Large group for malpractice coverage or small practice for ownership?

Join the one that wins after the premium is priced, because in this specialty the coverage is not a perk on one side of the comparison. The coverage is one of the largest numbers in it. A large group or system that carries your premium and your tail is paying a benefit the AMA reports at up to $243,988 a year in Miami Dade and $49,804 in Los Angeles and Orange County. A small practice offering ownership must clear that benefit with distributions and equity before ownership is ahead on money. In low premium states, a healthy small practice usually clears that bar across a career. In high premium states, the carried coverage can keep the large group ahead for years, sometimes for good.

Part of the OB/GYN hub.

What the large group is really paying you

Price the large group coverage package at its actual weight. The premium disappears from your budget entirely, which at the AMA figure of $135,974 in Philadelphia or $207,907 in Cook, Madison, and St. Clair counties is a six figure annual benefit that no salary bump at the small practice should be compared against raw. The tail risk shrinks with it. Large systems generally run coverage centrally and handle carrier switches with prior acts protection at the institution level, so the lump sum that ends a small practice departure is usually designed out of your contract entirely.

Put the tail saving in dollars. Tail coverage commonly runs 150 to 200 percent of the mature annual premium. On the Philadelphia premium, $135,974 times 1.5 is $203,961, and $135,974 times 2 is $271,948. On the California premium, $49,804 times 1.5 is $74,706, and $49,804 times 2 is $99,608. On the Florida premium, the same band reaches $365,982 to $487,976.

Size also buys things with real cash value that never appear in compensation tables: laborist coverage that takes nights off the rota, a benefits department, and often a nonprofit employer, which keeps Public Service Loan Forgiveness alive if your count is still running. What the large group does not sell you is a share of itself. The ceiling is the band, the vote is not yours, and the equity at the end is zero.

What the small practice is really selling you

The small practice sells the specialty's ownership economics: production that rewards your panel and your surgery with no band ceiling, distributions that ride the whole practice's collections in strong years, a buy sell formula that pays for your share at exit, and control over the decisions that shape your working life, from call structure to premium strategy. Across a long career in the right market, that package is worth more than any salary band, and it is the only route here that builds an asset you can sell.

It charges for it in the currency this specialty tracks. A buy in is priced by formula or by negotiation and paid in your early attending years. Your share of the premium runs as one of the practice's largest overhead lines, at the market figures above. The tail is assigned by the group documents at every departure, at the band already priced. And you take a share of the practice's malpractice history, including claims that arise from years before you arrived.

Small practices also concentrate risk that the large group spreads. One partner with a bad claims year, one lost hospital contract, or one departure with an unfunded tail lands on fewer shoulders, and each shoulder is partly yours. It makes the diligence the price of admission: the claims history, the coverage shape by era, the tail treatment for every prior departure, and the buy sell formula, all read before the buy in is signed.

The deciding questions, asked of both offers

Ask both offers the same five questions and compare the written answers. One, who pays the premium, and if the cost is shared or offset against distributions, what is the actual dollar figure in this state? Two, who pays the tail on each exit, and what does that tail price at on the current premium? Three, if loans remain, is the employer a qualifying nonprofit, and what is the remaining forgiveness worth across your count? Four, what is the real call burden in nights per month, and is any of it purchased away with laborist coverage? Five, for the small practice, what is the buy in, how is it paid, and what does the buy sell formula return at the exits you are likeliest to make, including dropping obstetrics later in your career?

The offer that wins those five answers in your state is usually the right employer, and the winner changes by geography. The same physician, choosing in California rather than Florida, is solving a different equation, because $49,804 of premium with a $74,706 to $99,608 tail and $243,988 of premium with a $365,982 to $487,976 tail are not the same obstacle.

Follow up questions

The small practice pays a higher salary than the large group. Does that settle it?

No. Add the premium the large group carries and the tail it absorbs at exit, and then compare totals across ten years. A higher salary that comes with a personal premium share and a personal tail can sit well below a lower salary with both carried.

How do I value the vote and the control that ownership brings?

As real, and as secondary to the priced lines. Control over call structure and premium strategy changes your working life every week, and for many physicians it is the honest reason to choose the small practice. Count it after the dollars, because control does not pay a $271,948 tail bill.

What if the large group is for profit and my loans are large?

Then the forgiveness line flips, and you should price it before anything else. Public Service Loan Forgiveness follows the employer that pays you, so a for profit large group keeps no count running. With the AAMC median education debt at $200,000 for the class of 2025, the forgiveness value can outweigh the coverage difference in the first decade.

Related questions

• Should I take a hospital employed OB/GYN job or join a private group?
• What does buying into an OB/GYN practice with a malpractice history cost?
• How does laborist shift pay compare with private practice over a career?

Sources

American Medical Association, Policy Research Perspectives, medical liability premiums (reported $1M/$3M OB/GYN premiums by market, from $49,804 in Los Angeles and Orange County to $243,988 in Miami Dade, accessed October 2026)

Physician Side Gigs, malpractice tail insurance coverage (tail coverage commonly costs 150 to 200 percent of the mature annual premium, the exit term priced in the comparison, accessed October 2026)

Medscape Physician Compensation Report 2026 (average OB/GYN compensation of $390,000, accessed October 2026)

Association of American Medical Colleges (median education debt of $200,000 for the class of 2025, accessed October 2026)

Takeaways

• Price the large group coverage at its real weight: the premium runs to $243,988 a year in Miami Dade, and the carried tail adds $365,982 to $487,976 of absorbed exit cost there.
• The small practice must clear the carried premium and tail with distributions and equity before ownership is ahead.
• Diligence is the price of the small practice: claims history, coverage shape by era, tail treatment for prior departures, and the buy sell formula, before the buy in.
• Ask both offers the same five questions: premium, tail, loan status, call, and the buy in.