Lawrence Casalino 0:00
So if you're treated like a widget and you start to feel like a widget, you're probably going to act more like a widget unless you're really a saint. And widgets aren't going to do well, I would argue, in areas of of quality that aren't measured or measurable.

Austin Littrell 0:27
Welcome to Off the Chart, a business and medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, Medical Economics senior editor Richard Payerton sat down with Dr. Lawrence Casalino, professor of population health sciences at Weill Cornell Medicine and founding director of the Center for Physician Practice and Leadership, funded by the Physicians Foundation. Dr. Casalino spent 20 years as a primary care physician and served six years on the Medicare Payment Advisory Commission, or MedPAC. Their conversation today starts with why independent practice keeps shrinking, and Dr. Casalino's answer runs down to five separate forces: from take-it-or-leave-it contracts, small practices get handed, to an administrative burden that hardly existed when he started seeing patients in 1980. From there, they turn to his recent essay in the New England Journal of Medicine, which argues that some of the things physicians do that matter most, like making a timely and accurate diagnosis, are exactly the things that nobody can measure at scale, and they get into what he calls widgetization, which happens to the quality of care when the people delivering it start to feel interchangeable. With all that said, Dr. Casalino, thank you for joining us, and now let's get into the episode.

Richard Payerchin 1:41
Dr. Casalino, thank you for joining us today.

Lawrence Casalino 1:43
It's a pleasure. Thanks for the opportunity.

Richard Payerchin 1:46
If I may, we'll take a step back in history a little bit. Your personal history. You spent several years as a community organizer with the United Farm Workers before becoming a physician. What led you into medicine?

Speaker 1 1:59
Yeah, I worked as an organizer with the farm workers and with other. This was during the Vietnam War with other community groups. I would say that I I valued that work, but I wanted to be able to put my hands on people and help them directly every day and see the results. So that seemed almost too good to be true to me when I first started to think about it, and that's why I chose to become a physician. And it's turned out better than I hoped. There's a lot of discontent among physicians nowadays, and for good reasons-very good reasons, I think. But the opportunity to do that, to meet people every day that you wouldn't meet otherwise, to get to know them pretty well, literally to put your hands on them and to help them in ways that they and you may not even have thought of is a great opportunity. So in the 20 years I was in full-time practice, you know sometimes I would feel pretty annoyed by the end of the day at various things, but looking back on it, it's a great honor and it's it's a great opportunity to be able to do that. And I hope that physicians can try to keep that in mind.

Richard Payerchin 3:13
Absolutely, I always like to remind our audience. In full disclosure, I'm not a physician myself, but every time we talk to to a physician, one of the things they always go back to is that the relevance, the importance, their passion for patient care. It's glad to. I'm

Speaker 1 3:27
glad to hear that. Yeah.

Richard Payerchin 3:29
Yeah. Excellent. And over time, your research has examined how policy shapes the type of provider organizations that survive and grow. You've noted in an article we're going to talk about here in a little bit about decreasing numbers of physicians in independent practice. In your mind, having worked as a primary care physician, what are some of those leading factors that have really led to that decline?

