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Each week, Health Affairs Editor-in-Chief Alan Weil brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;04 - 00;00;36;28
Alan Weil
Hello and welcome to “A Health Podyssey”. I'm your host, Alan Weil. Hospital ownership of physician practices has gone through various boom and bust cycles; we're currently in a boom phase with hospital acquisition of physician practices, a significant trend. Now, the motivations for hospitals acquiring physician practices are many. Some are clearly financial, others have to do with clinical integration. Does clinical practice differ between independent physicians and those who are part of a hospital system?
00;00;37;15 - 00;01;01;06
Alan Weil
That's the topic of today's episode of “A Health Podyssey”. I'm here with Brady Post assistant professor in the Bouvé College of Health Sciences at Northeastern University. Dr. Post and coauthors published a paper in the May 2023 issue of Health Affairs, examining differences in care among patients treated by cardiologists who are either practicing independently or as part of a hospital system.
00;01;01;22 - 00;01;15;10
Alan Weil
They found higher rates of high intensity interventions when cardiologists were in hospital systems. We'll discuss these findings and their implications in today's episode. Dr. Post, welcome to the program.
00;01;15;19 - 00;01;16;21
Brady Post
Thank you so much for having me.
00;01;17;08 - 00;01;37;22
Alan Weil
This is a really important topic given what's happening in health care these days. Let's start with just a couple of basics so our listeners can make sense of what your findings show. You're looking at the effects of hospital-physician integration. What does that term mean as you use it in this study?
00;01;38;06 - 00;02;09;01
Brady Post
Well, that is a great place to start. So it refers in general to hospitals and physicians becoming more aligned or more tightly interconnected, at least from an economic point of view. Two straightforward examples of that might be a hospital that buys out a physician practice and then employs the doctors who are working there. You might also think about a physician who completes their training and then takes a job working directly for a hospital-owned facility that would also qualify as integration, as we understand it here.
00;02;09;10 - 00;02;19;11
Brady Post
And there's lots of nuance around this, probably no one definition is going to satisfy everyone, but ultimately it's about bringing hospitals and physicians together, so to speak, under one roof.
00;02;20;09 - 00;02;36;00
Alan Weil
Okay. So that's a great explanation. I made a passing reference to it in the introduction, but you've been studying this phenomenon. What are some of the recent trends in the prevalence of hospital-physician integration?
00;02;36;08 - 00;03;02;11
Brady Post
Well, if you were to look at a longitudinal graph measuring the prevalence of hospital-physician integration, over time, you would be looking at a line that moves up and to the right. So the exact magnitudes might vary a little bit depending on who you ask. Differences in definitions, differences in data sources, that kind of thing. But I think most everyone would agree that in the last 10 to 15 years, there has been a major increase in the prevalence of hospital-physician integration.
00;03;02;26 - 00;03;29;12
Brady Post
Some estimates have placed that around, at least in certain specialties, 40, 50%, maybe more, have become, those physicians have become hospital integrated. And, you know, in some specialties in particular have taken off--oncology, cardiology. But there are, that's been true even in primary care and elsewhere. This is really a pretty big shift. You know, for a long time, doctors, for the most part, worked in their own practices.
00;03;29;12 - 00;03;40;12
Brady Post
And of course, they had admitting privileges at hospitals, but they were fundamentally distinct. And at least recently, this more hospital centric new world is really quite a change.
00;03;41;06 - 00;03;59;07
Alan Weil
So we could spend a lot of time talking about the financial side of this, and I'm sure we'll come back to that later in our discussion. But you focus on the clinical side. So how could integration of physicians into a hospital system affect how they practice medicine?
00;04;00;08 - 00;04;25;20
Brady Post
It's a great question. So I think there are lots of possible reasons out there. But, you know, maybe for simplicity, I'll try to distill them into kind of three simple categories. One, you might imagine that a physician who's in an organizational setting run by a hospital they might be exposed to, might be working with different care teams, might be more or less interaction with physician assistants, let's say, or discharge planners or what have you.
