Cardiac Compensation

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mwa

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I was recently looking at other local groups, trying to find one with a gentler call burden.

The best of the bunch seems otherwise suitable, but they seem to be kind of odd about how they reimburse the cardiac team. I should say upfront that they seem transparent enough and invite questions. I don't want to tell them what strikes me as odd, because I don't want to come across as anything but a team player. And, maybe, their way of doing things is the norm, and I'm the exception.

They blend units across all OR cases (everything is blended, but OB and pain procedures are blended (and dispersed) separate from the main OR). Cardiac cases are blended with the regular OR cases. All the cardiac guys (and they're all guys) do general, though most generalists don't do cardiac. Already, the cardiac guys (whose patients are 99.5% Medicare/Medicaid) are the beneficiaries, because they generate huge units (A-lines, swans, central access, +/- thoracic epidurals), all of which are reimbursed more generously as blended units than they would as case-specific units. (But that peculiarity is not unique. I have heard of other groups that blend everything together.) But the wrinkle in this group is that every other OR case cuts startup units in half, except cardiac cases. The cardiac guys (again, all guys) get full value for their startup units.

Does it appear to anybody else that the cardiac guys are double-dipping? First, the RVUs are higher for cardiac cases specifically because everybody knows that cardiac cases are Medicare. So, even before the heart team takes full fare for their inflated startup units, they are already picking the pockets of the ones doing insured cases like gallbladders and appendectomies. But, in addition, they then charge the rest of us twice as much to start those cases? Doesn't that seem a little unfair?? The only notion I heard that anybody is unhappy with it is that some of the younger full-time guys complained that the part-time cardiac guys generate more units in two weeks/month than they do working every week of the month. But, this group lets you do OB immediately, which some of the groups in town do not. (I'm not sure I consider OB a benefit or an obligation.)

Wouldn't it be more fair to blend cardiac separately, and distribute those monies anyway the cardiac team sees fit? If it turns out to be too little, shouldn't the cardiac team ask the hospital to make up the difference, rather than taking it from the regular OR?

Not that it matters, but the cardiac team are all the oldest partners. They don't officially have any more clout than the full partners who are younger, but...you know. I don't think a single one is fellowship-trained or TEE-certified. There was a younger cardiac-trained guy who was recruited to join the cardiac team, but stopped doing cardiac after a year or so. The cardiac team used that fact as a bargaining chip, saying that the cardiac hustle is so demanding as to require special reimbursement.

I don't think this will ever change. I won't dare say anything, of course. I'm sure that everybody has made peace with the inequality, if they have considered it at all.

I'm not looking for strategies to correct what I see is an inequality, but rather wanting to hear whether I am the bad person for letting it bother me.
 
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It is a way of getting the cardiac guys more $. Ask what the rationale is? Do the cardiac guys work harder? Are decisions about these matters made democratically?
 
Why don’t you join the cardiac team?

It’s a little weird everyone’s RVUs get cut in half except for cardiac. Are you running several rooms vs. the cardiac people working alone?

You must realize that Medicare doesn’t pay much for cardiac anesthesia but pays a lot to the hospital. You might not think their work is valuable but the hospital does. Without them the group wouldn’t have a contract with the hospital. How would you pay them properly with this in mind?
 
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Is this solo or supervision? If general cases are supervised at a higher ratio they may split the units with CRNAs for unit accounting purposes.

No system is going to be totally fair. I’d rather incentivize old guys taking care of sick patients than a non-blended system where they make 4 times as much doing ASA1s at the surgicenter.
 
Physician only. Eat what you kill. No hospital stipend.

The cardiac team does not want more cardiac anesthesiologists. So, yes, they end up (by choice) taking more call (which is not compensated, either for cardiac or general anesthesiologists--though the higher the call position, the better your room).

I think that part of the reason that the RVU values a CABG at 25 start up units is because everybody knows that most of those cases are going to be Medicare. So, once the rest of the non-cardiac team has agreed to let them blend their cases with the rest, then the non-cardiac guys are already shunting money to the cardiac team. Doubling the value of their startup (valuing one CABG at almost 8x a galllbladder (7 units cut in half))--before you consider additional units for lines--strikes me as a little absurd.

