Eighteen years ago, limited options brought a young Indian doctor to Hernando County by way of New York City.
Dr. Pariksith Singh had just completed his residency in New York and was in the country on a special visa that required him to move to an area in need of more doctors. He moved to Hernando with his wife, Dr. Maria Scunziano-Singh.
The visa requirement ended after a couple of years, but the Singhs stayed and founded what today is one of Hernando's largest and most influential health care companies.
If you haven't heard of the Singhs, you've probably heard of Access Health Care. Started in a former hardware store in Spring Hill, the company now has 65 locations and 700 employees - including 110 doctors and other providers - across nine counties. Most are in Hernando. All told, the company sees about 30,000 patients.
Observers say the Singhs capitalized on Hernando's fragmented health care sector as the industry faced a paradigm shift that continues today.
"Right before our eyes, health care is drastically changing, and we're just trying to stay ahead of the curve," Singh said. "Care was not coordinated, and no one was accountable. Now we're bringing it together, making it consumer oriented and backed by advances in technology.
"The old shotgun approach," he said, "is no more."
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By the time Singh, 45, arrived to work in Pasco and Hernando for Dr. Mohan Kutty, it was clear that medicine was already changing. Kutty had an understanding of what was happening, Singh said.
His visa requirement ended about 1998. By then, the first of the Singhs' four children had arrived, and the couple had established a loyal patient base.
"I was learning a lot, and we didn't want to go back to the city," Singh said. "This is a wonderful community."
There was also a clear opportunity to grow a business here.
Medicare and private insurance reimbursements were starting to shrink, and mounting regulations were increasing overhead and demanding more of a doctor's time. Many providers were banding together to pool resources and increase their leverage as they negotiated rates with insurance companies. Not so much in Hernando, though.
"It was a natural progression in other places, but didn't really materialize here," said Rob Foreman, vice president of physician services for Oak Hill Hospital. "A lot of doctors love their autonomy."
The Singhs, both of whom are board certified in internal medicine, started Access in 2001 in a former Ace Hardware store near the intersection of Spring Hill Drive and U.S. 19.
They envisioned a full-service business that would improve care by bringing various specialists under one umbrella. A patient's providers could communicate better to avoid duplicating services and prescribing conflicting medications. Services such as stress tests and lab work could be done in-house to keep down costs and reduce the need for patients to drive to five different offices. Doctors could share the company's back-of-the-house administrative operations to reduce overhead.
Access eventually added an entire department to ensure that the company and its doctors are complying with regulations.
The growth rate was surprising, said Scunziano-Singh, 52.
"I thought it would be just a little community practice," she said. "Every time we turn around, we have another practitioner who wants to join us."
In 2011, Access opened a 17,000-square-foot building on Spring Hill Drive just east of the Suncoast Parkway. Originally planned as medical offices, the building is filled mostly with administrative workers, including the compliance staffers and a team that audits bills before they are mailed. A team of care coordinators calls patients to remind them of appointments and make sure they are following doctors' instructions.
Access also has case managers in all three Hernando hospitals who keep tabs on patients until they are discharged.
The company tracks patient data to find out what's working and what isn't.
"You learn from it and act accordingly," Singh said.
There have been setbacks and missteps.
Access closed a Sumter County office a few years ago because the off-season population couldn't sustain it. An effort to turn around troubled provider offices north of Miami also failed.
In 2010, the Singhs dropped a plan for a medical office and spa at the northeast corner of U.S. 19 on Spring Hill Drive after nearby residents complained.
Some physicians have been resistant to - and some resentful of - the Singhs' growth and business model. But Access was clearly enjoying success, and pressure on sole practitioners continued to mount during the Great Recession and the new area of accountability ushered in by the federal Affordable Care Act.
It helped that Singh has the interpersonal skills of a diplomat, said Dr. Sankara Dinavahi, who has practiced family medicine in Hernando for 30 years.
"Dr. Singh was one of the few people who could talk to all the physicians and bring them together," Dinavahi said. "It requires a special talent, and that's what he has."
Despite his respect for the Singhs, Dinavahi joined Access just last year.
"At last I realized solo practice is going to be a dinosaur in a couple of years," he said. "The bureaucracy is making it impossible for a solo practitioner to function."
Dinavahi said Access's compliance department brings peace of mind, and he's hoping his income will stabilize.
There also was another, somewhat ironic benefit for his staff.
"Now," he said, "we can afford to have halfway decent health insurance."
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One recent morning, in an exam room at Access's main office on Spring Hill Drive, Singh rubbed the end of his stethoscope to warm the metal and placed it on Herbert Hentschel's back.
After pausing to listen, Singh asked about the 79-year-old Spring Hill resident's visit to one specialist and an appointment with another.
"I'm glad I saw you," Hentschel said, pulling down his shirt.
Singh said that early on he tried to focus exclusively on the business side of the company and not see patients. That lasted about three weeks.
"This is something I love, and I've known these people now for years," he said.
Later that morning, Singh stood in the gutted interior of a former diner a few doors down in the strip center. Access is transforming the space into diabetes and outpatient clinics. The latter will serve as the hands-on training ground for Oak Hill Hospital's internal medicine residents. The new residency program, which starts in July, is the first of its kind here.
Access is also about to break ground on a two-story, 7,400-square-foot expansion of its main office to house an urgent care center. A wellness center is in the works for Lake in the Woods.
As they've grown their business, the Singhs also have made a philanthropic mark on Hernando through their Auroveda Foundation. The nonprofit foundation has funded a community garden south of Brooksville and donated thousands of dollars to help feed needy children. At three Auroveda Centers, needy residents can learn about and apply for various kinds of state and federal assistance programs.
It's part of a holistic approach to caring for a community, the couple say.
"We provide compassionate care," Scunziano-Singh said. "There's no skimping on that."
News researcher Carolyn Edds contributed to this report. Tony Marrero can be reached at firstname.lastname@example.org or (352) 848-1431. Follow @tmarrerotimes on Twitter.
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Inside today's edition: Hernando Business
The Great Recession was not kind to Hernando County. Unemployment skyrocketed, the building industry screeched to a near halt and a county that had seen nothing but growth for decades came to a virtual standstill. These days, the economic picture is a bit rosier. Whether it's activity at Brooksville-Tampa Bay Regional Airport or along State Road 50, things are looking up.