'Not sustainable': The real impact of RVU cuts in electrophysiology
Electrophysiologists are being asked to do significantly more work while receiving little additional credit under the Medicare physician payment system. Electrophysiology (EP) experts say this is creating an unsustainable payment model that could worsen workforce shortages and accelerate the migration of procedures to ambulatory surgery centers (ASCs).
Speaking at Heart Rhythm 2026, cardiac electrophysiologist Joshua R. Silverstein, MD, outlined data showing a widening disconnect between physician workload and relative value unit (RVU) compensation in EP.
"We keep doing more and more procedures, see more patients in the office, and all that for the same amount of RVUs," he said. "Every year we're expected to keep growing."
Growing workload, flat RVUs
Silverstein's analysis examined trends between 2020 and 2025 within his health system. During that period, total hospital gross billable revenue associated with EP services increased by approximately 160%, while procedural volume nearly doubled. At the same time, clinic visits increased about 40%.
Despite these substantial increases in activity, physician RVUs remained essentially flat during the three years of available data, he said.
The findings highlight a growing concern among electrophysiologists that RVUs, which are used to measure physician productivity and compensation, may not accurately reflect the complexity and volume of the work being performed.
"The message is that this is an unsustainable model," Silverstein said. "We're continuing to do more and more work but not being given credit for it."
Long-term decline in Medicare physician payments
The issue extends beyond EP. Physicians across multiple specialties have voiced concerns about repeated Medicare payment reductions and the failure of physician reimbursement to keep pace with inflation. Silverstein argued that physician payment policies have increasingly shifted financial benefits toward hospitals and industry, while physician compensation has stagnated.
"Physician payment, when adjusted for inflation over the last 20 years, has actually gone down, and that's not sustainable," he said.
The discussion echoed concerns frequently raised by the American Medical Association and numerous other specialty societies. These groups have all noted that Medicare physician payments have declined substantially in real-dollar terms over the past two decades while hospital reimbursement has continued to rise. This is the main driver of why cardiology has moved from 90% private practice a decade ago, to only about 10% today; private practices are increasingly not financially sustainable.
How payment issues impact recruitment
Silverstein warned that continued payment pressures could have consequences for the future EP workforce. The specialty already faces workforce shortages as demand grows for catheter ablation, cardiac implantable electronic devices and other rhythm management procedures. With an aging population and expanding indications for EP interventions, demand is also expected to continue increasing.
"We're being asked to run faster and faster on the hamster wheel, and at some point we're going to fall off that hamster wheel," Silverstein said.
He added that persistent reimbursement pressures may discourage some physicians from pursuing the lengthy training required to become electrophysiologists.
The concern comes as many healthcare organizations report difficulty recruiting EP specialists, particularly in underserved and rural markets.
EP procedures increasingly migrating to ASCs
Silverstein said reimbursement challenges are also helping drive interest in performing more EP procedures in ASCs, a trend that has gained momentum following recent regulatory changes allowing additional electrophysiology procedures to be performed in these outpatient settings.
"I think this is a big part of the push for ASCs in EP, so that we can get some of that share of what we're really doing and the amount of revenue that we're bringing into the systems," he said.
He noted that other specialties such as ophthalmology and orthopedics experienced similar migrations toward outpatient surgical centers as physicians sought greater control over procedural economics.
"Unless something changes, that's the direction things are headed," Silverstein said.
Need for greater EP policy advocacy
The reimbursement debate has also fueled increased advocacy efforts within the specialty. The Heart Rhythm Society recently expanded its advocacy activities when it created Heart Rhythm Advocates (HRA) to help educate lawmakers and federal policymakers about the complexities of electrophysiology practice.
Silverstein said many policymakers may not fully appreciate the specialized nature of EP care, which requires extensive training beyond other cardiology subspecialties, and involves highly complex procedures.
"EP is a very unique field," he said. "We have a workforce shortage. It's only going to get worse as the demand for electrophysiology procedures continues to rise, and that's why something's got to give."
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]