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REPORT:
2015 Cardiovascular
Provider Compensation
and Production Survey
FORWARD
A Wealth of Information
By Joel Sauer
MedAxiom is proud to be publishing its 3rd annual Cardiovascular
Provider Compensation & Production Survey. These data, obtained from
our vast cardiovascular membership, provide invaluable peer comparisons
to programs trying to manage themselves at peak performance—more
and more a prerequisite for success in the tightening economics of
healthcare.
Joel Sauer
With each iteration of our publication MedAxiom attempts to refine and
expand the data available, and this year’s survey is no exception. For the
first time this survey contains valuable data for non-clinical compensation,
including administrative (leadership) positions, medical directorships and at-risk incentive
compensation. This information provides critical insight into value-oriented compensation for
our fair market valuators, allowing programs to better align provider compensation with the
new value economy.
VICE PRESIDENT
MEDAXIOM CONSULTING
Additionally, MedAxiom added a structural heart (TAVR) filter to its database, allowing direct
comparisons between programs with and without these services. This granularity gives a
more accurate peer assessment for important measures like diagnostic testing patterns,
work and compensation.
Pushed in large part by Medicare’s rapid transition from volume-based reimbursement to
one tied inextricably to value (quality, cost, service), healthcare as an industry is changing
at an unprecedented pace. At MedAxiom, we believe data sharing and peer-to-peer
networking provide the most powerful means for advancing cardiovascular programs
nationally. Our sole focus on the cardiovascular segment allows us to get extremely deep
and detailed into that world, providing our members with a wealth of useful and relevant
metrics. This publication is just one example of this powerful network.
MEDAXIOM CARDIOVASCULAR PROVIDER COMPENSATION & PRODUCTION SURVEY – 2015
3
CONTENTS
Contents
Forward ................................................................................................................. 3
Survey Highlights & Insights.................................................................................. 7
1. Aligning Economics with Value: The New CVSL Imperative ............................. 9
2. Overview of the Report .................................................................................. 14
3. Survey Results – Cardiology ........................................................................... 16
Ownership Comparisons ................................................................................ 16
Subspecialty Breakdowns ............................................................................... 18
Changes by Geography ................................................................................. 19
Key Volumes & Ratios ..................................................................................... 20
Panel Size ....................................................................................................... 23
Structural Heart Comparisons ........................................................................ 24
4. Survey Results – Surgery ................................................................................ 25
5. Survey Results – Non-Clinical Compensation................................................. 27
6. Delivering High Quality, Low Cost Care: The Growing Role of .................... 28
Advanced Practice Providers and Care Teams
Cardiology Tables ................................................................................................ 36
Surgery Tables ..................................................................................................... 38
Non-Clinical Compensation Tables ..................................................................... 40
APP Tables........................................................................................................... 41
5
EXECUTIVE SUMMARY
Survey Highlights & Insights
Continuing a trend, overall
$542,000
cardiology compensation ticked
up slightly in 2014; the median
moved from $512,401 per
Most of this gain is
Full Time Equivalent in 2013
to $542,000 per FTE in 2014.
attributable to a significant
INCREASE
However, most of this gain is
$512,401
change in subspecialty
per cardiologist
attributable to a significant
reporting mix within the
change in subspecialty reporting
private cohort.
mix within the private cohort.
The result of this survey bias
caused the private physician
compensation to spike over
10 percent from a median
level of $425,897 per FTE in
Production
10,351
2013 to $470,160 in 2014.
levels keep
per cardiologist
A detailed explanation of
9,862
falling
per cardiologist
9,637
this bias can be found in
9,538
per cardiologist
the narrative under “Survey
per cardiologist
Results – Cardiology” later
in this publication.
$29,599
Overall production levels, as measured by work Relative Value Units (wRVUs), fell for the fifth straight
year. Median cardiology production for 2014 now sits at 9,538 per FTE physician. In a similar trend, total
imaged stress studies fell back for a fourth straight year, dropping from an annual rate of 286 per FTE
in 2013 to 272 per FTE in 2014. A significant contributor to this decline was the continued erosion of
nuclear SPECT volumes where the ratio of tests performed to total cognitive encounters (a strong measure
of cardiology patient population) dropped from 9.0 percent in 2010 to just 7.1 percent in 2014.
In an effort to more accurately measure cardiology patient populations, MedAxiom added a patient panel measure
and started collecting data for the 2013 survey. Now with a clarified definition and robust member participation,
this metric will allow for more consistent testing and procedure comparisons than either the FTE or cognitive
encounter denominators can yield. Beginning with the 2016 survey, relevant trending data will become available.
Some specific volume measures using patient panel as the denominator can be found on page 23 of this report.
On the surgical front very little difference is noted between compensation for cardiac versus vascular
surgeons, with the former measuring in at a median of $584,854 per FTE and the latter just slightly
behind at a median of $570,345 per FTE—a difference of 2.5 percent. In sharp contrast, production
between these two cohorts, as measured by wRVUs, differ significantly with vascular surgeons
(9,085 per FTE) producing 22 percent fewer than cardiac surgeons (11,653 per FTE) in 2014.
7
EXECUTIVE SUMMARY
Surgeons’
Compensation
Like the findings in cardiology, surgeons in the integrated
environment fare significantly better than those in private
practice. For 2014 that difference was greater than 36 percent
with integrated surgeons showing a median compensation
level of $592,804 per FTE and private a median level of
$434,546 per FTE.
$592,804
$434,546
Non-Clinical Compensation Measures
36%
Also new to this publication are measures of key non-clinical
compensation metrics. These find that the median level of total
non-clinical compensation earned ($45,457 per FTE) is
approaching 9 percent of median total compensation.
Further, the at-risk incentives that are put in place as part
of co-management or other physician alignment strategies
are quite challenging to achieve. For 2014
the median ‘achieved’ was just 80% of the
total available in at-risk compensation.
It is by publishing these cutting-edge
measures that MedAxiom hopes to
continually move the needle forward for
cardiovascular programs across the country.
DIFFERENCE
PRIVATE
9%
NON-CLINICAL
COMPENSATION
INTEGRATED
Non-Clinical
Compensation
Leadership Positions
Medical Directorships
Call Coverage
Hospital/Health System Incentive Earned
Hospital/Health System Incentive Available
Non-Governmental Payor Incentives Earned
Non-Governmental Payor Incentives Available
ALIGNING ECONOMICS WITH VALUE: THE NEW CVSL IMPERATIVE
1. Aligning Economics with Value:
The New CVSL Imperative
Value both for the patient & organization
BY JOEL SAUER
Not that long ago we were talking about
value-based reimbursement in the same vein
we discussed personal jetpacks; probably
inevitable but way out in the future. Well,
that all changed earlier this year when the
Centers for Medicare & Medicaid Services
(CMS) announced very ambitious and
near-term goals to move 50 percent of
its reimbursement to some form of value
(Figure 1a). For those keeping track, by the
time of this printing the CMS fiscal year
2018 will be just two short years away!
Shortly after the CMS proclamation,
the nation’s largest commercial carriers
announced the formation of The Health
Care Transformation Task Force, with the
goal of shifting 75 percent of their contracts
to include incentives for quality and lowercost services by 2020.1 Between CMS and
these aligned commercial plans, you have
nearly 100 percent of the cardiovascular
patient population covered. So the value
train has indeed left the station and
now programs nationally are moving
to align around this new paradigm.
FIGURE 1a –Target percentage of Medicare FFS payments
linked to quality and alternative payment models in 2016
and 2018
This Change Won’t
be Easy or Quick
Like anything new in an industry as
complicated as healthcare, this fundamental
shift in how business is conducted won’t
happen easily or without intention.
Just about every aspect of the current
infrastructure, from data systems to
compensation plans, is oriented around the
volume paradigm—and every single one will
9
need to be retooled. What promotes success in the volume world is often in direct conflict with success in the
value world.
For instance, few would disagree that for the patient, readmissions are best to be avoided. However, in the volume
world readmissions mean additional revenue to a hospital. On the physician side, readmissions are also additional
work Relative Value Units (wRVUs) and revenue. This in no way is to even hint that any provider would intentionally
promote or allow a readmission to occur, but in its current state, improving patient care hurts margin.
It is this type of malalignment—and there are many more, both from external payors and inside our own
organizations—that needs to be squared. This alignment will take considerable time. Fortunately, many programs
are well on their way. To the rest, get started!
Measurements of Value are Improving
What is also interesting to watch is how the sophistication level of these “value” measures is increasing as those
who pay for services not only expand what they can measure, but also which needles actually make a difference. For
example, in the early years of the Physician Quality Reporting System (PQRS) most providers considered the metrics
nothing more than “checking boxes” with little to no impact for the patient regardless of how well they scored.
Similarly, the combined CMS and Joint Commission effort around hospital-based Core Measures were largely
regarded as documentation speed-bumps, not as strong correlates to quality or value.
Few would discount the importance
of patient satisfaction as an overall
indicator of healthcare value, and in
fact many early provider incentive
plans included patient satisfaction
improvement as a payment metric.
However, moving the needle from a
97 percent to 98 percent approval—
certainly a laudable advance—provided
little to no “bang” to the organization,
particularly from a financial standpoint.
FIGURE 1b – VBP Domain Weighting Percentages
Apparently CMS’ analyses of the data
yielded similar conclusions. At the same
©MedAxiom
time it announced the shift to 50 percent
value-based reimbursement, CMS also notified providers that it was shifting the value weighting within the overall
Value-Based Purchasing program (the collection of the individual initiatives), moving away from process and service,
and over to outcomes and efficiency—aka “cost” (see Figure 1b). Many expect this shift to continue in the future.
