Future of Cardiology

[chikaficarika]

Colleagues,

There is no particular event that triggered this email, but Dr.XYZ compiles a great set of facts about recent changes in practice. This is an recent email from Dr.XYZ.



It is quite sobering to consider how rapidly the landscape of cardiology practice has changed in less than 5 years.


In Sept. 2009, former BOG Chair, George Rodgers, et al (including my partner and great friend, Minnow Walsh) published the "ACC 2009 Survey Results and Recommendations: Addressing the Cardiology Workforce Crisis" (JACC 2009;54:1195-1208). One of the conclusions from the survey was "Clearly there is a need to increase the supply of CV specialists." The survey reported a shortage in 2009 of 1685 general, 660 EP, 1941 interventional, and 127 pediatric cardiologists, noting that only about 750 general cardiology fellows were completing training each year. What has ensued is one of the most amazing examples of "it is very difficult to make predictions, especially about the future!" I suspect in retrospect that those responding to the survey in 2008 did not have the same business perspective and discipline that they would now have in 2014.


Here is a brief (and I suspect very incomplete) list of changes and events that could not have been anticipated at that time that has turned the whole workforce issue on it's head:

• The 2008-2012 recession/depression and the collapse of 401k's, the squeeze on families due to rising health care costs as a percentage of household income, and the drop in employment overall, especially employment with health benefits (pre-dating the ACA).
• Dramatic delay in retirement of cardiologists in practice, driven not only by personal finances, but also not wanting "to be put out to pasture". "What will I do? I don't just want to play golf all day long." All want to slow down by not taking call or rounding in the hospital, but few want to retire completely.
• Meteoric rise in percent of physician practices integrating and the accompanying increase in compensation (on average up 15% compared to pre-integration) reducing the desire to leave practice.
• Increase in the "globalization" of cardiology and the increased desire of international cardiologists to practice in the US.
• Plummeting CV testing and procedures during the same time period: Stress imaging down 25%, PCI down 40 % since 2007 (CABG down 50%), decrease in MI (STEMI and NSTEMI) by 15% in the last 3 years.
• A healthier Medicare population: Less smoking, more statins, obesity curve "bending", etc.
• Up to 70% of CV patients in most practices covered by Medicare or Medicaid.
• Growth of practices (with or without integration) through merger or acquisition, which focuses on wringing out capacity and increasing man-power efficiency.
• Expansion of ACO's and other risk based payment models that de-emphasize early specialty referral.
• Broad application and, in general, acceptance of using AUC's to guide testing and treatment choices. Negative influence of Imaging Benefit Managers.
• Recognition of inefficient use of technical expertise: 60% of all PCI's done by operators doing <40 procedures per year.
• Dramatic impact of High Deductible Health Plans causing patients to have much more skin in the game and influencing their health care decisions based on economics.
• The uncertainties of the ACA's impact on demand for specialists' care.
• The being "bitten in the butt" by the failure to address transparency in health care pricing that has lead to greater consumerism on the part of patients and payers alike.
• Announcement by most large regional health care systems to reduce their costs of care by 20% over the next 5 years. With physician compensation as one of the largest expenses they incur, there is great incentive for the employed cardiologists to protect salaries by improving individual productivity and to resist hiring new physician associates. Increase in providers is coming preferentially through the employment of Non-Physician Providers.

The list could go on. None-the-less, the result has been an unprecedented drop in demand for professional services and a relative over-supply of highly compensated individuals. How long this "correction" will last is anybody's guess. We will likely see further physician layoffs in big systems until they are right sized. Given how quickly this all happened and how difficult it was to predict in 2009, it argues for the need to have better tools and models to determine and modify future work-force supply and demand. Future predictions are likely to be greatly influenced by how many now change their minds and start to retire, slow down, or explore job sharing.


Fellowship training directors are going to need to analyze not only whether or not they are matriculating the correct number of trainees, but if they are producing the right complement of trainees (too may interventionists?, too many EP? too few CHF and geriatric cardiologists?).


So in an environment where jobs are tight, compensation is under pressure, and there is an over-supply of trainees looking for jobs, it becomes increasingly important to know that the new associate is going to fit in and be a strong contributor right away and will be likely to stay. In our practice, it takes about 6 months from time of starting to when a new partner begins to cover their salary.


Lots of questions. Not many solutions.

