Off the Chart: A Business of Medicine Podcast

One in 21 physicians was sued last year, the lowest rate since 1973. The average payment made on behalf of a physician and reported to the National Practitioner Data Bank was $514,000, the highest on record. Both numbers describe the same malpractice market.Medical Economics Managing Editor Todd Shryock sat down with Robert White, president of The Doctors Company and TDC Group.White explains why falling claims frequency has quietly absorbed years of pressure from rising severity, and why that cushion is running out. He walks through the arithmetic of nuclear verdicts, awards above $10 million that now land somewhere in the country roughly once a week, and how a single plaintiff's verdict resets the settlement value of every comparable case that never reaches a courtroom. He also makes the case that artificial intelligence in diagnosis and treatment is the emerging exposure worth watching, and offers a blunt piece of advice about how physicians should be choosing a carrier.Music Credits:Healing Breeze by Cephas - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:29 | Cold open. White on the two malpractice numbers moving in opposite directions.0:29 – 1:33 | Introduction. Austin Littrell introduces the episode and the guest.1:33 – 1:52 | Meet Robert White. Shryock opens on current trends in malpractice.1:52 – 3:11 | Claims frequency at a 53-year low. One in 21 physicians was sued in 2025, down from one in five in 1999. White credits the patient safety push and tort reform.3:11 – 4:29 | Severity has never been higher. The average payment reported on behalf of physicians reached $514,000 per closed report in 2025, up about 20% since 2022, and carriers won't know whether today's rate is correct for three to five years.4:29 – 5:17 | Early warning signs. Severity trending up roughly 5% a year, and bellwether states showing increased claims frequency in 2026.5:17 – 6:35 | What a nuclear verdict is. Any award above $10 million, and the 2009 book that gave rise to reptile theory.6:35 – 8:24 | Why one loss sets the price of every settlement. Only 7% of malpractice cases reach trial and the defense wins six of every seven, but the seventh becomes the yardstick.8:24 – 9:49 | Where nuclear verdicts are landing. Georgia recorded 11 in 2025 and 33 across four years. Illinois leads since 2015 with 58, followed by Georgia, New York, Florida, Pennsylvania and California.9:49 – 11:10 | The consent policy. Why carriers think twice about trying any case, and why physicians rarely withhold permission to settle once they have seen the verdicts.11:10 – 12:44 | Thermonuclear verdicts. Awards above $100 million, three already by April 2026, and the largest medical liability award on record: $963 million in Utah, decided by a judge rather than a jury.12:44 – 16:47 | What it all means for rates. Falling frequency masked the pressure from severity for years. With frequency flat, White expects increases of 1% to 3% nationally and warns that plaintiffs' lawyers are not spending this effort for nothing.16:47 – 17:39 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.17:39 – 18:43 | The specialties carrying the most risk. Cardiovascular, orthopedic and general surgery, plus obstetrics.18:43 – 20:31 | Artificial intelligence as the next liability frontier. AI is already embedded in diagnostic imaging, and White explains why the legal system's lag is the real exposure.20:31 – 22:48 | The question to ask before choosing a carrier. The carrier's name never reaches the data bank. The physician's does.22:48 – End | Closing thoughts and outro. Shryock thanks White and Littrell wraps the episode.

