March 2023 marks my 11th year with MedAxiom. During this tenure, I’ve had the privilege of being the lead author on MedAxiom’s Cardiovascular Provider Compensation and Production Survey, including this past year which was its 10th Anniversary Edition. As a consultant now for over a decade, I’ve been witness to many changes in cardiology, with one significant being the deep subspecialization of the provider workforce.
When I first put pen to paper (or ones and zeros to a word processor), MedAxiom published just four cardiology subspecialties: electrophysiology, general/non-invasive, invasive and interventional. In the 2022 report that number had expanded to six with the additions of advanced heart failure (HF) and adult congenital. It likely won’t be too long before a seventh is added to recognize advanced imaging and/or structural heart – or other concentrated subspecialty areas.
My point is that cardiology is a deeply subspecialized team sport. While our patients have just one heart, they are likely to have multiple cardiovascular providers who all must work in harmony to deliver the best care. Therefore, it seems logical that our cardiology compensation models should also recognize the team – not only the individual’s contributions – in delivering high-value heart care.
Compensation Model Trends
According to the 2022 MedAxiom survey, the majority (55%) of cardiology compensation models are based solely on individual production (Figure 1). These plans most often rely on work relative value units (wRVUs) as defined by the American Medical Association for the Centers for Medicare and Medicaid Services. One-third (32%) of programs have a blended compensation model, where there is a portion tied to individual production along with a “sharing” component that in part recognizes the team contributions. This sharing strategy is probably the most common method for ascribing value to team efforts in cardiology.
What has come into play more frequently of late is caps on individual physicians in shared income models. These caps, imposed in the name of “fair market value,” are typically related to the physician’s resulting compensation per wRVU or less frequently compensation to cash collections ratio. To be clear, I am not a fair market valuator and cannot opine on the merits of these calculations or caps, nor is that the intent of this blog. What I can say unequivocally is that these individual caps interfere with the group’s strategy of rewarding the team – something that as an expert in the industry and as a consumer of cardiology services I value highly and find disruptive to patient care.
Even in these team-oriented models, the compensation pool that is shared is most often created entirely (or predominantly) based on wRVU production. While wRVUs are great for measuring relative billable work by physicians in a fee-for-service reimbursement world, they are not great at measuring individual contributions relative to the overall value of patient care and do not recognize the team as a whole. This is where I believe panel size can offer an appropriate alternative – or companion – production measure to the wRVU.
Panel Size as a Production Measure
Panel size is measured at the group level and is defined as the unique number of patients seen in a face-to-face or virtual cognitive encounter (evaluation and management spectrum of the CPT codes) during the past 18 months. For example, if Joel Sauer is seen eight times (consults and follow-up visits) by four different cardiology providers during the past 18 months, he counts as one for the panel calculation. If Joel Sauer only had an echo interpretation done by a cardiologist in the last 18 months, he would not count at all. In the 2022 MedAxiom survey (based on 2021 data) the median panel size per FTE cardiologist was 1,753.
Long a production measure for primary care physicians, I believe panel size makes good sense for measuring cardiology work as well. First, it is measured at the group level and is therefore inherently focused on the team as opposed to the individual. This has multiple benefits, but one that jumps out is that work can be distributed to the appropriate care team member (such as an advanced practice provider) and the team still gets credited. This could mitigate some of the economic resistance to letting go of “personally performed” services.
Second, panel size doesn’t discern value differences for what is done to the patient – it’s about the patient as a whole. In fact, a patient who is appropriately treated with medical management and frequent cognitive encounters has the same value as a patient who requires a battery of testing and procedures. In a wRVU compensation model, the provider remuneration between these two patient scenarios is vast. Clearly one patient consumes more cardiology resources than the other, which may need to be recognized, but this is where a blending of the two production measures can be deployed.
Patient Panel in Action
A very real example of where the above comments can rear its ugly head is with the subspecialty of advanced HF. Often these physicians concentrate on some of the most difficult patient populations in cardiology, which require frequent touch points through cognitive encounters. While the value of this work is very high to the group and the patient – tailoring care in a focused practice and largely removing these patients from general cardiology panels – the wRVU system under-appreciates these contributions relative to other cardiology work (Figure 2).
Third, panel size rewards access – something that is perennially at the top of health executives’ priority list. It’s also been my experience that programs have struggled to find other good methods for compensating access. As defined earlier, panel size grows by adding new patients to the practice. However, focusing only on new patients will lead to diminishing returns so groups must also appropriately maintain and manage existing cardiology patients. To balance these requires intentional focus on building sufficient new patient slots into scheduling templates, matching return visit demand with templated schedules, and effectively utilizing the entire care team for the delivery regimen. In short, this describes moving away from episodic and provider-centric care delivery to a more comprehensive panel-oriented approach, which lays the foundation for population management and ultimately going at risk.
Planning For the Future
For the reasons above I believe panel size provides a strong cardiology production measure in deeply subspecialized groups. It checks lots of boxes that are important to patients and cardiology leaders, both in today’s reimbursement environment and as we look ahead to heavier emphasis on risk and overall value. As we shift into new payment models it’s hard to imagine the wRVU maintaining its dominant (singular) weight in measuring cardiology production.
Any remuneration system can be gamed and I’m sure if I thought hard about it, I could come up with myriad ways panel size can be manipulated in negative ways. While unfortunate, this should not rule it out for consideration as ubiquitous wRVU compensation systems have well-documented vulnerabilities and shortcomings.
It’s important to note that any compensation model must pass compliance scrutiny, including being appropriate within the market (fair market value). Panel size is not a “free pass” from valuator analysis and individual physicians may be subject to the same calculations that exist now.
However, conversations with our valuator community reveal a big reason for focusing on just a few metrics – such as compensation per wRVU – is that these measures are well-worn and a trove of peer data exists. By building alternative data points, including ample published peer data (MedAxiom has published cardiology panel size for nearly a decade now), we bolster the tools valuators can bring to the table. Given how many calls I’ve had from frustrated cardiology program leaders with thwarted team-based pay models, we owe this to our community.
There are examples of panel size in cardiology compensation models within the MedAxiom membership and examples we plan to showcase during future CV Transforum conferences. What do you think?