Off the Chart: A Business of Medicine Podcast

Direct primary care has been around long enough that most physicians know the pitch: drop the billing, charge a monthly membership, keep a smaller panel and spend real time with patients. What takes longer to answer is whether the economics hold up once you're in it.

Josh Umbehr, M.D., co-founder of Atlas MD in Wichita, Kansas, moved into DPC straight out of residency in 2010 and has spent the years since helping other physicians make the same jump. He joins the show to walk through the real math of a DPC practice, what happens when a patient needs a specialist and why he thinks the window for insurance-based primary care is closing fast.

Music Credits:
Distant Memories by Buurd - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 Cold open: putting the hospitality back in health care
0:22 Introduction
1:44 How Umbehr found direct primary care
3:40 The basic math of a DPC practice
6:38 Panel size, and why bigger isn't the goal
8:11 Setting prices and the good-better-best tradeoff
11:18 What low overhead actually looks like
13:50 Specialists, imaging and hospitalizations
17:38 P2 Management Minute with Keith Reynolds
18:47 The honest timeline and runway to convert
22:31 What AI changes about primary care
26:38 The biggest misconceptions physicians have
29:42 How patient relationships change in DPC
32:34 Where DPC is headed, and 'peak insurance'
34:18 Closing thoughts

The same low-risk procedure can cost five to 12 times more in a hospital outpatient department than in a physician's office. That gap is giving hospitals the money to recruit physicians out of independent practice, and in growing parts of the country there is no independent practice left to choose.
 
Medical Economics Senior Editor Richard Payerchin sat down with three advocates working with the U.S. Women's Health Alliance: Jack Feltz, M.D., the Alliance's president and a founding member; Rebecca Herrero, M.D., MBA, FACOG, president and CEO of Women's Health Associates of Southern Nevada; and Daniel B. Frier, Esq., co-founder and co-managing partner of Frier Levitt.

They walk through the Independent Medical Practice Sustainability and Patient Access Act, the Stark and Anti-Kickback definitions the bill would tighten, and the counterintuitive core of their proposal: pay physicians more for office-based procedures and total cost of care goes down. Feltz and Herrero also make the case for why they're on Capitol Hill instead of in an exam room, when going hospital-employed would almost certainly pay them better.

Music Credits:
Elegant Jazz by Nadezhda Pilitskaia - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:14 | Cold open
Feltz on why the Alliance is fighting: private practice is the cornerstone of health care in the country, and it should be reinforced rather than left to disintegrate.

0:14 – 1:18 | Introduction
Austin Littrell introduces the episode and the three guests.

1:18 – 2:07 | Meet the guests
Richard Payerchin introduces Jack Feltz, M.D., Rebecca Herrero, M.D., MBA, FACOG, and attorney Daniel B. Frier, Esq.

2:07 – 2:52 | What the U.S. Women's Health Alliance is
Feltz describes a membership organization of independent OB/GYN practices operating in 37 states and the District of Columbia, with roughly 5,000 members caring for more than 10 million women.

2:52 – 4:06 | The financial reality for independent OB/GYNs
Herrero on the specialty's shortage, the office-all-day-plus-call-all-night lifestyle, and what younger physicians coming out of residency are asking for instead. The result is an access problem.

4:06 – 6:39 | Why they fight for it
Feltz on opening his first office 40 years ago, with curtains his mother sewed and a reception desk his father built, and what corporatization and vertical integration have done to that relationship since. Herrero is now delivering the babies of babies she delivered.

6:39 – 8:17 | The bill and the trip to Capitol Hill
Frier on building the Independent Medical Practice Sustainability and Patient Access Act with the Alliance's advocacy committee, and why physicians are left out of nearly every conversation about how physicians get paid.

8:17 – 10:27 | The five-to-12-times problem
Frier on how the site-of-service gap gives hospitals the cash to recruit physicians out of private practice, why student loan forgiveness at not-for-profit hospitals is nearly impossible to compete against, and what happens to patient choice once the local independent practices evaporate.

