Does independent medical practice have a future?

The landscape of health care is changing rapidly, driven by policy decisions, market consolidation and shifting expectations for physicians.

Independent practices are increasingly caught in the middle.

Payment pressure is tightening, administrative demands are accelerating and the competitive landscape is shifting as health systems, private equity and new care models all re-position. Yet, across the country, physicians are also re-examining what ownership means — and whether independence may once again offer the balance, autonomy and patient relationships that many feel are slipping away.

To make sense of these crosscurrents, Medical Economics and Physicians Practice convened a panel of health care leaders who sit at the center of policy, operations and clinical practice. Their perspectives span rural primary care, oncology, pediatrics, management services organizations (MSOs) and the business fundamentals that keep a small practice viable.

Together, they take a clear-eyed look at the financial realities, regulatory hurdles and strategic choices shaping independent practice today.

Across the discussion, the panel confronts the issues that determine whether practices can stay afloat — stagnant fee-schedule updates, staffing challenges, prior authorization strain and the growing costs of compliance. They also explore where opportunities are emerging: collaborative contracting models, smarter workflow design, AI-assisted operations, and a renewed cultural push among younger physicians toward autonomy.

This panel was recorded on October 29, 2025. The transcript has been edited for length, clarity and style.

Independent practice in 2025: Surviving in a changing landscape

Rebekah Bernard, M.D.: Independent physicians remain at the heart of patient-centered care in America, but many of us are feeling this squeeze. Flat reimbursements, escalating costs, prior authorization nightmares and the growing dominance of hospital systems are challenging our ability to stay independent. But independence isn't extinct. It's evolving. My name is Dr. Rebecca Bernard. I'm a family physician and the owner of Gulf Coast Direct Primary Care, and I'll be moderating a panel discussion convened by Medical Economics and Physicians Practice to examine what true physician independence looks like in 2025 and what it will take in terms of policy reform, technology adoption or innovative collaborative models to ensure that small practices not only survive but thrive. Today, we're joined by thought leaders in clinical practice, economics and policy. Our goal is for you to leave this session not only with a clearer understanding of the challenges facing independent practice, but also with practical strategies and a renewed sense of optimism that physician independence can still be maintained and even strengthened within our evolving health care system. Let's meet our panelists first. Dr. David Eagle, please introduce yourself.

David Eagle, M.D.: Dr. Bernard, thank you very much. Yes, I'm David Eagle. I'm a medical oncologist. I've been practicing since 2000. I'm currently with New York Cancer and Blood Specialists for roughly 300 doctors throughout Long Island in New York City. We're an independent group. We're also part of the OneOncology network, which is independent group of oncologists across the country, roughly 1,000 doctors. I'm the president of the American Independent Medical Practice Association, founded over two years ago now, over 12,000 doctors strong to fight for independent physicians.

Rebekah Bernard, M.D.: Can't wait to hear more about what you're doing. Next, we have Dr. Andrew Hertz.

Andrew Hertz, M.D.: Thanks, Dr. Bernard, I'm thrilled to be here. I'm a general pediatrician, co-founder and president of Zest Pediatrics Network, which is a purely pediatric DPC, direct primary care network. I bring an interesting perspective, I think, to this conversation today, in that before this current job, I was an administrator at a large academic health system in Ohio, and while I was there, I was overseeing 200 pediatricians and women health providers in the community. One of my main roles in that position was to acquire practices and to hire doctors, and now, with Zest Pediatric Network, I am encouraging doctors to be independent. We are a management service organization, or an MSO, and we really want to work with independent physicians.

Rebekah Bernard, M.D.: Looking forward to hearing about that, because I know pediatrics has been a little bit of a tough situation for direct care, so it's exciting to hear what you're doing. Look forward to learning more about that. Next, we have Dr. Melissa Lucarelli.

Melissa Lucarelli, M.D., FAAFP: Hi, good afternoon. I'm Melissa Lucarelli. I am a board-certified family physician. I am the founder and owner of Randolph Community Clinic, which is a rural full-spectrum family medicine clinic in south central Wisconsin. I've also been an editorial adviser for Medical Economics for the past 10 years, and we've been in practice here delivering primary care to our community for 25-plus years.

Rebekah Bernard, M.D.: Can't wait to hear your perspective. And last but not least, we have Mr. Andrew Swanson.

Andrew Swanson, M.P.A., FACMPE: I’m the lone nonphysician on the call, I realize. Hi everyone. My name is Andrew Swanson. I'm MGMA’s chief revenue officer and at Medical Group Management Association, our business is really the business of health care, and so what we try to do is advise, counsel, provide data, insights and advocacy to our members in the industry at large, to just champion the profitability and viability of physician practice, whether independent or system-owned. But we have a good lens on what it takes to be and maintain independence these days. I’m looking forward to sharing those perspectives today.

Vitals Check: Is Independent Practice Healthy in 2025?

Rebekah Bernard, M.D.: Can't wait to hear all about your thoughts. Let's start out by examining the state of physician independence in 2025. I'm going to ask each of you how you would describe the health of independent medical practice today. Is it resilient? Is it declining? Or is it evolving? Let's start with Dr. Lucarelli.

"According to the American Board of Family Medicine, when I was first in independent practice, 60% of family physicians were independent, and now it's somewhere around 33%.” — Melissa Lucarelli, M.D., FAAFP

Melissa Lucarelli, M.D., FAAFP: So, I think most of us are aware that, based on the numbers, independent practice is on the decline. According to the American Board of Family Medicine, when I was first in practice, first in independent practice 25 years ago or so, 60% of family physicians were independent, and now it's somewhere around 33%, 30% to 33%. What surprised me about the more recent study, though, was in solo practice situations like mine, 80, 80-point-something percent of family physicians are still independent. So that shows kind of the need for independent practices, especially in rural areas. We're also older, though, on average. So, the average family doctor is 48 years old, but the average solo family physician is 57, which makes me rapidly approaching average here.

