The Retinal Practice: Economics, Benchmarks, and Career Issues
A seasoned observer's perspective on the unique challenges and rewards.
JOHN B. PINTO

Although retinal specialists and general ophthalmologists may have started with the same mindset in medical school, retinal specialists' practices, patients, and treatments are completely different from their anterior segment colleagues.

"When we all made a choice to enter the eye care field, I think we were initially drawn to the remarkable features of the eye itself. Not lost in our decision however, was the realization that ophthalmology has a lot going for it: primarily healthy patients and a nice balance of medical and surgical work," says Willie K. M. Shields, M.D. "Ophthalmology is typically financially rewarding, it had good hours, and it had neat tools and things to look at -- really a nice, clean specialty. And then some of us threw much of that away and took up the field of retina."

This is an obvious fact most ophthalmology residents seemingly overlook. It takes luck, connections, brains, some lifestyle concessions and 2 years (5500 hours) to transform a general ophthalmologist into a retinal surgeon.

Your total practice career may be clipped from 35 years to 33 years, but if you're relatively energetic, you will make an extra $500000 or more in each one of those 33 practice years. If you reduce this annual "retinology dividend" for taxes, by multiplying it by 33, and divide it by 5500 (for the hours of extra training time) you arrive at over $1700 per hour that you're paid for every single hour in training in those 2 supplemental years.

That's nearly $10 million in after tax income for the extra 5500 hours of training. There is probably no other domain of post-graduate medical training that pays so handsomely. It's surprising there are only about 1500 of these subspecialists in America. This article will cover a few of the other hallmarks of this financially vital and administratively fascinating corner of eye care.

THE RETINAL PERSONALITY

In my many years of experience traveling around the country as an on-site consultant, I can say retinal subspecialists are just like other ophthalmologists -- only more so. They tend, as a cohort, to be more intense, more intellectually-focused, and more given to anxieties that are out of all proportion to the offending stimuli.

I find retinal surgeons to be somewhat more Renaissance in the breadth of their interests in and out of medicine, and far more enthralled by technology in most cases. I'm not entirely sure if this is because retinology has a higher demand for technology, or the favorable cash flow of retinal practice allows an accelerated adoption of every new technology. Their tendencies toward short attention spans in areas they don't particularly relish can make retinal surgeons very challenging to communicate with on matters requiring patient, linear projection. For example, when having to review financial trends or long-term plans for a satellite, their ample minds can end up with considerable drifting toward interesting but less relevant topics.

With a few prominent exceptions, retinologists are consummate gentlemen and ladies. And the more successful the doctor, the more gentle the person. I believe this flows from 2 aspects of this subspecialty.

First, retinal surgeons are not often about to abruptly reverse the disease process. A "win" for them can often mean a disease's progression has been slowed. As a result, patients who can't be cured are comforted.

Second, retinal surgeons are highly dependent on optometrist and ophthalmologist referrals. As every subspecialist knows, you learn how to be super affable and super accessible to patients and fellow doctors.

SURGICAL VS. MEDICAL RETINOLOGY

Congenial surgical retinal specialists who possess good skills and work hard in markets with an appropriate balance between patients and doctors can expect to generate $1.5 million to more than $2 million in collections, with more than a 50% profit margin available for distribution.

In today's environment, nonsurgical retinal specialists with the same strong professional attributes and favorable settings manage to generate about 60% to nearly 100% profit margin. Hour for hour, the take home pay for surgical care can actually be less than for office-based services.

WHERE'S THE BEST SETTING TO PRACTICE?

Newly minted retinal surgeons have at least 6 possible professional venues in which to put down roots and grow their nascent careers. Here is a breakdown of the different paths:

Solo subspecialty practice. This is a bittersweet setting in which to practice retinal care, with none of the delicate give and take required in a group practice, and 100% autonomy. However, being a solo retinologist can be exhausting and professionally isolating. In my experience, a majority of soloists attempt to increase patient growth to a level that will support a colleague joining them.

Group single subspecialty practice. This is often the "sweet spot" of every subspecialty. In a group setting, call coverage is far less of a burden, costly capital investments can be shared, and an intellectual peer is just down the hall in the next office.

As a result, not only are retinal providers in small group practices the happiest and least fatigued, they are also the most financially robust. Nonetheless, there are two prominent downsides to these type of practices. The growth of a successful practice may lead to several far-flung satellite offices, high-strung providers, and more complexity than the average administrator can handle. This can result in lower profits and discord at all levels in the practice.

The other downside, emerging more often as eyecare providers continue to consolidate into larger groups, is that retinal specialists are dependent on larger general groups developing their own retinal service in-house. Whereas a soloist can often scramble to find new referral sources, or go with the trend of become a visiting provider in a multiple general ophthalmology practice. A doctor in a larger-scaled practice can be painted into a corner.

Multisubspecialist practice. By this, I'm referring to a mixed glaucoma, plastics, retina or similar practice with little or no primary care or anterior segment care, so as to avoid competitive conflicts with the referral community. Such practices are not common, and when they do come together they are more often the result of friendships or proximity than advanced planning. Disparate subspecialists in the same practice create many fewer economies of scale and less business focus than a single subspecialty practice.

Generalist/subspecialist practice. Although solo and small group ophthalmic practices are by no means dead, many eye groups in urban and suburban markets are getting larger and vertically integrating by adding subspecialists rather than referring care. This trend can be either "OK" or "terrible" from a retinal surgeon's perspective.

