AUGUST 2026 | DALLAS COUNTY MEDICAL SOCIETY
A GUIDE TO PROFESSIONAL GROWTH
The skills no residency taught and how Dallas physicians are building them now
INCLUDES THE LEADERSHIP SKILLS MEDICAL SCHOOL AND RESIDENCY NEVER COVERED THE MYTH OF ARRIVAL
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AUGUST 2026
Vol. 112 No. 08
EXECUTIVE VICE PRESIDENT & CEO
Jon R. Roth, MS, CAE
E D I TO R I A L S TA F F EDITOR, PRINT & WEB CONTENT
Stephanie Jennings DESIGNED BY Morganne Stewart
ADVERTISING DCMS Business Development COMMUNICATIONS COMMITTEE Ravindra Mohan Bharadwaj, MD, Chair Sumana Gangi, MD Jawahar Jagarapu, MD Dylan Jacob Kruse Ravina R. Linenfelser, DO Sina Najafi, DO Erin D. Roe, MD, MBA Katelyn Williams, MD
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BOARD OF DIRECTORS Gates B. Colbert, MD, President
HOUSE CALL
No Rotation for This
Vijay V. Giridhar, MD, President-elect Sheila Chhutani, MD, Secretary/Treasurer Shaina M. Drummond, MD, Immediate Past President
IN EVERY ISSUE
Kimulique Harkley Allen, MD
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Max I. Galvan, MD Nazish Saeed Islahi, MD Benjamin C. Lee, MD Allison Moore Liddell, MD Riva Louise Rahl, MD
LEGAL CORNER
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What Legislative Actions Are on the Horizon for Texas in 2027
H E A LT H A L L I E S
Guide to Professional 20 AGrowth
Thomas Schlieve, MD Articles represent the opinions of the authors and do not necessarily reflect official policy of the Dallas County Medical Society (DCMS) or the institution with which the author is affiliated. Dallas County Medical Society does not endorse or evaluate advertised products, services, or companies nor any of the claims made by advertisers. Claims made by any advertiser or by any
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Redefining Success in a Medical Career
company advertising in the Dallas Medical Journal do not constitute legal or other professional advice. You should consult your professional advisor. ©2026 DCMS. According to Tex. Gov’t. Code Ann. 305.027, all articles in Dallas Medical Journal that mention DCMS’s stance on state legislation are defined as “legislative advertising.” The law requires disclosure of the name and address of the person who contracts with the printer to publish legislative advertising in the DMJ: Jon R. Roth, MS, CAE, Executive Vice President & CEO, DCMS, PO Box 4680, Dallas, TX 75208-0680. Dallas Medical Journal (ISSN 0011-586X) is published monthly by Dallas County Medical Society, 140 E. 12th St., Dallas, TX 75203. (214) 948-3622. Postmaster - Send address changes to: Dallas Medical
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H E A LT H A N D W E L L N E S S
H E A LT H A L L I E S
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2027 Medicare Physician Payment Schedule and Quality Payment Program Proposed Rule Summary
Journal | PO Box 4680 | Dallas, TX 75208-0680. Periodicals postage paid at Dallas, TX 75260 and additional post offices.
August 2026
DALLAS MEDICAL JOURNAL | 1
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PRESIDENT’S PAGE
Beyond Residency: The Lifelong Pursuit of Expertise Gates B. Colbert, MD 2026 President, Dallas County Medical Society DESPITE THE LINGERING HEAT AND ONGOING MLB season, the start of the academic year brings fresh energy to our medical schools, now bustling with new MS1s. I cherished the summer with my family as we adjusted to having both children fully immersed in school (kindergarten and third grade). This month, the Dallas Medical Journal focuses on physician development and the relentless pursuit of expertise. It has been over a decade since I completed my fellowship, and I am preparing for the ABIM Board Re-Certification Exam in 2026. While the process is undeniably demanding, it also serves as a valuable prompt to keep striving for clinical excellence. Continuing to expand our knowledge is key to providing the best care for our patients and making the most of new technologies and advancements. Ultimately, our patients want a physician committed to growth and learning by their side when a health crisis arrives. As physicians, we recognize that completing medical school, residency, and even fellowship is not the culmination, but the start of our lifelong professional journey. Medicine distinguishes itself as a field in perpetual motion, where new evidence, emerging technologies, and evolving treatments continually push us to refine our knowledge and clinical practice. Thus, career developAugust 2026
ment should be regarded not as mere upward mobility within an institution, but as an ongoing, purposeful process of growth. Cultivating expertise demands that we remain inquisitive, adaptable, and wholeheartedly dedicated to elevating both ourselves and the care we deliver to patients. Lifelong learning stands as a cornerstone of physician career development. While our initial medical training lays the groundwork for clinical practice, true expertise demands persistent engagement with the evolving medical literature and specialty-specific guidelines. In practice, we inevitably confront scenarios that extend beyond the scope of our formal education. Recognizing these knowledge gaps (and proactively seeking solutions) reflects a mature and humble approach to professional growth. Expertise, then, is not defined by having every answer, but by the capacity to discern uncertainty, critically appraise information, and judiciously apply the best available evidence to each unique patient. Reflection is equally vital to professional advancement. While our clinical experiences offer countless opportunities for learning, experience alone does not automatically yield expertise. We become more effective physicians when we intentionally scrutinize our decisions, outcomes, and interactions with both patients DALLAS MEDICAL JOURNAL | 3
PRESIDENT’S PAGE
and colleagues. Challenging cases, complications, and even routine encounters can all become powerful sources of insight, provided we thoughtfully consider what succeeded and what could be improved. By making reflection a consistent habit, we convert experience into meaningful growth and ensure that progress is measured not simply by the passage of time, but by the depth of our learning. Feedback, intrinsically linked to reflection, is indispensable to growth. While physicians are trained to make independent clinical decisions, true professional development hinges on our willingness to embrace perspectives from colleagues, allied health professionals, and patients themselves. Constructive feedback can illuminate blind spots that might otherwise go unnoticed. Although many of us excel at focusing intently on the challenges at hand, this very focus can sometimes obscure valuable opportunities for improvement. Fostering a culture in which feedback is welcomed as a catalyst for growth, rather than perceived as criticism, enriches both individual physicians and the teams with whom we collaborate. Mentorship and sponsorship play pivotal roles in career development. Seasoned colleagues offer invaluable insights into clinical practice, academic growth, and the complexities of sustaining a rewarding medical career. An effective mentor helps us identify our strengths, clarify our ambitions, and navigate pivotal decisions. Equally vital is our obligation to support those who follow in our footsteps. Teaching students, residents, and early-career colleagues not only reinforces our own understanding but also fortifies the profession as a whole. By investing in others, we amplify the impact of our personal development, extending its reach far beyond the patients we serve directly. Career development must also encompass the deliberate cultivation of skills beyond direct patient care. While clinical expertise is foundational to our identity, effective practice in modern medicine increasingly demands strong communication, collaboration, leadership, conflict resolution, quality improvement, and systems thinking. Many physicians will ultimately assume roles as medical directors, educators, researchers, committee members, depart4 | DALLAS MEDICAL JOURNAL
mental leaders, or advocates for patients and communities. Preparation for these responsibilities requires competencies often underemphasized during clinical training. Developing these abilities intentionally empowers us to make more substantial contributions to our organizations and to the broader healthcare system. Ultimately, expertise is forged through deliberate practice. There’s an important difference between simply having experience and achieving true expertise: experience shows how long we’ve been practicing, while expertise comes from purposeful reflection and ongoing learning. Expert physicians consistently question their assumptions, honestly evaluate their performance, and adjust as new evidence or situations arise. They embrace complexity and uncertainty, seeing them not as threats, but as opportunities for growth. Moreover, true expertise transcends diagnostic and procedural skill alone. Within our vibrant Dallas County healthcare community, we are fortunate to have abundant opportunities to challenge ourselves and continually pursue excellence. For practicing physicians, career development must not be relegated to periodic endeavors tied to promotions or career transitions. Instead, it should be embraced as a continuous discipline that accompanies us throughout our professional lives. Through the pursuit of lifelong learning, the active solicitation of feedback, thoughtful reflection, dedicated mentorship, cultivation of leadership and communication skills, and the establishment of meaningful professional goals, we ensure that our growth does not cease with the end of formal training but continues throughout our careers. The pursuit of expertise in medicine is, ultimately, a journey rather than a fixed destination. Our aim extends beyond accumulating knowledge; it is to become more thoughtful, adaptable, and effective in service to our patients and colleagues. When we approach our careers with purpose and intentionality, every clinical interaction, teaching moment, and professional relationship becomes a catalyst for growth. In doing so, we not only advance our own development, but we also elevate the profession and enhance the care entrusted to us. I readily acknowledge that I have much yet to learn on my path to becoming a respected nephrologist, and by striving for these ideals, I continue to grow into the physician I aspire to be. DMJ August 2026
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EVP / CEO LETTER
The Other Curriculum Jon R. Roth, MS, CAE, AAiP
LAST WEEK, I SPENT TIME AT THE TEXAS Medical Association Leadership Summit at the Irving Convention Center, and what struck me most was what the agenda did not contain. No guideline updates. No specialty board review. Instead: Organized Medicine 101. A mock House of Delegates. A panel on running a successful practice. A legislative update. A resolution-writing workshop. A closing session on combating health misinformation during a public health crisis, delivered by a Dallas physician. Three days of serious professional development, and almost none of it clinical. That is the subject of this month’s issue of Dallas Medical Journal (DMJ). Continuing medical education does exactly what it was built to do. It keeps clinical knowledge from going stale, and it does so on a reliable schedule, with a required number of hours and a renewal deadline that arrives whether anyone feels ready or not. CME was never designed to teach a physician how to read a contract, negotiate with a payer, sit on a hospital board, testify at a state legislative hearing, manage a budget, or hold a team together through a bad year. Those capabilities now shape 6 | DALLAS MEDICAL JOURNAL
the conditions under which medicine is practiced in Dallas County as much as any clinical development does. Here is the difficulty. Nobody schedules the rest of it. There is no registration reminder for learning how governance works, no required hour count for developing a public voice, no license consequence for never having sat in a room where health policy gets decided. It competes with clinic, with call, with family, and it usually loses. But the physicians who build these skills tend to be the ones who concluded, at some point, that they would rather help write the rules than read them afterward. Dallas offers two instructive examples. Our own DCMS past board member, Philip Huang, MD, MPH, has served as director and health authority of Dallas County Health and Human Services since 2019. He earned his medical degree right here at UT Southwestern, then added a master of public health in health policy and management at Harvard, a credential no clinical requirement asked of him. At the Texas Department of State Health Services he led statewide tobacco reduction work that involved testifying at more than forty city council hearings. Forty. That is not a line on a curriculum vitae. That is a skill built the way skills actually get built, one uncomfortable podium at a time. When Dallas County needed a credible public leader during the pandemic, it had one, because he had spent two decades becoming August 2026
EVP / CEO LETTER
it. In February the American Medical Association presented him its Award for Outstanding Government Service. Last week he closed the Leadership Summit teaching other physicians how to do the same thing. Jaclyn Albin, MD, took a different route toward a similar kind of influence. She trained in combined internal medicine and pediatrics at Baylor College of Medicine and spent the first decade after training in primary care. Along the way she kept noticing the same gap: patients whose conditions turned on what they ate, and a medical education that had taught her almost nothing about it. Rather than accept that, she went and got the training herself, earning certification as a culinary medicine specialist and a diplomate credential in lifestyle medicine, neither of which any board required of her. In 2017 she founded UT Southwestern’s Culinary Medicine Program with dietitian Milette Siler, then built the first culinary medicine clinical service line, embedding nutrition consults into actual patient care rather than leaving them as advice. Last year, Texas Governor Greg Abbott appointed her to a four-year term on the Texas Nutrition Advisory Committee. What both careers illustrate is that growth outside the clinical domain is cumulative, slow, and compounding. Neither physician set out to acquire influence. Each identified a gap, went after the skill required to close it, and kept at it long enough that other people started asking them to help decide things. The course nobody required at forty becomes the seat at a table that did not exist at fifty-five. The good news is that Dallas is well supplied with places to start. TMA runs a full calendar beyond TexMed: the Leadership Summit each September, the Business of Medicine Conference, resolutionwriting workshops, and First Tuesdays at the Capitol during legislative session. Members attend most of these at no registration cost. For physicians who want formal credentials, DCMS has supported the UT Dallas Alliance for Physician Leadership at the Naveen Jindal School of Management. Since 1997, this partnership with UT Southwestern has been built around physician schedules. Residential classes meet Saturday through Tuesday every other month; the degree can be finished in as little as 21 months, and candidates may pursue either an executive MBA or a master of science in healthcare leadership and management. August 2026
