The variance in experiences, satisfaction and pay between independent and employed physicians has become well known within healthcare — but new research suggests the gaps could be widening.
Researchers from RAND interviewed 30 U.S. primary care physicians — 15 employed by health systems and 15 in independent practice — about their day-to-day experience delivering care. The findings, published recently in the Annals of Family Medicine, identified five recurring themes that separate the two practice models. Here are 10 things to know.
1. Health system employment keeps climbing.
Health system ownership of physician practices has grown rapidly in the U.S. As of the study’s publication, 55% of physicians are employed by hospitals or health systems, a nearly 50% increase in health system employment since 2012, according to the Physicians Advocacy Institute data the authors cite. That backdrop is what prompted the researchers to examine how ownership shapes physicians’ daily experience, not just cost and quality metrics.
2. The study drew on 30 interviews, evenly split by practice type.
Two RAND investigators conducted hour-long, semistructured Zoom interviews from March through May 2024 with 15 physicians employed by health systems and 15 in independent practice. All were licensed MDs or DOs in family medicine, general internal medicine or geriatric medicine who had spent at least three years with their current organization; solo practitioners and physicians in private equity-owned practices were excluded.
Health system physicians in the sample were more likely to be female, work in general internal medicine and practice in larger, urban settings. Independent physicians were more likely to be male, work in family medicine, have longer tenure and hold an ownership or partner stake, and were concentrated in smaller, suburban or rural practices. The research was funded by two Agency for Healthcare Research and Quality grants.
3. Autonomy was the clearest dividing line between the two groups.
Physicians employed by health systems said clinical leaders didn’t dictate treatment decisions, but standardized scheduling rules and productivity expectations still left them with little control over their day. One physician said:
“I get 20 minutes per visit and that is my biggest dissatisfier. I have patients that are elderly, they have mental illness or dementia, they have 87 problems… it’s not freaking possible.”
Another, who had left a health system, described the oversight this way:
“Too many administrators telling me what to do, what not to do… micromanaging my practice, demanding that I work harder, charge more…. The CEO told a patient I spent too much time with my patients. I’m a family doctor. I enjoy my patients.”
Independent physicians, by contrast, said they built their schedules around what they considered appropriate care, and several said they’d turn down a system paycheck to keep that control:
“Even if we were making more money in a hospital system, we would not be willing to give up the autonomy.”
4. Employment comes with financial and legal cover independent physicians don’t have.
Several health system physicians said they didn’t miss running a small business. One put it simply:
“I like not having to manage my office and deal with the headaches that we used to have when we were a private practice.”
Physicians in the health system group linked their employment to relief from hiring staff, arranging benefits and malpractice coverage, and managing billing — burdens independent physicians in the study carried themselves.
5. Health systems offer embedded clinical support that small practices can’t match.
Health system physicians described on-site access to pharmacists, behavioral health counselors, dietitians, patient navigators and social workers for complex patients. One described a full care team:
“We have a full time PharmD and she sees patients on her own… a patient navigator, social worker, substance-use counselor, three psychologists, and a psychiatrist that comes a half day a week.”
Independent physicians generally worked with smaller teams of nurses and medical assistants and said the gap showed up most in behavioral health:
“The main [workforce] priority would be some sort of support staff for mental health… we’re really struggling to address that.”
6. Specialist referrals move faster inside a system.
Physicians in health systems described in-network specialty groups that simplified referrals and shortened wait times. One said:
“[The health system] has a lot of specialty groups — rehab, home care, nursing homes. They encourage us to use them and make our life easy because it’s just a click away.”
Independent physicians said they relied instead on long-standing personal relationships with specialists to get patients seen quickly, without the built-in network.
7. Shared EHRs ease coordination — and their absence costs independent physicians time.
Health system physicians credited enterprise-wide electronic health records with letting them see recent test results, specialist visits and hospitalizations in one place. Independent physicians described piecing together the same picture from faxes, patient reports and phone calls:
“We waste more time trying to get records and labs, whereas a bigger healthcare system is more seamless, fewer gaps, fewer delays.”
One added that the extra legwork cuts directly into patient time:
“I think that does compromise care sometimes, because if the majority of your visit you’re just trying to get notes and information, it leaves less time for you to spend on the patient.”
8. The two models optimize for different things: metrics vs. relationships.
Health system physicians described a culture built around patient satisfaction scores and productivity targets that they felt didn’t track with clinical quality:
“We almost feel like a Target cashier who’s getting rated. They’re focused just on the patient satisfaction numbers not on whether you’re practicing good medicine.”
Independent physicians pointed to continuity with the same families over years as their organizing principle instead:
“People come here because we spend the time and listen to them… That’s why I went into private practice, because I wanted to form that relationship over a period of time.”
9. Patients reach independent physicians directly; health system patients often hit a call center first.
Health system physicians said centralized triage lines, meant to route patient calls efficiently, instead created delays and frustration. One said she now tells patients to avoid the office line entirely:
“I literally have on my print-out when [patients] leave, ‘Do not call our office under any circumstances’ because [the patient] will get passed around. It goes to a central pool of nurses and three days later it comes to me.”
Independent physicians said direct access to a familiar staff member was central to patient trust:
“Patients like the responsiveness. They like that if they call, they get a live person. We don’t have a call center; it’s not a different person every time you call.”
10. The authors frame this as a trade-off, not a verdict — with real caveats.
The study’s conclusion holds that differences between the two models stem from how work is organized, not from clinical decision-making itself: health systems provide infrastructure and multidisciplinary support at the cost of physician autonomy and direct patient access, while independent practices preserve flexibility and relationships but lack the same support and coordination capacity. The authors suggest health systems could ease friction by giving physicians more say over scheduling, allowing longer visits for complex patients and simplifying productivity metrics, while independent practices could adopt selective integration — regional health information exchanges or co-located behavioral health staff — without giving up autonomy. They caution that the sample was small (30 physicians), not nationally representative, recruited through a research-focused vendor panel that may skew toward physicians open to participating, and based on self-reported perceptions rather than measured outcomes. The authors describe the findings as hypothesis-generating rather than definitive.
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