Is EP’s Success its Own Problem? An Update on EP Physician Recruitment

Technological innovations and an increasing demand for EP doctors are leaving hospitals with a shortage. How are hospitals faring with EP recruiting? Pinnacle Health Group, a physician recruiting firm with 15 years of experience, provides their perspective. What increased the demand for EP physicians? An increasing amount of patients desire specialist care. Electrophysiologists, meanwhile, are already swamped with a prevailing incidence of atrial fibrillation, particularly among the senior population. Along with biventricular defibrillators and lesion reintervention therapy, a majority of cardiology patients are electrophysiology candidates. The shared thought that cardiologists were in surplus in the mid and late 1990s translated into concerns about a shortage as expansions and innovations in the field, economic trends, reimbursements, as well as aging physicians and population affected the workforce. This rings true for electrophysiologists as well. Indeed, as healthcare delivery continues to evolve, with the constant adapting marketplace dynamics and technological innovations as well as a steadily increasing demand for specialized care, interventional procedures like EP and vascular will continue to increase in volume. For example, cardiac electrophysiology practices in Colorado, such as the University of Colorado’s Cardiology Division, have undergone business and clinical expansions in ablation techniques, resynchronization device implantations, and atrial fibrillation and tachycardia procedures. Pennsylvania-based Lancaster General Hospital, through the Joint Review Committee on Education in Cardiovascular Technology (JRC-CVT) and the Commission on Accreditation of Allied Health Education Programs (CAAHEP), initiated to change their cardiac EP internship into an education program to address their shortage of EP physicians in their four-room laboratory. In Florida, Munroe Regional Medical Center added an EP service in March 2010 to round out their cardiovascular program. Elsewhere, global and health and wellness healthcare company UnitedHealthcare and its affiliated offices and facilities in Florida, Montana, North Carolina, Ohio and Wisconsin have begun expanding their EP implantation service. The state of South Carolina, hosted by Health Sciences South Carolina (HSSC), invested $5M to support clinical development in the field, which included recruiting renowned physicians and experts in the field. In Chicago, where in the past cardiac patients had usually preferred to be treated as far away as Florida or California because of the perception of their better facilities, $10M was invested in Northwestern Memorial Hospital to support a comprehensive cardiac center, which included electrophysiology. When two of New York’s academic institutions (Columbia’s College of Physicians and Surgeons and the Joan and Sanford I. Weill Medical College of Cornell University) merged and introduced the service line model, its cardiac and EP lines were first to be upgraded — this included their financial performance, recruitment and retention, physician productivity and quality metrics, to business, marketing and research and development. Additionally, 25 researchers and physicians from Syracuse, New York went on to Ann Arbor, Michigan to enhance their base of arrhythmia specialists. Technological and demographic influences on cardiac EP’s growth have contributed to a concern for physician availability. The American College of Cardiology (ACC) reported1 that as early as 2000, at a time when there was a 20% reduction in cardiology and EP fellows, overall demand for their services influenced 40% of U.S. hospitals to recruit electrophysiologists and cardiologists. By 2004, ACC’s listing of positions had soared to 597. Regardless of being the fastest-growing cardiology subspecialty, the supply of electrophysiologists available might lag behind the demand for them. In 1995, the Heart Rhythm Society’s (HRS) workforce study reported1 there were 999 electrophysiologists in the U.S., making a ratio of one per every 263,690. “Since 2005, demand for electrophysiology and interventional cardiology has been increasing about one percent each year,” explains Craig Fowler, VP for Training and Physician Recruitment at Pinnacle Health Group. “Each year around 1,200 Internal Medicine residents apply for Cardiology fellowships, and only 800 are accepted. Clearly, we are dealing with a serious issue of supply and demand.” It is not surprising that most have to invest serious effort for recruiting cardiac EP physicians. As early as 2005, there was perceived poor distribution of electrophysiologists, with some states having more than they need. Healthcare groups in Indianapolis, Indiana and St. Louis, Missouri are losing them to other job offers. According to George Rodgers, MD, FACC, Chair of the recent workforce task force by the ACC,2 Cardiology and its subspecialties continue to have a 3,000-physician gap, and this number could potentially quintuple by 2050. Currently, 11% of Internal Medicine residents take up subspecialty in cardiovascular disease. There are approximately 1,856 board-certified or board-eligible EP physicians as of 2008, and around 700 electrophysiologists are over the age of 58. Recent data by the Heart Rhythm Foundation3 states that despite a firm