Interventional Echocardiography CV Anesthesia

[Section31]

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In some cases with some docs I agree, but at the end of the day the hospital decides what they want for credentialing. When I was interviewing, a very good established private group had to displace a bunch of their long time cardiac guys because they didn’t have the certification and would not or could not get it. I didn’t interview anywhere that had non echo certified docs doing hearts.

I think I’ve picked the wrong side of the argument to argue. Echo training will eventually be mandatory, you’re right. But I’m not convinced advanced will make a difference over basic. Even then, the Basic people could just become Advanced Testamurs. I doubt places would refuse to credential someone who passed the Advanced boards.

 

[deleted126335]

That might be true for guys coming out of training. But my experience has shown me that the only thing you need to prove you can do hearts is a recent track record of doing hearts.

There are still plenty of non-echo certified docs doing hearts and echos. But that is a number that is getting smaller every year. No sign whatsoever of that trend reversing.

 

[Modanq]

Im not sure if I am coming across clearly:

I feel as If we don't embrace en masse TEE, ICE (transjugular/transfemoral), and fusion imaging, peri operative imaging, TTE, we will be left out...Furthermore - Dont be surprised when the coding changes for "Interventional TEE" to be reimbursed at the level of the actual procedure itself i.e. 50% of the Mitral clip, TAVR or LAAO procedure code itself because the RVUs actually reflect that the interventional imager is doing 50% of the effort. There are grumblings on the ground regarding this effort...
If it happens there will be a free for all and cardiology might take back the territory and we will be back to bench warmers.

Feel free to debate...

 

[pgg]

I went to one of the best and worked by butt off for a year. It was exhausting. I’m simply jaded and bitter. Probably best not to listen to me.

I feel your pain.

But you surely got a lot out of the year. Cases and patients that you are coolly comfortable with, make others anxious. Don't sell yourself short on what you've accomplished and learned and what you can do.

 

[kidthor]

In some cases with some docs I agree, but at the end of the day the hospital decides what they want for credentialing. When I was interviewing, a very good established private group had to displace a bunch of their long time cardiac guys because they didn’t have the certification and would not or could not get it. I didn’t interview anywhere that had non echo certified docs doing hearts.

Cardiac fellowship training is legit. TEE training is legit.

Doing a "super"-fellowship in interventional-cardiac related device placement is not legit.

You interviewed at places that valued your skills...

 

[kidthor]

Im not sure if I am coming across clearly:

I feel as If we don't embrace en masse TEE, ICE (transjugular/transfemoral), and fusion imaging, peri operative imaging, TTE, we will be left out...Furthermore - Dont be surprised when the coding changes for "Interventional TEE" to be reimbursed at the level of the actual procedure itself i.e. 50% of the Mitral clip, TAVR or LAAO procedure code itself because the RVUs actually reflect that the interventional imager is doing 50% of the effort. There are grumblings on the ground regarding this effort...
If it happens there will be a free for all and cardiology might take back the territory and we will be back to bench warmers.

Feel free to debate...

That will never happen. And if it did - that is if 50% of the total procedural fee went to TEE and thought for these things - then the cardiologists will just steal the TEE and associated fees from you (they'll just bring in a second cardiologist while the first does the "procedure"). They don't care about you. The hospital doesn't care about you either.

I agree with you that we/you should be getting those fees, as they are commensurate with the brainpower and training involved. I respect you but few others do.

Our anesthesia overlords already sold us out. They only cared about themselves.

 

[deleted126335]

Way back when, when TEE was in it’s infancy there was at least one very desirable suburban hospital that I am familiar with where the GI docs would come down to insert the probe. They lost interest when the reimbursement for probe insertion went away.

 

[Twiggidy]

If all you got out of your cardiac fellowship was a slip of paper from NBE, you went to a lousy fellowship program.

I echo this

(see what i did there?)

 

[Section31]

Way back when, when TEE was in it’s infancy there was at least one very desirable suburban hospital that I am familiar with where the GI docs would come down to insert the probe. They lost interest when the reimbursement for probe insertion went away.

They still reimburse for that. It’s very small, but probe insertion alone is still reimbursed.

 

[AdmiralChz]

That will never happen. And if it did - that is if 50% of the total procedural fee went to TEE and thought for these things - then the cardiologists will just steal the TEE and associated fees from you (they'll just bring in a second cardiologist while the first does the "procedure"). They don't care about you. The hospital doesn't care about you either.

Totally agree. If you think the Cardiologists are going to split the procedural cost with you for your “echo expertise” you’re sorely mistaken. You wouldn’t let us do it either if you were them. If such a thing happens, expect to see Cardiologists come out of the woodwork to do the echo. Anesthesiologists as a whole aren’t very respected as echocardiographers, outside of a few national names (and even at those institutions, they have legit Cardiology superstars so I’d be curious to see how it really is). Yes, I know the incoming president of ASE is an anesthesiologist but that’s more of a “well, no one else wants to do it...” situation.

