Traditionally, physicians practiced as sole proprietors or as small partnerships.
A small number of physicians worked for employers such as railroads to
provide care to the employees, and, in some cases, care to the employee’s
families. Patients paid directly for their care, usually in cash, but sometimes
with barter. The physician’s only institutional relationship was with the local
hospital. Hospital privileges were simple independent contractor relationships,
usually vetted by the local medical society. Medical law was simple, dealing
mostly with medical negligence, hospital privileges, and perennially
controversial areas such as abortion and narcotics prescriptions.
These patterns reflected the simplicity of the pre-World War II medical
environment. There were relatively few effective drugs, technology was limited
and not capital intensive, and hospitals were run mostly by religious orders and
provided little more than nursing, laundry, and food services. Physicians
worked alone and specialty practice, beyond surgery, was very limited. After
World War II, medical specialization and advances in technology and
pharmacology profoundly changed hospitals and physician practice patterns,
but the old business organizations persisted beyond the point where they
made business sense for anyone but the physicians. Business innovation was
stifled by state laws, called corporate practice of medicine laws, that protected
the private practice model.