Dr. Mitchell Louis Judge Li, an emergency room M.D. who is the founder of the “Take Medicine Back” Facebook group and newly birthed nonprofit of the same name, is battling against the corporate practice of medicine (C.P.O.M. is what he calls it). If medicine is corporatized, he believes, the patient-physician relationship is spoiled. What is corporatization? We talked on Zoom recently, right after the spectacular collapse of the American Physician Partners, a medical staffing group, which left a number of doctors and other employees without jobs, without paychecks and without their protective medical malpractice insurance. This transcript of our conversation has been lightly edited for length and clarity.
Jeanne Pinder
So, Mitch Li, who are you? What do you do, and where do you do it?
Mitch Li
I’m a board-certified emergency physician. I live in western North Carolina now, where I practice as an emergency physician. I do work full-time at the V.A., but I am not speaking on behalf of the Veterans Administration. I also work additional shifts in the community as an emergency physician. And I’m the founder of Take Medicine Back, which is a public benefit company that was formed to raise awareness of the corporatization of the profession of medicine, and the healthcare system.
JP
So it started out as a Facebook group, then now it’s going to be a self-standing public benefit corporation?
ML
We started out as a Facebook group, in response to a lot of discussion being censored in other Facebook groups, because there’s corporate influence there. Then we became a public benefit L.L.C., just a couple of months after the Facebook group was formed. And we did that ahead of our first Take Emergency Medicine back summit. And now we’re incorporating as a nonprofit.
Facebook conversations censored
JP
You mentioned that some Facebook groups censor conversation, can you tell me a little bit more about that?
ML
Yeah, there are a number of Facebook groups that have a very large number of physicians in them. They tend to be run by a singular person who may have their own agenda, and also might be prone to being influenced by those corporate interests — not necessarily by selling out to them, but they may pressure them in other ways.
In any case, discussion about corporatization of medicine and emergency medicine has been kind of shut down a little bit for decades, including, in our main specialty group, the American College of Emergency Physicians. This is something that’s really important for us in the history of emergency medicine.
There is a book called “The Rape of Emergency Medicine,” and it mirrors what’s going on in the Facebook groups. It was published in 1992. It was a quasi-fictional account of the corporatization and commoditization of emergency physicians, with groups called contract management groups in the early 1980’s.
A lot of the people who lead that organization became leaders in the American College of Emergency Physicians. So there were a lot of conflicts of interest within that group. And a lot of the discussion was shut down on this corporatization, due to those conflicts of interest.
We started to seeing that mirrored in the modern day in these Facebook groups. If you’re wanting to look it up on Reddit, somebody posted a screenshot of what I had said that resulted in me getting kicked out of this Facebook group. There’s a physician named K.K. Moody, who is just kind of a controversial figure, and she runs a group of about 20,000, maybe 25,000 emergency physicians. Our group, Take Medicine Back, is not limited to just emergency physicians. We have a very dedicated and passionate group of people, but we don’t have the broad reach that some of these earlier groups have.
In the case of that group, it has been monetized to some degree by the creator. But it’s actually worse in some of the other Facebook groups, where anything that’s posted that really doesn’t directly benefit the owner of the group gets censored. So the media that is consumed by physicians is a little bit controlled and biased, I guess we could say.
And there’s been numerous controversies about, you know, during George Floyd, people discussing racism in healthcare, or shutting down those discussions and, and kicking out groups. The key is, she was kind of first to market. So it’s like the public square, it really kind of mirrors what’s going on with Twitter and Elon Musk — should one person have control over the discourse in the country?
But that was the impetus to start this group, because we were having discussions about these important issues of corporatization in emergency medicine. I think most people would agree, I’m one of the few voices that really speaks out about it. Many people fear retaliation. So it was pretty controversial when I got kicked out. Because it was important discussion that was being shut down.
JP
How many members are in your Facebook group?
ML
I think 4,700, last I checked.
Fear of retaliation by companies
JP
Tell me some of the things that you’ve learned in your Facebook group.
