Every one of us learned the same lesson early: You cannot treat what you have not examined, and you cannot examine well without first taking a history. We diagnose and plan treatment from the history, the signs, and the symptoms. Skip the history and you are guessing.
I believe the same is true of the system we practice in. Learning the history of our economics is as important as learning the history of a patient. Right now, too many of us are treating the symptoms without it.
The symptoms
You know them. A contract notice. A practice sold out from under its partners. Management services organization structures built to route around corporate practice of medicine laws. Acquisitions small enough to slip under the reporting thresholds that would trigger regulatory review. Roll-up after roll-up in gastroenterology, dermatology, anesthesia, radiology, and emergency medicine, until a specialty wakes up and finds that a few companies own most of it.
The diagnosis
The diagnosis is an idea: that health care is a commodity, that consolidation equals efficiency, and that a spreadsheet in a private equity office two states away can make better decisions about a patient than the physician at the bedside.
Real physician voices, twice a week
Free, and one click to unsubscribe.
That idea has a name: neoliberalism, applied to medicine. It has succeeded not because it is true, but because almost no one says its name out loud in a room full of doctors. This is not a conspiracy. It is arithmetic, running unchecked for a very long time.
Almost none of us were taught this. Medical school gave us pathophysiology and pharmacology, not political economy. No one walked us through how medicine came to be organized the way it is, who decided, and who profits. So when the symptoms appeared, we reached for the usual explanations: bad luck, a bad administrator, a bad contract. We treated each case as isolated, when the history says it is one disease.
My history
For years, I thought this was somebody else’s problem: a hospital problem, a policy problem, something happening near medicine rather than to it. I am a board-certified cardiac anesthesiologist. I led Midwest Anesthesia Partners, LLC, as both a practicing clinician and its president. For thirty years, our group had kept patients safe in the operating rooms of the hospital that would terminate us.
In August 2021, we were blindsided twice in two weeks. One of the takeovers was led by a board member of my own national society, who also served as national medical director of a private equity-backed staffing company. Twenty of our members stood in solidarity and walked out. Thirty years of loyalty did not matter. Quality of care did not matter. The hospital had been granting us monthly contract extensions, stalling negotiations until it decided to terminate us.
I remember reading the notice and thinking that I had trained for a decade to care for patients, and none of it mattered.
Then the hospital made a critical error. The new entity was not contracted to begin until October, which left September with no coverage at all. Surgeries were transferred to surrounding hospitals. The hospital temporarily lost its trauma designation. The community was in an uproar. Many of our members stayed with our organization at other sites, and some left for jobs closer to home. The surgical program was disrupted for years.
Nothing was merged. No regulator was asked a single question. We were simply replaced, and the terms were never shown to the clinicians who lost.
In January 2022, I spoke up at a town hall meeting at that same national society’s conference. The society chose to remain agnostic. That November, we launched the Association for Independent Medicine (AIM) to support, educate, and advocate for independent physicians. I suspect nearly every one of us has a version of that August: the day the abstraction became a letter with our name on it.
What we can do
I am writing this fresh off AIM’s first Independent Physician Summit in Chicago, a successful conference that sent physicians home with tools for advocacy and practice management to stay independent. Health policy experts laid out the strategies used to strengthen corporate practice of medicine legislation. Physicians and practice managers spoke to the financial awareness an independent practice needs to improve its standing. The history explains the problem. Those tools are how we treat it.
This is not a fight between independent and employed physicians. Whatever your practice model, the same idea is shaping your schedule, your autonomy, and your patients’ care. So we move, and we move together, because the only thing that has ever counterbalanced consolidated capital is consolidated conviction.
Learn the history. Know who owns your group and who sits across the table at your next contract renewal. Tell patients, neighbors, and legislators what consolidation has done to care: the waits, the churn, and the decisions made by people who have never met the patient. It lands because it is true and because we have nothing to sell. Few messengers are trusted more than a doctor, and the corporate practice of medicine doctrine will be strengthened or hollowed out in statehouses, in bills like Illinois HB 5000 and Oregon SB 951. Advocacy is not something we do in addition to practicing medicine. This year, it is practicing medicine.
Why I believe it can be done
My confidence comes partly from a health policy scholar. Dr. John McDonough, a professor at the Harvard T.H. Chan School of Public Health, served in the Massachusetts legislature and worked on the Affordable Care Act. His new book, America’s Wrong Turn: US Health Care in the Neoliberal Era, dates the break to 1980, when American health care stopped resembling that of its peers and became a category of its own.
His book is, in effect, a history and physical for the American health system. What I take from it is not despair. If the system we live in is the product of choices made in a particular era by particular people, then it can be chosen differently. He does not stop at diagnosis. He calls for radical action: stronger antitrust enforcement, tougher regulation of drug pricing, and a health system reoriented around patient care, equity, and affordability. That is a treatment plan, and treatment plans can be organized for.
These fights are winnable. Let’s go win them.
Marco Fernandez is a cardiac anesthesiologist.