Rebekah Bernard, M.D.: I think your point about rural care is important, and I'll just put in a highlight for a recent Medical Economics podcast that we did on whether direct primary care can actually be the salvation for the rural health care crisis that we have, or innovative models or solo practice. Dr. Hertz, tell us, what do you think the health of the independent medical practice is today?

Andrew Hertz, M.D.: I think after years of declining number of independent practices, I think that pendulum is finally swinging back in the other direction. I think physicians in general are unhappy, especially in primary care, working for corporate health as 70% of primary care doctors are, and I think more and more people are leaving those ranks to pursue either direct care, concierge care, independent group practice. Certainly, there aren't nearly as many left, but the number of practices I continue to hear are growing, people that are pursuing independence.

Rebekah Bernard, M.D.: Yeah, I also feel that the pendulum is starting to swing. How about you, Dr. Eagle?

David Eagle, M.D.: Thank you. To build on what the other panelists have said, I would describe it as evolving. When I started practice in 2000, 85% of oncology care was in community independent practices. Now that's less than 45% and I think independent medicine still faces a lot of challenges, which we'll discuss today. But I think one of the fundamental problems that we've seen is the unlevel playing field we've had with hospital competition and how the hospitals have been really willing, ready and able to acquire independent practices. I think after the recent reconciliation bill, though, I think we're going to see a hard reset of that issue, and I think that landscape is going to evolve, and I think we still need to find ways to fundamentally strengthen independent medicine. But I do think that that's probably the most fundamental shift that's happened over the next year that we're already starting to see it play out.

Rebekah Bernard, M.D.: Some cause for optimism, it sounds like. Mr. Swanson, more thoughts.

Andrew Swanson, M.P.A., FACMPE: Yeah. I mean, I think I would agree with Dr. Eagle and Dr. Hertz that I think the landscape has now changed, where the pendulum, as you suggest, Dr. Bernard, is back on the upswing, so to speak, with divestiture and some other things going on from major health systems of groups of physicians over the past, I would say three to five years. I think we're starting to see whether it's, as Dr. Hertz suggests, dissatisfaction with the employment models, or just a different landscape, or a renewed strive for independence. I think that that has occurred and is going to occur in greater swaths across the country. But I think different markets and different specialties will see different cases of that return to independence as we watch some of our private equity brethren and ownership eject from those organizations, I think we'll see some lessons learned about where group health can be sustainable, and in some successful exits of private equity and maybe some unsuccessful exits of private equity, I think there will be a lot of lessons learned there as people return to independence, and maybe not to health system employment.

How policy choices shaped today's challenges

Rebekah Bernard, M.D.: Let's turn to health care policy. Many argue that the decline of independent practice is a result of health care policy decisions. How have government and payer policies like Medicare's payment structure created headwinds for independent groups? We'll start with Dr. Eagle.

"Hospitals simply get paid at higher amounts for many of the same services." — David Eagle, M.D.

David Eagle, M.D.: Thank you. I completely agree. I think there's a lot of structural issues, both in the government and the payers, that disadvantage private medicine. And I think it was a choice. I think it really accelerated with the Affordable Care Act. You can look at examples, bundle payments and shared savings models using hospitals, anchor institutions. I mean, those are just structural issues that really favored hospital institutions, and, I wasn't there, but I heard that there was behind the scenes conversations with staffers and say, hey, we got to employ the docs. So, I think there was both formal and informal intent to do that. I think meanwhile, the fee schedule payment for physicians declines, while compliance costs, like keeping up the MACRA, MIPS and meaningful use requirements, is not easy, and it gets harder every year, and I think it's a huge problem for smaller, independent practices. The other structural advantage is hospitals simply get paid at higher amounts for many of the same services. They have a different fee schedule, they collect facility fees, and they're able to leverage higher commercial payment amounts from private insurance, and hospitals are even able to codify any steerage provisions that are into their commercial contracts where the insurers can't even try to direct the their patients care to lower cost, types of services, like independent practices. I can never figure out the payers honestly, you know, I always have this hard time understanding what they're really trying to do. I think a lot of the private insurance plans are self-insured and operate as basically third-party administrators on a cost-plus model. If you look at the exchange plans with the medical loss ratios, it's similar. So, it's never been clear to me what the payer's motivation really is in particular circumstances.

Rebekah Bernard, M.D.: Yeah, and I agree with you that you can't underestimate the demands that administrative requirements cause on private practice physicians. It was MACRA that pushed me out of traditional practice and into direct primary care, where I decided to opt out of Medicare because I just knew that I could not afford all of the requirements that Medicare would demand for me just to simply bill Medicare. Mr. Swanson, what are your thoughts on policies affecting independent practice?

Andrew Swanson, M.P.A., FACMPE: The list is long and it goes back out, you know, in recent history, right, even before the ACA. I mean, I think we start talking about HIPAA and Stark and some of the things that maybe were well-intentioned out of the gate, and even with the advent of EMRs. I mean, I think the notion of achieving quality, high-quality outcomes, is noble, and when regulation gets in the way of administering those desires and outcomes, then I think we are where we are. And so no doubt the regulatory landscape has gotten overly complex, overly burdensome on all medical groups and makes independent practice less sustainable, and very much less sustainable in a solo or dual practice sort of environment, for all the reasons that have just been articulated. So, I think if that's the policy landscape, then I think the future of independent practice, knowing that regulation isn't largely going to change in the relatively near term, then I think the question becomes, how to operate successfully, both with high-quality outcomes and a modicum of profitability inside of those arrangements? And I think that's where we get to efficiencies inside of practices and groups and thinking about, how do you do things like reporting administrative burden tied to payers, whether it's government payer or private pay, with some efficiency, and we'll get into some of the technology advantages that maybe practices will have going forward that they haven't had in the past to offset some of the staffing costs and turnover that we've experienced in the last decade or so. But I think those are the ways that we fight ourselves out of this situation, despite the regulatory burdens and policy burdens that have been placed upon practices.

Rebekah Bernard, M.D.: Mr. Swanson, do you think that there's any political will to make policy changes to better reimburse independent practices?

