Ten years ago, I quit my job and started a solo office-based practice in rural Washington. I serve patients like Mr. G, an elderly gentleman who drove over 70 miles through mountain passes and rural highways to receive care for gangrene of his foot, as nearby hospitals were either too full or too far away. But Medicare’s broken payment system is endangering practices like mine, quietly dismantling access to affordable care in underserved and rural areas.

People often hear “office-based care” and assume it means primary care checkups. But medicine has advanced dramatically. Today, complex procedures from vascular interventions to radiation oncology can safely be done in office settings without general anesthesia. The problem is the money hasn’t followed the medicine.

Medicare’s Physician Fee Schedule was originally developed in 1992 to cover physicians’ labor, not million-dollar equipment or high-cost medical supplies, and has failed to keep up with the times. According to The Center for Medicare and Medicaid Services’s (CMS) own data, there are at least 300 office-based services where reimbursement is less than the direct cost of performing them. When you can’t even cover your costs, your choices are bleak: close your doors, sell to a hospital, or get swallowed up by private equity.

This reality is reflected in the data, which shows that independent practices are disappearing at an alarming rate. In fact, nearly half of rural independent physicians have vanished in the past five years. And when hospitals or private equity firms acquire small practices, costs don’t go down; they skyrocket. The Medicare Payment Advisory Commission has shown time and time again that consolidation raises costs without improving quality. When care moves from the office setting to the hospital, Medicare (and the patient) end up paying three to five times more.

I can attest to this personally. In the last five years, reimbursement for the procedures I perform has dropped by 40-50 percent without accounting for inflation. There were months I couldn’t even pay myself. I left the hospital system to treat patients with dignity and independence, but now it’s almost impossible to sustain.

The finalized Physician Fee Schedule for 2026, to its credit, offers a rare moment of optimism. For the first time in years, office-based providers will see a small increase in their rates. It’s a step in the right direction, but it’s still not enough to undo years of cuts.

The solution is simple: Take supplies and devices out of the Physician Fee Schedule and reimburse them like hospitals and ambulatory surgical centers do, with a “technical” fee schedule.

However, this is about more than just the numbers. In the office setting, I have the freedom and opportunity to hear each patient’s story. No patient is lost here, and every patient is a priority; a standard that cannot be matched or afforded in large health systems. In Mr. G’s case, his car broke down on the way to my office. Knowing that no one else could treat him for months if he wasn’t seen, we rearranged our schedule to accommodate him same day.

Preserving independent, office-based care isn’t just about fairness; it’s about protecting patients. Offices like mine deliver accessible care at the highest standards and lowest cost, in welcoming settings that patients prefer. If we do not fix the reimbursement system, we will lose them. And when that happens, it’s ultimately not the physicians who will suffer; it’s the patients who can’t afford to wait.

Saravanan Kasthuri is the medical director at Northwest Endovascular Surgery in Richland, Washington. He specializes in interventional radiology and minimally invasive, image-guided endovascular surgery.

He treats vascular conditions, heals spine fractures, and provides additional outpatient care. Dr. Kasthuri uses imaging techniques to perform minimally invasive procedures that reduce risk, tissue damage, and patient recovery time.