• Practice Perfect

    Trends in Ophthalmology Practice

    By Jessica Kuo, MBA, Academy Director of Membership and Customer Service, and Chris McDonagh, Senior Editor, EyeNet Magazine, interviewing Aaron M. Miller, MD, MBA, Academy Secretary for Member Services

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    In what ways has the prac­tice of ophthalmology evolved in recent years? To track such changes, the Academy periodically surveys a sample of its membership. Last fall, the Academy invit­ed 9,000 ophthalmologists to participate in its most recent survey. They were randomly selected and were represen­tative of the Academy’s U.S. practicing members. The survey had a response rate of 10% and a confidence level of 95% (± 3%).

    A look at the 2021 survey. Academy Secretary for Member Services Aaron Miller, MD, MBA, discussed some points of interest.

    Practice Sales and Mergers

    What happened in the past three years? More than 10% of respondents were involved in a practice sale or merger in the three years leading up to the survey. This activity breaks down as follows:

    • 6% of respondents sold their prac­tice to private equity
    • 4% consolidated their practice with one or more other ophthalmologists
    • 1% sold their practice to another physician or physician group

    Note: Ophthalmologists who sold their practice and then retired would not have been included in the survey.

    Future plans? Looking ahead to the next three years, 3% of respondents plan to start their own practice.

    During the same time frame, about 16% expect that their practice will be sold or involved in a merger, as follows: 

    • 5% expect to merge with another ophthalmologist or group
    • 4% anticipate selling their practice to a private equity firm and becoming an employee
    • 5% expect to sell their practice to another ophthalmologist or group
    • 2% expect to sell their practice to a hospital or health care system

    Some of these prospective sellers were among the 11% of respondents who expect to retire in the next three years.

    A pent-up desire for change? “People have been riding out the pandemic,” said Dr. Miller. “During that time, they were just trying to maintain their current work condition. The near future may show some notice­able shifts in the practice environment of our members, including transition to retirement.”

    Ophthalmologists in Private Practice

    Practice Type Career Stage* Gender
    Young
    Ophthalmologist
    Mid-
    Career
    Senior
    Ophthalmologist
    Female Male
    Practice owner or partner 28% 73% 80% 59% 76%
    Employee in a physician-owned medical group 47% 14% 7% 23% 11%
    Private–equity owned practice 12% 5% 8% 6% 7%
    Independent contractor 11% 6% 3% 8% 4%
    Other 1% 2% 2% 4% 1%
    * Young ophthalmologists are in the first five years of practice. Senior ophthalmologists are aged 60 or older. Other practicing ophthalmologists are classed as mid-career.

    Owner or Employee?

    Of the ophthalmologists who are in private practice, respondents who have an ownership stake in their practice outnumber employees by 3-to-1.

    Private practitioners characterized themselves as follows:

    • Practice owner or partner—70%
    • Employee in a physician-owned medical group—15%
    • Employee in a private equity–owned practice—7%
    • Independent contractor—6%
    • Other—2%

    Private equity and eye care. “We now see 7% of private practitioners in private equity–owned practices, and we are all wondering how much of a role that model will play in ophthalmology,” said Dr. Miller. “The Academy will need to monitor this trend to see if it contin­ues to grow.”

    What Type of Practice?

    Survey respondents identified their practice type as follows:

    • Ophthalmic group practice—46%
    • Solo practice—26%
    • Academic institution or hospital/health care system–employed—19%
    • Multispecialty group practice—6%
    • Government/military—2%
    • Other—1%

    These 2021 results are similar to those of the 2011 survey, when the two most common practice types were ophthalmic group practice (45%) and solo practice (28%).

    Solo practices holding steady. The proportion of survey respondents iden­tifying as solo practitioners has declined little over the last 10 years, despite numerous challenges—such as regula­tory burdens—that disproportionately impact small practices. “The pandemic placed an even heavier burden on solo physicians because they are unable to share the economic challenges with other partners,” said Dr. Miller. “Mean­while, the pandemic provided time for members in other practice models to reassess their work environment and consider solo practice as a way to gain control of their professional lives.”