Speaker 1 3:55
Yeah, I mean this is a trend that's really been going on since I started in practice, really in the early 1980 s, and has accelerated over time, I think there are very powerful reasons. First of all, if you're in a in an independent practice, unless it's huge and very prestigious, you have little or no negotiating leverage with health insurance plans in the rates you're paid. It's basically take it or leave it. Take it or leave it. What we'll pay you. Take it or leave it. What our prior authorization requirements are, and so on. So it's an unlevel playing field for physicians in independent practices, and they can get higher payment rates for better or for worse from the point of view of the country, if they're in a very very large medical group, or a group that's owned by hospital, or private equity owned group in some cases. That's one issue, and it's an important one. The other is, when I started practice, there was practically no administrative burden on physicians at all or their practices. This was in 1980, and. Now the burden is really enormous. Dealing with value-based purchasing programs and and various kinds of quality measurement programs, dealing with prior authorization. In our practice, we had nine primary care physicians, and we had two employees, two of our best paid employees, who did almost nothing except try to get prior authorization approvals from health insurers for our patients, and understand that these were not patients that we were going to provide some service to and get paid for it. These were patients, you know, in those days. If if I want to refer a patient to a dermatologist and an HMO, this was in California. We had to get prior authorization. So that and that prior authorization burden is still pretty intense, and there are other administrative hassles as well. So I think for people who want to practice medicine and don't want to have to deal with that kind of thing, it's much easier to go with a bigger organization. Most commonly a hospital, but nowadays sometimes a health insurer or or Optum, which is owned by a health insurer, obviously by United or private equity firm. I think that so you know so two good reasons are trying to get paid a reasonable price for your services, having the negotiating levers to do that, dealing with the administrative load, and the third I think, which is well, there's a third. Electronic health records are overall, I would say, a good thing, but small practices are at real disadvantage at evaluating and purchasing and using them, and getting service from the provider of the EMR or EHR. So that's the third thing. And the fourth, I think, not talked about as much, but I think really important is that there's so much uncertainty in healthcare right now. Things are changing every year. It's unclear which direction various policies are going to do, and I think that it's very hard to track that when you're in a small practice or or prepare for changes that might happen. So I think there's a lot of seeking shelter from the storm. That's a fourth and a fifth. I'm probably giving you a longer answer than you want here, but it's actually interesting to me to talk about. The fifth is I think that people coming out of training now expect to have a reasonable life and and and not to you know to actually be there sometimes for their children's dinner and bedtime and things like that, and it's easier to have that if you work in a large organization than in a small practice, small independent practice.

Richard Payerchin 7:30
You know, doctor, and I was going to say any one of those factors we could probably spend the rest of the afternoon talking about, and maybe some different policies and solutions to address them. If I may, I want to shift gears slightly because, frankly, I'm just very curious about your work on MedPack. I made a long career as a community journalist before I joined medical economics, and when I did, I was frankly surprised at the scope and scale and the influence that Medicare has over the health healthcare system overall. As a Medpac commissioner, you advised Congress on Medicare payment policy. What are one or two changes about Medicare payment to, especially for primary care physicians, that you would believe that you believe would have the greatest effect on practice sustainability and patient outcomes?

Speaker 1 8:20
Well, first of all, I'm speaking for myself, not for Medpac, for for sure. I I I wouldn't want to try to speak for Medpac, and I also wouldn't be authorized to, even if I were still a commissioner. The meetings are public. The public can see what goes on at the Medpac meetings, which occur almost monthly, either by Zoom or or just recently we've resumed or they've resumed the ability to attend the meetings in person as well, I believe, and the transcripts of the meetings, which are quite long, and the slides that are presented to meetings are also publicly available after the meetings are over. The slides are available, yeah, after the means are over, so what do I think would help primary care? I don't think there's any single answer. I think that there are things that could be done to reduce the administrative burden. I think that higher payment rates for primary care physicians would help. The and Medicare can influence that because the the commercial rates are to some extent set off as multiples of of commercial payment rates by by health insurers. So that would help, but it's hard to see how that would ever happen, given that you know independent practice, unless they're very large, and there are very very few very large independent practices left, are not going to have much say over. They're going to they're going to talk to a health insurer. They're not going to talk to them. They're going to get a contract sent to them, and it's take it or leave it. Right. Unless you're a big group or aligned with a hospital or another larger organization, I think that those two things would help. But honestly, it's it's tough time for primary care physicians, family practice residencies. As I believe, didn't quite fill their positions this year, there's more respect, generally speaking, for specialists than primary care physicians. I never really understood that because to be a good primary care physician, you have to know a lot. You you don't you don't deal with the cardiac problem, and and have anybody think it's okay if if you don't do a good job with it, you can't say, "Oh, I'm not I'm not a cardiologist, therefore I screwed up. Too bad your father died. You can't do that. So I think it's a very hard job. I think if you're a specialist, particularly a subspecialist, it's not easy either. But you can know very well about a narrow range of things and do them very well, and I think you can go to work every day feeling pretty confident. I have to say that I went to work every day for 20 years, kind of nervous. Our practice was a little unusual in that we were in a relatively rural area, so we had people come in and have fractures, have people have respiratory arrest in the office. That was a little scary, but it's a hard job. And I think the good specialists, the specialists know who the good primary care physicians are because they see what has been done and not done for the patients who get referred to them. So I haven't. I realize I haven't given a very satisfactory answer. I will say that the rewards of having a longitudinal relationship over years are pretty great, and patients do appreciate it. That that that that have a physician like that. It's a little. This is oversimplifying, but it's a little bit like having a car and no mechanic. If something happens to your car and you go into a shop and they say, "Oh, you need a new transmission, you don't really need to know whether that's true or not, and you don't really know whether they're going to likely to do a good job or not. But if you have a decent primary care physician, you should be able to trust have trust when a person to whom the physician has referred you has said you need a coronary bypass surgery or or whatever.

