Abstract
Background
Compensation for interventional cardiologists varies substantially by patient population and practice setting, yet no prior study has compared lifetime, discounted earnings between pediatric and adult interventional cardiology. Understanding these differences is essential for workforce sustainability and equitable access to congenital heart interventions.
Methods
We conducted an economic evaluation using benchmark compensation and productivity data from pediatric academic, adult academic, and adult private. Lifetime earnings were estimated using a net present value (NPV) framework over a 32-year career (age 35–67) at a 3% discount rate (2025 USD). Models incorporated academic promotion scenarios, private-practice fixed and ramp-up structures, and a 10,000-iteration Monte Carlo simulation varying salary percentile, career length, and promotion timing. Productivity was assessed using daily relative value unit (RVU) and NPV per career RVU.
Results
At the 50th percentile, lifetime NPVs were $8.03 million for pediatric academic, $10.45 million for adult academic, and $15.73 million for adult private practice—gaps of 30% and 96% relative to pediatrics. Median Monte Carlo NPVs were similar ($7.81 million, $10.29 million, and $15.01 million, respectively). Pediatric interventionalists generated fewer daily RVUs (20.6) than adult academic (41.0) and adult private (43.0) cardiologists, whereas compensation per RVU was comparable. These disparities reflect lower achievable procedural throughput and occur within an RVU framework that has repeatedly under-recognized the time and intensity of congenital work. Limited private-practice opportunities in pediatrics further widen earnings gaps.
Conclusions
Pediatric interventional cardiologists experience pronounced lifetime earnings disadvantages compared with adult counterparts because of throughput constraints, RVU valuation shortcomings, and labor-market structure. Addressing these systemic inequities will be essential to sustaining the congenital interventional workforce and ensuring equitable access to advanced cardiovascular care for children
Keywords: interventional cardiology, health inequity, pay disparities
Introduction
A large and persistent pay gap separates pediatric and adult physicians in the United States, with significant implications for workforce sustainability and health equity. Lifetime earnings analyses consistently demonstrate that adult physicians’ discounted incomes substantially exceed those of pediatric physicians, reflecting underlying structural disparities rather than differences in training.1 Contemporary compensation surveys similarly place adult procedural specialties, particularly cardiology, at the top of the earnings distribution, whereas pediatric cardiology is often grouped closer to primary care fields that require far shorter training pathways.2
These disparities are not merely economic but reflect systemic inequities in how the health care system values different types of work. Pediatric interventional cardiologists provide highly specialized, life-saving care for children with congenital heart disease—a population that has no alternative to pediatric expertise. Yet if compensation systems consistently undervalue this work, the long-term risk is fewer pediatric interventionalists, reduced geographic coverage, and inequitable access for children in under-resourced regions. Similarly, academic physicians—both pediatric and adult—deliver a disproportionate share of care to publicly insured and underserved patients, while also leading research and training that advance the field, yet their compensation lags far behind private practice.2 This raises broader concerns about whether the current system adequately supports those who shoulder the greatest responsibility for vulnerable patients and for sustaining the academic mission. These concerns have been echoed by recent policy analyses, including the Society for Cardiovascular Angiography & Interventions (SCAI) Position Statement on structural economic barriers in congenital interventional cardiology, which highlights similar challenges in current reimbursement frameworks.3
Recent national compensation analyses, including the 2025 Doximity Physician Compensation Report,4 have demonstrated persistent pay inequities between pediatric and adult specialists, whereas others have contrasted adult versus pediatric cardiology in aggregate; however, to our knowledge, no study has directly compared adult interventional with pediatric interventional cardiology using a discounted, lifetime framework. This comparison is important because interventional cardiology sits at the top of physician earnings in many reports, so detecting a pediatric–adult gap here would indicate disparities that persist even where procedure intensity and compensation are highest.
Although multiple factors contribute to the pediatric–adult pay gap, 2 mechanisms are particularly relevant to the comparison of pediatric and adult interventional cardiology. First, pediatric care and procedures often demand greater time, coordination, and periprocedural complexity, yet reimbursement—anchored to relative value units (RVUs)—does not scale proportionally. Policy statements from the American Academy of Pediatrics have long argued that elements of the RVU framework undervalue pediatric work and should be revised to better account for time and intensity.5 Second, in pediatric subspecialties—such as pediatric interventional cardiology—where employment opportunities are almost entirely in academic settings, market structure plays a critical role. Unlike adult cardiologists, who benefit from robust private-practice opportunities that elevate academic salaries through retention pressure, pediatric subspecialists face limited outside options, constraining wage competition.