More than 530 alumni now hold leadership positions across the industry. Several of the classes carry AMA PRA Category 1 credit, so advancement and compliance are not always competing uses of the same weekend. DCMS also partners with the Alliance on a year-long physician leadership certificate covering valuebased contracting, quality performance, financial management, and physician well-being, designed for members who want the substance without the full degree commitment. Beyond formal programs, the least expensive professional development available to any member is service. Committee work at DCMS. Teaching at DCMS Foundation programs, including the summer camp that brings underserved Dallas middle schoolers onto a campus to work alongside physicians. Mentoring a medical student. Serving in the TMA or AMA House of Delegates. Writing for this Journal, which is always open to members with something worth saying. Each of those builds judgment, network, and voice, and none of them requires tuition. If we are being honest, there is a cost to all of this. Time in a committee room is time not spent in clinic or at home, and the profession is already stretched thin. But the alternative carries a cost too, quieter and larger. Decisions about reimbursement, scope, prior authorization, and the shape of practice get made in rooms where physicians are either present or absent. Organized medicine works best when the house of medicine sends people who know how the building is wired. There is an old saying around here that you cannot plow a field by turning it over in your mind. The encouraging part is that nobody in Dallas has to start from scratch. The programs exist, the rooms are open, and the physicians already in them are glad to see a new face come through the door. Pick one thing this fall. Show up once. That is how every career described above began. DMJ
Jon R. Roth, MS, CAE DCMS EVP/CEO
WHERE TO START Texas Medical Association Leadership Summit. Held each September; the 2026 Summit met Sept. 17-19 at the Irving Convention Center. texmed.org/LeadershipSummit TMA Business of Medicine Conference and First Tuesdays at the Capitol. Practice economics and direct legislative advocacy. Free to TMA members. texmed.org/Events UT Dallas Alliance for Physician Leadership. Executive MBA and MS in Healthcare Leadership and Management, exclusively for physicians. Residential classes Saturday through Tuesday, every other month. apl.utdallas.edu UT Dallas and DCMS Physician Leadership Certificate. Year-long cohort program covering leadership, valuebased contracting, quality, finance, and wellbeing. Contact Ruby@dallas-cms.org American Association for Physician Leadership. Certification in physician leadership, plus the Certified Physician Executive credential. physicianleaders.org AMA and TMA House of Delegates, and DCMS committee service. The least expensive leadership training available, and the most directly consequential. Contact Alyce@dallas-cms.org DCMS Foundation programs and medical student mentoring. Teaching sharpens judgment faster than almost anything else. dallas-cms.org
DALLAS MEDICAL JOURNAL | 7
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What Legislative Actions Are on the Horizon for Texas in 2027 That Physicians Should Be Aware of? by Brandon Kulwicki, Shareholder, Chandani Patel, Associate, and Stuti Desai, Summer Associate, Hall, Render, Killian, Heath & Lyman, P.C.
T
HE LEGISLATIVE LANDscape in Texas is in flux, with many items currently being discussed or reviewed. Planning for the 2027 legislative session is in full swing, and legislative committees are investigating many important topics that are likely to impact physicians, care teams, and patients downstream. The Texas Medical Association has been diligent about tracking legislative efforts on a number of subjects. One such example is the legislature’s continued review of the argument that expansion of advanced practice providers’ scope of practice will increase access to care in dense urban and rural areas. This expansion of independent authority will have a significant impact on the delivery of care, staffing, reimbursement, and specific employment provisions. Providers should also be aware of the possibility of changes to Texas’s telemedicine laws, with the possibility of renewed interest in outside providers providing virtual care to Texans. In addition to the federal focus on fraud, abuse, and waste in health care, the state’s Senate Committee on Finance and the House Committees on Government Efficiency and Healthcare Affordability will be reviewing health care costs and their impact on Texans, including how consolidation of health care entities impacts patient costs and affordability, access to care, and market competition. This is an area ripe for both risk and education in health care. Hospitals and physician practices should continue to have processes in place to educate their staff on fraud and abuse risk factors and compliance requirements to ensure safety of the organization and its patients.
August 2026
As part of the state’s focus on reviewing the nature of increasing health care and insurance costs, the Texas Senate and the House Committees on Business and Commerce and Insurance, in partnership with the Senate Health and Human Services Committee, will be broadly reviewing the impact of insurance and health care delivery processes. The renewed focus will include assessments of activities for all involved stakeholders, including payers, hospitals and health care entities, and patients. The joint committee efforts will focus on reviewing the oversight of the Texas Department of Insurance, which oversees health insurance and occupational health practices, the efficiency of insurance claim processes from submission to payment in the state, and the evolution of artificial intelligence use in insurance processes. Texas was also awarded funding through the Rural Health Transformation Program. The state is expected to receive approximately $1.4 billion in federal funding to expand rural health care efforts and level the playing field in terms of access and care. Texas plans to allocate funding based on six targeted initiatives focusing on preventive care, the use of AI and telehealth, and improving infrastructure. The legislature will be working on disseminating those funds through the identified state initiatives and stakeholders and assessing the impact
of any implementations. Most importantly, physicians and health care entities should be aware of renewed legislative efforts around the requirement for health care entities to notify the state of any type of health entity merger over a certain dollar threshold. The latest 2025 effort around such a requirement faced great scrutiny and discussion in the legislature and ultimately led to the bill’s defeat. Health care is an ever-changing industry. The practice and delivery of medicine are influenced by federal and state activities, but at its core, the focus should continue to remain on the patient. As such, it is essential that health care organizations and professionals stay engaged with policy efforts and consult legal expertise to ensure that legislative efforts continue to be in favor of sound patient care. DMJ This article is educational in nature and is not intended as legal advice. Always consult your legal counsel with specific legal matters. If you have any questions or would like additional information about this topic, please contact Brandon Kulwicki at (214) 615-2025; Chandani Patel at (214) 615-2037; or your primary Hall Render contact. Brandon Kulwicki and Chandani Patel are attorneys with Hall, Render, Killian, Heath & Lyman, P.C., a national law firm focused exclusively on matters specific to the health care industry. Please visit the Hall Render Blog at blogs.hallrender.com for more information on topics related to health care law.
REFERENCES Texas Senate Interim Charges Signal 2027 Priorities, Tex. Policy Rsch. (Mar. 27, 2026), https://www.texaspolicyresearch.com/texassenate-interim-charges-signal-2027-priorities/. Amy Lynn Sorrel & Phil West, Legislative Interim Charges Add Health Care Affordability to Recurring Concerns, Tex. Med. Ass’n. (May 11, 2026). https://www.texmed.org/TexasMedicineDetail.aspx?Pageid=46106&id=67968. Texas House of Representatives Introduces Health Care Transaction Notification Requirement, Hall Render (Apr. 8, 2025), https:// hallrender.com/2025/04/08/texas-house-of-representatives-introduces-health-care-transaction-notification-requirement/. Rural Health Transformation Program, Tex. Health & Hum. Servs. Comm’n. https://pfd.hhs.texas.gov/rural-health-transformationprogram (2026).
DALLAS MEDICAL JOURNAL | 9
HOUSE CALL
W
E SPEND A DECADE, SOMETIMES LONGER,
learning to read a chest X-ray, titrate a pressor, or break bad news to a family in a windowless room. We are drilled, tested, and re-tested until these skills become reflex. Yet the moment we’re handed a medical staff appointment, a directorship, a practice to run, or a team of twelve to manage, we are expected to simply know how. There was no rotation for this. No attending stood at the bedside and taught us how to negotiate a contract, read a P&L statement, or have a difficult conversation with an underperforming colleague. We learned medicine by design. We are learning leadership by accident. After 25 years in clinical practice and a decade spent building organizations alongside that practice, I’ve come to believe this gap isn’t a minor omission in an otherwise thorough curriculum. It’s one of the most consequential blind spots in medical training, and one that a growing number of physicians, whether we intend to or not, end up paying for in real time: in contracts we didn’t negotiate well, teams we struggled to lead, and burnout that had less to do with patient volume than with the unfamiliar weight of running something. This gap has also become harder to avoid. Physicians today are more likely than any previous generation to find themselves in some kind of leadership role earlier in their careers, whether that’s a medical directorship taken on in the first few years of practice, a service line they’ve been asked to build, or a practice they’ve founded outright. Health systems are consolidating, private equity has changed the ownership landscape of many practices, and physicians who might once have practiced quietly for thirty years are now being asked, often with little warning, to also run something. The training hasn’t caught up to that reality, which means most of us are still filling the gap the same way physicians have for decades: on the job, under pressure, and usually alone. THE NUMBERS DON’T LIE It helps to see the imbalance rather than just describe it. Figure 1 lays out a rough comparison: the cumulative hours most of us spend on formal clinical training against the hours most of us spend on formal leadership training. The clinical side is measured in the tens of thousands 10 | DALLAS MEDICAL JOURNAL
August 2026
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NO ROTATION FOR THIS The Leadership Skills Medical School and Residency Never Covered by Sejal Mehta, MD, MBA, Psychiatric Medical Associates, PA; Co-Founder and Chief Medical & Scientific Officer, PraxisOne, Inc. of hours. For the roughly half of medical schools that offer anything formal at all, the leadership side is typically measured in a handful of workshop sessions. This isn’t a criticism of medical education, which does an extraordinary job of what it was built to do. It’s a description of a gap that widens the moment we step into any role beyond direct patient care, and one that most of us have had to close on our own, usually mid-crisis, with whatever we could learn from a mentor, a hard conversation, or a mistake we didn’t want to repeat. FINANCIAL LITERACY: THE LANGUAGE NO ONE TAUGHT US TO SPEAK Physicians are trained to be excellent stewards of a patient’s physiology and, on average, remain financially naive about their own practice, compensation, or the organizations they lead. We can calculate a MELD score or titrate an insulin drip without a second thought, but many of us graduate residency unable to read a balance sheet, understand the difference between revenue and margin, or evaluate whether a proposed compensation structure actually serves us over a five-year horizon. This isn’t a character flaw; it’s a curricular one. Financial literacy needs to be treated as a core competency, not an elective interest for the MBA-inclined. Whether you’re negotiating a medical directorship, evaluating an employment contract, considering equity in a venture, or simply trying to understand your own practice’s productivity metrics, the ability to model out the numbers yourself, rather than trusting the number handed to you, is the difference between advocating for yourself and hoping someone already did it for you. I’ve watched physicians sign employment agreements with productivity bonuses they couldn’t independently verify, join partnerships without understanding buy-in or buy-out mechanics, and accept medical directorship stipends calculated hourly when a flat monthly fee would better reflect the role’s scope and unpredictability. In each case, the physician wasn’t unintelligent or careless. They simply had never been taught to ask the questions that would have surfaced the issue before signing, not after. August 2026
Where to start: • Learn to read your own practice’s or department’s P&L statement, even if someone else prepares it. • Understand RVUs, payer mix, and overhead allocation well enough to ask informed questions, not just receive answers. • Before signing anything with a compensation formula attached, model out three scenarios: best case, expected case, and worst case. • If a role has open-ended scope (call coverage, administrative duties, oversight of a PHP or IOP program), push for a flat fee structure rather than hourly billing. It’s easier to negotiate up front than to renegotiate later once the actual time commitment becomes clear. NEGOTIATION: BEYOND “TAKE IT OR LEAVE IT” Most physicians’ first real negotiation is their first contract, and most of us walk into it with no framework at all. We’re taught to advocate fiercely for patients and almost never taught to advocate for ourselves. The result is a profession full of highly capable people who accept the first offer, avoid the conversation about compensation structure entirely, or conflate the discomfort of negotiating with being difficult, ungrateful, or not a team player. Negotiation is a learnable skill, not an innate trait some people have and others lack. It starts with knowing what you actually want, such as a flat monthly fee instead of an hourly rate, defined scope boundaries, and protected administrative time, before you sit down at the table, and understanding that the first number offered is rarely the only number available. It also means recognizing that silence, a follow-up question, or simply asking for something in writing are all legitimate negotiating tools, not confrontations. I’ve found that reframing the goal helps enormously: the objective of a negotiation isn’t to win; it’s to reach an agreement you can sustain without resentment for the length of the contract. That reframe alone changes how physicians show up at the table. It also helps to remember that most of what you’re negotiating DALLAS MEDICAL JOURNAL | 11
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ESTIMATED TRAINING HOURS: CLINICAL CURRICULUM VS. FORMAL LEADERSHIP EDUCATION 16,000
15,360
14,000 12,000 10,000 8,000 6,000
5,760
4,000
2,800
2,000 15
0 Preclinical science (yrs 1-2)
Clinical rotations (yrs 3-4)
Residency (yrs 3-7 avg.)
