Midlevel encroachment in Cards

[MilesDavisTheDoctor]

Right now it's my understanding that cardiologists pretty much only benefit from midlevels. They make the practice more efficient and allow the cardiologists to do less menial tasks in favor of other tasks that generate higher RVUs. Is there any possible threat to general cards or even invasive cards from midlevels in the future? At the institution I work at right now the Cards PAs and NPs seem to be surprisingly autonomous lol. I'm interested in cardiology and wondering what you all think.

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[cards67]

I'm not worried. Patients (and their referring doctors) want to be seen by a doctor, especially for something heart related. Everyone freaks out about the heart. IMO, cards will be one of the last to see midlevel takeover. Moreover, cardiology is one of the more powerful and lucrative specialties for the hospital, you don't mess with cards.

 

[timpview]

I wouldn’t say Cardiologists particularly “benefit” from midlevels at the current time, though I also agree they’re currently not a Huge threat either.

At least in my part of the woods with the current set up of hospital-employed cardiologists, our APPs are hired Directly by the hospital and basically function autonomously from us. We don’t financial benefit from them and the APP’s don’t answer to us, which means they’re looking to make their bosses happy not us. They do off load a little work though they do carry some risk as well.

Now obviously the set ups vary and some groups can get APPs to help them more.. perhaps even with some call Or the work that allows them to be more efficient. However, at least in my experience, most situations are not like G.I. or other subspecialties where a group of mid-level’s are pumping a bunch of RVUs to the docs where we are financially benefiting from them… mostly because as I alluded to above the hospital claims them as their own and hospitals are trying to limit certain docs from being outliers with large compensation packages. Basically they don’t want to pay a cardiologist 900k because they have an efficient system of APPs

 

[MilesDavisTheDoctor]

@timpview Would you say from a midlevel perspective as a medical student right now, cards is a pretty safe field to go into?

 

[bronx43]

@timpview Would you say from a midlevel perspective as a medical student right now, cards is a pretty safe field to go into?

Go into rads. You'll thank me later.

 

[chessknt]

@timpview Would you say from a midlevel perspective as a medical student right now, cards is a pretty safe field to go into?

No area of medicine is safe, the conversion factors are dropping and insurers got laws passed to drive reimbursement in to the toilet. The safest fields are surgical subspecialties with ridiculous rvu/hour ratios. Beyond to that is a specialty that predominantly impacts young employed people with private insurance and not older people (derm, allergy). But picking a career based on perceived safeness is embarrassingly myopic. Rad onc, em, anesthesia all come to mind as having their projected desirability change within the training time course.

 

[bronx43]

No area of medicine is safe, the conversion factors are dropping and insurers got laws passed to drive reimbursement in to the toilet. The safest fields are surgical subspecialties with ridiculous rvu/hour ratios. Beyond to that is a specialty that predominantly impacts young employed people with private insurance and not older people (derm, allergy). But picking a career based on perceived safeness is embarrassingly myopic. Rad onc, em, anesthesia all come to mind as having their projected desirability change within the training time course.

With the way inflation is going, I’m not sure that young privately insured patients are necessarily the honeypot. Every insurance is now high deductible, which means every visit costs people the full amount of the visit. It’s often $300-400 with the facility fee included (if you’re with a large hospital system). Seeing how a significant percent of the American public can’t even come up with $500 for emergencies, paying hundreds for a 30 min visit for a rash or sniffles would be bottom of their priorities. Same concept applies for certain elective surgeries. Having even a minor elective surgery done would wipe out $4000-8000 from your bank account or future earnings (if payment plan used) before your insurance even kicks in.

You‘re honestly better off having a bunch of Medicare with supplement patients who have no copay or coinsurance.

 

[timpview]

Yes. Cardiology (especially Int and EP) are as safe as they get. I would say it’s “safer” than anything else out there.

With that said I would echo the others and not even consider it. If I were to select a specialty again my first criteria wouLd be to pick a path without heavy call or night shifts. Second woukd be something that wasn’t dependent on hospitals. Pick something where you can thrive on your own (urology, psych, derm, etc)

 

[bronx43]

Yes. Cardiology (especially Int and EP) are as safe as they get. I would say it’s “safer” than anything else out there.

With that said I would echo the others and not even consider it. If I were to select a specialty again my first criteria wouLd be to pick a path without heavy call or night shifts. Second woukd be something that wasn’t dependent on hospitals. Pick something where you can thrive on your own (urology, psych, derm, etc)

Urology may be the best field out there. People can often put off sinus surgeries or minor rashes, but kidney stones, prostate cancer, hematuria will be taken care of Immediately.

 

[timpview]

No area of medicine is safe, the conversion factors are dropping and insurers got laws passed to drive reimbursement in to the toilet. The safest fields are surgical subspecialties with ridiculous rvu/hour ratios. Beyond to that is a specialty that predominantly impacts young employed people with private insurance and not older people (derm, allergy). But picking a career based on perceived safeness is embarrassingly myopic. Rad onc, em, anesthesia all come to mind as having their projected desirability change within the training time course.

