June 26, 2026
Dear Interested Readers,
When Will Doctors Take A Stand?
Exactly a year ago, The New England Journal of Medicine began a remarkable series in its “Perspectives” section entitled The Corporatization of U.S. Health Care. There was a companion editorial with the first article published last June. I have commented on most of these articles because I believe that just as human-driven global warming is slowly changing what it feels like to live on this planet, the Corporatization of Health Care is a creeping threat to the climate of healthcare. I won’t repeat my veiled rant from the letter of July 11, 2025, about how the phrase “no margin, no mission” has been distorted from a challenge to wisely use resources for charitable purposes into a justification for administrative atrocities in healthcare. In the letter, I quoted the first two paragraphs of the editorial, which was published in the July 3, 2025, NEJM, and introduced the series. This time around, I have bolded what I don’t want you to miss.
Whether one is examining health disparities within the United States or between it and other high-income countries, probing U.S. patients’ frustrations with their health care experiences, or exploring the causes of widespread burnout among U.S. physicians and other health care workers, one quickly arrives at allegations against a single (if vast and nebulous) culprit: the corporatization of the U.S. health care system.
Though there is undoubtedly truth to the “no margin, no mission” axiom — without adequate ongoing funding, no health care system is sustainable — the trends toward corporate ownership of health care organizations, market consolidation and concentration, and emphasis on the bottom line are widely seen as primarily benefiting corporate executives and their shareholders. Clinicians are becoming increasingly demoralized and are either seeking viable ways out of a system that they feel treats them as cogs in a wheel or attempting to fight back with collective bargaining. Patients of financial means are following their doctors to concierge practices. And lower-income patients are getting increasingly lost amid ballooning patient panels, the prioritization of checklists and billing over humanistic care, byzantine insurance requirements and administrative burdens, and ever narrower provider networks.
The most recent article in the series, Regulating Corporate Control in the U.S. Health Care System was published in the June 4, 2026, edition of the NEJM. Unlike the previous eleven articles of the last year, this most recent installment had what appeared to be a companion article in the “Perspectives” section entitled “Perversity in Medicine—When Vocation and Corporatization Clash,” which really appealed to me because it was laced with some cynicism, frustration, and thinly veiled anger, which I share.
I am always very excited when a reader reaches out to me with a comment. I have been surprised that I get more comments directly to my personal email, drgenelindsey@gmail.com, than to the comment box on this website. That is fine with me. You are welcome to use that pathway to get your thoughts to me. I am always delighted to have a conversation. Last week’s letter about AI in the future of healthcare generated a terrific response from an old friend, and there were several follow-up emails. His initial response generated a great conversation that we will continue today on Zoom. In one of his emails, he asked me if I could refer him to someone who was actively involved in introducing AI into current practice. My response was that I couldn’t, because I no longer had contact with anyone in a position of responsibility in a large organization that might be introducing AI to its staff. As I was confessing my relatively isolated status, I realized that now, 13 years into my retirement, the world has changed. There was a time when I had relationships with many of the leaders in healthcare. Now, most of them are also retired and, in a few cases, have gone on to their eternal reward. My metaphor for my current lack of connections in healthcare is that a professional life is like a train ride. I got off the train several years ago, but the train has continued on. I do get second-hand reports about where the train has gone, but I am no longer on the train. I told my friend that, like the philosopher-humorist Will Rogers said over a hundred years ago, “All I know is what I read in the papers, and that’s an alibi for my ignorance.” If you are a regular reader of these notes, you know that many of these letters are “riffs” on what I have read, which explains what follows, because once again, I would like to lift up what seems important to me from the two most recent articles connected to “the corporatization of U.S. healthcare.”
The first article Regulating Corporate Control in the U.S. Health Care System was written by Loren Adler of the Brookings Institution in Washington, where he is an economist and the associate director of Brookings’ Center on Health Policy. He begins his piece by stating that all forms of corporatization are deeply embedded in our delivery system.
Organization of health care delivery in the United States has increasingly become centered around large corporate entities — including hospital systems, insurer-affiliated organizations, and investor-backed firms — that concentrate decision-making authority over staffing, contracting, and billing. According to the American Medical Association’s physician-practice survey, the share of physicians in private practice fell from approximately 60% in 2012 to approximately 42% in 2024, as hospital ownership of practices and direct employment of physicians increased substantially.
