Small Practices Will Survive

Is the future of ophthalmology practices big or small? It’s a question being pondered by many – and the common view is that small and solo practices could become a thing of the past. But I want to share my view that small practices will survive, and here’s why… Ophthalmologists are a “savvy” bunch. Back in 1995, during the height of the Clinton healthcare debates and push towards primary care, it was estimated that there would still be sufficient demand for ophthalmologists going forward if our specialty reconfigured as preferred primary eyecare providers (1). In addition, an AOS report published in 2011 described that the ophthalmic community was quick to respond to market demand, and a positive relationship exists between GDP growth and demand for private practice ophthalmologists (2).  Interestingly, the AOS study noted a 2–3 year decline in ophthalmologists demand following a recession.

In 2016, David Parke II (Executive Vice President and CEO of the American Academy of Ophthalmology) wrote on the changing eyecare workforce. He noted that among 17,000 US ophthalmologists (there are 40,000 optometrists), more than 40 percent are 100 percent comprehensive ophthalmologists.  He also illuminated that 32 percent are in solo practice and around 60 percent of Academy members are in small groups of 1–3 ophthalmologists (3). So there is this huge cohort of ophthalmologists in small or solo practices who aren’t going to disappear overnight. The bonus is that there will always be enough demand for ophthalmologists. Why? Because approximately 10,000 baby boomers turn 65 every day. And this baby boomer bulge is set to continue for the next 30–50 years (4) – meaning ophthalmologists continue to have the opportunity to thrive in practice. So I am not worried about patient populations. Reimbursements are a different matter – especially since the majority of our patient base consists of Medicare and Medicaid patients, and we face the numerous challenges with acronyms of MIPS, MACRA, PQRS, MU, and perhaps BRCA. But this is where the IRIS Registry is showing itself to be invaluable to our profession. The IRIS Registry is the nation’s first comprehensive eye disease clinical registry. The Registry was launched in recent years and after the government passed legislation to incentivize physician transition towards using electronic medical records (EMRs). IRIS works in the background of EMR systems, extracting data every night from patient visits that day. In a way, the registry has been far more successful than originally anticipated in gathering data and outcomes that are helping patient care. What does this mean for small practices? It helps to relieve the regulatory burden. As the federal government is transitioning to paying doctors for quality rather than quantity, the data collected in the IRIS Registry can show the government that outcome measures are being met. It relieves a lot of the burden in “paperwork” to reach the incentives and avoid penalties. We are already providing quality care, and the IRIS Registry helps us show that we’re meeting measures. Report cards are also issued from the registry to help physician analytics with our patient outcomes. I call it the “small practice savior.” There are a lot of mergers and acquisitions in medicine (think cardiology in the last five years) but ophthalmology may just be unique. I think we’ve benefitted from technological gains in our profession, including the advent of OCT, increasing efficiencies in cataract surgery, and wonderful treatments for macular degeneration and retinal disease.  So we don’t necessarily need to merge into big groups. There is, however, a role for ophthalmologists to find their niche – however they like things to be. Ophthalmologists in a big city may be more likely to join a group, but can still thrive in a small practice. Those who are motivated and ambitious – of any age group – can break away and thrive on their own, even if they initially joined a group. Small practice ophthalmologists are not going to wither away: small practices will survive.