00;04;26;03 - 00;04;50;07
Brady Post
So that's one possibility. A second one would be technology. The most go to example here is going to be electronic medical records. It's easy to imagine that in a hospital setting you might be as a physician, you might see, you know, more use of electronic medical records than you might in a smaller, independent practice. You might also have more ready access to certain kinds of clinical technology.
00;04;50;07 - 00;05;19;24
Brady Post
You might, for example, MRIs or other expensive, expensive equipment that hospitals are more likely to have. And then the third category I would say, would be incentives. Economists will certainly try to persuade you that people respond to incentives, and there's plenty of evidence that physicians do this as well. And so hospitals might very well have their employees, including employed physicians, to help them meet organizational goals. That could be quality improvement.
00;05;20;01 - 00;05;41;00
Brady Post
It could be reductions in readmission, maybe seeing a certain number of patients, lots of different possibilities here. And so taken together, a physician who's working in a hospital integrated practice has a lot of different types of features in their environment that gives, in my view, ample reason to think that practice patterns might change.
00;05;41;20 - 00;06;14;10
Alan Weil
Okay. So I'm struck as I listen to you, that I've heard this story a thousand times, that those on the integration bandwagon focus heavily on the potential positives for clinical practice. As you mentioned, access to technology, electronic records and increasingly, you know, decision support systems of care pathways that they learn and perfect and improve over time. These are all things that would be positive.
00;06;14;19 - 00;06;42;08
Alan Weil
And yet on the other side, I hear people talking about how the financial incentives can distort practice in potentially negative ways. The arguments are made almost by rote on both sides. And now comes the question, well, what evidence can we bring to this as opposed to just talking sort of thematically about what's possible? So you looked at cardiologists, one of the groups you just mentioned as part of the trend of integration.
00;06;42;18 - 00;06;56;06
Alan Weil
What questions were you trying to answer with respect to the care cardiologists provide? And then what did you find regarding, let's start with the use of diagnostic techniques and these higher intensity procedures?
00;06;56;28 - 00;07;22;00
Brady Post
Well, one way to put the broader question that was on our minds is suppose that, you know, you know that your doctor works for some organization. Does that organization affect the kinds of care that you receive? And we've seen prior work that hospital-physician integration is associated with more use of MRIs, for example, specifically inappropriate MRIs.
00;07;22;14 - 00;07;45;18
Brady Post
I imagine that that sounds familiar because it was also published in Health Affairs. So this type of thing led us to wonder, well, what else might integration affect? And so our research took kind of the same concept and said, you know, could integration potentially be associated with more aggressive treatment patterns, maybe a preference for hospital based services?
00;07;46;06 - 00;08;17;07
Brady Post
And so we looked at this specifically for patients who had gotten a new diagnosis of stable angina or chest pain. And this is an interesting clinical setting because there's a little bit of discretion. One physician might choose to do this and another might choose to do that. And in that kind of setting, you might imagine that is where the organizational context could potentially influence the type of practice behavior, at least in principle.
00;08;17;24 - 00;08;49;03
Brady Post
And so we looked at three of the common services that often are associated with a diagnosis of stable angina. And those are a stress test, a cardiac catheterization and a coronary angioplasty. With advance apologies to the clinicians on my team, as I, you know, don't know these details nearly as well as they do, those approaches, you know, a stress test is, you know, traditionally physician puts their patient on a treadmill and hooks them up to a monitor and they monitor heart activity, etc..
00;08;49;18 - 00;09;17;08
Brady Post
That's a very, you know, low, you know, low non intense kind of a procedure. It's very common in offices to have that, the technology demands are not that large and that will allow a physician to gather certain diagnostic information. A cardiac catheterization, I would say is a more intense type of procedure. And that's where, you know, a small, small tube gets inserted through a blood vessel into the heart.
00;09;17;08 - 00;09;42;11
Brady Post
And physicians can gather more diagnostic information about what's going on. An angioplasty is something that would happen after collecting a certain amount of information about this, determining that the blood vessels need some sort of intervention and, you know, sort of blow up a balloon there and improve blood flow. So, tying that back to our study.
