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Optho most accessible lucrative field in all of medicine easily
Less true lately, it’s gotten a lot more competitive. Anesthesia or gen surg are probably the main candidates for that.
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Retina: 600k-2mm
Plastics: 400k-1m+
General/cataract/glaucoma/refractive: 300k-1.2mm
Peds: 200-400k (RIP)
My reply is based on him saying this is the middle 1/3 of the income distribution. For retina, if you're getting upwards of 1.5-2mil, you're close to the top. There are some that make more than that but it's not common.
Plastics, these numbers sound right however again 1mil is very near the top unless you've ventured out into more than just the typical cosmetic offerings of an oculoplastic practice.
Gen/cat/refractive: these numbers actually sound pretty good to me but I would think a mid career doc wouldn't be lower than 400-500K unless they changed jobs recently.
Peds is probably pretty accurate unless you've made partner in a group.
Plastics: 400k-1m+
General/cataract/glaucoma/refractive: 300k-1.2mm
Peds: 200-400k (RIP)
My reply is based on him saying this is the middle 1/3 of the income distribution. For retina, if you're getting upwards of 1.5-2mil, you're close to the top. There are some that make more than that but it's not common.
Plastics, these numbers sound right however again 1mil is very near the top unless you've ventured out into more than just the typical cosmetic offerings of an oculoplastic practice.
Gen/cat/refractive: these numbers actually sound pretty good to me but I would think a mid career doc wouldn't be lower than 400-500K unless they changed jobs recently.
Peds is probably pretty accurate unless you've made partner in a group.
The people who I think are making near the top end of those ranges are in an older generation.
Ophtho has always been one of the most competitive specialties. 10-20 years ago it was still extremely competitive. Probably more so today, yes, but it was never as “accessible” as radiology and anesthesiology.
Rads/Anes make good money and they’re usually very do able.
The good thing though as above is that cataract surgeons, retina, plastics all pay well and you’ll never be without a job.
Rads/Anes make good money and they’re usually very do able.
The good thing though as above is that cataract surgeons, retina, plastics all pay well and you’ll never be without a job.
Can speak to retina specifically. A salary of 2 million isn't impossible, but very tough. You'd be quite limited in terms of geography (forget living in a big coastal city) and you would have to find a non-PE, retina-only private practice group. These spots are competitive and typically only graduates from top fellowships are those that have a shot. Even after you land the coveted job, you'd have to build up to partnership (anywhere from 2-5 years) and in the meantime, pray that your practice doesn't sell to PE in the interim. Most of all, you'll have to be comfortable seeing a very large number of patients per day in clinic (80-100+ depending on state and practice set-up).
You can still expect to make around 7 figures quite reasonably if you work hard and make good decisions. That being said, don't choose retina, or any other medical field or subspecialty, for the money. The landscape is always changing and today's situation may not apply tomorrow. Even if retina paid peds-level salaries, I would still choose it all over again. The opportunity to help those at most risk of impending vision loss, with surgery that feels like a mix between laparoscopic surgery and neurosurgery, with therapies we can even inject in the clinic that cure diseases previously believed to be a one-way ticket to blindness, in a field where you are surrounded by the most brilliant minds.. what a truly special career we are blessed to be a part of.
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As someone who's applying for surgical retina next year and probably won't land a top fellowship, I was hoping to work at a non-PE + retina-only private practices in the future. Are you saying these are rare entities nowadays?
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I wouldn’t call them rare, but the market is definitely shifting. A large number of practices sold within the last few years. A couple in my region sold within the last 6 months. This happened years ago and the needle swung back, so I wouldn’t get too worked up about it. As much as I hate PE, not all of those jobs are bad, either.
I agree with antiVEGF, we have a really cool specialty. Don’t jump in so you can make $2M/yr (you’re not going to). Get the best training you can and vet the practices you’re interested in. The best ones are where your mentor or friend knows somebody and can get you the real scoop on a practice. Next best is the ASRS or AAO job board. If non-PE is a big deal for you (I would say it should be), ask up front so hopefully the rug doesn’t get pulled out from under you, which I’ve seen more times than I can count.
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You need to explore positions outside of metros and not confine your search to only a couple of areas. There are truly great opportunities if you're willing to go to them. There are also practices that are willing to write PE sale protection clauses in their contracts at this time but that's not something you can really search for, you just have to have the discussion and find out.
