In an earlier edition of TrustWorks On Call, we shared a graphic detailing the decline of physician independence and the tradeoffs that come with health system or corporate employment. This week, we’re highlighting analysis of the American Medical Association’s Physician Practice Benchmark Survey to provide a new lens on this trend: that payer relations are the problem, and scale—whether through health system or corporate employment, or through practice size aggregation—is increasingly seen as a primary solution. Three of the top five reasons physicians reported for why their private practices were sold in the last decade relate to payers, with sellers seeking higher reimbursement, more capacity to manage administrative burdens, and easier participation in value-based contracts. Affiliating with a health system has the potential to help with all three of these concerns, but so too does joining (or becoming) a larger practice. From 2012 to 2024, the share of physicians in practices of fewer than five people dropped eleven points, while the share in practices of 50 or more increased by six points, nearly equal to the growth of direct hospital employment. The most drastic change in physician employment across the last decade isn’t just the decline of physician independence in general, but rather the near disappearance of small, independent practices. Instead, the ranks of large, multispecialty groups (whether allied with or independent from health systems) are growing because they can boast a scale and market essentiality worthy of payers’ respect at the negotiating table.