They still reimburse for that. It’s very small, but probe insertion alone is still reimbursed.

This is true! Reimbursement was around $80-$100 from CMS when we used to do this.

 

[deleted171991]

OK, I'll make a Doom And Gloom prediction: in 15 years, most valve procedures will be done by cardiologists (the same way most coronary procedures are PCIs today, and not CABGs), and all anesthesia will do is provide MAC (or not even that). 😛

On topic, nobody gives a crap about one's board certifications, without the proper club membership specialty. It's like when hospitals don't hire anesthesiologist-intensivists for MICUs, despite the latter being at least as board-certified and competent in critical care as their internist counterparts (if not more). If the interventional TEE pie will become big, sweet and creamy, the cardiologist proceduralists will ask for cardiologist echocardiographers. This is so Turf Wars 101.

 

[Section31]

OK, I'll make a Doom And Gloom prediction: in 15 years, most valve procedures will be done by cardiologists (the same way most coronary procedures are PCIs today, and not CABGs), and all anesthesia will do is provide MAC (or not even that). 😛

On topic, nobody gives a crap about one's board certifications, without the proper club membership specialty. It's like when hospitals don't hire anesthesiologist-intensivists for MICUs, despite the latter being exactly as board-certified an competent in critical care as their internist counterparts. If the interventional TEE pie will become sweat and creamy, the cardiologist proceduralists will ask for cardiologist echocardiographers.

The cardiologists where I work want us to do the echocardiography for MitraClips, TAVRs, etc because they have a very busy cath service and would lose boatloads of money if a cardiologist did the Echo. I asked our cardiology team about a scenario where reimbursement changed to 50-50. They replied they would still lose too much from Caths to justify another cardiologist. I don’t know, however, if the opinion of my team is generalizable.

 

[Twiggidy]

OK, I'll make a Doom And Gloom prediction: in 15 years, most valve procedures will be done by cardiologists (the same way most coronary procedures are PCIs today, and not CABGs), and all anesthesia will do is provide MAC (or not even that). 😛

On topic, nobody gives a crap about one's board certifications, without the proper club membership specialty. It's like when hospitals don't hire anesthesiologist-intensivists for MICUs, despite the latter being exactly as board-certified an competent in critical care as their internist counterparts. If the interventional TEE pie will become big, sweat and creamy, the cardiologist proceduralists will ask for cardiologist echocardiographers. This is so Turf Wars 101.

Just given direction the world is moving, I will 100% agree with you. Everything SHOULD move towards the most minimally invasive work for the benefit of the patients. If CV surgeons were smart they would've been trying to learn how to do interventional procedures like vascular surgeons. We, as a specialty, will always have the work because quite frankly cardiologists don't know how to sedate patients and if you need TEE guidance they'll probably want them to be asleep. It would be interesting to see what would happen to the number of unit assigned to a minimally invasive valve. What is it currently?

 

[T-burglar]

15 units base for a valve in my area.

With respect to who is better at echoes, generally speaking CT anesthesia is better at intra op and post op echocardiography believe it or not. Our surgeons want the CT dudes in my group to do echoes in the CTICU. Of course just like anything this is variable. There are probably places where the surgeons want the cardiologists to do it.

 

[AdmiralChz]

The cardiologists where I work want us to do the echocardiography for MitraClips, TAVRs, etc because they have a very busy cath service and would lose boatloads of money if a cardiologist did the Echo. I asked our cardiology team about a scenario where reimbursement changed to 50-50. They replied they would still lose too much from Caths to justify another cardiologist. I don’t know, however, if the opinion of my team is generalizable.

I am sure if you put pen to paper and actually cut into their reimbursement their story will change and a cardiologist will be very much available for echo. In an era where each specialty will be fighting for healthcare dollars, this is an easy prediction to make.

 

[anes121508]

There are still plenty of non-echo certified docs doing hearts and echos. But that is a number that is getting smaller every year. No sign whatsoever of that trend reversing.

The demand of the newer ct surgeons who have the ears of the hospital admin are pushing this trend. I’m currently going through it now.

 

[anes121508]

Im not sure if I am coming across clearly:

I feel as If we don't embrace en masse TEE, ICE (transjugular/transfemoral), and fusion imaging, peri operative imaging, TTE, we will be left out...Furthermore - Dont be surprised when the coding changes for "Interventional TEE" to be reimbursed at the level of the actual procedure itself i.e. 50% of the Mitral clip, TAVR or LAAO procedure code itself because the RVUs actually reflect that the interventional imager is doing 50% of the effort. There are grumblings on the ground regarding this effort...
If it happens there will be a free for all and cardiology might take back the territory and we will be back to bench warmers.

Feel free to debate...

I’ve been trying to tell the older cv guys in my group this and they are resistant and won’t listen.

