January 16, 2026
Dear Interested Readers,
Thinking About Today From the Perspective of The Past
Throughout my years as a clinician and later as CEO, our practice offered convenient urgent care during regular business hours as well as evenings and weekends. We tried to keep a few appointment slots open on our clinicians’ schedules because we felt it was preferable for our PCPs to add same-day appointments if possible. We maintained a telephone advice line, manned by mid-level clinicians with on-call physician backup overnight, after our regional urgent care facilities closed.
I always felt that seeing a clinician who knows you, or someone on your care team, is better than seeing someone who doesn’t have any information about you. Staying “within the system” also minimizes delays in follow-up care and the loss of records and lab results that might not get back to your PCP from outside sources. Another motivating reason for a robust “urgent care” option within our practice was to protect patients from long waits at the hospital ER, unnecessary testing, and the higher expenses associated with uncovered care and co-pays resulting from what was often unnecessary emergency room utilization. For routine urgent care, we were more efficient, less expensive, and offered greater continuity of care for most patients.
In full disclosure, we realized savings on our capitated patients when unneeded ER visits were avoided, since we usually paid the bill for their emergency care. For our fee-for-service patients, the financial advantage went both ways. We were able to collect for the visit, associated lab tests, and radiology fees since we provided those services “in-house.” We also had less risk of “losing” the patient and the income from future care to hospital-based practices. Our fee-for-service patients benefited from coming to our urgent care facilities because the charges they might be responsible for paying out of pocket for the same care they might get in the ER were considerably lower, and because we “knew them,” duplicate, wasteful, unnecessary testing and procedures were less likely to occur.
For many years, we rented space adjacent to the Brigham’s ER to provide emergency care for our patients who opted not to come to urgent care at our ambulatory sites but preferred, or really needed, more traditional ER care. Focusing on where care was delivered was advantageous to us and for our patients. To manage most acute problems that were not life-threatening trauma or true medical emergencies in our offices or in our urgent care, rather than in an emergency room, was a win-win, good for us and good for our patients.
In the early years of our practice, if our patient went to the ER, one of our physicians would most often meet them there. I was flabbergasted when, while I was working in the ER as a Peter Bent Brigham intern in 1971, a Harvard Community Health Plan doctor, Dr. Sigrid Tishler, an oncologist and PCP, joined me late at night at the bedside in the ER of a woman with cancer and obvious sepsis. I had never seen the physician of any other “private patient” show up to see their patient in the ER, even during daylight hours.
It’s been a dozen years since I retired, and things have changed. The most significant change is that, as an early victim of the financial difficulties precipitated by COVID, Atrius Health is no longer an independent non-profit medical practice. It has been sold to Optum, the physician practice arm of UnitedHealthcare. The sale was a depressing event for me, since it seemed there were many other possible options that would have been more consistent with our history, mission, and culture.
I would have preferred our practice to follow the example of Group Health Cooperative of Puget Sound, a like-minded practice focused on quality and patient experience, when, for financial reasons, it joined Kaiser, with which both Atrius and Group Health shared strong cultural similarities. I had been gone for over seven years by then, and no one asked me for advice. Like everyone else, I was shocked to see the practice had been sold to Optum. To this day, all I know is what I read in the news after the deal was done.
Some of the work done by our able and committed staff, using the Lean management philosophy, during my years as a clinician and corporate leader, has survived the transfer of ownership to Optum. I can contact the pharmacy for a refill, and within less than a minute, my order is taken. I usually receive the medicine in my mailbox within 24 to 48 hours, even though I live more than 100 miles away. Telehealth is now a robust option for appropriate care. I usually get responses to my questions and requests on MyHealth, Atrius’s version of Epic’s MyChart, within a few hours. My Atrius medical record, appointments, and lab results, as well as all my appointments, past visits, communications with providers, and lab results, are presented together on the MyChart App intermixed with my Dartmouth Health visits, procedures, and labs. Dartmouth Health calls Epic’s MyChart app MyDartmouth.
When I show up for my appointments at Atrius, the service is efficient. I rarely wait. The lab turnarounds are faster than in many hospital systems. On most of my visits, a few old friends recognize me as I sit in a waiting room or check in for my appointments. When I see some of the current employees who were on the staff during my thirty-eight years in the practice, they tell me that they fondly remember our days together. Occasionally, an old employee will whisper to me that things feel different, as have a few old friends who stayed with Atrius for their care since the practice was acquired by Optum.
