Navigating the Evolving Landscape of Private Cardiology Practice

ABSTRACT

The landscape of cardiology practice in the US is rapidly shifting from physician-owned models toward consolidation, hospital integration, and increasing private equity (PE) investment. Historically, community-based cardiovascular care relied on independent physician groups that fostered close relationships and localized service delivery. Over the past 2 decades, however, escalating practice costs, declining reimbursement, and rising infrastructure demands have eroded independence and pushed many practices toward mergers, acquisitions, or hospital employment. Although these arrangements offer stability and capital, they often reduce autonomy, limit flexibility, and contribute to higher costs without consistently improving outcomes. This commentary explores the evolving dynamics of private cardiology practice, the challenges imposed by PE ownership, and the consequences for physician independence, patient access, and quality of care. We review key financial and regulatory pressures, including reductions in Medicare reimbursement and administrative burdens under the Merit-based Incentive Payment System. Additionally, we highlight strategies that independent practices can adopt to preserve autonomy, such as diversification of services, participation in clinically integrated networks, and use of modern technologies such as telecardiology. Finally, we emphasize the importance of physician leadership, succession planning, and advocacy in ensuring that independent cardiology remains a viable component of US health care. Sustaining private cardiology is essential to preserving patient-centered care, operational flexibility, and clinical judgment in a consolidating health care environment.

Am J Manag Care. 2026;32(3):e62-e65. https://doi.org/10.37765/ajmc.2026.89897

Takeaway Points

Independent cardiology practices are rapidly disappearing due to hospital consolidation and private equity investment. Although consolidation offers resources, it can lead to higher costs and reduced physician autonomy. This article outlines strategies for sustaining independence and improving patient-centered care.

• Independent cardiology is shrinking under financial and regulatory pressures.
• Hospital employment and private equity ownership raise costs without improving outcomes.
• Practices can sustain independence through innovation, alliances, and advocacy.
• Supporting private cardiology preserves access, quality, and physician judgment.

The landscape of cardiology practice in the US is rapidly shifting from a physician-owned model toward consolidation, hospital integration, and growing private equity (PE) investment.¹ Historically, cardiovascular care in community settings has relied on small, independent groups that fostered close physician-patient relationships and localized care delivery. Over the past 2 decades, however, rising market concentration has eroded independence. By 2016, 91% of hospital markets and 65% of specialist physician markets were already highly concentrated, leaving small practices at a significant disadvantage.² Declining reimbursement, rising practice overhead, and capital and infrastructure demands have pushed physicians toward mergers, acquisitions, or hospital employment.² Although consolidation provides capital and infrastructure, it simultaneously threatens physician autonomy, quality of care, and patient access.³ This commentary explores the evolution of private cardiology practice, the challenges posed by PE investment, and strategies to preserve independence.

The Current State of Private Cardiology Practice

There are more than 2500 active cardiology group practices nationwide, spanning physician-owned, hospital-owned, and PE-owned models.⁴ However, only about 350 remain independent and sizable, defined as employing 5 to 10 cardiologists, operating across multiple locations, or maintaining substantial procedural capacity.⁵By 2022, nearly 90% of cardiology practices were hospital integrated, leaving only 10% to 12% independent.⁶ Hospital employment of cardiologists rose from approximately 26% in 2008 to nearly 63% by 2019, and by 2024, only 30.7% of cardiologists worked in physician-owned practices.^7,8 Of the nation’s approximately 33,000 cardiologists, only 10,000 remain in independent practice, and nearly 80% of them work in groups of fewer than 10.⁹ Large independent practices, those with more than 50 cardiologists, are rare, with only 30 nationwide.⁹ Solo and 2-physician practices, once dominant, accounted for just 16.1% of the field in 2017.¹ Some groups now adopt hybrid models that blend private practice autonomy with health system affiliations to navigate consolidation pressures.⁶

