PPOs are a contrivance, an artificial structure designed to facilitate discounts, lower payments, and exert leverage over the stakeholders. Sometimes they work, sometimes they don't. No provider ever feels that they "work for "or have allegiance to a PPO. They join because it is in their best interest to do so (preservation of patient volume at the cost of lower revenue per patient, mostly).
HMOs are another issue (staff-model, that is, with employed providers). At their worst, they are cost-reduction machines with everyone too busy, underpaid, and so on. At best they are efficient providers of protocol-based care, transparently exposing themselves to quality measures, adherence to national guidelines when applicable, and a culture of safety and value care.
Historically, many in the profession equate HMOs with socialized medicine, but that is not a supportable view IMHO. I regret that the country did not tilt that way in the 70s and 80s since I believe it was our best shot at an affordable, accessible, high quality health care system within a competitive economic system. They can be overseen using accepted outcome measures, can compete with one another, can offer fluffy optional services at a fee (house-calls which are not strictly medically necessary, wellness clubs, in-house pharmacy and retail, etc.). Cherry-picking of the healthiest patients can be legislatively monitored away. Kind of like a big department store: some like Penneys, some like Nieman Marcus and are willing to pay. But everybody can buy pants somewhere.
Reasons? Lobbying from the insurance industry, AMA (which at the time was a small private practice advocacy lobby unlike now where it is largely irrelevant), and confused congress, among others.
If I were 30 years old and interested in a nonacademic primary care career, I would seek a high quality HMO with colleagues of a similar mindset. If there are any left.
