Ahmed Hasan, MD, has been practicing gastroenterology independently in Pennsylvania’s Lehigh Valley for 30 years. Six independent GI groups with their own ASCs used to operate alongside him in the Greater Lehigh Valley, a total of roughly 60 gastroenterologists. Today, two remain.
“I’m the last of the Mohicans around here,” Dr. Hasan, president of Lehigh (Pa.) Gastroenterology Associates, told Becker’s.
Dr. Hasan joined Becker’s to discuss what has happened to independent practice in the Lehigh Valley and speak more broadly about what the ASC industry loses when independent competition disappears.
The referral diversion playbook
According to Dr. Hasan, when a primary care physician employed by a hospital network wants to refer a patient to an independent gastroenterologist, even one in the same insurance network, the system often pushes back. Physicians who refer outside the network face internal questioning. Some have described it to Dr. Hasan as going through “a torture chamber” for sending a patient elsewhere.
Patients face pressure too. When independent primary care physicians sell their practices to hospital networks, Dr. Hasan said, the acquiring system redirects their established patient panels to employed specialists. Patients who ask to continue seeing their long-time independent gastroenterologist may be told the hospital cannot coordinate care if they go outside the network.
“They’re lying to the patients,” he said. “That’s not good for medicine. It’s not good for continuity of care.”
A group of colorectal surgeons in the Lehigh Valley he described as “very good and very busy” stopped getting referrals as soon as the hospital hired its own colorectal surgeons. Some retired. The competition was eliminated.
The financial consequences of that consolidation are well documented. A July 2025 National Bureau of Economic Research study found that two years after a hospital-physician merger, hospital prices rose 3.3% and physician service prices rose 15.1%, with no measurable improvements in quality. A Government Accountability Office report also found hospital-physician consolidation is associated with 17% higher commercial office-visit prices. Nearly all of the estimated deal valuations in the NBER study fell below the Federal Trade Commission’s Hart-Scott-Rodino merger reporting thresholds, meaning they proceeded without mandatory federal review.
Common medical procedures can cost more than twice as much in a hospital outpatient setting compared to a physician office or ASC, according to a 2023 analysis from the Blue Cross Blue Shield Association. When Dr. Hasan called Highmark directly to pitch the price differential, he was told the insurer couldn’t act — the hospital network had 500,000 patients and the contractual leverage to match.
“I would love to tell Mark Cuban to get involved and say, ‘Hey, why don’t you come in this thing? Because you know these people are going to crash the healthcare system,'” he said.
The barriers to independence
Two structural forces make it hard for physicians who want to leave hospital employment to actually do so.
The first is business education. Medical schools do not teach physicians how to run a practice, and residency programs are entirely hospital-based — residents never rotate through private physician offices. The Pennsylvania Medical Society passed a resolution on this after forming its independent physician section, sending it to all training programs in the state.
According to a 2024 study in the National Library of Medicine, 79% of medical trainees reported below-average understanding of personal finance, despite nearly all agreeing that this education should be an integrated part of their training. According to Encoda’s “The state of financial health” survey, only 47% of physicians expressed confidence that their current financial reporting accurately identifies issues and financial risks.
The second is the restrictive covenant. Hospital networks in Pennsylvania sometimes cover a 20-mile radius of 20 facilities, forcing physicians who go independent to commute 50 miles each way for one to two years while waiting for their covenant to expire. The American Medical Association estimates between one-third and nearly half of all physicians have a noncompete clause in their employment contract.
“Noncompetes and the way that they’re used serve as a blanket restrictive covenant for physicians when they sign a contract is really problematic,” Marcelo Hochman, MD, an independent physician and former president of the Independent Doctors of South Carolina, told Becker’s. “It abridges the patient’s rights to follow their doctor if their doctor is going to leave the hospital system and now they have to move X miles away. That patient may not have that option, [especially] senior patients, or maybe even just geographically … 30 minutes, 45 minutes away may just not be feasible, or you may just not want to do that.”
What keeps Lehigh GI running
Dr. Hasan’s formula for survival is straightforward: know your costs, know your patients, and out-service a system that treats both as abstractions.
“Our overhead is not that high because we know how to run a business like a private person — like a pizza guy,” he said. “The networks don’t have their money in the business, they don’t have a dog in the fight, so costs keep going up.”
In a high-deductible insurance environment, the price advantage of independent practices is becoming more visible to patients bearing more of the cost themselves. Dr. Hasan believes insurers are beginning to recognize the same dynamic.
“Insurance companies should be wise enough to save money,” he said. “Don’t let the independent ASCs and independent practices go down and be acquired, because then the cost of healthcare will go up. We keep the cost of healthcare low, and the effort by the big networks is to remove us. It’s like the guy across from you is selling ice cream for $2 and here you are selling it for $10 — you don’t want that competition.”
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