Formal leadership / management training
Figure 1. Estimated cumulative hours of formal clinical training versus formal leadership/management training across medical school and residency. Clinical hour estimates are order-of-magnitude approximations based on typical preclinical course loads, clerkship schedules, and ACGME duty-hour limits. Leadership hour estimate reflects the scope of most formal programs identified in the medical education literature (typically a handful of workshops or seminar sessions, where offered at all). Approximately half of U.S. allopathic medical schools report having any formal leadership curriculum, and only about a third of those make it a required part of training.
isn’t actually about money, even when money is the number under discussion. Scope, autonomy, protected time, call frequency, and termination terms often matter more to long-term satisfaction than the headline compensation figure, and they’re almost always more negotiable than physicians assume, precisely because so few candidates think to raise them. MANAGING PEOPLE: THE SKILL SET PATIENT CARE DOESN’T TEACH Clinical training teaches us to manage patients, not people. Those are different disciplines. Leading a team, whether it’s clinical staff, an administrative group, or a company you’ve founded, requires skills that overlap with, but are distinct from, bedside manner: delegation, conflict resolution, performance feedback, and the willingness to have an uncomfortable conversation before a small problem becomes a large one. Many physicians default to one of two extremes when they find themselves managing others: over-functioning, doing the work themselves because it’s faster than delegating and explaining, or under-functioning, avoiding confrontation because clinical training rewarded harmony and patient rapport over direct feedback to colleagues. Neither serves a growing organization. Leadership requires a third path: clear expectations set up front, timely feedback delivered without excessive apology, and the discipline to hold people, including yourself, accountable to standards everyone actually understands. In my experience, this is the skill that surprises physicians most. Clinical excellence does not automatically translate into 12 | DALLAS MEDICAL JOURNAL
managerial competence, and pretending otherwise is how good clinicians become resented, ineffective managers. Consider the difference between giving a patient a diagnosis and giving a colleague performance feedback. The first is a clinical skill we rehearse for years, delivered with empathy but also with clarity, because ambiguity in a diagnosis can cause real harm. The second is treated, culturally, as something almost impolite to do directly. Physicians will often soften a serious performance concern into vague language, hope the person reads between the lines, and then feel blindsided when nothing changes. Most of us already have the clinical skill of clear, compassionate, direct communication. It simply hasn’t been pointed at our teams. STRATEGIC THINKING: SEEING PAST THE NEXT PATIENT Clinical training rewards a particular kind of focus: the patient in front of you, the problem at hand, the next differential to rule out. It is, by necessity, a short time horizon, and an appropriate one at the bedside. Leadership requires the opposite muscle: the ability to step back from the immediate and ask where an organization, a practice, or a career needs to be in three years, and what needs to happen this quarter to get there. This is a genuinely difficult shift for many physicians, not because we lack the intellectual capacity, but because we’ve spent a decade being trained out of long time horizons. Building that muscle deliberately, whether through formal business education, mentorship from someone who has already made the transition, or simply setting aside protected time each month to think beyond the next clinic day, is what separates physicians who react to their organizations from those who shape August 2026
HOUSE CALL
them. Strategic thinking also means getting comfortable with uncertainty in a way clinical training doesn’t prepare us for. A differential diagnosis eventually resolves. A three-year organizational plan rarely does, and physicians who wait for that same level of certainty before acting tend to wait far too long. One practical habit I’ve found useful: block time on the calendar, treated with the same non-negotiable status as a clinic day, explicitly for thinking rather than doing. Not answering messages, not seeing patients, not putting out the fire of the week, but sitting with a single question: where does this need to be in three years, and what has to happen this quarter to get there. Most physicians in leadership roles never protect this time because nothing forces them to. It’s rarely urgent. It’s almost always important. SELF-ADVOCACY AND BOUNDARIES: THE SKILL THAT PROTECTS THE REST Perhaps the least discussed leadership skill in medicine is the ability to protect your own time, energy, and scope, and to say no without guilt. Medical training instills a powerful, largely unspoken belief that saying yes is a virtue and setting a limit is a failure of dedication. That belief serves patients well in a code. It serves no one well over a twenty-year career. Physicians who lead well, whether a department, a practice, or a company, tend to share one trait: they’ve learned to distinguish between the obligations that are genuinely theirs to carry and the ones they’ve simply never questioned. Learning to say “that’s outside the scope we agreed on” or “I need that in writing before I take this on” isn’t a leadership soft skill. It’s the foundation that makes the other four skill sets possible, because none of the skills above matter if you have no time or energy left to apply them. This is also, not coincidentally, the skill most connected to physician burnout. A substantial body of research links burnout not simply to workload but to a mismatch between the demands placed on a physician and the control they have over how those demands are met. Leadership roles, taken on without boundaries, tend to multiply that mismatch rather than resolve it. Learning to negotiate scope before accepting a role, and to revisit it once you’re in it, is one of the more effective, and least discussed, protections against burning out in a job you otherwise wanted. WHAT CLOSING THE GAP LOOKS LIKE IN PRACTICE None of this requires going back for a second degree, though for some physicians that’s the right path. For most of us, closing the gap is more incremental than that, and more achievable than it might seem: • Find one mentor who has made the transition you’re trying to make, whether that’s from clinician to medical director, or from practice owner to multi-site founder, and ask specifically how they learned the parts nobody taught them. • Treat your first few contracts and negotiations as practice, not just outcomes. Debrief them afterward: what worked, what you’d do differently, what you didn’t know to ask. • Read outside medicine deliberately. Business, negotiation, and organizational leadership have a substantial literature that translates well to clinical settings, even though it wasn’t written for us. • Consider formal training, an executive MBA, a leadership fellowAugust 2026
ship, a hospital-sponsored physician leadership program, if your role and trajectory justify the investment. It compresses years of trial and error into a structured curriculum. • Build a peer group of physicians facing similar transitions. Much of what I’ve learned came not from a course but from comparing notes with colleagues navigating the same unfamiliar terrain in real time. A FEW PLACES TO START LEARNING For physicians who want a more structured entry point than trial and error, a few resources are worth knowing about: • The AAMC and specialty societies (ACP, APA, ACS, among others) increasingly offer physician leadership certificate programs and workshops, often shorter and less expensive than a full degree. • Hospital and health system-sponsored physician leadership academies, where available, are frequently underused simply because they aren’t well publicized internally. • Executive and physician-focused MBA programs exist specifically to bridge this gap, and many are structured for practicing clinicians rather than requiring a career pause. • Books on negotiation and organizational leadership written for a general business audience (the genre is large and well developed) translate more directly to clinical leadership than most physicians expect. • Peer mentorship, structured or informal, remains one of the highest-yield and lowest-cost ways to close this gap, particularly with a colleague a few years ahead on a similar path. CLOSING THE GAP None of this is an indictment of medical education, which does an extraordinary job of what it was designed to do: produce excellent, safe clinicians. But an increasing number of us are also becoming administrators, directors, founders, and executives, often with no more preparation for that role than what we’ve cobbled together ourselves, one difficult negotiation or one mismanaged team at a time. The good news is that every one of these skills is learnable, at any career stage, and often faster than we expect once we decide to take them as seriously as we once took Step 1. There was no rotation for this. That doesn’t mean we can’t build our own curriculum now, and it doesn’t mean the physicians coming up behind us have to learn it the same hard way we did. DMJ
SEJAL MEHTA, MD, MBA, is a triple board-certified psychiatrist at Psychiatric Medical Associates, PA, Plano, and Co-Founder and Chief Medical & Scientific Officer of PraxisOne, Inc.
