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Voices of MCMS:

Life in Private Practice

A conversation with Rahul S. Rishi, DO, FAAAAI, FACAAI, of Arizona Allergy Associates.

MCMS: Why do you work in private practice?

Dr. Rishi: Private practice provides you with a lot of control and you have a lot of decision making in terms of how you approach and manage patients. I want to offer my patients some of the newer monoclonal antibody therapies which, if I was working for a hospital system, I may not have access to.

MCMS: How many other physicians are in your group practice?

Dr. Rishi: There are five other physicians besides myself, one of whom is my wife.

MCMS: Does it ever get awkward working alongside your spouse?

Dr. Rishi: Sometimes it can interfere with family time because when we're having dinner at home, we'll talk shop. You know, we try to limit that obviously.

MCMS: How did you meet?

Dr. Rishi: While she was in residency. She was already close to finishing, and I was working in the technology industry. I had come from a completely different sector and then we were dating, and I was in the process of applying to medical school. For many years, she worked while I was still in school and then residency. She was very supportive.

MCMS: What would you say motivates you each day to care for patients?

Dr. Rishi: Well, there are multiple factors. Having a daughter with special needs made me see more clearly what patients go through and, having that experience, I feel like I can empathize with patients more than I did prior to having her. I feel I need to make a difference and improve patients’ quality of life. With allergy and immunology, we have a lot of treatments. We can truly disease modify and improve their conditions.

MCMS: Have you seen a lot of changes in the field?

Dr. Rishi: Novel treatments are coming out. Treatments that were not available when I was training. These include monoclonal antibody therapies that treat conditions like eczema. In the past, you only had oral and topical steroids. We have similar treatments for asthma, nasal polyps, and even angioedema. Allergy injections have been around for a very long time, but they are also disease modifying. If patients commit to shots for three to five years, many no longer require oral antihistamines and nasal steroid sprays and are primarily symptom free for most of the year. I think most patients are under the impression that they will need to be on these for the rest of their life and that's not correct.

MCMS: Let's talk about managing the practice. Some practices have one managing partner who runs it, or they outsource to a CEO or empower practice managers to make key decisions. Office managers are also in the mix. Which non-clinical decisions require your involvement, like staffing or marketing?

Dr. Rishi: Right. So, there are different private practice setups. Ours is a partnership where each partner is an equal. And we are involved. With not just patient care, but we are also personally invested in the business side.

MCMS: You have an equity stake in the organization?

Dr. Rishi: That's correct. We do oversee marketing and employee-related issues such as health insurance and 401(k). Think of it as a small business. You have the patient care side of it and then you have the small business side of it. It’s like two jobs that you’re always doing sometimes. Friends and family will joke that I may only work a certain number of days of the week but when you're an owner, you're never really not working even on the weekends. You're constantly working, and you're constantly involved with the small business element of a practice. For some people that can be a turn-off and overwhelming, and that's why they would prefer to work for an employer or as a hospitalist.

MCMS: You mentioned you worked in industry before you went into practice. Did that help to provide a perspective that you can manage a small business?

Dr. Rishi: Yes, absolutely. I was not fearful of being involved and running a small business as a result of my prior experience. I do feel that a lot of physicians are very weary and intimidated by the idea of having their own practice. Many would benefit if they tried it, but I think because of this lack of experience and knowledge, they feel that they are not equipped to run a private practice.

MCMS: With the way that healthcare is today, do you believe it's feasible to run a practice and be profitable? You’re doing it but do you think the barriers to entry are low enough that if people wanted to put up their own shingle, they could do it today?

Dr. Rishi: That's a great question. And to be honest, it depends on the type of medicine that you're practicing. I do feel that primary care physicians are not benefited by going into private practice because the reimbursement tends to be on the lower side, and it's made it very difficult for them to keep offices open. I've always championed higher reimbursement for primary care physicians for this reason. And we've seen a lot of good practices shudder because of this one loophole that hospital systems take advantage of. If they purchase a private practice, they're allowed to charge hospital rates, which can be substantially higher than a physician in private practice, who is limited by what they can charge based on insurance.

MCMS: There’s a difference between the service fee and a facility fee. The different rates have led to mergers and acquisitions of private practices.

