Cardiac Electrophysiologist Compensation and the Helix
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EP LAB DIGEST. 2026;26(1):6-7.
Bradley P Knight, MD, FACC, FHRS
Dear Readers,
As more cardiac electrophysiologists (EPs) become hospital employees, Medicare continues to cut physician payments for catheter ablation procedures, and EPs become increasingly busy and productive, compensation for EPs is receiving closer scrutiny. In November 2025, a group of EPs led by Scott Greenberg, MD, FHRS, published a timely paper in Heart Rhythm entitled “How Fair is the Fair Market Value for Cardiac Electrophysiology Physician Reimbursement?”1
The manuscript begins by outlining the history of fair market value (FMV) regulations, which were originally intended to prevent conflicts of interest. Hospitals and independent physicians are subject to statutes such as the Anti-Kickback Statute and therefore rely on FMV to ensure compliance. The authors then make the case that the current application of FMV has become increasingly restrictive and detrimental to the compensation of subspecialists, including EPs.
Most cardiologists have become hospital employees, and the consolidation of hospitals has resulted in many cardiologists being employed by large medical centers and health systems. Over the past 2 decades, business-sector compensation models have increasingly been applied to physicians, typically incorporating a base salary with productivity-based bonuses. These physician compensation models—and the decisions surrounding them—have often become centralized within an “MD compensation” office.
In many respects, this approach has benefitted both hospitals and EPs, particularly within academic medical centers (AMCs). Incentive pay structures at many institutions have effectively incentivized and rewarded highly productive EPs for their additional work and for the increased revenue they generate. Most models use relative value units (RVUs) to anchor compensation to objective measures of work.
Although models vary widely, AMCs often provide “protected time” that allows salaries to be supplemented by external research funding, directorship stipends, endowed chair support, and other revenue from outside the hospital, thereby lowering an individual’s clinical effort and associated productivity target. In this framework, for example, a 50% full-time equivalent appointment carries approximately half the expected RVU generation.
A major limitation of most physician compensation models is their reliance on survey-based benchmarks, such as those provided by the Medical Group Management Association (MGMA) and MedAxiom (now part of the American College of Cardiology). The use of these benchmarks often introduces confusion into compensation plans. Additional inconsistency arises when one benchmark (eg, MedAxiom) is used for productivity expectations and another (eg, MGMA) is used for compensation. Confusion also occurs when total compensation—rather than a dollar-per-RVU ratio—is used as the compensation benchmark.
Many physician contracts use a $/RVU amount in their bonus structures, allowing an apples-to-apples comparison across offers and institutions. When total compensation is used instead of $/RVU, hospitals can report that they are paying at a certain benchmark for total compensation without paying a fair $/RVU. For example, a hospital may claim to pay an individual at the 50th percentile of MGMA total compensation—including non-RVU-based income—while simultaneously paying a $/RUV far lower than any national standard.
This issue is particularly problematic at AMCs, where total compensation may include income that is not hospital based. An example is when AMCs include grants from federal research funding or support from an affiliated medical school at part of the total compensation.
Several additional challenges exist within current compensation models. Although RVUs were designed to standardize the amount of work required for clinical activities, many models apply different $/RVU rates to different cardiology subspecialties. This includes compensation for tasks that are shared across subspecialties, such as electrocardiogram interpretation. Another source of undercompensation occurs when EPs are expected to supervise or evaluate patients in collaboration with mid-level providers, yet receive no RVU credit for this work.
The following passage from the November 2025 Heart Rhythm article1 summarizes the issue: “For EPs and other specialists, current FMV methodologies often fail to properly value their extensive training, technical expertise, and complex procedural skills, creating systematic undervaluation and artificial compensation constraints… The mathematical inconsistencies in RVU-based systems and the mismatch between productivity and compensation percentiles demonstrate fundamental flaws in how FMV is currently determined.”1 In other words, much like an active-fixation pacing lead with an extendable and retractable helix being advanced into myocardial tissue, EPs are getting the helix.
Disclosures: Dr Knight has served as a paid consultant to Medtronic and was an investigator in the PULSED AF trial. He has served as a consultant, speaker, investigator, and/or has received EP fellowship grant support from Abbott, AltaThera, AtriCure, Baylis Medical, Biosense Webster, Biotronik, Boston Scientific, CVRx, Philips, and Sanofi; he has no equity or ownership in any of these companies. Dr Knight reports payment or honoraria from Convatec for a lecture.
