In a spring 2026 conversation with Medical Economics editors, Lawrence Casalino, M.D., Ph.D., M.P.H., laid out a concise argument: as medicine consolidates, health systems increasingly treat physicians as interchangeable units. Casalino said the consequences appear first in parts of care that standard quality programs do not measure — for example, the speed and accuracy of diagnosis, long-term patient trust built over years, and the nuanced judgment that directs patients to the right specialist.
Casalino is a professor of population health sciences at Weill Cornell Medicine and founding director of the Center for Physician Practice and Leadership, a center funded by The Physicians Foundation. He spent 20 years practicing primary care and six years serving on the Medicare Payment Advisory Commission (MedPAC). Those experiences frame his concerns about how structural and market pressures shape physician practice today.
Casalino identifies five distinct forces pushing clinicians away from independent practice and into larger organizations:
These forces interact, Casalino says, making it harder for small practices to survive and harder for independent clinicians to secure the systemic changes they say would help primary care.
During the interview, Casalino said two practical levers could improve primary care: reducing administrative burdens and increasing payment rates. He noted, however, that independent practices likely lack the leverage needed to win such changes from payers or policymakers. He explained this skepticism in light of market consolidation and the bargaining dynamics facing small practices.
Casalino’s description of what patients lose as consolidation proceeds included a concrete analogy: comparing a trusted physician referral to the way a car mechanic might recommend a specialty shop. When practices consolidate, that personal judgment can be lost or diluted, and the continuity that fosters trust can erode.
A central theme in Casalino’s recent New England Journal of Medicine essay — discussed on the podcast — is the gap between measurable quality metrics and the unmeasured dimensions of clinical performance. Standard quality programs can capture some process and outcome metrics at scale, but they do not measure many aspects of care that matter to patient outcomes and experience, such as:
Because these dimensions are hard to quantify at scale, they do not translate into financial incentives or measurable performance indicators. Casalino argues that when organizations prioritize what can be measured, the unmeasured but essential aspects of care rely increasingly on clinicians’ professionalism and altruism.
Casalino discussed his research finding that physicians are, on average, more altruistic than the general population. He warned that the corporatization of medical practice can undermine the professionalism that the health system depends on but does not always acknowledge. As organizations grow, they face incentives and operational constraints that can encourage standardized roles and processes — which, in turn, risk reducing clinicians to interchangeable contributors rather than recognized professionals with discretion.
To help policymakers evaluate proposed reforms, Casalino offered a simple test: would the policy make clinicians and staff feel more like widgets or less? He suggested that this experiential measure — how a policy affects the day-to-day sense of professional agency — should factor into policymaking discussions.
Casalino described his time on MedPAC, noting the commission’s bipartisan standing and the often slow pace at which Congress acts on MedPAC recommendations. He described the commission as a place that examines Medicare payment and delivery issues but emphasized that translating recommendations into legislative or regulatory change can take time.
The Medical Economics episode was hosted by Austin Littrell, with Richard Payerchin conducting much of the interview. The conversation included a short practice-management segment — the P2 Management Minute — in which Keith Reynolds offered practice tips and invited listener contributions. The episode was fact-checked by Keith A. Reynolds and Ron Panarotti, and the transcript and episode timestamps were produced using AI tools.
A full run-through of topics is available via episode timestamps, beginning with a cold open on what happens when physicians feel interchangeable, through discussions of Casalino’s path from community organizing to medicine, the five forces confronting independent practice, what could help primary care, and the New England Journal of Medicine essay’s ideas about measurement and professionalism. The conversation closes with a practical test for policymakers and final remarks.
Casalino’s analysis points toward two clear arenas for further attention: policy changes that reduce administrative burdens and payment reforms that better support primary care, and renewed attention to how large organizations structure roles and incentives so they do not erode unmeasured yet essential elements of care. He remains skeptical that independent practices, on their own, will regain sufficient leverage to secure major changes.
Listeners and readers interested in the full discussion can find the Medical Economics episode referenced here for the complete interview and timestamps. Related Medical Economics coverage includes recent episodes and articles on malpractice rates, physician-owned hospitals, prior authorization, and other practice management topics.
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