10:27 – 11:35 | What patients actually pay
Feltz on rising copays and deductibles, double-digit insurance inflation, health care debt as the leading cause of family bankruptcy in America, and the studies showing no difference in quality between hospital-based and independent physicians.

11:35 – 12:34 | Why office-based procedures win
Herrero on why patients are more satisfied when low-risk procedures happen in a familiar office, often without an anesthesiologist, and at a fraction of the patient responsibility.

12:34 – 13:25 | P2 Management Minute
Keith Reynolds shares practice management tactics and invites listeners to submit their own workflow ideas.

13:25 – 15:52 | "We could easily become hospital-employed physicians"
Feltz on why he and Herrero would both rather be seeing patients than testifying, why leaving for a hospital would likely pay them more, and why they aren't. Herrero adds where she goes for her own care, and why.

15:52 – 18:56 | Inside the legislation: fair market value and the HOPD delta
Frier on tightening what "commercially reasonable" and "fair market value" mean under Stark and the Anti-Kickback Statute, and the counterintuitive ask: narrow the office-versus-hospital gap by paying physicians a little more, not by cutting hospital rates.

18:56 – 19:57 | Where hospitals and practices should be spending their energy
Feltz argues the current competitive landscape benefits no one, hospitals included, and that Congress cannot let health care inflation keep running.

19:57 – 21:33 | Physician-owned hospitals and the conflict-of-interest argument
Frier says the bigger conflict already exists: employed physicians who are judged on patient leakage and risk their jobs if they refer outside the system.

21:33 – 22:41 | Nevada's OB/GYN hospital
Herrero on a physician-owned obstetrics hospital and why the overutilization argument struggles when every pregnant patient eventually delivers.

22:41 – 25:15 | "I don't even call myself an OB/GYN anymore"
Feltz on the shift to whole-woman care, the roughly 80% of health care dollars he says are spent on women's decisions for themselves and their families, and 40-year patient relationships. Herrero on why she refers to independent specialists whenever she can.

25:15 – 27:07 | Do physicians still want independence?
Feltz says the desire is enormous and the economic model is stacked against it, pointing to the AMA House of Delegates speaker who couldn't afford to stay. Herrero is seeing pockets of physicians leave hospital systems and come back.

27:07 – 28:04 | An open invitation
Feltz invites any hospital or health plan executive to come talk about a path where both sides prosper and patients get the best care.

28:04 – 29:05 | Outro
Littrell thanks the guests and wraps the episode.

Independent practices are being squeezed from every direction: rising labor costs, shrinking reimbursement and an administrative load that keeps growing. Andy Colbert, senior managing director at Ziegler and leader of the firm's physician advisory practice, has spent nearly two decades helping physician groups decide whether to stay independent, merge or sell.
In this conversation with Medical Economics Senior Editor Richard Payerchin, he lays out the scale it takes to remain independent today, what a practice is actually worth when an offer arrives, and how private equity, hospital partnerships and management services organizations really compare. Physicians weighing their next move get a clear framework for the decision, and a reminder to build a strategic plan before someone else sets the agenda.

Music Credits:
Velvet Sunday Drift by Tea Studio - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:28 | Cold open — Colbert on why clinical work alone no longer builds practice value.

0:28 – 1:31 | Introduction — Austin Littrell previews the episode.

1:31 – 3:18 | Meet Andy Colbert — from a family of physicians to leading Ziegler's physician advisory practice.

3:18 – 8:27 | The biggest shift in physician M&A — waves of consolidation, the roughly 40 to 50 physician threshold it takes to stay independent, and why ownership now means thinking like a business person.

8:27 – 15:39 | What a practice is actually worth — cash flow as the real measure of value, the 30% "scrape," and how the math shifts with years left in practice.

15:39 – 16:30 | P2 Management Minute — Keith Reynolds.

16:30 – 20:47 | Hospital deal vs. private investor — day-one reimbursement bumps, the defensive play, and platform vs. tuck-in.