Three Current Procedural Terminology codes for immunization counseling on days when no vaccine is administered, 90482 through 90484, took effect Jan. 1, 2026. They were built to capture the time a physician spends on a conversation that ends without a shot. CMS does not pay for them, and most private payers do not either.Medical Economics Associate Editor Austin Littrell sat down with Sarah C. Nosal, M.D., FAAFP, president of the American Academy of Family Physicians and a family physician who has practiced in the South Bronx for nearly two decades.Nosal points family physicians to the AAFP's 2026 immunization schedules, developed with input from other medical organizations and the Vaccine Integrity Project. In this episode, she explains why most childhood doses are still given in a primary care office, what a practice gives up when it stops stocking and starts sending patients to a pharmacy, and how she handles a visit that opens with exemption paperwork instead of a question. Read the full written Q&A with Nosal.This conversation was recorded before the Aug. 10 executive order calling for universal childhood vaccine recommendations to cover 11 diseases rather than 18. Nosal does not address the order here.Music Credits:Coffee Shop Sketches by Buurd - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:20 | Cold open. Nosal on the one thing every parent walking into the exam room has in common, whether they came for a shot or an exemption.0:20 – 1:49 | Introduction. Austin Littrell introduces the episode and the guest.1:49 – 2:23 | Which schedule to work from. Nosal points family physicians to the AAFP's recommendations, developed with other major medical organizations and the Vaccine Integrity Project.2:23 – 3:25 | What shared decision-making actually means. More vaccines sit in that category than a year ago. Nosal argues it describes what family physicians already do at every visit: answer the questions, offer the information the patient did not know to ask for, and let them decide.3:25 – 5:15 | Does stocking vaccines still pencil out. Vaccines are expensive and reimbursement is the common complaint, but most childhood doses are still given in a family physician's office. Large networks with capital and in-house pharmacies have squeezed the smaller practices.5:15 – 6:11 | The counseling codes nobody pays for. Practices can document the work and use the codes. CMS does not reimburse them, most private payers do not either, and the AAFP is still advocating.6:11 – 7:30 | When a family brings exemption paperwork. Nosal's approach: acknowledge the form, ask what they are thinking, and partner instead of argue.7:30 – 9:13 | Where the AAFP lands on staggered schedules. The full regimen at each scheduled appointment. Nosal will not turn a family away for declining, but says most parents choose the traditional schedule once they have had the conversation.9:13 – 10:04 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.10:04 – 11:52 | What actually moves a parent. Setting the expectation months ahead rather than at the visit, then walking a family through the specific worry until they talk themselves out of it.11:52 – 13:18 | Longitudinal relationships under pressure. Consolidation, panel size and short visits are eroding the model. Nosal describes working around it in an under-resourced community by treating the whole family as the unit of care.13:18 – 14:49 | What a practice loses at the pharmacy counter. Pharmacies often will not vaccinate infants or children, registry reporting is inconsistent from state to state, and patients end up with records nobody can reconcile.14:49 – 15:56 | Why she does not say "hesitancy". Nosal closes on parents who are not hesitant so much as working from information that does not line up.15:56 – 17:04 | Closing thoughts and outro. Littrell thanks Nosal and wraps the episode.

Independent practices know technology is what keeps them independent. They just don't trust the technology they have. Veradigm surveyed 360 leaders at independent ambulatory practices, including 210 physicians, and found 79% call technology essential to staying independent while only 64% are confident their current tools can deliver. Aaron Ledbetter, solutions and growth strategist at Veradigm, joins the show to explain what sits inside that gap: denied claims that take one to two weeks to surface, payer contracts multiplying faster than the staff to manage them and a labor market where physicians are the hardest position to both recruit and retain. He also makes the case that the electronic health record is about to stop being a system of record and start being a system of work.Medical Economics and Veradigm are hosting a live virtual event on the same subject, "The State of the Independent Practice in 2026," on Wednesday, Aug. 26 at 2 p.m. EDT: https://globalmeet.webcasts.com/starthere.jsp?ei=1770655&tp_key=bf8dd29613&sti=mjhpopup&utm_source=mkt_layer&utm_medium=popup&utm_campaign=ME+State+of+Independent+Practice+8.26&utm_content=news%7Ctopics%2Ftechnology%7Ctopics%2Findustry-trends%7Ctopics%2Fvalue-based-care%7Ctopics%2Fpractice-managementMusic Credits:Sky Drifter by Cephas - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:32 | Cold open. Ledbetter previews the episode's central claim: the electronic health record is about to stop recording what happened and start doing the work.0:32 – 1:33 | Introduction. Austin Littrell introduces the episode, the guest and the Aug. 26 Medical Economics and Veradigm virtual event.1:33 – 2:27 | Meet Aaron Ledbetter. Ledbetter describes Veradigm's clinical and revenue cycle work with independent practices, and his own path through value-based care consulting in Washington, D.C., direct work with CMS and CMMI on model design and payer contract negotiation for roughly 1,600 clinicians at a New England ACO.2:27 – 4:16 | The confidence gap. Seventy-nine percent of practice leaders call technology essential to staying independent; 64% trust the tools they have. Ledbetter attributes the gap to tools aging out mid-adoption, an arms race with payer technology and the administrative weight of a growing book of payer contracts.4:16 – 5:52 | Why practices walk away from acquisition talks. Twenty-six percent of practices surveyed reached serious acquisition negotiations before deciding to stay independent. Ledbetter says strain gets them to the table, whether administrative, operational or financial, and what pulls them back is the belief they can still solve it with