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I'm not a retina specialist but most of those non major metropolitan area retina only private practices do not care if you did a top retina fellowship. There is a massive shortage of retina specialists out there and they'll take any reasonable person who wants/willing to be there. On the other hand, those prestigious (formerly) megagroups in the major metro areas that only take people from top fellowships...They're all PE.
Not if you cannot spell "Ophtho" correctly lol
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100% agree with this. My group does NOT care if you went to Bascom Palmer, or Wills, or wherever. We want you to have good surgical training, have good recommendations from your mentors saying you are ethical and work hard, and we want you to have a willingness to build a practice so you stay long term and become an equal partner
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For me personally, and many other retina docs, underestimate……by a lot
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MGMA data is an aggregate of physician compensation under an RVU model. It should in no way be used to compare with private practice/production models. It can be used to compare Kaiser-like and hospital-based positions - any using an RVU model.
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How do you feel the PE practices compare? You know the behind the scenes of way more positions than any of us.
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As far as I know, all PE practices (I don't work with all of them but do hear about all of them) are on production models so MGMA data wouldn't be helpful for those practices. The PE practices will come closer to MGMA data than private groups but in many cases won't meet it. Here are the base salaries I generally see and hear about across the country for physician-owned private practices:
Comprehensive: $200,000-$250,000
• Cornea: $225,000-$275,000
• Glaucoma: $250,000-$325,000
• Oculoplastic: $200,000-$280,000
• Pediatric: $175,000-$250,000
• Medical Retina: $275,000-$350,000
• Surgical Retina: $300,000-$400,000
There are plenty of outliers to this and the number is very dependent on location and type of practice. For a private practice, I would really just check you're in this general range and dive deeper into the partnership buy-in, how busy you can get, and the production bonus. $50K extra in your first year of practice will be negligible in 5-10 years if you become a partner. I don't say that meaning that $50K isn't a lot of money, it is, but in the long term not so much. The base is more to say "ok, I'm not getting used". If you're evaluating a PE practice, digging into the base salary will be more important because the traditional partnership is not available down the road. I would say a PE offer is likely to be anywhere from 10-30% higher than a private practice but take this with a huge grain of salt because there are many factors that adjust here too. Just to note, there are some PE groups/PE-like groups who are getting more creative with buy-ins and partnerships, generally being more beneficial to the doc.
Here is a helpful tool for comparing base salaries and bonuses on a production model:
Compensation math comparison share
Sheet1 Base salary,multiplier for bonus threshold,Bonus threshold,Bonus percentage,Base salary,multiplier for bonus threshold,Bonus threshold,Bonus percentage $300,000.00,0,$1,000,000.00,0.32,$350,000.00,3,$1,050,000.00,0.3 Production in net collections,Bonus ,Total compensation,Production in ne...
One of the core issues with the MGMA data besides it being only RVU-based models is the low number of data points/docs that report income.
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Matt, do you know the rationale behind why PE groups would pay 10-30% higher than private practice? Are they generally better run/organized practices and so one would be able to produce more? Are the so called partner track practices assessing sweat equity? Given the long standing mistrust of partnership tracks, would it be advisable for practices to instead of assessing sweat equity just ask for the equity at buy in? Are there any any true advantages to practices charging up front sweat equity vs sweat equity after buy in ($ collections for x years) or straight up cash? (other than the potential to not have to actually give up any equity)
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I’m not as well versed on this as Matt but I’m betting the reason for the PE being 10-30% higher is two fold:
1. Might be hard to recruit to PE groups so a higher starting salary is enticing.
2. The amount of money you can make, as a partner, is noticeably higher in the private world vs PE so PE tries to start you off higher knowing you might not ever be A “true partner” and there’s a ceiling to your earnings with PE
And for my own education, help me understand what you define as sweat equity? I don’t want to misunderstand you so I figured it’s best to ask
1. Might be hard to recruit to PE groups so a higher starting salary is enticing.
2. The amount of money you can make, as a partner, is noticeably higher in the private world vs PE so PE tries to start you off higher knowing you might not ever be A “true partner” and there’s a ceiling to your earnings with PE
And for my own education, help me understand what you define as sweat equity? I don’t want to misunderstand you so I figured it’s best to ask
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I'm not sure of the specific terms either but some private practices consider taking a lower salary (lower than a hospital or PE employed job, 10-30% as described here so that you can make more later) as part of paying your dues. I can see both sides. Why not assess the dues after the practice and the doc have had a chance to evaluate each other for a few years at market employee salary...via cash and Partner salary reduction at buy in? Are there any true advantages to the former (taxes?) other than making more money (by paying a below market salary) off of potential partners who never become partners?