00;09;42;11 - 00;10;03;26
Brady Post
We're thinking about this in the context of, you know, which ones hospital integrative physicians are more likely to prefer. You know, we found that there was no effect or maybe even a small negative effect of hospital-physician integration on stress tests. In other words, they were more or less not likely, neither more likely nor less likely to use a stress test.
00;10;04;10 - 00;10;19;01
Brady Post
But if the cardiologist that was managing your care was hospital employed, you were statistically more likely to get a cardiac catheterization and to get a coronary angioplasty compared to equivalent patients that got their care managed by an independent physician.
00;10;19;27 - 00;10;22;26
Alan Weil
So can you give me a sense of the magnitude of the differences?
00;10;23;04 - 00;10;53;27
Brady Post
Sure. So among the, with the outcome of cardiac catheterization, we found around a four percentage point increase or higher rate among hospital integrated physicians relative to independent. And compared to our sample average, that was around a 13% increase in or higher probability. And with respect to angioplasty, there was around a two percentage point increase. And relative to our sample average, that was about an 18% higher chance of getting angioplasty.
00;10;54;19 - 00;11;20;00
Alan Weil
So what you're finding is a statistically significant and clinically significant increase in the use of higher intervention services when the cardiologist is part of a hospital system and you did say of patients of the same nature. So one argument we often hear is, oh, well, you know, patients in hospital settings are sicker and therefore, of course, you'd expect higher levels of intervention.
00;11;20;00 - 00;11;22;05
Alan Weil
Is that, that's something you looked at, right.
00;11;22;19 - 00;12;03;25
Brady Post
That is something we looked at. And we really did not find that patients being treated by hospital integrated physicians were actually any sicker than their independent counterparts were. Of course, there's always the potential for unobserved levels of complexity. That's, you know, that's always, always an issue. But, you know, it's easy to understand the concern. Maybe it's that sicker patients prefer doctors who are affiliated with hospitals systems. It could be that maybe those with certain types of more complex health problems want their physician to be part of a bigger care team or have ready access to certain technology.
00;12;03;25 - 00;12;23;13
Brady Post
That's totally possible. And of course, that's a big problem in this kind of study. So if you find that there's more intense treatment styles among hospital based physicians, well, maybe that's just because their patients were sicker. So we were sensitive to that. And we really didn't find that, at least in terms of the things that we were able to see.
00;12;23;18 - 00;12;47;24
Brady Post
We looked at several common comorbidities like COPD, diabetes, cancer. In most cases, there were no statistical differences between these groups. And if anything, the patients of independent cardiologists appeared to be a few months older and more likely to have hypertension. And we also did an instrumental variables analysis on this, and that gets a little bit technical.
00;12;47;24 - 00;13;14;17
Brady Post
But the, you know, the essence of it is we started with the, we selected the subset of patients who had initially chosen an independent physician. And over the course of our study period, some of those physicians got bought out or integrated with hospital systems. And so to some degree, those patients got randomly assigned to integration and the effects didn't go away.
00;13;14;17 - 00;13;25;16
Brady Post
In fact, if anything, the effects got bigger, which suggests that that patient’s sickness is probably not, at least to the best of our ability, it does not appear to be the reason for a more intense care style.
00;13;26;06 - 00;14;05;06
Alan Weil
Okay. Well, these are important findings. And I want to talk to you about the implications of them, what conclusions we can draw, and maybe what we should do about it. We'll talk about those topics after we take a short break. And we're back. I'm speaking with Dr. Brady Post about the effects of hospital-physician integration among cardiologists on how they practice.
00;14;05;22 - 00;14;32;28
Alan Weil
Before the break, we heard that the rates of some fairly invasive procedures are notably higher, and we've screened out the possibility that it's due to differences in the patient population. Now, can you comment directly I know you said you're not the clinician on the team and I'm not a clinician interviewing you for this podcast, so let's be careful with our language, but based on your work, can you talk about the appropriateness?