20:47 – 24:56 | The private equity debate — Colbert's case for PE as a healthy third option between hospital employment and the health plans.

24:56 – 28:54 | The AI question — where artificial intelligence helps practice economics, and why it favors scale.

28:54 – 31:48 | Staff and overhead in a deal — why headcount usually holds, and how to communicate change without spooking staff.

31:48 – 34:55 | The MSO strategy — using a management services organization to think and act like a real business.

34:55 – 37:56 | A message to primary care physicians — build scale and write the three-to-five-year strategic plan before someone knocks.

37:56 – 39:05 | Closing thoughts and outro

More physicians are turning to concierge and hybrid concierge models to shrink their panels and steady their finances, but the move carries legal exposure that's easy to miss until it becomes a problem.
 
Ericka Adler, J.D., health care practice group manager at Roetzel & Andress, joins Medical Economics Managing Editor Todd Shryock to walk through the rules that trip practices up: why a membership fee has to be tied to a service insurance doesn't already cover, how Medicare and commercial contracts can quietly prohibit what a practice is planning, and what physicians have to put in writing so patients are never left feeling like they have to pay up or walk. She also lays out the planning, market research and runway it takes to make the transition actually work.

Music Credits:
Nightfall Reverie by KBH Production - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:26 | Cold open Ericka Adler on why calling yourself a concierge practice doesn't let you cut legal corners.

0:26 – 1:33 | Introduction Austin Littrell previews the episode and the legal considerations behind concierge medicine.

1:33 – 1:53 | Meet Ericka Adler Todd Shryock introduces the guest and the topic.

1:53 – 3:07 | Choosing the right entity Why entity selection for a concierge practice is no different than for any medical practice, and how state law drives the choice.

3:07 – 5:36 | Hybrid vs. cash-only, from a legal view In a hybrid model the membership fee has to cover something insurance doesn't, and what counts as "not covered" changes year to year.

5:36 – 9:02 | What physicians overlook in the switch Proper notice, terminating contracts and why you can't force insured patients to pay a concierge fee to stay.

9:02 – 11:43 | The Medicare problem Annual physicals are covered now, 24/7 access may already be required, and old membership documents can leave you charging for things you no longer can.

11:43 – 14:12 | The patient contract What the agreement has to spell out: the fee, what it covers, proration and what happens when a patient dies, moves or leaves.

14:12 – 15:03 | P2 Management Minute Keith Reynolds shares practice management tactics and invites listener submissions.

15:03 – 16:48 | The documents you still need Informed consent, HIPAA, financial forms and good faith estimates all still apply, no matter the specialty.

16:48 – 18:30 | Risks unique to concierge How a cash-based practice's exposure differs from a hybrid model that still bills insurance.

18:30 – 21:25 | The 24/7 access marketing trap Why "24/7 access" can't be the basis of a hybrid membership fee when most plans already require equal treatment.

21:25 – 25:29 | Planning, patients and market research Giving patients runway, avoiding abandonment and making sure your community can actually afford the fee.

25:29 – 28:27 | Building the transition the right way The financial, marketing and legal steps to take in order, plus the private equity money moving into concierge care.

28:27 – 28:42 | Closing thoughts and outro Todd thanks Ericka and Austin wraps the episode.

Physician compensation has never been simple, but in 2026 it is especially fraught. Medical groups and health systems are contending with workforce shortages, flat or declining reimbursement, rising operating costs and the regulatory limits that come with employed and affiliated models all at once — and a competitive offer, on its own, no longer closes the deal.

Medical Economics Associate Editor Austin Littrell sits down with Tynan Kugler, M.P.H., MBA, CVA, a principal in PYA's consulting practice, to break down the four forces pulling physician pay in competing directions and what physicians and organizations tend to get wrong about how compensation actually gets built.

