Do large health systems provide better care than small, independent practices? Is the corporatization of medicine resulting in better outcomes for patients?
These are the types of questions The Center for the Study of Physicians Practice and Leadership is looking to answer. Lawrence Casalino, MD, Ph.D., the center’s director, wants to gather the data necessary to show how changes in healthcare are affecting patient care and advocate for policies that help physicians do their jobs.
The center, a partnership from the non-profit advocates The Physicians Foundation and by clinical and research center Weill Cornell Medicine in New York, launched last month. Medical Economics spoke with Casalino to learn more about his goals and how the center can improve the practice of medicine.
Medical Economics: What are the goals for the center? Why is something like this needed?
Casalino: We are in a time of tremendous turmoil and change in healthcare as a whole, especially on delivery side, and for physicians in particular. The purpose of the center is to look at the forces affecting physicians, particularly how they affect the way physicians are organized—such as solo practice, multi-physician practices or practices that were once independent that have sold to a hospital. How are forces affecting the way physicians are organizing, and what are the results of this? How is it leading to physician burnout and what effect does it have on patient outcomes?
We are in a time where we’re moving to a corporate transformation of healthcare—for better or worse—where larger corporate entities appear to dominate. We are looking at this process, why it’s happening, and the advantages and disadvantages of small practices and ways they can survive.
ME: How will your background help the center reach its goals?
Casalino: I am unusual in the sense I was a full-time family physician for 20 years. I was in private practice for the first 15, then [that practice] was bought by a hospital. I have on-the-ground experience for what it’s like in the real world in private practice, but at the same time, I have quite a bit of academic training and 18 years as an academic researcher.
ME: How is the center’s research focus different than what other organizations are doing?
Casalino: We can move quickly to do different kinds of studies, and there are a lot of things we’re interested in and Medical Economics readers are interested in that are not necessarily things that get funded by normal sources. The center is an opportunity to do good work in a timely way. With the rate of healthcare change, timing is a critical component. We can quickly move into areas and begin studying things and not have to write grant proposal and wait for months.
One of the projects we are working on is looking at private equity investment in physician practices. There is a lot of it going on, and it is happening rapidly. We are trying to understand what’s happening and why, and the advantages and disadvantages compared to remaining independent or being acquired by a hospital.
Another project is looking at a collaboration between the American Hospital Association and the American Medical Association and a set of principles they came up with for joint, integrated leadership in hospitals. These are great principals, but are not widely known. We are looking at the extent people are aware of the principles and if they are being implemented. We are also looking at whether hospitals that have more physicians integrated into their leadership get better outcomes.
ME: How do you hope the center’s research changes the way medicine is practiced?
Casalino: I think that because research comes out, policymakers can change what they are doing. Our work does have an impact. Prior to my work at the center, I worked on documenting the administrative cost of physician and staff interacting with health plans and dealing with quality measures. The research was cited in congressional testimony.
Part of what we do is draw attention to problems and suggest policy solutions and suggest things physicians can do. One way or another, research can affect the way people think and can help them affect change. There are powerful forces moving toward the corporate transformation of medicine, and I’m wondering if 20 years from now if there will be any independent practices.
ME: What else should physicians know about the center?
Casalino: We are always happy to hear from people and the ideas they would like to see studied. The center is unique, and I have a real sympathy for small practices.
We are going to be objective in what we study, but I think the question is: What provides for better care? For something like a liver transplant, you are probably going to go to a big place with a good reputation. But if we are talking about day-to-day care—including chronic disease management—are you better in a corporate system that is large and has the ability to put standardized processes in place to help patients without physician involvement, or something that is smaller scale and where there is an intense personal relationship between the patient and the staff? Which gets the better outcome?
There is no question large entities score better on process measures of care and that’s what gets measured in standard programs. They always do better because they have industrial-type processes in place to make that happen. But are they better in diagnosis and things that don’t get measured that are important in what happens to patients?
Probably what is going to happen [is] the large corporate entities will score better on what gets measured and have more negotiating leverage and get more funding and will be able to drive the smaller practice out of business—but we’ll never know how they compare.
I think the policy world by and large believes that it’s a no brainer that large entities provide better care and would be happy to see more consolidation, and MACRA assumes everyone will be in something big. So that’s what most people believe, and I’m not sure they are wrong. But we would at least like to get data to make the comparisons to find out if that’s true. That’s one of the functions of the center.