Public Data is Quickening the Pace of Change
Pushing advancement forward on the value front is the expansive and
growing publically available healthcare data. HospitalCompare (https://
cms.gov/hospitalcompare) and PhysicianCompare (https://cms.gov/
physiciancompare) are two examples of CMS making data available
to the public and in a very easy-to-use web-based portal. Figure 1c
provides a sampling of other public sources of healthcare data.
The original cohort of these data were from Medicare claims, strongly
tied to reimbursement and the economics of medicine, but more loosely
to the clinical side. However, this vast warehouse of claims data is now
being married with true quality measures from sources like the American
College of Cardiology’s Catheterization Percutaneous Coronary
Intervention (Cath PCI) and the Society for Thoracic Surgery’s (STS)
10
FIGURE 1c – Public Data Sources
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©MedAxiom
registries. The marriage of these formerly separate data sets will allow for correlate studies on cost and outcomes,
filling a huge void in the ability to measure overall value.
The power of this expanding knowledgebase cannot be underestimated and it’s likely the pace at which its
sophistication grows will only increase, giving payors and other healthcare stakeholders more tools for measuring
value. It’s also important to note that the interest in these data goes beyond traditional healthcare patients,
providers, payors and consumers; entrepreneurs and investors are also taking note and finding creative ways to
leverage the data for profit. So if you don’t feel like the current measuring sticks accurately reflect quality and value,
just wait, they’ll get there—and fast!
Growing Physician/Hospital Partnerships
There is no denying that the declining economics within the
private cardiology practice model drove some, if not all, of the
migration to hospital or health system employment. However,
in its 2013 Annual Integration Survey, MedAxiom found that
over three quarters of respondents cited the evolving healthcare
market as a major motivator for integration.
At the time of that survey, barely more than 50 percent of
cardiology practices were integrated with a hospital or health
system. Today that ratio is 73% (Figure 1d). For cardiovascular
surgeons it’s even higher, where 85 percent are in an integrated
environment. On the private group front, many are establishing
co-management and other financial alignment strategies with
hospitals to sync risk and reward. The bottom line is that in
the new value economy hospitals and cardiovascular physicians
are partners going forward—regardless of where the physicians
are employed—and leveraging this partnership will be a key
to success.
Although no one, including Medicare, really knows exactly what
50 percent value-based reimbursement looks like, this is clear:
physicians control or influence nearly 100 percent of the costs in
healthcare2, so having them engaged beyond just clinical quality
will be paramount. In response, more and more hospitals and
health systems that employ physicians are moving a portion of
compensation away from traditional production measures, like
work Relative Value Units (wRVUs) to value indicators. Similarly
with the private group setting, hospitals and physicians are
partnering around value through legal vehicles such as gain
sharing arrangements, co-management, clinically integrated
networks and the like.
The value indicators used for incentives in these partnerships
tend to be very specific to the organization, but are generally
centered on three main categories, collectively referred to
as the Triple Aim: quality (outcomes), service (stakeholder
satisfaction) and efficiency (cost). Figure 1e shows the top
5 value initiative categories based on the MedAxiom 2013
Annual Integration Survey.
FIGURE 1d – Ownership Split
©MedAxiom
Physicians control
or influence nearly
100 percent of the
costs in healthcare.
FIGURE 1e – Top 5 List of Value Initiatives
1. Heart Failure Care Improvement
2. Process Improvements
3. Reductions to Length of Stay
4. AMI Care Improvement
5. Patient Satisfaction Improvement
©MedAxiom
11
New Peer Data Available
In anticipation of the need for data around value compensation, in 2015 MedAxiom added several key value
measures to its Annual Survey. The definitions for these new measures can be found in Figure 1f, with the actual
data contained in the table on page 40 toward the end of this publication. Following are several important call-outs
from these data points.
FIGURE 1f – Non-Clinical Compensation Definitions
Include only payments not at risk for performance, such as time or
stipend based chair positions and administrative leadership positions
(CMO, CMIO, CVSL Director, etc.). NOTE: Do not include medical
directorships here; they go in the box below.
Include only payments not at risk for performance, such as time
or stipend based directorships (cardiac rehab, cath lab, EP lab,
non-invasive imaging, etc.).
Call Coverage
Call pay for STEMI, general, outside facilities, etc.
Hospital/Health System Incentive
Compensation
Include non-production performance (at risk) payments for
improvements to quality, serivce and cost, co-management incentives,
VBP, gain sharing, administrative incentives, etc. Please also provide the
total payment available in Column C.
Commerical (non-governmental)
Payer Incentive Compensation
Include non-clinical performance (at risk) payments for improvements
to quality, serivce and cost, coding & documentation, etc. Please also
provide the total payment available in Column C.
©MedAxiom
First, looking back at the 2013 Annual Integration Survey,
it’s noteworthy that the percentage of at-risk compensation
for cardiovascular physicians has grown from approximately
7 percent of total compensation to 8.4 percent. Anecdotal
evidence from the MedAxiom Consulting team based on work
with integrated systems across the country suggests this trend
will continue into the future and may be accelerating. Second,
these value incentives are far from slam dunks. Figure 1g shows
that only 80 percent of the available incentives were actually
earned; 20 percent were not achieved. Last, it is interesting to
note that the total non-clinical compensation earned per FTE
physician is over $45,000, which is nearly $1 million in aggregate
for the median sized group. That’s real money!
12
FIGURE 1g – Median Incentive
Achieved vs Available
©MedAxiom
©MedAxiom
Conclusion
For years now there has been speculation as to IF and WHEN
reimbursement would shift from volume measures to quality,
service and cost. With the recent announcements by Medicare
and major commercial carriers, those questions have been
answered. Still ahead is the frontier of direct population health,
but the current reward/penalty system Medicare has created
around the Readmission Reduction Program (RRP) relative to
the heart failure population is already providing a glimpse of
the challenges that lay ahead.
Given the nature of the
overall cardiovascular
product spectrum,
physicians and hospitals will
need each other for success
in this new environment—
regardless of where the
physicians are employed.
Through all this murkiness there is clarity on several fronts. As a
group, physicians are the single largest influencer of healthcare
costs overall. In order to succeed in a value economy, this
asset must be oriented and economically aligned with both
organizational and third party payor value objectives. These
changes will take significant time and effort which, given the pressing timeline, mandates that programs get earnest
soon. Further, the amount of value data currently available is vast and growing. Expect the sophistication and
meaningfulness of these data to improve, and for the pace of this evolution to increase over time.
Given the nature of the overall cardiovascular product spectrum, physicians and hospitals will need each other for
success in this new environment, regardless of where the physicians are employed. This mutual dependence will
require careful thought around Triple Aim initiatives and a commitment to recognizing and dealing with economic
misalignment, whether in compensation models or co-management agreements. The consequences of missing on
this front will bring painful, albeit predictable, results.
1
Modern Healthcare, “Major providers, insurers plan aggressive push to new payment models”, January 28, 2015.
2
Health Care: The Disquieting Truth” [NYR, September 30, 2010], Arnold Relman, MD
13
OVERVIEW
2. Overview of the Report
Methodology
Each year in early spring MedAxiom surveys its membership on financial, staffing, productivity, compensation
metrics, and a number of demographic measures such as location, size of practice, ownership model, physician
subspecialties, and so on. Data is submitted through online data entry and via direct exports from the practice
management system.
Member submissions are processed in MedAxiom’s data warehouse and compiled into over 800 measures for
member analysis. Members then use MedAxiom’s proprietary Business Intelligence tool, called MedAxcess,
to perform many different types of analyses. MedAxiom also extracts its own data to create reports for the
membership, partnering organizations, and the public.
The physician compensation and production data provided in this report was collected over the 2008-2014
timeframe. It has also been filtered to only include full-time physicians.
MedAxiom Data Integrity: The Vetting Process
MedAxiom realized long ago the importance of well-vetted data and how errant information can destroy the
value of a data set. With this recognition, MedAxiom now goes above and beyond in its pursuit of data integrity.
The fact-checking process begins with an automated comparison of self-reported RVUs to those calculated by
MedAxiom based on the CPT upload provided by our members. If there is a discrepancy of 1% percent or greater,
a more thorough review of the data is triggered. Additionally, data manually entered online immediately shows the
operator a trend for comparison to the previous year. This provides an instant review if there are large differences
from year to year.
Once data is loaded into our MedAxcess database, some of
the critical measures relating to Full Time Equivalent physicians
and mid-level providers, as well as some elements of financial
information, are verified to make sure that they are in
alignment with the statistical norms of the rest of the database.
A set of limits defined by a team of cardiology administration
experts is the key to this step. All data points are examined
against their own same-practice historical trend and against
the practice’s peer set to determine if the data point is outside a reasonable range. If a data point is determined to
be an outlier it is excluded from the data set until the practice is contacted and the data point can be verified. Once
confirmed or corrected, the data point is allowed back into the data set where it can be viewed by other members
in a de-identified fashion.
MedAxiom goes above
and beyond in its
pursuit of data integrity.
Data verified this way is included in the overall calculations such as percentiles, mean, median, and standard
deviation. All submitted data goes through a rigorous process that relies on cross-checking, computer-automated
vetting and review by human eyes, with follow-up phone calls and emails to data submitters when there are
questionable results.
Having the right measures and high data integrity is what has made MedAxiom’s data the most trusted data in the
cardiovascular industry.
14
OVERVIEW
Demographics
A total of 150 practices, which represents 2,574 full-time physicians, completed the 2014 Annual Survey. Not
represented in this survey were an additional 352 part-time physicians. The integration trend continued to
accelerate this year as the number of hospital integrated practices (113) again outnumbered the private groups (37).
