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May 17, 2023
David Burda
Economics Outcomes System Dynamics

Hospital-Based Cardiologists Are Putting More Than Just Their Hearts Into It

Thirty or so years ago, I experienced chest pain after doing some strenuous yard work. I was using one of those old-time, manual sod cutters to cut sod from the side of our house to make a big herb garden. You know the cutter. It’s the one with the blade that you kick with your foot until you’re exhausted.

Anyway, I drove to the ER at our local hospital to get checked out. It turned out the chest pain was not heart-related and more likely the result of muscle strain or the amount of peanut butter I had for lunch to fuel my yard work. I was back home after a few hours.

I dutifully followed the post-visit instructions from the ER doctor and saw my primary care physician the following week. I told my PCP what happened, and the first thing he said was: “I’m surprised they didn’t keep you there.” After that, each time I saw him, he sarcastically asked me if I had any more ER visits. To say he was a minimalist when it came to medical interventions would be an understatement.

I missed his point at the time, but now I get it. He was saying, in his experience as an independent physician, that it would have been more likely for the hospital-affiliated ER doctor to admit me for a battery of cardiac tests and procedures whether I needed them or not. Once the hospital grabs you, it’s hard to escape. He was saying I was one of the lucky ones and warning me not to go back unless I was holding my severed foot in my hands from trying to cut sod again.

A new study highlights the importance of hospital-physician integration and how that healthcare vertical integration market phenomenon affects the use of cardiac tests and procedures.

Using Medicare claims data from 2013 through 2020, researchers from Northeastern University and Lawrence (Mass.) General Hospital compared the frequency of three cardiac interventions ordered by independent cardiologists and by hospital-integrated cardiologists, i.e., employed by the hospital, for about 15,000 Medicare patients newly diagnosed with stable angina. That’s chest pain or discomfort brought on by exercise or stress. (Think cutting sod and returning the rented sod cutter on time.)

The three interventions were cardiac stress testing, cardiac catheterization and coronary angioplasty. Independent cardiologists treated about two-thirds of the patients, integrated cardiologists handled the rest.

Here’s how it broke down:

  • 30% of the patients treated by integrated cardiologists got stress testing compared with 32% of the patients treated by independent cardiologists.
  • 38% of the patients treated by integrated cardiologists got cardiac catheterizations compared with 33% of the patients treated by independent cardiologists.
  • 14% of the patients treated by integrated cariologists got coronary angioplasties compared with 11% of the patients treated by independent cardiologists.

“These results imply that hospital-cardiologist integration may tilt treatment mix toward higher-intensity services,” the researchers said.

“Hospitals might incentivize or otherwise encourage their physicians to steer patients toward care that supports the hospital’s financial health, such as MRIs,” the researchers said. “Our results are consistent with this explanation, although explicit incentives might not be necessary.”

In other words, employed cardiologists know who butters their bread. Nudge, nudge, wink, wink.

There’s other noteworthy stuff in the research that I won’t go into detail on, like employed cardiologists coding their patients as sicker when they’re not, the federal antitrust enforcement policy not being sensitive enough to detect anticompetitive, physician practice acquisitions and hospitals subjecting their patients to unnecessary safety risks.

Vertical integration is a strategy to control the means of production for economic gain. It’s as true in healthcare as it is in any other industry.

So, the next time you think about cutting sod to put in a garden, hire a lawn service.

To learn more about this topic, please read:

Thanks for reading.

About the Author

David Burda

Dave Burda began covering healthcare in 1983 and hasn’t stopped since. Dave writes this monthly column “Burda on Healthcare,” contributes weekly blog posts, manages our weekly newsletter 4sight Friday, and hosts our weekly Roundup podcast. Dave believes that healthcare is a business like any other business, and customers — patients — are king. If you do what’s right for patients, good business results will follow.

Dave’s personal experiences with the healthcare system both as a patient and family caregiver have shaped his point of view. It’s also been shaped by covering the industry for 35 years as a reporter and editor. He worked at Modern Healthcare for 25 years, the last 11 as editor.

Prior to Modern Healthcare, he did stints at the American Medical Record Association (now AHIMA) and the American Hospital Association. After Modern Healthcare, he wrote a monthly column for Twin Cities Business explaining healthcare trends to a business audience, and he developed and executed content marketing plans for leading healthcare corporations as the editorial director for healthcare strategies at MSP Communications.

When he’s not reading and writing about healthcare, Dave spends his time riding the trails of DuPage County, IL, on his bike, tending his vegetable garden and daydreaming about being a lobster fisherman in Maine. He lives in Wheaton, IL, with his lovely wife of 35 years and his three children, none of whom want to be journalists or lobster fishermen.


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