How fair is the fair market value for cardiac electrophysiology physician reimbursement?

Fair market value (FMV) regulations were established in health care to prevent fraud and eliminate conflicts of interest by ensuring that physician compensation reflects the value of services rendered, independent of referrals or business volume. The current application of FMV is restrictive, particularly disadvantaging subspecialists including cardiac electrophysiologists. We critically examine the historical context, legal underpinnings, methodologies, and limitations of current FMV models-focused on electrophysiology. FMV determinations rely on compensation surveys (eg, Medical Group Management Association, American Medical Group Association, MedAxiom) that apply percentile-based thresholds, which fail to account for procedural complexity, extended training, and exceptional productivity, thereby undervaluing highly skilled physicians. Electrophysiologists are uniquely affected owing to their labor-intensive procedures, cognitive demands, and role in generating substantial facility revenues-factors largely unrecognized by existing work relative value unit-centric frameworks. Trends toward hospital employment/consolidation have exacerbated the problem. This has created a "monopsony"-a market with a single dominant buyer, where they wield disproportionate power over wages and contract terms owing to the lack of competing employers-allowing hospitals to exert downward pressure on physician compensation. This misalignment contributes to physician burnout, deters entry into demanding specialties, threatens workforce sustainability, and limits patient access to care. We propose a multistakeholder reform strategy, emphasizing the need for the Heart Rhythm Society to spearhead the development of a specialty-specific FMV framework. Through enhanced data collection, regional benchmarks, and novel compensation tools, FMV can be restructured to reflect market realities, support physician well-being, and promote excellence in high-skill, high-value care.