Music Credits:
Rooftops by Buurd - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:32 | Cold open — Kugler on the central problem: once compensation is set it creates a floor, and that floor is very hard to step back down.
0:32 – 1:26 | Introduction — Austin Littrell welcomes listeners back from the Fourth of July weekend and previews the episode.
1:26 – 9:04 | The four forces — Supply-and-demand imbalance, the shift to employment and affiliation, reimbursement pressure and the productivity-versus-value tension. Kugler walks through how each is pulling on physician pay, plus the 2026 Medicare conversion factor and the coming 2027 unbundling of global obstetric codes.
9:04 – 13:22 | Competitive pay without runaway costs — Why the strongest groups redesign their models instead of raising salaries each year: hybrid base-plus-incentive structures, quality and access measures, shorter guarantee periods and smarter advanced practice provider strategy.
13:22 – 17:22 | Why pay is so hard to walk back — Compensation sets a floor that keeps ratcheting up. With demand outstripping supply, flat reimbursement and regulatory limits on changing contract terms, employers have little room to pull pay back down.
17:22 – 18:13 | P2 Management Minute — Keith Reynolds shares practice management tips and invites listeners to send in their own workflow ideas.
18:13 – 21:59 | Where there's room to move — Base pay and productivity metrics are the least flexible, because they track market data most closely. The give tends to live in quality incentives and recruitment tools like signing bonuses and forgivable loans.
21:59 – 27:58 | How an offer actually gets evaluated — Most systems work from a board-approved compensation philosophy, then run each physician's facts through it. Kugler contrasts three cases — a physician new to a market, a resident coming out of training and an owner leaving private practice — and walks through how benchmarking decides whether an offer is supportable.
27:58 – 29:17 | Closing thoughts — Not all roles are equal, alignment matters as much as the number and compensation is complicated. Kugler's parting advice: know what you need going in.
29:17 – End | Outro — Austin Littrell wraps the episode.

For the first time in years, physician compensation and productivity have moved in opposite directions — pay is up, encounter volume is down — and practice leaders are trying to work out what it means heading into a turbulent year. Physicians Practice Managing Editor Keith Reynolds sits down with Andy Swanson, chief customer success officer at the Medical Group Management Association (MGMA), to unpack the group's latest provider compensation and productivity data report and the forces behind the split. They dig into why encounters are falling while acuity and pay climb, whether rising compensation against flat reimbursement can hold, and how the new Medicare efficiency adjustment — a 2.5% cut to the work RVU value of roughly 7,700 codes — will land hardest on procedural specialties.

Music Credits:
Paper Cranes by Buurd - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:25 | Cold open — Swanson sets up the central tension: if costs keep climbing while reimbursement stays flat or falls, the current path isn't sustainable.
0:25 – 1:10 | Introduction — Austin Littrell previews the episode and the guest.
1:10 – 1:39 | Welcome and setup — Keith Reynolds welcomes Swanson and introduces MGMA's latest provider compensation and productivity data report.
1:39 – 3:15 | What's behind the split — Encounters are down but carry higher acuity, and compensation rose roughly 1.5% to 3% even as work RVUs slipped. Swanson cautions against reading the volume dip as lower physician effort.
3:15 – 4:29 | Can the split last? — Two long-term problems: pay can't rise indefinitely as production falls, and rising costs against flat or negative reimbursement eventually hit a breaking point.
4:29 – 6:50 | The Medicare efficiency adjustment — A 2.5% cut to the work RVU value of about 7,700 codes hits procedural specialties hardest. Swanson explains how to benchmark around it and defend against the paper-only reimbursement hit.
6:50 – 9:19 | Recruiting into the squeeze — Cutting starting salaries in hard-to-recruit specialties won't land top candidates. Swanson makes the case for schedule management and smarter APP staffing ratios instead.
9:19 – 10:25 | P2 Management Minute — Keith Reynolds shares practice management tips and invites listeners to send in their own workflow ideas.
10:25 – 12:12 | Is burnout the new baseline? — Swanson says the industry has hit a new baseline, with one in three doctors citing burnout as a reason to leave, and argues it's still unsustainable.
12:12 – 14:43 | Why AI's payoff is so uneven — The clear win has been ambient scribes at the bedside. Swanson urges patience on the next wave of gains and pushes back on the industry's short attention span.
14:43 – 14:57 | A quick aside on the OpenAI IPO — A brief, lighter exchange. (Swanson: no personal investment advice.)
14:57 – 17:37 | The one number beyond work RVUs — Total visit volume. Swanson makes the "back to the future" case for panel size and encounters, and a rethink of base-plus-production pay models as APPs absorb more volume.
17:37 – 18:30 | Closing thoughts — Swanson expects 2026 baselines to be wonky and is already looking ahead to 2027.
18:30 – End | Outro — Austin Littrell wraps the episode with a Fourth of July send-off.