Andrew Swanson, M.P.A., FACMPE: No. I hate to be that blunt about it, but we have a closed government today who has massive division amongst both parties and regardless of left or right, health care until recently, until we start talking about the large chunks of American populations coming off of the Medicaid ranks, has really been on the back burner for at least, you know, five to eight years, and I don't foresee it becoming front of burner from a policy and regulatory perspective anytime soon. You know, my hope is that with the loss of subsidies, the telehealth nonreimbursement, all the things that are coming undone now because of the closure of the government, perhaps some of those things will rise to the top. But I don't have faith that we can wait for the government to undo some of the mess that we're in, self-inflicted on their own part. But I think we're going to have to operate within the constraints we've been given, even though the constraints get tighter and tighter around us.

Rebekah Bernard, M.D.: Yeah, I mean, I tend to agree with that. A lot of people say, well, we just have to keep asking and petitioning and lobbying. And my opinion is, like, I've done that for so many years. We did that with SGR, and now we're doing that with MACRA. For me, it's like, I'm just going to say I'm not going to play the game that I can't win, and that's why I've stepped outside of the traditional system. But Dr. Eagle, do you think that there are any policy changes that could turn things around for independent practices?

David Eagle, M.D.: We'll come to them. And I think we do have our limited champions. I think Congressman (Greg) Murphy, who's a urologist in North Carolina and chair of the doc caucus, I think he very much wants inflation updates to the fee schedule. I think there are a few people that absolutely want to help us. We do have some doctors retiring for Congress. That's a problem. I think everybody of us on the front lines of medicine see it every day, though, that the workforce shortage is just a real issue. I think even though our elected officials may not want to confront this, I think the workforce shortage is going to force people to confront this. I find it harder and harder each and every year to take care of patients, because it's just so hard to get other doctors and other providers involved at the speed of cancer. And I think that's, for so many reasons I think that's going to get even worse. You know, the demographic challenges, the aging of the population, the aging of the workforce. I think as much as the policymakers would like to ignore this, that's going to force them to reckon with where we are right now.

Practical steps to stay viable

Rebekah Bernard, M.D.: Well, in the meantime, while we're waiting on that, let's talk about what practical actions independent practices can take to function within these constraints, as you'd said, to improve our margins, to strengthen our bottom line. Dr. Lucarelli, thoughts on how doctors can do that?

"Chronic care management actually is a good revenue generator for our practice." — Melissa Lucarelli, M.D., FAAFP

Melissa Lucarelli, M.D., FAAFP: Well, that's a good question. I think the answer is probably different for independent surgeons or independent consultants than it is for primary care. Maybe not, but a first step as a primary care doctor would be to try to take advantage of all of the various piecemeal fee-for-service programs that are out there. So, for example, transitional care management, and set up a program for that at your clinic. Chronic care management actually is a good revenue generator for our practice. Remote telemonitoring, there’s regulations changing all the time, that's a moving target, but remote telemonitoring is also a good service to provide that can generate some revenue. Going forward, I think the biggest thing that primary care practices can do next is to become more adept at value-based care. That's the payment model that CMS has said they'd like all Medicare programs to adopt by 2030, I think it is. Medical Economics, to put in a plug, has published many helpful blogs and articles on the topic. There was one recently that was called Saving Primary Care. To be successful in value-based care, I think it's important that you start by understanding how to code risk adjustment factors, and that's just giving you credit for the complexity of the patients that you're caring for, and also how to get credit for our care quality through claims. I didn't even know what a CPT II code was until, like, a year ago, and that boosted our quality payments phenomenally by just flipping that switch on. And so that's a sidebar, but as far as policy changes go, there are other panelists that are much more knowledgeable about that than I am. But I think the number one policy goal would be to fix the Medicare Physician Fee Schedule. I think that's critical. As Dr. Eagle was discussing, hospital reimbursements continue to rise and have continued to rise over the past decade, but inflation adjusted physician payments have continued to fall. And this year was especially challenging for us because Medicare cut our reimbursement by almost 3% at the beginning of 2025 combined with all of the inflation and everything costing us more. It was a really, really challenging beginning of the year, and also very difficult to budget, and it still is difficult to budget.

Rebekah Bernard, M.D.: Yeah, it feels like physicians are the only profession that doesn't get a cost-of-living raise, and in fact, we get cost of living cuts somehow, and yet we're expected to continue to provide this high-level care. Dr. Hertz, what practical actions do you recommend independent practices take to strengthen their ability to function?

Andrew Hertz, M.D.: I think I can clump them or classify them into technology, collaboration, and then advocacy or policy. And in the technology front, certainly data analytics to help them manage their population better. AI, whether that's prescribing or for coding or for, again, population management. But these things can be expensive, as somebody referenced earlier, so that brings me to the collaboration, and we're an MSO, I obviously believe in that model, but having independents work together with a backbone, an administrative backbone, can take away a lot of the burden that they have when they want to just see patients. And more and more doctors just want to see patients. They don't want to be administrators.

Rebekah Bernard, M.D.: Dr. Hertz, define MSO for us.

Andrew Hertz, M.D.: A management service organization so the doctor can see patients, run their own autonomous practice, but have some common services and contracting in a backbone. And then third is the advocacy some of the policy things we talked about, payment reform, certainly, but we also need reform on noncompetes. Noncompetes are inhibiting doctors from going into independent practice, and that may need to be addressed. There's pros and cons to that, but certainly that needs to be addressed. The payment reform, even the payment fee schedule now tries to accommodate for facility fees versus non-facility fees. But the independent practices, by a lot of measures, are lower cost of care, but their fee structures are no different, and they're often less than health system fee structures. So again, that's advocacy to let people know that independent practices do and can deliver cheaper total cost of care.

The prior authorization bottleneck

Rebekah Bernard, M.D.: Well, I want to send all of y'all to D.C. to straighten all this out, because I think you've got the right ideas. So, I'll throw another one at you that hopefully we can solve, which is prior authorization. It remains one of the biggest nightmares for independent practices, and I guess all practices. How are physicians coping, and what reform efforts could make the biggest difference? Dr. Lucarelli.