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[kayrish]

Colleagues,

There is no particular event that triggered this email, but Dr.XYZ compiles a great set of facts about recent changes in practice. This is an recent email from Dr.XYZ.



It is quite sobering to consider how rapidly the landscape of cardiology practice has changed in less than 5 years.


In Sept. 2009, former BOG Chair, George Rodgers, et al (including my partner and great friend, Minnow Walsh) published the "ACC 2009 Survey Results and Recommendations: Addressing the Cardiology Workforce Crisis" (JACC 2009;54:1195-1208). One of the conclusions from the survey was "Clearly there is a need to increase the supply of CV specialists." The survey reported a shortage in 2009 of 1685 general, 660 EP, 1941 interventional, and 127 pediatric cardiologists, noting that only about 750 general cardiology fellows were completing training each year. What has ensued is one of the most amazing examples of "it is very difficult to make predictions, especially about the future!" I suspect in retrospect that those responding to the survey in 2008 did not have the same business perspective and discipline that they would now have in 2014.


Here is a brief (and I suspect very incomplete) list of changes and events that could not have been anticipated at that time that has turned the whole workforce issue on it's head:

• The 2008-2012 recession/depression and the collapse of 401k's, the squeeze on families due to rising health care costs as a percentage of household income, and the drop in employment overall, especially employment with health benefits (pre-dating the ACA).
• Dramatic delay in retirement of cardiologists in practice, driven not only by personal finances, but also not wanting "to be put out to pasture". "What will I do? I don't just want to play golf all day long." All want to slow down by not taking call or rounding in the hospital, but few want to retire completely.
• Meteoric rise in percent of physician practices integrating and the accompanying increase in compensation (on average up 15% compared to pre-integration) reducing the desire to leave practice.
• Increase in the "globalization" of cardiology and the increased desire of international cardiologists to practice in the US.
• Plummeting CV testing and procedures during the same time period: Stress imaging down 25%, PCI down 40 % since 2007 (CABG down 50%), decrease in MI (STEMI and NSTEMI) by 15% in the last 3 years.
• A healthier Medicare population: Less smoking, more statins, obesity curve "bending", etc.
• Up to 70% of CV patients in most practices covered by Medicare or Medicaid.
• Growth of practices (with or without integration) through merger or acquisition, which focuses on wringing out capacity and increasing man-power efficiency.
• Expansion of ACO's and other risk based payment models that de-emphasize early specialty referral.
• Broad application and, in general, acceptance of using AUC's to guide testing and treatment choices. Negative influence of Imaging Benefit Managers.
• Recognition of inefficient use of technical expertise: 60% of all PCI's done by operators doing <40 procedures per year.
• Dramatic impact of High Deductible Health Plans causing patients to have much more skin in the game and influencing their health care decisions based on economics.
• The uncertainties of the ACA's impact on demand for specialists' care.
• The being "bitten in the butt" by the failure to address transparency in health care pricing that has lead to greater consumerism on the part of patients and payers alike.
• Announcement by most large regional health care systems to reduce their costs of care by 20% over the next 5 years. With physician compensation as one of the largest expenses they incur, there is great incentive for the employed cardiologists to protect salaries by improving individual productivity and to resist hiring new physician associates. Increase in providers is coming preferentially through the employment of Non-Physician Providers.

The list could go on. None-the-less, the result has been an unprecedented drop in demand for professional services and a relative over-supply of highly compensated individuals. How long this "correction" will last is anybody's guess. We will likely see further physician layoffs in big systems until they are right sized. Given how quickly this all happened and how difficult it was to predict in 2009, it argues for the need to have better tools and models to determine and modify future work-force supply and demand. Future predictions are likely to be greatly influenced by how many now change their minds and start to retire, slow down, or explore job sharing.


Fellowship training directors are going to need to analyze not only whether or not they are matriculating the correct number of trainees, but if they are producing the right complement of trainees (too may interventionists?, too many EP? too few CHF and geriatric cardiologists?).


So in an environment where jobs are tight, compensation is under pressure, and there is an over-supply of trainees looking for jobs, it becomes increasingly important to know that the new associate is going to fit in and be a strong contributor right away and will be likely to stay. In our practice, it takes about 6 months from time of starting to when a new partner begins to cover their salary.


Lots of questions. Not many solutions.

The Damage is done, we need to do something about our future.
Let's draft an online petition to cap the number of spots to 600.

 

[chikaficarika]

I think it should be reduced by 350 like GI have controlled there spot. Also Interventional and EP spots needs to be reduced dramatically.

