Is it still possible to go solo in this era of consolidation?
Absolutely yes. There was a editorial in EyeNet (the trade news magazine for AAO) about the viability of solo practice. Our extended response is on this link. We wholeheartedly believe in this editorial that more solo practitioners will strengthen our profession. If you choose to find an associate position instead, read this article about how to evaluate an associate position. But a $300,000 junior associate position may not be as good as it seems.
How much time does it take to start a medical practice?
Anywhere from three months to a year.
The first step is deciding to go solo. We know of some colleagues who have been “deciding” to go solo the last two years. Their job may not be intolerable but not great, so there’s no huge impetus to push you to go solo.
On the contrary, one colleague’s boss sold the practice. Being the junior associate, he was told he was let go from the practice, without any warning. He hustled, so it took him less than four months to open doors. It’s also easier if you’re already practicing in the same area that you plan your solo practice in.
For most of us, the two rate limiting steps are finding an office space and for the time it takes for tenant improvements. Frequently, the first office space you look at doesn’t work out and you’re back to starting your search again. Don’t count on anything until the ink dries on the lease agreement!
The other potential rate limiting step is tenant improvements. Many of us have to build out a empty shell (get an architect to help create floorplans, hire a contractor, and build the walls, fixtures, etc). This usually takes longer than predicted, frequently 3-6 months from scratch.
Ho Sun took about eight months to open doors. Since I had almost no tenant improvements, it took me six, but I could’ve opened up a month earlier, I just wanted a extra month to take vacation and get ready.
How much does it cost to start an ophthalmology practice?
The most common estimates for startup costs for ophthalmologists are between $200-300K, with a $100K line of credit to cover operating expenses after opening, as it typically takes three to six months to break even. I know many colleagues who took no or minimal salary their first year.
Although this sounds like a lot, if you choose to join a practice and buy in the number can be higher. I have heard of up to $400 to $500 grand. The money you invest in starting a practice is not a sinkhole- at the least you should be able to sell your equipment, at the best you might be able to sell your practice to a buyer for goodwill and equipment value (a blog post on practice valuations is here, along with one about the pros and cons of buying an existing practice).
The two most important factors for startup costs are how much your equipment costs, and how much you pay in tenant improvements. If you buy lots of brand new equipment, your startup will cost more than someone who buys less equipment and buys it used.
I was fortunate that my office was previously a psychologist’s office, so all of the rooms were the exact right size for me, so I didn’t pay anything for tenant improvements (TIs) nor did it take any time. Often times the landlord will give you a TI allowance (rolled into your rent), but we know of colleagues that have paid upwards of $80,000 in TIs.
Ho Sun spent about $450,000 for his startup costs, which included about $300,000 for equipment and $60,000 for tenant improvements. That’s because he fully equipped his office and built out a shell. On the other hand, I only spent about $155,000, which included $125,000 for equipment. Because my lease was structured to be rent free for my first six months, I was actually profitable my third month.
What are the steps to start a medical practice?
As Ho Sun stated in his consultants re-revisited post, he figured out all the steps by himself. I used his original iballdoc blog as a general guideline, but here are the steps one by one.
Ironically, when Ho Sun read this post, even after figuring out the process himself without any outlines, he texted me “this sounds really intimidating!”
We want to reassure you it isn’t intimidating. It takes time and legwork, but anyone can do it. Surviving medical school rotations and ophthalmology residency was much more intimidating and stressful at least for me.
There will be at least one, if not multiple blog posts, about each of the following steps to start a medical practice coming up. We will link them to this post so click on the links:
Things You Can Do Without a Practice Address
- Choose practice location
- Obtain state medical license
- Obtain DEA number
- Obtain Type 1 NPI number
- Write business plan (pro forma)
- Obtain financing
- Find commercial real estate agent or lease an office from another physician
- Pick office, negotiate, and sign lease
- Design floor plan if office needs to be built out
- Choose contractors for tenant improvements/ buildout
- Pick malpractice insurance carrier
- Name your practice
- Design website
- Choose EHR and practice management system
- Shop for equipment
- Obtain business phone number
- Review personal insurances for proper coverage
Once You Have Your Business Address
- Incorporate practice
- Obtain tax ID number
- Open business bank account
- Obtain Type 2 number
- Obtain business insurance
- Credential with Medicare (PECOS application)
- Credential with Medicaid (if rates for your state justify so)
- Obtain hospital privileges
- Obtain local business licenses
- Credential with commercial plans (CAQH application) and IPAs
- Obtain ambulatory surgery center privileges
- Consider joining any ACOs affiliated with your hospital
- Choose where you will do your procedures and cases
Prior to Completion of Tenant Improvements/Buildout
- Order medical and office supplies
- Order business cards and prescription pads
- Find IT company and buy computers
- Arrange for office phone and internet service
- Pick credit card processing
- Choose how you will advertise
- Write or obtain employee manual
- Create forms (patient intake and consent forms)
- Obtain office furniture
Things to Do One Month Before Opening Day
- Update address with Google places, Healthgrades, Vitals, and insurance companies
- Advertise for employee(s)
- Interview potential candidates
- Run background checks on candidates
- Hire employee(s)
- Set up payroll service
Things to Do Around Opening Day
- Shake hands with potential referring doctors and sources
Things to Do Now and Forever
- Learn ins and outs about billing and revenue cycle (so you can do your own billing or supervise to keep in house)
- Learn about bookkeeping
- Learn basics of accounting
- Stay up to date with the latest medicine in your speciality
- Learn how to avoid penalties for Medicare quality program (MIPS and MARCA)
And this is just the beginning… setting up the practice. We also have many posts on how to run the practice!