00;14;32;28 - 00;14;39;05
Alan Weil
In other words, higher? Yes. But maybe higher is more appropriate, maybe lower is less appropriate.
00;14;40;01 - 00;14;56;27
Brady Post
Yeah, that's exactly right. It may very well be, that may very well be the case. It's a really important question. Strictly speaking, we didn't set out to make those kinds of, you know, pretty normative claims. But I would say that we made a good faith effort to at least come up with some insights, you know, even if not perfect.
00;14;57;09 - 00;15;22;29
Brady Post
And I'll mention a couple of things that we did to address this. And, you know, to be honest, the results are a little bit mixed. So I'll give an example of one in each direction. So we tried to get at this concept of possible overuse of catheterization. One of the main reasons to do a catheterization is to see if an angioplasty is warranted and I think it might be easiest to just take an extreme case.
00;15;23;10 - 00;15;44;28
Brady Post
Suppose you've got a clinician that just recommends a catheterization to everybody who walks through the door, everybody with the faintest trace of heart pain, you go straight to the cath lab for you, you get a catheterization. We did not see that in our data, for which I'm glad. But very few of those patients would actually go on to get an angioplasty because there are conditions when warranted.
00;15;45;29 - 00;16;10;04
Brady Post
And what that means is you'd probably get a really, you probably measure really low rates of catheterizations that are followed by angioplasties. So if you've got a rate like that where lots of caths, very few angioplasties, that could be a signal at least of potential overuse. So we measured that and compared the patients of integrated physicians compared to the patients of independent physicians.
00;16;10;15 - 00;16;36;06
Brady Post
And in this case, the integrated physicians actually came out a little bit ahead. It looked like they were maybe using cath in this way, suggesting potentially less overuse by this very crude measure. But on the other hand, we also know that stress testing usually precedes catheterization. You usually put a patient on a treadmill before you go with a, put a tube into their heart.
00;16;36;19 - 00;17;00;12
Brady Post
And if the patient does a stress test, and the results come in and show a positive result, in other words, that there are signs of heart disease or issues, then you might proceed to a catheterization. So one really good measure would be, you know, among patients who did not receive a positive stress test or who got a negative stress test, did they still go on and get a catheterization?
00;17;01;10 - 00;17;22;12
Brady Post
Much to our chagrin, we cannot see the results of, the contents of the stress test result directly, but we can see whether they got one at all. And so we said, okay, well, among the patients who did not have a stress test, how many went on to get a catheterization anyway? And in this case, the results were more favorable to independent physicians.
00;17;22;29 - 00;17;33;11
Brady Post
So I would say that this is at least, there's at least some evidence here that there may be some overuse; at a bare minimum, it warrants better understanding.
00;17;34;00 - 00;18;03;07
Alan Weil
You know, so I think this is a great example of where each piece of research adds to our understanding of the situation. But no single piece can answer all questions, and that's as it should be. So you've provided us with a quantitative understanding of differences, and you might want a different kind of examination that's looking at the clinical results and trying to determine something about appropriateness.
00;18;03;12 - 00;18;30;12
Alan Weil
But still, the overall findings definitely raise an alarm and I suppose the real alarm here, of course, is going back to the financials, which is, there something about moving in to or participating in a hospital system that sends signals to the clinician that they should err on the side of higher levels of intervention rather than lesser levels, either subtly or not so subtly?
00;18;30;12 - 00;18;58;08
Alan Weil
And that concern, I think, is appropriate given the finding, even though it's not dispositive, the findings are not definitive. So let's look at the broader environment. You mentioned early on that if you looked at a measure of the degree of integration that exists, it would be upward sloping to the right. So we already have a lot of this and then it's raising some questions about whether it's affecting clinical practice.
00;18;58;08 - 00;19;08;27
Alan Weil
How do we think about the policy response to a situation where there's significant existence of integration and some reasons to worry about it?
