By Julia Buchfuhrer, DO & Nilanjana Bose, MD, MBA

Every physician that tells a colleague or mentor that they want to go into private practice has at some point been given these lines: “Private practice is dead!” “There’s no money left in it.” “It’s not viable.” At the same time, anyone who has done an Accreditation Council for Graduate Medical Education residency or fellowship has heard those in academia view private practitioners as “money grubbing,” “cash cows,” or “just in it for the money.” How could two very opposite perceptions coexist at the same time, both of which often lurk together in the same hallways of academic hospitals?

To understand why some believe private practice is “dead,” it helps to look back. In the early 2000s, private practice rheumatologists thrived in part because of ancillary revenue, especially infusions. Newly approved biologics like Remicade (infliximab) created meaningful margins that helped offset the rising costs of running a practice. Although this enabled many practices to stay afloat for years, federal reimbursement changes in the mid-2000s sharply reduced infusion profitability, and in the past few years the arrival of biosimilars and other market pressures have further compressed margins, making this once-reliable ancillary far less viable.

Infusions were not the only ancillaries hit hard. Nearly every rheumatology office once had a DEXA machine, and in 2000 a scan was reimbursed at roughly $150. Today, it is closer to $40, while the cost of employing a DEXA technician has risen substantially. The same trend applies across the board: medical assistants, nurses, receptionists, and even basic supplies have all become significantly more expensive. At the same time, Medicare has continued to cut physician reimbursement year after year. Private practice is being squeezed from both sides, and the financial cushion that once supported independent clinics has largely disappeared, forcing rheumatologists to pivot toward new strategies and ancillaries such as medically integrated dispensing to remain sustainable.

Now that we’ve painted a fairly grim picture, why would anyone still assume we’re “in it for the money”? That perception comes from a long-gone era when infusion margins offered a financial buffer. But today, running an infusion center requires meticulous oversight. One audit or claw-back can erase months of revenue and even push a clinic into the red. There is nothing passive about it; it is labor-intensive, high-risk, and far from the effortless profit center people imagine.

The real story isn’t about money, but about why we stay independent despite all of this. Private practice gives physicians something increasingly rare in healthcare: autonomy. We can make decisions based on what is best for the patient in front of us, not based on corporate mandates, productivity quotas, or impersonal national patient satisfaction surveys. Independence allows us to practice medicine at a humane pace, build deeper relationships with patients, and tailor care in ways that large systems often make impossible.

Being in private practice has forced many rheumatologists to wear multiple hats, often doing one-and-a-half to two full-time jobs with work that is not always compensated. Yet we choose it anyway. We choose it because independence gives us the flexibility to pivot, the freedom to create the culture we want, and the ability to preserve the parts of medicine that matter most: connection, continuity, and advocacy. Regardless of the financial return, it is simply not the primary reason we remain independent. Many of us have developed strong business skills along the way and earning more than an employed position feels like a bonus. This actually reflects the additional responsibilities we shoulder and the value we deliver to our patients and teams.