For years, Medicare and Medicaid effectively excluded coverage for the medications proven to treat obesity. That is starting to change. In 2026, CMS rolled out two new programs, the Medicare GLP-1 Bridge and the Medicaid-focused BALANCE Model, that open access to GLP-1 drugs for eligible beneficiaries and signal a shift toward treating obesity as a complex chronic disease.

In this episode, Medical Economics Senior Editor Richard Payerchin speaks with Tracy Zvenyach, vice president for advocacy and research at the Obesity Action Coalition, about what those programs do and what they mean for primary care. Zvenyach explains how the two programs differ, the central role physicians will play in determining eligibility and why CMS's move represents a real policy shift after years of debate. She also digs into the persistent problem of drug pricing, where compounded GLP-1 drugs fit in, the place of metabolic and bariatric surgery in comprehensive care and the weight bias and stigma that still shape how patients are treated across the health care system.

Music Credits:
Cherry Blossom Memories by Cephas - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:26 | Sponsor message Copic medical liability insurance

0:26 – 0:53 | Cold open Zvenyach previews the throughline of the episode: the workarounds patients rely on are a direct result of a system that wasn't built to support people living with obesity.

0:53 – 1:42 | Introduction Austin Littrell introduces the episode and guest, previewing the federal push to expand coverage of GLP-1 drugs and what it means for primary care.

1:42 – 2:50 | Meet Tracy Zvenyach and the OAC Richard Payerchin opens the conversation, and Zvenyach introduces the Obesity Action Coalition, a national nonprofit focused on access to evidence-based obesity care and reducing weight bias and stigma.

2:50 – 4:19 | Is obesity finally treated as a disease? Zvenyach reflects on 15 years of advocacy and says the old "eat less, move more" framing is fading as medical guidelines and policymakers increasingly recognize obesity as a complex chronic disease.

4:19 – 6:46 | What primary care physicians are saying Zvenyach describes a spectrum of clinician comfort with obesity medicine, from fully fluent to resistant, and says policy and coverage barriers make it hard for any of them to get patients the full range of treatments.

6:46 – 8:59 | What the BALANCE model does Zvenyach explains the Medicaid-focused BALANCE model, which pairs GLP-1 access with a lifestyle support program at a negotiated $245 price, and notes the Medicare arm was recently split off into a separate program.

8:59 – 10:32 | BALANCE vs. the GLP-1 Bridge The two programs share the same negotiated price and nearly identical clinical criteria, Zvenyach says, but are now split by population: Bridge covers Medicare from July 2026 through 2027, while BALANCE is a voluntary program for state Medicaid plans.

10:32 – 12:30 | Eligibility and the physician's role GLP-1 access won't be automatic. Zvenyach explains that clinicians must attest a patient meets BMI-based criteria, giving physicians a central role in identifying candidates for the programs.

12:30 – 13:21 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

13:21 – 14:50 | Will there be enough time to prove it works? With Bridge set to run only through 2027, Zvenyach explains CMS's plan to gather outcomes and cost data and potentially fold it into BALANCE in 2028, though carrying it forward depends on insurers opting in.

