In bygone days, your community hospital was a place where babies were born and gallbladders were removed. They were often run by city governments or local religious organizations. Of course, a lot has changed since then. Now your hospital advertises on television and extols the viewer about the medical miracles that are performed inside its walls. They also are getting bigger and merging with smaller and occasionally coequal institutions in the name of efficiency and in the effort to expand their patient catchment.
In an even larger sense, hospitals have been gobbled up by insurance companies and by for-profit networks in an attempt to maximize profits and minimize overhead. Some prestigious hospitals like the Mayo Clinic, the Cleveland Clinic, and MD Anderson Cancer Center have even established affiliations with community hospitals thousands of miles away seemingly to improve local care and at the same time to expand their referral network. Where local hospitals are not adequate and the market beckons, some have even built their own facilities not only in the United States, but also in countries around the globe.
The intent of these network affiliations is not only to improve their image but to impart some of their prestige to the local entities as well. As a result of these mergers and consolidations, they are positioning themselves to be more competitive in the new world of health care. Some would profess the altruism of providing better care either locally or at a distance, but in the long run, economics and market share are the driving force. They have not been concerned with delivering babies or taking out gallbladders for a long time.
Few can predict what the new world will look like, but it is quite certain that the Affordable Care Act will re-create or substantially modify American health care as we know it. The potential of attracting thousands of previously uninsured patients, who – with the help of the federal government – can come in the front door for care rather that using the back door of the emergency department for treatment, will be an important target.
In this environment, the practicing physician is caught in the changing tide. Many who are not in the swim will be washed up on the beach. Cardiology, along with oncology and gastroenterology, are the prime targets for the anticipated efficiencies evolving from the hospital system expansions and mergers. Although there is a well-recognized need for primary care health care professionals, much of this need is already being filled by nonphysician professionals. It is possible that cardiology, which has been one of the star profit centers, could become a target for consolidation and economy in the future. We may be seeing some of this, as the opportunities for finishing trainees appear to be diminishing.
It is obvious that there has been a major shift in the setting cardiology practices in the last few years. Since 2007, the proportion of physician-owned practices has decreased substantially. While the number of cardiologists employed by hospitals has grown from 11% to 35%, physician-owned practices have decreased from 59% to 36%. This migration of private practice to hospital-based practice is sure to continue. Cardiology practice will soon be directed by managers representing corporate health care who will be intent on putting in place programs that will establish protocol-driven therapy in the name of "quality" and "cost." Many of the changes will lead to better outcomes. Patient "satisfaction" will be measured by metrics already operational in the corporate environment. As the era of cardiology entrepreneurism faces institutional controls, such profit centers as imaging already are facing significant obstacles. The "down side" of this process will be the death of medical care as we knew it. It was not all bad. That mode of physician-driven, patient-centered care will not be easily transferred into the corporate care environment. The physician will need to ensure that at least that vestige of old-style medical care will not be entirely lost.
Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.