better tools.5:52 – 7:06 | Why a denial takes two weeks to surface. Ledbetter calls it a symptom of a lagging operating model, with detection, root cause analysis and resolution scattered across different people and different systems. Fifty-eight percent of practices run a hybrid revenue cycle split between internal staff and outside vendors.7:06 – 8:17 | Denial drivers across the whole revenue cycle. Eligibility errors, missing data and coding mismatches all trace back to information that wasn't captured, was captured incorrectly or didn't surface early enough. Ledbetter argues against fixing one stage in isolation.8:17 – 9:08 | P2 Management Minute. Keith Reynolds shares practice management tactics and invites listeners to submit their own.9:08 – 10:56 | Scale doesn't insulate. Eighty-two percent of practices reported increased financial pressure and 60% called that increase significant. Larger practices feel it as volatility driven by payer complexity, solo practices feel it as a staffing problem, and Ledbetter argues both are expressions of a shrinking margin for error.10:56 – 12:31 | What's different about AI this time. Ledbetter grants that physicians are right to be skeptical and names app fatigue as a real problem, then makes the case that ambient documentation and background automation of prior authorization, reporting and denial follow-up move the electronic health record from a system of record to a system of work.12:31 – 14:03 | The administrative barrier to value-based care. Nearly half of respondents named administrative requirements the top barrier to value-based care participation, ahead of clinical complexity and financial risk. Drawing on his ACO contracting experience, Ledbetter describes tracking the differences between arrangements as work that takes a small army, and argues technology should automate quality measure tracking and surface care gaps before the visit.14:03 – 15:34 | Automation as a recruiting advantage. Physicians ranked hardest to both recruit and retain. Independent practices can't match a guaranteed employed paycheck, but Ledbetter argues automating documentation, denials and prior authorization buys the work-life balance that decides where a physician lands.15:34 – 17:30 | Running independence as an operating model. For practices with little or no administrative staff, Ledbetter says the answer isn't hiring but choosing technology that surfaces the right signals in days instead of months. He also expects more independent practice associations banding together for leverage with vendors and payers.17:30 – 19:02 | The inflection point. Health care has spent years throwing people at manual problems and adding complexity in the process. Ledbetter's closing case is that this is the first moment technology can look at the entire system of work at once.19:02 – [runtime] | Closing thoughts and outro. Littrell thanks Ledbetter, points listeners to the full Q&A and the report, and reminds the audience about the Aug. 26 virtual event.

Practice costs are climbing on every line at once: staffing, medical supplies and a technology stack that has grown at some organizations from two or three main systems to as many as 15. Reimbursement has not moved with any of it, and when the math gets that tight the reflex is to start cutting. Physicians Practice Managing Editor Keith Reynolds sat down with Shawntea Gordon, CEO of Atlas & Perpetua Healthcare Consulting, to explain why that reflex is where most practices go wrong. A cut made without data behind it is a guess, Gordon argues, and the wrong guess costs more than it saves. She and Reynolds get into the leaks she finds most often, how to tell which benchmarks are actually worth trusting, why staffing reductions so frequently backfire and the recurring expense that has been quietly billing practices since the paper era.Music Credits:Groovy 90s Hip Hop Acid Jazz by Musinova - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:23 | Cold open. Gordon on the practices that call staffing their biggest cost and then find out they were understaffed all along.0:23 – 1:30 | Introduction. Austin Littrell introduces the episode, the guest and the gap between what practices spend and what they collect.1:30 – 2:22 | Why the pressure feels different now. Gordon points to the widening spread between costs and reimbursement, plus staff shortages and a technology stack that has grown at some organizations from two or three main systems to as many as 15.2:22 – 3:19 | Where the money leaks. Front desk data entry, coordination of benefits, uncaptured patient responsibility, undocumented in-office services, unappealed denials and downcoding. The one she sees most: unmanaged denials and claims sitting in accounts receivable.3:19 – 4:01 | The first step if you have never benchmarked. Start with your own history. Pull 12 months of invoices, check what you ordered against what you paid, then look at alternatives and group purchasing contracts.4:01 – 5:12 | Which benchmarks are worth trusting. Gordon on separating established associations from organizations that only claim to be validated, and why an apples-to-apples comparison starts with an honest read of your own size, location, service mix and payer mix.5:12 – 6:16 | The right-sizing test before any staffing cut. Pull your administrative and clinical support ratios against validated benchmarks first. Groups convinced staffing is their biggest cost are often already understaffed, with burnout capping what they can collect.6:16 – 7:20 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.7:20 – 7:58 | The contract nobody rereads. Practices that moved from paper to electronic and left shredding services on the same rotation, paying monthly minimums against bins that never fill.7:58 – 9:35 | Cutting costs without creating new risk. The four questions Gordon runs before any systemic change, and the practice that switched medical supply vendors and lost access to a surgical item that was chronically backordered.9:35 – 10:59 | Building a framework that holds. A holistic review, a 90-day improvement plan, then the same monthly block of time converted into continuous improvement. Gordon makes the case for 1% a month over an annual look back.10:59 – 11:32 | One thing to do Monday morning. Run a monthly report comparing the CPT codes billed against the codes reimbursed. Every variance is a possible downcode.11:32 – [END] | Closing thoughts and outro. Reynolds thanks Gordon, and Littrell wraps the episode.