But it does appear that I am in the minority.
 
mwa said:
Physician only. Eat what you kill. No hospital stipend.

The cardiac team does not want more cardiac anesthesiologists. So, yes, they end up (by choice) taking more call (which is not compensated, either for cardiac or general anesthesiologists--though the higher the call position, the better your room).

I think that part of the reason that the RVU values a CABG at 25 start up units is because everybody knows that most of those cases are going to be Medicare. So, once the rest of the non-cardiac team has agreed to let them blend their cases with the rest, then the non-cardiac guys are already shunting money to the cardiac team. Doubling the value of their startup (valuing one CABG at almost 8x a galllbladder (7 units cut in half))--before you consider additional units for lines--strikes me as a little absurd.

But it does appear that I am in the minority.
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what do you think it boils down to in dollars, after all that other stuff is considered? how much more do they make ? i bet not as much more than you think and the call and cases are a PIA
 
How much call do the cardiac guys take over general guys? Are they taking overnight call when they are lower on the list (not the pick of the juicy lines)? How fast are your surgeons? Big difference between a CT that bangs out 2 pump runs cases by 2 and others that bang out 2 cases by 5pm. CT is not lucrative for DHCA cases that take you from 10pm to 6 am... with higher risk and poor outcomes (liability). Are they intimately involved in expanding services that will secure your future contracts (echo service, structural heart, pre-op/peri-op echos?). There are a lot of moving parts... CT takes on the highest risk that requires specialized skills to make it through a successful case- think large PVL that is picked up b4 leaving the room.

I’ve worked in groups where CT guys easily make 150k+ more than generalists. I was on call and available a lot more... including weekends.

I am q6-7 weekends now on cardiac and looking back, I was compensated adequately for my availability now and then.

Keep in mind you can do 4ish easy ortho cases with easy blocks in the time we do a heart.

Value your sub-specialties.

My 2 cents.
 
There is some value with individuals going through fellowship/advanced echo/holding advanced certification....

Inherently there is significant time commitment/cost to the individual going through this process.
 
mwa said:
Does it appear to anybody else that the cardiac guys are double-dipping? First, the RVUs are higher for cardiac cases specifically because everybody knows that cardiac cases are Medicare. So, even before the heart team takes full fare for their inflated startup units, they are already picking the pockets of the ones doing insured cases like gallbladders and appendectomies.
Click to expand...

Why do you deserve anything extra for taking care of somebody with good insurance? Anything other than a blended unit is an unfair practice IMO.
 
mwa said:
I don't think a single one is fellowship-trained or TEE-certified.

There was a younger cardiac-trained guy who was recruited to join the cardiac team, but stopped doing cardiac after a year or so.
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I find both statements odd. Where is this location? BFE?

Why did they recruit a CT fellowship trained guy just so he doesn't do cardiac?

I once interviewed with a group for a generalist position, in passing they mentioned the cardiac guys get what works out to be a 20% pay bump compared to the position that I was taking. I didn't bat an eye. Because I knew how hard it was to find a fellowship and they are more qualified than me even though i was an advanced PTE testamur at the time. Their pts are way sicker. They also took what seemed to be Q5 call (admittedly with lower call in %). I thought that arrangement was pretty fair from the generalist point of view. I would reserve judgement if i was in OP's shoes until i get to know what their actual pay is vs time being available.
 
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A small cardiac group means people are taking a fair amount of call and being "available" costs SOMEONE. Since the hospital isn't paying a stipend then the anesthesia group pays the tribute and as someone mentioned, having that cardiac group is probably helping that anesthesia group maintain it's status with the hospital.
 
As others have mentioned in this thread, there’s nuance to having a cardiac squad and the pay structure goes beyond simple billing of RVUs. If you just had a simple eat what you kill system that wasn’t insurance blended then nobody would do cardiac and we would all be trying to work in ASCs.
 
T-burglar said:
As others have mentioned in this thread, there’s nuance to having a cardiac squad and the pay structure goes beyond simple billing of RVUs. If you just had a simple eat what you kill system that wasn’t insurance blended then nobody would do cardiac and we would all be trying to work in ASCs.
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Thank you, finally! None of our cath lab or cardiac rooms get above 2/3 of what our ortho rooms clear - mostly because it’s almost entirely CMS.