ML
That was one of the things I learned is, who’s not in the group and why. And I’ve invited some colleagues who are so afraid of retaliation by these corporate entities. To even be in the group, they’re afraid that they’ll be found out for being in the group — not even participating, but just being a Facebook group member. So that’s been kind of alarming, as you’ll see a number of anonymous posts in the group because people are afraid of retaliation from these corporate employers.
People sort of presume that physicians have plenty of autonomy, plenty of power. And I think most people would think that we’re immune to these issues. But where we really are — there’s regional labor monopsony. If you have a family and you’re tied to an area, then if your ability to work is threatened, and you have substantial educational debt, then your ability to provide for your family is gone — eliminated essentially.
So we recently did expand the group beyond the emergency medicine. So that’s why it’s “taking medicine back.” We’re starting to learn more about how other specialties work.
Another angle is to know how little we as physicians know about how the healthcare system works. And the concept of the corporate practice of medicine, which is a core theme for us.
We have an intuitive understanding, just like the general public, that something’s not fair in the healthcare system. But very few people know about the corporate practice of medicine doctrine. And the laws that prohibit the corporate practice of medicine in most states. And we’re so uninformed about that — yet that affects pretty much all of our lives, when these corporations own our practices. So that’s been a central theme and concern is this C.P.O.M.
Just a point of comparison, this isn’t this is normal thing for attorneys. An investor or non-attorney can’t have a financial stake or ownership in a law firm. And that’s actually upheld by the legal community. It’s not in the medical community. We’re so poorly informed about that, that I think we’re very vulnerable to takeover by these corporate entities.
Restoring the profession of medicine
JP
So corporate practice of medicine. Maybe that leads us into the next question: What do you see as the biggest challenge facing U.S. medicine today?
ML
We’re focused on the profession of medicine, as distinct from the whole healthcare system. A profession, you know, is essentially a trade, or something that requires substantial amount of training that the general population can’t do for itself. That includes, like, attorneys, but also includes the professional army — having somebody go to West Point and understanding how an army works and where the ethics are within that, that allows for the defense of a nation when individuals couldn’t defend themselves as threats.
So we as doctors play a role in society. And the profession of medicine is becoming very disenfranchised, compared to all the financial interests within medicine.
The payment system as ‘original sin’
If I wanted to distill this down, I would say that our current payment system is the original sin, in terms of creating conditions that have allowed fraud and scams to flourish. We have such lack of transparency inherent in our broken insurance system, and also relying on the concept of insurance as a free paid health plan. That is, it has allowed all corrupt practices to flourish.
That includes both how employer-based health insurance began in the country as a benefit right after World War II — when health insurance benefits became an expectation as a benefit. And then Medicare formed after that. We started treating the initial insurance concept as a prepaid medical plan.
Now to bring this together with emergency medicine: We haven’t as a nation reconciled the fact that we don’t have any form of universal health care with the fact that we still don’t want to see people dying on the streets.
As a society our broken Band-Aid solution to that is EMTALA, the Emergency Medicine Treatment and Labor Act. Legally hospitals can’t turn patients away who present at the emergency department without a medical screening exam and treatment and stabilization to the extent that the hospital has capabilities, regardless of the patient’s ability to pay. That doesn’t mean that the hospital or the E.R. group can’t then send you crazy bill and then send the Mafia after you. They just couldn’t turn you away in the first place.
Control by external financial interests
That dynamic has been exploited by big business and private equity firms. But within medicine, the profession of medicine itself will take medicine back. What it is trying to do is to stand up for the sanctity of the profession, which is not supposed to be controlled by external financial interests that could then affect the judgment of physicians, or affect the staffing of physicians in overburdened emergency departments.
While patients are exploited, so there is quite the history of surprise billing. Are you familiar with the group Doctor Patient Unity? That was a dark money PAC, that was funded by TeamHealth and Envision, which are two large staffing groups. Envision just went bankrupt, like A.P.P., and filed for I think, Chapter 11. And it was a little more organized than whatever is happening with A.P.P.
