for one, it ended up being a marketing tool for them and two, the research itself, if done properly and negotiated properly, should be revenue positive, especially for large corporate trials. And so, I also made a point that with research, there's gonna be some home runs in terms of some projects and what we might collect for it. And there might be some that are a little bit more cost neutral. But if you do more of the cost neutral ones, then it will set us up to get more of the home runs. And so, I think there's ways that you can show that it's not a huge sink in terms of cost, but at the end, there's other ancillary benefits. And again, like Sameet was saying, it's about working with your team and showing that you're bringing value both to the patients as well as to the hospital. And Ameet, you guys built a research program. Yeah, what do you have to add? Yeah. So, I'd say that we got lucky in that part of building to what Jonathan was just saying leads to reputational capital. And at least locally, we have a partner, we're named after Mario Lemieux now, who's a hockey player and has a triple relation and his foundation supports our program. Before that though, that was fortunate in 2019, before that, we actually worked with our administration to include research productivity as part of our physician compensation. So, we've sort of pushed the envelope beyond the RVU. And we decided as a group, a unified group, which is our leverage, that we would one, stick together, but two, do so for the purpose of building value into the program as we saw fit. And that's a whole different discussion I can have with you if anyone's interested afterwards, but I think that in and of itself led to, in some ways, setting us up to get lucky. And I also think it can help build the team spirit, which I think is what you're talking about. I think if the staff understands that it's part of a mission, it's not just a factory and you really believe in what you do and continuing to get better, the staff see that. And I think they become more invested and it just helps everyone buy into what you're doing. Yeah, actually, I'll add just one word about that. It's the whole idea of innovation, right? And innovation is an investment. It also does pay off in many of the ways that you all have talked about and in the ways that Jonathan talked about it, is that research should actually be revenue positive. And you know that HRS is an organization that is built upon innovation, research, education, and HRS is a financially sustainable operation. And that's how it does it. And so there is a business model built in there and not each piece needs to be necessarily a huge moneymaker, but it's all part of the mission and ultimately everything builds upon each other. All right, with that, we'll close the session and wish you all an enjoyable rest of the meeting. Thanks everyone. Thank you.

health policy

electrophysiology

Chris Liu

Scott Greenberg

CPT codes

RUC process

Resource-Based Relative Value Scale

Ambulatory Surgical Centers

healthcare economics

practice management