It's "OK" if you enjoy working in a larger professional setting, with perhaps a little more collective acclaim in your market and perhaps secure contract access as a result of your clout and geographic coverage. It's "terrible" if you're on the outside of such a group, working in a single subspecialty practice, and about to lose group referrals as they keep retinal care in-house.

Again, in these settings a retinal department of two providers makes more sense than just one subspecialist buried in a larger, mixed provider group. For fairness and harmony, it is critical that the group's compensation methodology acknowledge the naturally lower cost margins in retina, and not create a comp model where the retina department is unduly subsidizing the general or pediatric ophthalmologists.

Classic multispecialty practice. Multispecialty practices, with everything from appendectomies to vitrectomies available under the same roof, grew in the managed care 90s and are on the wane for the moment. But they will assuredly return with whatever is coming down the line next in health reform. Most such practices are punishing environments because of high overheads, bureaucracy, and a high degree of profit shifting to primary care providers. Unless the group is huge, well-established and august, the prestige and security won't offset the frustrations of practice in such settings for the average, ambitious retinologist.

Institutional practice. Working in an educational, pre-paid health or governmental facility has its attractions. These type of practices can be a stepping stone to the next career stage, or as a haven for retinal surgeons whose financial needs and independent streaks are subordinate to being part of a larger institution with a mission that resonates.

IMPORTANT BENCHMARKS

General ophthalmologists, and especially surgically oriented anterior segment practices, have invested significant resources in benchmarking their financial and volume performance against fellow providers, whereas, considerably less benchmarking is performed in retinal practice settings. This is in line with the generally slower pace at which the other vanguard practice management tactics are adopted by these subspecialty practices.

There are several reasons for this:

► Retinal practices, as compared with general ophthalmology practices, enjoy a much higher profit margin. As a result, they have been understandably less concerned about nuances in their cost of doing business or individual doctor productivity.

► Retinal practices have been arguably under less threat of fee reductions than other ophthalmologists over the past decade.

► Retinal practices are somewhat more complex, and can have a higher diversity of patients and procedures. There are more new procedures and clinical maneuvers to master every year. These other concerns can translate into there being less time for the average retinologist to think about the business details of the practice, and much less the administrative minutia of comparative benchmarks.

► Retinal surgeons, while at least mildly competitive with their in-town colleagues, tend to be less adversarial in their relationships compared with cataract and LASIK surgeons. So there is a reduced motivation to compare a retinal practice with others.

► Retinal practices tend to be somewhat insular, and are not comfortable sharing confidential practice performance data.

► There are fewer retinal surgeons and retinal practice managers than general ophthalmologists; so the odds are reduced of someone taking the time to ask benchmarking questions.

THE NUMBERS ON RETINA PRACTICES

► little over 2 years ago, we studied a limited cohort of pure, retina-only practices. The results were not statistically significant, but in line with my on-site observations through the years:

► The average practice ran a 45% average profit margin; this was thrown off by a couple of practices that were still growing, and others that put larger than usual amounts into promotion and outreach.

► The average doctor was generating annual collections of $1.3 million. The most productive practice generated $2.6 million in annual collections per doctor, and the least productive just $848000.

► There was a wide divergence in clinical productivity between groups in this limited study. The most productive doctors saw nearly 600 patient visits per month, and in the least productive saw just 271 patients per month.

► The average practice had 19% new patients. As might be expected, practices with the lowest new patient ratio tended to have the lowest revenue yield per patient visit (due to serial rechecks and a lower surgical yield.)

► The revenue (collection) yield per patient visit (including post-ops) was similarly wide-ranging. In the average practice, the figure was $321. The highest revenue yield was $406, in the suburban solo practice. The lowest was $227. It's interesting to note that this figure was once well below $200, raised in recent years by the use of Ocular Photodynamic Therapy (OPT). Indeed, the average practice performed one OPT for about every 46 patient visits.

► The most efficient practice was able to generate $199000 in collections per lay staff full-time equivalent per the least efficient practice, just $122000.

► Vitrectomy rates were wide ranging in the study group, with a low incidence of one vitrectomy per 54 patient visits and a high of one vitrectomy per 14 visits. The average was one vitrectomy per 31 visits.

THE GENERAL VS RETINAL SPECIALIST

As retinal surgeon Willie Shields observed, general ophthalmologists and retinal subspecialists work in remarkably different professional environments. Whereas cataract and refractive surgery occur among primarily healthy patients seeking an elective procedure, often in a festive atmosphere, retina patients are typically down beat, with chronic, permanently sight-debilitating conditions.

In this manner, retina clinics may be more similar to oncology practices, and these patients to my mind do not mix well with the buoyant waiting room atmosphere sometimes established for high volume anterior segment practitioners. The retina world is also ruled by emergencies. This obviously affects scheduling, and by its very nature demands a flexibility of the staff, doctors, and the surgical environment.

Perhaps, in light of these special professional constraints and challenges, the nearly $10 million lifetime earnings premium enjoyed by retinal surgeons is more than appropriate.

John Pinto is president of J. Pinto & Associates, Inc., an ophthalmic practice management consulting firm established in 1979. Pinto is the country's most-published author on ophthalmology management topics. He is the author of John Pinto's Little Green Book of Ophthalmology, Turnaround: 21 Weeks to Ophthalmic Practice Survival and Permanent Improvement, Cashflow: The Practical Art of Earning More From Your Ophthalmology Practice, and The Efficient Ophthalmologist: How to See More Patients, Provide Better Care and Prosper in an Era of Falling Fees. The Women of Ophthalmology, written with Dr. Elizabeth Davis, will be published later this year. He can be reached at (619) 223-2233, e-mailed at pintoinc@aol.com or on the Web at www.pintoinc.com.