Vertical Integration in Cardiology Brings Less Value, Analysis Finds

Vertical integration, which has consolidated independent cardiologists into hospital systems over the past 15 years, has led to higher costs in Medicare with “minimal evidence” of any increase in quality, according to findings presented during the recent 2024 American Heart Association (AHA) Scientific Sessions in Chicago, Illinois.¹

The analysis, “The Association of Cardiologist Vertical Integration With Care Quality, Patient Outcomes, and Utilization,” was presented by as part of the poster session, “Behind the Curtain: How Healthcare Policy Shapes Patient Outcomes,” which took place on the final day of the AHA sessions, Monday, November 18, 2024.

The findings were simultaneously reported in the Journal of the American College of Cardiology.²

Vinay Kini, MD, MSc | Image credit: Weill Cornell Medicine

The study’s senior author and presenter, Vinay Kini, MD, MSc, a cardiologist and health services research with Weill Cornell Medicine, acknowledged that the results mean those paying for Medicare cardiology services are receiving less value due to consolidation.

Kini said the study was designed to measure if the purported benefits of vertical integration result in better quality care. First, he explained how consolidation of the supply chain in health care can take different forms, from physician practices affiliating with hospitals to physicians become direct employees of the hospitals. Data presented showed that the percentage US cardiologists employed by hospitals increased from 26% in 2008 to 61% in 2018.^1,2

“Proponents of integration say that there's improved communication and care coordination, particularly between inpatient and outpatient settings, that it can facilitate systems approaches to quality improvement because of larger systems, and it can reduce duplicative testing and readmissions,” Kini said.

“Critics of integration cite a fair amount of work that has shown that integration leads to increased prices, because of the ability of larger organizations to command higher prices, particularly from commercial insurers,” he said. “Reduced competition and reduced patient choice are also potential drawbacks of integration.”

In the analysis, Kini and coauthors followed cardiologists as consolidation picked up steam from 2008 to 2018. They could trace when physicians switched from using individual provider numbers to a hospital tax ID numbers to bill Medicare. Based on each physician’s billing for Medicare fee-for-service patients, they tracked billing for hospitalization for incident heart failure. Using a 3-year lookback period, the researchers excluded prior hospitalizations and examined mortality, readmission, and other quality and care utilization metrics.

The cardiologists studied were then split into 3 groups for a differences-in-differences analysis: nonintegrated, always integrated, or “switchers,” with the latter being those who changed from a nonhospital tax ID to a hospital tax ID for billing. These cardiologists were compared with the nonintegrated group for study period.

According to the abstract, the sample covered 186,052 patients with acute myocardial infarction (MI) and 259,849 heart failure (HF) patients treated by cardiologists who switched to integrated practice and 168,052 acute MI patients and 245,769 HF patients cared for by nonintegrated cardiologists.

“So, what did we find? In a nutshell, we really found no differences between the 2 groups,” in terms of quality, Kini said.

He reviewed results for mortality, readmissions, and various quality of care metrics. The only significant difference was a small difference in the 30-day follow-up clinic visit; (adjusted difference: 1.04%; 95% CI: 0.46%-1.62%).² Authors reported “no differences in utilization between patients treated by hospital-employed cardiologists (postswitch) vs independent cardiologists.”

Giving the evidence that health care consolidation has contributed to rising costs, The American Journal of Managed Care^® asked if the classic definition of value—quality divided by cost—meant vertical integration results in less value. Kini replied, “Yes.”

Americans Want Health Care, but Don’t Want to Pay More

The first poster at the November 18, 2024, session covered a perennial problem: Americans want a service but want someone else to foot the bill.

Sudheesha Perera, MD, MSc, MPH | Image credit: LinkedIn

Sudheesha Perera, MD, MSc, MPH, a Yale medical resident presenting on behalf of the Smith Center for Outcomes Research in Cardiology, outlined data that used the 2022 General Social Survey to assess perceptions of US health care coverage, access, and equity.³ “It’s well understood that increased access to care leads to better cardiovascular outcomes,” he said.

“The AHA 2024 goal, which is Championing Health Equity for All, specifically outlines the urgent need to identify and address barriers to access to high quality care. This effort comes at a time of unprecedented inequity in the US, most directly in terms of income and wealth,” Perera said.

However, despite adoption of the Affordable Care Act in 2010, coverage gaps and the challenge of the underinsured remains.

Based on responses from 3544 adults with a mean age of 47.1 years (SD, 17.9 years), a majority of US adults agree that the rich have easier access to health care (79.5%; 95% CI, 75.7%-83.3%). Additional results showed:

• More than half believe differential access based on income is unfair (56.5%; 52.0%-60.9%), with opinions varying significantly based on party affiliation; 70.8% of Democrats believe access to health care based on income is unfair, compared with 34.0% of Republicans.
• Only 10.7% of Americans (8.1%-13.3%) are willing to pay higher taxes to expand or improve the level of health care for all. Again, support splits by party affiliation, with 20.3% of Democrats supporting higher taxes vs 2.6% of Republicans. There was no statistically significant variation in responses based on age or income.