DALLAS MEDICAL JOURNAL | 13
HEALTH AND WELLNESS
The Myth of Arrival Redefining Success in a Medical Career by Aashoo Mentreddi, MD, Co-Founder, The Neurology Collective
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August 2026
HEALTH AND WELLNESS
M
EDICINE IS A PROFESSION BUILT AROUND milestones. From the moment we decide to pursue it, we almost always have a clearly defined next step: getting into medical school, graduating, matching into residency, completing training, pursuing fellowship, passing boards, and finding a first job. The path is long and often difficult, but its structure provides a certain reassurance. We know what we are working toward, and even during the most demanding periods, we can usually identify the next goal on the horizon. Then, after years of following that carefully prescribed path, the structure changes. We become practicing physicians, establish ourselves in our fields, and eventually reach the stage we have spent much of our adult lives preparing for. Yet medicine provides remarkably little guidance for what happens afterward. We are taught in great detail how to become physicians, but far less about how to continue shaping a professional life once the prescribed milestones are behind us. For many of us, there is an implicit assumption that if we have chosen our path carefully and worked hard enough to reach it, professional fulfillment will naturally follow. I believed that for much of my career. I also believed, perhaps without realizing it, that success in medicine had a relatively fixed definition. During my training, I remember hearing some version of the idea that private practice was a choice physicians made for lifestyle, while academia was where the “real” work happened. Like many assumptions we absorb during training, it was presented less as an opinion than as an accepted truth. I respected the physicians who trained me and admired their careers, so it was easy to adopt their definitions of success before I had enough experience to develop my own. When I ultimately chose private practice, I quickly discovered how incomplete that distinction was. I was able to build a subspecialty practice while remaining involved in many of the things that had drawn me to academic medicine in the first place. I participated in clinical trials in Parkinson’s disease and Alzheimer’s disease, taught medical students, and continued to learn from complex neurologic patients. At the same time, I developed something I had not fully appreciated during training: long-term relationships with patients and their families. I could follow people over years, sometimes through multiple stages of disease, and understand their lives in a way that is difficult to capture in a single consultation or research encounter. That experience taught me an early lesson about professional success. The career that was meaningful to me did not need to resemble the career someone else had defined as meaningful. I could combine different aspects of medicine in ways that suited my own interests and priorities. At the time, I thought I had solved the problem by defining success for myself. What I August 2026
did not yet understand was that defining success is not something we necessarily do once. WHEN ACHIEVEMENT AND FULFILLMENT DIVERGE As my career progressed, I became increasingly involved in physician leadership. I accepted opportunities that stretched me beyond what I initially thought I was ready to do, and over time those roles became an increasingly important part of my professional identity. Eventually, I became president of a large neurology practice, a position that represented years of clinical work, organizational involvement, and gradual progression into leadership. By most external measures, I was exactly where I had been working to go. That was what made the next realization so difficult: I was no longer certain that I wanted to stay there. There was no dramatic event that precipitated this change. I had not stopped enjoying medicine, and I was not looking for an easier career. I still enjoyed caring for patients, solving difficult clinical problems, leading, and working hard. I remained grateful for the opportunities I had been given and proud of what I had accomplished. Nevertheless, I began to recognize that achievement and fulfillment, which I had assumed would continue to move together, had started to diverge. Physician dissatisfaction is frequently discussed through the framework of burnout, and appropriately so. Burnout is an enormous problem in medicine. But I also think that framework can sometimes be too narrow to describe the more complicated questions that arise in the middle of a long career. It is possible to remain engaged in medicine and still realize that the professional structure in which you have been successful is no longer the one in which you want to spend the next decade or two. The problem is not necessarily that the work has become too hard. Sometimes the question is whether the work is still taking you somewhere you want to go. That question is particularly uncomfortable when things are going well. An understandable narrative exists around changing course after failure or crisis. If a practice fails, a job disappears, or a situation becomes intolerable, change becomes necessary. Voluntarily leaving a successful path is more difficult to justify, both to other people and to ourselves. The further we advance, the more we have invested in getting there: years developing expertise, professional relationships, institutional knowledge, reputation, and leadership experience. A title or position can also gradually become part of how we understand ourselves professionally. Walking away from any of that can feel less like changing direction and more like abandoning something we worked very hard to earn. DALLAS MEDICAL JOURNAL | 15
HEALTH AND WELLNESS
THE COURAGE TO RECONSIDER Medicine reinforces this tendency because perseverance is deeply embedded in our professional culture. We learn early to tolerate discomfort, finish what we start, and keep moving toward the next goal even when the process is difficult. Those qualities are essential during medical training and often make us better physicians. They can also make it difficult to distinguish perseverance from inertia. At some point, I found myself considering a question that was much simpler than the decision it implied: if I were designing my career today, with everything I now knew about medicine and myself, would I build the same career again at this time in my life? The answer was no. That answer did not mean that the career I had built was a mistake. In fact, I remain deeply grateful for it. It meant that the person evaluating the career was no longer exactly the same person who had originally designed it. This seems obvious when stated plainly, yet much of our thinking about professional success assumes the opposite. A medical career may last thirty or forty years, but we often behave as though the ambitions we developed early in that career should remain binding for its duration. Over time, my interests had broadened. I became increasingly curious about aspects of neurologic health that did not always fit comfortably within the traditional boundaries of a neurologic visit. I found myself thinking more about nutrition, exercise, sleep, hormonal changes, lifestyle, and healthy aging, and about how these factors intersect with neurologic disease. Some of this curiosity grew out of my own experience as a patient during pregnancy, becoming a parent, and raising young children. I explored approaches I might have previously dismissed as outside my conventional medical framework. What stayed with me was not a conclusion about any particular therapy, but the experience of being a patient who wanted someone to consider aspects of my health that did not fit neatly into the traditional medical encounter. That experience made me more curious about the questions my own patients were asking. How did nutrition affect Parkinson’s disease? What role did exercise play beyond the recommendations we routinely gave? How should we think about hormonal changes and cognition? What did healthy aging mean for someone who was not yet ill but wanted to protect neurologic health? I did not always have satisfying answers, and I became increasingly interested in learning more rather than dismissing those questions because they fell outside the boundaries of my formal subspecialty training. In retrospect, I had created a silo for myself without realizing it. It was simply a different silo from the one I had rejected earlier in my career. I had become highly specialized, increasingly experienced, and
comfortable operating within a system I understood. Expertise had opened many doors, but it had also made it easy to remain within familiar ones. BECOMING A BEGINNER AGAIN Eventually, I decided, along with my physician partners, to leave the established practice where I had spent much of my career. We did not immediately replace it with a fully formed vision of what came next. I spent a period doing locums work while we considered what we wanted to build, what we wanted to preserve from our previous experiences, and what we wanted to do differently. That period of uncertainty was uncomfortable, particularly after years in which my professional identity and trajectory had been so clearly defined. It was also useful. For the first time in a long time, the absence of an obvious next step forced me to think deliberately about what I wanted that step to be. When we decided to start our own practice, I assumed that my years in private practice and physician leadership had prepared me reasonably well. I understood how practices worked, or at least I thought I did. I soon discovered the difference between leading an established system and building one from the ground up. Decisions about credentialing, staffing, contracts, electronic medical records, technology, phone systems, websites, workflows, forms, compliance, and countless operational details that had once existed quietly in the background to a large admin staff suddenly belonged to us. The experience was humbling in ways I had not anticipated. After years of feeling comfortable in my expertise and confident in my ability to lead within a medical organization, I was once again asking very basic questions. Yet I found that position unexpectedly energizing. It reminded me how much of professional growth comes from being willing to enter spaces where we do not already know the answers. I began doing that more intentionally in other areas as well. I pursued additional education in lifestyle and wellness, fields that intersected with my existing interests but extended beyond my formal neurologic training. I became a student again, learning from people whose expertise differed from mine and becoming more comfortable acknowledging the limits of what I knew. For physicians, that can be harder than it sounds. Our professional identities are built around competence, and by mid-career we have spent years becoming experts. Returning voluntarily to the position of novice can therefore feel like moving backward, even when it is exactly what allows us to continue growing. REDEFINING WHAT IT MEANS TO GROW The practice we ultimately created is a fraction of the size of the organization I left. Earlier in my career, I might have interpreted that as a contradiction. Ambition is often associated with scale: larger organizations, larger clinics, more senior titles, broader influence. We tend to describe successful careers as trajectories that move continuously upward and outward. Yet I had reached a point where scale was no longer the measure I most wanted to maximize.
DR. AASHOO MENTREDDI is a board-certified neurologist and movement disorders specialist in Dallas, Texas. She is co-founder of The Neurology Collective, where she focuses on personalized neurologic care and a broader approach to brain health. Her interests include Parkinson’s disease, migraines, dementia, healthy aging, and the intersection of lifestyle and neurologic health. More information is available at myneurologycollective.com.
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August 2026
HEALTH AND WELLNESS
I wanted greater autonomy over how I practiced medicine and more time to develop meaningful relationships with patients. I wanted the ability to explore areas of neurologic health that interested me without requiring every idea to fit into an existing organizational structure. I wanted to continue working hard and taking on difficult problems, but I also wanted greater agency over what that work was building. In that sense, building something smaller allowed me to think more expansively about the career I wanted. None of this has made me view my previous career as time spent on the wrong path. I needed those years. Leadership taught me how organizations function and how difficult decisions are made. Working in a large practice exposed me to problems and perspectives I would never have encountered on my own. My clinical experience gave me the confidence to question how I wanted to practice, and even the roles I eventually chose to leave helped clarify what I valued enough to carry forward. Changing direction did not require rejecting what came before it. MOVING THE GOALPOSTS Perhaps that is where the myth of arrival is most misleading. It suggests that a career should eventually resolve into a final form, as though the purpose of all those early milestones is to reach a destination and remain there. In reality, a medical career is long enough to accommodate multiple definitions of success. The goals that motivate us during training may not be the ones that sustain us in mid-career, and the career that feels right at forty may not
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August 2026
be the one we want at fifty or sixty. That evolution does not necessarily represent dissatisfaction, failure, or a loss of ambition. It may simply reflect the fact that experience has given us better information about what we value. There are good reasons to approach major professional changes cautiously. Careers have financial, personal, and family consequences, and reinvention should not be romanticized. At the same time, staying on a path also has a cost because we have already traveled so far along it. The more successful we become, the easier it can be to confuse the accumulation of achievement with evidence that we should continue in the same direction. Medicine gives us an extraordinary amount of structure as we learn how to become physicians. What it cannot provide is a roadmap for the decades that follow. Eventually, the goalposts stop being assigned to us, and we have to decide where to place them ourselves. More importantly, we have to remain willing to move them. The most meaningful chapters of my career have not all been part of the plan I originally imagined. I no longer see that as a deviation from a successful career. I see it as part of one. Dreaming bigger does not always require climbing higher, accumulating more, or building something larger. Sometimes it means recognizing that the destination has changed and giving ourselves permission to change course with it. DMJ
8/13/268/13/26 9:57 PM 9:57 PM 8/13/26 9:57 PM
DALLAS MEDICAL JOURNAL | 17
Free Alzheimer’s CME for Providers
What you need to know as a primary care provider. Earn free online Continuing Medical Education (CME) credits developed by the Texas Department of State Health Services and physician experts on Alzheimer’s disease and related dementias. These courses will keep you up to date on the latest validated assessment and screening tools, help you direct patients to community resources, and reinforce your role in helping patients and their families manage symptoms throughout the disease process.
DSHS Alzheimer’s Disease Program Learn more at dshs.texas.gov/alzheimers-disease/provider Content on the Texas Department of State Health Services Alzheimer’s Disease Program website has been accredited by the Texas Medical Association and American Nurses Credentialing Center.
HEALTH ALLIES
Critical Illness Protection by TMA Insurance Trust HEALTH INSURANCE COVERS MEDICAL TREATMENTS, but what about the many other expenses a serious illness can bring? The TMA Member Critical Illness Insurance plan, issued by the Prudential Insurance Company of America, is designed to assist with these additional costs. To help you understand how the plan works and highlight its value, here’s a step-by-step walkthrough. STEP 1: EASY ENROLLMENT WITH GUARANTEED ACCEPTANCE Securing coverage is straightforward, especially for TMA members. • Guaranteed Acceptance for Members: If you’re a TMA member under age 65, you’re guaranteed acceptance for $20,000 in coverage. No medical exams, health questions, or underwriting are required. It’s truly that simple. • Guaranteed Acceptance for Your Spouse: Once you are enrolled, this guaranteed acceptance also extends to your spouse or domestic partner under age 65, providing $10,000 in coverage upon their enrollment. Seeking more extensive coverage? • You can apply for up to $250,000 in total coverage. • Spouse and family coverage options are available. Enrollment is quick and easy, whether you complete it online or by contacting an advisor. STEP 2: WHAT HAPPENS IF YOU’RE DIAGNOSED? Should you be diagnosed with a covered illness, you receive a $20,000 lump sum benefit paid directly to you. This payment remains unaffected by any other insurance benefits you receive. There are no deductibles, co-pays, or coinsurance to manage. You have complete freedom to use the benefit in whatever way best supports your recovery and eases your mind, whether for medical or non-medical expenses such as travel, time away from work, household costs, childcare, home modifications, or other personal needs.
STEP 3: UNDERSTANDING YOUR COVERAGE: WHAT CONDITIONS ARE INCLUDED? Many of the most serious health challenges are addressed by this coverage, with benefits provided as shown below. 100% Benefit Paid For: Invasive Cancer Heart Attack Stroke Major Organ Failure Renal Failure Alzheimer’s Disease Non-Invasive Cancer (excluding skin cancer) 25% Benefit Paid For: Multiple Sclerosis Parkinson’s Disease Severe Coronary Disease Occupational HIV Infection Terminal Illness This plan aims to alleviate some of the financial stress that critical illnesses can place on individuals and their families.
STEP 4: YOUR COVERAGE STAYS WITH YOU As long as you maintain your TMA membership, your coverage remains active. This means your vital protection continues with you, even if your job or practice situation changes.
GET STARTED TODAY With guaranteed acceptance, a direct lump-sum payment, and coverage that follows you through career changes, the TMA Member Critical Illness Insurance plan is a smart way to strengthen both your financial and health strategies. DMJ
August 2026
DALLAS MEDICAL JOURNAL | 19
HEALTH ALLIES
A Guide to Professional Growth– Employment Agreements by Brandon Kulwicki, Shareholder, Chandani Patel, Associate, and Stuti Desai, Summer Associate, Hall, Render, Killian, Heath & Lyman, P.C.
