On/Offcall: How Much Do Physicians Earn vs. What Do Hospitals Bill For the Same Exact Procedures

Welcome back to On/Offcall!

"We're last in longevity among peer nations. Worst in maternal and infant mortality."

That's from the one and only Dr. Robert Pearl, this week’s guest on How I Doctor. Dr. Pearl spent 18 years running The Permanente Medical Group, the largest physician-led medical group in the country. Now, he’s written multiple books challenging the culture of American medicine and challenging the ways that medicine has become monetized and consolidated. Together with Dr. Graham Walker, Robert dives into:

✨ Why monopolistic consolidation is the uniquely American driver of healthcare dysfunction
✨ Why fee-for-service is the real barrier to AI adoption
✨ His vision for a doctor's visit five years from now
✨ And more!

👀 Listen to the podcast here

Most Talked About On Offcall

What Physicians Are Paid vs. What Hospitals Bill for the Same Exact Procedures
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Tell Us: How Do You Really Feel About the State of Medicine?
We teamed up with Women in Medicine® to build the State of Medicine Project, one of the largest physician-led snapshots of medicine today. Thanks to everyone who has participated! Be sure to tell us what you think here.

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Physician Spotlight: Meet Dr. Benjamin Schwartz

1. Benjamin, what's one task you've fully handed off to AI that you'd never take back? Hah, trick question! I have increasingly incorporated AI into my day-to-day workflow including research, brainstorming, creating a Virtual Personal Assistant that helps coordinate my calendar/email, etc. The tools have gotten incredibly good, but I'm not to the point that I would "fully" turn something over to AI. I'm still very much in the "human-in-the-loop" camp. One of my mentors always said "Trust, but verify." That stuck with me throughout my medical career, and I think it's especially true with AI.

2. Are you worried about deskilling — that the next generation won't develop the intuition you did because the model handled it? Absolutely. I think anyone that uses these tools on a regular basis feel the allure of using them for ... just about everything. But, especially in healthcare, intuition is incredibly important. If we outsource critical thought and our knowledge base to AI, we lose something important: the ability to see into the grey areas and the intuition you mentioned. AI gives us infinite access to knowledge, but knowledge is not the same as expertise. If I'm using a surgical robot, and something goes wrong half way through the surgery, I need to have the skills and experience to finish the job safely. In the same way, we need the skills to spot where the AI may be incorrect, and the confidence to act.

3. Will AI solve the physician shortage or quietly make it worse? I'm not sure we have much of a choice at this point. It is extremely difficult to quickly grow the physician workforce. It seems like, between retirements and physicians leaving the frontlines, the shortage will get worse before it gets better. AI is probably as good a solution as any to help address this gap. However, a lot depends on implementation, oversight, guardrails, liability, etc. There's also the unresolved question of how comfortable patients are with AI. The assumption is that AI-powered access is better than no access. But I'm not sure that's a forgone conclusion.

4. Independent practice in 2026 — endangered species or quiet comeback? That's really the question. Honestly, it's easy to see it going either way. But, I'm a believer in cycles, and I think we've hit peak consolidation. It's only natural for the pendulum to swing back in the other direction as docs want more autonomy and realize that trading the safety and stability of employment for the freedom of independence is a risk worth taking. It is still a very challenging environment, and I think the definition of independence is changing. You either have to be really small (DPC, concierge, micro-practice) or really large (MSO, supergroup) to survive the current climate. Physicians are risk-averse, and may not take the leap back into independence unless there is a firm landing spot. I'm curious to see who will create it. (And, yes, AI has a role to play here too -- e.g., practice management tools).

5. What's something physicians are quietly worried about that the public doesn't know about yet? The rise of misinformation. I think the public kind of knows about it, but it's become so pervasive and so insidious. It's increasingly difficult to figure out what's truly cutting edge, what's pseudoscience, and what's flat out grifting. There is a very fine line between being an innovator and pushing boundaries and offering poorly studied quick fixes that may be harmful. Public frustration with the traditional healthcare system and growing distrust in all institutions has created a void that some are happy to step into, often for their own gain. For physicians, it's important to find the balance between skepticism and paternalism.

