Zero-Sum Game: How Solo Practice Can Save Ophthalmology

Zero-Sum Game: A situation in which one person or group can win something only by causing another person or group to lose it.


Our profession is in its current state because practicing ophthalmology, or any other specialty in medicine, is a zero-sum game. Our predecessors’ incorrect response to decreasing reimbursements is hanging the future of ophthalmology out to dry. I don’t know what the world of ophthalmology was exactly like 30 years ago, but I’m surmising that when reimbursements began to decrease, ophthalmologists felt compelled to find new ways to maintain their bottom line. Believing that seeing more patients would be the answer to their woes, they made exclusive arrangements with referring doctors and capitated insurance plans, ensuring an increased and steady flow of patients. Because patient volumes increased, these practices ended up needing to hire more staff and move into larger spaces, increasing their operating expenses. Ironically, their larger overhead ultimately trapped these practices into inescapably relying on and being beholden to their new source of patients for sustenance. Pretty much, practices sold their independence in exchange for more revenue.

The problem with the rise of high volume practices is the fact that there are only a finite number of patients to go around in a given area. If every ophthalmologist sees 60 patients a day, of course the market will quickly become saturated even with only a handful of ophthalmologists. And because everyone has now “starved” each other of patients, ophthalmologists have moved on to look for other ways to increase revenue: ie. FLACs on EVERY patient, converting 50% cataracts to premium IOLs, Lipiflow for $1,500 as first line treatment of blepharitis and dry eye syndrome, etc. With the exception of Lipiflow, I have nothing against these procedures in themselves. I just have an issue with the gross up-selling of these premium services beyond what is best for the patient. So now, industry has you by the balls as well. They charge you an arm and a leg for the latest technology. Practices get suckered into purchasing these new machines to increase revenue and to stand out from their competitors. Thereby, increasing the cost of care, without necessarily improving the quality of care for all but a few.

In addition, many of these practices hire new grads and young ophthalmologists with questionable promises, making them see an insane number of patients and perform hundreds of cataracts surgeries a year, all the while paying them less than 20% of collections. As a reminder, I will be taking home 63% of my collections this year.

I know that both Howie and I are super Gung Ho about ultra low overhead, low volume practices. Well, it’s because it works. If properly run, a good solo practice can thrive on just 20 patients a day. So, a 60 patient per day, high overhead practice that supports 1 single ophthalmologist should be able to support 3 solo practice ophthalmologists that see only 20 a day. And the income potential and the hours worked would not be very different either. So where would the saturation be if more practices went solo?

I feel like the trend toward big box medicine has entrapped and enslaved us all. The fact that the AAO career advice talks and panels for young ophthalmologists have been marginalizing the solo/small practice doesn’t help either. I believe that a significant part of our fledgling readership are residents and fellows. You all know that the only two career options that they feed down your throats are: associate position in private practice with “partnership” track, and academics. As an aside, you can learn about the realities of partnership buy-ins on Practice Valuations.  Solo practice or buying a practice usually ends up being only mentioned as a mere asterisk or as a “dinosaur” by older ophthalmologists who believe that their antiquated, inefficient practice model is the ONLY way anyone can run a practice. So, if your mentors and role models tell you that the only way to survive and succeed in private practice is to see 40-50 patients a day, all the while trying to appease the hand that dangles the carrot over you, then how can you fault anyone for getting suckered into becoming a cog in the wheel of a machine that puts to waste and replaces over 70% of them within 3 years. I’m not singling out only group practices by the way. There are plenty of excellent and ethical group practices out there, and there are also plenty of crooked solo/small practices as well. My main criticism lies with high to ultra high volume practices, which on average, tends to be larger group practices.

The main reason I started blogging, which unintentionally ended up leading to the creation of Solo Eye Docs group, was to contribute something unique toward the betterment of my fellow ophthalmologist. I’m not smart enough to find the cure for Stargardt’s disease. There are plenty of other brilliant people to do that. However, I knew that my path was a road less traveled, and I hoped that sharing my experience would either inspire others to follow or at least show them what had lead to my failure (had I failed).

7 years later, I still want to help empower my fellow ophthalmologist, and try to free everyone from this vicious cycle of political and predatory medicine. I know Howie feels the same way. The sad thing is that we did this to ourselves. In pursuit of maintaining one’s own current self interests, ophthalmology has sacrificed its future, and bound it to politics and industry, compromising and destroying the spirit of ethical and quality patient care.

As a solo practice ophthalmologist, I answer to NO ONE but my own patients. No one can ever influence what I think is the best care for my patients. All my referring doctors trust me and know that I try to provide good honest care. In fact, most of them are also my patients. They don’t care if I send them patients back or not. That’s the beauty of the low overhead, low volume solo practice. I can’t be bought, and I can say whatever I want to whomever I want. No one owns me. I have excellent clinical outcomes, and patients love waiting less than 5 minutes to spend 20-30 minutes face to face with their doctor. Because I provide what I believe to be superior care over high volume practices, I have a positive presence in social media, which has been a great source of organically generated patients for me. In fact, I get a good number of patients whose doctors instruct them to go see Dr. X, but instead they end up coming to see me because of my online reputation.

4 thoughts on “Zero-Sum Game: How Solo Practice Can Save Ophthalmology

  1. This is a fantastic article. I didn’t realize that some of the things I have fallen into out of sheer professional/personal comfort (like discontinuation of drug reps and therefore samples in my office) are actually big reasons why I like controlling my own small practice. Now I am new to this group – is there a blog article on how the heck you created that overhead number?!

  2. im an internist, is there a way to do for internal medicine AND make it lucrative, since the overhead is much less ?

    • Hi there, I don’t know the numbers for internal medicine, but I do know that most of the docs that refer to me are in solo, or two to three MD practices. Some have NP/PA, the others don’t. They still seem to be doing very well despite the push towards consolidation and the unfounded belief that small groups or solo docs won’t survive.

      As a specialist I get many referrals from such docs because they don’t want their patients sucked into the HMO mill.

      From my perspective it clearly is possible for internists to do well.

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