Before going further, I should confess that I was once the CEO of a large nonprofit organization/corporation with more than 8000 employees, which was responsible for the care of almost a million people. We gained approval for the mergers that grew us by presenting to our state’s attorney general all the potential benefits of corporate growth outlined in Mr. Adler’s analysis. In part because of our strategies, corporate growth, and use of innovations in quality management, I was honored in 2012 to be asked by the Massachusetts Medical Society to deliver the annual “Oration.” The Oration has a history that goes back to the early 1800s. My topic was the transformation of the practice of medicine from a “cottage industry” to an enterprise in my lifetime. I presented this as a good and necessary step if we were ever to achieve the Triple Aim. Click here to read that speech.
One of the primary motivations for the creation of Atrius Health and for my management team’s growth and innovation strategies was in response to the monopolistic, market-dominating, and predatory practices of the largest and most politically connected corporation in our market, Partners Health Care, now known as Mass General Brigham. Our opposition to Partners included moving tens of millions of dollars in annual business from Partners-affiliated hospitals and specialists to the Beth Israel Deaconess and Lahey systems. Many people, especially my friends who were clinicians and managers in the Partners system, were surprised and confused by this strategy because I was trained at the Brigham and had practiced there for more than thirty years. I have a rocking chair embossed with the Brigham’s shield and bearing a thank-you for 35 years of service.
Through corporatization and the development of monopolistic control over the market, the Partners-affiliated hospitals and practices had ceased to be our colleagues and had become a threat to our existence. By moving care from Partners, which, for some services, was more than 30% more expensive than BIDMC and Lahey, and also had, according to data from our data warehouse, superior measured patient satisfaction and quality than Partners, which had more market power, political influence, and a better PR department, we were seeking to lower the cost of care and achieve a degree of competitive balance in our market. Our strategic plan was built on using reclaimed resources to fund innovation that would improve quality, enhance the patient experience, and still yield a small margin for future use in a very turbulent and uncertain market.
In my speech at the Mass Medical Society, I assumed that a larger, more robust organization could more efficiently support clinicians’ efforts to meet patients’ needs. Mr. Adler continues his paper by reviewing many of the same positives of larger enterprises, but also details the negatives that have accompanied corporatization. The point of his presentation is that corporatization has often been associated with promises of efficiencies, improved quality, greater patient satisfaction, and improved outcomes that have not been delivered. What has often been delivered is higher costs, clinician burnout, moral injury, and declines in patient satisfaction and access, at the expense of huge sums of money garnered through monopolistic practices that have increased the cost of an inferior product. Unfortunately, corporations, for-profit and non-profit alike, are here to stay, and we’d better learn how to regulate them.
Corporate investment can provide organizations with capital and management expertise and facilitate care-coordination activities that smaller organizations may struggle to finance. Yet factors that typically impose discipline in other markets may have weak effects in health care. High prices or poor quality may not reliably translate into lost volume. Quality is difficult to observe, patients have limited ability to shop for services, and insurers or public programs pay most of the bill for many services. Under these conditions, although corporatization may sometimes yield efficiencies, it can also generate returns for entities that consolidate bargaining power and exploit payment and regulatory rules.
Corporatization often occurs by means of consolidation that increases market power. In commercial markets, consolidation can reduce competition and allow dominant players to increase prices. A growing body of evidence suggests that prices for physician services tend to rise after hospitals or private equity firms acquire practices, particularly when consolidation involves competing entities. In labor markets, consolidation may reduce mobility and weaken workers’ bargaining leverage.
Corporatization can also involve the exploitation of payment and regulatory rules to increase revenue without commensurate improvements in care.
How do they get away with these predatory practices? Are there even more negative outcomes that aren’t readily observable to the average consumer? Adler answers:
When quality is hard to observe and patients have few alternatives, cost-reduction activities may lead to leaner staffing, higher turnover, reduced supervision, or reduced clinical coverage and ancillary supports. Problems may not be readily identified and may not be corrected until they attract scrutiny. Some corporate strategies can also undermine financial stability. Loading institutions with debt and extracting value from them by means of “related-party payments” can threaten the viability of locally important institutions, with the costs of failure being borne by patients, communities, and public programs.
The concept of caveat emptor, or “let the buyer beware,” doesn’t work very efficiently for consumers of healthcare and efforts to find quality care get more difficult as competition is reduced by consolidation and there is more distance from the point of care to managerial authority in the C-Suite or at a corporate board level, where “shareholder value” may trump commitments to patients for access and quality, and to clinicians for clinical support and practice autonomy.
Mr. Adler is left with the impression that the process of corporatization is established and will most likely persist, even if the overall outcome is more favorable to institutions’ bottom lines than to the quality of care, cost reduction, or a tolerable work environment. His solution is to improve regulation and review.