Nah. Those specialties definitely offer the higher ceiling but the highest floor (“safest”) is to hitch yourself to one of the most powerful lobbies in this country (hospitals). Cards is the most critical dept for hospitals when you combine the revenue generation (fee for service), resource utilization (aco),hospital metrics (CHF, mi), need for STEMI coverage, etc. You’ll always be needed and incomes will reflect that in general you’ll be valued (monetarily speaking) by hospitals.

With that said easier ways to make money and currently better ways of making more money too.

 

[chessknt]

With the way inflation is going, I’m not sure that young privately insured patients are necessarily the honeypot. Every insurance is now high deductible, which means every visit costs people the full amount of the visit. It’s often $300-400 with the facility fee included (if you’re with a large hospital system). Seeing how a significant percent of the American public can’t even come up with $500 for emergencies, paying hundreds for a 30 min visit for a rash or sniffles would be bottom of their priorities. Same concept applies for certain elective surgeries. Having even a minor elective surgery done would wipe out $4000-8000 from your bank account or future earnings (if payment plan used) before your insurance even kicks in.

You‘re honestly better off having a bunch of Medicare with supplement patients who have no copay or coinsurance.

Medicare reimbursement is so **** it can't cover overhead. Its why nephrology (where almost all patients are on medicare) is so ****ed. You need to be able to avoid government payors entirely or be able to generate 40 wRVU in 45 minutes like ortho to be in an optimal position. Or you can generate so much facility fee bank like CT surgery that you get paid a massive supplement by a hospital to just do cases there. Cardiology is good from an IM perspective but far from the best in the entire clownfest known as American medicine.

 

[timpview]

Urology may be the best field out there. People can often put off sinus surgeries or minor rashes, but kidney stones, prostate cancer, hematuria will be taken care of Immediately.

Urology to me is #1. Easy, quick, outpt procedures in your clinic that you own. Cash based procedures.. Endless clinic pts. Ability to profit off hospitals. Hospitals need you still. Minimal specialty crossover. Multiple revenue sources. Minimal high patient acuity or risk.

 

[chessknt]

Nah. Those specialties definitely offer the higher ceiling but the highest floor (“safest”) is to hitch yourself to one of the most powerful lobbies in this country (hospitals). Cards is the most critical dept for hospitals when you combine the revenue generation (fee for service), resource utilization (aco),hospital metrics (CHF, mi), need for STEMI coverage, etc. You’ll always be needed and incomes will reflect that in general you’ll be valued (monetarily speaking) by hospitals.

With that said easier ways to make money and currently better ways of making more money too.

You think cardiology exceeds the surgery/OR department in importance? Many smaller hospitals will have an OR but no cath lab; have never seen the reverse. There is a reason for that.

 

[timpview]

No. The OR is more valuable.,but the OR has multiple specialties contributing to its volume and small/rural hospitals can cherry-pick low acuity cases. To support a Cath lab you need to ensure adequate coverage by a single specialty and be able to support volume/complications that small/rural hospitals might not able to support.

 

[bronx43]

Medicare reimbursement is so **** it can't cover overhead. Its why nephrology (where almost all patients are on medicare) is so ****ed. You need to be able to avoid government payors entirely or be able to generate 40 wRVU in 45 minutes like ortho to be in an optimal position. Or you can generate so much facility fee bank like CT surgery that you get paid a massive supplement by a hospital to just do cases there. Cardiology is good from an IM perspective but far from the best in the entire clownfest known as American medicine.

I don't know that Medicare doesn't cover overhead for everything. For routine outpatient things, it is reasonable and not much worse than private payers. In fact, it actually pays more than some like UHC. Perhaps for some of the expensive cardiology ancillaries, Medicare doesn't pay enough. For other things like office drug infusions (chemo or biologics), Medicare is actually the primary revenue generator. That's why you still have private rheumatologists or oncologists making bank.
In general, I'm seeing a lot more privately insured patients cancel or no show their appointments, and from what I hear over at the allergist office, they're seeing the same if not more.

 

[aafisahar]

Medicare reimbursement is so **** it can't cover overhead. Its why nephrology (where almost all patients are on medicare) is so ****ed. You need to be able to avoid government payors entirely or be able to generate 40 wRVU in 45 minutes like ortho to be in an optimal position. Or you can generate so much facility fee bank like CT surgery that you get paid a massive supplement by a hospital to just do cases there. Cardiology is good from an IM perspective but far from the best in the entire clownfest known as American medicine.

? a hospital can literally keep the lights open with just cardiology and CT surgery and most people treated by these departments will be on medicare

 

[wamcp]

 

[MilesDavisTheDoctor]

this is nuts lol

 

[scoopdaboop]

literally nothing in medicine midlevels can encroach. even the worst case scenarios ie FNPs who can practice independently in several states now, FM docs are still highly in demand in those states. any subspecialty isnt even near there yet.

 

[MilesDavisTheDoctor]

what do the interventional cardiologists on this board think about this?

 

[deleted980918]

If you let anyone do the same procedure a few hundred times, he or she can probably do a straightforward case by themselves.

But if a complication occurs, that person won’t have the background knowledge to handle it in a timely manner, and for that reason this will never become mainstream.

No road is wasted in medicine and there’s no shortcut.