The interchangeable physician, with Lawrence Casalino, M.D.

Almost everything that makes a physician good at the job goes uncounted. The accuracy and timeliness of a diagnosis, the trust built over years with a patient, the judgment behind sending someone to exactly the right specialist. None of it can be measured at scale, so none of it is rewarded, and what fills the gap is professionalism.

Medical Economics Senior Editor Richard Payerchin sat down with Lawrence Casalino, M.D., Ph.D., M.P.H., 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.

Casalino practiced primary care for 20 years and spent six on the Medicare Payment Advisory Commission. He lays out five forces pushing physicians out of independent practice, from the take-it-or-leave-it contracts small practices are handed to an administrative burden that barely existed when he started seeing patients in 1980. He walks through what Medicare could realistically do for primary care and why he doubts independent practices will ever have the leverage to get it. And he explains the argument at the center of his recent New England Journal of Medicine essay: that large organizations cannot help but treat the people inside them as interchangeable, and that the damage shows up first in the parts of care no one is measuring.

This conversation was recorded in spring 2026. References to the current year reflect that timing.

Don’t miss our recent episodes on malpractice rates, physician-owned hospitals, vaccine stocking costs and prior authorization.

Music Credits:

Rooftops by Buurd - stock.adobe.com

A Textbook Example by Skip Peck - stock.adobe.com

Editor’s note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.

0:00 – 0:27 | Cold open. Casalino on what happens when physicians start to feel interchangeable.

0:27 – 1:41 | Introduction. Austin Littrell introduces the episode and the guest.

1:41 – 1:59 | From the United Farm Workers to medicine. Payerchin opens on Casalino’s years as a community organizer before medical school.

1:59 – 3:29 | Why he chose medicine. Wanting to help people directly and see the result, and why he still calls 20 years in practice an honor.

3:29 – 7:30 | Five forces squeezing independent practice. No negotiating leverage with payers, an administrative burden that barely existed in 1980, EHR purchasing and support, policy uncertainty, and what physicians coming out of training now expect from their lives.

7:30 – 12:29 | What would actually help primary care. Casalino on administrative relief and higher payment rates, and why he doubts independent practices will ever have the leverage to get them.

12:29 – 13:03 | The referral you can trust. A car mechanic analogy for what patients lose as practices consolidate.

13:03 – 13:55 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

13:55 – 14:49 | The measurement problem. Payerchin raises Casalino’s New England Journal of Medicine essay and the dimensions of quality that cannot be captured at scale.

14:49 – 17:00 | Inside MedPAC. Casalino on the commission’s bipartisan standing and how long it can take Congress to act on what it recommends.

17:00 – 17:48 | Timely and accurate diagnosis. How should unmeasurable quality factor into physician performance and pay?

17:48 – 22:35 | Professionalism, altruism and widgets. Casalino’s research finding physicians more altruistic on average than the general population, and what corporatization does to the professionalism the system quietly depends on.

22:35 – 24:11 | A test for policymakers. Will this policy make physicians and staff feel more like widgets, or less?

24:11 – End | Closing thoughts and outro. Payerchin thanks Casalino, and Littrell wraps the episode.