workforce capacity, the ratio for a U.S. population average is 3.79:1,000,000, with 21 states having eight electrophysiologists each. In previous surveys, Philadelphia and Washington, DC staffed 50 cardiac EP doctors, while New Mexico and Idaho had less than five. This creates a rather one-sided competition among healthcare facilities. “I’ve had experiences with clinics overcome by nearby hospitals,” related PHG’s Chief Operating Officer Mike Broxterman, “Either because they are underserved with electrophysiologists, or their cardiologists cannot, for instance, implant ICDs by themselves. I’ve also had experiences with larger hospitals who cannot recruit a single EP doctor, one who can meet their alignment needs.” What makes EP a challenging specialty to recruit stems from the supply and a decline in cardiovascular trainees in the 1990s. The most quantifiable aspect of it is that the growth of cardiology graduates is fairly small — when around 800 doctors finish their cardiovascular disease training program, only a quarter or so of them pursue cardiac electrophysiology. When you combine cardiac EP to interventional, invasive and non-invasive specialties, along with 500,000 annual ICD procedures that market experts project, it’s no surprise that EP remains the fourth most recruited specialty today. In fact, there are approximately only 90 trained EPs who enter the workforce annually. Fowler comments, “Subspecialties like EP are in high demand and short supply. Seeing that it’s a young specialty (less than 12% of electrophysiologists are over 55), you are dealing with the issue of the physicians’ quality of life and compensation arrangements. Even with ample lifestyle incentives (time off, flexible schedules, etc.) and reimbursement packages, recruiting electrophysiologists is easier said than done. These doctors usually enter a group. Many electrophysiologists feel that a four-physician group is not large enough for an electrophysiologist. Some EPs feel that they need more than six cardiologists to justify an EP physician. Most are also looking to go into urban areas that have the population to justify their service line.” Then there is the issue of healthcare reform. Broxterman notes, “We are adding over 32 million uninsured patients to healthcare facilities nationwide, and that is an outstanding increase in the demand for EP services, across the board.” Although the prospect can be daunting, it depends on how the healthcare reform would generate enough incentives to attract physicians to become EP specialists — particularly at a time when there’s a 21% cut on reimbursements on Medicare physician payments, which was already implemented last April. According to HRS, this could severely impact practice expense reductions by as much as 40% for electrophysiology evaluation and management services.4,5 Moreover, cardiology is already experiencing Medicare payment cuts by 36% in single photon emission computed tomography (SPECT), 10% in transthoracic echocardiography with spectral and color Doppler, 5% in ECG and 14% in combined echo codes. Some physicians take these changes as opportunities. For instance, specialists in Cardiology (EP included), Orthopedics, Neurology, Ophthalmology and Oncology are forming large single-specialty groups to practice in outpatient settings. A recent survey reports6 that these physicians prefer to be members of a specialty medical group because they can “negotiate leverage with health plans” and focus on the delivery of care while undertaking a profitable practice. In Massachusetts, subspecialized groups like in Orthopedics and Cardiology are already forming single specialty or multi-specialty groups. Others are optimistic. The ACC, who advocated an expansion of funded CV fellowships, recently proposed in their workforce study2 a fast-track initiative to increase fellowship classes that would alleviate the demand for trainees, which can help in the early entrance of doctors into interventional cardiology or electrophysiology. Meanwhile, the healthcare reform bill will focus on establishing Center of Excellence programs focused on enhancing an applicant pool of minorities by re-authorizing a $50 million fund to improve training, recruitment, academics and other necessary support.7 For instance, the Health Professions Training for Diversity, as one of the bill’s provisions, will provide scholarships to students who can work in areas underserved in healthcare services — the $50 million fund that will be used through 2013 will also increase loan repayments of up to $30,000 for faculty positions. “When recruiting EPs,” advised Broxterman, “A well-planned initiative is important. As competition for a relatively small pool of EPs increases, more and more hospitals — even community facilities and clinics — are compelled to get creative. Hospitals will often invest in the program first before hiring another EP, allowing more time for the practice to develop. And when they finally recruit one, they offer higher compensation, signing bonuses, student loan repayments and other incentives. It only shows the value of these doctors to their communities.” Pinnacle Health Group (PHG) is a 15-year Atlanta-based full service physician recruiting firm with associated offices located in Cincinnati, OH; Hartsburg, MO; Sarasota, FL; and York, PA. For more information, please visit: https://www.phg.com/