Like the cardiology industry as a whole, the current trends and statistics in interventional cardiology are sending mixed signals. On the one hand, volumes in the catheterization lab have been decreasing over the past few years. These declines have been so substantial that some pundits in the industry believe we may be looking at an interventional cardiologist oversupply in the near future. However, there are other signals that point to increases in demand, including invasive services such as transcatheter procedures and a decrease in the number of available cardiologists. Together, these factors may actually cause a shortage of interventional cardiologists. How this all shakes out remains to be seen, but we can use data to help draw more accurate conclusions.

DOWNWARD PRESSURES ON DEMAND

According to the 2014 MedAxiom Provider Compensation & Production Survey,1 the median number of cardiac catheterizations per full-time cardiologist peaked in 2006 at 168 and has been declining ever since. Correspondingly, the volume of percutaneous coronary interventions (PCIs) has also declined (Figure 1). Perhaps an even better measure to capture this trend is the ratio of catheterizations to total cognitive encounters (the evaluation and management codes of the current procedural terminology spectrum). This latter ratio more accurately reflects the number of cardiac catheterizations per population of cardiology patients, as opposed to the number of physicians, which is subject to workload differences. When looking at this measure (Figure 2), we see that from 2008 to 2011, the ratio decreased from 5.1% to 4.1%. Likewise, the ratio of PCIs to cognitive encounters also decreased from 1.85% in 2008 to 1.6% in 2013 (Figure 2).

Although these may seem like relatively small declines, Tables 1 and 2 demonstrate the significant affect this change has had on the average cardiology practice. These volume declines—and the corresponding revenue—are part of the story behind the mass integration of private cardiology practices into hospital or health system models. In the last 2 survey years, the catheterization ratio has trended back up slightly, but the total volume remains substantially lower than in years past. The PCI ratio also trended back up in 2013. These latest upticks suggest that we have perhaps hit the bottom of these downward trends, although it is too early to definitively make that call.

The reasons behind these declines are myriad and not the focus of this article, but we can point to some very significant stimuli during the past several years. In no particular order, these reasons include the role of statins in the reduction of cholesterol levels and coronary heart disease, the “Great Recession” beginning in 2008, the substantial shift of medical expenses from employers and insurers to patient out-of-pocket expenses, the advent of the Affordable Care Act, and appropriate-use criteria along with other evidence-based analyses that more clearly define when (and when not) to perform testing on patients.

As an example of this, the recently concluded FAME II trial further clarifies when angioplasty should be utilized over medical therapies.2 “FAME II was kind of the antidote for the COURAGE trial,” said Edward Fry, MD, Cardiovascular Service Line Director and Chairman of the Cardiology Division for St. Vincent Health in Indianapolis, Indiana. “It’s a complicated equation, but I don’t think it’s going to be a game changer in terms of interventional volumes. We may see the age curve shift right in terms of who undergoes procedures.”

Dr. Fry sees the real potential game changer on the payer side. “If third-party payers start to limit reimbursement based on volume or credentials, such as interventional board certification, that will have a major impact,” he notes. “You’d definitely see volumes consolidate as physicians and centers are cut out based on these requirements.”

Examples of payment restrictions ostensibly based on clinical evidence, such as onerous payment authorization requirements set by radiology benefit managers, are already creeping into the equation. Further evidence that the industry is moving in this direction can be found in national “centers of excellence” contracts, in which companies such as Walmart and Lowe’s steer their employees to a select number of United States cardiac centers.

SIGNS OF INCREASED DEMAND

There are, however, powerful signals on the horizon suggesting that the demand for cardiology services, including interventional procedures, may trend back up. For starters, 12,500 Americans turn 65 years old every day, with projected totals to hit 71.5 million by 2030.3 Cardiology patient populations skew toward this population (Figure 3), which mathematically suggests that demand will increase. Further evidence of looming demand increases can be seen in the growing prevalence of key chronic diseases, including obesity, which is projected at 50% of our total population by 2030 (Figure 4). Obesity is a major driver of heart conditions, such as coronary artery disease, diabetes, high blood pressure, hyperlipidemia, and stroke. Additionally, the population of United States adults with multiple chronic conditions increased from 22% in 2001 to 25% in 2010—an addition of nearly 2 million adults.4

Technology is certainly having, and will continue to have, an impact on demand as well. Interventional physicians are able to perform many new therapies via catheter that were not possible just a few short years ago. Obvious examples of these procedures include aortic and mitral valve repair/replacement and patent foramen ovale closure. These new technologies are also having an upward impact on other cardiac testing volumes, such as echocardiography.

SUPPLY SIDE FORCES

Perhaps the most significant pressure on the supply side of the interventional cardiology workforce is age. According to the 2014 MedAxiom Annual Survey,5 more than one-third (34%) of the interventional cardiology workforce is older than 59 years, with a median age of 54. Although this age does not trigger automatic retirement, we can rationally assume that a physician who is 60 years of age or older is closer to the end of his/her career than the beginning. The toll of long hours in the catheterization lab and wearing lead, which was much heavier in the early years of catheter- based procedures, forces many interventional physicians out of the lab and into more general cardiology roles. This shift in roles is also more common for senior physicians than those early in their careers.

