April 10, 2023

There was a time, not too long ago, when cardiovascular anesthesiologists were the most respected members of anesthesia practices. Their specialized training and complexity of cases distinguished them both in terms of clinical skills and compensation. It was not uncommon for the cardiovascular surgeons to only allow certain members of the anesthesia practice into the heart room. Although these anesthesiologists rarely performed the greatest number of cases, the acuity of care inherent within their casework was often intense as most patients had advanced stages of coronary artery disease.

One of the hallmarks of these cases was the introduction of invasive monitoring, such as arterial lines, CVPs, Swan-Ganz catheters and, more recently, transesophageal echocardiography (TEE). As so often happens, though, the significance of the cardiovascular anesthesia team, while still a necessity, has diminished significantly.

A Review of Volume

A review of surgical activity for a sample of large anesthesia practices indicates that cardiac cases (ASA codes 00560 to 00580) now represent only about one percent of all surgical cases, and this has been fairly constant for the past five years. Because of the nature of cardiovascular disease, the number of heart cases—typically CABGs and valves—was not significantly impacted by the pandemic. Coronary artery disease was not a condition for which treatment could be deferred, especially if the patient had experienced a heart attack.

The Relative Value

While cardiac care involves high acuity patients with compromised cardiac function, the cases are not only long (often lasting more than four hours) but complex. A typical CABG would result in about 40 base and time units, as well as separate charges for the invasive monitoring. (The arterial line, the CVP, the Swan-Ganz catheter and TEE are paid from a surgical fee schedule, not ASA units.) The problem, of course, was that, because these patients are often covered by Medicare, the effective net yield per billed unit is well below the group average. In other words, a practice that generates an average $40 per unit might only generate $30 or less for the cardiovascular cases.

Paradoxically, then, while it may look as though hearts should provide an above-average yield per case, the net yield per hour is not significant once you divide the total payment by the length of the case.  The chart below shows the changes in the yield per cardiac case over the last five years.

As a result of the relative undervaluing of cardiac cases, cardiovascular anesthesia has come to epitomize the challenge of today’s medicine: providers who are being asked to assume cases of greater complexity in an era of an aging population for less compensation per hour of work. As most hospitals continue to invest in their cath labs, the cardiovascular anesthesia time continues to be critical; it has simply become somewhat of a loss leader. For most practices, cardiovascular anesthesia is now the least profitable line of business.

Continuing Challenges

Coverage and call requirements for cardiac anesthesia can be especially problematic. Typically, only cardiac certified anesthesiologists can cover this call, which means that a cardiac specialist must be available every night when cardiac cases are performed. Historically, this has required an additional stipend from the facility.

Another problem that continues to challenge many practices is the need for cardiovascular specialists for unproductive heart programs. A group may go to great lengths to hire a cardiovascular anesthesiologist only to learn that the heart program is being phased out due to a lack of sufficient volume of cases. This can have a very disruptive impact on a practice.

If you have any questions, please reach out to your account executive.

With best wishes,

Rita Astani,
President, Anesthesia