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HETHER YOU’RE SIGNING YOUR first contract out of residency or weighing your next move after years in practice, your employment agreement deserves substantial attention because of the impact it can have on your career and life. It shapes where you can practice if your current job ends, any leadership or administrative obligations you may have, who owns what you invent, and what you’re financially exposed to after you leave. While taking stock of your aspirations and priorities, it’s important to understand the implications of your employment agreement on your current and future employment opportunities. RESTRICTIVE COVENANTS: TEXAS RULES Legislative movement in favor of physicians and health care practitioners has increased in recent years. Texas physicians have more leverage on non-competes than they did in prior years. Senate Bill 1318, signed in June 2025 and effective September 1, 2025, revised Texas Business and Commerce Code Section 15.50. For non-competes entered into or renewed on or after September 1, 2025, the law now requires: (i) a five-mile radius cap, measured from your primary practice location at termination; (ii) a one-year maximum duration; (iii) a hard buyout cap, equal to no more than
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your total annual salary and wages at termination; and (iv) a withoutcause exception, which voids your non-compete if you are let go for reasons unrelated to your conduct or performance, such as for a layoff, a restructuring, a budget cut. For the radius restriction, the primary practice location should be named specifically in your contract. Specificity will help ensure the legislative change provides you the greatest protection the law intended. The new buyout cap replaces the old “reasonable price” standard, which previously sent buyout disputes to arbitration. This provision change sets a standard that is likely difficult to contract around, thereby setting a ceiling for a buyout agreement. A couple of additional nuances worth knowing as you plan your next step: • First, none of this applies retroactively. If your current contract hasn’t been renewed since September 1, 2025, you’re still under the old “reasonableness” standard, and the new provisions don’t apply. But they will apply upon renewal, or if you change roles, so it’s important to be aware of these legislative changes. • Second, SB 1318 carves out administrative non-competes, such as medical director agreements and management duties, from these new protections. The bill does this by stating the practice of medicine doesn’t include administrative responsibilities. Non-compete provisions for administrative or management-type roles are reviewed under Texas’s Business and Commerce Code 15.50(a), which covers August 2026
HEALTH ALLIES
all other non-compete arrangements. If your current role or next career step blends clinical and administrative work, it’s worth understanding which part of your restrictive covenant falls under the different standards. • Additionally, the statute doesn’t yet say how the buyout provision works if you’re paid based on productivity rather than salary. If your compensation fluctuates, it’s worth getting that structure defined clearly in your contract rather than leaving it open to interpretation later. CORPORATE PRACTICE OF MEDICINE: KEEPING PHYSICIANS IN THE DRIVER’S SEAT Texas bars non-physicians from owning medical practices or controlling clinical decisions under what is commonly referred to as the “Corporate Practice of Medicine” doctrine. It exists as part of the Texas Occupations Code in a number of provisions to ensure that entities or unlicensed individuals cannot practice medicine or guide medical judgment. Therefore, your medical judgment stays yours, not an administrator’s. If an employment provision would let a non-physician executive override your clinical decisions in the name of productivity or efficiency, that’s worth a real conversation with an attorney. The provisions in the Occupations Code are designed to protect you and your medical judgment to provide the best treatment to Texas residents, and employment agreements should reflect those protections. TAIL COVERAGE: UNDERSTAND WHERE THE PROTECTION LIES Tail coverage covers claims that surface after you’ve left your employment or independent contracting arrangement but arose from care provided during the term of your arrangement. While medical malpractice insurance can be a condition of employment, your contract should reflect which party will be handling conflicts should your employment end. Even as part of a sale or purchase of a physician practice, a common source of friction is who handles issues around liability or audits when physicians move on. These issues can be complex and interwoven between layers of regulatory, licensing, and payment requirements. Because of the complexity of the health care industry, working with an attorney who specializes in it can help provide the protection required through your employment agreement. PROTECTING WHAT YOU BUILD More and more physicians are leading research initiatives or playing an active role in the development of medical devices, software, and protocols. These advancements are what keep health care moving forward and are an incredible exercise of the human mind and fortitude, and those efforts are worth protecting. Before you sign an agreement related to a research or administrative role, review these four things: • Invention assignment: Many contracts can assign everything you invent during the term of your employment to the employer, even work done entirely on your own time with your own resources. It’s reasonable to ask that this be narrowed to inventions actually related to the employer’s business and built with the employer’s resources. • Prior IP exclusion: If you already own a patent or have a project underway, list it by name in an exhibit. This will provide protection for items that were researched or invented outside of employment. • Royalty splits: If you expect to build something using institutional August 2026
resources, it’s worth understanding how the revenue will be split between you and your employer ahead of time. • Publishing rights: Hold onto the right to publish your research without needing corporate pre-approval, limited only by narrow, clearly-defined confidentiality carve-outs. Your contributions to the field are valuable, and your contract shouldn’t stand in the way of sharing them. PAYER MIX: PROTECT THE INCOME YOU’VE EARNED If your pay or bonus is based on productivity, it may be worth understanding what happens when your employer changes its payer contracts. If the hospital drops a major commercial plan or renegotiates tiering, that can impact your practice. Though this is less likely to occur with health systems and larger practices, it can be critical to discuss with your attorney ahead of time to understand the impact of such a change and what options exist for inclusion in an employment agreement that would provide a certain level of protection. THE BOTTOM LINE Engage Counsel that Understands Health Care. A generalist attorney can review your agreement and offer general advice; however, a health care attorney will catch issues that can affect your longterm career and professional goals: licensure-linked restrictive covenants, corporate practice of medicine limits, payer-mix exposure, and appropriate non-compete provisions. It is worth working with a specialist to understand the protections that exist in your agreement or identify the gaps that may exist in your agreement. SB 1318 yields tangible and welcome progress for the clinical market in Texas, and it’s a good sign of where the law is headed. To note, it’s not retroactive, it doesn’t cover administrative roles, and it leaves the buyout calculation unresolved for anyone not on a flat salary, but that’s exactly why a thoughtful, health care-specific review matters. Combine that with the long-standing fundamentals of health care delivery, the corporate practice of medicine, and IP ownership, and a careful contract review becomes one of the best investments you can make in your own career. As you take your next step, give your agreement the attention it deserves, and bring in counsel who can help you take that step with confidence. DMJ This article is educational in nature and is not intended as legal advice. Always consult your legal counsel with specific legal matters. If you have any questions or would like additional information about this topic, please contact Brandon Kulwicki at (214) 615-2025; Chandani Patel at (214) 6152037; or your primary Hall Render contact. Brandon Kulwicki and Chandani Patel are attorneys with Hall, Render, Killian, Heath & Lyman, P.C., a national law firm focused exclusively on matters specific to the health care industry. Please visit the Hall Render Blog at blogs.hallrender.com for more information on topics related to health care law. REFERENCES S.B. 1318, § 1, 89th Leg., R.S. (Tex. 2025). Tex. Occ Code Ann. §155.001 (West 1999). Tex. Occ Code Ann. §155.003 (West 2023). Tex. Occ Code Ann. §162.0021 (West 2011). Tex. Occ Code Ann. §162.0022 (West 2012). Tex. Occ Code Ann. §164.052(a)(17) (West 2023).
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LEGISLATIVE DEBRIEF HEALTH ALLIES
2027 Medicare Physician Payment Schedule and Quality Payment Program Proposed Rule Summary by American Medical Association Staff
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N JULY 14, 2026, THE Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2027 Revisions to Payment Policies under the Medicare Physician Payment Schedule (PFS) and Other Changes to Part B Payment and Coverage Policies proposed rule and fact sheet. The proposed rule includes proposals related to Medicare physician payment and the Quality Payment Program (QPP). If finalized, these policies will take effect on January 1, 2027, unless otherwise noted. The American Medical Association (AMA) will submit detailed comments by the September 14, 2026 deadline. The AMA will provide a draft version of its comments to Federation members in advance of the deadline. PAYMENT PROVISIONS CY 2027 Medicare Conversion Factors For the second year, there are four proposed conversion factors, as outlined below: These conversion factors reflect: • Expiration of the temporary 2.5 percent update for CY 2026 included in H.R. 1 • A 0.53 percent budget neutrality adjustment to balance proposed coding and payment policy changes • 0.5 percent higher update for Qualified Participants (QPs) in Advanced Alternative Payment Models (APMs) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
CY 2027 MEDICARE CONVERSION FACTORS Medicare Conversion Factor
Medicare Anesthesia Conversion Factor
For APM QPs
For non-APM QPs
For APM QPs
For non-APM QPs
$33.1693 (-1.19%)
$32.8409 (-1.68%)
$20.4165 (-0.89%)
$20.2143 (-1.38%)
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The AMA continues to strongly advocate for annual Medicare payment updates to reflect the growth in physician practice costs as measured by the Medicare Economic Index (MEI), which CMS projects will be 2.5 percent. On July 15, Representatives John Joyce, M.D. (PA-13), Greg Murphy, M.D. (NC-03), and Kim Schrier, M.D. (WA-08), chairs of the GOP and Democratic Doctors Caucuses, introduced the Patients First Act (HR 9693), a comprehensive, bipartisan, AMA-supported MACRA reform legislation that includes an inflation-based update tied to MEI, budget neutrality reform, a MIPS replacement, APM reforms, and a new primary care payment pilot that would not impact budget neutrality. In its 2026 report, the Medicare Payment Advisory Commission (MedPAC) recommended increasing payment rates for physician services “to bring fee for service Medicare’s overall payment levels closer in line with providers’ costs.” The 2026 Medicare Trustees Report likewise warned MACRA “raises important long-range concerns that will almost certainly need to be addressed by future legislation… physician payment updates …do not vary based on underlying economic conditions, nor are they expected to keep pace with …physician cost increases… Absent a change in the delivery system or level of update by subsequent legislation, the TrustAugust 2026
LEGISLATIVE DEBRIEF
ees expect access to Medicare-participating physicians to become a significant issue in the long term.” PRACTICE EXPENSE (PE) METHODOLOGY – NEWLY PROPOSED CHANGES In response to the AMA’s previous request, CMS published the algorithm utilized to calculate PE relative value units (RVUs) to promote transparency. CMS proposes the following changes effective Jan. 1, 2027: • Allocate indirect practice expense based on both physician work RVUs and clinical labor for all services except 10- and 90-day global period codes. CMS does not provide a rationale for excluding 10- and 90-day global codes, which would be disadvantaged in any redistribution that results from this change. • Simplify the methodology by removing the indirect practice cost indices (IPCI) from the calculation of the practice expense RVUs over a two-year transition period. The specialty-level IPCIs are published on the CMS website and vary from 0.6 to 2.2. This modification would result in specialty redistribution. • Introduce a stabilization adjustment to practice expense RVUs to ensure services not otherwise modified (new, revised or revalued) are not impacted in practice expense adjustments by more than five percent relative to the previous year. This stabilization adjustment will occur prior to the statutory phase-in, which limits all codes that are not new or revised to a 19 percent decrease in total RVUs in a given year. MEDICARE ECONOMIC INDEX (MEI) CMS proposes to continue the MEI cost shares for physician work, PE, and professional liability insurance for 2027, which the AMA supports. A previous CMS alternative would have resulted in a significant decrease in the proportion of physician payment allocated to physician work and was opposed by organized medicine. UPDATE TO PRACTICE EXPENSE SITE OF SERVICE PAYMENT DIFFERENTIAL In 2026, CMS implemented a controversial methodology change to reduce the indirect practice expense payment for all services provided in the facility setting, citing concern that duplicative payments were made between the physician and hospital payment systems. CMS reduced the portion of facility practice expense RVUs allocated based on work RVUs to half the August 2026