Furthermore, we know that older physicians generate less work (as measured by the current gold-standard resource, work relative value units [wRVUs]) than younger physicians. As seen in Figure 5, productivity peaks in the mid-40s and then trails off, with a precipitous drop after age 58. These data show that as our current crop of interventional physicians age, more of them will be required to perform the same volume of procedures than in past years, when this workforce was younger.

Unique to interventional cardiology is the burden of night and weekend on-call shifts, particularly for treatment of ST-elevation myocardial infarction. Providing this 24/7 service can create the need for additional physicians, regardless of adequate volumes and noninterventional work, to financially support them. Compounding this stressor is the increase in the number of centers providing treatment for ST-elevation myocardial infarction, which expands on-call coverage needs. Hospitals, particularly smaller community facilities, are facing tightening of financial returns and are adding historically lucrative services, such as interventional cardiology, to bolster bottom lines.

Given these burdens and the physical nature of the work, it is not uncommon for interventional physicians to desire reduced or eliminated catheterization and on-call responsibilities. In a recent informal poll of its membership, MedAxiom found that the majority of groups are facing issues around physician slow-down and reduced on-call participation. Furthermore, the 2014 MedAxiom Annual Survey found that nearly 16% of cardiologists are now taking less than full call, which can create significant stress within a group.

“We were staring at what we called ‘a gray tsunami’ in terms of our cardiology workforce,” said Dr. Fry, who chairs a cardiology division of more than 80 cardiologists. “Nearly 40% of our physicians were older than 60 years, so without action, we were facing a critical situation.”

Within Dr. Fry’s group, a full quarter of the interventional physicians were older than 60 years, so high turnover within a 5- to 10-year horizon seemed imminent. “With interventional coverage, you’re balancing individual physician volumes to maintain proficiency and call coverage,” says Dr. Fry. “In our case, it looks like we’ll be able to achieve this balance, but for many groups, satisfying one of these often comes at the price of the other.”

Effect of Reductions in On-Call Participation

As noted earlier, there is a significant decline in wRVUs as a cardiologist ages, beginning in his or her mid-40s. Likewise, there is a dramatic decline in wRVUs when a physician reduces his or her on-call participation, as evidenced in Figure 6. As these data show, a cardiologist who only partially participates in being on-call produces one-third less wRVUs than those taking full on-call shifts; this delta widens to 55% less production when a physician declines to be on-call altogether. These data make it easy to understand the stress caused to a group as its workforce ages, not just in providing the 24/7 coverage itself, but also in terms of balancing workloads and the number of physicians.

SUMMARY

Recent volume declines suggest the need for fewer interventional cardiologists. However, over the next 10 years, we will likely see a significant exodus of physicians due to retirement and other age-related reasons. Without major expansion of our cardiology training programs (which is quite unlikely in today’s political and budget climate), mathematically, there will be fewer interventional cardiologists.

Anecdotal evidence from on-line medical jobs forums, such as the Student Doctor Network,6 suggests a soft market for interventional fellows leaving training. Perhaps a net reduction in interventional physicians would be appropriate to balance supply and demand, particularly in the short term. On the other hand, if procedure volumes trend back up, or if there are significant restrictions around reimbursement that limit physician participation, we suddenly have an entirely new situation. Given that it takes more than 10 years to train an interventional cardiologist, changing the physician supply side won’t happen quickly.

Microsoft Founder Bill Gates is credited with saying, “We always overestimate the change that will occur in the next 2 years and underestimate the change that will occur in the next 10.”7 This may be a fitting warning for programs that are assessing their interventional workforce. In medicine, we have a hard time thinking 10 years into the future, but for planning purposes, this may be the most prudent course.

Joel Sauer is Vice President, Consulting at MedAxiom Consulting. He works with organizations across the country in the area of physician/hospital partnerships. His work includes full-service line development, comanagement arrangements, and integration transactions. Mr. Sauer may be reached at jsauer@medaxiom.com.

  1. Sauer J. 2014 MedAxiom Provider Compensation & Production Survey.
  2. De Bruyne B, Fearon WF, Pijls NHJ, et al, for the FAME 2 Trial investigators. Fractional flow reserve–guided PCI for stable coronary artery disease. N Engl J Med. 2014;371:1208-1217.
  3. US Census Bureau 2013. http://factfinder.census.gov. Accessed December 22, 2014.
  4. Ward BW, Schiller JS. Prevalence of multiple chronic conditions among US adults: estimates from the National Health Interview Survey. Prev Chronic Dis. 2013;10:E65.
  5. The 2014 MedAxiom Annual Survey (a proprietary survey based on MedAxiom membership data).
  6. The Student Doctor Network. http://www.studentdoctor.net. Accessed February 2, 2015.
  7. BrainyQuote. http://www.brainyquote.com/quotes/quotes/b/billgates404193.html. Accessed February 2, 2015.