The median size of the responding groups to this year’s survey was 15 FTE physicians.
2014:
150 total practices
2,574 physicians
OWNERSHIP MODEL 2012-2014
NUMBER OF PHYSICIANS
COMPENSATION METHODOLOGY
PROVIDER BASED BILLING
GEOGRAPHIC AREA
15
SURVEY RESULTS – CARDIOLOGY
3. Survey Results - Cardiology
Ownership Comparisons
Let’s start off with a great example of how survey data has to be considered carefully so as not to draw
inaccurate conclusions. On the surface it looks like the biggest surprise in the 2015 data is that private physician’s
compensation jumped by more than 10 percent from $425, 897 in 2013 to just over $470,000 in 2014 (Figure 3a).
This would represent a pickup of over $44,000 per full time equivalent (FTE) cardiologist.
FIGURE 3a – Cardiology Compensation per FTE by Ownership
$500,000
$555,411
$555,365
$600,000
$470,160
$425,897
$400,000
$300,000
30%
$200,000
18%
$100,000
$-
2013
2014
Private
However, when we look at
the subspecialty participation
rates as compared to last year
(see Cardiology Table in the
back of this book), we see that
the number of non-invasive
physicians—the lowest paid of all
the subspecialties—participating
in the survey dropped from
201 in the 2013 data to 126 in
2014. By contrast, the number
of participating interventional
physicians—the highest paid of
the subspecialties—jumped by 31.
It is this ratio mix that caused the
overall median to increase, not
any real improvement in private
physician compensation over the
past year.
Two key data points support this
conclusion. First when looking at
the individual subspecialties within
16
Integrated
©MedAxiom
It is this ratio mix that caused the overall median
to increase, not any real improvement in private
physician compensation over the past year.
TABLE 3a – Private Physician Compensation per FTE
2013
2014
% DIFFERENCE
Electrophysiology
$456,337
$460,621
0.9%
Invasive
$425,000
$428,378
0.8%
General Non-Invasive
$394,586
$411,667
4.3%
Interventional
$479,017
$497,840
3.9%
©MedAxiom
TABLE 3b – wRVUs Comparison by Ownership
2013
2014
% DIFFERENCE
Private
10,246
10,438
1.9%
Integrated
9,411
9,210
-2.1%
©MedAxiom
the private cohort we see that none improved more than 4.5% from 2013 to 2014 (Table 3a). Since the comparisons
are at the median (half above, half below) the reduction in lower compensated physicians (general non-invasive)
and the increase in higher compensated physicians (interventional) pushed the median upward. Second, private
physician productivity, as measured by work Relative Value Units (wRVUs) increased less than 2 percent (Table 3b).
Since wRVUs correlate very strongly with physician compensation, it seems unlikely that a 2 percent increase in
production could translate into a 10-plus percent spike in compensation. A 5-year trend on wRVU production can be
found in Figure 3b.
FIGURE 3b – Median wRVUs per FTE Cardiologist
10,800
10,600
10,400
10,200
10,000
9,800
9,600
9,400
9,200
9,000
10,536
10,507
10,351
10,438
10,336
10,084
9,862
9,678
10,246
10,007
9,709
9,637
9,411
9,538
9,210
2010
2011
2012
Private Groups
2013
Integrated Groups
2014
Overall
©MedAxiom
FIGURE 3c – Private Group Revenue per FTE Cardiologist Trend
$1,400,000
$113,060
$1,200,000
$100,000
$1,000,000
$82,660
$80,000
$70,134
$800,000
$60,000
$600,000
$40,000
$400,000
$200,000
$120,000
$24,026
$20,000
$-
$-
2011
2012
Patient Service Revenue
2013
Total Revenue
2014
Net Difference
©MedAxiom
There is an interesting trend within the private cohort
patient service revenue per FTE cardiologist (Figure 3c).
It would appear that private groups are gaining expertise
at earning revenue beyond just patient services, as the
net difference between total and patient services has
grown from around $24,000 per doctor in 2011 to over
$113,000 in 2014. There are myriad sources for this extra
revenue, but often a major source is through hospital
contracts for co-management and other value-oriented
objectives. Later in the survey we will publish more
detailed information on compensation for these types of arrangements.
The net difference between
total and patient services has
grown from around $24,000
per doctor in 2011 to over
$113,000 in 2014.
Looking back to Figure 3a we see that integrated doctors simply held steady with last year. This means
mathematically that private physicians closed the gap with integrated physicians by a significant margin over the
past 12 months, narrowing the differential from 30 percent in 2013 to 18 percent in 2014. Again, the survey bias
described above is the major driver of this improvement so only future surveys will provide clarity on the true spread
between these two groups.
17
FIGURE 3d – Overall Cardiologist Compensation per FTE
$542,000
$545,000
$540,000
$535,000
$530,000
$29,599
$525,000
$520,000
$512,401
$515,000
INCREASE
$510,000
per physician
$505,000
$500,000
$495,000
2013
Driven then almost entirely by the gains of the private
cohort, overall cardiology compensation increased nearly
6 percent to $542,000 per FTE, around $30,000 more
per physician than in 2013 (Figure 3d). The previous high
water mark for cardiology was in 2012 when the median
compensation topped $548,000.
2014
©MedAxiom
To produce the same
number of total wRVUs,
an integrated group
would require two
more physicians than
a private group.
Private groups continue to have higher production, as
measured by wRVUs, than their integrated peers (see
Cardiology Table in the back of this book). The production
gap widened in 2014, stretching from just over 800 wRVUs
per FTE to over 1,200 wRVUs. When considering that the
overall database’s median sized group is 15 cardiologists,
which is fairly consistent between private and integrated
groups, that production difference is equal to two FTE
cardiologists. In other words, to produce the same
number of total wRVUs, an integrated group would require two more physicians than a private group. At median
compensation of $555,000, that equates to an additional $1.1 million in provider compensation.
Subspecialty
Breakdowns
TABLE 3c – Compensation per wRVU by Ownership by Subspecialty
In addition to total
compensation and wRVU
production, MedAxiom
calculates a compensation per
wRVU data point. It’s important
to note that this is not the
same as a wRVU conversion
factor, a common term used
for the contractual payment
rate in integrated employment
models. The calculated rate
discussed here and reported
later in the tables is simply
18
2013
2014
% DIFFERENCE
Overall
$53.78
$53.47
-0.6%
Private Blended
$41.59
$42.63
2.5%
Electrophysiology
$36.41
$36.89
1.3%
Invasive
$43.77
$47.94
8.7%
$41.59
$42.20
1.5%
Interventional
$41.97
$44.01
4.6%
Integrated Blended
$57.21
$56.67
-0.9%
Electrophysiology
$51.86
$50.80
-2.1%
Invasive
$55.89
$56.30
0.7%
$62.30
$61.33
-1.6%
Interventional
$57.43
$56.56
-1.5%
©MedAxiom
total physician compensation
divided by total wRVUs.
Overall the compensation per
wRVU rate remained flat in
2014 (Table 3c). These same
data show only modest changes
at the subspecialty level, with
private invasive and private
interventional achieving the
largest gains at 8.7 percent
and 4.6 percent respectively.
When reviewing compensation
at the individual subspecialty
categories all physicians except
the interventional cohort saw
increases from 2013 to 2014,
as shown in Table 3d. The
biggest increase went to
non-invasive physicians (7.7%),
then to electrophysiologists
(5.6%) and finally invasive
cardiologists (3.9%). A
subspecialty breakdown by
ownership model can be found
in Table 3e.
TABLE 3d – Compensation per FTE Cardiologist by Subspecialty
2013
2014
% DIFFERENCE
Electrophysiology
$525,664
$554,958
5.6%
Invasive
$521,740
$542,000
3.9%
$454,837
$489,776
7.7%
Interventional
$564,654
$563,485
-0.2%
©MedAxiom
TABLE 3e – Compensation per FTE Cardiologist by Subspecialty
PRIVATE
INTEGRATED
Electrophysiology
$460,621
$574,459
Invasive
$428,378
$554,157
$411,667
$500,000
Interventional
$497,840
$595,056
©MedAxiom
TABLE 3f – wRVU Production by FTE Cardiologist
2013
2014
% DIFFERENCE
Electrophysiology
11,495
11,624
1.1%
Invasive
9,502
9,350
-1.6%
8,211
7,858
-4.3%
Interventional
10,322
10,188
-1.3%
©MedAxiom
Turning now to production,
EP was the only subspecialty
to see gains, although slight, in wRVUs per FTE from 2013 to 2014 with just a 1.1 percent increase (Table 3f).
Even this very small gain for EP is noteworthy, however, as it is the first increase in wRVU production since 2010.
Outside of EP all other subspecialties lost ground on production, with General Non-Invasive physicians falling
back the most (4.3%).
Changes by Geography
Compensation in the Northeast region jumped nearly 17 percent
from 2013 to 2014, by far the largest gain in the database (Figure
3e). In stark contrast, both the Midwest and West pulled back in
total compensation, 3.4% and 5.4% respectively. Additionally, the
Midwest fell from the top earning spot—a position it has held since
2010—and the South took over as number one.
Northeast region
jumped by nearly
17 percent.
The Northeast was able to achieve these gains
despite a decline in wRVU production (Table 3g), which suggests that some form of survey bias may
again be at play. Only the South region—still the reigning champ in terms of wRVU production—
saw gains from 2013 (Table 3g). The West, which had the largest compensation decline as noted
above, also had the largest wRVU decline, losing nearly 10 percent from 2013 to 2014.