My care is now split between Atrius and Dartmouth. I travel south to see the NP who practices with my PCP, who quickly answers my questions on MyHealth because she practices remotely from Western Massachusetts. I can’t “see her on a video visit” because you can’t do telehealth across state lines. For a video visit, I would need to drive south 75 miles to a location below the New Hampshire-Massachusetts border. Even though our contact is secondary through an NP or indirect via a MyHealth message, I feel that she understands the scope of my medical issues and, as an added benefit, knows Dartmouth and some of the specialists I see, since she did her training there.
I also drive 200 miles round-trip to see my dermatologist and neurologist at Atrius. I see my cardiologist, hand surgeon, knee surgeon, back surgeon, urologist, eye surgeon, and podiatrist at Dartmouth Health, where I also get PT following surgical interventions. It takes less time for me to drive thirty miles up the Interstate to Dartmouth than I once spent driving from my home in Wellesley to our Kenmore Center in Boston’s famous Longwood Medical Area.
I discovered some changes at Atrius when I called this week to schedule my annual health review and the renewal of my medications with the nurse practitioner who teams with my PCP. I was a little surprised when the “phone tree” did not offer me the option of going directly to the appointments secretary in Internal Medicine. As I was advised that there would be a short wait before the next available operator would take my call, “in the order received,” I was thinking that perhaps I should have booked online, but I was committed to completing my task, even if it took some time. I also declined the offer to leave my number so someone could call me later.
As I waited on the phone, I was presented with a steady stream of reminders about important immunizations. That was OK, but then came the surprise. I was advised that if I needed to be seen soon, I should hang up and go to a walk-in clinic. The computer voice on the line gave me the names of a couple of clinics that it thought were near me. My guess is that AI was reading the area code on my cell phone, which is consistent with the northern and western suburbs of metropolitan Boston so I didn’t get advice to go to one of the dozens of urgent care facilities that have popped up along the Interstate highways in Southern New Hampshire, or the new one associated with the New London Hospital and Dartmouth. I have had the same cellphone number for at least twenty years.
Telling an Atrius patient to go to a walk-in urgent care clinic surprised me. I wondered, “Does Optum own the clinic it wants me to visit? Will the record of any care I might receive at a walk-in clinic be shared with my PCP or recorded in my medical record? Is access so compromised that Optum has given up trying to maintain practice integrity? Have there been so many complaints about urgent or even routine access that it is a good business move to give up continuity of care to patient demands for same-day access? Is this what is happening everywhere as the cost of maintaining practices becomes prohibitive, primary care declines, and the workforce shrinks? If this is happening in Massachusetts, which, along with New Hampshire and Vermont, is one of the top three healthiest states in 2025, what is happening in Mississippi, Louisiana, and Arkansas, the three least healthy states in 2025, as judged by a recent article in Medical Economics?
Without too much delay, but while these thoughts were running through my head, a voice came on the line and asked me where I wanted my call directed. I was quickly connected to my primary care team’s appointment coordinator and offered an appointment in late February, which was just fine with me because I had no urgent need and had expected a delay. I did kick myself for delaying my call because with a little more foresight, I could have gotten my physical on the same day as my next derm visit, which I scheduled six months ago at my last semiannual harvesting of the basal cell and squamous cell sequellae of a youth spent in the southern sun with no shirt or sunscreen, plus years of running without sunscreen.
After pondering what might be happening to business at Atrius that led them to suggest to callers that they go elsewhere for an urgent need, I remembered seeing an article about the “corporatization of ambulatory care” in the January 1, 2026, edition of the New England Journal of Medicine. The title had been a turnoff for me, and I feared that I had already bored you, dear reader, with my references to the earlier articles in the series entitled “The Corporatization of U.S. Health Care,” which the Journal had been running every few weeks for the last several months. The article was now interesting to me in the aftermath of what I had learned during my time waiting for my call to go through to its destination.
“From Patients to Consumers — The Corporatization of Ambulatory Care” was the lead article on page one of the January 1, 2026, edition of the NEJM. The author of the article is Ambar La Forgia, Ph.D. Dr. La Forgia is an assistant professor in the Management of Organizations group at the University of California, Berkeley, Haas School of Business. There is also a link to a 10-minute interview with her where you can hear her answer questions from one of the NEJM editors that cover most of what she wrote. She begins:
The core principles of retail business — convenience, customer service, and efficiency — are becoming increasingly pervasive in U.S. health care. The retail model is especially evident in ambulatory care…in settings ranging from walk-in retail clinics to specialized, office-based medical practices. Attracted, in part, by profitable outpatient services and consumer demand for convenient care, a diverse set of corporate entities — including retail chains such as CVS, big tech companies such as Amazon, and financial investors such as private equity (PE) firms — have expanded into U.S. ambulatory care… these developments have also led to concerns about the prioritization of profits over patient well-being and the exacerbation of inequities in access to and cost of care.