Speaker 1 12:29
I think it's pretty reassuring to patients when you say you can say you know I know you're worried about this, but I'm going to refer you to Dr. Jones. I've known him for 15 years. He's a terrific cardiologist. He's not going to recommend anything that doesn't absolutely need to be done. And later today, I'm going to give him a call and tell him about you. And I think that's a good feeling for a patient. But nowadays, I think with the big organizations we have, that happens less and less and less, actually.

Keith A. Reynolds 13:03
Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60 seconds, we deliver proven, real-world tactics you can plug into your practice today. Whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch, but the best ideas don't all come from our newsroom. They come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to feature it. Shoot me an email at kreynolds@mjhlifesciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next P2 Management Minute. One

Richard Payerchin 13:55
of the things that that I was really fascinated about when I joined medical economics was, as a community journalist, frankly, I really was not aware of the level of research that goes into healthcare and science at large in our country. That's a reassuring point. Recently, you were the author of the article "Physicians, Corporatization, and the Unmeasured Quality of Care. That article was in the New England Journal of Medicine, and you had mentioned about a fundamental challenge that some of the most important dimensions of quality in medicine really can't be measured at scale. If those qualities are difficult to measure, maybe impossible to measure, how should patients, Physicians, payers, and policymakers account for those when they evaluate physician performance and payment.

Speaker 1 14:49
That's a hard question. I think that I just reviewed an article submitted to a medical. Journal that tries to deal with that question and probably doesn't succeed. And in my recommendations about the article, I'm not sure I have to the journal and the authors. I'm not sure that I have much to add. I think that I will say this. First of all, let me just digress for a minute. I want to take the opportunity to say a little bit more about Medpac, it was a tremendous experience, and what was tremendous about it was you had 16 commissioners or whatever it is, and a very hardworking staff who all have their own biases, come from different sectors of the industry, are there in part to represent that sector, but are expected to think about what's good for the country as a whole, not just their sector. And you know, in six years on the commission, I probably saw worked with probably about 20 or no, probably about 20 to 30 commissioners over that period of time, maybe more. And I would say, with the exception of to some extent, of only one or two out of all of those did I see someone who. Everyone tried really hard to put aside their biases, their own sectors' interests, and think about what's good for the country. And I really admire that, and I think Congress does too. Medpac has bipartisan respect. The staffers for the congressional staffers, when they want to know more about something or get some ideas for policy changes, they get in touch with Medpac staff very often, and this is Republicans and Democrats. So it was very moving experience, really, especially in this kind of divided times we have now, to see that people could get together and really make some progress about thinking what's what's best for the country, and you know Congress actually sometimes listens. Sometimes it takes Congress eight or nine years to listen, but quite a few of the things that Medpac puts out there do become law or influence what issues policymakers focus on.

Richard Payerchin 17:00
Regarding the article that had appeared in the New England Journal of Medicine, the article was titled "Physicians, Corporatization, and the Unmeasured Quality of Care, and you had mentioned about how some of the most important dimensions of quality in medicine really can't be measured at scale. One of those qualities, for example, was the physician's ability to make timely and accurate diagnoses. Again, one of the things that's really fascinating about medicine is how much study goes into it. You know, physicians and academics really want to try to measure almost everything for purposes of better management. It's not just you know busy work. But if those qualities are difficult or sometimes impossible to measure. How should those be accounted for when you evaluate physician performance and physician pay?

