Worthwhile Partnership

[percyeye]

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I'm an Optometrist in the Midwest and we don't have any local Ophthalmology so for years we have been sending patients an hour or more in every direction depending on the week and needs to get cataract consults and surgery done. Like most practices our toric, MF, Light adjustable lenses, are dramatically increasing in usage and we also have a healthy amount of Glaucoma that adds on extra like migs etc.

Would there ever be enough volume that it would worthwhile for a surgeon to partner with our practice where they would come in 2 days a month and knockout all the cataracts, yags, SLTs etc? If we keep expanding like we are planning we'd have a large population base where we have to scatter them all over for service and we'd prefer to localize it. Would 40? 50? or more cataracts a month provide enough interest for someone to consider it?

I sometimes see on here newer grads in So Cal complaining they don't have enough volume or only will do a 200-300 cataracts a year. Would it be worthwhile to travel and knockout 25-30 cataracts in a morning that are heavy with Torics, MFs etc?

 

[mjohnsonets]

I'm an Optometrist in the Midwest and we don't have any local Ophthalmology so for years we have been sending patients an hour or more in every direction depending on the week and needs to get cataract consults and surgery done. Like most practices our toric, MF, Light adjustable lenses, are dramatically increasing in usage and we also have a healthy amount of Glaucoma that adds on extra like migs etc.

Would there ever be enough volume that it would worthwhile for a surgeon to partner with our practice where they would come in 2 days a month and knockout all the cataracts, yags, SLTs etc? If we keep expanding like we are planning we'd have a large population base where we have to scatter them all over for service and we'd prefer to localize it. Would 40? 50? or more cataracts a month provide enough interest for someone to consider it?

I sometimes see on here newer grads in So Cal complaining they don't have enough volume or only will do a 200-300 cataracts a year. Would it be worthwhile to travel and knockout 25-30 cataracts in a morning that are heavy with Torics, MFs etc?

If you could provide 50 cataracts per month and get that knocked out in 2 half surgical days with a strong conversion rate for cash pay lenses as you suggest. I'd think there is someone who would do this for you. Is there an ASC nearby with a scope and phaco though?

You could potentially get a hospital nearby to buy the equipment but doing that many cases in a hospital OR in a half day I've not heard of. They would also need to release the ophtho of call responsibility. There are companies with roll on roll off services too like Ophthalmic Surgical Equipment and Services

I'll send you a PM.

 

[percyeye]

If you could provide 50 cataracts per month and get that knocked out in 2 half surgical days with a strong conversion rate for cash pay lenses as you suggest. I'd think there is someone who would do this for you. Is there an ASC nearby with a scope and phaco though?

You could potentially get a hospital nearby to buy the equipment but doing that many cases in a hospital OR in a half day I've not heard of. They would also need to release the ophtho of call responsibility. There are companies with roll on roll off services too like Ophthalmic Surgical Equipment and Services

I'll send you a PM.

Our state is very protective and you don't see many ASCs. Our local hospital has a scope and phaco. There is already a surgeon who comes 2 days a month that we are not currently partnered with that is already doing 20-25 in half day every month, but like I said we have many patients that are scattered and don't come here and we'd focus on bringing most into one location. We also plan on expanding and gathering a larger geographical area that would also filter in volume.

This also doesn't include a large amount of Blephs that we refer out that don't get done locally, so they are going 1 to 2 hours away which it would be nice to keep around here for the patient's sake. It seems less and less are doing cataract and blephs, but I may be mistaken by that. We have the space and would invest in equipment for all of the YAGs, SLTs we refer out as well.

 

[dantt]

Tough situation. Presumably you don't want to refer to the traveling surgeon as they are working out of one of your competitors offices?

 

[TheLesPaul]

Our state is very protective and you don't see many ASCs. Our local hospital has a scope and phaco. There is already a surgeon who comes 2 days a month that we are not currently partnered with that is already doing 20-25 in half day every month, but like I said we have many patients that are scattered and don't come here and we'd focus on bringing most into one location. We also plan on expanding and gathering a larger geographical area that would also filter in volume.

