By Dr. Wendy Dean & Dr. Christian Macedonia

Not long ago, the highly personal relationship between doctors and patients, based in selflessness and trust, respectively, was the cornerstone of healthcare. Today, though, corporatization and greed have driven a money-shaped wedge between us.

Hospital systems want patients to relate to their brand, not to a particular physician. They jealously guard interactions and control communication. Physicians are caught – with incentives and threats – in conflicted relationships with health systems, third-party payers, and profit-seeking middlemen.

This shift has put physicians in a position akin to the betrayal soldiers experience when leaders give orders that violate the soldiers’ oaths. Following corporate imperatives, rather than professional oaths, has led to widespread moral injury among health workers. Staggering numbers of physicians plan to leave the profession or curtail their work hours in the next few years. How did we get here?

A half century ago, government began its steady turn away from independent physicians toward healthcare corporatization. The Health Maintenance Organization Act of 1973 and President Bill Clinton's failed healthcare reform that favored Preferred Provider Organizations aimed to control independent doctors who wielded too much power.

The government gave another unfair advantage to hospitals in April 2000, when Medicare allowed hospitals to charge “facility fees,” even on services provided at health system-owned locations outside the hospital, such as a doctor’s office. Over two decades, these fees have become ubiquitous and cost Medicare more than $6.6 billion a year­. While small, rural, and government-run hospitals depend on facility fees to stay solvent, they have helped finance larger systems’ buying sprees.

A decade later, ObamaCare’s Accountable Care Organization initiative brought together groups of hospitals, doctors, and other healthcare providers ostensibly to deliver coordinated care to Medicare patients at lower cost. ACOs were a conundrum, though, because the best way to lower costs was to prevent the big-ticket medical services that are hospitals’ lifeblood. Health systems cried foul, urging the Obama administration to waive anti-kickback and anti-trust laws, so groups could coordinate care without accusations of monopolistic behavior and reward physicians for self-referrals without accusations of self-dealing. The Centers for Medicare & Medicaid Services promptly wrote, and subsequently updated, exemptions to the Anti-Kickback Statutes and freed hospitals to steer referrals in-house. This also led to tracking physicians’ performance with “leakage reports” gleaned from required electronic medical records.

Health systems could finally “manage” physicians by employing them. Directed referrals fed each system's own beast and starved competing independent practices. In 2012, just 3 in 10 physicians worked for hospitals or health systems. But after a decade of intense market pressures, more than 7 in 10 did. This corporate strategy expanded health systems’ local healthcare market share, increasing negotiating leverage with insurers, ratcheting up reimbursement levels, and negating any ACO cost savings. Worst of all, these machinations dehumanized patients. Employed doctors, pressured to produce and constrained by corporate decisions, felt more like traffic cops than patient advocates.

Dedicated doctors morph from patient-centered healers to corporate enablers in the face of restrictive covenants, non-disparagement clauses in older contracts, and productivity metrics. These measures limit their freedom to work for competitors or criticize the corporation, even when patient access and safety are at risk. Performance measures emphasize productivity, shifting incentives from healing to churn. When a physician resists, defending their oaths, their patients, and their own wellbeing, the experience is often costly, painful, and lonely.

Despite all these challenges facing physicians, over 75% of us trust them when we are patients. Despite the inherent asymmetry of the physician-patient relationship, our physician, unlike members of almost any other economic sector, wields their advantage solely for our benefit. When we physicians allow ourselves to become instruments of industry and stop being trusted and trustworthy agents, we forsake our oath, our patients, and our profession.

Urgent steps are needed to repair physicians’ moral injury.

First, we must restore and safeguard physician independence, reconfirming medicine as a profession. Healthcare corporations must become authentic brokers of patient-centered care. "That principle, the needs of the patient come first, should apply to and be enforced by law in every single agent in the world of care," Dr. Don Berwick, former Director of CMS stated in a March 2024 hearing, "Not just clinicians but also organizations, payers, entrepreneurs and investors. At the moment we are dropping that ball." Banning non-compete and non-disparagement clauses so physicians can leave or speak out about troubling working conditions is a step in the right direction. Then, ban waivers that raise costs for patients and encourage healthcare corporatization, and ban leakage reports that punish physicians for personalizing patient referrals. Next, reevaluate ACOs’ outcomes and cost savings. If they don’t measure up, discontinue their experiment. We must also encourage human-sized healthcare systems, promoting choice while discouraging monopolization. Finally, enhance physician and patient education about the healthcare business environment, highlighting potential conflicts between clinical goals and corporate objectives.

Physician “independence” should not be a function of where a doctor practices or the terms of their employment contract. It should be a universally accepted fact that a doctor works only in the interest of their patient. No stockholder, board of trustees, or corporate entity should ever stand between them.

Physicians seek to uphold the covenant they made with society when entering this profession: to provide a service that transcends self-interest, grounded in knowledge and skill. Ensuring choice and independence for physician practice and constraining healthcare corporatization are the best ways to protect patients.

Dr. Wendy Dean is CEO and co-founder of the nonprofit organization Moral Injury of Healthcare and author of If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard for Clinicians to Put Patients First.

Dr. Christian Macedonia is a practicing maternal fetal medicine physician and a former senior health policy official in the Bush and Obama administrations