Are part-time cardiologists, diagnostic caths fading away?
![Large peridevice leaks after left atrial appendage occlusion (LAAO) are incredibly rare and not associated with a greater risk of adverse outcomes, according to new research published in JACC: Clinical Electrophysiology.[1] Smaller residual links are more common, however, and associated with a risk of thromboembolic and bleeding events.](/sites/default/files/styles/top_stories/public/2018-08/olderpatient-doctor.jpg.webp?itok=Cv18wcDr)
The proportion of part-time cardiologists is declining at a time when one would expect health systems to be doing everything they can to keep competent physicians on board, according to MedAxiom’s 2018 Cardiovascular Provider Compensation & Production Survey.
Part-time physicians account for just 5.9 percent of the total cardiology workforce, based on the report, which included responses from 186 healthcare groups and 2,637 physicians. That’s down from 13 percent in MedAxiom’s 2013 data, despite the most recent survey showing that 24 percent of cardiologists are 61 or older and 40 percent are 56 or older.
“Everybody we talk to is having difficulty recruiting top cardiologists, and we just heard from one of the (American College of Cardiology) heads that the number of cardiology fellowships in this country will not keep pace with the demand for cardiologists,” said Joel Sauer, the author of the report and vice president at MedAxiom Consulting. “When you have physicians already on board and everybody is having a hard time finding the next generation, it would seem like we’d be hanging onto these people as best we can but that’s not what the data show.”
Cardiovascular Business summarized the survey last week but dove deeper into some of the data during an interview with Sauer. In addition to average salary information broken up by subspecialty and region, the report features insight into procedural volume trends across the U.S. and what may be driving those changes.
Sauer said the decline in part-time cardiologists could be a case of more physicians retiring altogether versus transitioning to a part-time role, but it’s more likely that private practices and hospital systems are having a harder time accommodating part-time doctors and are pushing them out the door.
“It’s hard in a private group to make the finances work because they tend to consume the same amount of space, they have the same amount of overhead that needs to be allocated to them, yet their revenue goes down substantially, so it’s just really hard to make the ends meet financially with those physicians so they tend to get pushed out,” he said.
For hospital groups, Sauer speculated the lack of part-time physicians is a result of a misalignment in terms of what the cardiologists want and what the hospital systems need. For instance, the first thing part-time cardiologists might want to get rid of is taking call at night, which is precisely where the hospital’s demand may lie.
“If I recruit a physician to work both day and night I may not have enough volume to keep them busy during the day because I have these part-time physicians who are still working days but not taking nights, and then you get into a challenge of I’m not doing enough procedure volume to stay competent, I’m not reading enough echos and nukes and other diagnostic imaging to stay competent,” Sauer said. “There’s just not enough to go around of that daytime work. So that’s the big tug-of-war.”
Disappearance of diagnostic catheterizations?
According to the report, the median number of catheterizations per 1,000 patients among responding practices dropped to 68 in 2017—down from 73 the year before and 79 in 2014. Despite this decline, the number of percutaneous coronary interventions (PCIs) has remained steady, which Sauer attributes to advances in noninvasive imaging and functional assessments of stenosis that can contribute to revascularization decisions.
“So dramatic are these changes that it is likely that this trend will continue; we may even see the disappearance of the diagnostic catheterization in the future,” Sauer wrote.
Sauer made this prediction before seeing a presentation last week in which a cardiologist showed data that it takes about 15 years for new technologies to disperse nationwide.
“It may go slower than I was thinking,” he acknowledged. “But we have new technologies that do at least close to the same thing as diagnostic catheterization, and those are PET imaging and then also CT angiography with (fractional) flow reserve.
“Those technologies are getting so good that they’re able to tell the cardiologist not just that there is a problem but where the problem is so they can send them straight to the cath lab and say here are the vessels that need intervention.”
Another reason these techniques have the potential to replace diagnostic caths is their noninvasive nature, which most patients would prefer versus receiving a puncture for a coronary angiogram.
Structural procedures increasing
Structural heart volumes have risen steadily over the last few years, with 2.2 out of every 1,000 patients receiving TAVR and 0.7 undergoing left atrial appendage (LAA) closure in 2017. Fewer than one patient per every 1,000 in a program’s panel received TAVR, LAA closure or mitral valve replacement or repair in 2013, according to MedAxiom data. Sauer expects these volumes to continue to rise as indications for transcatheter structural procedures progress to populations at lower risk of surgical complications.
However, he noted those are generally low-margin procedures because the costs of the implants are so high, and added most structural heart program administrators he’s talked to haven’t reported much of a halo effect. That is, they haven’t seen an increase in related, higher-margin valve surgery procedures by evaluating more patients through expanding their less-invasive offerings.
“Most are trying to figure out how to ratchet down the cost so that they can make money directly on these transcatheter procedures since they haven’t seen the halo impact on the open procedures and the things that they make a lot more money on,” Sauer said. “The people who make these implants—the valves and the mitral clips and the other structural implantable devices—don’t want to hear it but all the programs are looking forward to them having competitors so that the prices for the implants themselves come down because that’s the biggest cost on these procedures.”
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.