14:50 – 17:31 | Why covering these drugs is a policy shift Responding to the long debate over whether Medicare and Medicaid should pay for GLP-1 drugs, Zvenyach explains how prior administrations read the statute as barring coverage of "weight loss drugs," and argues these are obesity treatments, with weight loss being an outcome rather than the disease itself.

17:31 – 19:47 | The drug pricing problem Zvenyach summarizes the OAC's stance on antiobesity drug pricing: costs have fallen over the past 12 to 18 months, but coverage still isn't part of most standard benefits, leaving many patients unable to afford treatment even through alternative programs.

19:47 – 21:34 | Where compounded GLP-1s fit in Zvenyach frames the rise of compounded GLP-1 drugs as a symptom of system failure, and urges patients to weigh the different safety and risk profile of compounded versus FDA-approved products while the OAC works to close the coverage gaps that push people toward them.

21:34 – 23:15 | The role of surgery Zvenyach makes the case for the full continuum of obesity care, including metabolic and bariatric surgery and newer endoscopic procedures, noting many patients need more than one type of intervention over the course of their treatment.

23:15 – 26:21 | Weight bias, stigma and people-first language In her closing thoughts, Zvenyach points to weight bias and stigma as the root of many barriers, from exclusionary policy language to how exam rooms are equipped, and calls for people-first language and more respectful media representation.

26:21 – End | Outro Austin Littrell thanks the guest and wraps the episode.

Health care hiring is in a strange place. Clinical job applications jumped 10% at the start of 2026, yet the gap between open positions and actual hires keeps widening, a sign that getting candidates in the door is only half the battle.
In this episode, Medical Economics Managing Editor Todd Shryock speaks with Trent Cotton, head of talent insights at iCIMS, about what the data reveals and what physician practices can do with it.
Cotton explains why so many candidates drop out between the application and the offer, how smaller practices can out-recruit enterprise hospital systems by competing on candidate experience and why pay transparency in a job posting keeps the hiring funnel clean. He also digs into the friction that drives applicants away, the two factors that most influence whether staff stay and where AI genuinely belongs in hiring, from automated scheduling to the conversations that should always stay human.

Music Credits:
Steady State of Mind by Yigit Atilla - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:26 | Sponsor message Copic medical liability insurance.

0:26 – 0:57 | Cold open Cotton frames the question driving the episode: how do practices fast-track top talent from hello to hire?

0:57 – 1:39 | Introduction Austin Littrell introduces the episode and guest, previewing what the latest data reveals about health care hiring and how physician practices can compete for talent.

1:39 – 3:14 | What's behind the surge in clinical applications Todd Shryock opens the conversation, and Cotton explains the January jump in clinical applications, tying it to post-pandemic turnover leveling off and clinicians looking for better compensation.

3:14 – 4:35 | Why hires lag behind openings Clinical openings are up far more than actual hires. Cotton points to a steep drop-off after the application, the gap between recruiter and hiring-manager interviews and the bureaucracy of offer approvals, with the fastest-moving practices winning.

4:35 – 5:57 | How a small practice out-recruits a hospital system Cotton's answer is candidate experience. He argues smaller practices win by making hiring feel personal and frictionless, citing survey data that 60% of candidates abandon applications that are too long, opaque on pay or unclear on qualifications.

5:57 – 8:17 | Compensation and the case for pay transparency Cotton says the data doesn't show practices have regained leverage on pay, and makes the case for listing compensation in the posting: it keeps the top of the funnel clean and avoids wasting everyone's time, even as he acknowledges why some employers hesitate to post pay.

8:17 – 10:55 | The non-clinical side Non-clinical applications are outpacing both openings and hires. Cotton attributes the slow pace to the same screening and scheduling bottlenecks, and urges understaffed practices to build a pipeline now, re-engaging strong past applicants before the candidate pool tightens.