"The AMA says that on average, a physician completes 39 prior auths per week per doctor." — Melissa Lucarelli, M.D., FAAFP

Melissa Lucarelli, M.D., FAAFP: This could be an entire hour talk in itself, but let's not. So, the AMA says that on average, a physician completes 39 prior auths per week per doctor. So electronic prior auth systems have helped our practice with prescription prior auths, so there's portals that we can go in and a lot of times get things straightened out that way. But I think there should be a standardized, evidence-based criteria for approving procedures and imaging across all payers, so we don't need to log into multiple portals, take time to answer questions without knowing what the right answer is for that particular imaging study or that particular procedure that we're trying to get authorized, or durable medical equipment. It just doesn't make sense. It's a huge time drain. And sometimes I feel like it maybe is partially by design, because it wears us down and it's burning us out. And at some point, I think you kind of get — a person could potentially get frustrated and just say, oh, well, I guess I'm not going to pursue this care that my patient needs, because it's too much time, it’s too onerous.

Rebekah Bernard, M.D.: I think you're so right. I'm just thinking of the last one I did when I called and they said, What's your first name and your initial? And I said, Doctor B., and they said, no, your first name. And it kind of felt like just a runaround, and then they wanted me to give them the same information over and over again. And so, yeah, I think that there's something to what you're saying. What about you, Dr. Hertz, what are your thoughts on prior auths?

Andrew Hertz, M.D.: I loved everything that Dr. Lucarelli said. We need to automate it. We need to stop, and I'm going to sound a little cynical here, but, you know, we need to stop the perverse incentives that exist in volume-based medicine, in for-profit insurance, and create some standardization so that these perverse incentives are not standing in the way of doctors providing care. I do think that technology is a solution there as well and standardization. It doesn't have to be an expensive, bureaucratic solution. I think it can be a very simple solution that has to be regulated and demanded.

Rebekah Bernard, M.D.: I think this is also an area where some innovation can be helpful, in the sense that I won't do a prior authorization on a generic, inexpensive medication when I can give the patient a GoodRx price that's pennies on the dollar. Or I have here in Florida, and many states we’re allowed to have in-house dispensing of medications. So I keep almost all the basic generic meds here. Again, you know, you can sell a bottle of 90 Lisinopril for, you know, $3, $4 there's no reason I should do a prior authorization for something like that. So, a little bit of pushback in that respect.

Adopting AI without overstretching

Rebekah Bernard, M.D.: Let's shift gears and talk a little bit about AI and automation. We know that artificial or augmented intelligence (AI) is reshaping documentation, coding and patient communication. So how can smaller practices adopt AI effectively, without creating new costs or ethical risks? I'm going to start with Dr. Hertz.

"[AI] can really help you and streamline some of the work that needs to be done." — Andrew Hertz, M.D.

Andrew Hertz, M.D.: Thank you for starting with me. I think the independent practices can use it in many ways, including running a typical business. So marketing, so much — I don't want to offend any marketers, but much of things can be done through AI to assist you so they're not spending five hours, you're spending one hour on your marketing campaign to get your messages out. I think it can also certainly help, as you said, prescribing, coding, patient care, data analytics. All that will help, but even your finances, your marketing, basic, simple compliance issues, it can really help you and streamline some of the work that's that needs to be done.

Rebekah Bernard, M.D.: I love my AI documentation. I wrote about it for Medical Economics because it has been such a game changer for my time management. What are your thoughts, Dr. Lucarelli?

Melissa Lucarelli, M.D., FAAFP: Well, we're not using AI right now, because I looked at integrated ambient AI transcription and to get one that works and actually is part of the electronic health record, runs around $500 per provider per month, and we have a three provider practice, because I have a physician assistant and nurse practitioner who work part time in my practice. So, $1,500 a month is a lot for a practice my size. So we elected to hold off. My hope and what I've talked to my clinic manager about is that, just like AI has become integrated into our search engines now and our online shopping and all that, that AI is just eventually going to be part of the EHR without having to purchase it separately because it's going to be a requirement of a fully functioning EHR, so that our practice can have the same benefits that other practices that are well-funded and perhaps not on an independent physician budget, could afford. Again, I think it's better patient care, I'm on board with it, but can't afford it right now.

Rebekah Bernard, M.D.: Hopefully, like you said, that's going to start to change as it gets more and more advanced. Dr. Eagle, do you want to weigh in on AI or automation?

David Eagle, M.D.: Yeah, I'm, you know, the area where I really personally like a lot, is OpenEvidence. I think it's absolutely spectacular in terms of being able to use that. And it's like having a very smart doctor right beside you that you can ask questions to all day. And I think on the operation side, I think there's a lot of room, and I'm not part of this, but for revenue cycle management and how many personnel were directed to that, and there's a huge opportunity for AI to help with that, among other things. And I think this will be one of the most rapidly changing areas that we've ever seen in our career. I'm excited to see what comes.

Rebekah Bernard, M.D.: It is amazing, OpenEvidence. I've just started recently using that, and it just feels so good to double check yourself, and the patients are very accepting of it. And I think some people fear that AI is going to replace physicians, but I don't see that at all, because you have to know the right questions to ask, you have to then dig in deeper, again, with the right questions, and interpret that information for that patient in front of you. So I think it will only help us. That's my opinion.

Consolidation, divestiture and the new competitive landscape

Rebekah Bernard, M.D.: Let's shift over to talk about consolidation and competition. Mr. Swanson, you did mention that there's a little bit of divestment now happening with PE. Do you see that continuing to trend, or are you seeing that there are still some acquisitions happening for private practices?

