Electrophysiology Roundtable Forum: A Candid Conversation About Profits, Procedures and Patients

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 - Cardiology Phone
Top: Intracardiac echocardiography (ICE) Doppler image of left pulmonary veins. Bottom: Registered CT image of a left atrium with a projected electrical activation on its shell.
Source: Biosense Webster (top) / Siemens Healthcare (bottom)

Cardiovascular Business invited some of the most prominent physicians in the field of electrophysiology to talk about the current and future state of the subspecialty. Participants in the roundtable discussion are:

  • David Cannom, MD, director of cardiology at Good Samaritan Hospital, Los Angeles, Calif.
  • David. E. Haines, MD, chairman of cardiovascular medicine at William Beaumont Hospital, Royal Oak, Mich.
  • Daniel Morin, MD, staff electrophysiologist and director of electrophysiology research at Ochsner Health System, New Orleans, La.
  • Andrea Natale, MD, executive medical director for the Texas Cardiac Arrhythmia Institute at St. David’s Medical Center, Austin, Texas
  • Jonathan S. Steinberg, MD, chief of the division of cardiology and Al-Sabah Endowed Director of the Arrhythmia Institute, St. Luke’s-Roosevelt Hospital Center, New York, N.Y.
  • Bruce L. Wilkoff, MD, director of cardiac pacing and tachyarrhythmia devices at the Cleveland Clinic, Cleveland, Ohio
  • Moderator: C.P. Kaiser, Editor, Cardiovascular Business
Listen to highlights from the interview.

It’s been said that the electrophysiology lab is a loss leader for cardiology departments. Given the current economic climate, what can be done to ensure the EP lab remains a viable economic success?

Jonathan S. Steinberg, MD: I don’t agree with the statement, although it’s been an historical canard that was bandied about, often by hospital administrators. It relates to an era that doesn’t exist anymore, when patients spent much more time in the hospital. Nowadays, on the contrary, EP is very lucrative for institutions. The procedures are complex but reasonably well reimbursed. Hospital stays are short or ambulatory. In general, they can be a profit leader for hospitals or cardiology divisions.  

Bruce L. Wilkoff, MD: I agree that it is not the case any longer. The volume in the electrophysiology laboratory, although not growing robustly, has the potential to continue to grow as we have advances in both implantable devices and ablative therapies. In years past, coronary disease ran cardiovascular medicine in the hospitals, but coronary disease definitely is not what’s leading things now.

David Cannom, MD: It’s a complicated question. Los Angeles is an economic environment unto itself. We have a very high HMO penetration. If you depend on HMO reimbursement for complicated procedures, particularly atrial fibrillation (AF) ablation, you would have a very difficult time economically. What we have been forced to do, as have other places, is renegotiate contracts with the HMOs. Routine ablations, such as simple AVNRT (AV nodal reentrant tachycardia), bypass tracts and atrial flutter, are clearly disappearing or being done at other places. When you depend on atrial fibrillation, as we do, it really can be very dicey because of the expense of the equipment and the time it takes to do the procedure.

Daniel Morin, MD: I’d like to provide a regional contrast to Dr. Cannom’s view. We are the major EP force down here in Louisiana, and at a place historically very cath heavy. Recently, we had a consulting group that came into our place and identified—among all the different cardiology and hospital services—electrophysiology as a source of future revenue growth.

David. E. Haines, MD: At our institution in Michigan, the interventional volume is falling. We get some backfill from peripheral intervention, but those numbers are flat. The only growth area within cardiology is noninvasive imaging, predominantly CT angiography, and EP—and A-fib is driving EP. The device numbers are flat right now. One of the things about the profitability, or lack thereof, is that it’s very dependent on the cost accounting in the individual institution. There is no question that heart rhythm services have a substantial contribution margin and how you determine the profitability is all in the calculation of overhead expenses. We are way lopsided in terms of devices being a huge component of the cost of providing our service. If your hospital does a percentage overhead based on inventory cost, it looks very expensive. If you use other formulas for assessing overhead, then it looks relatively profitable. Depending on how the cost accounting is done at the individual institutions determines whether heart rhythm is an area that they want to support or not.

Andrea Natale, MD: The big potential for growth is in ablative therapies, especially in complex arrhythmias. Device therapy has reached a plateau, as