Figure 3f shows the compensation per wRVU calculation for each region. It is somewhat expected that this figure
rose for the Northeast based on the results described above. Less expected was that the West also improved its
compensation per wRVU at nearly the same rate.
The full cardiology data tables including historical years can be found on pages 36-37 at the back of this publication.
19
FIGURE 3e – Changes in Compensation by Region
20.0%
$600,000
16.7%
$500,000
15.0%
10.0%
$400,000
5.5%
$300,000
5.0%
0.0%
$200,000
-3.4%
$100,000
-5.0%
-5.4%
-10.0%
$Northeast
South
Midwest
2013
2014
West
% Chng
©MedAxiom
FIGURE 3f – Compensation per wRVU by Region
$62
$60.30
$60
$58
$56.91
$56.24
$56
$54
$52.54
$53.69
$52.35
$50.63
$52
$50.41
$50
$48
$46
$44
Northeast
South
2013
Midwest
West
2014
©MedAxiom
TABLE 3g – wRVUs per FTE Cardiologist by Region
2013
2014
% DIFFERENCE
Northeast
9,103
8,731
-4.1%
South
10,173
10,586
4.1%
Midwest
9,242
9,147
-1.0%
West
9,108
8,276
-9.1%
©MedAxiom
Key Volumes & Ratios
Continuing a trend, cardiologists are performing a decreasing percentage of their total cognitive encounters, as
defined by the Evaluation & Management (E&M) spectrum of the CPT codes, in the hospital. Figure 3g shows that
total encounters are almost flat, but the number performed in the hospital fell for a fifth straight year. This is in
keeping with healthcare trends in general, where more and more of the delivery is happening at an outpatient level.
Total new patients to the practice, a strong indicator of a healthy practice and a key driver of other production
measures, jumped to 567 in 2014 on a per FTE basis (Figure 3h); this is the highest level seen since 2011. In contrast
to this improvement, but in keeping with a historical trend, total imaged stress studies per FTE cardiologist fell for
the fourth straight year (Figure 3i).
20
FIGURE 3g – Trends on Encounters per FTE Cardiologist
3,000
2,845
2,816
2,819
2,856
2,738
1,853
1,878
1,849
1,854
1,908
965
954
867
851
829
2010
2011
2012
2013
2014
2,500
2,000
1,500
1,000
500
-
Total Cognitive Encounters
Total Office Cognitive
Total Hospital Coginitive
©MedAxiom
FIGURE 3h – Total New Patients
580
570
566
567
566
560
550
540
530
526
527
2012
2013
284
286
2012
2013
520
510
500
2010
2011
2014
©MedAxiom
FIGURE 3i – Total Imaged Stress Studies
400
350
335
335
300
250
272
200
150
100
50
2010
2011
2014 ©MedAxiom
It is important to note using FTE cardiologists as the denominator may not give us the best picture of a true trend.
First, this count presumes all FTEs are the same from one group to the next and we know this isn’t the case just by
variations in time off (Figure 3j). Second, the volumes for each physician may be strongly impacted by differences
in group demographics like age distribution, the number of physicians working reduced schedules and individual
productivity expectations, etc.
For these reasons, perhaps a better indicator of the trend is to use total cognitive (E&M) encounters, which is a
measure of the patient population as opposed to the provider population (we exclude 99211 in this E&M total
as it is a non-physician provider code), as the denominator. For imaged stress studies, this method shows a slight
21
FIGURE 3j – Days Off per Year
60
48
50
40
40
33
26
30
20
10
0
25th
50th
75th
90th
©MedAxiom
FIGURE 3k – Non-Invasive Imaging Ratios per Total Cognitive Encounters
30%
25%
24%
25%
26%
25%
25%
12%
9%
11%
9%
12%
8%
10%
8%
10%
7%
2013
2014
20%
15%
10%
5%
0%
2010
2011
2012
Total Imaged Stress Studies
Total Echos
Total Nuclear SPECT
©MedAxiom
FIGURE 3l – Invasive Volume Ratios per Total Cognitive Encounters
6.0%
5.6%
5.1%
5.0%
4.9%
4.8%
1.7%
1.7%
1.5%
1.6%
1.5%
2010
2011
2012
2013
2014
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
Catheterization
PCI
©MedAxiom
improvement for 2014 moving from 9.4 to 9.6 percent (Figure 3k). In other non-invasive imaging ratios also on
Figure 3k, echoes held steady and nuclear continued a 5-year downward trend.
On the invasive side, both catheterizations and PCI (percutaneous coronary interventions) have declined over the
past five years (Figure 3l). By contrast, pacemaker inserts have held steady when using total cognitive encounters
as the denominator (Figure 3m). ICD implants as a ratio of total cognitive also have fallen four years straight (Figure
3m). ICD implants continue to receive a lot of attention from regulatory agencies and auditors, so there is clearly a
blunting impact from these efforts on volumes. Figure 3m also shows one bright spot in the electrophysiology (EP)
realm with a nearly straight line progression upward for ablations.
22
FIGURE 3m – EP Volume Ratios per Total Cognitive Encounters
0.45%
0.40%
0.43%
0.39%
0.39%
0.43%
0.39%
0.38%
0.38%
0.35%
0.35%
0.30%
0.43%
0.32%
0.29%
0.26%
0.25%
0.25%
0.23%
0.20%
2010
2011
Pacemaker Inserts
2012
ICD Implants
2013
2014
Ablations
©MedAxiom
Panel Size
For three years MedAxiom has been receiving member data on cardiology patient panel size, where panel size is
defined as unique patient cognitive (E&M) encounters during the past 18 months measured at the group level. We
believe panel size is the truest measure of a cardiology patient population, more so than physician FTEs and total
cognitive encounters. It will become the standard denominator for many of the key ratios identified above.
In the first year our sample size was too small to be relevant and there were some known problems with the
interpretation and consistency of the data definition. Last year the sample size grew and the definition stabilized.
For 2015, we feel a high level of confidence in the panel size measure and believe trending will be available starting
next year. Figure 3n shows patient panel size data per FTE cardiologist.
FIGURE 3n – Patient Panel Size per FTE
1,968
2,000
1,636
1,500
1,218
1,000
500
-
25th
Median
75th
©MedAxiom
Table 3h provides some key volume indicators utilizing panel size as the denominator. An interesting call out from
these data is from the catheterization measures. At the median levels we see that approximately one third (34%)
of patients receiving a catheterization also have an intervention. As more and more catheterization registry data
become public, correlates can be run to gain additional insights.
23
Structural Heart
Comparisons
TABLE 3h – Key Volumes per 1,000 Patients (Panel Size)
Continuing its tradition of creating
a more sophisticated and relevant
peer database, MedAxiom has
added a new filter that allows
comparisons at a more granular
level, in this case those systems
with structural heart programs.
The advent of these new product
offerings often has impact on
other traditional volumes, such
as catheterizations. Without the
ability to compare like programs,
inaccurate conclusions might be
drawn about physician ordering
habits, financial impact of the
program and other components.
Table 3i shows these volume
comparisons across several key
tests and procedures.
24
25TH
MEDIAN
75TH
1,075
1,372
1,571
Inpatient E&M
342
559
745
Total Echos
371
465
558
Total Nuclear SPECT
88
129
183
Total Catheterizations
52
76
92
PCIs
22
29
38
Ablations
5
8
11
WITH
WITHOUT
DIFFERENCE
Catheterizations
76
80
-5.3%
PCIs
52
48
7.7%
Echos
453
472
-4.2%
Nuclear SPECT
129
131
-1.6%
Outpatient E&M (exclud 99211)
©MedAxiom
TABLE 3i – Structural Heart Impact on Key Volumes
*Median per 1,000 patients (panel size as denominator)
©MedAxiom
SURVEY RESULTS – SURGERY
4. Survey Results - Surgery
Similar to cardiology, surgeons in an integrated ownership model fare significantly better than their peers in private
practice (Figure 4a), out earning them by more than 36 percent. Interestingly, private surgeons out-produce their
integrated peers by around 7 percent when considering wRVUs as shown in Figure 4b.
FIGURE 4a – CV Surgery Compensation by Ownership
$700,000
$592,804
$600,000
$500,000
$434,546
$400,000
36%
$300,000
DIFFERENCE
$200,000
$100,000
$-
Private
Integrated
©MedAxiom
FIGURE 4b – CV Surgery Production by Ownership
11,370
Private
10,000
10,200
10,400
10,600
10,800
11,000
11,200
11,400
©MedAxiom
10,582
Integrated
11,600
Comparing at the surgical specialty level we see that compensation for both cardiac and vascular surgeons is quite
similar (Figure 4c), varying by less than 3 percent. However, wRVU production between these cohorts is significantly
lopsided, with cardiac surgeons performing 22 percent more units than vascular (Figure 4d).
The full surgical data tables including 2013 historical data can be found on pages 37-38 at the back of this
publication.
25
SURVEY RESULTS – SURGERY
FIGURE 4c – CV Surgery Compensation by Specialty
$590,000
$584,854
$585,000
$580,000
$575,000
$570,345
$570,000
$565,000
$560,000
Cardiac
Vascular
©MedAxiom
wRVU production between these
cohorts is significantly lopsided,
with cardiac surgeons performing
22% more units than vascular.
FIGURE 4d – CV Surgery Production by Specialty
14,000
12,000
11,653
9,085
10,000
8,000
6,000
4,000
2,000
-
Cardiac
26
Vascular
©MedAxiom
SURVEY RESULTS – NON-CLINICAL COMPENSATION
5. Non-Clinical Compensation
In the “Aligning Economics with Value” article above it was noted that reimbursement in healthcare is quickly
moving from a sole focus on volume (wRVUs, CPT codes, procedures done, etc.) to one more focused on value
(outcomes, cost, service). Given the critical role physicians must play in order to be successful in this transition,
new compensation arrangements are springing up to help align economics between hospitals and physicians. Fair
market valuators have noted a dearth of published peer data capturing these arrangements that is hindering their
development—a dangerous miss given Medicare’s rapid migration to 50 percent value-based payments.
