Recently, I witnessed a conversation between two attendings about the grueling process of trying to understand billing. One — a new dermatologist just setting up his practice — had spent days trying to find a benchmark for a routine procedure. Frustrated, he'd finally called the insurance company directly.
"Just tell me the range," he’d pleaded.
The representative refused. "We can't disclose that," they’d told him. "Just write down whatever you think is fair, submit it, and we will let you know what we cover."
Forced into a blind guessing game, the attending submitted an exorbitant number — just to guarantee he wouldn't accidentally under-bill the insurer's secret allowable rate. The insurer eventually came back with a much lower approved amount.
"I was fine with that amount," the young attending told his senior, throwing his hands up. "But why couldn't they have just told me the range in the first place? It makes me look like the bad guy to patients."
An Iron Curtain Has Descended
For decades, confidentiality clauses buried in payer contracts prevented physicians from knowing what the practice across the street was reimbursed for the same CPT code. Setting up your own contracts with insurers offered little relief. When an insurer's representative told you their offer reflected "market rates," you had no way to verify it — and they knew it. This secrecy had a predictable consequence: physicians who tried to negotiate independently felt like they were negotiating blind, while large hospital systems with dedicated contracting departments extracted far better terms. The rational response was consolidation. Let someone else fight.
Between 2012 and 2024, the share of physicians in private practice dropped from 60% to 42%, according to the American Medical Association (AMA). When the AMA surveyed physicians who had sold their practices, 70.8% cited the need to "better negotiate higher payment rates with payers" as a very important or important reason.
It didn't work.
Despite hospitals continuing to consolidate, gain leverage with insurers, and charge massive facility fees, those gains were not passed on to physicians. In 2022, self-employed surgeons out-earned their hospital-employed counterparts by 11%. For non-surgical specialists, the gap widened to 35%. A Health Affairs analysis found that vertical integration with hospitals was actually associated with lower income for specialists. To be fair, hospital employment often wins at entry: salary guarantees, signing bonuses, and loan repayment programs make the first few years more predictable for residents carrying six-figure debt. But the hope that consolidated medicine would drive better payments for physicians hasn't come true. With the continued information asymmetry from contract confidentiality clauses, as well as new ballooning administrative costs, some physicians felt that working within hospital-owned systems was the only option. Yet over the past five years, the payment playing field has been leveled — and most physicians and trainees don't even know it.
Tear Down This Wall!
In 2022, the 2020 CMS Transparency in Coverage rule came into effect, requiring health insurers to publicly disclose their negotiated rates with every clinician. For the first time, a solo internist could, in principle, look up exactly what United Healthcare pays the practice down the block for a Level 4 office visit. The confidentiality clause that made this information off-limits became no longer enforceable.
In principle. In practice, the data is published in machine-readable files so large and complex they typically require enterprise software to parse. Transparency became a business of its own, with a $2 billion market size. Insurers have faced zero published enforcement actions for non-compliance, with a 2025 study finding notable differences in transparency between different insurers. Most of all, from my experience speaking with residents deciding between employment and ownership, many have never heard of this legislation. The practical asymmetry lives on, sustained now not by contract but by inertia and obfuscation.
In March of this year, the Trump Administration's Department of Justice filed a civil antitrust lawsuit against New York-Presbyterian (NYP), the largest hospital system in New York City, for using "all-or-nothing" contracts to force commercial insurers to include every NYP hospital in every plan. The DOJ's argument was straightforward: NYP used its market power to make itself impossible to exclude, which let it maintain prices substantially higher than competitors offering equivalent quality care. This contract prevented payers from offering budget-conscious alternatives or steering patients to lower-cost rivals. A nearly identical case was filed against OhioHealth in February.
The mechanism NYP allegedly exploited — the ability to use contracting leverage to insulate itself from price competition — is the same mechanism that made physicians feel they couldn't negotiate alone. The DOJ is now saying that sort of game is rigged. The structural critique of opaque payer contracting has achieved rare bipartisan agreement, suggesting staying power for rule changes and enforcement. For example, the Transparency in Coverage rule continued to be enforced and supported by the Biden CMS. The question is whether physicians will act on it.
The private sector is running an experiment using this new transparency regulation. Mark Cuban's Cost Plus Wellness now has over 9,200 clinicians on direct contracts with self-insured employers. Every contract is published publicly for any employer to download, benchmark, and replicate. Cuban has explicitly stated that publication of contracts is the point. "When we talk about transparency," he told a Senate panel, "it's one thing to talk about prices, but most companies don't have the sophistication to understand the contractual details. We'll publish them for anybody to copy."
Cuban reports that clinicians are agreeing to rates below insurers, sometimes below Medicare, because the terms are better in every other dimension: immediate payment, no prior authorization delays, no claim denials. I suspect the goal is to create a new, freer market where physicians who are willing to contract directly can find patients and employers who want to work with them.
When I speak with residents, one of the biggest concerns about private practice or ownership is the significant capital spend on administration. The need to hire full-time employees to fight insurers and guarantee one actually gets paid for services rendered. The need to hire consultants and legal experts to check contracts with insurers. If the private market experiment holds, this reality will radically change the calculus for any early-career physician weighing employment against ownership.
What Belongs Together Will Grow Together
The incentive to educate residents about the tools of independent practice is low, because the pipeline of residents into employed positions serves the institutions that house them. The result is a generation of physicians making major career decisions based on an information environment that no longer reflects reality. The wall that made private practice feel unnavigable was real when it was built. It is coming down, piece by piece, through regulatory action, market innovation, and antitrust enforcement.
I am not arguing that every physician should go into private practice. Hospital employment offers genuine advantages, particularly early in a career: stability, benefits, infrastructure, and institutional support that takes years to replicate independently. For physicians who want to focus on research, it may be the right choice permanently.
What I am arguing is that the reason most physicians default to employment, the belief that independent contracting is structurally impossible, rests on premises that are eroding faster than academic medicine admits. Contract confidentiality has been legally outlawed. The federal government is actively dismantling the mechanisms that allowed large systems to contractually exclude competition. And experimental direct contracting platforms are live and growing.
The walls built to keep you from knowing your own rates are coming down. Physicians can expect a more transparent, varied, but competitive medical environment in the next five years. A generation of physicians were forced out of ownership, but the next has the opportunity to build an entirely new system. Now you know the range.
Did you go into private practice? Would you do it all over again? Share your experience in the comments!
Aditya Jain is an MD student at Harvard Medical School, and a researcher on applications of AI in medicine at the Broad. He is interested in the business of health care and its intersection with technology and policy. More of his writing can be found on Substack @adityajain42. Aditya was a 2023–2024 and a 2024–2025 Doximity Op-Med Fellow, and continues as a 2025–2026 Doximity Op-Med Fellow.
Illustration by Diana Connolly