This also doesn't include a large amount of Blephs that we refer out that don't get done locally, so they are going 1 to 2 hours away which it would be nice to keep around here for the patient's sake. It seems less and less are doing cataract and blephs, but I may be mistaken by that. We have the space and would invest in equipment for all of the YAGs, SLTs we refer out as well.

yeah if you have a guy who operates at your local hospital and has a set up infrastructure, it seems like the easiest solution for your patients is to refer to him, rather than referring an hour out. unless he's a bad surgeon, it seems like your decision not to refer is political?

 

[DrZeke]

yeah if you have a guy who operates at your local hospital and has a set up infrastructure, it seems like the easiest solution for your patients is to refer to him, rather than referring an hour out. unless he's a bad surgeon, it seems like your decision not to refer is political?

shocking.

 

[RetinaDude]

Hate to say it but another surgeon already coming in to this small town to operate would be a red flag for me. I’m retina and I would be very unlikely to want to set up shop with another OD’s office if there was already a retina surgeon coming into the same small town. I would be concerned about dedicating my resources to driving to your town, getting everything up and running with the local hospital, and then something happening to sour the relationship with you or the hospital. And then this other doc would have a ready supply of patients, possibly. I know this scenario can happen anytime you open a satellite office anywhere but I have seen way too many optom/ophth co-management situations turn awry over the years for ridiculously petty reasons (on either side)

 

[Dusn]

Reading this scenario, a big concern that I’d have if I were considering this is whether I’d face pressure to upsell or do unnecessary procedures, or be pressured to operate on poor candidates. If you could reassure any interested parties that that will never happen, it might help them make the decision.

 

[eyeeye_captain]

I agree with all of the prior concerns. A couple other things seem a little off.

1000 cataracts a year for a small town sounds high to me unless that spread out catchment area gets to the hour mark. Even then, why aren’t people getting their pre-op assessments closer to where they will have surgery if they’re really going back the opposite way they came? Is there some reason that the areas every direction for an hour are desirable enough for surgeons but only one is willing to do 2 days a month there?

I’ve spent enough time in my life in rural America to know that when Walmart is an hour away, driving isn’t too much of a concern for the locals. Similarly, most Meemaws and Papaws aren’t lining up to pay for premium lenses or blephs.

I’m skeptical that a rural hospital knocks out 20+ cataracts in a half day, but I’ve been wrong before. The current traveler may have an exclusivity clause with the hospital, or just raise enough hell to kill credentialing, which would make this all moot.

If someone does bite, you folks better make sure that everyone is beyond cool with the financial arrangements and that there is a real plan for space/staffing where toes will not be stepped on. The ugliest partnership breakups I’ve seen/heard of with people working in someone else’s office are generally from one or both scenarios.

 

[percyeye]

I agree with all of the prior concerns. A couple other things seem a little off.

1000 cataracts a year for a small town sounds high to me unless that spread out catchment area gets to the hour mark. Even then, why aren’t people getting their pre-op assessments closer to where they will have surgery if they’re really going back the opposite way they came? Is there some reason that the areas every direction for an hour are desirable enough for surgeons but only one is willing to do 2 days a month there?

I’ve spent enough time in my life in rural America to know that when Walmart is an hour away, driving isn’t too much of a concern for the locals. Similarly, most Meemaws and Papaws aren’t lining up to pay for premium lenses or blephs.

I’m skeptical that a rural hospital knocks out 20+ cataracts in a half day, but I’ve been wrong before. The current traveler may have an exclusivity clause with the hospital, or just raise enough hell to kill credentialing, which would make this all moot.

If someone does bite, you folks better make sure that everyone is beyond cool with the financial arrangements and that there is a real plan for space/staffing where toes will not be stepped on. The ugliest partnership breakups I’ve seen/heard of with people working in someone else’s office are generally from one or both scenarios.

For a small town, performing 1,000 cataracts annually would be unusually high, and I don’t recall ever claiming that figure. However, our catchment area spans 3–4 counties, and small towns are typically home to many elderly residents, which naturally leads to a higher prevalence of cataracts. Currently, patients are traveling elsewhere for pre-operative testing, a trip that can require over two hours of driving round-trip. While most people are fine with driving, it becomes a significant burden for those over 75. Many prefer to stay local because of the strong patient relationships we’ve built. We care for the majority of residents in this area, while the surgeon is usually someone they meet for just 10 minutes. Patients don’t have a strong preference for one surgeon over another, which makes staying local more appealing.