00;19;09;27 - 00;19;38;11
Brady Post
Well, that is, that's the million dollar question. And I would say, you know, off the bat that there's probably not one, you know, one comprehensive answer that addresses all of this. But I would say in, to kind of frame it, the question in some ways becomes, as we move toward a system, and it appears that we are, where most of us are going to be getting our care from hospital based or hospital integrated physicians, what kind of care are we going to get?
00;19;38;21 - 00;20;04;20
Brady Post
What should we expect? And so I wouldn't, I don't take, you know, the findings of this, you know, this study in isolation, as you were just saying a moment ago, every study builds a little bit. And so I would view these findings as contributing to the prior work on integration. And some of those prior findings have shown higher use of inappropriate MRIs and preference for more expensive chemotherapy drugs, for example.
00;20;05;03 - 00;20;39;07
Brady Post
And so I think that it's probably safe to say that generally hospital-physician integration has been associated so far with more intense or more expensive approaches to care. And so, you know, suppose that we accept that as kind of a stylized fact and maybe not everyone will, but suppose that we do accept that for the sake of argument. The right response to that depends a little bit on where you stand, perhaps in general with the perspective on having providers that are more closely aligned, at least in the sort of economic sense.
00;20;39;28 - 00;21;19;22
Brady Post
And if you're generally okay with more integrated systems, if you think that there are often lots of benefits to it, I think you would still say, at least given these findings, let's look at appropriateness and quality and maybe quantify the upsides a little bit. At least do our due diligence on that. Maybe we're getting something for it, as you were alluding to, alluding to earlier, maybe there are some benefits. On the other extreme, for those who are very skeptical, you might say, you might take maybe a nonproliferation approach and you want to equip the Federal Trade Commission to more aggressively challenge vertical mergers and that sort of a thing.
00;21;20;26 - 00;21;47;05
Brady Post
Somewhere in the middle perhaps you could say, alright, well, we know we've got, we know we're moving toward more integrated systems. And it looks like there are there could be potential for overuse or potentially to treatment that's maybe too intense or outside of what patients want. Certainly do the research to understand that better and then also treat it like any other time where we encounter overuse in the health care system.
00;21;47;05 - 00;22;13;28
Brady Post
Let's look for payments and regulatory approaches to incentivize in these organizations more conservative treatment patterns, at least wherever that is clinically appropriate. Ultimately, the right response could be pretty nuanced. I don't see any of these approaches as mutually exclusive, and I think that identifying the situations where integration is helpful for patients and where it is maybe not so effective is one of the biggest challenges ahead.
00;22;15;02 - 00;22;40;09
Alan Weil
Well, you've identified an issue right at the intersection of sort of the economics and the clinical practice of medicine, and it's always hard. We need to bring multiple methods and perspectives to the discussion. As we come to a close, you've been working on this general topic for a little while. I wonder if you could say a little bit about what comes next in the questions you're trying to answer with respect to hospital-physician integration.
00;22;41;02 - 00;23;07;11
Brady Post
There's no shortage, which is one of the fun parts. And so, you know, so I think that certainly thinking about some of the specific clinical settings where you might expect to see some improvements, maybe clinical settings that are more care coordination dependent. There's a lot of talk that hospital-physician integration could improve care coordination and discharge planning and things like that.
00;23;07;17 - 00;23;29;00
Brady Post
And that's possible. And I think that maybe hasn't been explored all that well, even with this particular study here, as I mentioned, you know, we don't have direct clinical information to comment on appropriateness and combining the type of data that we have with electronic health records, things like that could really enhance our understanding.
00;23;29;08 - 00;23;31;23
Brady Post
And that's what follow up studies are for.
00;23;32;29 - 00;23;50;16
Alan Weil
Well, Dr. Post, thank you for doing this important work and putting it in context, helping us understand this complicated topic and the multiple dimensions of effects associated with hospital-physician integration. Thank you for being my guest today on “A Health Podyssey”.
00;23;50;24 - 00;23;52;16
Brady Post
My pleasure. Thank you so much for the opportunity.