Cardiology needs to evolve in the face of employment trends

Economic pressures behind the shift in cardiology employment

Aronow pointed to several long-term economic pressures that have driven cardiologists toward employment models. Over the past 20 years, inflation-adjusted physician reimbursement has declined sharply, while ancillary revenue from in-office imaging has been reduced due to policy changes and lower per-test payments. At the same time, payers have pushed procedures into lower-cost sites of service, such as ambulatory surgery centers, and private equity has become more active in the market.

“All of these things have changed the market,” Aronow said, adding that a new generation of cardiologists has different priorities than their predecessors. “Not better or worse, but just different."

As a result, employment can bring stability, but also friction. Aronow said cardiologists increasingly face “economic misalignment,” loss of autonomy and gaps in governance once they become employees, underscoring the need for more collaborative strategies with health systems.

Aligning cardiology work incentives beyond productivity

A central theme of Aronow’s talk was the need to rethink how success is measured in employment models. Traditional productivity based compensation, he said, does not capture the full value cardiologists bring to health systems.

“So instead of perhaps just looking at physician productivity, we need to understand that there’s a margin involved there,” Aronow said. That opens the door for physicians to partner with hospitals on cost management and operational efficiency, including vendor standardization, improving case start times and optimizing staffing models.

“All of these things, I think historically we thought of as the role or the responsibility of the hospitals and the health systems, but it’s really our responsibility too, if we’re going to be successful,” he said.

Aronow emphasized that new payment models are needed to reward contributions that go beyond relative value unit (RVUs) for work, because cardiologists are called on to do many things that improve care at hospitals beyond diagnosing and treating patients. These things include quality improvement, innovation, program development and outreach.

“So we need to really redesign how we compensate physicians in these newer, more contemporary models so that we’re all rowing in the same direction,” he said.

An issue with heart teams

While heart teams are key drivers for improved care at many centers, Aronow highlighted that these teams are often a clear example of misaligned incentives. While the multidisciplinary collaboration of these teams leads to better outcomes, current compensation structures often fail to recognize the time required for that work.

“Very few people would argue that heart teams are not best for the patient, but the way that we are set up right now, it’s not in a way that incentivizes that financially. In fact, if anything, it disincentivizes that,” Aronow said.

No going back for cardiology

While the shift toward employment has been rapid over the past decade, Aronow does not expect things to return to how they were in the past.

“I don’t think we’re going to go back,” he said, adding that many private cardiologists are under increasing financial pressure and looking for partnerships with health systems.

Geography will continue to matter, with some regions maintaining higher levels of private practice than others, he explained. Still, the broader trend appears stable and possibly still moving toward more employment, he added.

Work-life balance has become a key employment factor in cardiology

Work-life balance has also become a key factor, particularly for younger physicians reevaluating career priorities after the COVID-19 pandemic. Aronow said generational differences play an important role, especially as the financial upside of long hours has narrowed with lower reimbursements and increasing levels of insurance prior authorizations and other administrative burdens.

“I think we want people to be well-rounded,” he said. “We don’t want them to live in the hospital. We want them to get out and be engaged in the community.”

Ultimately, Aronow said health systems and cardiologists must adapt together.