This is why I find it ironic to see ophthalmologists grinding away in cities with low surgical volume, while rural areas like ours—essentially “ophthalmology deserts”—could easily offer them more surgery than they’d know what to do with.

In fact, it’s not uncommon for small hospitals in this region to perform over 20 cataracts in a single morning. I can’t remember the last time our hospital had fewer than 20 cataracts scheduled on a surgery day.

To be clear, I have no ill will toward the groups or surgeons to whom we currently refer patients. However, offering cataract surgeries locally would benefit both our patients and our practice from a business perspective. The trend is clear: many newer ophthalmology graduates are less interested in owning practices (though this isn’t universal). High surgical volume could make hiring a surgeon more feasible than continuing to refer out so many cases. And what would be the difference between one of the Ophthalmology groups hiring an Associate and sending them our way 2 times a month, versus us just hiring one? It seems many surgeons just want to have full surgery days and not think about the back side of the business, which is fine but then people will step in who don't mind the business aspect such as PE or corporate.

Ideally, we’d partner with someone interested in joining and staying in the community, but recruiting to rural areas is a challenge. Even “cities” located 1–2 hours from here struggle to attract ophthalmologists, making it unlikely someone would come to this area without a compelling reason.

 

[TheLesPaul]

For a small town, performing 1,000 cataracts annually would be unusually high, and I don’t recall ever claiming that figure. However, our catchment area spans 3–4 counties, and small towns are typically home to many elderly residents, which naturally leads to a higher prevalence of cataracts. Currently, patients are traveling elsewhere for pre-operative testing, a trip that can require over two hours of driving round-trip. While most people are fine with driving, it becomes a significant burden for those over 75. Many prefer to stay local because of the strong patient relationships we’ve built. We care for the majority of residents in this area, while the surgeon is usually someone they meet for just 10 minutes. Patients don’t have a strong preference for one surgeon over another, which makes staying local more appealing.

This is why I find it ironic to see ophthalmologists grinding away in cities with low surgical volume, while rural areas like ours—essentially “ophthalmology deserts”—could easily offer them more surgery than they’d know what to do with.

In fact, it’s not uncommon for small hospitals in this region to perform over 20 cataracts in a single morning. I can’t remember the last time our hospital had fewer than 20 cataracts scheduled on a surgery day.

To be clear, I have no ill will toward the groups or surgeons to whom we currently refer patients. However, offering cataract surgeries locally would benefit both our patients and our practice from a business perspective. The trend is clear: many newer ophthalmology graduates are less interested in owning practices (though this isn’t universal). High surgical volume could make hiring a surgeon more feasible than continuing to refer out so many cases. And what would be the difference between one of the Ophthalmology groups hiring an Associate and sending them our way 2 times a month, versus us just hiring one? It seems many surgeons just want to have full surgery days and not think about the back side of the business, which is fine but then people will step in who don't mind the business aspect such as PE or corporate.

Ideally, we’d partner with someone interested in joining and staying in the community, but recruiting to rural areas is a challenge. Even “cities” located 1–2 hours from here struggle to attract ophthalmologists, making it unlikely someone would come to this area without a compelling reason.

you still haven't answered -- why don't you send to the guy who already comes to your town?

 

[percyeye]

you still haven't answered -- why don't you send to the guy who already comes to your town?

We already do, depending on where the patient lives or what they need. Probably 40-50% to them, and then the other 50% is split between 2 other places also an hour away.

 

[dantt]

"Ideally, we’d partner with someone interested in joining and staying in the community,"

I'm confused. Are you wanting somebody to satellite in your town (which somebody already does) or hire somebody full time? Sending it to the doc who is already satelliting in your town would not be "sending it out." I've never heard of practices operating a satellite hospital but bringing the patients to their practice for preop testing. It's always the other way around. Patients get seen/testing locally and drive in to have surgery.

It's illegal in most states for an optometrist or any other corporation to hire an MD/DO.

 

[percyeye]

"Ideally, we’d partner with someone interested in joining and staying in the community,"

I'm confused. Are you wanting somebody to satellite in your town (which somebody already does) or hire somebody full time? Sending it to the doc who is already satelliting in your town would not be "sending it out." I've never heard of practices operating a satellite hospital but bringing the patients to their practice for preop testing. It's always the other way around. Patients get seen/testing locally and drive in to have surgery.

