Is solo practice still possible? The answer is yes!

Multiple articles in the lay press and for physicians are about the decline of solo practice. These articles cite the political forces towards consolidation towards health care, government regulations such as quality measurement (MIPS), required use of electronic health records, the cost of equipment, the lifestyle (always on call), being excluded from insurance plans, and financial security as often newly minted physicians have lots of debt immediately after training.

There is no doubt that every practice model, solo, small or large group has its positives and negatives. And we’re not saying that everyone must go into solo practice. Rather, we just want other physicians, especially young docs right out of training, to understand that it’s a perfectly viable option as we have 130 docs in our google group who can vouch for it. No, things don’t always go smoothly and there are problems and issues to be solved, but our ethos is that as a solo doc we are quicker to respond, adapt, and come up with a solution in a more efficient way than some clueless bureaucrat administrator.

Some of the articles such as this one from CNN in 2013 are a bit dramatic, such as doctors driven to bankruptcy. Believe me when I say that no one in our google group is complaining of going bankrupt. You can choose to make bad decisions such as opening a 5000 square feet office when you only need 1800, overpaying for equipment and buying more than needed, hiring five staff with a office manager when you’re seeing six patients per day, contracting with lowball insurance plans that flood your office with low reimbursing patients, and outsourcing your billing to a company (pretty much all companies for that matter) who lets things fall through the cracks instead of collecting payments at the time of service and relentlessly following up on the few outstanding claims. Or you can make wise decisions and reap the rewards.

No, you don’t need a MBA or a business background. In fact, the reason why I initially was afraid to go into solo practice was because I had no business background! With a little common sense and a little help from my friends (in the google group) I am able to run my practice WAY more to my liking and more efficiently than any group I’ve ever worked for.

One other recent article about solo practice is this one from Physician Practice. This article is more balanced than the CNN article, and my favorite quote from the article which I believe to be 100% true is “More needs to be taught about the business of medicine at the medical school level and through residency… A top complaint among providers was that they didn’t get an adequate education in this area.” That’s exactly why we are writing this blog, because no such educational resource to teach physicians how to start and run a solo (or small) practice exists, and we desire for this blog to be to the best available resource.

It’s easier for ophthalmologists to be solo compared to many other fields, because hospital systems don’t need us to drive referrals or bring cases, so the push for consolidation is less than say cardiology (some other fields where it is easier to go solo are psychiatry, dermatology, plastics, ENT, urology, and I would still include family practice and internal medicine). It is quoted in the article below that the number of solo practitioners in all fields dropped from about 25% to 17% from 2012 to 2016 (thanks, Obamacare), but as of 2016, 26% of ophthalmologists are in solo practice.

However, a recent survey by the AAO indicated that only 3% of residents and fellows were interested in solo practice. Looking back, I wasn’t in that interested 3% myself. I always thought there would be more safety in groups.

A recent editorial about solo practice was published in EyeNet, the American Academy of Ophthalmology’s monthly trade news magazine. The article was written by Dr. Ruth Williams, a former President of the AAO. The article can be found here.

While we have the greatest respect for Dr. Williams and her contributions to our field, and agree with her positives about solo practice, we differ with some of the points she makes in her editorial. We wrote a letter to the editor, which EyeNet was kind enough to accept and publish. It can be seen here on this link on the second page. Be sure to read the other responses!

It is stated that “as in rural markets…solo ophthalmologists may be positioned to serve smaller markets within a larger metropolitan area.” Guess what, we have colleagues practicing solo in the heart of the most competitive urban areas- oculoplastics or general in Bay Area, retina docs and comprehensive ophthalmologists in Los Angeles and Orange County, upscale suburbs of Chicago, Dallas, and Atlanta for instance.

As Ho Sun writes in this post, a good product is a good product. If you want to practice in NYC, which matters more, if you’re a excellent surgeon and clinician who makes patients comfortable (compared to if you’re a poor surgeon with bad bedside manner), versus if you’re solo or in a group?

While it’s true that it’s more difficult to thrive in NYC compared to less saturated areas, joining a group isn’t going to change that. It might make things worse if you’re competing with your partners for patients or cases. We actually have members of our group that saw more patients and did more surgeries after they went solo compared to working in their group! And if a group promises you a good starting salary and a ton of patients, read this post about why a $300,000 associate salary may not be as good as it seems.

Dr. Williams also writes that solo docs must shoulder costs for EHR, may have difficulty contracting with Medicare advantage plans, have less leverage when contracting with payers, must be experts in MIPS and HR, and need to pay for expensive equipment themselves. Here’s my take:

EHR has cost me less than 2% of my gross revenues to date ($10,000 upfront and $300 per month for EyeMD, which has made my life easier, not more difficult). I researched it carefully and chose it myself. It’s a different story to have EHR without ophthalmology templates designed for primary MDs forced down your throat by your mega group.

