Ten Years of Operation: The Struggles of a Standalone Medical Practice in Rural Washington
A decade ago, I made a pivotal choice. I left my secure employment and initiated a venture to establish a solo outpatient medical practice in rural Washington. This choice stemmed from a commitment to deliver essential healthcare services to underserved regions, a purpose that became increasingly evident with patients like Mr. G. He is an elderly man who traveled over 70 miles through demanding mountain routes and rural roads to secure needed treatment for gangrene in his foot. His experience is not unique; local hospitals are frequently overcrowded or simply too distant for timely assistance.
Yet, the practice I developed to support patients like Mr. G is now at risk. The reason? The significantly flawed Medicare payment system, which is quietly diminishing access to affordable healthcare in these rural and underserved communities.
When people think of “office-based care,” they often immediately associate it with primary care visits. However, the landscape of contemporary medicine has progressed well beyond that perception. Nowadays, the medical sector has advanced to such a degree that intricate procedures—from vascular interventions to radiation oncology—can be safely executed in an office environment, without requiring general anesthesia. Nevertheless, the financial framework has failed to keep up with these medical innovations.
The Medicare Physician Fee Schedule was established in 1992, concentrating on physician labor costs, and was not intended to account for the expenses of high-end equipment or expensive medical supplies. Regrettably, it has not adapted to current needs. According to the Center for Medicare and Medicaid Services’ own figures, there are at least 300 office-based services where existing reimbursements fall short of the direct costs involved in their provision. This results in a bleak situation for independent practices like mine: shut down, sell to a hospital, or be absorbed by private equity.
Statistics reflect this harsh truth. Independent practices are diminishing at a troubling pace. In just the last five years, nearly half of rural independent physicians have vanished. When small practices are assimilated by hospitals or private equity firms, expenses generally increase without any corresponding enhancements in quality—an effect repeatedly emphasized by the Medicare Payment Advisory Commission. The transition of services from office settings to hospitals can escalate costs for both Medicare and patients by three to five times.
Personally, I have felt the financial pressure firsthand. Over the past five years, reimbursements for the procedures I routinely perform have plummeted by 40-50%, excluding inflation. During certain periods, the struggle was so intense that I couldn’t afford to pay myself a salary. When I departed from the hospital system, it was to maintain patient dignity and preserve autonomy in treatment choices—a goal that is barely feasible under current circumstances.
Nonetheless, a beacon of hope has emerged in the finalized Physician Fee Schedule for 2026. For the first time in several years, there is a modest increase anticipated for office-based provider rates. While this marks a positive shift, it is merely a superficial fix for years of systematic cuts.
The remedy is deceptively straightforward: Distinguish supplies and devices from the Physician Fee Schedule and reimburse them as hospitals and ambulatory surgical centers do, utilizing a “technical” fee schedule. This change would relieve the financial strains on independent practices and foster sustainable operations.
However, this matter extends beyond mere economics. In my practice, I have the privilege of fully engaging with each patient’s unique experience. Here, no one is overlooked; every individual is a priority—an ideal of patient care that large healthcare systems cannot replicate. When Mr. G’s vehicle malfunctioned on his way to my office, we adjusted our schedule to accommodate him that same day, recognizing the urgency of his situation and the delays he would encounter elsewhere.
Maintaining independent, office-based care is not just a question of fairness; it’s a vital step in protecting patient welfare. Practices like mine provide accessible care of the highest caliber at the lowest feasible cost, in environments preferred by patients. If the reimbursement framework is not revised to acknowledge the actual costs and value of these services, these essential centers of care will vanish. Ultimately, it isn’t the physicians who will suffer the repercussions of this loss; it’s the patients, those who cannot afford to wait, who will bear the brunt of the impact.
Dr. Saravanan Kasthuri is a medical director at Northwest Endovascular Surgery in Richland, Washington, specializing in interventional radiology and minimally invasive, image-guided surgeries. He concentrates on treating vascular issues, spinal fractures, and various outpatient care needs using advanced imaging techniques to conduct procedures that minimize risk, tissue damage, and recovery time.