Net present value (NPV) analysis provides a structured economic framework for comparing physician careers by incorporating both the magnitude and timing of income over the course of a career. This approach is well suited to questions of workforce disparities because it accounts for delayed entry into practice, variation in earnings trajectories, and differences in career length. NPV methods have been applied in multiple areas of medicine to evaluate the financial impact of specialty choice and training pathways, including analyses of physician career earnings,6 postgraduate training decisions,7 and pediatric versus adult specialty disparities.8 These studies demonstrate that NPV analysis can reveal policy-relevant differences that correlate with market forces, competitiveness, and long-term workforce sustainability.
In this study, we apply an NPV framework to (1) quantify lifetime earnings for pediatric versus adult interventional cardiologists across practice settings, (2) examine whether earnings disparities reflect differences in compensation per unit of work (NPV per RVU) or in achievable work volume (daily RVUs), and (3) evaluate how practice structure—predominantly academic in pediatrics versus a mix of academic and private practice in adult cardiology—contributes to these disparities (Central Illustration).
Central Illustration.
The lifetime earnings gap between pediatric and adult interventional cardiologists. This highlights the key structural drivers—including lower RVU throughput, flawed RVU valuation, and limited private-practice leverage—that contribute to persistent economic inequities in the congenital interventional workforce.
Methods
We constructed NPV models for interventional cardiologists using salary and productivity benchmarks from 3 primary sources. The Association of Administrators in Academic Pediatrics (AAAP) Faculty Compensation and Productivity Survey provided both compensation and RVU data for pediatric academic practice. The Medical Group Management Association (MGMA) DataDive Provider Compensation survey supplied both compensation and RVU data for adult private practice. The Association of American Medical Colleges (AAMC) Faculty Salary Report provided compensation data for adult academic practice, whereas productivity benchmarks were obtained from the Faculty Practice Solutions Center work RVU database, also administered by the AAMC. Based on these sources, we modeled 3 career pathways: (1) pediatric interventional cardiology in academic practice (AAAP), (2) adult interventional cardiology in academic practice (AAMC), and (3) adult interventional cardiology in private practice (MGMA).
Career timing and base-case horizon
All models assumed physicians entered independent practice at age 35, reflecting a median age of 28 at medical school graduation (AAMC), followed by approximately 7 years of postgraduate training. Retirement was set at age 67, corresponding to the full retirement age defined by the Social Security Administration. This base case yields a 32-year career duration. Sensitivity analyses considered shortened (29 years) and extended (35 years) careers to capture variation in timing of career entry (eg, accelerated training) and retirement (eg, delayed exit from practice).
Academic promotion trajectories
Academic salaries were modeled under 5 predefined promotion scenarios as follows:
Typical promotion: Promotion to associate professor after 7 years and to full professor after an additional 7 years (years 1–7 assistant, 8–14 associate, 15–32 full).
Early promotion: Promotion to associate after 5 years and to full after an additional 5 years (years 1–5 assistant, 6–10 associate, 11–32 full).
Late promotion: Promotion to associate after 10 years with no subsequent promotion (years 1–10 assistant, 11–32 associate).
No promotion: Salary remains at the assistant professor level for the entire 32-year career.
Leadership track: Same timeline as typical promotion, followed by service as division chief for the final 10 years.
Private-practice trajectories
Private-practice compensation was modeled using 2 approaches. In the fixed model, salaries were assumed to remain at the same percentile throughout the entire career. In the ramp-up model, salaries began at the 25th percentile for years 1–5, increased to the 75th percentile for years 6–20, and then stabilized at the 50th percentile for years 21–32.
NPV calculation and discounting
NPV was calculated as the sum of discounted annual compensation over the career horizon using a real discount rate of 3.0% and reported in constant 2025 US dollars. Formally, NPV = Σ (NI_t/(1 + r)ˆt) for t = 1…n, where NI_t is total compensation in year t, r is the real discount rate, and n is career length. Additional sensitivity analyses used discount rates of 0% and 5% to illustrate the effect of valuing future income more or less heavily.
Percentile modeling
Salaries were analyzed at the 25th, 50th, 75th, and 90th percentiles using the matched percentiles from AAAP, AAMC, and MGMA sources. Within a given scenario, the same percentile was applied to all years of a simulated career to enable cross-pathway comparisons.
Monte Carlo simulation
To account for uncertainty, we conducted a 10,000-iteration Monte Carlo simulation for each pathway, in which input parameters were randomly varied while the discount rate was held constant at 3% (the base case for this analysis):
Career length: Triangular distribution with minimum 29 years, mode 32 years, and maximum 35 years.
