From the Intimate to the System Wide, From Micro to Macro

    • March 24, 2010

The Problem: Any successful reform of the existing health care system must actively engage physicians, but under the current system, in which policies are set by government, insurers and large health organizations, front-line physicians—most of whom operate in group practices of fewer than 10 members—have little power to effect change. What policy changes might be required if physicians are to take a more active role in improving quality and reining in costs?

Grantee Background: Larry Casalino, MD, PhD, has followed an indirect but beautifully timed career trajectory since graduating from Boston College with a degree in philosophy in 1970. Right out of school, at the height of the anti-war movement, he signed on with the American Friends Service Committee as an organizer and editor, then headed west to organize for the United Farm Workers in the Bay Area, formative experiences that "made me want to have a skill that would directly—right in front of my eyes—help people, and that would involve manual as well as intellectual skill, including actually touching people."

Though he had never given medicine a thought previously, he began taking pre-med courses at the University of California, Berkeley and went on to get his medical degree from University of California, San Francisco. By 1980, he was a primary care physician in a two-physician practice in Half Moon Bay, 25 miles south of San Francisco. Over the next two decades, he would help expand the practice to nine physicians while receiving an invaluable postgraduate education in medical realities.

"Our practice was pretty much the only one in town," says the Jersey City native, "so there would be everyone in the waiting room from chief executives of Silicon Valley firms to illegal alien farm workers to fishermen. We had a real socioeconomic mix—more, I think, than most practices."

For the first 10 years, Casalino worked the 65-hour-a-week schedule typical of a family doctor and loved it. "There's nothing like it. It's one of the best experiences a person can have—completely different from being an academic, doing research, writing, giving talks. You're directly helping a person who's right in front of you: You put your hands on them, you know them for years, and you get to know them really well—people you would never get to know well in the normal course of life. And you form really tight relationships...very strong bonds, often with multiple generations of the same family. There's nothing to replace that."

But the view from the examining room also gave Casalino an up-close look at the limits and contradictions of American health care, pushing him toward a career shift that would equip him to analyze and help redefine it.

"It was clear to me that there were systemic problems that you couldn't solve one patient at a time," he says, and in 1991, he cut his practice back to 45 hours a week and enrolled once again at Berkeley, this time for a master's degree in public health. A year later, he began work on a PhD in Health Services Research, working with such mentors as health economist James C. Robinson, PhD, now director of Berkeley's Center for Health and Technology, and sociologist Stephen Shortell, PhD, currently dean of the university's School of Public Health. His focus was "organizational sociology," a term that barely hints at the broad but intersecting lines of inquiry he has pursued since.

"When Jamie [Robinson] and I first started studying physician practice in the 1990s," Casalino recalls, "it was pretty unusual. Now there are more people doing it, but it's still not what most people do. One reason is, you still have to go and get the data; there's not a lot of it sitting around."

The Investigator Award: Casalino had yet to land his first post-doc position, as assistant professor in the department of health studies at the University of Chicago, when he decided to apply for an RWJF Investigator Award in Health Policy Research, with the idea of helping create that missing database. His research goals were ambitious but grounded in clinical experience: "To help reframe public and private policy agendas to include consideration of the importance of physician organizations as units of analysis for quality measurement and for competition, and as essential structures for improving quality and controlling costs... to show how key public and private policies affect the organization of physician practice...[and] cooperate with the Community Tracking Study and the National Survey of Physician Organizations and the Care of Chronic Disease (NSPO) to introduce these issues."

To his surprise, he got the grant award. Within the year, he would be the senior academic on the Community Tracking Study research team studying physicians and hospitals as well as one of the principal architects of the NSPO. "Most people who get this grant have careers that are already pretty well established, and it helps them move further along. I was not in the prominent category. It wouldn't be a stretch to say that almost every article I've done since comes, if not directly, then indirectly from that grant. And I really think I would be in a completely different position if I hadn't received it. It was absolutely critical to my career."

Grantee Perspective: Casalino's research has ranged over a wide swath of medical practice at what might be called the "retail level"—burrowing in on structural and process issues within physician practice to identify ways to improve quality of care and, along the way, building a pointillist portrait of a system badly in need of a makeover. Over the last decade, his studies have analyzed the importance of external incentives and information in improving quality of care for patients with chronic disease; explored the potential of pay-for-performance systems to increase or decrease health care disparities; and looked at how physicians and HMOs are regularly rewarded for their skill in leveraging markets and controlling costs but rarely for quality and efficiency of care.