Andrew Swanson, M.P.A., FACMPE: Yeah. I mean the level of the volume of transactions to set this certainly curved. There was obviously a halt during COVID, and then afterwards, there was some bump in M and A activity and purchase activity, primarily in the private equity space, less so in the health system space, that also has now quieted down. And so I think we're in this lull period because people don't know what they're investing in, right? And I think that is on both buyers and sellers. And so that's good, I think that's a healthy place for the market to be. And as we see health systems getting concerned about their own reimbursement rates, we are seeing divestiture of different groups, whether that's certain specialties or different practice locations, depending on the market, we are seeing groups come out from under health system employment. And of course, they're either going to PE or more largely turning back to independent practice, I would say, at scale. So where you see a group of primary care docs coming out in small numbers, a dozen here, six to eight there, they are forming their own practices. And so there was a big divestiture in North Carolina, I think a year and a half ago. We're seeing that happening a little bit in California. So across the country, and starting on the coast, and then what tends to happen, right, is that it moves to the central part of the country. So I think we're on the beginning waves of seeing some of those, again, whether it's health system ejection of providers or providers just saying, I'm not signing on for this contract anymore, and leaving health system employment and joining with some of their cohorts and building their own practices up again. I think people now understand some of the downside of employment, as some of the physicians have mentioned on this call before, and have relearned the new way. And I think the notion of technology augmentation helping some markets where staffing is not quite as volatile as it was two or three years ago, I think that's also a harbinger of better things to come. More stability in the workforce, I think is causing people to re-examine independent practice and thinking about it as a more viable model. I think all those things point to a bit of a rebirth of that ownership structure.

Rebekah Bernard, M.D.: You kind of wonder if private equity has squeezed out as much money as they possibly can at this point, and now they're jumping out. What I'm hearing from colleagues is that those golden parachute buyouts are not happening to the same extent where you'd have the senior physicians take these ginormous amounts of money to sell their practice. I understand now it's really been cut down quite a bit, so I think that is probably motivating physicians to not sell to those companies as much as well. Dr. Eagle, what have you noticed in the arena of consolidation?

David Eagle, M.D.: Yeah, so I'm part of New York Cancer and Blood Specialists. You know, we're 300 doctors at New York City and Long Island. We hired 52 doctors last year, you know, as a private group, and we're not in a market that has any natural advantages to private groups. We have extremely talented management, our CEO, Dr. Jeff Vacirca, and our president, Todd O'Connell, are extremely good operators. But we focus on the patient service that I think is getting harder and harder to find. Getting patients in for visits quickly. You can do walk-in visits to our clinic, we do a lot of same day visits. You know, when patients need something, we try our best to give it to them. We're in people's local communities. We open clinics in places that other systems don't want to go. And I think that's getting more and more important to people these days. I think these big institutions, they're just not as nimble, and I think just believing you can do it is important, you know, that there's still a way to succeed in private medicine. It's not easy, but it can be done. We're part of a management service organization. Dr. Hertz mentioned that he's part of an MSO. We're part of OneOncology, and that began about eight years ago. We're up to about 30 member practices across the country. I think it's important to say that that whole MSO got started with the help of private equity capital, that’s not necessarily a bad thing. I think that can be a very good thing. And I think particularly when it's equity capital and everybody's interests are aligned, that does not have to be a bad thing at all. In fact, I think done properly, it's a very positive thing, and that's what we've experienced. And I think oncology practices that would have had no choice a few years ago but to go to a hospital now have another option, another pathway, to do that. And we can improve operations. You know, we can help them with financial performance, we can help them with MACRA MIPS compliance and cybersecurity. When the Change Healthcare cyberattack happened, you know, roughly 18 months ago, there was financial support to practices that otherwise may have put them under and I think it's really so much as to how you do things. We try to offer things to practice that improve operations and financial performance, but doctors never like it when you tell them what to do. You have to give it to them as an offering, but never really tell people to do things that they don't want to do. So I think how you do things is just critical.

Rebekah Bernard, M.D.: We may all need a psychiatrist as part of our teams, maybe.

David Eagle, M.D.: Yes, exactly.

Rebekah Bernard, M.D.: You know, I am curious, like, what is that line between PE that kind of comes in and squeezes money out and flips it and sells it in pieces, and good PE that helps practices like yours get going? Is the difference having physician leadership involved?

"There's no way to grow an operation without capital these days, and there is a proper way to do it." — David Eagle, M.D.

David Eagle, M.D.:I think it is very much about, I think it's about the amount of ownership, in the percentage of ownership, the physician leadership. I think some of the problems that have happened in bad PE stores tend to be debt capital, where there's too much debt laid on an organization, particularly on the hospital side. I think when you have things like equity capital, the interests are more aligned. I think the key concept, though, is there's an absolutely productive, responsible way to do it that is very good for physicians. And I think instead of just kind of like trying to push the whole area back, understand that everybody has a capital partner. It could be Bank of America, it could be some other group. There's no way to grow an operation without capital these days, and there is a proper way to do it.

Rebekah Bernard, M.D.: Thanks for that. And just one last question on MSOs, because I don't know too much about them. Are those traditionally physician-owned? Can they be any type of structure?

David Eagle, M.D.: I think they can be structured in many, many different ways. But you know, ours is, there's a lot of physician ownership in that. The other element is, is, you know, what is the percent interest of the outside group in the practice? And just physician leadership, Again, our CEO of OneOncology is a medical oncologist. And I think that type of leadership arrangement makes a big difference as well.

Rebekah Bernard, M.D.: What about your MSO, Dr. Hertz?

Andrew Hertz, M.D.: Same idea, it's physician-owned, physician-run. All the doctors that contract with the MSO become owners in the MSO as well. So it's very important, and it allows you to create the importance of culture, and really think about culture.

Rebekah Bernard, M.D.: I love that. I think physicians getting back into medicine, taking back control of medicine, making sure that patients are put first, I think all of that is just such a recipe for success.

The workforce strain: How to retain good people

Rebekah Bernard, M.D.: Let's move into workforce. We know that we have a lot of struggles with staffing shortages. We know there's physician shortages, and we know burnout is still very much an issue. What innovative models are emerging to recruit staff, to retain good doctors, and to delegate work to support physicians and staff? We'll start with Mr. Swanson.