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PE groups are generally paying more to be competitive with private groups. The traditional partnership is something they can't offer so they must offer something else. Bonus structures are also more rigid. Most private groups have a pretty rigid bonus structure as well though at this point.
PE groups will generally get your patient volumes built up quicker because they either own the referral network or have market capture to the point referring groups almost have to send them patients. This should produce more surgery so you can then produce more in general. Really the upside here is in the beginning. After a couple of years, I see little difference in how busy a PE doc and a private doc are.
There are two PE-like practices (funded by an outside investor who is not a PE group) I work with who will allow for immediate buy in for experienced docs in some cases. I think for smaller groups this is risky. 1 of 50 is much less than 1 of 4-6 (private practice) and there should be some "dating" period. I would point this is for both parties involved. I know the goal is to become a partner but I've worked with a few docs who got to know a partner within a group more and found out they don't want to even work with them anymore. I think a way to bridge this gap is for partners and associates to lay out some metrics they're looking for an associate to hit to be considered for partner. These don't have to be guarantees of partnership but it's a form of over-communication so everyone's expectations are set where they should be going into the arrangement.
As for the upfront sweat equity thing, my blunt assessment is this tends to be generational. I tend to find younger/middle aged partners less interested in this form of "buy-in". However, when I think about this concept, to me it's just wanting to see that someone is willing to make sacrifices for what they want in life. To give a small example in our company, we have support associates who help us daily. These support associates will eventually become recruiters if they stay long enough and have the right kind of mindset. Sometimes I have to take calls on the weekend or late at night (8pm, 9pm, 10pm during the week, calls can be an hour long) and I did this A LOT in my first few years. I always share when I have these with the support associates to see who is put off by it. I don't have to do them as much anymore but it's a way for me to see who to put more mentorship effort into. I know this isn't quite the same as partnership but thought it ran in that same lane for this example.
Retina is already doing great money-wise. But this is what I think of Retina if they are eventually able to inject both wet and dry ARMD one day. Dang near everyone walking into their clinic may need an injection.
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Eh CMS will probably slash the reimbursement by half as a result.
Been a while since I posted
I know 2 groups where partners make >2 million. One is multispecialty, everyone in the population has AMD, everyone is getting injected, retina in that group gets all the injection/drug money. No sharing. The other group is retina only. Their overhead is 25%, some years lower. This is simply a consequence of where they are located and cannot be reproduced anywyere. There are probably less than 15 of those types of groups (maybe even less) still remaining for retina. The vast majority have been eaten by PE, so its not a good target...
MGMA numbers are based on RVU numbers -> that is correct. But in general I would say the middle of retina reimbursement is probably 600K to 1 mill. I'm early in the retina career, so please feel free to correct me, but in general if you make > 1 mill, you are doing well for retina. If you are > 1.5 mill you are doing very well. If you are > 2 mill, you have very unique circumstances. Over 2.5mill, probably expect a visit by CMS for fraud... I have a really hard time getting a sense of PE "partner" numbers and you have to take it with a grain of salt because the payouts aren't factored in, but i get the sense the ceiling in PE for regular Jo schmo retina-guy in 800-900K. The selling point is no buy-in, which for some reason many people in my generation seem to think is a plus [large shudder/shrug].
I know 2 groups where partners make >2 million. One is multispecialty, everyone in the population has AMD, everyone is getting injected, retina in that group gets all the injection/drug money. No sharing. The other group is retina only. Their overhead is 25%, some years lower. This is simply a consequence of where they are located and cannot be reproduced anywyere. There are probably less than 15 of those types of groups (maybe even less) still remaining for retina. The vast majority have been eaten by PE, so its not a good target...
MGMA numbers are based on RVU numbers -> that is correct. But in general I would say the middle of retina reimbursement is probably 600K to 1 mill. I'm early in the retina career, so please feel free to correct me, but in general if you make > 1 mill, you are doing well for retina. If you are > 1.5 mill you are doing very well. If you are > 2 mill, you have very unique circumstances. Over 2.5mill, probably expect a visit by CMS for fraud... I have a really hard time getting a sense of PE "partner" numbers and you have to take it with a grain of salt because the payouts aren't factored in, but i get the sense the ceiling in PE for regular Jo schmo retina-guy in 800-900K. The selling point is no buy-in, which for some reason many people in my generation seem to think is a plus [large shudder/shrug].