Given all of this, MedAxiom is very pleased to be publishing for the first time eight key measures capturing these
“value-based” compensation payments to cardiovascular physicians (Table 5a). This list will undoubtedly grow, both
in terms of number and sophistication, over time just as the rest of the MedAxiom peer database has done since its
inception. By capturing these data points annually MedAxiom will also be able to provide trending data in the years
ahead. The definitions behind each measure can be found in Figure 1f.
TABLE 5a – Non-Clinical Compensation per FTE
25TH PERCENTILES
50TH PERCENTILES
75TH PERCENTILES
$2,373
$6,667
$16,156
$6,667
$11,869
$20,667
Call Coverage
$15,833
$22,853
$34,261
$11,451
$22,046
$38,608
$22,046
$30,000
$56,917
$268
$419
$11,381
$7,722
$10,250
$31,826
Total Non-Clinical Compensation Earned
$13,703
$45,457
$69,884
©MedAxiom
There are several interesting results worthy of attention. The single
largest bucket is for “Hospital/Health System Incentive Available”
at a median level of $30,000 per physician. Given the median size
of the group that responded, this represents a total pool available
approaching $600,000 per year. This money is in some fashion tied
to performance outcomes and therefore, is at risk. When looking
at its companion measure, “Hospital/Health System Incentive
Earned,” we see that these performance measures had some
real substance behind them and were a challenge to succeed, as
the median achieved was 80 percent of the total available.
When you consider all of the compensation earned for these nonclinical “value” activities they total over $45,000 per FTE physician. This
represents 8.4 percent of the median compensation for a cardiologist.
The two at-risk components (Hospital/Health System Incentive Available
and Non-Governmental Payor Incentive Available) total more than
$40,000 per FTE, so the majority of this compensation is performance based.
Non-Clinical
compensation
now accounts for
8.4% of median
cardiology
compensation.
These data will continue to evolve and grow in the coming years. MedAxiom encourages groups to submit data to
help expedite this progression and narrow the variability.
27
APPs AND CARE TEAMS
6. Delivering High Quality, Low Cost Care:
The Growing Role of Advanced Practice Providers
and Care Teams
By Joel Sauer and Ginger Biesbrock, PA-C,
Vice Presidents, MedAxiom Consulting
This isn’t a new story, but it bears repeating: America can’t afford the healthcare system it currently has. Despite all
our best efforts, including passage—and Supreme Court confirmation—of the Affordable Care Act, healthcare costs
continue to eat more and more of our gross domestic product (see Figure 6a). We’ve slowed the pace of this growth,
but the healthcare inflation rate is still far outpacing the economy as a whole and certainly American’s income
growth. If left unchecked, healthcare expenditures will put the US at a severe disadvantage in a global market.
FIGURE 6a – Healthcare as Percentage of GDP
19.5%
19.1%
19.0%
18.5%
18.1%
18.0%
17.5%
17.6%
17.2%
17.0%
16.5%
16.0%
2012
To put this spending into context,
the Organisation for Economic
Co-operation and Development
(OECD) finds that the US spends
2-1/2 times more on healthcare
than the average of the rest
of the world (Figure 6b) and
ranks number one in the world
on total spending. Yet despite
all of this expense, the World
Health Organization ranks the
US at number 37 in the world
in terms of serving the entire
country’s population. Put
bluntly, we’re not getting much
bang for our mega bucks!
28
2015
2019
2023
FIGURE 6b – US Spends Two-and-a-Half Times the OECD Average
APPs AND CARE TEAMS
Part of the problem can be found in wide variations in spending nationally, regionally and even locally. Because
Medicare is now making claims data—both on the hospital and physician sides—publically available, these variations
for Medicare patients are being revealed by organizations like Dartmouth Atlas and others. What the data show is
that there is nearly no correlation between cost and outcomes. Put another way, the US often spends healthcare
dollars needlessly—this has to change.
The Cardiovascular Patient Population is Growing
Beginning in 2008 a perfect storm of negative stimuli hit the cardiovascular segment of healthcare all at once and
from multiple fronts: the economy went off the rails, Appropriate Use Criteria began entering the testing world
and narrowing the “appropriate” category, employers shifted more and more costs over to patient out-of-pocket
expenses, Medicare dramatically cut reimbursement for nuclear and echo testing and cardiology groups started to
sell to hospitals and health systems in a big way. All of this produced major downward trends in volumes as shown
in Figure 6c. These trends were so severe that many were (and perhaps still are) predicting major oversupply in the
number of cardiologists.
FIGURE 6c – Cath Percentage to Total E&M Encounters
8%
7%
6%
5.1%
5%
4.7%
4.5%
4.2%
4.4%
2011
2012
3.9%
3.9%
2013
2014
4%
3%
2%
1%
0%
2008
2009
2010
A couple data points suggest, however, that these trends may be short lived. First, America is getting older.
According to the US Census Bureau, 10,000 Americans turn 65 every single day. Absent any changes to the age
eligibility, these aging Baby Boomers will add 31.5 million new seniors to Medicare by 2030. America is also still
getting fatter. According to the
OECD, the combined overweight
FIGURE 6d – Trends in Prevalence of Overweight (Including Obesity)
and obesity rate in the US could hit
Adults, Projections and Recent Estimates, Selected OECD Countries
75 percent by 2030 (Figure 6d). This
has and is leading to an increase in
chronic disease rates, with heart and
cancer leading the way (number 1
and 2 causes of death in the US). Add
to these numbers general growth in
the population, the impact of newly
insured through the Affordable
Care Act and an aging cardiology
population (Figure 6e) and there
will undoubtedly be some volume
pressures for providers.
29
APPs AND CARE TEAMS
FIGURE 6e – Aging Cardiology Workforce
CARDIOLOGY AGE QUARTILES
2012
OVERALL
2013
2014
EP
Age 46 and below
31%
28%
30%
40%
28%
28%
27%
Age 47-58
41%
40%
39%
42%
38%
33%
40%
Age 59-70
25%
28%
27%
17%
32%
31%
31%
Age 71 and over
2014 BY SUBSPECIALTY
INVASIVE
GENERAL
INT
3%
4%
4%
1%
2%
8%
2%
100%
100%
100%
100%
100%
100%
100%
Unknown Population
There’s one more group of patients that, to date, haven’t been part of the
equation. These are patients with chronic conditions that have not yet had
an acute episode. As Medicare and other payors move to population health,
this group may have a tremendous impact on cardiovascular providers. In
our current system, we won’t find out about this population until they have
some problem that brings them into the office or hospital. However, under
population health where we’re trying to avoid these acute episodes entirely,
we may reach into this group. And since several of the most costly chronic
conditions are within the cardiovascular realm, this population will impact
our world.
Right now several readers are thinking, “But chronic disease management
should be handled by primary care.” In an ideal world this is true.
Unfortunately, projections on primary care availability in the US all come to the
same conclusion: we won’t have enough. The Association of American Medical
Colleges, based on study performed by IHS, Inc., is projecting a primary care
shortage of between 12,500 – 31,100 providers by 20251. The bottom line is
there simply won’t be the resources in primary care to manage the chronic
disease population.
This could be a huge opportunity for cardiovascular
programs. However, given the cost problem detailed
above, we can’t simply extend care of physician
providers costing north of $500,000 per year. We
need to find a new model that leverages much lower
cost resources efficiently and effectively. This is where
Advanced Practice Providers (APPs) are an ideal fit!
Team-Based Care
APPs have been assisting in patient care since the
1970s, but as we look to transform the care that we
need to provide, it is time that we relook at APPs and
their roles in how we take care of patients. A recent
editorial described the use of APPS as a ‘practice
innovation’ that will provide more services in a new
way. Another recent article from the Carle Clinic
notes that high performing organizations promote
a more collaborative role than a functional area of
30
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disease, stroke, type 2 diabetes and certain
types of cancer, and are some of the leading
causes of preventable death
UÊ ÊÃÊvÊÓä£Ó]Ê>LÕÌÊ>vÊvÊ>Ê>`ÕÌÃp££ÇÊ
million people—had one or more chronic
health conditions. One of four adults had two
or more chronic health conditions.
UÊ Ê-iÛiÊvÊÌiÊÌ«Ê£äÊV>ÕÃiÃÊvÊ`i>ÌÊÊÓä£äÊ
were chronic diseases. Two of these chronic
diseases—heart disease and cancer—together
accounted for nearly 48% of all deaths.
APPs AND CARE TEAMS
responsibility.2 We describe this newer model as ‘Team-Based Care’. Team-Based Care requires a challenging
transformation from the traditional doctor-with-helpers model to a new model in which all team members share
responsibility to care for the team’s patient population.
Advanced Practice Providers are made up of Physician Assistants, Nurse Practitioners, and Pharmacists. A ruling by
CMS in 2012 allow all three to be considered part of Medical Staff and granted them the power to perform duties
that they are trained for and allowed to do within their scope of practice and state law. The objective per CMS was
to free up physicians to work on more medically complex patients. As we look to transform cardiovascular care, the
APP will play an invaluable role. There are several key areas in which APPs can contribute including patient panel
(Figure 6f) support, acute care support, and ‘special populations.’