Subspecialty patterns differ. Interventional cardiology and electrophysiology, with capital-intensive catheterization and electrophysiology labs, remain closely tied to hospitals.¹ In contrast, general cardiology remains more prevalent in physician-owned settings that focus on longitudinal care and diagnostics, and as a result, it has been a stronghold for private practice, attracting PE acquisitions.⁵

Key Challenges Confronting Private Cardiologists

Several forces are pushing independent cardiology toward consolidation.¹⁰ Federal reporting mandates, such as the Merit-based Incentive Payment System (MIPS) created by the Medicare Access and CHIP Reauthorization Act of 2015, have caused heavy administrative and financial burdens for small physician practices.¹¹ At the same time, PE investment has surged, with 342 unique cardiology clinic acquisitions in the past decade, 94% of them occurring between 2021 and 2023.¹² Yet despite these structural shifts, evidence suggests that hospital employment increases spending without improving key outcomes such as mortality or readmission rates after myocardial infarction.¹³ These pressures frame the financial and operational challenges that follow.

Private cardiology practices face sustained financial strain as reimbursement fails to keep pace with costs. From 2005 to 2021, Medicare payments for cardiology fell by approximately 29%, and physician pay across all specialties declined 26% after adjusting for inflation.¹⁴ During the same period, hospital reimbursements rose nearly 70%, widening the gap between independent and hospital-based practices.¹⁵ This widening gap has eroded the viability of independent practice and accelerated the shift toward hospital employment and PE ownership. In 2025, CMS reduced the Medicare Physician Fee Schedule conversion factor by 2.83%, resulting in an average 2.9% cut in physician payments for covered services.¹⁶ Quantitatively, inflation-adjusted Medicare payments to cardiologists fell approximately 29% from 2005 to 2021, whereas hospital facility payments increased markedly over the same period.^14,15 PE activity also accelerated, with 342 outpatient cardiology clinic acquisitions in the past decade and approximately 94% occurring since 2021.¹² Specialty societies describe these repeated reductions as “death by a thousand cuts,” underscoring the mounting strain on independent cardiology practices.¹⁷ These payment cuts compound escalating operational expenses for staffing, supplies, and technology, further eroding already narrow margins.¹⁸

Administrative demands such as documentation, prior authorizations, and electronic health record requirements require physicians to spend approximately 15.1 hours per week on quality reporting activities.¹⁹ Compliance with federal quality programs such as MIPS adds additional complexity and overhead. These administrative and regulatory pressures are compounded by structural and workforce challenges that limit competitiveness. Independent groups often cannot match the infrastructure, economies of scale, and depth of resources of large hospital systems and academic centers, limiting their ability to compete.²⁰ Recruitment and retention are also hindered by high burnout and shifting priorities among younger physicians, many of whom seek the stability and work-life balance of employed positions rather than independent practice.²¹

PE investment in cardiology is fueled by the specialty’s high revenue potential and fragmented practice landscape.²² PE models typically involve acquisitions and consolidation, offering capital, infrastructure upgrades, and management expertise. However, they often reduce physician autonomy and incentivize profit-driven behaviors such as increased testing.²³ Evidence links PE ownership to higher health care costs and mixed or negative impacts on quality, prompting growing regulatory and ethical scrutiny.²³

Opportunities and Innovations

Diversifying revenue streams, such as cardiac rehabilitation, imaging, sleep medicine, and preventive cardiology, can improve stability; compliance with the Stark Law safeguards against conflicts of interest.⁶ Additionally, optimizing billing workflows and using digital payment platforms can enhance cash flow.¹⁹ Joining group purchasing organizations or alliances with other independent practices can improve negotiating leverage with payers and suppliers.¹⁸

Independent physician associations allow practices to pool resources in contracting, compliance, and technology while preserving local control and ownership. Clinical comanagement agreements with hospitals enable shared governance of cardiovascular service lines and quality metrics.²⁴ Participation in clinically integrated networks (CINs) further supports data sharing, care coordination, and stronger payer negotiations, all without requiring full hospital integration.²⁵ In practice, one regional CIN allowed independent specialists to contract directly with employers and insurers under a joint vehicle while retaining ownership.²⁵ Such frameworks, with active physician participation, shared quality goals, interoperable information technology, and nonexclusive participation, allow independent groups to align clinically and negotiate collectively without a full merger.²⁵