It's illegal in most states for an optometrist or any other corporation to hire an MD/DO.

Sure if they'd want to stay, but chances are slim.

I don't think we'd be able to hire someone full time, but would nice to hire someone to treat the patients in our geographic area. Again I have nothing against the surgeon who satellites into our hospital to do surgery, simply a business decision on volume. Also they are are on the older side, and who knows how much longer they will be coming into town at all.

It is legal for an OD to hire a MD/OD in our state. There is one that is currently doing this not too far away and I have chatted with them about this setup. As a matter of fact I've talked with a few ODs who already do this around the country, that is how I got the idea. Again you need the volume to get someone interested. I guess what would be difference between our local hospital hiring an Ophthalmologist vs our group? The hospitals are just happy to have the surgeries. I'd build an ASC if I could, but state laws are very restrictive.

As much as it will be hated, the tides are turning for the worse in business ownership amongst the medical community. Even here our hospital system has bought out every surgery, ortho group, specialty group in the area. I'm a strong advocate for owning your practice and controlling your own fate. Talking to these other ODs, if you offer a decent deal, good pay and setup, they haven't had much trouble hiring a MD/DO.

 

[eyeeye_captain]

The 1000 cataracts came from you stating an average of ~45 cataracts a month while not “partnering” with the current surgeon. The assumption was that you could double that volume since you were promising (90 x 12 = 1080), but it turns out you actually do have a relationship. Even if you just handed over your last 50% (45 x 150% x 12 months), you’re at 800 assuming the other referring volume stays the same.

“However, offering cataract surgeries locally would benefit both our patients and our practice from a business perspective. The trend is clear: many newer ophthalmology graduates are less interested in owning practices (though this isn’t universal).”

I was wondering when the quiet part (bolded) would be said aloud. I believe you when you talk about serving your community, but there had to be some money involved. You’re running a business and you want to get paid - makes total sense and there’s no shame in that. I suspect you would like more favorable terms than the current surgeon is giving you for comanagent, which again is totally fine. If you’re already having trouble recruiting to the area, I wouldn’t expect a hypothetical new person to give you much more.

The joining PE or Kaiser or hospital thing “because they don’t want to run a practice” thing doesn’t really hold water for me. Kaiser at least has the benefits, but what does it also have? Location. Most of the people taking the employed jobs do it to be where they want to live, and with the growing number of purchased practices, sometimes those are all you can find. Of the people I’ve trained with and interviewed, most are somewhere with family or training connections. I know a few who went rural, but that was for family or a love of some outdoors stuff that it doesn’t sound like your area has. None of those folks were gung ho to be employed (although Kaiser can be an exception).

That hospital is never going to be able to hire. We don’t utilize most other services like imaging/labs/PT, so we’re a money loser. The offers that get emailed out are bad. Average pay at best in places most people don’t want to go. The worst one I saw recently was rural Georgia requiring trauma call every 2 weeks. Cooperstown, NY has been sending emails for like a decade. Inefficient setups with corporate politics are no good.

You hiring would entail the red flags discussed previously plus some other bits. Employment of course. Rural old folks sounds like a payor mix of mostly Medicare and Advantage plans. Decent chance the younger folks are going to be Medicaid. I’m still skeptical that the Granny who is having trouble driving a decent distance is shelling out for an EDOF lens or getting a bleph. Optometry practices generally run at a higher overhead than ophthalmology, so depending on who subsidizes who, there will potentially be tough money conversations.

If it sounds like I’m bagging on your area, I promise I’m not. We all see care deserts. There is no easy option to fix them because there’s only so many people willing to live or work rurally. If you can fill a gap, great. The potential job sounds like a tough sell outside of good cataract volume though.

 

[TheLesPaul]

I would also say -- there's an ego disconnect in having an ophthalmologist hired by an optometrist. I'm not saying that's right or wrong. I'm just calling it how I see it. It might be hard to convince someone who has an MD to be hired by someone who does not, unless you are offering something they cannot live without (either location, or piles of money).

 

[rotarman]

Let’s not mince words.

You have someone coming and operating locally. The best thing for your patients is to send to them.

