Every year, we see the same song and dance play out: the proposed Medicare physician fee schedule (PFS) includes an unacceptable cut, lobbying groups work frantically to either change the final rule or get Congress to intervene, and when the net result is essentially the maintenance of last year’s levels, physicians almost feel like they’ve won. What that process obscures is how, over the last 25 years, the Medicare PFS conversion factor, used to assign dollar values to the services for which physicians bill Medicare, has declined 9 percent, while the Medicare Economic Index, which measures practice cost inflation, has increased 59 percent. Health Secretary Kennedy has signaled a willingness to reform how Medicare pays its physicians, but it seems unlikely this administration would do away with relevant budget neutrality requirements in order to make physicians feel whole. Instead, physician groups have been left to sort out rising costs and flat-lined payments on their own, leading to workforce instability, widening specialty shortages, and downstream access problems for patients, especially in rural and safety-net settings where Medicare is the dominant payer. These issues of cost and revenue may seem operational on the surface, but they have deep implications for strategy and governance. Such a threat to the survival of the physician group, and the viability of its underlying operating model, should demand the entire organization’s attention, from the C-suite and boardroom down to the clinic floor, back office, and supply room.