The Economics of a Cardiac Anesthesiologist

We cannot consider “the cost” of a cardiac anesthesiologist without discussing their value in terms of the specific services they can provide to the cardiac surgical patient in particular, or to the institution as a whole. The “value proposition” varies depending on whether the cardiac anesthesiologist provides solely intraoperative anesthesia care versus the wide range of services that many cardiac anesthesia groups can provide in 2018. These services may include some or all of the following:

• ■ Preoperative optimization of patients with cardiac disease
• ■ Intraoperative transesophageal echocardiography – cardiac and non-cardiac surgery
• ■ Perioperative transesophageal echocardiography services – pre-op and ICU
• ■ Postoperative intensive care
• ■ Post-intensive care in-hospital management
• ■ Non-operating room administrative services
• ■ Decreased resource utilization through development of patient care pathways
• ■ Improved outcomes through incorporation of evidence-based practice guidelines

Compensation for a cardiac anesthesiologist varies depending upon the practice type (academic vs. private practice), geographic location, payer mix and model of care (i.e., medical direction vs. personally performed). The common theme, however, is that the compensation demanded by highly performing cardiac anesthesiologists who are able to provide all of the services listed above usually exceeds the revenue collected from the provision of traditional anesthesia services alone. In a private-practice model of care, the difference between collected revenue and the costs of a cardiac anesthesiologist becomes a negotiation between the hospital and the entity that employs these professionals. From the hospital’s perspective, a cardiac surgical program generates good financial profitability and it is therefore important to recruit and retain talented physicians who contribute significantly to the program’s success. The hospital may be willing to support the gap between collected revenue from patient services and total compensation. But as hospital profit margins shrink, the challenge to maintain fair and reasonable compensation becomes increasingly difficult to maintain. The subsidy paid to the contracted entity must be at a level where both the hospital and the anesthesia group can maintain their financial stability. Excessive subsidies due to market conditions, case volume or payer mix are generally not sustainable. Similarly, inadequate subsidies may not afford the hospital or group the ability to recruit and/or retain the appropriate talent to run a successful cardiac surgical program.

Many hospitals faced with supporting the financial gap between cardiac anesthesia revenue and compensation use MGMA and AAMC as resources to establish benchmarks for productivity and compensation. However, the data provided does not consider many factors, such as call requirements, percentage of time actually doing cardiac cases, etc. As a means to provide more specific information regarding compensation for cardiac anesthesiologists faced with hospital or individual negotiation for compensation, the SCA established its salary survey of U.S. members. As a product of the SCA’s Economics Committee, this biannual survey has been conducted every two years since its inception in 2008, when I had the privilege of chairing this SCA committee. The most recent survey was conducted earlier this year and asked more than 20 questions designed to provide insights into practice patterns and compensation trends. The highlights were reported in the August 2018 SCA newsletter by Gordon Morewood, the current chair of the SCA Economics Committee. Only SCA members who complete the survey receive detailed information of the survey results, as an incentive to submit data, thereby increasing participation and providing more meaningful results.

It is unclear what the impact of value-based payment models will have on cardiac anesthesiologists’ compensation. Groups and individual cardiac anesthesiologists who are able to provide comprehensive perioperative care and contribute to the success of the overall program should stand to gain a greater proportion of payments than those whose practice is solely based upon intraoperative care. Fee-for-service is still the predominant payment model in 2018, so it is unlikely that the new and evolving payment models have impacted the results of this past year’s SCA salary survey. It will be interesting to see the trends develop in the years ahead. The trend away from private practice and fee-for-service models will likely continue in the years ahead as the resources required to collect and report quality data make it challenging for small groups to maintain their autonomy and independent practice. It is also difficult for small groups to provide the wide range of services described above without being integrated into the hospital either through direct hospital employment or within a multispecialty group.

The SCA has evolved over recent years to provide a variety of resources to help its members add value to their services through new educational endeavors such as our Point of Care Ultrasound (POCUS) education, Continuous Practice Improvement (CPI) initiatives and partnering with other organizations to identify best practices. Our goal is to help all our members develop the skills and knowledge they desire in order to provide as many of the comprehensive services described above as possible. Plans are well under way for next year’s SCA Annual Meeting, where economics-related, CPI and enhanced recovery after cardiac surgery (ERACS) topics and panels will be featured. Make your plans now to join us in Chicago, May 18-22, 2019, at www.scahq.org.