amount allocated to non-facility PE RVUs. This resulted in a seven percent cut to facility-based payment, while non-facility-based payment to physicians increased by four percent. Resulting payment changes to individual physicians and specialties were substantial. The AMA pushed back strongly against the proposal and called for CMS to make changes based on reviewing individual services, rather than broad disruptive policies, highlighting the results of our Physician Practice Information Survey. In this proposed rule, CMS acknowledges “unintended, but significant” issues that resulted from this policy. The Agency proposes to address one particular anomaly to ensure that nursing facility visit payments will again be equalized in 2027. CMS further states that there are ongoing concerns with the policy as the “current binary of facility and non-facility does not account for the range of employment models associated with physician services that drive significant differences in actual practice expenses.” CMS requests comment on alternatives, including a percentage less than 50 percent; utilizing a new modifier to identify employed physicians to isolate payment reductions; or other methods to address their concern about duplicative practice expense payment. STRATEGIES TO IMPROVE PAYMENT TRANSPARENCY, ACCURACY, AND CONGRUENCY ACROSS PAYMENT SYSTEMS Professional and Technical Components A file is posted to the CMS website that displays the non-facility (office) practice expense RVUs and the facility practice expense RVUs, labeling facility RVUs as “26 – professional” and the difference between the non-facility and facility RVU as “TC-technical.” CMS states that it is sharing this information to provide transparency and to “facilitate more consistent comparisons across services and settings.” CMS requests comment on how it could use this information to assess payment differences across settings. Global Surgical Packages CMS continues to express concern about the accuracy of global surgery payment, specifically that post-operative visits are not being provided. This hypothesis is largely derived from a flawed attempt to require some physicians to report non-covered CPT code 99024 Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation
and management service was performed during a postoperative period for a reason(s) related to the original procedure for certain services. The AMA has previously detailed the concern with this data collection effort and resulting CMS analyses, beginning on page 31 of the AMA comment letter on the 2022 PFS proposed rule. CMS now proposes to pause the data collection effort for CPT code 99024, citing undue burden to physicians. However, the Agency requests comment on whether the CPT code 99024 reporting requirement should be expanded to all physicians or if other data sources are available to demonstrate the number of visits provided. An Excel file is posted to the CMS website that computes relative values without the post-operative visits for all 10- and 90-day global period services and CMS also calls for comment on potential revaluation strategies to consider in future rulemaking. VALUATION OF SPECIFIC CODES CMS proposes to accept 88 percent of the AMA/Specialty Society RVS Update Committee (RUC) recommendations and 100 percent of the RUC Health Care Professionals Advisory Committee (HCPAC) Review Board recommendations for new/revised CPT codes and codes identified via the RUC’s potentially misvalued services process. CMS also proposes to accept nearly 100 percent of the AMA’s direct PE recommendations. CPT 2027 will include a major restructuring of maternity care services and speech-language pathology services, and several other coding and payment changes ranging from prostate biopsy to magnetic resonance angiography - head and neck. Maternity Care Services The AMA is pleased that CMS adopted AMA’s recommendations to update the Maternity Care Services coding structure. Beginning January 1, 2027, the CPT codes will be updated to comprehensively revise the maternity codes, reflecting modern obstetric practice. The new code structure will provide muchneeded transparency for patients, and the increased granularity will improve the ability of physicians and researchers to DALLAS MEDICAL JOURNAL | 23
LEGISLATIVE DEBRIEF HEALTH ALLIES
better understand the drivers of maternal mortality. The AMA believes CMS’ solicitation for comments on maintaining current coding through the creation of HCPCS G-codes will create unnecessary confusion and urges CMS to finalize the Maternity Care Services CPT code set without maintaining the historical global structure via HCPCS G-codes. Remote Monitoring CMS began payment of CPT codes for remote physiologic monitoring (RPM) in 2019. Codes for remote therapy monitoring (RTM) followed, as well as an expansion of coding for RPM. CMS has required that RPM services be furnished only to established patients since 2021. For 2027, CMS proposes that RTM services also be furnished only to established patients. Clinicians reporting RPM or RTM services must furnish a separately reportable initiating visit in association with the onset of RPM or RTM services. For 2027, CMS is proposing to only allow payment for RPM or RTM services when performed by clinical staff employed by the practice and not when those services are delivered by contractors. Citing their belief that a lack of data regarding the typical device used in the provision of RPM and RTM services has led to possible overpayment, CMS proposes to decrease the PE RVUs for several of these services using crosswalks to other services and eliminating all direct practice costs for the treatment management codes. These changes will result in significant payment reductions in RPM and RTM services in 2027. As payment reductions are limited to 19 percent per year, several of these codes will continue to be reduced in future years until CMS’ proposed values are fully implemented. However, CMS is not bound by the 19 percent reduction for new codes. Accordingly, CMS proposes bundling the RPM and RTM CPT codes and creating four new HCPCS G-Codes in 2027 to describe remote monitoring services, which would lead to immediate implementation of significant cuts to the monthly supply codes. The RUC is scheduled to re-examine the RPM codes in January 2028 and de24 | DALLAS MEDICAL JOURNAL
termine if the RTM codes need to be examined in 2030 after claims data are available. EVALUATION AND MANAGEMENT (E/M) VISIT COMPLEXITY ADD-ON (HCPCS CODE G2211) CMS proposes to replace E/M Visit Complexity add-on HCPCS code G2211 with a modifier referred to as MOD1. CMS believes that the resource costs of furnishing longitudinal care for beneficiaries are not best characterized as a separate service and code. Rather, CMS believes that since the work is an inherent part of the visit, it would be more accurately valued as a modifier to the base E/M code. MOD1 would be reported under the same circumstances that HCPCS code G2211 is reported now with a slightly different descriptor: Visit complexity inherent to new or established office/outpatient or home or residence evaluation and management service, associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. CMS proposes payment for MOD1 as 16 percent of the E/M base code using a weighted average of the percentage increase that G2211 comprised relative to two office or other outpatient visit E/M codes, weighted by utilization, and adjusted for budget neutrality. The Agency would also create a separate modifier MOD2 to be exclusively available to Accountable Care Organization (ACO) participants, paid at 32 percent of the E/M base code. ADDITIONAL NEWLY COVERED SERVICES CMS is proposing to create G codes and cover a number of new services in 2027, including: shared medical visits; advance care planning by clinical staff; vaccine adverse effects management; health coaches; and vascular embolization or occlusion procedure with use of a pressure-generating catheter. ACCOUNTING FOR E/M RESOURCE OVERLAP BETWEEN STAND-ALONE VISITS AND GLOBAL PERIODS CMS proposes to change payment for services using Modifier -25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service. CMS proposes to
reduce payment when a separately identifiable E/M office visit is furnished by the same physician (or a physician in the same group practice) on the same day as a 0-, 10-, or 90-day global procedure. Under this proposal, the most expensive service (either surgical or E/M visit) would be paid 100 percent, and all other surgical procedure(s) or E/M visit(s) would be paid at 50 percent. The AMA will vigorously oppose this policy, as the procedure codes most impacted by this proposal have already been valued to include only the work and resource costs that are above and beyond the E/M office visit. This proposal is inherently unfair to office-based physicians who perform minor procedures in their office. CMS is also seeking comment on how this policy might apply to an E/M visit reported on the same day as CPT code 67028 Intravitreal injection of a pharmacologic agent. SOFTWARE AS A MEDICAL SERVICE (SAMS) LABORATORY ANALYSES CMS proposes a change in terminology from Software as a Service (SaaS) to Software as a Medical Service (SaMS). SaMS will refer to software-based technologies that support clinical decision-making through algorithmic analysis, including those that provide clinical or diagnostic functionality. CMS takes the position that a SaMS should be treated the same way whether its algorithm analyzes an imaging test (e.g. a CT scan) or data produced by a laboratory test. In its view, all such algorithmic analyses are comparable to other SaMS analyses and fall within the broader proposed framework for SaMS. CMS expects that applying this consistent approach to SaMS technologies would support stability and predictability in payment for similar services. Accordingly, for CY 2027, CMS is proposing to contractor price ten HCPCS codes that describe various SaMS analyses performed on laboratory tests under the PFS. These ten codes were identified using each code’s CPT descriptor. Where a descriptor included no laboratory method and described only a computer analysis, CMS classified the code as a SaMS analysis performed on laboratory tests. CMS solicits comments on the ten-code proposal and any other SaMS analysis performed on lab tests that should be removed from the Clinical Laboratory Fee Schedule (CLFS) and contractor priced under the PFS, as well as input on approaches to payment for these services.
August 2026
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POTENTIALLY MISVALUED SERVICES The positive budget-neutrality RVU adjustment is partially due to the savings produced from the RUC’s identification and review of potentially misvalued services. For 2027, CMS received 13 nominations identifying potentially misvalued services for future review. CMS reviewed these comments and welcomes additional comments and review by the RUC on several areas.
thresholds (formerly known as therapy caps), which would increase from $2,480 to $2,540 for CY 2027 based on a proposed MEI update of 2.5 percent. The KX modifier thresholds would be updated in the final rule using more recent MEI data. The targeted medical review threshold remains at $3,000 through CY 2027, as set by statute, and will begin receiving annual MEI-based updates in CY 2028.
MEDICARE TELEHEALTH SERVICES CMS did not receive any requests for additions to the Medicare Telehealth List, but proposes to add several of the new services mentioned above to this list: advance care planning services provided by clinical staff under the direction of the treating physician; group-based medical sessions; treatment of speech and certain other disorders for pediatric patients; and visits to diagnose and treat vaccine adverse effects. The Consolidated Appropriations Act (CAA), 2026, extended flexibilities that allow Medicare telehealth services to be delivered nationwide and patients to receive services in their homes through 2027. Audio-only services are also extended, and in-person visit requirements for telehealth for mental health services are delayed through 2027. The CAA 2026 also requires CMS to create modifiers for telehealth furnished through a virtual telehealth platform by a physician who contracts with or has a payment arrangement with an entity that owns the platform. CMS establishes modifiers BB and BC for this purpose. CMS also proposes changing the G-codes for telehealth critical care to mirror the two CPT codes for critical care, so there will now be G-codes for the first 30 to 74 minutes and for each additional 30 minutes. Finally, CMS is changing its policy on teaching physicians providing virtual supervision of residents. The current policy requires that the teaching physician, resident, and patient be in three different locations. The new policy will allow teaching physicians to bill for services involving residents when either the teaching physician or the resident is in the same physical location as the patient.
SUPPORTING BENEFICIARIES PLANNING FOR FUTURE MEDICAL DECISIONS (ADVANCE CARE PLANNING SERVICES) CMS proposes two new HCPCS codes for advance care planning (ACP) services provided by clinical staff under the direct supervision of a physician or other qualified health professional. The existing ACP codes would be limited to time personally spent by the billing practitioner. The proposal reflects growing recognition that ACP is a longitudinal, team-based service and could help practices incorporate these conversations more routinely into ongoing care, expand patient access, and preserve physician involvement when clinical expertise is required.