Salary percentile: Random draw from (25th, 50th, 75th, and 90th).
Academic promotion track: Random draw from (no promotion, late, typical, early, leadership) with probabilities 10%, 25%, 50%, 10%, and 5%, respectively (applies only to academic pathways).
For private practice, each simulation used either the fixed model at the selected percentile or the ramp-up trajectory as a scenario analysis. Each iteration produced 3 NPVs (pediatric academic, adult academic, adult private). Distributions were summarized with medians, means, and interquartile ranges to assess central tendency and overlap.
Productivity metrics
Annual RVUs were converted to daily RVUs using a denominator of 236 workdays per year. 236 workdays/year is a conventional assumption in workforce analyses, which accounts for vacation, holidays, and administrative time. We also calculated NPV per career RVU (discounted lifetime dollars divided by total career RVUs at the matched percentile) to estimate dollars per unit of clinical work.
Results
At the 50th percentile, assuming a 32-year career (ages 35–67) and a typical academic promotion trajectory, the estimated NPV of lifetime earnings was $8.03 million for pediatric academic interventional cardiologists, $10.45 million for adult academic, and $15.73 million for adult private practice. This corresponds to disparities of 30% and 96% relative to pediatrics (Fig. 1). Within academic pathways, promotion timing materially influenced outcomes, ranging from $6.62–$8.21 million for pediatric and $9.73–$11.90 million for adult interventional cardiologists. Leadership-track trajectories with chief-level compensation in the final 10 years produced the highest academic estimates, whereas late or no promotion scenarios resulted in substantially lower NPVs. For private practice, a ramp-up trajectory yielded the highest estimate ($16.91 million) compared with a fixed 50th-percentile salary ($15.73 million).
Figure 1.
Net present value by career path and promotion trajectory (academic) and private-practice model.
When varying salary percentiles, pediatric–adult disparities persisted across the distribution (Fig. 2). Adult academic interventional cardiologists exceeded pediatric academic colleagues by 18% to 53% from the 25th to the 90th percentile, whereas adult private practice exceeded pediatrics by 73% to 135%. Dispersion was greatest in private practice, whereas academic pathways were more tightly clustered, indicating greater predictability in academic settings but wider upside potential in private practice.
Figure 2.
Net present value across salary percentiles.
Monte Carlo simulations (10,000 iterations varying salary percentile, career length, and promotion trajectory) confirmed these patterns (Fig. 3). Median NPVs were $7.81 million for pediatric academic, $10.29 million for adult academic, and $15.01 million for adult private practice, with distributions clearly separated in central tendency. Adult private practice showed the widest spread and the highest upper tail, whereas pediatric academic was concentrated at the lowest end of the distribution.
Figure 3.
Monte Carlo distributions of lifetime net present value (10,000 iterations).
Sensitivity analyses behaved as expected: lower discount rates increased NPVs across all pathways, whereas higher rates reduced them; similarly, shorter (29 years) and longer (35 years) careers shifted absolute NPVs proportionally. In all cases, the relative order of pediatric < adult academic < adult private remained unchanged (Supplemental Figures S1 and S2).
Productivity analyses aligned with these earning disparities (Figures 4 and 5). At the 50th percentile, pediatric academic interventional cardiologists averaged 20.6 daily RVUs, compared with 41.0 in adult academic and 43.0 in adult private practice. The disparity persisted at higher percentiles: pediatric 23.6 and 27.1 (75th/90th) versus adult academic 50.5 and 61.1, and adult private 55.5 and 64.3. Despite these differences in achievable RVU volume, compensation per RVU was broadly similar between pediatric academic and adult private practice ($51.7 vs $48.5), and lower for adult academic ($33.8). These findings indicate that the primary driver of pediatric–adult earning disparities is the lower effective valuation of pediatric interventionalists’ clinical time—demonstrated by the substantially fewer RVUs they generate per full day of procedural work compared with adult interventionalists. Although per-procedure RVU assignments may be similar, the longer duration and lower repeatability of congenital catheterizations result in markedly lower-RVU–based productivity across a full-time clinical schedule.
Figure 4.
Daily RVUs by percentile and practice type. RVU, relative value unit.
Figure 5.
Net present value per career RVU by percentile. RVU, relative value unit.
