‘The widgetization of care’ — physicians are not just a bunch of interchangeable parts

Measurements are crucial to health care at the micro level when doctors are at bedside with patients and at the macro level when considering policies and practices that can affect huge populations of people.

But not everything in health care can be measured, including some of the things that are most important to individual health and the health care economy.

Lawrence P. Casalino, M.D., Ph.D., M.P.H., is a 20-year primary care physician who has treated patients and analyzed health care policy at the highest level. He was founding director of the Center for Physician Practice and Leadership, funded by The Physicians Foundation at Weill Cornell Medical College. He served on the Medicare Payment Advisory Commission (MedPAC), the panel of physicians and economists who advise Congress on the federal health insurance program now worth more than $1 trillion.

This year he explored concepts of performance measurement, physician altruism, and the economic conditions working against them in U.S. health care.

“Culturally, extreme size and corporate ownership are leading to the widgetization of care,” he wrote in The New England Journal of Medicine. “It is difficult or impossible for a large organization, even one with well-intentioned leaders, to avoid treating its physicians and staff like interchangeable widgets whose behavior can be monitored and controlled to maximize profit.”

Casalino spoke with Medical Economics about the business of health care and his time as a MedPAC commissioner, speaking individually and not on behalf of the Commission, which makes its proceedings public. This transcript has been edited for length and clarity.

Medical Economics: You spent several years as a community organizer with the United Farm Workers before becoming a physician. What led you into medicine?

Lawrence P. Casalino, M.D., Ph.D., M.P.H.: I worked as an organizer with the farm workers and, this was during the Vietnam War, with other community groups. I would say that 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. It 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. In the 20 years I was in full-time practice, 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 a great opportunity to be able to do that, and I hope that physicians can try to keep that in mind.

Medical Economics: You've noted in the article about decreasing numbers of physicians in independent practice. Having worked as a primary care physician, what are some of those leading factors that have really led to that decline?

Lawrence P. Casalino, M.D., Ph.D., M.P.H.: This is a trend that's really been going on since I started in practice, really in the early 1980s, and has accelerated over time. There are very powerful reasons. First of all, if you're in an independent practice, unless it's huge and very prestigious, you have little or no negotiating leverage with health insurance plans and 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. Now the burden is really enormous, dealing with value-based purchasing programs 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, in those days if I want to refer a patient to dermatologist in an HMO, this was in California, we had to get prior authorization. That prior authorization burden is still pretty intense, and there are other administrative hassles as well. 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 hospital, but nowadays, sometimes the health insurer or Optum, which is owned by a health insurer, United (Healthcare) or private equity firm. I think that so two good reasons are trying to get paid a reasonable price for your services, having the negotiating leverage to do that, dealing with the administrative load.

And the third, electronic health records are overall I would say a good thing, but small practices are a 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, not talked about as much but I think really important, is that there's so much uncertainty in health care right now. Things are changing every year. It's unclear which direction various policies are going and I think that it's very hard to track that when you're in a small practice or prepare for changes might happen. So I think there's a lot of seeking shelter from the storm.

Fifth is, I think that people coming out of training now expect to have a reasonable life, and 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 independent practice.

Medical Economics: 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 believe, would have the greatest effect on practice sustainability and patient outcomes?

Lawrence P. Casalino, M.D., Ph.D., M.P.H.: What do I think would help primary care? I don't think there's any single answer. There are things that could be done to reduce the administrative burden. Higher payment rates for primary care physicians would help the and Medicare can influence that, because the commercial rates are, to some extent set off as multiples of commercial payment rates by health insurers. So that would help, but it's hard to see how that would ever happen, given that 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. 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 the hospital or another larger organization.

Those two things would help, but honestly, 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 and primary care physicians. I never really understood that because to be a good primary care physician, you have to know a lot. You don't deal with the cardiac problem and have anybody think it's OK 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. It's a very hard job. If you're a specialist, particularly a subspecialist, it's not easy either, but you can know very well about this narrow range of things and do them very well. 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 arrests in the office. That was a little scary, but it's a hard job and 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.

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 have a physician like that. 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 be likely to a good job or not. But if you have a decent primary care physician, you should have trust when the person to whom the physician has referred you has said, you need a coronary bypass surgery or whatever. I think it's pretty reassuring to patients when you say, 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. 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.

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 hard-working 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. In six years on the commission, I saw probably about 20 to 30 commissioners over that period of time, maybe more. And I would say, with the exception of only one or two out of all of those, everyone tried really hard to put aside their biases, their own sectors’ interests, and think about what's good for the country. I really admire that. And I think Congress does too. MedPAC has bipartisan respect. 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, especially in this kind of divided times we have now, to see that people could get together and really make some progress about thinking about 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 policy makers focus on.

Medical Economics: Recently, you were the author of the article, “Physicians, Corporatization, and the Unmeasured Quality of Care,” in The New England Journal of Medicine. You 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?

Lawrence P. Casalino, M.D., Ph.D., M.P.H.: It is really a large question. 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 to have care given at a 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 physician assistants, 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're staying late to take care of the patient.

And I by no means want to argue that physicians are saints and that all physicians are highly professional and highly altruistic and always put the patient's interest first. But actually, we refer to this 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 in these experiments, much more altruistic than elites, and much more altruistic, much more altruistic than law students at a certain famous law school. So that was interesting. Then we did another paper, we tried to see, OK, do the more altruistic physicians get better outcomes for their patients? And insofar as we could measure them, we found that they actually do. The point of the article is that 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. In other words, the extent to which a physician behaves professionally probably depends on the physician's genes, their upbringing, their training, and the environment that they practice in, and the incentives that they face. Some of those things can be affected by policies. Some can't. But the purpose of this particular article was to argue that as medicine is corporatized, and 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 to the private equity firm is to make as much money as it can, as quickly as we can. Hard to think that that won't impact the physicians who work for that firm, or nonphysicians 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 things get more corporatized, large organizations, especially publicly traded organizations, private equity companies that that have extreme pressure 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 widgets, as interchangeable widgets. And I think physicians in big organizations do feel that to some extent, in some organizations more than others. 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 quality that aren't measured or measurable. Are we ever going to be able to prove that? Probably not.

As a recommendation, I would say that people who make policy for Medicare or Medicaid or government policies that affect care, but also people who run organizations that provide health care, or are involved in health care, 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 a foreseen. And I would just argue that what I call public and private policy makers, so, public government policy makers 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 be able to prove it? I'm not so sure we will. But actually if we measured patient experience at scale, and kind of did it before and after, I would suspect that patient experience decreases as staff and physicians feel more like widgets. There are high rates of physician burnout right now and there's probably some relationship between what I'm calling widgetization and clinician burnout.