Independent or employed? AOA leaders on the choices facing today’s DOs

Osteopathic physicians (DOs) have long been associated with primary care and independent practice in smaller communities. More than half (55%) of DOs practice in a primary care specialty, according to the American Osteopathic Association’s (AOA) 2026 Osteopathic Medical Profession Report, “Enduring growth of a timeless philosophy.”

But the profession’s 151,240 practicing physicians face the same choices and pressures as their allopathic, or M.D., colleagues:

• Whether to own a practice or join a larger employer
• How to manage rising costs against flat or falling payment
• How to keep up with certification requirements.

Those pressures are familiar to readers following coverage of employed vs. independent practice and Medicare pay that lags practice costs.

Medical Economics spoke separately with AOA President Richard R. Thacker, D.O., MACOI, an internist who practiced for 23 years in Tallahassee, Florida, before moving into academia, and AOA CEO Kathleen S. Creason, MBA, about practice models, policy and where the profession is headed. Their answers are grouped by topic, and this transcript has been edited for length and clarity.

How is the AOA adapting as more physicians become employed?

Kathleen S. Creason, MBA: Like many other associations, we continue to have to demonstrate the value of membership to prospective members, and to ensure that as the medical community is changing, we continue to evolve as well. There’s a higher percentage of physicians employed than ever before in history. So whereas many of our products and offerings had focused on independent private practice, now we are offering additional products and services that are geared toward physicians who are employed, and the needs are very different.

What are the tradeoffs between employment and independent practice?

Richard R. Thacker, D.O., MACOI: Independent practice is not really incentivized enough, so folks have to make hard decisions. Your return on investment in getting a practice started can be great, but it’s also risky. Physicians also have to have partners. Once again, back to that work-life balance: 24/7, 365 days a year is not conducive to a healthy lifestyle and wellness. So you have to share call. Who’s covering after hours and on weekends? Who’s going to take care of my patient if they’re really sick and go to the emergency room and are admitted to the hospital? There’s strength, safety, reassurance and lifestyle that can be built in by sharing with a group.

That has its own economic forces: how you distribute income and overhead costs, and who’s using more resources than someone else. So having someone overarching to take care of the management, the hiring and firing, paying bills, dealing with vendors, scheduling patients and the front office staff can be attractive to a lot of physicians, especially if they want that work-life balance.

What’s the downside? Your income is going to top out at some point. The sky is not necessarily the limit. But more and more young folks are saying, “I’m in a strong profession that’s needed and well compensated, and I don’t want to worry about billing and collection. I just want to take care of people.” I can respect that.

I worked for the federal government in the National Health Service Corps, I was later in private practice, and then my partners and I sold our practice and became employees of HCA. I was treated well. I worked hard before we joined them, and I worked hard after, until I decided to go into academia for the latter part of my career. So everything has worked out for me, but individuals have to figure out what’s best for them.

The days of one doctor hanging a shingle — young people don’t even know what that means — putting a sign out front that says, “The doctor is in, I’m the only one, and this is my practice,” that model is, I won’t say extinct, but nearly so. Even if you go into private practice, you’re not going to show up out of residency and be a partner. You’re going to be employed by that private firm and earn your way into partnership. But more often than not, you will be employed by a larger entity. And it can be a very rewarding career if you have that mindset.

Kathleen S. Creason, MBA: The value is oftentimes that employed physicians are able to focus more on patient care than when they’re in private practice, operating a business and having to worry much more in depth about billing and coding and hiring and firing and a lot of administrative tasks. That doesn’t all go away for employed physicians, but their focus tends to be more on the patient and the patient encounter.

Some of the challenges are that employed physicians sometimes feel as though they are being directed how to practice. They are provided with more strict guidelines and requirements as far as the number of patients they need to see, so there are time pressures they may not have had in private practice.

What are the biggest pressures on physicians who stay independent?