Discussion
This study is the first to apply an NPV framework to compare the lifetime earnings of pediatric and adult interventional cardiologists. Three central findings emerged. Pediatric interventional cardiologists earn substantially less over a career than their adult counterparts in both academic and private-practice settings. Rather than being driven by lower reimbursement per RVU, these disparities appear to be strongly influenced by an RVU framework that undervalues the clinical time and effort of pediatric interventional cardiologists compared with their adult counterparts, as evidenced by the substantially fewer total RVUs generated per full day of clinical work in pediatric practice. Finally, labor-market structure amplifies these inequities, as adult cardiologists benefit from private-practice opportunities that elevate academic salaries, whereas pediatric interventional cardiology is almost exclusively confined to academic practice. Together, these findings highlight structural inequities with important implications for both workforce sustainability and equitable access to congenital heart interventions, consistent with recently proposed frameworks emphasizing systemic reforms to promote equity in interventional cardiology by SCAI.3
The disparities identified in this study are not only persistent but also among the most pronounced ever reported between pediatric and adult specialties. Prior studies using NPV frameworks have consistently demonstrated differences favoring adult specialties over pediatric ones6,8; however, our findings suggest that interventional cardiology may represent one of the starkest cases. Adult interventional cardiologists earn approximately twice the lifetime income of pediatric interventional cardiologists, with gaps increasing further at higher salary percentiles. This underscores how systemic inequities are magnified in procedure-intensive fields. That this occurs within interventional cardiology—a specialty that typically ranks among the highest in physician earnings—further emphasizes how pediatric careers are structurally undervalued. These disparities also carry implications for the training pipeline. Pediatric subspecialties—including pediatric cardiology—have recently faced significant challenges in attracting trainees, and workforce projections highlight that shortages are likely to worsen under current trends.9
Our analysis demonstrates that the disparity is driven primarily by productivity, not reimbursement per RVU. Pediatric interventional cardiologists generate about half the daily RVUs of their adult colleagues. This difference is rooted in case mix and throughput. Pediatric cases often involve greater complexity, require smaller and more delicate anatomy, necessitate specialized equipment, and demand more extensive periprocedural coordination. As a result, pediatric interventionalists are typically limited to 3 or 4 cases per day, whereas adult interventionalists can achieve significantly higher throughput. Importantly, our analysis shows that per-RVU reimbursement is broadly similar between pediatric academic and adult private-practice cardiologists, whereas adult academics actually earn less per RVU. This reinforces that the disparity is not due to undervaluation of each unit of work, but rather the structural limits on achievable work volume in pediatrics. These findings align with longstanding concerns from the American Academy of Pediatrics, which has argued that the RVU framework fails to adequately reflect the time and intensity required for pediatric procedures.10,11 For interventional cardiologists, this mismatch between procedural complexity and RVU accrual creates an enduring disadvantage that is unlikely to be remedied without policy reform. Truly, the highlighted productivity differences must be interpreted within the context of a reimbursement system that may not adequately reflect the true time, intensity, and preparation required for congenital procedures. The American Medical Association Relative Value Scale Update Committee (RUC) has repeatedly recommended higher work RVU valuations for congenital catheterization codes, yet CMS rejected 20 of 24 recommended updates over the past 3 years. This ongoing pattern suggests that measured RVU productivity is at least partially constrained by structural undervaluation, suggesting that lower recorded throughput is more a function of flawed valuation than reduced clinical effort or procedural intensity.12
Labor-market structure further compounds these inequities. Adult interventional cardiologists benefit from robust private-practice opportunities that raise the academic wage floor through retention pressure, whereas pediatric interventionalists have few if any viable alternatives outside academia. Some may attribute lower compensation in pediatrics to the payer mix, given the higher proportion of publicly insured patients. However, comparisons with pediatric surgical subspecialties suggest otherwise. Congenital heart surgeons—who care for the same patient population—often earn more than their adult cardiothoracic counterparts, demonstrating that high compensation is possible in pediatric practice when labor-market dynamics allow cross-competition between adult and pediatric roles.13 A critical difference is training structure. Congenital heart surgeons train first in general surgery and cardiothoracic surgery, enabling them to practice as adult surgeons if desired. Pediatric interventional cardiologists, however, enter from pediatric residency, pediatric cardiology fellowship, and advanced interventional training. Their skills are not directly transferable to adult interventional practice without retraining, effectively binding them to academic pediatric roles. This lack of labor-market mobility exacerbates inequities and highlights how structural features of training pathways interact with labor markets to shape compensation. These disparities are further magnified by geographic maldistribution. Many children’s hospitals already rely on only 1 or 2 interventional cardiologists, and workforce shortages risk threatening regional coverage, resulting in increasing distances to referral centers and potential delays in care for rural and underserved populations.