The eighteenth-century intellectual, Adam Smith, is often referred to as the father of capitalism and free markets. In my mind, the current process of corporatization of healthcare is an example of perhaps how those ideas can play out to the disadvantage of the majority. I have recently listened to an audiobook about the impact of Smith’s ideas in our times. I got the surprising idea from what I heard: contrary to the laissez-faire ideal and the anti-government atmosphere of much of libertarian thought, Smith saw a role for regulations similar to Mr. Adler’s suggestions. So I asked ChatGPT:
Is it true that in his book, The Theory of Moral Sentiments, Adam Smith suggested that some regulations were required because of human nature?
I was surprised by the in-depth quality of the answer, which you may choose to read or skip. It is about an additional 500 words, but I think it’s worth the effort. I have bolded some key points to speed you along.
ChatGPT answered:
Yes. One of the most common misconceptions about Adam Smith is that he believed markets should operate with no government intervention at all. In fact, when you read both The Theory of Moral Sentiments (1759) and The Wealth of Nations (1776), a more nuanced picture emerges.
Smith believed that human beings are motivated by self-interest, but he did not believe that self-interest alone would always produce just or desirable outcomes. In The Theory of Moral Sentiments, he argued that people also possess capacities for sympathy (what we might call empathy), conscience, and moral judgment. At the same time, he recognized that human nature includes greed, vanity, ambition, and the tendency to pursue personal advantage at the expense of others.
Because of these aspects of human nature, Smith believed that society required:
1. The Rule of Law
Smith argued that government must protect people from violence, fraud, theft, and exploitation. Justice was not optional; it was a prerequisite for a functioning market economy.
He wrote that society could survive without perfect benevolence, but it could not survive without justice. In effect, markets require rules and enforcement to prevent predatory behavior.
2. Regulation of Certain Economic Activities
Although Smith opposed excessive government interference and monopolies created by government favoritism, he recognized that some regulations were necessary.
For example:
- He supported regulations on banking to prevent reckless financial practices.
- He worried about the power of monopolies and business collusion.
- He warned that merchants and manufacturers often sought policies that benefited themselves at the expense of the public.
One of his famous observations was that people in the same trade rarely gather together without eventually conspiring against the public interest.
3. Public Goods and Public Institutions
Smith believed government should provide services that markets would underprovide, including:
- National defense
- Courts and administration of justice
- Infrastructure (roads, bridges, canals, harbors)
- Education
He was particularly concerned that repetitive factory work could dull workers’ intellectual capacities and believed public education was needed to counteract this effect.
4. Protection of the Vulnerable
While Smith was not an advocate of the modern welfare state, he believed that a decent society should not tolerate extreme deprivation.
In The Wealth of Nations, he argued that necessities are partly socially defined. People should be able to participate in society with dignity, not merely survive biologically.
What Did Smith Mean by Human Nature?
A central idea in The Theory of Moral Sentiments is that human beings are neither angels nor purely rational profit maximizers.
Smith believed that:
- People seek approval and status.
- People often deceive themselves about their motives.
- Wealth and power can corrupt moral judgment.
- Sympathy and social norms help restrain selfish impulses.
- Institutions are needed because moral self-restraint is imperfect.
This insight led him to support both:
- Competitive markets, because they can channel self-interest productively.
- Government institutions and laws, because self-interest can become destructive.
Relevance to Modern Debates
If Adam Smith were participating in today’s debates about healthcare, banking, environmental regulation, or social welfare, he would likely reject both extremes:
He would probably oppose:
- Excessive government micromanagement of markets.
- Special privileges for politically connected businesses.
- Regulatory systems captured by special interests.
But he would also likely oppose:
- Monopolies.
- Fraudulent or exploitative business practices.
- The idea that markets alone solve every social problem.
- The abandonment of public education and essential public goods.
Many historians of economic thought argue that Smith would be more comfortable with a well-regulated mixed economy than with either laissez-faire absolutism or comprehensive state planning.
For someone interested in healthcare policy—as you often are—the most intriguing Smithian question is not “Should government be involved?” but rather:
“What institutions best align private incentives with the public good?”
That question lies at the heart of modern debates about fee-for-service medicine, value-based care, pharmaceutical markets, health insurance, and the social determinants of health. Smith would likely have viewed those as institutional design problems rather than simple choices between markets and government.
I offer thanks to ChatGPT for supporting my biases. I was totally surprised by its reference to my interest in healthcare policy when it casually said as if it were in conversation with me:
For someone interested in healthcare policy—as you often are—the most intriguing Smithian question is not “Should government be involved?” but rather:
“What institutions best align private incentives with the public good?”
