Physicians largely still hold their patients’ confidence in the exam room. About 87% rate patient trust in their clinical judgment as high, according to Medscape’s 2026 Patient Relationships Index. But more than half said rising healthcare and insurance costs are damaging those relationships, and 20% called the impact substantially negative.
A string of billing disputes in recent months illustrate this growing trend. In September, The New York Times reported that Sen. Roger Marshall, R-Kan., sued more than 700 patients over unpaid bills during his career as an OB-GYN in Kansas. Courts issued arrest warrants for 81 of them after missed court dates. His law firm charged 18% annual interest and garnished wages, and many of the patients were new mothers in rural Barton County billed for delivery costs. One, Joe Vasquez, spent two days in jail over a $4,561 bill from his wife’s emergency hysterectomy.
A spokesperson for Sen. Marshall said his hospital “used the exact same billing and outside collection procedures as every other business or hospital in Kansas.” The case is extreme, but physicians and non-hospital providers now drive the majority of medical debt lawsuits nationally, according to KFF Health News.
The No Surprises Act was meant to remove patients from a different billing fight by routing out-of-network payment disputes to federal arbitration. Instead, about 6 million disputes have been filed since 2022, against an original projection of 22,000 a year. Providers win about 85% of decided cases, and awards reached $15 billion in 2025.
Surgical assistants, who typically receive about 16% of a surgeon’s reimbursement, have produced some of the starkest results. In one Dallas case, an assistant won $50,456 through arbitration for a prostate removal while the surgeon received $1,843.
Brady Connaughton, a New Jersey lawyer who advises union health plans, told the Times the pattern shows “a disregard for the law’s intent.” Patients rarely know their case went to arbitration, but the cost comes back through premiums.
“If we pay every out-of-network provider seven times what their network peers are getting paid, imagine what that would do to overall healthcare costs,” said Ariel Bayewitz, vice president of health economics at Indianapolis-based Elevance Health.
Physicians see the same system from the other side. Winning in arbitration does not guarantee getting paid, and Fort Worth, Texas-based Radiology Associates of North Texas projects more than $51 million in avoidable costs tied to batching rules and unpaid awards.
“Large insurers already held the upper hand, but they now frequently waste IDR resources,” said Kimberly Cimino, PsyD, chief medical officer of an independent occupational medical group in Ohio.
Only 5% of physicians say they have significant leverage with private payers, according to Medscape, and seven in 10 do not trust payers to make fair, evidence-based decisions. The American Medical Association and every state medical society are now pressing Congress to give regulators authority to enforce arbitration payments.
The cost to the patient relationship is already showing. In a May Medscape survey, 44% of physicians said patients’ trust in prescribed treatment had worsened or significantly worsened, and 40% said trust issues had influenced their career plans, including considering leaving clinical practice.
Whether the dispute is with a patient or a payer, the exam room is increasingly where the bill comes due.
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