Another important disparity highlighted in our analysis is the earnings gap within adult interventional cardiology itself, where academic physicians earn substantially less than their private-practice counterparts. This divide carries significant implications. Academic interventionalists disproportionately provide care for publicly insured and underinsured patients and shoulder the bulk of responsibilities for research and training that drive innovation in the field. Yet by undervaluing these roles, the system risks both diminishing equitable access for vulnerable populations and undermining the scientific advancement of interventional cardiology. If compensation differences continue to widen, the field may face a loss of talented physicians to private practice, where incentives are driven primarily by procedural throughput rather than discovery and mentorship. Such a shift would ultimately threaten both the future growth of the discipline and the patients who most depend on academic institutions for care, exacerbating inequities in access for underserved populations.
This study has several limitations. First, salary and productivity data were derived from national surveys that are not fully harmonized, and our models reflect stylized estimates rather than observed individual career trajectories. Second, assumptions regarding the age of entry, retirement, and promotion scenarios may not apply universally. Third, we focused on salary-based earnings and did not capture nonsalary compensation such as benefits, bonuses, or research support. Fourth, our analysis cannot account for institutional variation in resource allocation or cross-subsidization that may influence individual compensation. Finally, compensation structures and RVU-based reimbursement are specific to the US health care environment, and findings may not generalize to countries with different payment models. These limitations are unlikely to alter the central findings, but they should be considered in interpretation.
These findings raise fundamental questions about whether current compensation systems adequately support the physicians who deliver the most complex and resource-intensive care to the most vulnerable patients. If pediatric interventional cardiology is consistently undervalued, the long-term risks include fewer trainees pursuing the field, reduced geographic coverage, and inequitable access to life-saving interventions for children with congenital heart disease—disparities that will disproportionately affect under-resourced regions and publicly insured populations. Similarly, if academic adult interventionalists remain undervalued relative to private practice, the consequences include both reduced access for publicly insured patients and a weakening of the research and training missions that sustain the field.
Policy and institutional reforms are urgently needed to address these inequities. Achieving meaningful reform will require coordinated national advocacy. Professional societies such as SCAI, AAP, and ACC are positioned to jointly petition CMS and the AMA RUC for revised valuation of congenital codes, support federal loan-forgiveness and incentive programs for pediatric subspecialists, and encourage alternative payment models that reward case complexity rather than throughput. Without unified organized advocacy, market forces alone are unlikely to correct these structural imbalances. First, recalibrating RVU valuation to better reflect pediatric time and intensity is essential; without such adjustments, pediatric procedures will continue to be disadvantaged relative to higher-volume adult cases. Second, alternative payment models that reward complexity and outcomes rather than sheer volume could mitigate disadvantages for pediatric providers. Third, institutions and payers may need to consider explicit cross-subsidization to sustain pediatric interventional cardiology programs, recognizing their societal value despite limited market leverage. Fourth, targeted policy incentives—such as loan repayment programs, academic salary supplements, or federal support for pediatric subspecialists—may be necessary to preserve workforce sustainability. Finally, addressing the undervaluation of academic adult interventionalists is equally critical to ensure that the field continues to advance scientifically and equitably serves patients who rely on academic centers for care.
Conclusions
In conclusion, pediatric interventional cardiologists face among the most pronounced structural earnings disparities in medicine compared with their adult counterparts. These inequities are driven by lower achievable productivity and constrained labor-market mobility rather than by physician effort in the context of a reimbursement framework that has struggled to assign equitable value to congenital procedures. In parallel, academic adult interventionalists remain disadvantaged relative to private practice, raising concerns for equitable access and the future advancement of the field. Without policy reforms, these disparities threaten both workforce sustainability and patient care. Ensuring fair compensation for interventional cardiologists—pediatric and adult alike—is essential not only for workforce viability but also for advancing health equity and maintaining progress in the treatment of cardiovascular disease.
Acknowledgments
Declaration of competing interest
The authors have no conflicts of interest relevant to the article to disclose.
Funding sources
This work was not supported by funding agencies in the public, commercial, or not-for-profit sectors.
Ethics statement and patient consent
This is an original research article with no human subjects, and thus, ethical approval was not required.
Data availability
Benchmark compensation/RVU data from AAAP, AAMC, and MGMA; derived model outputs available on reasonable request.
Footnotes
To access the supplementary material accompanying this article, visit the online version of the Journal of the Society for Cardiovascular Angiography & Interventions at 10.1016/j.jscai.2025.104194.
Supplementary material
Supplemental Figure 1.
Supplemental Figure 2.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Benchmark compensation/RVU data from AAAP, AAMC, and MGMA; derived model outputs available on reasonable request.