 

[kayrish]

Rodgers et al gave a golden opportunity for small cardiology groups to hire unlimited cheap labour(fellows).
It was very short sighted of ACC to do what has been done.

My worst fear is that the oversupply will decrease the competitiveness of cardiology(which it already has, given the latest match). This will translate to more bad longtime implications.

https://petitions.whitehouse.gov

 

[kayrish]

Actually http://www.change.org/petition might be better to forward the petition to ACC, ACGME and APDIM

 

[kd649]

I think it should be reduced by 350 like GI have controlled there spot. Also Interventional and EP spots needs to be reduced dramatically.

I don't know if GI is really "controlling" their spots. GI is predicting a shortage right now and there was a dramatic increase in the number of spots last year as you can see here.
http://www.gastro.org/gi-fellowship/gastroenterology-fellowship-match/gi-match-statistics
Who knows maybe 5-10 years from now they'll finally develop something that can get close to the accuracy of colonoscopy when it comes to colorectal cancer screening. Maybe by then PCSK9 inhibitors will further reduce the need for cardiologists and their market will tank even more. Or everything stays as is and GI and cards continue to dominate the next 30 years in income and innovation. Trying to predict the future will drive you crazy. I am just going to go into whatever I enjoy the most. If worst comes the worst I will always have general internal medicine/hospitalist to fall back on.

 

[kayrish]

Gi increased the spots to 400 something, that is still almost half of 800 in cardiology.
And the Demand for GI is almost everywhere.
We need to stop talking about other fields and focus on rescuing cardiology.

 

[gutonc]

Actually http://www.change.org/petition might be better to forward the petition to ACC, ACGME and APDIM

Yeah...that will totally work.

 

[chikaficarika]

KD649,

No wonder why there is not a strong lobby for cardiology. we just fight with each other instead of understanding the problem. why you are worried about GI ? why even you wants to look how many spots they have ?

Problem here is Cardiology demand and spots.

By the way, if you still don't understand bad situation of cardiologist right now, let me tell you who wrote this letter to who.

This letter above was written by one of the state ACC president. This city is one of the biggest city in Midwest where i live. In mid west people think salary should be higher right but we have General, EP and Interventional fellows trouble finding a job even after working with 3 most reputed cardiologist whom i think every cardiologist in USA knows.

He wrote this letter to ACC President and to other ACC presidents.

Think about it, why he wrote a such big letter. He is practicing for more than 35 years. What he saw that we are no still aware ? They have seen ups & downs of the cardiology and they want to protect this field.

So you are right that no one knows the future but we can do something now to protect this field and make it better for tomorrow.

You can always go back to Hospitalist. Thats implies that we don't love cardiology and you are here only for money. If money goes down then we will be hospitalist.
Not just calculate money that you have lost in last 4 to 5 years to become a cardiologist. around 1 million dollar if you make 200K per year and one week on & off.

 

[amine2086]

KD649,
You can always go back to Hospitalist. Thats implies that we don't love cardiology and you are here only for money. If money goes down then we will be hospitalist.
Not just calculate money that you have lost in last 4 to 5 years to become a cardiologist. around 1 million dollar if you make 200K per year and one week on & off.

This does not sound right. I am sure he got a salary as a fellow (perhaps not as much as a hospitalist). So that must be subtracted before saying the opportunity cost of training as a fellow is $1M. I think hospitalist itself is in a bubble- it's growing at a rate that is likely not going to be sustainable in the future. But none of us can predict the future. As for cardiology, I don't think the future is as bad as some people on SDN make it to be. Considering the aging population, there will always be demand cardiologists (just like many other specialties).

 

[CanIMakeIt]

This does not sound right. I am sure he got a salary as a fellow (perhaps not as much as a hospitalist). So that must be subtracted before saying the opportunity cost of training as a fellow is $1M. I think hospitalist itself is in a bubble- it's growing at a rate that is likely not going to be sustainable in the future. But none of us can predict the future. As for cardiology, I don't think the future is as bad as some people on SDN make it to be. Considering the aging population, there will always be demand cardiologists (just like many other specialties).

I don't don't know about future but the math seem correct to me. Fellow salary about 55-65K depending on the region. Hospitalist salaries, incl bonuses etc, is about 250-325K. So it would be close to a million $ for about 4-5 years (assuming you do sub-fellowship)