Kathleen S. Creason, MBA: We absolutely do have a significant core of our membership that is in private practice. Osteopathic physicians tend to practice at a higher percentage in rural and underserved areas than allopathic physicians do, and as such, they tend to be more in the private practice realm. Many, many osteopathic physicians are employed, too. But those who still maintain their private practice are facing quite a few challenges when it comes to payment, particularly as regulations have changed and health plans are reducing payment rates.

There’s a perception that physicians are very well compensated, but Medicare rates have decreased pretty dramatically over the last 30 years when accounting for inflation. Costs continue to go up — costs of employing staff, technology, equipment, all of those administrative costs — and that line doesn’t cross well when you have expenses going up and payment going down. That’s a really significant concern for private practice physicians.

How is the AOA making board certification less of a burden?

Kathleen S. Creason, MBA: The AOA and its certifying board services continue to focus very heavily on making sure that the quality of board certification is outstanding, and secondarily, that the experience for physicians is as streamlined and as efficient as possible. The entire point of board certification is to allow physicians to demonstrate qualifications. It’s not to add additional burdens or administrative tasks.

We know physicians are very busy, and we don’t want to waste time with unnecessarily burdensome tasks. So we continue to look at things like osteopathic continuous certification to see if there are ways to make it more streamlined. The American Osteopathic Association has actually designated over $2 million in the last two years to focus specifically on board certification, to ensure that quality is as high as possible and that the process for physicians is as streamlined and simplified as possible.

Do DOs still face unequal treatment in training or hiring?

Kathleen S. Creason, MBA: DOs and osteopathic medical students sometimes do face discrimination. Not always, not often, but it does occur. As an example, there are rotations in a certain Midwestern state that charge allopathic students about $300 to participate, and charge osteopathic students about $4,000 to participate, and they have their stated reasons. It’s something we continue to advocate on behalf of osteopathic medical students.

We’ve found that oftentimes it’s unintentional. In that case, it’s very intentional. But there are circumstances where, as an example, a health care search firm will look to fill a position, and they will advertise for MDs who have [American Board of Medical Specialties] board certification. When we’re made aware, we contact them and make sure they really meant to include DOs and osteopathic board certification. Almost exclusively, it was an error, an oversight, and that is corrected. But there are still times that osteopathic physicians or osteopathic medical students face discrimination, and that’s one of the areas where we advocate very hard on their behalf.

Why should practicing physicians get involved in advocacy and leadership?

Richard R. Thacker, D.O., MACOI: Being involved in health care policy has helped me be a better doctor and serve my patients. I love being an advocate for my patients at the bedside, and an advocate to their insurance companies to get the prescriptions they need, whatever it takes. I never shied away from calling, writing the letter, filling out the forms. Some of it’s mundane and tedious, but if that’s what it takes to get my patient what they need, then I would do that. Advocacy on a health policy level is the same thing to me.

First and foremost, I was so appreciative of the opportunity to become an osteopathic physician. I was that nontraditional student. I had that weak start, the junior college transfer, the psychology major. The osteopathic community recognized something in me: that I would be a good fit, a good communicator, with the humanistic qualities they were looking for. They snapped me up right away, and I felt that I was home. I like to say I didn’t choose osteopathic medicine. It chose me. I have zero regrets in my pathway, and I’m constantly giving back. This is just another way.

Where is the osteopathic profession headed?

Kathleen S. Creason, MBA: The osteopathic profession is going to continue to grow. The number of schools continues to expand, the number of students enrolled continues to expand, and therefore the number of physicians is growing exponentially. The philosophy of the osteopathic profession is so well received by patients, by insurers and by colleagues that the profession will continue to be integrated and will actually, I believe, influence health care in the next one, five, 10, 20 years.

The profession has been around for 150 years, but a lot of people still don’t know what a DO is. DOs are trained and educated in a way that is equivalent to their allopathic, or MD, colleagues, but they tend to have a more holistic, whole-person, hands-on approach, along with the training to perform osteopathic manipulation to diagnose and treat issues of concern. The most important thing to know is that patients are demanding the type of care that osteopathic physicians provide.