Hospital-Physician Integration Leads to More Intense Cardiac Care

Patients who see cardiologists employed by hospitals are significantly more likely to receive high-intensity, hospital-based coronary interventions compared to patients who see independent doctors, according to a new Health Affairs study.

The finding suggests hospital-physician integration plays a role in the intensity of treatment received by patients with stable angina, researchers from Northeastern University said in the study. Greater antitrust enforcement of hospital-physician integration and payment reform could decrease unnecessary utilization of high-intensity treatment.

“Receiving the appropriate level of care within the first twelve months of diagnosis could quickly place patients on a path toward recovery and effective condition management,” wrote first author Brady Post, PhD, an assistant professor in the Department of Health Sciences at Northeastern University, and colleagues. “However, excessive reliance on higher-intensity services, including minimally invasive procedures such as angioplasty, could also expose patients to unnecessary risk.”

Healthcare has become more consolidated, especially as hospitals employ more specialists like cardiologists to bolster high-demand service lines. In particular, the percentage of hospital-integrated cardiologists increased by more than 50 percent from 2011 to 2018, according to research cited in the study.

With an aging population, hospitals need to boost cardiac service lines to meet patient needs. However, these service lines also typically generate high margins for hospitals and hospital-employed cardiologists are more likely to refer patients for services in-house, which contributes to the hospital’s bottom line.

The Health Affairs study indicates that hospitals may be incentivizing or encouraging their doctors to steer patients toward care that boosts profits, although researchers questioned if explicit incentives are necessary.

Patients of hospital-employed cardiologists were much more likely to receive cardiac catheterization, a higher-tech procedure, and angioplasty, a minimally invasive procedure that, although safe and effective, entails some risks. The rate of catheterizations followed by angioplasties was also slightly higher among hospital-employed cardiologists, as was the probability of patients receiving a catheterization without a stress test.

Meanwhile, patients of hospital-employed cardiologists were slightly less likely to receive a cardiac stress test, a low-tech diagnostic tool.

Researchers noted that patients of employed cardiologists were just as healthy as those seen by independent cardiologists despite research demonstrating that diagnoses among patients of integrated physicians are coded more aggressively.

“These changes could simply reflect employees playing to the strengths of their organization: Those in higher-tech settings can and do perform higher-tech services, especially when treating conditions that offer latitude in clinical decision making,” Post et al. wrote. “Whether this is a net good for patients remains unclear.”

The jury is still out on whether hospital-physician integration — and the care patterns that come with it — improves the healthcare system, reseachers said. But the findings should equip policymakers with new information so they can assess the pros and cons of a consolidated healthcare system.

“The primary concern from our study is that patients might be subjected to excessive risk simply because of who employs their doctor,” Post et al. wrote in the study. “If one adverse outcome of hospital-physician integration is overly intense treatment, a possible additional policy response is to develop payment methods for such integrated systems that explicitly incentivize appropriate conservative treatment.”