This article highlights the problem that no one is talking about. Every legislator and regulator in DC wants to discuss the problems getting into a primary care doctor. They couch it as a problem within our payment system that everyone wants to be a specialist because (implied) everyone who enters medicine does so to make the most money possible and specialists tend to make more money. Dr Pelzman outlines the real problem… specialists are just as difficult to find as primary care doctors. Even with an “inside track” as a physician in a captured system, Dr Pelzman couldn’t even get an appointment for his patient. Policies like cutting payment by 25% for total joint replacement, paying 50% for the -25 modifier (which lets your orthopedic surgeon inject your knee the day you see them instead of waiting another several months for the follow up), and penalizing physicians who provide services at facilities, all contribute to the specialist shortage. We have to stop the bleeding and focus on the real problems in healthcare while engaging physicians in finding those solutions medpagetoday.com/opinion/pat…

Fix It Friday: Prior Authorization Next Steps There is momentum in Congress right now for Medicare Advantage prior authorization reform. The House Ways and Means Committee advanced H.R. 3514, the Improving Seniors' Timely Access to Care Act, on July 15 with a substitute amendment, alongside its Senate companion, S.1816, from Senators Warner and Marshall. The bill would require Medicare Advantage plans to build electronic prior authorization systems, meet real-time decision standards for routinely approved services, and publicly report denial rates and processing times. It is worth noting that a version of this bill has been introduced in nearly every Congress since 2019 with broad bipartisan support and still has not reached the President's desk, so no independent physician should treat its passage as settled. Whether this particular bill becomes the vehicle or not, the standard it should be measured against already exists and CMS built it. WISeR bars its contractors from writing new coverage criteria and ties every determination to existing statutory and regulatory coverage policy. It guarantees a real peer-to-peer review with a clinician on every denial. And as of July 6, it now includes a gold-card exemption for physicians with a 90 percent affirmation rate. Medicare Advantage plans have never been required to do any of that. Physicians should be telling CMS and their members of Congress, through whatever legislation is moving, comment letters on Medicare Advantage rulemaking, or direct advocacy, that this is the floor: coverage criteria tied to existing National and Local Coverage Determinations rather than proprietary standards, a genuine same-specialty peer-to-peer review before any denial is finalized, and a gold-card pathway for physicians with demonstrated track records. CMS proved this is operationally possible in six states in six months. There is no remaining excuse for Medicare Advantage plans to offer physicians less. Separately, Congress should let WISeR's own FY2027 funding stand rather than adopt the House Appropriations rider blocking it. The physicians operating under this model today have more real protections than they have ever had under Medicare Advantage. The fix is not to tear that down. It is to make every plan build the same thing.

Day 3: How MSO’s Become Vehicles for Control The Corporate Practice of Medicine doctrine exists in the majority of states to prohibit non-physician entities from owning or controlling medical practices. The principle behind it is that clinical decisions must be insulated from the financial interests of non-physician investors. MSOs developed partly as a compliant structure for outside capital to participate in healthcare administration without crossing that line. The problem is that the line is not always where it needs to be, and enforcement is uneven. An MSO carefully structured to handle administrative functions while leaving genuine clinical autonomy intact is entirely different from one designed to exert maximal control of decision making. The legal structure can look identical while the operational reality can be entirely different. The conversion from administrative support to de facto control follows recognizable patterns. Management services agreements often run ten or fifteen years with automatic renewal provisions and termination penalties that make exit economically catastrophic. Option agreements giving the MSO the right to acquire the professional entity, or to install affiliated physicians as ownership transfers, can hand over practical control without any visible transaction. Private equity understood this structure early. The PE-backed physician practice management model is now the dominant force in specialty consolidation across dermatology, gastroenterology, ophthalmology, orthopedics, cardiology, and increasingly pediatrics. The PE fund owns the MSO. The physicians own the professional entities in states with CPOM laws. The management services agreement, combined with restrictive employment terms and option structures, means physicians retain formal ownership of something that no longer operates as an independent practice in any meaningful sense. Global healthcare private equity disclosed deal value exceeding an estimated $191 billion in 2025, a record. PE-backed physician practice management recapitalization transactions are expected to return in force in 2026 after a three-year slowdown. The capital is back, the infrastructure is in place, and the principal mechanism is the MSO. Oregon's Senate Bill 951, enacted in June 2025, is the most direct state-level response so far. It prohibits MSOs and their shareholders, directors, and officers from owning or controlling a majority of shares in professional medical entities with which they contract. Washington, Vermont, and North Carolina have considered similar legislation. The Milbank Memorial Fund's April 2025 analysis recommended that states require disclosure of MSO financial backers, ownership structures, and contractual affiliations to regulators, with strengthened prior notice and review requirements for MSO transactions. The legislative instinct is right, but there is a meaningful implementation risk: restrictions built too broadly around MSO governance make it harder for physician-owned MSOs to function, which leaves small practices more isolated rather than better protected. Getting that balance right is the whole challenge.