Envision had built its entire business model on extorting patients through surprise out-of-network billing. Now, there are two sides of the story. Insurance companies would say, that’s what’s happening. The private equity companies and some doctors would say, it’s the insurance companies that don’t want to pay and they’re the greedy ones. And the way I see it, they’re both greedy.
There’s an African proverb that says, “when elephants fight, the grass suffers.” So you have this big insurance company behemoths fighting with these big private equity behemoths. And it’s the patients and the physicians and the people on the front lines that are suffering.
‘It was an extraction operation’
Envision really built its model on billing six, seven, eight times Medicare to the insurance companies, and then balance-billing the patients and going after them very aggressively. TeamHealth, similarly, is also known for balance-billing patients and garnishing the wages of poor patients.
So that’s how they made an awful lot of money, to fund the over-leveraged debt, and pay the investors on top of paying physicians. It was an extraction operation.
So Take Medicine Back is basically saying, well, we should not have these external business interests in our house. That’s very similar to attorneys.
A lot of doctors would say that they think attorneys are sleazy characters, but they still hold themselves to a higher standard than we do as a profession, because they’ve kept business interests out of the ownership of their practices. They can, of course, take on a client who might be less than savory. That’s where their professional ethics come in. They have attorney-client privilege.
But we allow business interests into our profession of medicine. I’d ask the public what seems more sacred to them, the attorney-client privilege or the patient-physician relationship?
Bright spot: More awareness
JP
What are the biggest bright spots you see in us medicine today?
ML
That’s a difficult one. I think people are starting to become more aware of this. But the biggest challenge is, everyone has an intuition about how corrupt things are, but it’s not a nuanced understanding.
We, as physicians, get caught in the crossfire, because people see our name on the bills, even when we’re not doing the billing and collecting — so that’s not really a bright spot.
I think the bright spot is that there’s growing momentum for understanding this issue. And in the public and the media, you actually covering this is great. So I think we’re starting to see that — there’s growing interest in understanding the issue among journalists. The story needs to be told for an effective democracy. So that’s been encouraging.
Increasing access to healthcare
JP
We hear every day about people who are shut out of the healthcare system because of money, because it’s too complicated or because of structural racism. What can and should we all be doing to increase equitable access to health care?
ML
I think we have to reconcile the fact that we pretend that we have universal access with EMTALA. But we haven’t changed the fundamental payment system. Theoretically, everyone has access to the emergency department, but it’s extremely broken.
You’re of course very familiar with direct primary care. I don’t think that’s the answer for everything. But I think it does prove that health care and access to a physician as well as a large majority of high-yield medical care and interventions, including laboratory tests, are actually very affordable.
It may be arguable that it’s not affordable to an individual who might be in poverty. But as a society, what direct primary care to me does is kind of hit the reset button. It’s a case study and demonstrates that the majority of healthcare is not that expensive. That’s a reset button that should be used in any example of healthcare reform, to just fundamentally disprove the misperception that medicine and doctors are too expensive.
Healthcare isn’t actually unaffordable
Once we acknowledge that, then we can look at the larger cost items. You know, inherently, emergency medicine — treating an emergency — is a good place for an insurance concept, with direct primary care more like a wraparound plan. It’s the idea that this is a catastrophic event, in theory, when you go to the emergency department, because it’s not a planned maintenance — you’re not supposed to be going there for your yearly checkup.
So we have to reconcile, I think, two concepts: One, that basic healthcare access isn’t actually unaffordable when there is true transparency, and when you take out the middlemen. Then, two, there are interventions that are expensive.
This dates back to pretty much like the invention of the ventilator. Once you have the ventilator and surgery, you could have a very resource-intense intensive care unit that might save your life after surgery and anesthesia. But it takes a lot of staff and it takes technology. And that’s where we should be applying the concept of insurance — as opposed to a prepaid health plan that makes everything unaffordable, like what we have now.
Advice for young doctors
JP
What advice do you have for young doctors who are starting out?