I bolded that last sentence because I am biased toward the view that prioritizing corporate profits over patients’ primary interests is a road we are on that I believe will lead to a destination that compromises everyone’s care. Is “corporatization” the explanation for the recent observations I made in my own care at Atrius after it was purchased by a for-profit corporate giant?
The article is broader than the corporatization of the ambulatory primary care. The author addresses questions about the corporatization of ambulatory surgery, fertility care, cosmetic dermatology, eye care/cataracts, and physical therapy. You may imagine that walk-in clinics save money or reduce emergency room utilization. They don’t because it seems patients are more inclined to go to a clinic for self-limiting problems or to demand treatment for viral illnesses that a traditional medical practice would not feel compelled to satisfy, when medical issues and wisdom could be explained by a trusted provider.
I was surprised to learn that there was one exception. The corporatization of fertility care has led to measurable improvements in “live births” even when socioeconomic factors are included in the analysis. IVF is expensive, requires establishing best practices to achieve the obvious result of a baby, and those paying out of pocket for services not covered by many policies and not mandated are wise consumers who do research to find quality providers. In the management of infertility, patient needs and corporate profits align to improve outcomes.
She points out that since the early 2000s, when retail clinics first appeared in big-box stores and CVS pharmacies, the sites have popped up by the thousands, mostly in metropolitan areas. Now, many hospitals and health systems, like my local hospital, are developing these services on demand as alternatives to emergency room utilization. Dr. Forgia writes:
Most freestanding urgent care centers are owned by hospitals or health systems, but a growing share are backed by PE firms (e.g., ConvenientMD and GoHealth Urgent Care) or owned by insurers (e.g., Optum’s urgent care network). Collectively, there were more than 200 million visits to these facilities in 2022, a number that surpasses the annual visit volume for EDs. …there is some evidence that use of urgent care centers can reduce ED visits, especially for minor conditions and among Medicaid beneficiaries or uninsured patients, but the cost of new utilization of urgent care probably outweighs any ED-associated savings. The convenience of urgent care centers could also encourage unnecessary or harmful care…clinicians may feel pressure to satisfy patients in order to receive high ratings on online platforms.
Aha! I bolded the comment about Optum because it may be that the explanation for the new directive to go to a walk-in clinic that I heard while waiting on hold was based on the likelihood that the revenue lost from the traditional care path at Atrius, now owned by Optum, would still end up with Optum. Who knows? Is this a response to patient dissatisfaction with access? Certainly, access is the explanation for another trend toward corporatization — concierge practices, which she also discusses —often ascribed to issues of access and clinician burnout.
Whereas retail clinics and urgent care centers tout on-demand access for everyone, concierge medical practices market exclusivity…Most traditional concierge practices cater to wealthy patients, with high fees and low patient-to-doctor ratios…Traditional concierge models, in particular, could benefit patients by allowing physicians to provide more individualized, attentive care.
As you may remember from previous comments I have made, I view the trend toward concierge practice negatively. She shares some of my concerns. I have bolded important points:
These models have important implications for equity, however, and could exacerbate shortages of primary care physicians. Every time a doctor shifts to a smaller concierge panel, there is one fewer doctor available to the general pool of patients. Questions have also been raised about the broader value of concierge care. A recent study of primary care practices that converted to a concierge model found that patients who opted in to concierge care had higher incomes but weren’t any healthier than those who did not, and that after the conversion to concierge care, health care spending increased, but there was no change in mortality among patients.
She continues with the positive possibility that if it weren’t for the option of concierge practice, some burned-out docs would just retire and be available to no one, a point with some possible merit that is hard to measure. She has much more to say, and I urge you to listen to the interview or read her paper. It is a quick read of about 1500 words, used economically to draw our attention to yet another area of much uncertainty about the future of healthcare.
Uncertainty is the constant companion of anyone who attempts to provide care. I was fortunate to have spent most of my practice years at a time when most of the uncertainty was about the clinical problem. Now the uncertainty is as much about the future of our system of care and how to reverse what is clearly a time of decline, and return to a time when the focus was not so much on making a profit as on improving the lives of patients and advancing the boundaries of medical science.