 

[anes121508]

That will never happen. And if it did - that is if 50% of the total procedural fee went to TEE and thought for these things - then the cardiologists will just steal the TEE and associated fees from you (they'll just bring in a second cardiologist while the first does the "procedure"). They don't care about you. The hospital doesn't care about you either.

I agree with you that we/you should be getting those fees, as they are commensurate with the brainpower and training involved. I respect you but few others do.

Our anesthesia overlords already sold us out. They only cared about themselves.

I’d argue that many cardiologists are clueless as to how to guide these untill they put in the work and effort to learn. Anyone with good fundamentals in 2d and 3d can learn. I’ve seen it first hand.

I’m thinking about how to position now so if reimbursement goes up, it doesn’t get clawed back by cards.

 

[kidthor]

I’d argue that many cardiologists are clueless as to how to guide these untill they put in the work and effort to learn. Anyone with good fundamentals in 2d and 3d can learn. I’ve seen it first hand.

I’m thinking about how to position now so if reimbursement goes up, it doesn’t get clawed back by cards.

I'm sure they are clueless about that. But they don't care - how many clueless surgeons have you seen putting in tunneled lines? They still bill for them entirely under their own name, even if they need our input.

Basically, I'm saying that they proceduralists will never give us anything. Even if we materially contribute.

 

[deleted126335]

I’d argue that many cardiologists are clueless as to how to guide these untill they put in the work and effort to learn. Anyone with good fundamentals in 2d and 3d can learn. I’ve seen it first hand.

I’m thinking about how to position now so if reimbursement goes up, it doesn’t get clawed back by cards.

Better to position yourself so that the cardiologists love the quality of your work your service, and that they lobby the hospital to pay you for it. If the stand alone, unsubsidized, reimbursement becomes worth their time, they will be the ones who will grab it.

 

[anes121508]

Better to position yourself so that the cardiologists love the quality of your work your service, and that they lobby the hospital to pay you for it. If the stand alone, unsubsidized, reimbursement becomes worth their time, they will be the ones who will grab it.

So you are ahead of the curve, provide a service that the interventional cardiologist really wants, interventional guy lobby's on your behalf and the hospital to stipends your group in order for you to go 1:1 rather than 3:1 or 4:1, what do you do in order to keep the the cardiologists hand out of the cookie jar in the future when reimbursement goes up? Even it's it's not possible, and you wanted to try, what would you do?

 

[vector2]

So you are ahead of the curve, provide a service that the interventional cardiologist really wants, interventional guy lobby's on your behalf and the hospital to stipends your group in order for you to go 1:1 rather than 3:1 or 4:1, what do you do in order to keep the the cardiologists hand out of the cookie jar in the future when reimbursement goes up? Even it's it's not possible, and you wanted to try, what would you do?

In my experience as the guy who joined a group where previously nobody had any cardiac expertise, once you’ve established yourself as the go-to guy for when ct / vascular surgeons or ICs have a tough case, that relationship becomes very sticky. It’s very unlikely that if you successfully guided 100+ tavr/mitraclip/watchman/amplatzer/impellas with excellent patient outcomes that the proceduralist group is going jump ship unless the compensation difference is enormous.

 

[AdmiralChz]

In my experience as the guy who joined a group where previously nobody had any cardiac expertise, once you’ve established yourself as the go-to guy for when ct / vascular surgeons or ICs have a tough case, that relationship becomes very sticky. It’s very unlikely that if you successfully guided 100+ tavr/mitraclip/watchman/amplatzer/impellas with excellent patient outcomes that the proceduralist group is going jump ship unless the compensation difference is enormous.

I agree, but a double digit percentage change (10%+) in reimbursement by “sharing” with the echocardiographer will change any relationship.

 

[anes121508]

I agree, but a double digit percentage change (10%+) in reimbursement by “sharing” with the echocardiographer will change any relationship.

Btw is this whole increase in reimbursement hypothetical or is this something that is truly being discussed by people who make the rules on these things?

 

[pgg]

Btw is this whole increase in reimbursement hypothetical

In a Healthcare system that's broke and flirting with "Medicare For All" I'm not sure I'd bet on any procedure getting increased reimbursement, ever.

 

[AdmiralChz]

Btw is this whole increase in reimbursement hypothetical or is this something that is truly being discussed by people who make the rules on these things?

Purely hypothetical. Payment schemes are looking to be more simple and pay less, not split with another provider.

Honestly if such a thing was going to happen for advanced echo skills it would have happened within the last 10 years when 3D echo and structural procedures gained prominence. If reimbursement hasn’t changed yet, I simply don’t see it happening at all.

 

[Modanq]

Btw is this whole increase in reimbursement hypothetical or is this something that is truly being discussed by people who make the rules on these things?

At the SCA MTG this year it was brought up and there are people in the ASE who are for and against it. There is a working group at the ASE that is looking into reimbursement petitioning for TEE. The biggest hang up that the committee is facing is if they approach medicare to revisit the coding for TEE then all the codes will be open to re-evaluation.