ML
The biggest challenge with young physicians is the growing amount of debt that they have. So they become essentially indentured servants to corporations, and those corporations have growing power regionally. So the best basic advice is to get a handle on personal finances very quickly, and live within your means, and have a really an honest conversation about what your values are. Because they’re going to be different for everybody – including family and how mobile somebody is.
But whenever possible, staying mobile and learning about employment contracts, and avoiding trapping yourself with non-competes, and avoiding signing away due process rights, which are in a lot of contracts, that would disempower the physician and allow them to be essentially fired without any without any trial or due process or any good reason.
So be very careful when signing employment contracts, and consider, depending on their specialty, working a little bit of locum tenens [temporary] or independent contractor work in addition to whatever they might consider their main job.
Essentially you could call it diversifying their employment portfolio. As we talk about the S&P 500 or index funds, in diversifying your investments, but we don’t really talk about diversifying your work.
One other piece of advice or perspective I would give is that stability is more or less an illusion. So even if you are going for an employed job, because you think it’s stable, the system is changing so frequently, and doctors lack protections, like workplace protections, that that job could disappear in an instant — the hospital could close, the hospital could swap groups, A.P.P. could just collapse. You could be out of a paycheck.
So diversifying your employment options, meaning, if there’s one place you want to feel like is your home, then having a kind of main employment there, but then branching out, working in a few different hospitals, or depending on specialty starting a private practice, might all be viable options.
What about that doctor shortage?
JP
Speaking to patients — or, as we like to call them, people — we keep hearing that there’s a shortage of doctors. We just wrote a story about how you can’t get a doctor’s appointment, either a general practitioner or a specialist. Do you have any words of wisdom for people about this?
ML
Well, you say that patients are people, and we also say that everyone’s a patient. That includes physicians and healthcare workers.
I would say that the physician shortage is a manufactured crisis in in two ways. One was essentially the doing of Congress, which kept residency slots low. So we have a glut of young doctors who haven’t gone through residency and can’t practice. These are people who went to four years of medical school, but then didn’t do a residency training that will allow them to get licensed.
The other way it’s a manufactured crisis is that the corporations who have gotten involved prefer not to hire physicians because we’re more expensive. The training makes us more expensive than non-physician practitioners — physician assistants and nurse practitioners.
So if you’re a corporation, and we’re widgets, then they can bill the patients and insurance companies the same or roughly the same amount for seeing a non-physician who they can pay, you know, two-thirds less than a physician.
Then they’ve just increased their corporate profits, while staffing fewer physicians.
A shortage of fair jobs
So this is used as an excuse by a lot of hospital systems saying it’s a physician shortage. This is mirrored exactly in the nursing shortage. You can look up the National Nurses United. They say there’s not a shortage of nurses, there’s a shortage of fair nursing jobs, that hospitals are are not willing to actually staff those nurses, and so many people are leaving, the same as in medicine.
People are leaving altogether, taking early retirement, or are actually underemployed because the corporations are staffing, understaffing, in preference of their profits.
As far as getting access. I certainly am a proponent of direct primary care for getting access to a doctor. Of course, their follow-up is, well, that’s not everywhere, and patients can’t afford it — or some patients can’t afford it. I say yes, absolutely, our system is broken. And it’s not saying that direct primary care is the end-all and be-all, but if you do want reasonable access, where you can actually get an appointment, then cutting out a lot of those third parties is the key to it.
A threat to public health
JP
What else do we need to know? What haven’t we talked about that you think is important in this context? What would you like to leave readers with?
ML
The emergency department and emergency physicians are pretty much the only federally guaranteed universal access to health care. And that’s our only safety net. Yes, there’s [Federally Qualified Health Centers]. But even that, they’re not guaranteed. You’re not guaranteed regardless of your ability to pay.
So this is the only access we have. The emergency physician in the E.R. is really the patient’s strongest natural advocate. But when emergency physicians are disempowered to speak out and advocate on behalf of their patients, then we have we have a clear and present threat to the public health.
That’s something I really want to emphasize, because the conversation needs to go beyond niche esoteric discussions about ownership. This disempowerment really threatens public health.