Nearly half of the health care organizations in Experian Health's 2026 State of Patient Access Survey say patient access improved over the past year. Among patients, fewer than one in five agree. Medical Economics Managing Editor Todd Shryock sat down with Mindy Fortson, chief operating officer of Experian Health, to work out what's behind that split, why 73% of respondents on the practice side say patients delay or forfeit care when they can't get a cost estimate up front, and how much of the prior authorization burden a practice can realistically fix on its own. Fortson also gets into the survey's most counterintuitive finding: after years of pushing patients toward portals and mobile billing, paper is coming back.Read Experian Health's 2026 State of Patient Access Survey here.Music Credits: Sleepy Sunday by Buurd - stock.adobe.com A Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using AI tools.0:00 – 0:26 | Cold open. Fortson names the survey finding that unsettled her most and explains why she reads it as a public health problem rather than a billing one.0:26 – 1:39 | Introduction. Austin Littrell introduces the episode, the guest and the perception gap at the center of the survey.1:39 – 1:53 | Meet Mindy Fortson. Todd Shryock introduces the guest and the 2026 State of Patient Access Survey.1:53 – 3:04 | Why practices and patients score access differently. Forty-six percent of organizations say access improved. Eighteen percent of patients agree. Fortson traces the split to two groups measuring different outcomes: staffing and digital adoption on one side, affordability and speed on the other.3:04 – 4:07 | Prior authorization and what a practice can actually fix. Thirty-six percent of patients reported authorization difficulties. Fortson puts most of the burden on payer and policy reform, since requirements are plan specific and carry heavy clinical review.4:07 – 5:43 | Insurance verification delays. Nearly three in 10 patients hit one. Fortson frames these as administrative rather than clinical problems and points to front-end coverage discovery, eligibility checks and MBI lookups as the automation targets.5:43 – 7:42 | The cost estimate problem. Seventy-three percent on the practice side say patients delay or forfeit care without an up-front estimate. The bright spot: surprise billing complaints have fallen considerably where estimate tools are in place.7:42 – 8:55 | Why training deficits keep surfacing. Thirty-nine percent cite training gaps. Every payer is different and every encounter is different, which makes front-end registration a heavy manual lift.8:55 – 9:46 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.9:46 – 11:28 | Where automation and AI pay off first. Twenty-eight percent report adopting AI, a figure the survey didn't measure at all last year. Fortson expects AI to move out of pilots and into general infrastructure within one to two years.11:28 – 12:46 | Ninety-three percent say patients struggle to pay. Fortson on Medicaid uncertainty, regulatory ambiguity and employers shifting costs onto employees.12:46 – 14:33 | Access to practitioners, four years running. Still the top patient-reported challenge. Scheduling and portal tools help, but a meaningful share of patients either lack a smartphone or won't navigate a portal.14:33 – 15:41 | The paper billing surprise. Snail mail metrics jumped this year against the mobile trend. Fortson points to regulatory and HIPAA notices that default to mail, plus cybercrime anxiety about entering personal information online.15:41 – 17:17 | The metric to watch next year. Speed to access shows up as both a top frustration and a top success, depending entirely on whether the practice has adopted the tools.17:17 – 18:35 | Closing thoughts and outro. Littrell points listeners to the survey in the show notes and wraps the episode.