One recent study—which received widespread media attention when it appeared in the June 22, 2009, Archives of Internal Medicine—looked at physician processes for informing patients of abnormal test results and found that failure to inform or to document abnormal results was both fairly common (7.1% of the sample, but as high as 26% in one large medical center practice) and easily corrected when simple processes were in place. The lowest failure rates were found in practices that had switched from paper to electronic records; the worst were in practices or institutions that used both paper and electronic documents—a possibility that Casalino and his co-researchers had anticipated based on earlier studies.

"Adding an EMR (electronic medical record) to a poorly organized system may make things worse. For example, in a paper-based practice that uses poor processes there may nevertheless be a good chance that a test result will eventually show up on a physician's desk, but in a poorly organized EMR-based practice, the physician may never realize that the result has been received."

Another study on a significant and hotly debated issue—the amount of time clinicians spend interacting with medical plans and insurance—hit close to home. When the opportunity for the study came up, says Casalino, "I was trying to decide whether to do it or not, and I was thinking I wouldn't because it would be really difficult to do well. I mentioned it to my wife, and she said, 'The hell you're not going to do it. For 20 years I listened to you, you'd call me up from your office to complain, and now you have the chance to do something about it? You're damn well going to do it.'"

The report, which appeared in the May 14, 2009, issue of Health Affairs, found that, on average, physicians spend a full three and a half weeks—one-twelfth of a year—dealing administratively with health plans, while their nursing and clerical staffs spend even more time, at an estimated cost of $23 to $31 billion. "That's a lot," said the family doctor.

RWJF Perspective: "One of the important criteria for selecting investigators is the likelihood that their work will inform health policy," says Lori Melichar, PhD, RWJF director. "Equally important to being selected is the promise of the investigator's proposal to rejuvenate the field of health policy research by asking innovative questions, applying innovative frameworks and using innovative methods."

Bibliography

Articles Arrow K, Auerbach A, Bertko J, Brownlee S, Casalino LP, et al. "Toward a 21st Century Health Care System: Recommendations for Health Care Reform." Annals of Internal Medicine, 150(7): 2009.

Casalino LP. "The Federal Trade Commission, Clinical Integration, and the Organization of Physician Practice." Journal of Health Politics, Policy and Law, 31(3): 569–585, 2006.

Casalino L. "Disease Management and the Organization of Physician Practice." Journal of the American Medical Association, 293(4): 485–488, 2005.

Casalino LP. "Physicians and Corporations: A Corporate Transformation of American Medicine?" Journal of Health Politics, Policy and Law, 29(4–5): 869–883, 2004.

Casalino LP. "Unfamiliar Tasks, Contested Jurisdictions: The Changing Organization Field of Medical Practice in the U.S." Journal of Health and Social Behavior, 45(Suppl.): 59–75, 2004.

Casalino LP, Devers KJ and Brewster LR. "Focused Factories? Physician-Owned Specialty Facilities." Health Affairs, 22(6): 56–67, 2003.

Casalino LP, Devers KJ, Lake TK, et al. "Benefits of and Barriers to Large Medical Group Practice in the U.S." Archives of Internal Medicine, 163(16): 1958–1964, 2003.

Casalino LP, Gillies RR, Shortell SM, et al. "External Incentives, Information Technology, and Organized Processes to Improve Health Care Quality for Patients with Chronic Diseases." Journal of the American Medical Association, 289(4): 434–441, 2003.

Casalino L. "Markets and Medicine: Barriers to Creating a Business Case for Quality." Perspectives in Biology and Medicine, 46(1): 38–51, 2002.

Casalino L. "Canaries in a Coal Mine: California Physician Groups and Competition." Health Affairs, 20(4): 97–108, 2001.

Casalino L. "Managing Uncertainty: Intermediate Organizations as Triple Agents." Journal of Health Politics, Policy and Law, 26(5): 1055–1068, 2001.

Book Chapters Casalino L. "Managing Uncertainty: Intermediate Organizations as Triple Agents." In Uncertain Times: Kenneth Arrow and the Changing Economics of Health Care, Hammer PJ, Haas-Wilson D, Peterson MA, Sage WM (eds). Durham, NC: Duke University Press, 2003.

Casalino L, "Managing Uncertainty: Intermediate Organizations as Triple Agents." In Organization Behavior and Change: Managing Human Resources for Organizational Effectiveness, Head T, Sorenson P, Baum B Yaeger T and Cooperrider D (eds). Champaign, IL: Stipes Publishing LLC, 2002.