I also make more and work less than the new cardiac surgeons I work with, by a substantial amount.
 
mwa said:
Physician only. Eat what you kill. No hospital stipend.

The cardiac team does not want more cardiac anesthesiologists. So, yes, they end up (by choice) taking more call (which is not compensated, either for cardiac or general anesthesiologists--though the higher the call position, the better your room).

I think that part of the reason that the RVU values a CABG at 25 start up units is because everybody knows that most of those cases are going to be Medicare. So, once the rest of the non-cardiac team has agreed to let them blend their cases with the rest, then the non-cardiac guys are already shunting money to the cardiac team. Doubling the value of their startup (valuing one CABG at almost 8x a galllbladder (7 units cut in half))--before you consider additional units for lines--strikes me as a little absurd.

But it does appear that I am in the minority.
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Sounds like the units are not cut in half for the non cardiac cases like you originally described. You just claim they are cut in half once they get blended, because the money is diluted. Am I correct?
 
I weighed this whole issue carefully before deciding to go back to cardiac fellowship after many years of PP. I watched a group across town get their contract snatched by another group when they couldn’t adequately staff high acuity cardiac cases that came with a couple of the new surgeons.
Whether it’s fair or not, docs who can handle those cases allow a group to maintain the contract because they’re not easy to replace. Before my fellowship I did hearts but I was in over my head with some cases that required legitimate echo skills that the surgeons wanted. When we need to replace a cardiac doc due to retirement, our pool of people with the advanced certification(required by the hospital) is smaller, so it’s harder to find than a generalist .
So a competent cardiac team brings value to the table besides just RVUs. Supply and demand.
 
urge said:
Sounds like the units are not cut in half for the non cardiac cases like you originally described. You just claim they are cut in half once they get blended, because the money is diluted. Am I correct?
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What they told me was that they value each other's time more than the ASA does, so their internal solution was to credit themselves only half the startup units in order to make the units generated during the case more valuable. The specific example they gave was how many units the older guys were getting doing cataracts. But then they said the only exceptions are "cardiac cases, who get full fare startup units."

I can't say more than that, besides to speculate exactly what it means.

I don't have any trouble respecting sub-specialists, especially those who gave up a year's salary for an extra year's training. (But these guys aren't fellowship-trained.) My contention is that the published startup values are already the ASA's way of valuing cardiac expertise (way above that of, say, pediatric fellows). On top of that, this group has made the cardiac team the beneficiaries of a blended unit that further values cardiac expertise at the expense of the generalists. And, on top of that, they have then double-dipped by doubling again the ASA's published cardiac premium (versus "regular cases," which include many, many cases performed by fellowship-trained subspecialists).

But, point taken. I'm in the minority.
 
mwa said:
And, on top of that, they have then double-dipped by doubling again the ASA's published cardiac premium (versus "regular cases," which include many, many cases performed by fellowship-trained subspecialists).

But, point taken. I'm in the minority.
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It isn't about minority, majority, or wrong or right. The fact of the matter is you don't know the bottom line and you're purely going off conjecture.

If you really want us to weigh in on the situation. Find out how much money they gross, how much call they take, and how many pump cases they do. Then give us info on the demographics of the place, e.g. is it a major city or a BFE? Then we will actually begin the real conversation of what is fair and what is not.

You even said yourself you're speculating. That's not a good way to go through life.
 
Ronin786 said:
Why do you deserve anything extra for taking care of somebody with good insurance? Anything other than a blended unit is an unfair practice IMO.
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An attending told me at his old private practice, their group would watch out for each other and if the next case is Medicare, they would take longer to get out of the room so the other group would take the poor paying pt.

Not practicing in that environment became the top of the list when I'm looking for a job. LOL
 
dchz said:
An attending told me at his old private practice, their group would watch out for each other and if the next case is Medicare, they would take longer to get out of the room so the other group would take the poor paying pt.

Not practicing in that environment became the top of the list when I'm looking for a job. LOL
Click to expand...


Yep. Not blending results in endless shenanigans.
 
What is a common way groups subsidize for their cardiac guys? Do they pay a daily stipend for them to take call? Assuming a straight forward blended unit eat what you kill model.

We are trying to find a fair way.
 
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