Modern technology can further support independence by streamlining workflows, enhancing the clarity of performance metrics, and improving practice efficiency. Telecardiology and remote monitoring can expand access, support timely interventions, and improve patient retention and outcomes.²⁶ These innovations are most effective when paired with strong physician networks and community ties. Robust referral relationships with primary care physicians and subspecialists help sustain patient volume. Convenience-oriented features such as flexible scheduling, transparent pricing, and attentive service further encourage loyalty and attract new patients.

Benchmarking tools help independent practices identify inefficiencies early and adjust operations. MGMA DataDive benchmarking enables leaders to assess productivity, staffing, and cost patterns against national norms, helping them identify and correct inefficiencies early.²⁷ Additionally, MedAxiom’s advanced practice provider compensation and utilization data inform efficient workflow scaling through advanced practice provider deployment.²⁸

Long-term stability also depends on succession planning. Recruiting and mentoring early-career cardiologists who share the commitment to independence helps preserve a practice’s culture and vision. Clear ownership pathways and well-structured shareholder agreements can ensure leadership transitions smoothly while protecting against unwanted outside control. Equally important, ensuring that the next generation inherits not only a thriving practice but also a favorable policy environment requires active engagement in advocacy. Participating in state and national cardiology societies can provide a platform to influence legislation on reimbursement, scope of practice, and regulatory requirements. Furthermore, collaboration with specialty coalitions can strengthen efforts to challenge unfavorable payment models and consolidation trends. Direct engagement with policy makers can also be beneficial for reinforcing the value of independent cardiology in improving access, lowering costs, and preserving patient choice. Specifically, national societies coordinate Capitol Hill visits and submit detailed comments during CMS rulemaking, such as that for the 2025 Medicare Physician Fee Schedule, to oppose conversion factor cuts and reduce reporting burden.¹⁶ The American College of Cardiology’s 2024 Health Policy Statement outlines priorities for that advocacy: Streamline prior authorization with transparency and automation, address cost-sharing barriers, and advance site-neutral, value-based payment for cardiovascular care.²⁷

Conclusions

Private cardiology practices remain vital for delivering adaptable patient-centered care. Their strengths, which include close physician-patient partnerships, operational flexibility, and rapid innovation, are increasingly rare in consolidated systems. Preserving these strengths requires payment reform, reduced administrative barriers, and sustained stakeholder support from policy makers, payers, and professional organizations. Hybrid models, such as telemedicine linkages, CINs, and comanagement agreements, offer practical near-term paths to balance independence with resource sharing.²⁹

Looking ahead, independent groups can serve as specialized hubs within larger networks, participate in accountable care organizations, and expand adjacent services such as behavioral health and chronic disease management for defined populations.²⁹ Sustaining independence will require physician leadership in governance. Additionally, policy makers should adapt value-based models to practices of different sizes and reduce administrative friction. Professional organizations should also equip physicians with infrastructure, training, and data tools to compete on quality and outcomes.³⁰ Backing independent cardiology is an investment in a health system where quality, cost-effectiveness, and clinical judgment are paramount. 

Author Affiliations: Trinity College (WJB), Hartford, CT; Harvard Medical School (FOR), Boston, MA; Washington University in St. Louis (KT), St Louis, MO; ProMedica Physicians Cardiology (RP), Toledo, OH.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (WJB, FOR, KT, RP); analysis and interpretation of data (KT); drafting of the manuscript (WJB, FOR, KT); critical revision of the manuscript for important intellectual content (WJB, FOR, RP); and supervision (KT, RP).

Address Correspondence to: Ronak Patel, MD, ProMedica Physicians Cardiology, 2940 N McCord Rd, Toledo, OH 43615. Email: Patelrb33@gmail.com.

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