10:55 – 11:47 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

11:47 – 13:44 | Removing friction from hiring Cotton defines friction as any point where candidates drop off, and explains how AI-driven skills matching and job simulations are reshaping the process, including a notable shift among Gen Z candidates who now prefer assessments to compete on skills rather than résumés.

13:44 – 14:46 | What drives retention Retention comes down to two things, Cotton says: hiring for genuine skill fit and giving employees a visible career path, especially in high-volume and entry-level roles where people often leave simply because they can't see a future internally.

14:46 – 16:33 | Where AI belongs in hiring Asked whether a hands-on practice has an edge over a hospital using AI, Cotton, a self-described AI advocate, says it depends entirely on where it's applied. He keeps the hiring-manager interview, the deeper recruiter conversation and the offer human, and automates much of the rest.

16:33 – 17:28 | The next 12 to 18 months Cotton points to growing concern about a shrinking candidate supply, and says recruiters are already getting creative, partnering with local universities to build talent pipelines and shape curriculum.

17:28 – 18:43 | Final advice and close Cotton's parting advice: map your candidate journey, decide what only a human can do and what can be automated, then share that roadmap with applicants for transparency. Todd Shryock thanks Cotton.

18:43 – End | Outro Austin Littrell thanks the guest and wraps the episode.

When a patient is treated by an out-of-network physician at an in-network hospital, the resulting payment dispute is supposed to be settled through the No Surprises Act's independent dispute resolution process. A newly finalized rule is meant to make that process work better, and for practices, the headline change is significant: the fee to initiate a dispute has dropped from $115 to just $15.

In this episode, Physicians Practice Managing Editor Keith Reynolds sits down with Anders Gilberg, senior vice president of government affairs at MGMA, to unpack what the rule actually changes, where administrative burden still weighs on practices and why so many physicians win in arbitration only to never see payment from insurers. Gilberg also responds to the insurance industry's criticism of the process, explains which specialties are most affected and lays out the regulatory developments practices should be watching through the rest of the year, from two pending HIPAA rules to the physician fee schedule.

Music Credits:
Moonlit Whispers by Cephas - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:23 | Sponsor message Copic medical liability insurance.

0:23 – 0:56 | Cold open Gilberg previews one of the episode's central frustrations: physicians win the vast majority of payment disputes through arbitration, only to never receive payment.

0:56 – 1:46 | Introduction Austin Littrell introduces the episode and guest, previewing what the new independent dispute resolution rule changes for practices.

1:46 – 4:06 | What the IDR rule is and where it came from Keith Reynolds opens the conversation, and Gilberg recaps how the independent dispute resolution process grew out of the No Surprises Act to settle out-of-network payment disputes, often involving specialties like emergency medicine, radiology, pathology and anesthesia.

4:06 – 5:17 | What the final rule changes Gilberg explains the two biggest wins: the fee to initiate a dispute dropped from $115 to $15, and new remittance codes will tell practices which claims actually fall under the No Surprises Act.

5:17 – 6:12 | What the delay cost practices With the rule under regulatory review for more than two years, Gilberg says the lag kept fees high and left practices to navigate ambiguity over which claims were even eligible.

6:12 – 8:20 | Where the administrative burden still sits New transparency codes will help, but Gilberg says the process remains cumbersome and points to a bigger problem: physicians win arbitration more than 80% of the time and still go unpaid, with enforcement legislation needed to make payers actually pay.

8:20 – 11:01 | The payers' pushback Responding to insurers who say the rule does too little to stop ineligible claims, Gilberg argues they are hiding behind a handful of egregious cases while ignoring how often physicians legitimately prevail, and acknowledges that a few profit-driven ownership arrangements are rare exceptions.

11:01 – 11:52 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

11:52 – 14:08 | What it means for administrators Gilberg notes the IDR process mainly affects hospital-based specialties like emergency medicine, anesthesia and radiology, but advises any administrator to treat denials more seriously now: the path from a 30-day negotiation to baseball-style arbitration is clearer, cheaper and tends to favor the practice.