The implications of these findings for cardiovascular health policy makers are challenging. Partisan dynamics, Perera said, “are more powerful than other demographic considerations when expanding health care coverage for cardiometabolic conditions, including preventive screening, guideline-directed therapies and in hospital care.”

Given challenges to vaccination, “alternative strategies such as supplementing income, increasing minimum wage, and addressing inflation” are in order, he said. “More globally, this work is just a reminder of the power of perceptions that people act not based on realities, but their perception of reality when making these big decisions, such as how to vote or how to seek care.”

Total Spending on CV Care in US Could Reach $460 Billion by 2050

A forecast of the cost of cardiovascular (CV) care in the US presented during the poster session shows that spending could rise from the $324 billion spent in 2019 to $460 billion by 2050—a 41.9% increase over a 30-year period.⁴

Feras Wahab, MS | Image credit: LinkedIn

The forecast reflects an aging population and shifts due to the fallout of the COVID-19 pandemic, according to the analysts, from the Institute For Health Metrics and Evaluation (IHME) and the University of Washington, both in Seattle.

The analysis, funded by the AHA and prepared by, was presented by Feras Wahab, MS, of IHME. “Cardiovascular care in the US has seen a dramatic increase in the last couple of years and decades,” he said. “The lack of detailed future cost forecasts poses a significant challenge to health care systems and policymakers who are unable to target the diseases or types of care that are most impacting the rising costs.”

“So given all this, the objective for us was to estimate future US cardiovascular disease spending and utilization rates for 2020, to 2050, specified to the sex, state, disease, age and type of care level.”

Using IHME’s analysis of spending from 2000 to 2019 as a starting point, the analysts evaluated data from insurance claims, drug prescriptions, emergency department visits, inpatient stays, ambulatory care visits, nursing facility stays, and population forecasts from the Global Burden of Disease study.

Results show the highest sources of increased spending will be from nursing facility care and home health care, which will rise form 11.8% to 13.9%, and from 7.1% to 8.2% of total spending, respectively. By 2050, spending for ischemic heart disease will be $110 billion up from $79 billion in 2019. Heart failure (HF) will follow at $102 billion, up from $64 billion in 2019.

As a share of overall spending, HF is expected to increase from 19.7% of CV spending in 2019 to 22.1% in 2050. During this period, spending on obesity will rise from $13 billion to $15 billion, but obesity will shrink slightly (0.8%) as a share of all spending on CV spending, due to rising costs for other conditions.

Other results presented at the session showed detrimental effects of Medicaid work requirements on enrollment,⁵ showed that publicly insured patients in Michigan had lower rates of cardiac rehabilitation utilization,⁶ and found that over a 20-year period ending in 2023, the American College of Cardiology (ACC) and the AHA spent $34.1 million and $14.3 million, respectively, on lobbying activity.⁷

The poster session was comoderated by Jay B. Lusk, MD, MBA, preventive medicine resident, University of North Carolina at Chapel Hill, and Paula Chatterjee, MD, MPH, director of Health Equity Research, Leonard Davis Institute of Health Economics and assistant professor of Medicine, Perelman School of Medicine, University of Pennsylvania.

References

1. Moghtaderi A, Magid DJ, Masoudi FA, et al. The association of hospital-cardiologist integration with patient outcomes, care quality, and utilization. Presented at: 2024 American Heart Association Scientific Sessions, November 16-18, 2024; Chicago, Illinois; Abstract MDP1544.
2. Moghtaderi A, Magid DJ, Yuan AY, Black B, Luo QE, Kini V. The association of hospital-cardiologist integration with patient outcomes, care quality, and utilization. J Am Coll Cardiol. Published online November 15, 2024. doi:10.1016/j.jacc.2024.10.109
3. Perera S, Wadhera RK, Khullar D. Americans’ views on healthcare coverage, access, and equity in the US: implications for cardiovascular health. Presented at: 2024 American Heart Association Scientific Sessions, November 16-18, 2024; Chicago, Illinois; Abstract MDP1540.
4. Wahab F, Lindstrom M, Roth GA, Dieleman J. Forecasting US state-level health expenditures for cardiovascular diseases through 2050. Presented at: 2024 American Heart Association Scientific Sessions, November 16-18, 2024; Chicago, Illinois; Abstract MDP 1541.
5. Engel-Rebitzer E, Marinacci L, Zheng Z, et al. Medicaid work requirements and changes in insurance coverage, employment, access to care, and health status overall and among people with cardiovascular disease. Presented at: 2024 American Heart Association Scientific Sessions, November 16-18, 2024; Chicago, Illinois. Abstract MDP1542.
6. Pedamallu H, Mantey J, Sukul D, et al. Publicly-insured patients have lower rates of cardiac rehabilitation enrollment: a statewide experience in Michigan. Presented at: 2024 American Heart Association Scientific Sessions, November 16-18, 2024; Chicago, Illinois. Abstract MDP1543.
7. Patel PN, Milks MW, Miller AP, Mehta LS. Advocacy in cardiology: healthcare lobbying and campaign finance activities of major cardiovascular professional societies, 2003 to 2023. Presented at: 2024 American Heart Association Scientific Sessions, November 16-18, 2024; Chicago, Illinois. Abstract MDP1547.