The most legally significant change in medical practice over the last twenty years has been the corporatization of medical care services. This has accelerated in the last ten years with the growing dominance of managed care organizations (MCOs). In this book, an MCO is any organization with a financial interest in medical care delivered to a group of patients and that contracts with medical care practitioners for the delivery of medical care and exercises some control over that medical care. These range from closed-panel health maintenance organizations (HMOs) with all employee physicians, to loosely structured preferred provider organizations (PPOs), and include hospital- owned physician’s practices and other arrangements with noninsurers who nonetheless have a financial interest in the medical care that the medical care practitioners deliver.

The legal consequences of the corporatization of medicine has been to broaden the legal threats facing medical care practitioners from traditional medical malpractice litigation to include fraud, financial crimes, and other civil and criminal business litigation. The losses from such litigation are potentially much greater than from individual medical malpractice cases. Civil fines can run to the tens and hundreds of millions of dollars, and the individuals may be criminally prosecuted and face prison sentences.

This section deals with the special risks that arise from medical care practitioners working with MCOs and in team care environments. Most of these risks arise from the conflicts between the medical care practitioner’s fiduciary duty to the patient and the MCO’s pressure to make the medical care practitioner a gatekeeper who protects the interests of the MCO. Most of these risks run to physician medical care providers because the vast majority of the statutes and case law dealing with fiduciary duty in medical care are directed at physicians.