Collective Hive September 2026

September 01, 2026

1,592 Pages About You

There is a document that will determine what physicians are paid next year, and it has been sitting in public view since the middle of July. It's free to read. It runs 1,592 pages (depending on how you access it - someone told us they got it into a 716 page PDF!). Almost nobody who actually sees patients has opened it.


Medicine trains you, early and thoroughly and mostly without saying so, to treat this material as somebody else's department. Coding is what the biller handles. Reimbursement is what administration worries about, in meetings you are relieved not to attend. Somewhere in the middle of training you absorbed the idea that a physician who thinks too carefully about money has drifted a little from the actual work, and you've probably met the attending who announces, with something close to pride, that he has no idea what any of his visits bill for. That posture gets read as integrity. It functions more like a habit that someone else profits from, and like most of the myths we discussed in June, it survives because it's useful, just not to the person carrying it.


The rule CMS proposed on July 14 is a reasonable place to test this.
Start with the conversion factor, which is the single dollar figure Medicare multiplies against the work of a service to arrive at what it pays. For 2027 there are two of them. Physicians who qualify as participants in an advanced alternative payment model get one number, $33.17, and everyone else gets $32.84. Both of those represent cuts (1.19% and 1.68%) because the temporary 2.5% bump Congress wrote for 2026 expires at the end of the year and nothing has replaced it. That lands on top of a real decline in Medicare physician payment of roughly 26% since 2001, which is the kind of statistic that has been repeated so often it has stopped registering as alarming, though it should.


Two conversion factors have been around for a couple of years now. What's new sits one layer down, in a code most physicians only vaguely know.
G2211 is the add-on that pays a little extra for the complexity that comes with being someone's ongoing doctor - not a harder single problem, and not extra time, but the accumulated weight of the patient you have managed for years, whose medication history and family situation and general trajectory live in your head rather than in any note you could hand to a stranger. CMS proposes deleting the code and replacing it with a modifier worth 16% of the associated visit, which scales more sensibly across visit levels than a flat fee did.


Then it proposes a second modifier, worth 32%, available only to physicians practicing inside a Medicare Shared Savings Program ACO or a LEAD model ACO. The same patient, the same complexity, the same fifteen minutes, and double the payment on one side of a line that has nothing to do with the medicine.
CMS has a rationale for this, and it's worth stating fairly: ACO clinicians take on additional resource costs in serving as the focal point of an accountable care relationship, and the agency is trying to pay for that. You can find that persuasive or not. What's harder to argue with is the scale of it, and the fact that the variable determining which modifier you're eligible for is an organizational arrangement rather than anything a patient would notice from the exam table.


There's a version of this your patients will see directly, too. Beginning in April 2027, approved ACOs would be permitted to reduce or waive a beneficiary's Part B cost-sharing, which means that a Medicare patient weighing you against the ACO practice across town will have, for the first time, a straightforward financial reason to walk. Your patient's copay would depend on your business card.


Most of what surrounds all this requires a kind of reading that nobody teaches in residency, which is the ability to hear a phrase like burden reduction and immediately ask whose burden, reduced by what mechanism, and setting up what.
Traditional MIPS, for instance, is being sunset by 2029, which sounds great until you notice that it's being replaced by MIPS Value Pathways and that CMS is separately introducing a new mandatory Core Measure every clinician must report starting in 2027, carrying a zero-out-of-ten penalty if nothing on the list happens to apply to your practice, plus a self-attestation process for getting out from under it. A two-for-one swap, in the name of efficiency!


The global surgery proposal is a cleaner example. CMS has multiple years of data indicating that a substantial share of the post-operative visits bundled into surgical global periods never actually take place, while the bundled payment goes out unchanged. Rather than address that now, the agency proposes pausing the MACRA-required data collection that tracks it, framed as paperwork relief for surgeons, soliciting comments on revaluation strategies for future rule making. It's difficult to read that as anything other than preparation for a cut that lands in a later rule, being disguised as a favor to physicians.


And then there's the practice expense methodology, which is the part most likely to genuinely annoy people who have been paying attention. The overhead side of the fee schedule, rent, staff, supplies, has leaned for decades on AMA physician surveys and the RUC, the specialty-society process through which physicians themselves recommend how services get valued. That process is slow, opaque, skewed toward proceduralists, and has been complained about by physicians for thirty years with cause. CMS now proposes phasing it out in favor of cost data it describes as objective, routinely updated, and auditable, and is separately asking for comment on its whole reliance on CPT and the RUC, citing conflicts of interest in physician service valuation.