OUTPATIENT REHAB FACILITY SERVICES AND KX MODIFIER THRESHOLDS CMS proposes routine and technical changes, including technical corrections to fix outdated cross-references and the statutorily required annual inflation update to the KX modifier August 2026
RURAL HEALTH CENTERS (RHCS) AND FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS) CMS proposes to recognize diabetes self-management training (DSMT) and medical nutrition therapy (MNT) as stand-alone billable RHC visits paid at the all-inclusive rate, provided the services are furnished by a certified provider under the direct supervision of RHC professional staff. Currently, these services are not separately payable when furnished during an RHC encounter, and CMS cites low utilization as justification (in 2024, DSMT reached just 0.005 percent of RHC beneficiaries, with utilization rates 22 times higher in FQHCs and 17 times higher in rural physician offices). As in FQHCs, if DSMT or MNT is furnished on the same day as another qualifying visit, the RHC would be paid at a single per-visit rate. CMS states that it does not expect to propose additional preventive services beyond those already payable in FQHCs and physician offices. CMS proposes other routine updates for CY 2027 including the annual FQHC prospective payment system market basket update of 2.5 percent, which would raise the base payment rate from $207.72 to $212.91 (to be updated in the final rule using more
recent MEI data), as well as other conforming regulatory text changes. PROPOSED CHANGES TO THE AMBULATORY SPECIALTY MODEL (ASM) In 2026, CMS finalized ASM as a mandatory payment model that will run for five years beginning in 2027. Several types of specialists in 240 geographic areas will be required to participate: (1) cardiologists who deliver services to 20 or more patients with heart failure, and (2) anesthesiologists, pain management physicians, neurosurgeons, orthopedic surgeons, and physiatrists who deliver services to 20 or more patients with low back pain. Beginning in 2029, specialists participating in ASM will face payment adjustments based on their ASM scores from two years earlier of +/- 9%, growing to +/- 12% by 2033. These scores will be based on participants’ performance on measures relative to other physicians in ASM. CMS is proposing to make a number of “technical refinements and adjustments,” several of which are responsive to the AMA’s prior recommendations, including: • A specialty group practice would be permitted to have a single Collaborative Care Agreement (CCA) with a primary care practice that covers all the specialists in the group, rather than every individual specialist in the group being required to have their own separate CCA with that practice. • Cardiologists could be exempted from ASM if they notify CMS that their primary specialty is cardiac electrophysiology, cardiac surgery, interventional cardiology, advanced heart failure and transplant cardiology, or adult congenital heart disease rather than general cardiology. The AMA objected to having specialty determinations made by CMS based on out-of-date or inaccurate information, which led to inappropriately including subspecialists. • The Functional Status Change for Patients with Low Back Impairments measure would be removed and replaced with the Functional Outcome Assessment measure, which would measure whether functional outcome assessments are conducted, DALLAS MEDICAL JOURNAL | 25
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rather than attempting to determine whether functional status has improved. • CMS proposed several AMA-sought revisions to Promoting Interoperability (PI) requirements for ASM participants to reduce reporting burden. Specifically, a separate attestation to completing a security risk analysis would no longer be required; the Office of the National Coordinator for Health Information Technology (ONC) Direct Review and ONC-Authorized Certification Body (ACB) Surveillance attestations would be removed; and the Electronic Prior Authorization (ePA) measure would be optional (and unscored) for 2027. These changes align with those proposed in the MIPS PI Category. Unfortunately, other proposed ASM changes are potentially burdensome or problematic, including: • Performance scores for physicians practicing in a rural area (regardless of their practice size) would be increased by five points (i.e., 5 percent). Because of the tournament structure of ASM, this could make it more likely that non-rural physicians receive a payment reduction despite good quality performance. • Performance scores would be increased by five points (i.e., 5 percent) if a physician voluntarily submits patientreported outcome data and risk adjustment data in a manner specified by CMS. However, CMS has left this largely undefined. Larger and better-resourced practices may be more equipped to receive these additional points, which could negatively impact physicians in small and independent practices. • Administrative claims-based quality measures would be calculated at the individual level, even if a small practice reports quality measures as a group, which could penalize physicians focused on complex patients. • A modified version of the Magnetic Resonance Imaging of Lumbar Spine for Low Back Pain measure would be added back into the low back pain component of ASM, despite previously having been removed due to concerns from the AMA and other stakeholders. The proposed new measure would attribute an MRI to any physician who delivered other low 26 | DALLAS MEDICAL JOURNAL
back pain-related services to a patient up to a year prior. CMS did not address several outstanding issues the AMA previously identified as problematic, including: • Despite the AMA’s strong opposition, ASM would remain a mandatory model. • The model design continues to use a “redistribution percentage” of 85 percent, which guarantees that the majority of participating physicians will receive a reduction in their Medicare payments regardless of how well they perform on the measures. The AMA recommended increasing the percentage to 100 percent. • Physicians would be rewarded or penalized based on whether their performance score is higher or lower than the scores received by the other physicians in ASM during the same year. The AMA recommended setting performance thresholds in advance so physicians know what they need to do to avoid a penalty. CMS would also only provide performance feedback after the performance year has ended. • Unlike other models in which downside risk is phased in over time, physicians in ASM could see their payments cut by up to 9 percent during the first year of the program. The AMA recommended reducing the maximum risk level in the initial two years to two percent. • Physicians treating as few as 20 relevant patients would be required to participate, even if ASM patients are a small subset of their patients. The AMA recommended a higher threshold. • No additional points would be awarded for improved quality and spending performance. • The AMA remains concerned that the proposed quality measures would not accurately or adequately assess whether Medicare beneficiaries had achieved better outcomes nor prevent patient safety concerns, while the cost measures could penalize physicians for aspects of spending they cannot control, such as when services are ordered by other specialists, or when drug prices increase. • No additional payments would be provided to support enhanced preventive care, coordination with primary care physicians, care management, and other services that could improve outcomes for ASM patients. CMS indicated that it was exploring “whether including additional conditions and specialists would be appropriate,” although it did not propose any expansion of the model in this proposed rule.
LIMITING MEDICARE COVERAGE OF CERTAIN INDIVIDUALS The proposed rule would add a new Medicarespecific definition of “eligible noncitizen.” Specifically, an “eligible noncitizen” would be an individual who is (1) an alien lawfully admitted for permanent residence under the Immigration and Nationality Act; (2) an alien who has been granted the status of a Cuban or Haitian Entrant, as defined in section 501(e) of the Refugee Education Assistance Act of 1980 (Pub. L. 96-422); or (3) an individual who lawfully resides in the United States in accordance with a Compact of Free Association (COFA) referred to in 8 U.S.C. 1612(b)(2)(G). The rule expressly states noncitizen U.S. nationals who are eligible for Medicare under section 1899C(a)(1) of the Act would no longer be considered “eligible noncitizens.” However, legal permanent residents who meet the five-year continuous residency requirement and other applicable Medicare requirements would maintain their Medicare benefit. On January 1, 2027, individuals that do not meet the proposed revised definition of an “eligible noncitizen” would no longer be able to obtain benefits under Medicare. CMS includes a proposed termination, enrollment, and notification framework to implement these changes. MEDICARE SHARED SAVINGS PROGRAM (SSP) This year’s rule includes myriad SSP changes, mainly to increase beneficiary enrollment, reduce administrative burden on ACOs, and make the program more “efficient,” i.e., reduce federal payouts to ACOs. CMS predicts that collectively, these changes will reduce SSP outlays by $5.5 billion over the next decade. For beneficiary assignment, CMS proposes to exclude allowed charges for primary care services billed through a non-ACO TIN and slightly loosen eligibility criteria pertaining to Medicare enrollment status starting in performance year 2028 (PY 2028). Both changes are expected to slightly increase the number of assignable ACO beneficiaries for the vast majority of ACOs, with a larger impact on a select few. Because these newly assignable beneficiaries are anticipated to have higher costs and be more medically complex, these changes are anticipated to negatively impact gross savings/losses. In addition, CMS proposes to add the following services to the list of primary care services used for assignment: screening, brief intervention, referral to treatment, vaccine adverse effects August 2026
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management, and Advance Care Planning. Regarding financial methodologies, CMS proposes changes aimed at “recalibrating incentives” between the BASIC and ENHANCED tracks to ensure ACOs do not advance to higher levels of risk too quickly, then drop out. Specifically, CMS proposes to increase the sharing rate for ACOs in BASIC Level E from 50 to 60 percent and to lower the maximum positive regional adjustments for ENHANCED ACOs from 50 to 35 percent. CMS also proposes to increase the prior savings adjustment from 50 to 75 percent to encourage continued participation by existing ACOs. To incentivize ACOs to expand into new participating practices and beneficiary populations, CMS proposes to add a new “growth adjustment factor” that would be applied on top of the existing adjustment factors (up to the cap). CMS also proposes to riskadjust the five percent benchmark adjustment cap to allow ACOs with complex patient populations to more fully benefit from benchmark adjustments. All these changes would apply to new agreement periods starting in 2027 or later. CMS proposes to adjust the Accountable Care Prospective Trend (ACPT) component of the benchmark update factor on an annual basis and to apply the same annual rate to all ACOs regardless of start date to promote consistency across cohorts. CMS would apply guardrails to mitigate large fluctuations. Lastly, CMS proposes to replace the visit complexity add-on code G2211 with modifiers that would reimburse physicians at 32 percent of the E/M base code for ACO participants, twice the amount as for non-ACO participating physicians. CMS proposes to discontinue prepaid shared savings due to limited uptake in 2026, the first year they were available. Uptake was limited due to strict guardrails overqualified spending categories and mandatory itemized spend plans. Out of 23 ACOs that applied, only four were approved. AMA plans to push back on this proposal and reiterate previous asks to loosen restrictions on this funding. CMS intends to improve the accuracy of advance investment payment calculations by adding a rural component and replacing Area Deprivation Index with a flat per beneficiary rate for non-rural, non-Low-Income Subsidy/ dually eligible beneficiaries starting in PY 2028. This year’s rule includes substantial quality reporting changes for SSP ACOs, many of which align with long-standing AMA asks, including extending the availability of the MIPS August 2026
clinical quality measure (CQM) collection type, establishing Medicare electronic CQMs (eCQMs) as a collection type (in addition to Medicare CQMs), amending MIPS data completeness requirements, updates to the APP Plus quality measure set, applying flat benchmarks to measures reported through Medicare CQMs and Medicare eCQMs, and revising scoring policies for excluded measures and non-benchmarked measures. CMS proposes several changes to the APP Plus quality measure set for SSP ACOs, including the removal of Initiation and Engagement of Substance Use Disorder Treatment (Quality ID: 305) and Adult Immunization Status (Quality ID: 493), which the AMA supports. The APP Plus quality measure set would include a total of eight measures in PY 2027, including five eCQMs/MIPS CQMs/Medicare CQMs/Medicare eCQMs; two administrative claims-based measures; and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey measure. In response to unified stakeholder opposition led by the AMA and other stakeholders, CMS proposes to reverse its previously finalized change from the 2024 PFS final rule that SSP ACO participants, regardless of track or Advanced APM QP status, must report all MIPS PI measures in order to satisfy SSP CEHRT use requirements. Instead, CMS proposes to allow SSP ACO participants to satisfy CEHRT use requirements through one of the following three flexible options: 1) successfully report at least one ACO-reported measure in the APP Plus quality measure set through eCQMs or Medicare eCQMs; 2) attest to using Fast Healthcare Interoperability Resources (FHIR) capabilities in certified health IT to support reporting of at least one ACO-reported measure; or 3) attest to one of three ACO CEHRT use metrics, a longtime AMA ask. In another victory for AMA advocacy, CMS proposes to reverse another burdensome previously finalized requirement that every ACO provider/supplier in the ACO must successfully report on a PI measure for an ACO to satisfy CEHRT use requirements. Instead, ACOs would be allowed to attest “Yes” to CEHRT use metrics for purposes of satisfying CEHRT use requirements if at least one ACO provider/ supplier in each of the ACO’s participating TINs performed the relevant action, with certain exclusions for those with special status, a
MIPS exception, or a hardship exception. CMS also proposes to extend enforcement discretion related to these proposals through the 2026 performance year so that failure to satisfy PI requirements will not negatively impact an ACO’s shared savings or losses. CMS does clarify that SSP ACO participants that are not Qualified Advanced APM Participants will still be required to report PI measures (unless they are otherwise excluded) for purposes of MIPS participation as before. Effective Jan. 1, 2027, CMS proposes to revise beneficiary notification requirements to reduce operational burden on ACOs. Specifically, timing for initial beneficiary notification requirements would be a set date that aligns with the ACO REACH Program, rather than prior to or at the first primary care service visit. CMS also proposes to eliminate the beneficiary follow-up communication requirement, citing a lack of evidence that it improves beneficiaries’ understanding of ACOs or value-based care. Lastly, CMS proposes to allow ACOs to elect to reduce or waive beneficiary cost sharing for certain services, including deductibles and/or coinsurance amounts. Applications would be collected in early 2027 and applied by a target date of April 1, 2027. CLINICAL LABORATORY FEE SCHEDULE CMS is proposing conforming regulatory changes to implement statutory amendments to the Protecting Access to Medicare Act of 2014 (PAMA) enacted in CAA, 2026, specifically data reporting and payment phase-in requirements including use of 2025 private payor data to establish updated CLFS rates beginning in 2027 and annual payment reductions of no more than 15 percent through 2029. These changes do not address underlying structural issues in the PAMA methodology, including concerns about whether the reported data adequately represent physician-office, hospital outreach, rural, and other laboratories. CMS cannot alter the statutory methodology through rulemaking; Congress must act to permanently reform PAMA and address potential payment reductions. AMA is actively working in concert with multiDALLAS MEDICAL JOURNAL | 27
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ple stakeholders on a Congressional fix. QUALITY PAYMENT PROGRAM (QPP) PROVISIONS Merit-based Incentive Payment System (MIPS) Following ongoing advocacy by the AMA, last year CMS finalized policy to maintain the threshold to avoid a MIPS penalty at 75 points through the CY 2028 performance year/2030 MIPS payment year. MIPS Value Pathways (MVPs) Despite strong objections by the AMA, CMS has proposed to sunset traditional MIPS and transition to MVPs in 2029. CMS is proposing to expand the MVP portfolio to include Diabetic Disease, Hypertension and Hospitalist MVPs starting with PY 2027. In addition, CMS is proposing to modify all 27 existing MVPs to include MIPS core measure selections for each MVP, add measures that expand upon a clinical concept or capture additional specialties most applicable to report an MVP, address maintenance requests from the public, and remove measures and activities that would either be finalized for removal from their respective MIPS inventory or replaced by more robust measures. In addition, CMS is proposing to rename the Rehabilitative Support for Musculoskeletal Care MVP to Rehabilitative Support MVP. Furthermore, CMS is proposing that virtual groups would be able to report an MVP beginning with in PY 2029. Despite AMA support, CMS proposes to rescind its policy to not publicly report any MVP data any new Improvement Activity or Promoting Interoperability measure, objective, or activity during the first year it is included in an MVP. Quality Starting with PY 2027, CMS is proposing to replace the outcome / high-priority measure reporting requirement in traditional MIPS and MVPs with a MIPS core measure reporting requirement. Eligible clinicians or group practices would have to report a core measure as one of their six measures in MIPS or as one of their four measures in an MVP. Small practices would be exempt from this re28 | DALLAS MEDICAL JOURNAL
quirement. Any eligible clinician, group, virtual group, subgroup, or APM entity that does not report a MIPS core measure and is not a small practice would receive zero points for one of their required measures unless they submitted an attestation that they did not have an applicable MIPS core measure and submitted another measure in its place. CMS has proposed to designate 78 MIPS quality measures, many of which were previously designated as outcome/high priority. In general, the AMA has not been supportive of the outcome measure requirement or moving to core measures, as measurement should be based on what is most appropriate for a physician’s scope of practice or following an episode of care, not arbitrary metrics and reporting for the sake of reporting. Beginning with PY 2027, topped out MIPS core measures subject to the seven-point scoring cap (i.e., those topped out for two or more consecutive performance periods) would no longer be subject to that cap and would instead be scored according to the defined topped out measure benchmark (with a 10-point maximum). CMS has proposed to designate 17 measures as topped out but with the defined measure benchmark and not subject to the seven-point scoring cap due to limited measure choice. CMS also proposes a number of changes to the PY 2027 quality measure inventory including removing 20 existing quality measures, adding 10 new measures, and substantive changes to 43 quality measures, all of which are summarized in Appendix 1. Qualified Clinical Data Registry (QCDR) measures are not included in Appendix 1 because they are subject to a separate review process.
