Why Has “Balance of Power” Shifted from Physician Autonomy to Corporate/Government Control?

As editor of Minnesota Medicine Dr. Richard Reece pointed out the risks of HMO medicine in the 1970’s warning of the medical profession. Let’s ask Dr. Reece about the notion of “balance” between physician autonomy and corporate/government control.

Lee Beecher, M.D., psychiatrist, leebeecher@aol.com

Thank you, Lee, for posing the question. You ask. Why the shift of balance of power for control of health care from autonomous physicians to managed organizations?

As you observe in your email, physicians and their societies may appear to have “sold out” to government and corporate interests. Consequently , physicians have given up much of their autonomy. They now move to the beat of corporate and government drummers.

And as you further indicate, I warned of this shift of balance of power in my editorials and my book And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota (Medica Medicus, 1988), which is still available on Amazon.

To your question, I would add another question: Why Minnesota? To that I would say, Minnesota is bedrock of the cultural phenomena known as “Group Think.” In Minnesota Group Think, which may reflect a gathering together to combat the cold, organizations become more powerful than individuals in promoting the social good. This may be why Minnesota is home of large HMOs and their variants, the Mayo Clinic, Group Health, Partners Health Plan, United Healthcare, and 34 multinational corporations.

To me the balance of power shift in Minnesota and elsewhere is not a question of “selling out” but of succumbing to larger societal and market forces.

Compared to organizations like HMOs, PPOs, health insurers, other members of the medical-industrial complex, and government, we physicians as individuals in our quest for “autonomy” are pygmies in terms of the balance of power shift.

Organizations have the powers of:

Scale - The typical physician has an audience of 2000 patients, United Health has 100 million customers, Obama has 315 million mandated followers, hospitals dominate 80% of U.S. metropolitan markets, the social media, especially Facebook and Twitter, and Twii have billions of connectors, worshippers, listeners, and broadcasters.


Access to capital – Corporations have stakeholders and venture capital, government has taxpayers .


Leverage - Organizations can mobilize teams of specialists under one umbrella to finance , deliver, and market high tech care . To take one example, Kaiser health care owns hospitals, employs physicians, and controls its health plans.


Information technologies - Organizations can deploy IT to collect data to manage input and output, to measure improvement, to standardize care, and to spread word of their products.

Individual physicians and even their organizations have few of these corporate/government advantages or the business skills to deliver mass services to massive audiences across the social spectrum.

Throw in the reality that the public entrusts socially responsible large organizations to manage and deliver social tasks, and you will realize why the private independent practice of medicine is in decline and why the balance of power for physicians is out of kilter.

Individually or in larger organizations, physicians can empower their smaller constituencies, and they can opt out of the government and corporate power structures by delivering a more direct higher quality, lower cost, more personal brand of care, but they are unlikely to have the advantages of scale, capital, range of technologies, and IT digital social media.

On the horizon, I see an evolving two-tier system – one mandated by government, the other directed by physicians.