Unfortunately, my concerns begin with the future of healthcare and the preservation of our democracy, but in ways we often overlook, the quality of many American lives and the opportunity for a majority of Americans to pursue “life, liberty, and happiness” has declined to third-world levels, ironically for many who mistakenly voted for the current administration. You might be shocked by what you learn if you read Nicholas Kristof’s opinion piece in Thursday’s New York Times. It was entitled “Life, Liberty, and the Pursuit of Unhappiness.” Our quality of life and happiness are down, and the decline has been going on so long that many may intellectually deny it, but know it in their gut. He writes:
A careful study released Wednesday and based on a measure called the Social Progress Index suggests that in terms of quality of life, the United States ranks 32nd out of 171 countries, behind Poland, Lithuania and Cyprus.
More alarming, the United States has fallen steadily in the rankings over the years, under Republican and Democratic presidents alike — and now seems poised to fall further because of cuts in health care and other services by President Trump.
Kristof goes on to detail all the damage Trump has done and continues to do to our healthcare, then reports on the opinion of another expert who says Trump is not the cause of the problem, which has been evolving since the seventies, but rather the result of our decline. Perhaps that is the point behind the empty promise to “Make America Great Again” in all the wrong ways. He writes:
Liberals may be tempted to focus on Trump’s shortcomings. But there is something larger going on here as well: Since about 1970, the United States has been lagging peer countries in some quality-of-life measures.
“It’s not about Trump,” Green said. “Obama and Biden did little to reverse the decline, nor did the Bushes or Clinton. It’s a multipresident, bipartisan, long, slow car crash. Yet voters seem to have been anesthetized by a rising stock market and economic growth, until in recent years it’s become clear to people that their living standards have stagnated — and that’s why they’ve turned to the populist promise of MAGA and Trump.”
He added, “We have to think about Trump as the consequence rather than the cause of America’s progress decline.”
From my own experience, I can attest to the truth of the observation and can also attest to our decline in happiness and progress on social issues over the last fifty years. Maybe you also recognize its truth. As we approach next Monday’s holiday celebrating the life of Dr. King, I am reminded that he had a prescient view of what might happen in our society if we failed to effectively address poverty and inequality. Did he have the Cassandra Curse, the ability to see the future, but have no one except your vision?
King asks a big question in the title of his last book, Where Do We Go from Here: Chaos or Community? Given that we can look back on the past year under Donald Trump as chaotic, I guess the question now is: how do we move away from chaos and back toward community? Any experienced clinician knows that most serious medical problems occur over long periods of time. There is a U-shaped description of disease development and recovery. It often takes a long time to resolve problems that have developed over a long time.
Instant solutions don’t usually address the “root causes” of chronic health problems or chronic social problems. It is time to begin to turn around both healthcare and our chronic social problems that define our deteriorating Social Determinants of Health, and unhappiness. Failing to effectively address a chronic medical problem often leads to a bad outcome, even death. A failure to collectively address chronic societal problems does not augur well for the poor or the wealthy among us. We have work to do, and we are already decades behind.
Let’s Go Fishing!
Over the years, especially when things weren’t going my way, I would take a walk or go fishing. One type of fishing where I have not had much success is ice fishing. Last winter, when my grandsons were visiting from California during their February school vacation, I made a big effort to enjoy some ice fiishing wth them. I bought a shelter much like the one you can see in today’s picture and spent money updating the gear I “inherited” from a fishing buddy who died several years ago. We had no success.
I have seen some big fish pulled out of the lake by guys like the ones in the picture in today’s header, but a few years ago, my wife and I wandered out onto the ice to visit a similar crew, and I left with the distinct impression that ice fishing is a male drinking escape from weekend tasks requested by spouses. One fisherman we met had even brought an infant son in one of those portable bassinets, which may have been the result of a negotiation he lost with the child’s frustrated and exhausted mother.
One of my favorite Garrison Keillor stories, before he lost status during our # MeToo era, was about ice fishing. It seems this character from Lake Woebegone had a telephone installed in his ice-fishing house out on the frozen lake. He had a great process. He would tie his fishing line to the receiver of the phone, and then retreat to the Sidetrack Tap, his favorite watering hole, where he would sit at the bar with friends and imbibe. Periodically, he would dial the phone number in the ice house. If he got a busy signal, he would rush down to the lake and pull in his fish. To appreciate the story, you need to be old enough to remember landline telephones with hand-held receivers and busy signals.
For me, the joy in fishing and walking is that during either activity, you can let your mind wander away from the chaos of the day. I guess liberal use of libations can achieve the same result. I hope that over the weekend, you can exercise your favorite way to relieve stress or chaos, but on Monday, you will give Dr. King’s messages and the lives of the collective some productive thought.
Be well,
Gene