"People want to be challenged. They want to do exciting and interesting things at work." — Andrew Swanson, M.P.A., FACMPE

Andrew Swanson, M.P.A., FACMPE: As long as I've been in health care, it's about 15 years now, I mean, we've been talking about operating at the top of your licensure for at least that long and then some time. And not to bring back an old wives’ tale, but I think that notion outside of the provider lens is also highly valuable. So making sure that the right staff are doing the right thing becomes, I think, the key to unlock this here. And that’s first and foremost to relieve our provider burden and making sure that the staff that we are employing is doing challenging work, so that providers who should be focusing on patient care can focus on patient care and don't have to worry about the denial that they're fighting with this payer, or whatever the issue du jour is at the moment. And also that brings employee satisfaction, which I think is at the at the crux of keeping and retaining staff, if they are operating at quote, unquote, the top of their license, although they're not licensed, I think that that challenging effort and knowing their contribution to the success of the practice, I think, ultimately becomes the retention carrot that perhaps we've been lacking. People want to be challenged. They want to do exciting and interesting things at work. As we circle back to the AI conversation, you know, giving staff autonomy to bring these new, innovative tools and technologies into the practice, to help them augment their own work, I think, gives them the autonomy and creativity and how they get work done that perhaps before that technology, we were locked into the old ways. And so as we engage staff to support us and think about how to make our groups in patient care successful, I think giving them some of that ownership in the creativity and solving these problems that have long been challenging to solve, but perhaps with some technology, there's a little bit now ubiquitous across groups, I think maybe that gives staff some excitement, some ownership in the solution. And that maybe solves some of our retention challenges when we know we can't just keep compensating more and more and more because our cost structures are way too high.

Rebekah Bernard, M.D.: Yeah, it's so interesting when you say that. I think about the old days when you know you would have you would give an order verbally. To a desk clerk or ward clerk, and then came computerized physician order entry. You say, function to the top of your license, and yet, here you have physicians typing in orders and spending all this time. And likewise, I often wonder, if it wasn't for billing and coding, would we need to pay a nurse practitioner or physician assistant at these higher salaries, if a registered nurse or even an LPN could, if it wasn't about just submitting a code, and then you wouldn't necessarily have to pay those higher amounts of salaries. So just kind of almost again coming full circle, you think. Dr. Hertz, what are your thoughts on staffing?

Andrew Hertz, M.D.: Yeah, I agree with Mr. Swanson, and use of technology will help to make people's lives easier. But I'm going to answer a little more on a higher philosophical level, push back a little bit to Mr. Swanson. Look, the country is highly polarized. There's a lot of animosity. Patients have a lot of animosity. They don't like being treated like a number and high volume, and the same for the staff. So we have to solve the staffing issues, both the doctors and the support staff, with culture, with love, with compassion, with relationships. I like this idea of practicing the top of your license, but remember, doctors really have two parts to their brain as to why they went into medicine. They want to practice at the top of their license and be stimulated or challenged, intellectually challenged. But most doctors also want to have relationships with patients, have compassion, interact. And when you're always acting on the top of your license, sometimes that relationship is going away. And we need relationships with our staff. We need relationships with our patients to stop the moral injury. The doctors want to be able to be there and spend time with their patients. When you're always top of your license doesn't necessarily mean time with a patient. It doesn't necessarily mean compassion or empathy or sympathy, whatever word you want to use. So I think we have to relook at our cultures. I think the independent practices have an advantage in being more nimble in creating a culture which can attract and retain staff and physicians. And I'm not saying that's bad about all health care systems, but when you have 20,000 employees, 15,000 employees, and you're paying all these HR staff and all these lawyers, it's a lot harder to be nimble and create a culture which is really supportive of compassion, love relationships. I'll stop there.

Rebekah Bernard, M.D.: Well, I love that, because when you ask doctors, why do you enjoy medicine? Why did you go into it? It was for relationships, it was for those patient interactions and experiences. And that's what keeps us going. And I think that has been a problem with introducing electronic health records and introducing these burdens that have basically put barriers in between us and patients, and I think these, being able to own your own practice and come up with an innovative practice model, does help us to reclaim some of that part that we love so much and what our patients really yearn for and need. Dr. Eagle, do you have any comments on workforce?

David Eagle, M.D.: I do, I think it's such a critical issue. And I think this is where doctors are really at an advantage, because, you know, those are from the front lines really see something that the rest of the world doesn't see quite yet and don't appreciate. I noticed so many things. I mean, the world has changed so much in the 25 years that I've been in practice. But one of the real things that I noticed is, like, the division between authority and responsibility. You know, so much of how my patients are taken care of, I'm not in charge of anymore. It's these distant people in corporate board rooms or distant bureaucratic agencies, government agencies, and it's not between myself and the patient any longer. And I think that can be really a source of frustration and burnout for physicians and everyone else, and such a frustration for the patients too. And I think one thing that I would like to see independent physicians argue thematically, is a realignment of authority and responsibility. Those two things should go together. I'm happy to take responsibility for my patients, that's what I want to do. But don't give me the responsibility and then tell me that I don't get to do X, Y or Z when I take care of them. I think that should be a thematic thing that independent medicine really argues for.

Rebekah Bernard, M.D.: Right, or punish physicians financially, if your patients aren't adherent to medical plans for whatever reason.

David Eagle, M.D.: Yes.

Rebekah Bernard, M.D.: You know that it puts a lot of responsibility for outcomes on minimal chance for making change. You know, there's only so much that we can do, and yet we're shouldering all this responsibility. I think you make an excellent point. Dr. Lucarelli, you're in solo practice. Talk to us about the challenges of running a solo practice. How has that evolved over the years? What kind of changes have you had to make to keep the practice viable and growing?