sures. Specifically, CMS proposes to update the definition of CEHRT to align with ONC’s changing Health IT Certification Program, remove the ONC Direct Review and the optional ONC-ACB Surveillance attestations retroactive to the CY 2026 performance year, and remove the Security Risk Analysis measure to reduce redundancy, as security risk analysis and risk management activities are already separately required under the HIPAA Security Rule. CMS proposes to make the previously finalized electronic prior authorization measure optional for the 2027 performance year, with an opportunity to earn 10 bonus points. The attestation-based measure would then become mandatory in 2028. CMS proposes more explicit technology requirements, including use of ONC CEHRT, and use of CEHRT that includes health IT certified to all three ONC ePA criteria. Lastly, CMS proposes a new attestationbased electronic prior authorization (ePA) for prescription drugs measure to assess utilization of standards-based ePA. For PY 2028, CMS proposes that a MIPS-eligible clinician attest to having requested PA electronically using CEHRT for at least one prescription drug ordered. There are several proposed exclusions, including clinicians that do not prescribe drugs that require PA. A summary of proposed requirements for the PI Category can be found in Table C-G 6.
Cost CMS does not propose to adopt any new, remove any existing, or propose substantive changes to any existing MIPS cost measures for the 2027 performance year. However, CMS proposes non-substantive updates to the list of care episode and patient condition codes to reflect coding changes, summarized here. The AMA will continue to advocate for more targeted and clinically relevant cost measures.
ADVANCED APMS CMS proposes to apply Qualifying APM Participant (QP) status and Partial MIPS-eligible at the TIN/NPI combination level. Any APM-related financial incentives, including APM Incentive Payments and the QP conversion factor differential, would apply only to claims associated with Advanced APM-participating TINs. CMS says this will “prevent an increasing windfall for TINs that do not participate in Advanced APMs, particularly given that the higher qualifying conversion factor update.” The agency estimates that “relatively few QPs would be affected” because the majority of QPs are participating in an Advanced APM through all TINs. CMS estimates that this change would result in approximately
PROMOTING INTEROPERABILITY (PI) In response to longstanding AMA advocacy, CMS proposes several changes to the MIPS PI category to reduce administrative burden and focus on high-value, outcome-oriented mea-
Improvement Activities CMS proposes various updates to the inventory of improvement activities, including adding six new, modifying five, and removing 11 activities. These changes are summarized in Appendix 2.
August 2026
LEGISLATIVE DEBRIEF
$2.38 billion less being paid out to APM participants over the next decade. CAA 2026 reinstated the APM Incentive Payment for payment year 2028 (based on 2026 performance) at 3.1 percent. Absent further congressional action, the APM incentive payment will expire at the end of the 2026 performance year/2028 payment year. The QP thresholds are also set to increase from 50 to 75 percent of Medicare payments, and from 35 to 50 percent of Medicare patients. The AMA continues to advocate for Congress to extend the APM incentive payment, freeze the QP thresholds, and to adopt permanent flexibility for the Secretary to adjust QP thresholds as needed. The latter two are included in the Patients First Act. REQUESTS FOR INFORMATION (RFIS) CMS included several RFIs in the proposed rule, including one that targets the CPT code set and the processes used to develop and value it, and another that takes a broader look at primary care payment, signaling CMS may be
considering more significant changes in the future, as explained further below.
amination of how Medicare pays for primary care, with the goal of better supporting prevention, longitudinal care, and practice transformation. Specifically, CMS is requesting feedback on three areas: (1) whether the PFS appropriately values primary care services relative to other services; (2) how payment policies should evolve to account for the growing role of technology in delivering primary care; and (3) whether Medicare should transition from traditional fee-for-service payment toward prospective, population-based payments or outcomes-based payments for primary care, beginning with the Medicare SSP and potentially expanding more broadly across Original Medicare. The RFI reflects an important shift in CMS’ thinking about primary care payment, signaling it may place greater emphasis on longitudinal accountability for patient outcomes, rather than reimbursement for discrete visits and services in the future. DMJ
Current Procedural Terminology (CPT) RFI CMS includes an RFI examining the AMA’s CPT coding system, CPT licensing, the CPT code development process, and the RUC. The RFI asks about alleged harms associated with the AMA’s “monopoly over CPT-4 licenses” and cites concerns about reliance on a private organization with an “obvious conflict of interest” in recommending physician service values, seeking input on CPT licensing costs and effects, the role of medical necessity in code development, possible alternatives or supplements to CPT as the national physician services code set, alternative governance and valuation processes, and whether physician services could instead be paid using ICD-10-PCS or other bundled payment approaches. Redesigning Primary Care to Make America Healthy Again CMS is seeking comment on a broad reex-
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SPOTLIGHTS
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CAREEXPAND IS THE CLINICAL OPERATING system for continuity of care. Founded by Dr. Javier Viñals, a practicing physician, and headquartered in Plano, the platform brings the core of a practice into one place: telemedicine, EHR and clinical documentation, e-prescribing, and remote patient monitoring. CareExpand is built on an interoperable, HIPAA-compliant architecture designed for the way practices operate today. The platform has powered more than 160,000 consultations, including a health plan serving over 500,000 members and a network of 247 physicians and 900 network providers. Where conventional systems added AI to records built for an earlier era of medicine, CareExpand embeds intelligence directly within the clinical workflow. Documentation, coding, and follow-up are generated by the encounter itself rather than appended to it afterward. The platform is ONC Health IT certified, HIPAA compliant, and SOC 2 Type II attested. The clinical case is straightforward. Physicians in ambulatory practice spend roughly 3.5 hours a day in the chart and more than 1 hour beyond that once the clinic closes. CareExpand was built to give that time back, and the effect has been measured: across 363 documented encounters, consultations averaged just over 7 minutes, and those supported by the pre-encounter AI agent took 20% less time and 37% fewer clicks than those without it. Ambient documentation drafts the note during the visit, so the chart is substantially complete before the patient leaves the room, and the record is built to be read in a single pass, with the patient’s history, encounter timeline, and open follow-ups on one screen instead of using unintegrated screens, giving back 15 hours of consultation time per week. Adoption does not require a rip-and-replace. The CareBridge integration layer connects to the systems a practice already runs, which lets a practice start with one workflow and expand at its own pace, on plans priced to its size and needs rather than a single enterprise contract. Every practice runs differently, and we would be glad to show you how CareExpand would fit yours. Visit careexpand.com or contact us at https://www.careexpand.com/contact for a short demo. August 2026
Business Overhead Expense (BOE) Insurance
Because Your Practice Doesn’t Take Sick Days What Happens to Your Practice If You Can’t Work? If illness or injury keeps you from seeing patients, revenue can pause—but your fixed costs don’t. Personal disability insurance can help replace your income, but it doesn’t address the cost of running your practice. What Helps Cover Those Costs? Business Overhead Expense (BOE) insurance works like disability insurance for your practice, helping cover overhead expenses when you’re unable to work due to a covered illness or injury. Who Should Consider BOE Coverage? Physicians who own or are partners in a practice may want to consider BOE insurance. If you’re unable to work, your share of business costs continues, and BOE can help manage those obligations while supporting staff retention. What Expenses Can BOE Help Cover? BOE insurance can help cover rent, employee salaries, payroll taxes, utilities, loan payments, equipment, and even the cost of a locum tenens. What does the TMA Member Business Overhead Expense Insurance plan, issued by The Prudential Insurance Company of America, offer? • Two Plan Options: Up to $50,000/month for 12 months or $35,000/month for 24 months • Retroactive Benefits: Begin after 30 days and include the waiting period • Premiums Waived: No premiums due while receiving benefits • Extended Benefits: Coverage available for up to 36 months (or until the full benefit is paid) • TMA Member Rates: Designed to offer a cost advantage compared to many competing carriers How Does BOE Help Protect Your Practice Long Term? It helps stabilize operations, supports employee retention by continuing payroll, and can ease the financial burden on partners during your absence. Recently approved for the TMA Member Long Term Disability Insurance plan?
You may be eligible to add BOE coverage using the same underwriting.
Help your practice remain strong and independent, even when challenges arise. Visit tmait.org or call 800-880-8181, Monday through Friday, 8:00 AM to 5:00 PM CST, to speak with a TMA Insurance Trust advisor and learn how BOE coverage may fit your needs. SCAN TO CALL
TMA Member Business Overhead Expense coverage is issued by The Prudential Insurance Company of America, Newark, NJ. The Booklet-Certificate contains all plan information, including limitations and exclusions. CA COA #1179, NAIC #68241. Contract Series 83500 1091458-00001-00
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