14:08 – 16:41 | What practices should watch for next Gilberg doesn't see the rule as a signal of broader change, but flags a busy regulatory year ahead: two pending HIPAA rules on privacy and security, the physician fee schedule due in early July and payment issues set to expire at year's end, with a post-election lame-duck session likely to determine the rest.

16:41 – End | Outro Austin Littrell thanks the guest and wraps the episode.

Selling a medical practice is one of the most consequential financial decisions a physician will ever make, and many start the process far later than they should. In this episode, Medical Economics Managing Editor Todd Shryock speaks with Kevin Baker, director of business development at Emergency Care Partners, about how practice owners can prepare for a sale or succession years before they actually need to. 

Baker breaks down the most common mistakes sellers make, the factors that drive a practice's valuation, the financial and legal documents to have in order before approaching a buyer and how selling to a hospital system, a private equity-backed strategic partner or a junior partner each changes the outcome. He also digs into the parts of a transaction physicians tend to underestimate: the tax implications of deal structure, the emotional weight of handing off a practice that represents their life's work and how to protect staff and clinical quality through the transition.

Music Credits:
Jazz Warm Lo-Fi by Nadezhda Pilitskaia - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:23 | Sponsor message Copic medical liability insurance.

0:23 – 0:46 | Cold open Baker sets up the episode's central message: good decisions are rarely made under pressure, and failing to prepare is preparing to fail.

0:46 – 1:39 | Introduction Austin Littrell introduces the episode and guest, previewing how physicians can prepare to sell their practice and plan for succession long before they actually need to.

1:39 – 3:49 | The biggest mistakes sellers make Todd Shryock opens the conversation, and Baker points to four recurring errors: not lining up experienced advisors early, waiting too long to prepare, keeping financials that satisfy the IRS but not a buyer and fixating on the headline price instead of deal structure.

3:49 – 6:08 | How far in advance to start Baker argues the best transactions are intentional and begin years ahead, framed around one question: what would need to be true for the practice to thrive if you stepped away in three to five years?

6:08 – 8:04 | What drives valuation Value comes down to financial performance, risk profile and growth potential. Baker explains how EBITDA anchors the starting point and which risks can drag a number down, from hospital subsidy reliance and locums dependence to ED contract renewals and payer mix.

8:04 – 10:21 | Getting your documents in order Before approaching a buyer, Baker says practices should understand the tax implications of their legal entity structure, clean up the cap table, document partner buyout arrangements and begin assembling a data room of vendor contracts and payer agreements.

10:21 – 13:22 | Hospital, strategic buyer or your partners Baker compares the three paths: partner buyouts that pay out slowly and modestly, hospital deals that often open with teaser compensation before dropping to productivity-based pay and strategic acquirers who can pay more by realizing synergies and offering equity.

13:22 – 16:14 | Staff, patients and the identity transition Baker addresses the emotional side physicians tend to underestimate, urging sellers to define what success means beyond the closing table and to be wary of any buyer who doesn't put clinical quality and staff first.

16:14 – 17:05 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

17:05 – 19:24 | How open to be with your staff Discretion matters early in the process. Baker suggests routing buyer requests through a third-party CPA or advisor where possible, and having a candid one-on-one with a key operations or finance leader when documents and data are needed.

19:24 – 22:40 | Tax implications and deal structure With a "consult your tax advisor" disclaimer, Baker walks through the value of taking equity in the acquiring company, the difference between ordinary income and long-term capital gains treatment and the net present value advantage of receiving several years of earnings up front.

22:40 – 24:19 | Staying on part time after a sale For physicians who want to keep practicing, Baker's advice is to communicate it upfront, make sure there are enough physicians on the schedule to absorb the hours and understand how moving from full time to part time affects benefits.

24:19 – 25:22 | Final advice and close Baker's closing message: start the conversations now, since signing an NDA opens the door to information without committing you to a deal. Todd Shryock thanks Baker.

25:22 – End | Outro Austin Littrell thanks the guest and wraps the episode.