Melissa Lucarelli, M.D., FAAFP: Well, I was really resonating with what Mr. Swanson was talking about. Staffing at my clinic is totally different now. I went from, when I was first in practice, to having one dedicated registered nurse per physician, and now we have a physician assistant, an NP, myself, two CNAs, an MA, a chronic care coordinator, and we're working as a team and our clinic manager works hard to track our quality metrics and our pay-for-performance incentives. And recently, I guess the biggest change is, we joined a PC Flex ACO for our Medicare contracting. So our clinic staff meets monthly and we discuss workflow and coding updates and for patient visits now, we preprocess patient visits as much as possible. So before I see a patient, a team member has already completed the health screeners, which a lot of times are done online through the portal. They've already pulled all the relevant labs for me, they've already pulled the consultant notes that they've seen since my last visit with them, hospital records. If there was an imaging study, they have tracked that down already for me, it's already in my note. Now they're even putting my future labs in there, so that if they know that I always check a lipid panel every year they've already got the order for next year, just waiting for me to approve. So that as much as possible of the time that I spend in the exam room or in the telehealth visit, as the case might be, is spent listening to the patient and being able to focus on their care. I’m improvising here, but there's, there was a book that I read a while ago that was called “Attending,” it was sort of a dual meaning, because attending physician versus being present and mindful of attending to the patient. I really took that to heart, and I think I'm able to be more attentive and more mindful now than I was when I was first in practice. And I also take a lot less charting home now than I used to now that we've kind of figured out a way to do this, so that's what we're doing.

Rebekah Bernard, M.D.: You've invested a lot of time and focus in getting your policies and your procedures, and, you know, trying it out, and now you're reaping the benefits of that in a much smoother system. But it clearly, it took that physician leadership and that time to develop that.

Melissa Lucarelli, M.D., FAAFP: I think what Dr. Hertz was talking about is so true. You really need to be nimble, but also listen to your staff and try stuff. I mean, during COVID, it seemed like we were doing something new every week, trying to figure out how to stay open and how to take care of patients and trusting the input of all of your staff members is really important, but it also helps with retention. It helps you to keep good people.

Rebekah Bernard, M.D.: And that is not something that's easy to do when you work in a big system, trust me, that nimbleness, that ability to be flexible, like, let's try this, let's try that. I can't tell you how many times I would go to my administrator and say, I have an idea, and they'd say, that's not how we do things here. So it's a huge plus to owning yourself.

New models of independence: MSOs, DPC and shared infrastructure

Rebekah Bernard, M.D.: So on that note, Dr. Hertz, your pediatric network allows physicians to practice the way they want to, but they share the infrastructure. Talk to us about Zest’s model and what lessons we can learn from it.

Andrew Hertz, M.D.: It is a typical MSO, management service organization model. The doctors contract with us. I always say I work for the doctors. I think lessons learned are that we have to remain as we've just been saying, nimble. We have to remember to be innovative as we grow. We're about a dozen doctors now, and we want to grow much more, but a dozen in 2 ½, it's going to be very important to maintain a culture of simplicity and nimbleness. We cannot become overly bureaucratic. We cannot get a lot of infrastructure. We have to be lean. So let's add lean, nimble, innovative, and that it's really the culture that is going to help. All MSOs share infrastructure, have economies of scale. We designed this model to lower the barriers for doctors to become independent practices, and we have to keep that vision in mind, not become overly burdensome, lower the burden for doctors to be independent doctors, and support them. Again, I think it's, we work for the doctors, and that's the most important lesson we've learned.

Rebekah Bernard, M.D.: What I like that I'm hearing about the MSO is that a lot of physicians aren't ready to just jump into owning a business and figuring out all of these things. It's one of the reasons why I didn't follow Dr. Lucarelli’s model. I just felt like it'd be so daunting to figure out all these insurance things. Direct primary care felt easier, but it still wasn't easy. And it seems like if I had known about this MSO model, that might have been something I would have been very attracted to, because you guys kind of lay all that groundwork out. Is that right?

"Newer doctors ... want work-life balance. They want freedom. They want autonomy ... they want to make a decent salary and be able to get increases as they work harder ... MSO models allow that." — Andrew Hertz, M.D.

Andrew Hertz, M.D.: Well, what do doctors want? Newer doctors, people younger than I am. They want work-life balance. They want freedom. They want autonomy. And so you have to be able to give all of that to them, and then they want to make a decent salary and be able to get increases as they work harder, not the same, right, if they work harder. And MSO models allows that. It gives them autonomy. It gives them the freedom. But they're not doing it alone, they're not out there on an island, they're with a group. So it's really a lovely model. It's not for everybody. Some people want to run their own business, want to be a doctor, want to be a parent, and do all of it at once. But most people don't want to do all that anymore. They want to be doctors. They want to be parents. They want to be spouses. And they want to have their hobbies. It's much different than doctors from 30 years ago, 40 years ago or 60 years ago, where it was all about the practice of medicine.

Rebekah Bernard, M.D.: We've talked about direct primary care, we've talked about shared service networks. We didn't really mention but concierge practices are certainly another innovative practice model that are very attractive in certain areas. Mr. Swanson, what other innovative practice models are you seeing on the horizon? And which of these do you think hold the most promise for growth?

Andrew Swanson, M.P.A., FACMPE: The last 10 years, those are kind of the innovative models, right? So I'm not sure I've got a new silver bullet of practice type. But to me, the model isn't necessarily the answer or the silver bullet. I think it's a combination of the communities that we serve and the geography and the patient base that we're serving that I think forms the best model. So if you've just laid out a half a dozen different kind of practice models, then I think the answer is, depending on where you sit in the world, what model is going to best fit? And some of that's competitive landscape, if you're sitting in a place where it's a whole ton of independent practice and less dominated by health system medicine, then that maybe is a tougher place to stand up concierge medicine, right? If you live in a predominantly urban setting, with a lot of professionals who are living in an urban environment and health systems are dominant, then concierge medicine might be a really nice niche. So to me, it's evaluating the different type of practices that obviously your specialty could be a part of, or be in, and then examining the competitive landscape around you and looking at the patient base that you're trying to serve. And to me, that match of model with market becomes kind of the place where an evaluation can maybe get some differentiation and not just look squarely at, do I want to do direct primary care? Do I want to join a health system or do I want to hang my own shingle? Those things done in isolation, I think is a detriment to the decision making. And I think groups are coming at this from a much smarter and analytical lens, and I think that's why we're seeing some success in reinvigoration of the independent practices. I think groups are figuring that out. They understand the payment landscapes that they're operating in, what the payers are doing, and how they can operate best within that landscape.