In the remainder of his piece, Mr. Adler struggles to present actionable strategies to compensate for the downsides of corporatization and I encourage you to read his suggestions, but I am also biased that, in our current state of divided government, with a marked decrease in regulatory control by those in need of regulation, and the complexity and likely resistance to his proposals, our defense against further damage from the excesses of unchecked corporatization of care probably won’t come from government before I shuffle off this mortal coil. I predict that we will continue to struggle with the downsides of the corporatization of healthcare until physicians and other aligned healthcare professionals become much more involved in confronting the corporations that oppress them. Which brings me to the second article of interest in the June 4 issue of the NEJM.
The second “Perspectives” article of interest was offered by Louise Aronson, M.D., from UCSF. Click here to learn more about her significant contributions to Geriatrics and her copious writing. Her article is entitled Perversity in Medicine — When Vocation and Corporatization Clash. She begins: (Suffer my bolding of what I would underline.)
In this age of corporate medicine, when health system leaders say, we are building the new hospital of the future alongside world-class facilities for biomedical research, I hear: we are playing to win in our current medical system rather than innovating to improve it, even though it is failing patients and causing unprecedented departures from the health professions. And when — the situational complexity and their good intentions notwithstanding — they say, we have acquired two more community-based local hospitals, a move that will allow us to see more patients with complex medical needs at our flagship campus, I hear: having already ghettoized primary care and psychiatry, those desperately needed, health-essential, underfunded services, into another former community-based hospital where our cultural imperialism has already been established, we are continuing to invade foreign territories in search of locally scarce raw materials and significant captive markets, leaving the colonized literally and culturally impoverished while increasing our own wealth and power.
She is steaming. I can imagine smoke coming out of her ears!
When they say, this process has taken time and the collective efforts of many, I can’t help but hear: we know you, the organization’s faculty, staff, and students, made very clear a few years ago that you were against this merger–acquisition, but we hope that because we can now impose our beliefs and traditions on these sites, you will overlook the fact that rather than listening to you, we found a way to work around you.
She is on a roll, and I have no desire to cut her off. As far as I am concerned, she is preaching to the choir, and I love it:
When they say, we’re expanding access to primary and secondary care at the new hospitals, I have learned from reports of similar acquisitions, local and national, to hear: we don’t really care about the brand dilution of our culture, standards, and reputation, as long as that weakening takes place far from the main campuses and the lucrative, tertiary-care needs we don’t try to prevent (including at the new sites where, almost immediately, primary care will be eliminated from the plans).
Why stop now?
When they say, we look forward to welcoming our new teammates to our health system, I hear: we no longer pretend that health care is anything other than a business, and you “teammates” who wanted to help people and prioritize care and compassion are naive idealists with outdated notions of vocation and service.
Maybe in the interest of brevity and the possibility that you might finish reading this letter, I will just suggest that you click on her article and read the remaining ten points that she underlines using the formula “When they say…I hear.” Well, maybe I should include one more “When they say…I hear” reference.
When they say, clinician satisfaction is up and burnout rates are down this year, I hear: we use our knowledge of statistics only in ways that suit our endgame, and here it behooves us to ignore the fact that the denominator has also changed, what with all the departures from our institution and clinical medicine in recent years and the many clinicians who are too busy or disillusioned to fill out surveys.
We all know that Mark Twain (a.k.a. Samuel Clemens) said that there are lies, damn lies, and statistics. It seems that boardroom talk and institutional missives from the “suits” define one side of an abyss, while clinicians and patients are on the other side of a widening divide.
I have frequently referred to myself as an “organizational politician.” Truth be known, I was closer to being an “institutional insurrectionist.” By the mid-eighties, I was a coconspirator with colleagues who shared my belief that Dr. Ebert’s grand experiment was being turned into a corporate disaster, in which the aspirations to create a better model of care for clinicians and patients were being abandoned in favor of short-term attempts to grow “market share.” We had clandestine meetings and then began to resist the changes so forcefully that, within a few years, we created a rebellion that ousted a CEO with whom we disagreed. His replacement was associated with us gaining a greater voice in corporate decisions, but in a few years, after another merger and another physician-driven removal of an even more disconnected CEO who failed to bring the reforms that we felt were needed to preserve principles of practice that we could embrace, we began a process of separation that took about three years. In 1998, we emerged from Harvard Pilgrim Health Care as Harvard Vanguard Medical Associates.