    Teaching not limited to academic institutions. “The lines between academic and private practice are becoming more blurred,” said Dr. Miller. “On the one hand, we’ve seen academic practices transition to the production-based model that is found in private practice. On the other hand, 18% of survey respondents who are not employed by academic institutions are doing some teaching.”

    Who Accepts Medicaid and Medicare Patients
    WHO ACCEPTS MEDICAID AND MEDICARE PATIENTS? The survey found that 82% of respondents accept Medicaid patients, although some limit the number of these patients. Meanwhile, 98% accept Medicare patients.

    Practice Size?

    Because some ophthalmologists work part-time, the survey asked respondents for the number of full-time equivalent (FTE) ophthalmologists in their prac­tices, rather than a simple headcount. Results indicated that 59% of respon­dents were in practices with four or fewer FTE ophthalmologists. Here is a more detailed breakdown:

    • 1 FTE ophthalmologist—30%
    • 2-4 FTEs—29%
    • 5-9 FTEs—17%
    • 10-14 FTEs—8%
    • 15-19 FTEs—5%
    • 20-49 FTEs—7%
    • 50 FTEs—4%

    The mean size of an ophthalmic practice was 6.37 FTE ophthalmologists.

    Top Threats to the Profession?

    Survey recipients were asked to identify the top three threats to their profession. The following issues were selected by more than a third of survey respondents:

    • Changes in physician payment— 65% (down from 71% in the 2017 survey)
    • increasing practice overhead—48% (down from 58%)
    • regulatory environment—40% (down from 65%)
    • expanding optometric scope of practice—36% (up from 29%)

    What worries young ophthalmolo­gists? Among respondents who are in their first five years of practice, the top four threats were identified as: 1) Changes in physician payment; 2) expanding optometric scope of prac­tice; 3) acquisition by private equity or hospital/health care systems; and 4) burnout.

    Tackling ongoing challenges to the profession. Many of the threats mentioned above have consistently been identified as major concerns. In response, the Academy continues to invest significant resources in federal and state advocacy. Meanwhile, the American Academy of Ophthalmic Executives (AAOE) has developed guides, references, and tools to help practices keep up with coding policies (aao.org/coding) and improve practice efficiency (aao.org/lean). “These re­sources are important because we con­tinue to be challenged with doing more with less,” said Dr. Miller. “Between reimbursement issues and rising office overhead—including staff expectations for continued salary increases—we need to see more patients to maintain the same revenue.”

    Physician Burnout

    Almost one-third of survey respon­dents said that physician burnout is among the top three threats to the profession. For each practice type, the percentage of respondents who identi­fied it as a top concern was as follows:

    • Solo practice—23%
    • Group practice—27%
    • Health system, hospital, or multispe­cialty group—51%
    • Academic institution—50%

    Growing recognition of the prob­lem? “Members, in general, are ex­hausted,” said Dr. Miller. “Patients who avoided the office during the pandemic are now presenting with more advanced eye care conditions. We are having to spend more time with them to work through their individual challenges, and it does take a mental toll on us as providers.” Burnout wasn’t included in previous surveys, but member wellness is an important datapoint for the Acad­emy to monitor, he said.

    Wellness resources. The Academy hosts an annual symposium devoted to wellness. This year’s event, titled Physician Wellness: Tools to Take Home (Sym06), takes place at AAO 2022 on Saturday, Oct 1, 9:45-11:00 a.m. The symposium will focus on four modalities—work-life balance, mindfulness, yoga and ergonomics—that offer simple strategies to manage stress that one can integrate into their everyday practice lives. 

    You also can visit aao.org/wellness for wellness updates.

    Technician Certification

    Training is critical to get new technicians up to speed and to keep old hands current. To what extent are practices using certification to support staff training? Survey responses were as follows:

    • Most or all technicians are Certified Ophthalmic Assistants (COAs)—20%
    • Most or all technicians are Certified Ophthalmic Technicians (COTs)—6%
    • Mixture of various certifications—36%
    • Most technicians are not certified—20%
    • None are certified—18%

    Career Satisfaction

    In addition to the ever-increasing complexity of ophthalmic practice, Academy members have also navigated a pan­demic. Despite these challenges, 82% of respondents reported that they were ei­ther very satisfied or extremely satisfied with ophthalmology as a career choice.