More US Cardiologists Opting for Larger Practices

Debra L. Beck

July 28, 2020

US cardiologists are increasingly opting out of solo or small practices, and joining larger practices, according to a new analysis of US data from 2013 and 2017.

In 2013, 34.2% of US cardiologists worked in practices of 5 or fewer cardiologists. That number dropped to just 27% by 2017. On the flip side, the proportion working in practices with 25 cardiologists or more rose from 26% in 2013 to 35.8% in 2017.

"This is a trend we're seeing across healthcare — hospitals are merging and they're acquiring physician practices, primary care doctors are joining larger practices too — so to some extent it seems that cardiologists are just responding to changes in the market structure where they practice," said Jose F. Figueroa, MD, MPH, from Harvard T.H. Chan School of Public Health and Brigham & Women's Hospital, Boston, Massachusetts.

Figueroa and colleagues published their findings as a research brief in the August 4 issue of the Journal of the American College of Cardiology.

The average number of cardiologists in practice together rose from 3.6 in 2013 to 4.3 in 2017. This trend was less obvious in rural areas (2.05 to 2.20) than in urban areas (3.67 to 4.38).

Interestingly, the smallest change was seen in the mid-size practice tier. In 2013, 22.9% of cardiologists worked in a practice that included 11 to 24 cardiologists, and in 2017, the proportion was 23.2%.

To determine practices sizes, Figueroa and colleagues used publicly available data from 2013 and 2017 from the Centers for Medicare & Medicaid Services' (CMS) Physician Compare, a website that helps patients find and compare clinicians and groups enrolled in Medicare.

Market level variables were obtained from the Dartmouth Atlas Project, which uses CMS data to provide information and analysis about national, regional, and local healthcare markets, as well as hospitals and their affiliated physicians.

Market Forces Drive Practice Patterns

The investigators had no direct data from which to ascertain the reasons why cardiologists have tended to move from smaller to larger practices, but they did conduct a multivariable linear regression analysis to better understand possible market-level factors that may be influencing these trends.

What they found was that as hospital market concentration increased, practice sizes also increased. They found no association between any community-level and physician-level factors and changes in practice size.

So, for example, greater growth in the number of cardiologists in practice together was not associated with age or sex.

"It seems that cardiologists are responding to changes in the market structure where they practice, and in particular, to hospital market concentration. This is all in an effort basically to have more market power, which in part means better bargaining power when they're negotiating with payers," said Figueroa.

He also suggested that joining a large practice is almost a necessity these days given the administrative burdens imposed by value-based care initiatives and their attendant quality measure reporting.

"There are stringent requirements for electronic health records and a huge administrative burden related to requirements to ensure compliance and report on quality measures," said Figueroa.

"And then there are also all of these new 'alternative payment' models to figure out, like accountable care organizations and bundled payments, so you can imagine that if you're a solo practitioner, it would be really hard to manage all of these details yourself and still ensure you're taking care of your patient.

"As a cardiologist you need to invest in a bunch of resources, including a workforce to help you manage all the quality measures and keeping track of patients, ensuring they all get their blood pressures checked on time, etc," he said.

Anecdotally, Figueroa suggests it's also a quality-of-life decision for many cardiologists. "In terms of physician burnout, when you're a solo practitioner or in a small practice, it's really hard to go on vacation and find coverage."

Larry Sobal, MBA, MHA, the CEO of the Heart and Vascular Institute of Wisconsin, agrees that this consolidation is in large part a reflection of the trend toward consolidation seen across the healthcare system.

"This is because hospitals that purchase cardiology practices often pursue a tactic of consolidating previously separate independent groups into one practice — either legally or virtually — for purposes of controlling cardiology market share," he told theheart.org | Medscape Cardiology.

But it also suits the younger cardiology workforce. "My experience has been that cardiologists graduating from fellowships increasingly want to subspecialize and are less likely to join smaller practices where they cannot focus on the area of their training. Positions that allow this type of subspecialization can most easily be found in larger practices." said Sobal, who is also the cochair of the American College of Cardiology Management Publications Committee. 

And if professional incentives aren't enough, there is always money. While the study did not look at physician compensation by practice size, Sobal suspects physicians in larger practices have higher incomes.

Figueroa has disclosed no relevant financial relationships. Sobal is the CEO of a midsized cardiology practice (13 cardiologists).

J Am Coll Cardiol. Published August 4, 2020 issue. Abstract

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