The BDN Opinion section operates independently and does not set news policies or contribute to reporting or editing articles elsewhere in the newspaper or on bangordailynews.com
Jabbar Fazeli is an independent medical provider and president of Maine Geriatrics LLC.
Maine is steadily losing its independent primary care and rural healthcare infrastructure. Small hospitals, nursing homes, and rehabilitation facilities have closed or are struggling to survive. Independent primary care practices — the backbone of community medicine — are disappearing as well.
Although inadequate Medicare and MaineCare reimbursement contribute to these losses, another cause receives far less attention: a healthcare system increasingly structured to favor large healthcare organizations over smaller independent providers.
The consequences extend beyond economics. They affect access to care, whether older adults can remain near their families, and whether patients retain meaningful freedom to choose their providers.
In 2013, Pittsfield Rehab & Nursing provided long-term care while maintaining a limited number of skilled rehabilitation beds. Rehabilitation revenue helped offset inadequate MaineCare reimbursement. The facility needed just one skilled rehabilitation referral per month to remain financially viable.
Yet local residents discharged from hospitals were frequently referred to hospital-affiliated rehabilitation facilities instead.
During Maine’s 126th Legislature, I advocated for LD 447, An Act To Increase Patient Choice in Health Care Facilities and Health Care Settings, which became law in 2013 despite opposition from major organizations.
The legislation sought to strengthen patient choice in post-hospital care, require disclosure of certain financial interests, and give nursing facility medical directors a voice in the care policies of corporate-owned facilities.
Despite these protections, Pittsfield Rehab & Nursing closed in 2014, citing financial pressures. Residents were displaced, and families faced longer drives to visit their loved ones.
Its closure illustrates how inadequate reimbursement, combined with structural disadvantages facing independent providers, can devastate rural healthcare. In my view, the promise of LD 447 remains largely unrealized. Legislation is only as effective as its implementation.
Large healthcare systems increasingly own or affiliate with hospitals, physician practices, rehabilitation facilities, home health agencies, hospice services, and specialty practices.
Although vertical integration can improve coordination, it also creates potential financial conflicts. When an organization recommends a service from which it profits, patients may not receive a complete picture of their options.
Patients deserve information about appropriate alternatives, including independent local providers, as well as disclosure of relevant financial relationships. Independent providers cannot compete fairly when referrals are steered toward affiliated entities.
I believe Maine must examine whether patient-choice protections are being followed and adequately enforced. Choice must be genuine, not merely a procedural exercise to satisfy legal requirements.
Independent primary care physicians coordinate treatment, manage multiple conditions, and help patients avoid unnecessary testing, procedures, and specialist visits. Their independence helps keep clinical decisions focused on patients’ needs rather than institutional financial interests.
Yet independent practices face mounting administrative costs, complex reporting requirements, and reimbursement systems that favor organizations with dedicated billing and compliance departments.
The elimination of Medicare’s 10% primary care incentive removed an important source of support. Meanwhile, the Merit-based Incentive Payment System (MIPS) added administrative burdens, turning reimbursement into an annual exercise in metrics reporting and penalty avoidance.
Large healthcare organizations can distribute these costs across departments. Small practices cannot.
As independent practices disappear, communities lose local providers, competition, and independent voices in healthcare policy. Two decades of healthcare reforms have contributed to this imbalance without delivering the promised cost savings.
Independent physicians are the canary in the coal mine: their disappearance signals a healthcare system becoming less accessible, less competitive, and less patient-centered.
Maine’s rural healthcare debate must extend beyond reimbursement rates. I urge policymakers to examine referral patterns, enforce patient-choice and financial-disclosure protections, and ensure that independent providers can compete fairly on a level playing field. They must also recognize that current regulatory and payment requirements disproportionately burden smaller practices.
Large healthcare systems remain essential, but when a handful of organizations dominate regional markets, competition weakens, patient choice narrows, and costs may rise. Regional monopolies should be no less concerning in healthcare than in other industries.
Consolidation is often presented as synonymous with efficiency. But efficient for whom? Organizational savings do not necessarily translate into lower overall costs, better access, or improved outcomes.
Once a rural facility closes or an independent practice disappears, rebuilding that capacity can be difficult, if not impossible.
Maine’s challenge is not simply how much we are willing to spend. It is whether we will preserve a healthcare system in which patients have meaningful choices, communities retain local access to care, and independent physicians and small facilities can survive — and perhaps even thrive.
By the time Mainers fully recognize what has been lost, it may be too late.