Dr. Rishi: That's correct. A lot of times the facility fee is warranted. If revenue is based purely on what an office visit reimburses a physician, then they would not be able to cover their overhead, let alone make enough to earn a living. So, we really need to champion higher reimbursement for primary care positions.

MCMS: What are one or two changes that you would like to see in healthcare write large that would either make the conditions better for patient care or make it more conducive for physicians to choose where they practice medicine?

Dr. Rishi: I think you need to see increased reimbursement rates for physicians to make it worthwhile to pursue private practice. I feel that a lot of patients would prefer to see their physician in a private practice setting and they feel that their quality of care has suffered as a result. Insurance premiums for patients are incredibly high. It's gotten to the point that unless you work for a large corporation or a small business that provides healthcare, it's too expensive to afford on your own.

MCMS: Should we have universal catastrophic coverage or universal healthcare?

Dr. Rishi: We need to have a system where we can provide universal coverage. But we still have to reimburse the people who practice in a way to truly incentivize them to provide that quality of care. The quality of healthcare in this country, if you can afford it, is the best in the world by far. It's just that the coverage isn't ideal, and we need to improve coverage, but if we can find a way to merge the two systems, I think it would be great. It would be a beautiful system. I do feel that a lot of other industries, whether it's the pharmaceutical industry or insurance companies, need to be better regulated. If you look at their executive pay, they continue to go up every year and yet patient premiums continue to increase and reimbursement to physicians continue to decrease. That needs to be addressed.

MCMS:  There's horizontal integration with more private practices merging into larger and larger groups or selling out to private equity. We have more vertical integration with hospital systems scooping up practices. As an allergy immunology group, do you feel pressure and get calls often to sell to equity? When those discussions come up, what are the considerations about whether to do that or not?

Dr. Rishi: I have colleagues who sold their practices to private equity. There are pros and cons to that. At this time, we are not interested in selling. Primarily because we enjoy how we practice medicine and by selling to private equity or a larger corporation, that would impact how we're able to manage and see patients and it would cede some control. It would definitely impact our enjoyment of practicing medicine. By selling to a corporation, they're going to influence which medications I can prescribe, which treatments I can provide for my patients. Now, I have full autonomy over that and I feel that my patients understand and benefit from that. We have a very good relationship. So, that is my primary reason for not wishing to sell to private equity.

MCMS: There are about 13,000 practicing physicians in Maricopa County and it’s a growing area. What message do you have for other physicians about the medical community? What do you want to see for the future of healthcare in the county?

Dr. Rishi: Well, I would like to see more of a collaborative effect.

MCMS: What does that mean?

Dr. Rishi: When we see patients, we are truly working as a team with other physicians, whether we have met them in person or not. As an allergist, I may manage a patient's asthma and allergic rhinitis. But they also have a primary care physician who may be managing their high blood pressure and their diabetes. They may have a cardiologist that's managing their heart condition. They might have a gastroenterologist that's managing their Crohn's disease. A lot of our patients have multiple doctors. All of us, including myself, could do a better job communicating with other physicians and in the cases where I've done that, we've seen really good outcomes. I have a funny story about that. So, I had a belligerent patient once and he is a very good county attorney. He basically told me to get my act together and that all of the physicians on his team need to work together to help solve his condition. And he had a point. So, I picked up the phone. I talked to all his physicians. He had a much better treatment plan and outcome. And on the follow up visit, I thanked him. And I said that was really good advice that you gave, and we laughed about it. A tense situation turned into an amazing situation, and I learned from my patient in that case, and he was right. It's cool.

MCMS: We're in 2023. Hopefully the electronic health systems and all the different devices we have will lead to better communication and improved outcomes. But it seems like there is a disconnect between those systems. They’re not talking to each other, and physicians are drawn into corners by different networks.

Dr. Rishi: On the on the technology side, medicine has a long way to go. I was once talking to a colleague in the tech industry, and he laughed that physicians still use fax machines and I agree. How is it that we don't have a system where we all can send a note to somebody electronically within seconds and they have immediate access to a patient's electronic records from different physicians where I can see their treatment protocol? We have a long way to go.

MCMS: Dr. Rahul Rishi, thanks so much for your time.

Dr. Rishi: This was a lot of fun.

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