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I agree with pretty much everything @linevasel said. If you mean the middle of retina as 25th-75th percentile of partners, I’ll buy it potentially. Those 2 groups absolutely are outliers, and I’ll take their practice manager’s contact info if they can keep overhead to 25% or below (for those not running a practice, that’s crazy low expenses). I do worry when I hear $2M per partner with almost nothing but AMD that it’s old school docs injecting disciform scars with Lucentis every 4 weeks. More likely that they’re just killing it with real estate and ASC cash.
I also don’t get the love for PE jobs these days. Buy-ins suck and partnership isn’t a guarantee, but you’ve been betting on yourself for at least 10 years of medical training after college if you do retina. Why not bet again for better pay and control of a practice instead of working for the corporate overlords?
I also don’t get the love for PE jobs these days. Buy-ins suck and partnership isn’t a guarantee, but you’ve been betting on yourself for at least 10 years of medical training after college if you do retina. Why not bet again for better pay and control of a practice instead of working for the corporate overlords?
In fairness, multispecialty group sees a good mix, but population is white and old.... so lot of legit wet AMD. Real Estate, 7 room Eye-only (multispecialty group only) ASC, Bustling Research Arm, and good leadership are all present. Little Retina competition in the state.
General ophthalmology is still a great career. Good money in cataracts, Premium IOL’s and ASC’s. No fellowship needed. And it’s only one year transitional or similar internship and then only 3 years of ophtho residency. Best deal in medicine, time wise…
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One factor that PE may be loved by some is not only no management needed and high early salary, it may allow those who want to do side gigs outside of medicine.
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this doesn't make sense. most PE jobs are slamming your schedule with patients... when is the side gig game happening?
It amazes me how how physicians will complain endlessly about cuts from medicare and insurance companies (which are no doubt an important issue) but then willingly take a far more massive cut (probably close to 50%) from their future earnings/partner income and control over their work-lives by joining a group that's owned by private equity.
I doubt many patients will want to get injections for geographic atrophy. It barely slows down the progression. They won't notice improvement. The patient is still going to go blind. And it increases the risk of CNV. On the ideal patient, how many days of vision are saved by each injection? How many injections will they need to save a month of vision? Will it be 30 injection over several years to ultimately save 30 days of central vision? (I'm making these numbers up because the trials don't tell us the answer or show us an actual functional improvement in the patient's lives). Any what happens when the patient has to stop the injections, which will eventually likely happen for many reasons-- it is very common for many chronic diseases to progress rapidly to where they would have been without treatment once the treatment is stopped or paused. These are elderly patients who already spend all their time in doctor's offices for many other problems, at some point they need to just stop getting endless medical treatment and enjoy their remaining life.
As a retina specialist, I'll have to mention the option to patients. But when they ask me if I would get injections for GA myself or recommend it to a family member, my answer will honestly be a hard No.
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While I agree with this, we don't truly know how patients feel about this. Those who have had progressive GA will likely do anything to stop the progression because the know the terror of slow vision loss. Those who haven't, it will def be hard to buy into
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Are you talking about young docs or older docs? Young docs often feel they don't have much choice as they're choosing between PE practice, hospital owned, or revolving door physician owned practice. The ones complaining then selling their practice are cashing out. Emphasis on cash.
Don’t forget the old-fashioned way—starting a practice on your own. But I certainly understand it’s a tough road when you already have massive student loans and then have to take more debt to open your own practice.
This is a fair point. Unfortunately older docs are controlling the narrative.
I find all the pro/con debates for joining PE owned practices ridiculous. Why doesn’t AAO ever have a debate on pro/con of Medicare slashing Ophtho reimbursement? It should be no less absurd. But unfortunately much of Ophtho
leadership already has a stake in PE.
The messaging from our professional organizations should be 1) a stark warning to graduating residents/fellows on the downsides of PE, 2) advice on how to start your own practice, 3) lobbying to stop PE’s take-over and to end legal enforcement of physician non-competes.
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This will never happen unfortunately. The senior leadership that have sold to PE have a significant stake vested in shares. Retrieving that is dependant on a good second sale, which is dependant on recruiting younger docs to increase pt volume, practice collections and show future stability. They've not only sold away younger docs' futures, but they're hitting double hard by painting a false picture out of pure self-interest.
