Cardiac Rhythm Management
Articles Articles 2013 December

Letter from the Editor in Chief

DOI: 10.19102/icrm.2013.041201

John Day, MD, FHRS, FACC

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Dear Readers,

As I have been contemplating what I would write this month, my mind just keeps going back to how incredibly busy our practice is this year and what further changes are coming down the pipeline for us as a profession.

It seems like the end of each year just gets busier and busier. It is a struggle for us to find openings to see new patients in the clinic, to get procedures scheduled and patients are all rushing in to get a procedure done before the end of the year, as they have now hit their insurance deductible.

As we have all witnessed, the field of EP is nothing like it was even just five years ago. As I have been pondering this topic, I would like to discuss four trends we have been seeing in our practice. These trends are as follows: 1) Managing the new measures of quality, 2) Declining reimbursements, 3) Increasing clinic volumes, and 4) Flat procedural volumes.

New Measures of Quality

I’m sure many of you are seeing the same trends in your own hospital. It used to be that the only measure of quality was helping a patient to regain their health. Now it is completely different. In fact, 15% of our salary now comes from how patients perceive the care they receive from us, how effective we are at getting patients to sign up for online access to their electronic medical record, how effective we are at getting patients to fill our their advance directives, etc.

While there are no data showing that any of these “quality” measures actually improves care, these, and many other measures, are now the new standards of how quality is being measured. Everyone is demanding better healthcare quality and no one even knows what quality healthcare even looks like. As a result, we now allocate more physician and staff resources just to manage all of these new measures of healthcare quality.

In my mind, the real measure of healthcare quality is in disease prevention. It still amazes me that as cardiologists, Medicare and private insurance companies are willing to pay thousands of dollars for procedures but will not even reimburse us a dime for countless hours spent working with patients on changing their unhealthy lifestyles. The key for all of us is to get involved, both locally and nationally, to help establish how quality will be measured going forward. The choice is ours—we can accept these new quality measures or we can help to establish what quality means.

Declining Reimbursements

I must admit that this has been a very difficult year financially for the EP physicians at Intermountain Healthcare. With the bundling of EP ablation codes, we have seen a 20-30% salary reduction for all of our EP physicians this year. While we have tried to increase productivity, we just cannot even come close to compensating for these draconian cuts.

Where it is particularly unfair is with VT ablations. We now are reimbursed much more for seeing patients in clinic versus performing complex VT ablation procedures. My concern is that this is not the end of the cuts. The next big reimbursement cut likely coming our way is with the new reimbursement code for the sub-cutaneous defibrillator. As a new payment is established for this technology, we will likely see another steep reduction in reimbursement for the transvenous ICD.

To ensure that procedures are fairly reimbursed, we all need to actively participate in the process of establishing reimbursement rates. As we are sent surveys from medical societies asking us how long it takes to do specific procedures, it is imperative that we not only participate in these surveys but that we also need to honestly answer the questions. To often, I fear our tendency is to “brag” about how fast we can do these procedures rather than truthfully report how long all aspects of the procedure actually take. As a result of underestimating the time it takes us to perform procedures on these surveys, we then see steep reimbursement cuts.

Increasing Clinic Volumes

Perhaps because of the atrial fibrillation epidemic we are currently witnessing or the poor economy and rising annual deductibles of insurance plans, we are seeing a dramatic increase in our outpatient clinic volumes. In fact, for the last 5 years, we have seen an annual 10-20% increase in clinic visits.

With this ever-increasing number of out-patient EP clinic visits, we have struggled to keep up with this growth. Fortunately, this is a good problem to have. Over this past year, we have increased the number of EP patient exam rooms to 17. Moreover, we recently hired a full-time internist to see our patients each day in clinic just to help us manage the deluge of outpatient EP clinic visits. Even with our recently hired internist, we cannot keep up with all of the clinic visits. We have also grown our nurse practitioner/physician assistant ranks to 6 and we still cannot keep up.

One concern I have is that for us to keep up our skills in the EP lab, we need to regularly be in that environment. If too much of our time is spent in the clinic then procedural skills will suffer. Looking forward to 2014, we will be bringing on another EP and more midlevel providers. While this will manage the 10-20% clinic growth we are expecting in 2014, we will be in the same position for 2015.

Flat Procedural Volumes

After many years of rapid growth in EP procedures, we have seen flat procedural volumes for the last 3 years. As mentioned above, I suspect one factor for this trend has to do with the poor economy and rising insurance deductibles. For most working people on private insurance, having to pay three to five thousand dollars, out-of-pocket, for an SVT ablation is just cost prohibitive. This is particularly relevant to our younger patients with atrial fibrillation who may require two procedures to allow them to be Afib free.

A second factor impacting procedural volumes are the increasing regulatory oversight of what we do everyday. This oversight has had a significant effect on ICD and pacemaker utilization. It is just a matter of time before the same level of oversight happens to Afib ablation procedures. The sad thing is that it is primarily the patient who suffers as they may be denied a potentially life-saving procedure just because their particular case did not completely match the published guideline indications.

The third factor that will likely enter in is that with the rise of Accountable Care Organizations, EP procedures will no longer be viewed as revenue centers to hospitals but will rather be viewed as cost centers. This will completely turn the field of EP economics upside down. The silver lining to these new changes is that the emphasis will be more on disease prevention rather than disease palliation.

With each challenge brings unique opportunities. If we are to turn these challenging trends in our field to opportunities, we need to get involved and encourage our patients to do the same. We do have a voice and our voice matters.

How are the changes in healthcare affecting you and your practice? What challenges are you seeing in your practice? Please email me and let me know how you are adapting to the rapidly changing EP healthcare environment.

Warm regards,


John Day, MD, FHRS, FACC
The Journal of Innovations in Cardiac Rhythm Management
Director of Heart Rhythm Services
Intermountain Medical Center
Salt Lake City, UT