FIGURE 6f – Office Established Patient/Slot Ratio by Physician
PHYSICIAN
TOTAL PANEL
PATIENTS
ANNUALIZED EST
VISIT SLOTS
PATIENT/SLOT
RATION BEFORE
APP ADJ.
ANNUALIZED
APP SLOTS
NET PHYSICIAN
PATIENT VOLUME
PATIENT/SLOT
RATION AFTER
APP ADJ.
A
2000
1200
1.67 pts/slot
800
0
1 patient/slot
B
2000
800
2.5 pts/slot
800
(400)
1.25 pts/slot
C
2000
1500
1.3 pts/slot
800
300
0.87 pts/slot
©MedAxiom
Role in Prevention & Education
Part of our journey to population management is to better understand our patient populations. In the world of
cardiovascular medicine, much of our care centers on secondary prevention and risk factor modification. We see
thousands of patients routinely each year to review risk factors, medications and provide education. This is a perfect
role for a team-based model in which a physician and APPs manage a large group of patients providing routine,
surveillance care.
The addition of APP support to a physician and his/her patient panel would allow for significant expansion of that
patient panel size. An ‘every other’ model with a strong team-based message to the patient can create confidence
in the provider team and the model knowing that the objective is to increase physician access for when the patient’s
needs change and higher level decision making is required. A sample scheduling template can be found in Figure
6g, with the corresponding financial performance from such a schedule in Figure 6h.
FIGURE 6g – APP Schedule 20/30
MORNING
AFTERNOON
PATIENT TYPE
TIME
PATIENT TYPE
TIME
Established Visit (EST)
8:00
1:00
8:20
1:20
8:40
1:40
Urgent Clinic
9:00
Urgent Clinic
2:00
Urgent Clinic
9:30
Urgent Clinic
2:30
10:00
Urgent or Post Hospital Follow-Up/CHF
3:00
10:20
Urgent or Post Hospital Follow-Up/CHF
3:30
10:40
11:00
Patient Follow Up, Telephone, Tasking & Lunch
Patient Follow-Up, Telephone Tasking
16 Appointments Per Day
©MedAxiom
31
APPs AND CARE TEAMS
A second area in which APPs are valuable is in the acute care setting. The addition of an APP to provide hospital
rounding, admission and consult support can increase the capacity of a physician to allow for testing interpretations,
procedures and for seeing additional new patients. A strong APP added to a rounding team will improve access,
patient throughput, and outcomes, all leading to higher quality acute care services at a lower cost. A successful
acute care model has been described as having a group of fellows that just keep getting better but never leave.
The financial performance from an inpatient rounding service provided by APPs can be found in Figure 6i.
Figure 6h – Annualized: Outpatient Clinic Model
ANNUALIZED THE QUANTITIES IN FORECAST
48 WEEKS
5 Days/Week
99213
45%
99214
50%
99215
5%
15 Encounters/Day
DIRECT BILLING NP VISITS
CPT CODE
BILLABLE VISITS PER YEAR
MEDICARE REIM RATE
ANNUAL REV
99213
1620
73.08
$118,389.60
99214
1800
107.83
$194,094.00
99215
180
144.37
Grand Total
$ 25,986.60
$338,470.20
(Forecast Total)
3,600
80% Inc. To
$270,776.16
20% APP NPI
$57,539.93
$328,316.09
©MedAxiom
FIGURE 6i – Annualized Assumption: Inpatient Rounding Model
ANNUALIZED THE QUANTITIES IN FORECAST
48 WEEKS
5 Days/Week
Subsequent Level 2
15
Admission 2
3
Discharge 8
2
15 Encounters/Day
DIRECT BILLING NP VISITS
CPT CODE
BILLABLE VISITS PER YEAR
MEDICARE REIM RATE
99232
3,600
72.36
*.5
$130,248.00
99222
720
138.63
*.5
$ 49,906.80
99238
480
73.03
**.85
$ 29,796.24
Grand Total
4,800
$209,951.04
(Forecast Total)
* Shared visit
32
ANNUAL REV
** Billed under the APPs NPI
©MedAxiom
APPs AND CARE TEAMS
Innovative APP Role
for Care Coordination
& Care Transitions
FIGURE 6j – Sample Heart Failure Clinic Schedule
PROVIDER 1
The first two areas described are the
‘bread and butter’ of CV care, but
where we are seeing the greatest
impact of a team-based approach is
with our high-risk patients during times
of transition, long-term chronic care,
and higher acuity procedural programs
such as TAVR or VAD. All three of
these patient populations require high
levels of care coordination due to their
complexities and comorbidities.
13:00
A transitional plan that includes early
follow-up in the clinic or even at home
by an APP has proven to reduce
readmission rates and improve longterm outcomes.3 Likewise, a chronic
disease clinic using a team-based
approach has been proven to lower
costs of these patients.4 A sample
scheduling template for a heart failure
clinic can be found in Figure 6j, with the
corresponding cost of care reductions
calculated in Figure 6k . Finally, a
TAVR, VAD or CTO program that
utilizes an APP to increase capacity by
providing consult, peri-procedural, and
post-procedural support will improve
downstream revenue with increased
patient volumes.
14:40
13:10
LCSW
Est Patient
Est Patient
13:20
13:30
13:40
Est Patient A
New Patient A
13:50
14:00
14:10
Est Patient
New Patient A
14:20
14:30
New Patient C
New Patient B
14:50
15:00
15:10
Est Patient
New Patient C
15:20
15:30
15:40
New Patient E
New Patient D
16:10
16:20
16:30
New Patient B
Est Patient
New Patient D
Est Patient
Est Patient
15:50
16:00
PROVIDER 2
Est Patient
New Patient E
Est Patient
Est Patient
Est Patient
16:40
16:50
Team Huddle
Team Huddle
Team Huddle
17:00
©MedAxiom
Physicians want to provide excellent
care across the entire spectrum.
FIGURE 6k – Physician vs APP Cost Comparison in a Specialty Clinic
However, this is nearly impossible in a
single physician model where they have
E/M
REIMBURSEMENT
TOTAL
NET
to manage the disease, manage the
992014 *2
166.22
332.44 *.85
treatment of the disease, and manage
99214 *4
107.83
431.32
the comorbidities that contribute to the
99213 *2
73.08
146.16
disease. This is where the introduction
Revenue
860.05
of the ‘team’ can be a game changer.
COST
APP
$65/hr
*4
(260.00)
$600.05
As we continue to strive toward high
value in our healthcare system, the
COST – PHYSICIAN
$250/HR *4
(1000.00)
$(90.08)
team-based approach will be one of
©MedAxiom
the keys. However it is not just about
adding an APP to your medical staff.
For success we must start with a defined
team and purpose that has a shared vision, principle and goals—and aligned incentives.
33
APPs AND CARE TEAMS
Creating an Environment of Aligned Economics
Simply adding APPs to the organization will not guarantee added patient volumes, work RVUs and panel size.
All too often our physician compensation plans—whether the funding mechanism in an integrated (employed)
model or the internal distribution architecture in a private model or both—create a perverse competition between
the APPs and the doctors. When this is the case, we can predict with relative certainty that the APPs will be
underutilized, if not downright ignored.
Take for example a work RVU based funding model in an employed setting. Many employment contracts in such a
model state that physicians will receive credit only for work RVUs “personally performed.” In other words, they will
receive no credit for work performed by an APP. Experience shows that in this environment, physicians will gravitate
to utilizing APPs in a supporting role, or to “tee up” patients to shorten the physician’s time in the room, and then
billing entirely under the physician’s provider number. Although there is certainly value in this relationship, the APP
role could be adequately filled by a well-trained nurse at a much lower cost to the organization.
Likewise in a private setting where the internal distribution formula includes a significant production component,
measured by work RVUs, internal competition can be created. In this model a physician may receive credit for work
performed by an APP in an “incident to” arrangement, where the physician is concurrently in the office with the
APP, but not if the APP were to bill under his/her own provider number. This latter scenario may often be the most
efficient and effective way to utilize the APP—and provide greater patient access because there are fewer limits due
to physician availability—but the compensation model will incent the physician to hang on to the patient or only
schedule when “incident to” is available. Private groups with net revenue compensation plans can often create the
same inefficient outcome.
A better model is where the
compensation plan is agnostic to
whether a physician or APP delivers
the care; a work RVU is a work RVU
for funding or distribution purposes.
However, there has to be recognition
of the significant expense associated
with APPs, otherwise there is no
disincentive to over hire in order to
provide economic and lifestyle benefit
for the physicians.
Focusing first on the funding side of
an integrated model, a way to balance
this scale is for the direct costs (salary
plus fringe benefits) associated with
the APP to be deducted from the
physician compensation pool. Figure
6l shows an example of how the
calculation would work. This model
encourages efficient and prudent
deployment of APPs since the cost is
born out of physician compensation.
FIGURE 6l – APP Compensation Deduction from Physician Comp
WRVUS
PROVIDER
PERSONAL
INCIDENT TO
TOTAL
Physician 1
8,500
-
8,500
Physician 2
9,400
-
9,400
APP 1
2,800
2,200
5,000
APP 2
1,500
3,100
4,600
Totals
22,200
5,300
wRVU Conversion Factor
27,500
$50.00
Total wRVU Contribution to Pool
$1,375,000
APP Direct Cost Deduction
APP 1 Salary + Bonuses
$115,000
APP 2 Salary + Bonuses
$111,000
Total APP Salary + Bonuses
$226,000
Fringe Benefits at 31%
$70,060
Total APP Direct Costs
$296,060
Net Total Compensation Pool
$1,078,940
©MedAxiom
There are several important caveats
to the model described above. First, it presumes that the compensation funding model creates a group pool, as
opposed to the funding being at the individual physician level (MedAxiom believes strongly in the value of the
pool vs. the individual, but that’s for another article). Second, the method used to distribute the pool must meet all
legal, regulatory and compliance requirements. Third and very importantly, the APPs must not directly provide any
Designated Health Services (DHS) under the Stark Laws.