Any other field, this degree of conflict of interest would be illegal. Yay medicine.
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Not so bad in ophtho yet. You guys seen what's been going on in derm? Articles criticizing PE retracted.
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This was 2018 wow..
In ophtho the difference I think is the private and academic world's are so intermingled. Especially in retina with the privademic groups. I wouldn't expect to really see articles like this given how they're all mostly friends . It kind of amazing how aao's tone completely changed when the leadership figures sold. Money talks
Not exactly. The academic world (other than some retina) is not intermingled with PE. Most universities and training programs are very skeptical of PE. What is unusual in ophthalmology is that many of the great advances in ophthalmology are NOT from the universities/academic centers, but from private practice doctors (such as Phako, MIGs). And we revere the big cutters. And it’s those guys who are in bed with PE. Big names like Lindstrom, Osher, etc.
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Yes and no. The point is that academics in ophtho would never write a PE hit piece. There's a reason we dont have a writeup like this in ophtho. The great advances haven't necessarily been on the private side. Industry has just had more access to patients on the private side due to sheer volume and lack of red tape to perform clinical trials and take drugs etc. To market. And many times the academic centers and private practices both serve as centers for trials. Most bigwig academics are industry consultants.
At least on the retina side, the leadership, many of the fellowships are private dominant. The academic leadership is very close to the private leadership. No one is going to actively speak up against their buddies/training mates that they work with, are on adboards with etc. The lines are incredibly blurred at this point.
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I know I'm quibbling over this point but I disagree about the advances and the private side - a lot of the medical and surgical knowledge in the field comes from the private side (at least for retina). Some of the more well known academic ones already have a foot into the private side and eventually go into the private side completely. The younger rising stars are also getting pushed more and more into the private side too. The clinical trials, pushing of surgical edges, pivotal academic papers, etc, are all coming from these private/now PE groups. In fact the PE groups are the ones that will likely help with clinical trials because when run well, pharma clinical trials reimburse ridiculously well.
But yes I agree about PE overall - it's a great way to mortgage your future earnings. Reading the news, second sales are starting to happen soon because investors are jittery about rising interest rates and they want their cash soon. One of my colleagues has told me that if rates his 6-7%, PE will not be sustainable. In addition to the horror stories I hear from my colleagues that got screwed over by PE, I'm already seeing the warning flags from other fields dominated by PE (ER, anesthesia), and I can see PE firms tightening the screws enough to start causing bad outcomes. All of the "leaders" in our field don't want to speak out against it because many of them are in on the payouts in their PE firms. The reality is a lot of us physicians are "dumb money" - not only are we not educated enough to make good financial decisions, we also seem to enjoy shooting ourselves in the foot long term (maybe bragging about doing a phaco in 5-10 minutes isn't something you should tell CMS).
For disclosure, I am in academia, almost 7 years in. I personally would not be surprised to hybrid cooperation between private/PE and academia in the next 5-10 years, the lines are already starting to blur right now.
I’ve heard some people are getting more actual dollars on the second bite than the first, although I would imagine that higher interest rates are lowering buyout multiples.
Two tweets by Glaucomflecken that I agree with:
“Every physician who sells their practice to private equity is choosing to make health care worse for everybody. I hope the money helps you sleep at night, because you have made life worse for every single patient and employee walking into your PE Daddy’s practice.”
“Last thing I’ll say is that doctors who sign with PE are not bad people, some of them are my friends. But they have made a short term decision which has irrevocably harmed the practice of medicine in long run.”
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Some of the money amounts I have heard about (for the physicians), with the second round, are mind boggling.
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The replies to his tweets are amazing. Very easy to see who is gearing up to sell lol
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This is when things are about to get interesting and dangerous. The second PE will most likely hold the practice for a while, especially in this economy.
The opportunistic concern with keeping their physicians relatively happy will be nonexistant with the second PE. Not looking forward to watching the train wreck
Again those partners who get the cash upfront will be fine. Most can quit or retire. It’s the younger (non-partner at time of buyout) docs who will have to deal with things falling apart.
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Most won't quit or retire. They'll probably get even less in upfront cash on the second sale and more shares. it's the eternal carrot.
Other than location, not sure what will keep the younger docs working at these groups at that point.
I disagree. Those who sell to PE in the first place are self-selected for those who are usually near the end of their careers and want the cash.