You want a piece of the surgical pie, but there’s those pesky anti kickback laws. So your plan is to hire an ophthalmologist to capture more revenue. You’re going to get the bottom of the barrel to come work for an OD in BFE, if you find anybody at all. You can maybe find an international residency graduate or someone who burnt out elsewhere, but don’t pretend like that’s the best thing for your patients. Also don’t expect to send your disaster Friday PM NVG patient with an IOP of 48 to the local group who you’re now cutting out of phacos and lasers. They’re probably gonna tell you to call up the nearest university.

 

[percyeye]

Let’s not mince words.

You have someone coming and operating locally. The best thing for your patients is to send to them.

You want a piece of the surgical pie, but there’s those pesky anti kickback laws. So your plan is to hire an ophthalmologist to capture more revenue. You’re going to get the bottom of the barrel to come work for an OD in BFE, if you find anybody at all. You can maybe find an international residency graduate or someone who burnt out elsewhere, but don’t pretend like that’s the best thing for your patients. Also don’t expect to send your disaster Friday PM NVG patient with an IOP of 48 to the local group who you’re now cutting out of phacos and lasers. They’re probably gonna tell you to call up the nearest university.

This is already happening, probably more than you would think. There might be different factors for this changing, one being lower surgical volume in highly saturated areas, and the emergence of PE. Have you seen the AOA job board lately? If the majority of job ads aren't PE it is probably close, and frankly is quite embarrassing. Not saying Optometry is any better off. The moral high ground is slowly eroding with every practice that sells to Goldman Sachs or whatever pension fund buys them.

Here in I guess what you would call it BFE, other than cataract surgery and migs/stents everything has to be sent to larger areas/academic centers. Private practices seeing a NVG patient w/ IOP of 48 on a Friday? Didn't know that was a thing private practice still would see, at least not around here. Finding someone willing to do any sort of glaucoma procedure is a chore. Bad ulcer going south? Only academic or larger areas will see them. So not being able to send those type of things would be no different than it is now.

As of now we are going to keep going as is. But if/when the group around here sells to PE or they stop coming to town every so often then we will be out looking.

 

[percyeye]

I guess I will throw this out there as a hypothetical and have someone stay vs just coming in every 2 weeks, but does this type of practice appeal at all to any surgeons or is it pretty much city or bust nowadays? Where there are multi-county clinics filtering in surgeries and procedures, where someone could probably make a great living working 3 days a week with minimal call and minimal clinic time? Also have options of purchasing in real estate etc. A true comprehensive Doc would be needed due to not having anyone around for even something like a Bleph or Chalazion removal.

 

[TheLesPaul]

If you work in someone else's office, you have to work 2-3 times as hard to get the same take-home pay as if you were in your own office. Especially in a rural location that sounds like predominantly an insurance-based practice -- not only are reimbursements declining yearly, but then you take a cut off the top for really no reason, as it sounds like someone who really had a connection to your location could just start a solo practice and be immediately busy due to the lack of other ophthalmology coverage. It doesn't sound like a good deal to go to a rural location and also not be captain of your ship.

 

[percyeye]

If you work in someone else's office, you have to work 2-3 times as hard to get the same take-home pay as if you were in your own office. Especially in a rural location that sounds like predominantly an insurance-based practice -- not only are reimbursements declining yearly, but then you take a cut off the top for really no reason, as it sounds like someone who really had a connection to your location could just start a solo practice and be immediately busy due to the lack of other ophthalmology coverage. It doesn't sound like a good deal to go to a rural location and also not be captain of your ship.

Thanks for the feedback. I guess if someone actually came to the area it would be seen more as a partnership position so that income was maximized. And setup the schedule to their liking. The other positive would be that the systems are already in place that would help get things ramped up faster such as multiple admins, in house billers, etc etc. Again I know the chances are slim to none unless they were from the area, and even then chances are slim. But you always see folks frustrated by lack of surgery so I wonder how many people who inquire about a spot where total surgeries and procedures were listed and see if there were any takers.

And the place isn't just middle of nowhere on the side of a mountain or something, it is Lake country and most the general surgeons / Ortho etc work 4 days a week with their $1 million dollar home on the lake that would probably go for $4-5 million in HCOL areas.