34
APPs AND CARE TEAMS
Looking now at the private group setting, the mechanics on the production side are largely the same. In groups
that espouse distribution formulas with a productivity component, in order to avoid internal competition between
the physicians and APPs, the production measure cannot have a bias in favor of the physician. For instance, if the
production measure is work RVUs, but no credit is provided when an APP sees a patient independently, there is
malalignment. Many private groups also utilize a net revenue model where effectively each physician is his/her own
Profit & Loss Statement. In this environment APPs tend to be “cleaved to the hip” of a lone and specific physician,
which promotes underutilization when vacations don’t sync up or if the physician’s patient panel isn’t large enough
to maximize the APP’s schedule.
Conclusion
Healthcare is in an era of unprecedented change and
there are myriad unknowns as organizations attempt
to plan for the future. What is clear is that we must
bring down the cost of providing care—even as our
patient population may be increasing. To do this we
must look at strategies to expand the capacities of
our most expensive human resource, the physician.
At 20–30 percent of the cost of a cardiologist, APPs provide
a tremendous opportunity to increase a program’s patient
volumes and, if done right, provide a better overall product
particularly in the areas of care coordination and care
transitions. In order to achieve this, attention must be paid
to establishing a clear vision of the organization’s goals, a
clear definition of the care team with identified roles and
responsibilities, and a financial model that fosters, not
hinders, effective and efficient utilization of resources.
At 20-30% of the cost
of a cardiologist, APPs
provide a tremendous
opportunity to increase
a program’s patient
volumes and, if done
right, provide a better
overall product.
With all this in place, healthcare can truly be transformed.
1
Source: The Complexities of Physician Supply and Demand: Projections from 2013 to 2015
Prepared for: Association of American Medical Colleges; Submitted by: IHS Inc. March 2015
2
3
Betbeze, Philip. “How to Get the Most Out of Team-Based Care.” Health Leaders (2013). Web. 23 July 2015
Sochalski, Julie, Tiiny Harfan, Harlan Krumholz, Ann Laramee, and John McMurray. “What Works in Chronic Care Management: The Case of Heart
Failure.” Health Affairs 28.1 (2009). Web. 23 July 2015.
4
McAlister, F, S Stewart, S Ferma, and J McMurray. “Multidisciplinary strategies for the management of heart failure patients at high risk for
admission: a systematic review of randomized trials.” Journal of American College of Cardiology 22.2 (2004): 810-19. Web. 23 July 2015.
35
217
Interventional
$353,000
$299,851
$358,046
$443,072
600
Overall
Geographic Breakdown
128
196
Interventional
$33.21
$34.10
$34.20
$29.04
213
376
358
568
Interventional
155
West
Invasive
468
Midwest
Electrophysiology
671
372
Interventional
221
230
South
262
Invasive
Northeast
142
Electrophysiology
$40.70
$42.73
$46.24
$35.95
$37.14
$51.26
$39.40
$36.74
$50.48
$51.08
$51.59
$41.21
1,006 $49.52
114
Invasive
Integrated
71
Electrophysiology
$33.23
509
Ownership Model
Private
1,515 $41.38
Interventional
$358,491
379
$415,192
395
$451,397
Invasive
155
West
$458,841
219
482
Midwest
$400,000
$417,184
$527,085
$389,157
$448,688
$509,580
Electrophysiology
704
383
Interventional
South
250
252
262
Invasive
Northeast
146
Electrophysiology
3-1-0400 Physician Actual Compensation per Work RVU
Overall
129
$297,976
$374,684
1,041 $453,021
133
Invasive
Integrated
73
Electrophysiology
$325,862
552
Private
Ownership Model
25%
1,593 $416,578
N
3-1-0100 Actual Compensation per Cardiologist
TABLE 1: PHYSICIAN COMPENSATION
CARDIOLOGY TABLES
2012
$53.76
$55.16
$56.81
$46.32
$46.89
$64.81
$51.83
$50.11
$59.25
$61.10
$60.77
$52.54
$59.02
$41.55
$43.92
$48.85
$37.24
$42.55
$53.96
$586,154
$479,648
$541,324
$576,000
$461,657
$593,670
$550,000
$511,746
$639,800
$504,522
$576,000
$614,601
$588,996
$456,899
$473,852
$464,374
$477,345
$465,815
$548,587
50%
$67.66
$70.73
$67.34
$57.81
$57.30
$78.66
$61.76
$58.62
$73.01
$80.26
$73.04
$63.12
$73.19
$52.19
$54.72
$58.11
$45.62
$53.96
$67.28
$727,457
$583,943
$620,000
$680,614
$551,632
$682,840
$709,908
$598,575
$765,474
$615,800
$666,003
$698,889
$702,904
$604,898
$545,156
$567,029
$570,156
$565,000
$665,106
75%
$83.96
$94.17
$83.04
$72.95
$70.54
$97.91
$76.50
$69.18
$88.17
$102.31
$88.76
$78.64
$90.07
$61.23
$61.58
$66.30
$53.70
$61.64
$84.07
$877,025
$685,802
$743,969
$843,723
$697,413
$787,948
$866,284
$626,318
$911,116
$712,698
$775,984
$869,340
$824,233
$785,139
$598,800
$575,906
$734,704
$688,015
$796,191
90%
969
738
444
356
250
546
1,292
419
666
567
342
263
1,838
303
171
102
93
669
2,507
788
629
501
305
223
532
1,039
429
522
428
360
210
1,520
266
201
141
95
703
2,223
N
$43.08
$45.19
$47.39
$38.30
$39.16
$51.25
$41.31
$43.37
$49.79
$50.94
$50.47
$42.70
$49.33
$32.88
$35.19
$33.19
$30.39
$33.13
$43.47
$438,694
$339,235
$421,590
$421,823
$397,212
$425,279
$405,153
$387,491
$488,490
$377,073
$468,697
$451,795
$449,790
$370,583
$303,600
$332,000
$368,535
$333,517
$404,073
25%
2013
$53.79
$56.65
$54.53
$48.72
$50.41
$60.30
$52.35
$52.54
$57.43
$62.30
$55.89
$51.86
$57.21
$41.97
$41.59
$43.77
$36.41
$41.59
$53.78
$564,654
$454,837
$521,740
$525,664
$477,825
$565,720
$528,010
$464,326
$595,785
$498,419
$555,248
$572,522
$555,365
$479,017
$394,586
$425,000
$456,337
$425,897
$512,401
50%
$64.24
$69.23
$66.06
$57.05
$64.24
$72.37
$63.10
$62.33
$68.32
$73.43
$67.10
$58.90
$68.40
$53.44
$50.41
$62.17
$44.80
$51.66
$65.30
$691,189
$570,000
$625,799
$675,000
$570,521
$650,000
$687,329
$550,249
$733,383
$595,979
$681,572
$699,787
$676,729
$625,000
$463,753
$536,065
$559,004
$542,650
$635,891
75%
$80.61
$89.27
$79.20
$66.37
$82.08
$91.09
$77.08
$74.43
$84.48
$96.44
$77.61
$67.89
$84.72
$64.79
$57.11
$90.83
$50.19
$64.17
$80.78
$822,400
$661,517
$750,257
$798,490
$650,000
$775,755
$814,752
$615,993
$903,433
$678,985
$794,108
$852,098
$802,584
$728,148
$570,000
$570,000
$700,000
$675,684
$764,014
90%
907
593
419
307
215
479
1,162
370
617
469
342
222
1,650
290
124
77
85
576
2,226
933
612
427
310
223
488
1,182
389
636
486
346
225
1,693
297
126
81
85
589
2,282
N
$43.67
$44.83
$47.43
$37.86
$44.63
$47.13
$41.75
$48.02
$48.75
$49.41
$49.56
$43.81
$48.18
$36.14
$33.63
$36.61
$30.47
$34.53
$43.87
$431,588
$361,399
$424,438
$429,667
$379,995
$455,410
$391,102
$405,018
$487,500
$373,595
$451,816
$481,930
$433,863
$376,661
$325,509
$336,568
$349,262
$346,132
$403,005
25%
2014
$52.30
$57.11
$55.06
$47.60
$53.69
$56.91
$50.63
$56.24
$56.56
$61.33
$56.30
$50.80
$56.67
$44.01
$42.20
$47.94
$36.89
$42.63
$53.47
$563,485
$489,776
$542,000
$554,958
$451,816
$546,466
$556,819
$542,000
$595,056
$500,000
$554,157
$574,459
$555,411
$497,840
$411,667
$428,378
$460,621
$470,160
$542,000
50%
$65.09
$71.62
$66.25
$57.57
$82.33
$66.51
$62.35
$70.07
$70.69
$74.56
$66.45
$60.30