6. If you had a magic wand for one thing in medicine — not your whole career, just one thing — what would you fix tomorrow? The demand side of the equation (i.e., the societal factors that profoundly affect healthcare outcomes and utilization). Again, it sounds like cliched virtue signaling, but the reality is that we spend a lot of time fiddling with things that have a comparatively small impact. Outcomes are primarily driven by things that the healthcare system can't directly touch or change, yet these things are increasingly pushed onto the healthcare system (especially at the primary care level). All the payment reform, value-based care modeling, fancy technology, etc. will have less impact than figuring out a way for people to maintain good health in the first place.

Read the full-length version here. Know someone else who should be featured? Reply or tag them and their company in the comments!

3 Things to Read This Week

Medicine Was Never Clean (MDCalc)
From Dr. Graham Walker: “Medicine is dirty and messy and UGGO, and clinicians scrubbing the hell out of it is the only way it's ever worked, and the only way it ever WILL work.” Read more and add your comments here.

It's Time to Lift Limits on Physician-Owned Hospitals (Medscape)
From Dr. Willie Underwood, president of the AMA: Easing restrictions can increase innovation, competition, and access to care. Also see Dr. Adam J. Bruggeman’s op-ed on Offcall on the same topic here.

First, do NOHARM: a medical safety benchmark and randomized study of physician and AI teaming on clinical consultations (arXiv)
“In a randomized study of 101 U.S.-licensed generalist physicians, AI assistance improved physician performance compared to conventional resources. However, AI-assisted physicians frequently omitted valuable AI-generated recommendations and still scored lower than many AI systems alone… Collectively, these results show that despite strong performance on medical knowledge benchmarks, widely used AI tools can produce medical consultation advice with the potential for severe harm, and highlight the need for explicit measurement of clinical safety.” From: David Wu, Fateme Nateghi Haredasht, Saloni Kumar Maharaj, Arjun Rustagi, Jenelle Jindal, Bassman Tappuni, Sirus Jesudasen, Christopher V. Cosgriff, Rebanta Chakraborty, Jillian Caldwell, Susan Ziolkowski, David J. Iberri, Robert Diep, Rahul S. Dalal, Kristin Galetta, J. Carl Pallais, Nancy Wei, Kathleen M. Buchheit, Vartan Pahalyants, Allen Shih, Vishnu Ravi, Sarita Khemani, Thomas A. Buckley, April S. Liang, Nicholas Marshall, Austin J. Schoeffler, Sumant Ranji, Kevin Schulman, Nigam H. Shah, Jason Hom, Arjun K. Manrai, Adam Rodman, Jonathan H. Chen, and more!

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Medicine is complex enough.
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Highlights From Our Community

Each week, we celebrate career milestones, launches, & other goings-on in the physician community. Have something to promote? Reply and we’ll feature you.

Congratulations, Effie Andrikopoulou
Dr. Effie Andrikopoulou announced that she has been elected as one of the University of Washington Physicians (UWP) At-Large Board of Trustees! Congratulate her here.

Go ahead and apply, Stanford HAILS
Dr. Ethan Goh announced that applications for the Stanford HAILS course on AI in medicine has opened. The cohort begins May 2027 and spaces are capped, with last year’s speakers including the founders and leaders of ChatGPT Health, Anthropic for Healthcare, Google, FDA and Stanford and Harvard healthcare AI professors. Learn more and apply here.

Listen to the podcast, John Dayton
Dr. John Dayton appeared on the Signals and Symptoms podcast with Dr. Harvey Castro, Dr. Junaid Kalia, and Edward Marx to discuss whether innovation can be a cure for physician burnout and help physicians regain a sense of control over their work. Watch the video and listen to the podcast here.

Read this AI study, Nikhil Sahni and more
A new analysis in 12 domains for health care estimates that the impact of full adoption of AI could generate between $439 billion and $811 billion in annual net value (approximately 5.7%–10.6% of total U.S. health care expenses). Read it here. From Nikhil Sahni, Kate O’Gorman, Rahul Agarwal, Heather Bello Thornhill, and David Cutler.

Career news, Matthew Williams
Dr. Matthew Williams has joined Benchmark Health as Medical Director, working alongside Dr. David Mou and Dr. Thomas Insel. Learn more and congratulate him here.

Bravo, Brodi Lynch
3 months ago, Dr. Brodi Lynch opened the doors to her new independent practice: Generations Health MI, working alongside Aledade! H/t Dr. Shelley Overholt-Thiesen here.

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