You were told physician-owned hospitals were finished. That the 2010 legislation closing them out of Medicare was permanent. That if you wanted to own something, your options were a direct primary care practice, a concierge model, or a slow negotiation with the health system already employing half your colleagues. The hospital. The thing you actually trained to practice in. That was off the table.

It may not be anymore. But the window is small and it closes June 9.

On April 10, 2026, the Centers for Medicare and Medicaid Services (CMS) released CMS-1849-P, the FY2027 Inpatient Prospective Payment System proposed rule. Inside it is a Request for Information asking whether physician-owned hospitals should be allowed to voluntarily participate in the Transforming Episode Accountability Model, a five-year mandatory bundled payment model covering coronary artery bypass graft, lower extremity joint replacement, major bowel procedure, surgical hip and femur fracture treatment, and spinal fusion. More importantly, it asks whether CMS Innovation Center authority under Section 1115A can waive specific provisions of Section 6001 of the Affordable Care Act (ACA) to make that participation possible.

That is the question that matters. Not the Transforming Episode Accountability Model. Not bundled payments. The question is whether a federal demonstration model can crack open the legislation that ended physician hospital ownership fifteen years ago.

What Section 6001 actually did

In 2010, the American Hospital Association and the Federation of American Hospitals lobbied Section 6001 into the ACA. The provision froze new physician-owned hospitals out of Medicare participation and capped existing facilities at their 2010 bed and operating room counts. The stated justification was patient cherry-picking, that physician-owned hospitals were selecting profitable surgical cases and leaving community hospitals to absorb lower-margin services like emergency care and maternity.

A 2023 study commissioned by the Physicians Advocacy Institute and The Physicians Foundation analyzed 650,386 Medicare discharges across 186 physician-owned hospitals and found patient demographics and comorbidity levels statistically similar between physician-owned and traditional hospitals in the same referral regions. The same study found Medicare savings of 8.6 percent to 15.2 percent on the 20 most expensive conditions at physician-owned hospitals, projecting to approximately $1.1 billion in potential annual savings. The cherry-picking argument that justified the ban has not held up to the data.

What the ban did produce is documented. The health systems that lobbied for it spent the next fifteen years acquiring physician practices at scale. By 2024, nearly 80 percent of all physicians were affiliated with hospitals, health systems, or other corporate entities. The independent physician, the physician-owned surgical facility, the physician who wanted to build something outside the employment model, all of them were navigating a landscape that had been deliberately narrowed by legislation their own profession did not stop.

Why this RFI is different from the bills that went nowhere

There are currently three bills in the 119th Congress attempting to address Section 6001 legislatively. H.R. 4002 would repeal it entirely. H.R. 2191 and S. 1390 would create rural carve-outs. None has moved. Legislative repeal of Section 6001 has been attempted repeatedly and failed each time. The hospital lobby is effective on Capitol Hill and the political math has not changed.

This RFI is different because it is administrative, not legislative. Section 1115A of the Social Security Act, enacted in the same law as Section 6001, grants the CMS Innovation Center authority to waive Medicare statute for demonstration models. CMS is now asking whether that authority can reach Section 6001 specifically. The same statute that closed the door contains the authority being used to ask whether it can be opened.

That is not a guaranteed opening. It is a question on a federal docket. But it is the first administrative question of its kind in fifteen years, and the answer will be shaped entirely by who files comments before June 9.

What the opposition is already building

Eleven months before this rule was filed, the Blue Cross Blue Shield Association (BCBSA) submitted a twenty-six page letter to the Department of Justice Antitrust Division’s Anticompetitive Regulations Task Force (Docket ATR-2025-0001). BCBSA covers one in three Americans and contracts with 96 percent of hospitals. They asked for limited exceptions to Section 6001, and explicitly excluded surgical-specialty physician-owned hospitals from those exceptions. Orthopedic. Spine. Cardiac. General surgery. The facilities physicians can actually build without acute-care infrastructure and systems-scale capital. Excluded.

The American Hospital Association and Federation of American Hospitals will file on the same side. Their argument will be that the Innovation Center lacks authority to waive a provision Congress enacted deliberately, that opt-in should be limited to grandfathered 2010 facilities, and that surgical-specialty physician-owned hospitals represent a threat to safety-net hospital capacity. Every one of those arguments is designed to produce a narrow ruling that leaves the status quo intact for another decade.

The physician coalition will file. But the volume and legal sophistication of the opposition filings will dominate the docket unless the comment record reflects something the hospital lobby cannot manufacture, the actual experience of physicians who have watched what the ban did to their profession, their autonomy, and their patients.

What this means for physicians considering ownership

Direct primary care, concierge medicine, and direct specialty care exist in significant part because Section 6001 closed other ownership pathways. They are viable, patient-aligned models built by physicians who wanted out of the employment structure and took the options available to them. They are a choice that became a default when legislation eliminated the alternative. But they are not the ceiling of what physician ownership should be.

A physician-owned surgical facility, structured around aligned incentives, physician governance, and direct accountability to patient outcomes, represents a fundamentally different ownership architecture. Section 6001 made that architecture illegal for new entrants. This RFI asks whether a demonstration model can test whether that was the right call.

If the comment docket closes dominated by hospital lobby voices and surgical-specialty facilities are excluded from the opt-in, the next orthopedic surgeon or spine specialist who wants to build outside a health system employment model will face the same closed door in 2026 that their colleagues faced in 2010. Nothing will have changed except the calendar.

The design of this demonstration is being decided right now. In a comment docket. Before June 9.

What to file and where

Submit a comment at regulations.gov, file code CMS-1849-P, before 5 p.m. EDT on June 9, 2026. You do not need a lawyer. You need to describe, in your own words, what physician-owned hospital restrictions have meant for your ability to practice on your own terms, and what you want CMS to test.

Be specific about the operational waivers that matter. Bed count caps. Operating room caps. Service line restrictions. The expansion approval process. If the demonstration cannot waive those provisions meaningfully, physician-owned hospitals cannot scale participation and the test produces nothing useful. Say that directly.

The physicians who built and operate physician-owned hospitals today are already mandated into the Transforming Episode Accountability Model. They will file. The physicians who wanted to build one and were stopped by Section 6001 are the voice that is missing from this docket. That absence is not neutral. It is a position.

The final rule publishes in August. Whatever it says about physician hospital ownership will shape the structural options available to the next generation of physicians considering whether to build something of their own.

The door is open. Briefly.

Dana Y. Lujan is a health care strategist and operator with more than twenty years of experience across payers, providers, and health systems. She is the founder of Wellthlinks, a consulting firm that helps employers and providers redesign care models through concierge and direct primary care, and author of The CEO Physician: Strategic Blueprint for Independent Medicine. Dana has led multi-state network development, payer contracting, financial modeling, and compliance initiatives that strengthen provider sustainability and employer value. She previously served as president of the Nevada chapter of HFMA and is pursuing a JD to expand her expertise in health care law and compliance. She has been featured in Authority Magazine and publishes on KevinMD, MedCity News, and  Medium, where she writes on health care innovation, direct primary care, concierge medicine, employer contracting, and compliance. She has forthcoming BenefitsPRO. Additional professional updates can be found on LinkedIn and Instagram.