We called ourselves a physician-driven practice, but we were a corporation. Errors were made, the external environment was often hostile, but we did demonstrate that our actions were designed to pursue the Triple Aim. We did not solve all the problems we faced, and we were facing major market challenges when I retired, but we were still pursuing the positive possibilities of corporatization. COVID changed the basic financial realities, and now the practice is owned by Optum and is truly suffering from the concerns and committing some of the transgressions described in the two articles mentioned above. Nevertheless, I think we proved that engaged clinicians can make a difference. We talked about change from the inside out. I don’t believe it will be easy, but I hope that a better future for healthcare, in the dreams of any thoughtful person, could occur with an awakening of clinician leadership that yearns more for better care for everyone than for producing a handsome return for investors or greater reserves that are derived from compromising the care they deliver and the welfare of the clinicians they employ. She finishes her short piece with a move toward reconciliation, implying that we must learn to live in the world in which the corporatization of healthcare has evolved.
Dr. Aronson’s piercing translations of organizational motivations and communications underline many of the reasons why I agree with her condemnations. Both of us have intentionally ignored those indisputable complexities of delivering care in a politically divided society that struggles to strike a balance between the business of healthcare and the compassion and empathy that we believe motivates most caregivers. I also apologize for ignoring the laudable goals of some corporate leaders as I try to convey my emotional experience as a clinician and patient. Nevertheless, I share her belief that many individuals and corporations in healthcare have self-serving motives that undermine efforts to solve the increasingly complex problems of care delivery.
I fear Mr. Adler’s call for better regulation is unlikely to be realized in the near future. I hope that a miracle might occur, and physicians and other clinicians will organize efforts for local improvements within the corporations that now employ and dominate them. I know that can be done because I was part of an effort that, for a while, within a corporation, did try to make a difference.
What You Can See On a Dreary Afternoon With Intermittent Rain
I walk almost every day, rain or shine, when the temp is over 90, or at times in the single digits. My walks were once runs, and there have been few days since 1976 when I spent less than forty-five minutes on some road, trail, or track. According to my Nike App, I have covered 10,000 miles in the last nine years and ten months. I have slowed down. Ten years ago, I never did less than five miles and often more than fifteen. These days, my minimum is two miles, which, with Canadian crutches, takes me substantially longer than 5 miles did in 2020 when I was 75. I now move at an average pace of about 28 minutes per mile. What is surprising is that I get just as much joy from my effort now as I did when I started running the morning after the 1976 Boston Marathon.
It is a quarter of a mile from my door to the main road. On some days, especially if the weather is too hot or too wet, I go back and forth to the main road since the up-and-back is an even half mile. When I was young, I did a lot of my exercise on the quarter-mile track at my local high school. It was convenient, and my mind could wander because I didn’t need to pay attention to cars. Last Monday, when I took the picture, I went up and back six times for a total of 3 miles in a little less than 90 minutes. My road is quite safe. It’s a dead end. Over the 90 minutes, I saw one car. Someone was lost.
The picture shows ferns along the road at this time of year. There are at least four different types of ferns. There are also numerous green plants, including some poison ivy and various weeds and clovers. Late last summer, I downloaded an app that identifies plants, insects, and animals. In August of last year, after getting the app, I identified about 25 different wildflowers along the roadside on my usual walk. On the day of this picture, I identified 10 new species with names like spreading dogbane, oxeye daisy, purple crownvetch, and tufted vetch. Some are native species, and others, like the vetches, came from Europe or Africa. I wonder if ICE would consider them to be illeagal immigrants. What seems obvious to me is that there are some flowers that come out early and some, like goldenrod, that arrive in mid or late summer. What surprises me is that it took me over 80 years to slow down enough to look at the variety of flowers that were always along my travels.
The picture doesn’t show the flowers. They are too small and overshadowed by the ferns. The ferns also hide the old stone walls that line both sides of my road, which is simply named Old Route 11. Those walls are evidence that in the distant past, the land was “clear-cut” and farmed. At one time, my road was the principal route between Newport, Sunapee, and New London and points east and west. It now ends just past where I stood to take the picture. It ends because there is an inflow into the lake at that corner, and the culvert that carried its water under the road washed out. It is a convenient dead end where people who are lost sometimes turn around, and others occasionally party or have romantic encounters. I pick up what they leave as evidence of their visits. There is a new, wider, faster road, aptly named Newport Road, which is now separated from the scene by about 50 yards. My little road is evidence to me that there is a lot to see when you slow down, and that change is a constant.
Between this weekend and the ninth of July, we are expecting a house full of guests, maybe as many as 18 on the fourth, with some overflowing to the spare rooms of a neighbor and an antique B and B just at the front end of my road, where it takes off from Newport Road. I hope that you have great plans for this weekend and for our 250th birthday next weekend. I am happy to have so much going on here, but I am sad to say that I plan to pay no attention to what is happening in Washington.
Be well,
Gene