$69.37
$51.62
$50.89
$64.98
$45.93
$51.98
$66.22
$693,285
$586,338
$653,974
$670,959
$574,459
$615,460
$698,211
$600,000
$698,724
$586,983
$668,304
$699,095
$672,952
$622,910
$570,479
$560,330
$557,162
$600,000
$661,925
75%
$83.00
$91.07
$85.36
$73.87
$120.01
$78.46
$81.93
$81.13
$88.15
$94.52
$81.28
$76.77
$86.98
$62.32
$69.29
$109.72
$51.77
$69.29
$84.50
$821,245
$695,966
$750,817
$839,707
$676,016
$746,439
$857,642
$694,574
$834,945
$713,540
$776,434
$857,126
$796,537
$756,181
$678,458
$679,723
$704,867
$711,082
$774,536
90%
Overall
134
232
Interventional
9,066
8,203
7,601
10,922
400
400
614
Invasive
Interventional
158
West
226
525
Electrophysiology
735
Midwest
382
Interventional
South
266
222
273
Invasive
Northeast
146
Electrophysiology
8,795
6,650
7,714
9,682
7,862
6,931
8,720
8,138
8,779
6,028
7,715
9,042
1,067 7,721
127
Invasive
Integrated
80
Electrophysiology
8,444
573
Private
1,640 8,017
25%
Ownership Model
N
3-4-0100 Work RVUs per Cardiologist
TABLE 2: PHYSICIAN PRODUCTIVITY
37
2012
10,800
8,441
9,388
12,245
9,785
8,911
10,969
9,407
10,681
7,882
9,425
11,502
9,709
11,030
9,436
9,228
13,294
10,536
10,007
50%
13,063
10,225
11,509
15,606
11,764
11,250
13,532
11,223
12,841
9,566
11,811
14,710
12,042
13,777
11,383
11,013
16,665
12,962
12,428
75%
16,105
12,206
13,422
18,211
14,788
13,907
16,422
13,271
15,698
11,801
13,432
17,474
14,501
17,045
13,616
13,002
19,404
16,456
15,399
90%
801
675
498
308
211
521
1,131
419
554
500
365
223
1,642
247
175
133
85
640
2,282
N
8,478
6,391
7,917
9,325
7,430
7,541
8,098
7,467
8,182
6,248
7,917
9,145
7,560
9,125
7,467
7,958
9,894
8,427
7,751
25%
2013
10,322
8,211
9,502
11,495
9,108
9,242
10,173
9,103
10,055
7,837
9,502
11,179
9,411
11,226
9,228
9,461
12,041
10,246
9,637
50%
12,922
9,977
11,575
14,689
11,007
11,202
12,974
10,771
12,272
9,602
11,750
14,514
11,576
14,112
11,723
11,194
15,918
13,077
11,988
75%
15,872
12,193
13,910
17,340
13,962
13,821
16,073
13,012
15,238
11,040
13,815
17,128
14,342
17,743
14,142
13,999
18,661
16,545
14,898
90%
956
670
445
332
241
562
1,178
422
666
546
367
247
1,826
290
124
78
85
577
2,403
N
7,902
5,702
7,232
9,107
5,923
6,753
7,594
6,808
7,412
5,547
7,335
8,752
6,701
8,766
7,734
6,092
9,481
8,280
6,965
25%
2014
10,188
7,858
9,350
11,624
8,276
9,147
10,586
8,731
9,831
7,488
9,417
11,482
9,210
10,936
9,562
8,915
12,135
10,438
9,538
50%
12,878
10,352
11,764
14,621
10,600
11,404
13,454
10,662
12,386
9,867
11,847
14,491
11,935
13,779
12,418
11,084
15,361
13,359
12,283
75%
16,305
13,127
14,522
18,127
13,829
14,395
17,098
12,841
15,364
12,601
14,367
17,879
15,003
17,536
15,253
14,890
18,678
16,943
15,602
90%
Overall
23
34
Vascular
**
West
52
45
Midwest
Cardiac
37
South
20
Vascular
**
35
Cardiac
Northeast
67
**
Vascular
Integrated
20
Cardiac
Private
Ownership Model
$461,515
$43.00
$48.00
**
$48.00
$46.00
**
$32.00
$55.00
$52.00
**
$32.00
$29.00
$55.00
34
$45.00
Vascular
**
$451,019
**
West
$500,000
$428,811
**
$461,515
$664,382
$525,000
**
$252,514
$238,662
$451,019
25%
52
41
Midwest
Cardiac
37
South
31
Vascular
**
32
Cardiac
Northeast
63
**
Vascular
Integrated
20
Cardiac
3-1-0400 Individual Surgeon Salaries (no benefits) per Work RVU90
Overall
23
Ownership Model
Private
86
N
3-1-0100 Actual Compensation per Surgeon
TABLE 1: PHYSICIAN COMPENSATION
SURGERY TABLES
2013
$53.00
$61.00
**
$55.00
$57.00
**
$43.00
$70.00
$58.00
**
$43.00
$36.00
$75.00
$566,516
$617,611
**
$578,898
$574,022
**
$573,974
$790,532
$663,024
**
$432,183
$432,183
$574,022
50%
$64.00
$81.00
**
$77.00
$70.00
**
$62.00
$87.00
$76.00
**
$62.00
$83.00
$94.00
$636,806
$833,885
**
$733,744
$1,026,706
**
$663,024
$1,167,515
$810,410
**
$484,564
$496,126
$764,087
75%
$77.00
$101.00
**
$101.00
$93.00
**
$88.00
$142.00
$101.00
**
$88.00
$61.00
111
$801,329
$1,284,837
**
$812,034
$1,358,798
**
$731,237
$1,387,607
$1,190,791
**
$536,700
$523,086
$1,164,655
90%
27
84
**
38
55
**
24
69
93
**
15
18
$42.38
28
85
**
39
56
**
25
70
95
**
15
18
113
N
$46.95
$41.98
**
$38.13
$50.15
**
$50.74
$48.07
$48.27
**
$30.81
$30.81
$55.31
$399,730
$450,563
**
$535,289
$406,973
**
$452,664
$509,724
$500,000
**
$309,498
$309,498
$450,461
25%
2014
$54.82
$57.44
**
$48.27
$60.16
**
$54.82
$62.87
$59.69
**
$40.21
$39.83
$72.53
$570,345
$584,854
**
$587,019
$576,563
**
$576,563
$594,835
$592,804
**
$434,546
$434,546
$581,593
50%
75%
$71.03
$72.53
**
$66.23
$76.91
**
$68.66
$77.54
$75.80
**
$47.19
$47.19
$94.96
$629,719
$811,292
**
$762,500
$849,115
**
$662,154
$829,732
$809,814
**
$535,289
$535,289
$762,500
90%
$87.30
$98.3
**
$75.83
$98.64
**
$75.83
$99.36
$98.64
**
$58.65
$59.85
$711,000
$1,190,137
**
$836,672
$1,291,457
**
$711,000
$1,201,970
$1,187,854
**
$627,698
$629,719
$1,057,349
SURGERY TABLES
Overall
Ownership Model
38
Vascular
**
West
63
47
Midwest
Cardiac
46
South
35
Vascular
**
43
Cardiac
Northeast
78
**
Integrated
20
Vascular
23
101
N
Cardiac
Private
3-4-0100 Work RVUs per Surgeon
TABLE 2: PHYSICIAN PRODUCTIVITY
39
8,527
8,481
**
7,871
8,602
**
8,527
9,054
9,054
**
5,845
5,446
8,527
25%
2013
10,889
11,317
**
10,169
11,325
**
10,657
11,317
10,971
**
11,487
11,487
10,971
50%
11,833
14,525
**
12,118
14,252
**
11,419
15,727
13,572
**
13,008
14,525
14,094
75%
17,613
18,256
**
16,847
21,061
**
15,113
21,061
19,001
**
15,406
15,840
17,613
90%
27
85
**
38
55
14
23
70
93
**
15
19
112
N
7,330
8,479
**
9,096
7,330
3,374
7,464
8,230
8,072
**
9,319
7,947
7,947
25%
2014
9,085
11,653
**
11,915
10,253
8,874
9,085
11,837
10,582
**
11,370
11,370
10,703
50%
11,678
15,083
**
15,610
14,900
11,134
10,582
15,275
14,634
**
13,890
15,018
14,634
75%
18,445
20,660
**
21945.45
20013.64
20660.13
12,487
21,586
20,660
**
15,610
16,329
20,152
90%
25th
$2,373
$6,667
$15,833
$11,451
$22,046
$268
$7,722
$13,703
2.0%
Compensation per FTE
Call Coverage
Total Non-Clinical Compensation Earned
Percentage of Non-Clinical to Total Comp Earned
NON-CLINICAL TABLES
8.0%
$45,457
$10,250
$419
$30,000
$22,046
$22,853
$11,869
$6,667
50th
13.0%
$69,884
$31,826
$11,381
$56,917
$38,608
$34,261
$20,667
$16,156
75th
19.70
19.70
19.70
19.70
19.70
19.70
19.70
19.70
Median FTEs
$895,503
$201,925
$8,254
$591,000
$434,306
$450,204
$233,819
$131,340
Total Comp per Group
APPs
154
100
Midwest
West
477
219
88
South
Midwest
West
802
213
Integrated
Northeast
195
Private
Ownership Model
997
3-4-0100 Work RVUs per APP
N
519
South
696
163
Integrated
Northeast
240
TABLE 2: APP PRODUCTIVITY
Ownership Model
936
N
Private
3-1-0500 Actual Compensation per APP
TABLE 1: APP COMPENSATION
41
533
239
58
83
83
147
91
25%
$75,643
$68,138
$74,877
$56,416
$72,703
$67,669
$71,465
25%
2014
2014
1,211
814
253
308
364
803
414
50%
$99,840
$91,675
$91,134
$89,086
$91,375
$93,556
$91,690
50%
75%
2,092
1,798
1,167
987
1,205
2,148
1,409
75%
$114,504
$105,000
$104,014
$102,074
$103,475
$110,000
$104,899
90%
3,409
2,787
2,712
1,755
2,231
3,442
2,537
90%
$126,340
$121,437
$120,952
$119,153
$118,450
$127,591
$121,451
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[email protected]
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