Speaker 1 17:48
Yeah, as I as I said, it is a really a large question. I mean, if if everything in this circle is what a physician does, probably about this much of it is is is measured, and maybe this much of it is measurable. Like I don't think at scale will ever be possible to measure the accuracy and timeliness of diagnosis, and that's if not the most important, certainly one of the most important things that physicians do. That's valued highly by patients and by other other physicians. But let me let me stick to the point of the article. The argument I try to make is that the fact that a lot of quality can't be measured is important, and and to have quality be to have care given at high in high quality for areas that aren't being measured and rewarded, we really rely on physicians, and not just physicians, but nurses and nurse practitioners and physicians. we rely on professionalism. In other words, trying to do the right thing for the patient, regardless of its implications for you, regardless of implications for what you're going to get paid for, regardless of whether it's going to make you miss your kid's soccer game because you know you're staying late to take care of the patient, and I I by no means want to argue that physicians are saints and that all physicians are highly professional and highly altruistic and will always put the patient's interests first, but actually we we refer to this in the in the paper briefly. We have published some research that shows that there's an experimental method that economists use to measure altruism, actually, which is kind of important for physicians. Put the patient first, right? And we found that by no means are all physicians very altruistic, but they are, on average, much more altruistic than the general population, and much more in these experiments, much more altruistic than elites, and much more much more altruistic much more altruistic than law students at a certain famous law school. So. So that was interesting. Then we did another paper where we tried to see: okay, do the more altruistic physicians get better outcomes for their patients, insofar as we could measure them? And we found that they actually do. So I think that. So I think the point of the article is that we don't want to. This is all hard to measure, but it's probably not a good idea to do things that are going to make physicians less altruistic, act less professionally, and there are many, many things that, in other words, the the extent to which a physician behaves professionally, say, probably depends, you know, on the physician's genes, their upbringing, their training, and the environment that they practice in, and the incentives that they face. And some of those things can be affected by policies. Some can't. But the purpose of this particular article was to to argue that as medicine is corporatized, and I guess by corporatized I mean both things getting mega in size, but also increased saliency of financial incentives. For example, if a private equity firm buys a practice, the goal of the private equity firm is to make as much money as it can, as quickly as it can, and hard to think that that won't impact the physicians who work for that firm or non-physicians as well. But it's the physicians who we really and the other clinicians who we really expect to act professionally. So I think the bottom line of that article was as as things get more corporatized, large organizations, especially organizations that have to publicly traded organizations, private equity companies that that have extreme pressure to to make good financial margins, good profits. I think the leaders of those organizations, no matter how benevolent they may be, and I'm not sure that many of them are, but they can't help but treat people who work in those organizations as as widgets, as interchangeable widgets. And I think physicians in big organizations do feel that to some extent, some more in in some organizations, more than others. So, if you're treated like a widget and you start to feel like a widget, you're probably going to act more like a widget unless you're really a saint. And widgets aren't going to do well, I would argue, in areas of of quality that aren't measured or measurable.

Speaker 1 22:35
Are we ever going to be able to prove that? Probably not. But I think that that is as a recommendation. I guess I would say that people who make policy for Medicare or Medicaid or you know government policies that affect care, but also people who run organizations that provide healthcare or involved in healthcare, they'll often make policies that aren't intended to increase corporatization. For example, that's not their purpose, but it's a side effect that probably could be foreseen. And I would just argue that what I call public and private policymakers, so public government policymakers and private, like health insurance executives or hospital CEOs, also make policies. I'd argue that any policy they want to make, they might think about: Is it going to make their physicians and staff feel more like widgets or less like widgets? And I would argue that that's really important. Will we ever ever be able to prove it? I'm not so sure we will, but actually, if we could, if we measured patient experience at scale, and and kind of did a before and after, I think that I would suspect that patient experience decreases as staff and physicians feel more like wages. There are high rates of physician burnout right now, as I think you know, and there's probably some relationship between what I'm calling widgetization and and and clinician burnout.

Richard Payerchin 24:11
I'm Richard Payerchin, reporting for medical economics. My guest today has been Dr. Lawrence Casalino, a professor of population health sciences at Weill Cornell Medical College.

Austin Littrell 24:34
Once again, that was a conversation between medical economics senior editor Richard Payerton and Dr. Lawrence Casalino, professor of Population Health Sciences at Weill Cornell Medicine. You can find a link to Dr. Casalino's New England Journal of Medicine essay in the show notes below. My name is Austin Latrell, and on behalf of the whole Medical Economics and Physicians Practice Teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing. Strategies, stories, and solutions for your practice. You can find us by searching "Off the Chart" wherever you get your podcasts. Also, if you'd like the best stories that medical economics and physicians practice, delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. "Off the Chart, a business medicine podcast, is executive produced by Chris Masolini and Keith Reynolds, and produced by Austin Latrell. Medical economics and physicians practice are both members of the MJH Life Sciences family. Thank you.

Transcribed by https://otter.ai