Which sounds like someone finally listening, right up until you ask whose data ends up becoming the standard. Generating large, auditable, continuously refreshed cost data at national scale is not something a two-physician practice in Tennessee is positioned to do. It is something Optum can do, with the 90,000-plus physicians it employs or affiliates with, amounting to roughly one in ten physicians in the country, and it is something CenterWell and Oak Street and VillageMD can do. The specific complaint physicians have been making for a generation looks likely to be resolved by moving the influence toward the largest billers in the system.


What's operating here is an incentive gradient, and gradients produce outcomes without anybody deciding on them. Scale doesn't even reliably work: Cano Health, valued at $4.4 billion at its peak, and CareMax, both of them private-equity-backed vertically integrated behemoths built on exactly this value-based logic, filed for bankruptcy in 2024 once regulators tightened up on risk-adjustment gaming. The structure rewards consolidation without offering any guarantee that the consolidators make it.


But the direction has been obvious for a long time. Physician practice ownership was 53.2% in 2012 and 35.4% in 2024. Private practice went from 60.1% to 42.2% across the same period. Private-equity ownership climbed from 4.5% to 6.5% in the two years between 2022 and 2024 alone. This rule arrives well into that trend rather than anywhere near the beginning of it, and it adds fuel to something already moving.


Here is the part that matters, and the reason we're running this now instead of in December: none of it is final. This is a proposed rule, and the public comment period closes on September 14.


Public comment carries more weight than the phrase suggests. CMS is legally obligated to consider substantive comments and to respond to them in the final rule, and the comments that tend to land are the specific ones, from people who deliver the care, describing what a particular provision does to a particular practice. You don't need a policy background, or any interest in reading all 1,592 pages. Three paragraphs about what a 16-versus-32 split would do to your panel, in your town, with your overhead, is a real contribution to a federal record that will exist permanently whether or not you're in it.


And it will get written either way. It's being filled in right now by organizations with full-time government affairs staff and by systems large enough to hold sophisticated opinions about their own reimbursement, and every one of those comments will be well-argued, professionally formatted, and entirely indifferent to whether independent practice is still around in ten years.


We've said before that most of what physicians experience as personal inconvenience turns out to be structural. Usually there's nothing to do about that in the moment. This month there's a form, it takes twenty minutes, and someone at CMS is required to read it. That ends on September 14.


The rule is CMS-1848-P. Comment at regulations.gov/docket/CMS-2026-2377.

A Few Of Our Favorite 'Progress Notes' From August

The Benefits of Pathologizing Your Pop Culture

By Sacha McBain, PhD

When Pathologizing Pop Culture launched a little over a year ago, its premise was relatively straightforward: to use stories from film, television, literature, and art to explore the psychology of illness and healthcare. Over the past year, however, the column has evolved into something broader. Together, these essays have argued that stories do not simply reflect our experiences of illness and disability—they often reveal aspects of those experiences that medicine has not yet fully learned to name. We need a richer language for understanding what illness does to us, not just to our bodies. By illuminating the emotional, relational, and existential dimensions of health and healthcare, these narratives deepen our understanding of what it means to be a patient, support a loved one through illness, and care for others as healthcare professionals.

How To See A Consult

By Liz Malphrus, MD, MPP

Here’s what I know about how to see a consult: it’s the guide I wish I could go back and give junior me to help prevent a few unpleasant encounters and stop a few things falling through the cracks. The one saving grace of consults is that the workflow, at least, can be standardized, and if you figure that part out, it will give you a sense of control to fall back on no matter what the hospital throws at you.68yo Anesthesiologist Becomes Most Board-Certified Anesthesiologist in the World In Vain Attempt for Promotion

Helpless Helper

By Joan Chan, MD

My patient begs me for a guarantee
As if that were a possibility
Her belief that answers can be found
Will not be shaken, heels dug in the ground
She weeps and shouts, consumed with rage

Medicine Must Stop Mistaking Representation for Belonging

By Hayoung Ahn

Medicine's dominant model of professionalism developed within institutions shaped by whiteness. It often treats particular ways of displaying authority, confidence, emotional control, and leadership as universal evidence of competence. Cultural identity is not an accessory a student can remove before rounds. It shapes how we show respect, respond to hierarchy, communicate uncertainty, lead, seek help, and understand our responsibilities to other people.

Your Podcast Binge List

We linked some YouTube and Spotify pages for you, but click here to listen to any of our shows on the platform of your choice.

Explore Our Growing Podcast Network

Here’s what’s live and ready for your next commute, call-room break, or coffee run:

Want to Get Involved?

Since launching, we’ve been blown away by how many physicians have reached out asking, “How can I get involved?”

Here’s how:

  • Submit your writing for consideration on our blog

  • Pitch us a creative idea or original column

  • Apply to be a guest on a podcast

  • Follow us and share our content on Instagram, TikTok, and YouTube 

The Collective only works because of voices like yours, and there’s always room for more.

Until next month,
The HC Team

Join the movement

You bring the vision. We make it loud.