Many of the older docs who complain about the “death of solo practice” run their office inefficiently and haven’t kept up with technology. I don’t dictate as my letters to referring doctors are generated from templates. My ICD10 codes and CPT codes are suggested by my EHR and automatically cross over to my practice management system for billing. Patient eligibility and financial responsibility are also verified electronically. All of my claims come back and are posted electronically, which saves a ton of time and labor.

If I hadn’t purchased a EHR I probably would’ve paid MORE in dictation and transcribing fees and for a billing company to manually enter charges into my practice management system.

In terms of accessing insurance plans, Medicare advantage plans are when a commercial plan “replaces” traditional medicare with lower patient out of pocket costs, with the trade off of limited networks, or access to doctors. The penetration of these plans varies depending on state. These insurance plans often negotiate with big groups to direct patients to their practice in exchange for lower reimbursement rates. Many times these plans contract exclusively with big groups, so sometimes smaller groups and solo doctors can be excluded. We recently published this editorial about our opinions on large groups with high overhead that take these plans.

But other times, Medicare advantage plans rely on the medical staff of a hospital network, IPA (independent physicians organization) or ACO (accountable care organization) for their physician networks, and you can certainly join staff for multiple hospital networks or IPAs. As a specialist you can join more than one ACO.

Yes, human resources and finding the right employees to work for you can be difficult. But my group practice did a terrible job at hiring and managing employees, as a solo doctor you can choose who you want to work with!

My mega group forced me go to lengthy mind numbing meetings about EHR meaningful use and quality measures that were a flagrant waste of my time. For my solo practice it was a pain to learn how to do it the first year, but once you invest the time to figure it out now it’s on autopilot.

Especially if you have a EHR that’s compatible with a clinical registry (for ophthalmology the IRIS registry), meeting MIPS is not difficult, and I spend less time than I did in my group practice worrying about these annoying requirements.

Finally, in terms of contracting with payers, some solo docs have been able to negotiate rates or drop poor performing or reimbursing payers. Keep in mind if you run your practice efficiently you will come out WAY ahead! And one of the good things about running a solo practice is that if you decide new equipment will benefit your practice you don’t need the approval of a board or to convince the rest of your group, you just write a check and it will come.

Most of us report a much lower overhead than in a bigger group. It’s true for many types of organizations, not just medical practices, the larger the group is, in general the less efficient it becomes. Things fall through the cracks, the buck is passed. Just look at the way the government is run. As a solo doc I monitor my employees’ performance, my insurance payments, and overhead control like a hawk.

There’s no incentive for me to do this to feed the kids of the big man or a paper pushing administrator. And in terms of the lifestyle, I have colleagues who help cover me for the few patients that need to be seen while I’m away. I took eight weeks of vacation last year, and have more flexibility with my schedule than if I had to request time off.

For those of us that choose to go solo, there’s nothing better than working for yourself and being able to reap the rewards or consequences of your decisions. I can certainly live with that.

4 thoughts on “Is solo practice still possible? The answer is yes!

  1. Great read. So in reference to office size, 5000 vs 1800, what is the average size office people in the group start out with fresh out of residency (no patients following). Thank you.

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    • At the very minimum 1100-1200 sq ft is recommended but even this is probably tight depending on your goals (better for a satellite office). If it were the best location and you found a good deal it’s doable.

      1400-1600 sq ft is certainly very reasonable, but small for those who want multiple techs. 1700-1900 is a good size to grow into. There are some people who have hired optometrists that have larger offices, over 2000 sq ft.

      If you want to work up patients yourself and have minimal staff, get a smaller office; if you plan to hire multiple techs get a larger one.

      Location is just as important as size. Try to get it right first time, moving is a pain although many members of our group including Ho Sun have had to move. Getting busy and growing out of your space is a GOOD problem to have!

      > > >

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      • i started by sharing space with an internist–we shared a waiting room, and it was just me, a receptionist, our EHR, one exam lane, and a very small procedure room, maybe 500 sq ft clinic space total…I had to a move to a 1400 sq-ft space 10 months later, as patient volume grew rapidly (thanks, in part, to sharing space with the internist, whose patients needed diabetic exams and cataract surgery). I followed an experienced solo ophthalmologist’s advice and started small, and it is a great way to begin…having to move was not a big hassle, just one day and a rented truck.

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    • This is Ho Sun. Generally, most people stay in the 1,500 to 2,000 sf range. Mine was a little under 1,700 on my first one, and 1,800 on my current space. I am near maximum capacity, and I don’t foresee needing any more space with my current style and goals of practice.

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