Rebekah Bernard, M.D.: I think you are so right when it comes to thinking about your market. Just south of me, in Naples, Florida, there are 60, 70, maybe more, concierge practices, because it's an area of very concentrated wealth. I live, you know, 30 miles north of that, which is a very blue-collar community, a lot of small businesses that can't afford health insurance. DPC, affordable DPC that I call blue-collar concierge, is perfect for that market. Sometimes doctors talk to me about their dream and their vision of what they want to do, but they haven't thought about what the market will bear. And I think that that's a very important piece, that as physicians, we're maybe a little idealistic, we think about what our dream is, what we would love. Somebody is telling me, I want to open a gym and be a doctor and do Botox, and it's like, will that work in your market? And so I think that is such a key point that you've made. Thank you for that.

Where independent practice goes from here

Rebekah Bernard, M.D.: In our last moments, as we're rounding out this panel discussion, I'd like to hear from each of you, your closing thoughts about what we as physicians can do as a profession to promote independent practice. I'll start with Mr. Swanson.

Andrew Swanson, M.P.A., FACMPE: Sure, I mean, I think we talked just briefly about this, but I think understanding your group's cost of care becomes the launching point and everything that we do to think about the viability and success of independent practice, I think begins there. And I think Dr. Lucarelli did a really good job of enumerating her staffing model, what that looks like. We all understand the operating costs and the rising nature of our operating costs. But I think from there, you can really have a productive conversation with payers. You can have a productive conversation with partners, be it capital, as Dr. Eagle mentioned, from a private equity or traditional capital perspective. But I think it all begins with that cost of care and analyzing how our group is doing from that bottom line perspective, and how do we leverage the strength of our group, whether it's small or whether it's bigger. And I think that's the place where we can really understand our own operations and really launch from there and make a successful venture that's going to serve the patients that we want to serve.

Rebekah Bernard, M.D.: Dr. Eagle?

David Eagle, M.D.: You know, if I had to pick one structural performer change to make in the system, for me it would be inflation updates to the fee schedule. I just see it's the cumulative effect of the budget neutrality over the last 20 years, it's just gotten to be too much, and we just had this burst of inflation over the past four years. I think as physicians, we can battle in a lot of things, but simple math is a battle that I just can't win. And I think that's the fundamental reform that we're going to have to have. They call it the physician fee schedule, but I think they should call it the physician practice fee schedule, because the payments we get are used to pay for our employees, and there's been this massive burst of inflation over the last four years. Our employees need and deserve higher salaries, and we just can't do that without an inflation update with the fee schedule. I think we've done all we can with efficiency gains and seeing more patients, and I just don't think you can ask doctors to see more patients than they are right now. So that would be my number one ask for the system at the moment.

Rebekah Bernard, M.D.: How can we do that? Do we need to just get out there, get to D.C.? Be more aggressive with lobbying?

David Eagle, M.D.: Yes, it's going to be D.C., unfortunately, and that is hard. But, you know, we do have our champions. You know, I mentioned Congressman Murphy, chair of the doctor's caucus, because he is very much supportive of this. We have to broaden that voice. It's a hard battle, but it's, I think, for me, it's the one of the most fundamental things we need to do.

Rebekah Bernard, M.D.: Yeah, I totally agree. Dr. Hertz?

Andrew Hertz, M.D.: I think that doctors that are currently in independent practice need to do research, they need to advocate and they need to promote the benefits of being independent, prove the benefits of it. Those that are in employed model or in medical school need to remain curious, and they need to want to learn about alternative models. For example, a lot of people think that DPC or concierge is only for rich people. That's not true. There's a whole lot of Medicaid, Medicare going on, sliding fee schedules. Just be curious and learn about alternative models. And I think doctors that are employed in health systems need to demand that models of care be created that patients deserve. We have to create models of care that patients deserve. Right now they're getting, often getting models of care that are not optimal for them. So just advocate for your patients.

Rebekah Bernard, M.D.: I love that. Dr. Lucarelli, last word.

Melissa Lucarelli, M.D., FAAFP: So making your voice heard, as an independent physician takes time away from your practice. I still think our unique perspective is important. I haven't personally done government advocacy stuff. I'm glad that people like Dr. Eagle do that. I do attend state medical society meetings and I sit on hospital committees. In fact, I'm chief of staff-elect starting next year. One thing that I haven't heard anyone else mention is teaching. Being an unpaid adjunct preceptor is one of my most rewarding aspects of my job. Sometimes the rotation at my clinic is the medical students’ only exposure to practice management and their only exposure to independent medicine. And as Dr. Hertz was talking about, the new generation of students, I agree their goals are autonomy, freedom, and also, you know, being there for patients. I had a student the other day who was super excited because the patient who she was seeing for a diabetes visit agreed to try to quit smoking. And she was like, I did it, I was able to get them to actually reconsider. So the enthusiasm of the students about independent practice is what makes me hopeful for the future of our profession.

"This generation, they are smart, they're excited. They care about patients, they care about so many things in the world. And it does brighten my day when I get to spend some time with them in my practice." — Rebekah Bernard, M.D.

Rebekah Bernard, M.D.: You are so right about that. And this generation, they are smart, they're excited. They care about patients, they care about so many things in the world. And it does brighten my day when I get to spend some time with them in my practice. And then I get especially happy when they come in and they say, oh, I thought family medicine was just like the hospital clinic, and it's just, you got to see people every seven to 10 minutes, and I like this, I think I do want to do primary care. There is nothing that gladdens my heart more than to see somebody realize that there are other ways to provide medical care that brings that relationship back. Well, thank you all so much. That's all the time we have for today. On behalf of Medical Economics and Physicians Practice, I want to thank the panelists for joining us and for sharing their experience, expertise and insight on this important topic. Independent medicine is not disappearing. It's evolving. But it will take all physicians united in purpose to overcome the challenges ahead. Thank you for joining us and for all that you all do out there to keep independent practice alive and thriving.