CMS has released its proposed 2027 Medicare Physician Fee Schedule, and once again it carries a conversion factor cut: 1.68% for physicians outside an alternative payment model and 1.19% for those inside one, as the 2.5% congressional patch expires. Physicians Practice Managing Editor Keith Reynolds sits down with Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association, to sort out what the rule actually does. They dig into the budget neutrality rules that force CMS to cut one specialty to pay another, the agency's push to move away from the AMA's valuation process without new data to justify it, the sunset of traditional MIPS into MIPS Value Pathways and what that reporting burden means for multispecialty groups, and a sleeper change to modifier 25 that could hit same-day billing hard. Public comments on the proposed rule are due Sept. 14.Music Credits:Swinging Lounge Bar by NC MUSIC - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using AI tools.0:00 Cold open: Anders Gilberg on why these are real cuts, not cuts to the growth rate 0:17 Introduction 1:39 Keith Reynolds welcomes Anders Gilberg 2:11 The recurring themes in the proposed 2027 fee schedule 3:56 Five years of cuts, and what MGMA members are feeling 5:38 Congress's game of chicken and the new Patients First Act 6:58 Budget neutrality and robbing Peter to pay Paul 8:09 CMS's 20-year-old cost data and the move away from the AMA process 10:34 The end of traditional MIPS, and why MVPs are "MIPS on steroids" 13:20 P2 Management Minute 14:35 What small and rural practices should do now 16:13 The sleeper provision: modifier 25 and same-day billing 18:13 Comments are due Sept. 14, but will CMS budge? 20:20 The next fiscal cliff and the year-end lame duck session 22:29 Outro

Urgent care was never designed to be the front door to American health care, but that's increasingly what it has become. As the country faces a projected shortage of as many as 80,000 primary care physicians by 2037 and nearly 40% of Gen Z patients go without a primary care physician at all, more Americans are turning to urgent care as their first and often only point of contact with the health care system. Medical Economics Associate Editor Austin Littrell speaks with Andrea Giamalva, M.D., FAAFP, chief medical officer at Experity, about what urgent care is actually handling today, where its relationship with primary care breaks down and why she believes AI-enabled technology may finally help clinicians get the right patient to the right place at the right time. The conversation covers the generational shift away from primary care, the payer and cultural barriers that complicate care-gap closure, the growing role of advanced practice providers and how tools like AI scribes could bring humanity back to the exam room.Music Credits:Coffee Shop Sketches by Buurd - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using AI tools.0:00 – 0:24 | Sponsor message Copic medical liability insurance.0:24 – 0:51 | Cold open Giamalva previews the episode's central theme: the national shortage of primary care has turned urgent care into the front door to health care for many Americans.0:51 – 1:44 | Introduction Austin Littrell introduces the episode and guest, previewing the data behind the primary care shortage and the case for using technology to get the right patient to the right place at the right time.1:44 – 2:20 | Meet Andrea Giamalva Giamalva introduces herself as a family medicine physician and chief medical officer at Experity, the leading platform for on-demand health.2:20 – 4:28 | How urgent care became the front door From its 1970s origins to today, urgent care has grown from a cough-and-cold clinic into a multichannel digital front door offering employer-paid services, weight loss therapy, hormone therapy and mental health care.4:28 – 7:15 | Choice or access? The generational data Roughly 10% of baby boomers lack a primary care physician, rising to nearly 40% of Gen Z. Giamalva ties the generational shift, projected shortages of up to 80,000 primary care physicians by 2037 and health care deserts to the "Amazon-Uber-DoorDash" expectations now shaping patient behavior.7:15 – 9:49 | Right patient, right place, right time Giamalva argues the hardest problem in health care is matching patients to the appropriate setting, and that technology could let urgent care safely handle straightforward cases while primary care focuses on complex, time-intensive ones.9:49 – 11:28 | Reducing burden without adding fragmentation With one study finding it would take 27 hours a day for a primary care physician to manage their full panel, Giamalva says clear communication across the patient journey and better tools at the point of care are what let urgent care act as a partner rather than a competitor.11:28 – 14:02 | Treating patients like customers Giamalva makes the case that patient experience directly affects outcomes, and describes tools like Care Agent and AI scribes that aim to keep patients informed and bring human interaction back to the visit.14:02 – 14:53 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.14:53 – 17:55 | What primary care can learn from urgent care Urgent care's scheduling flexibility and retail DNA give it a head start on on-demand care. Giamalva says primary care could adopt a more hybrid, risk-stratified approach that routes patients to telehealth, urgent care or a full primary care visit based on need.17:55 – 19:43 | The expanding role of advanced practice providers As APPs take on larger roles in both settings, Giamalva calls for team-based models, clear expectations and proper training so urgent care teams can manage common chronic conditions like diabetes, hypertension and thyroid disease.19:43 – 22:01 | Closing the primary care gap Giamalva walks through what it takes for urgent care to help patients without an established primary care relationship, including patient willingness, payer contracts that can prohibit preventive care and the cultural shift required of clinical teams.22:01 – 22:53 | The case for AI-enabled technology In her closing thoughts, Giamalva argues AI-enabled technology is more than a fad and could finally reverse the administrative burden that has chipped away at the patient-provider relationship.22:53 – End | Outro Littrell thanks Giamalva and wraps the episode.