Twenty years ago a new physician could hang a shingle in practically any city or town and build a patient base. Those days are over. Managed care has changed the rules and tilted the playing field. Managed care presents a daunting set of economic, professional and legal challenges to those venturing out into an increasingly volatile and hostile healthcare delivery environment.

For the young ophthalmologist, the questions are many: Should I take an employee position and learn the rules of managed care in that setting? Is it realistic to jump straight into private practice? Should I buy into an established practice, or should I buy out a practice and assume its managed care business? Here are some factors to consider in finding the right answer for yourself.

Just as with real estate, a critical factor in your career choice is location, location, location. If you absolutely must practice in Boston, for example, you’ll find opportunities severely limited by managed care. One thing "A-list" cities such as Boston really don’t need today is another retinologist, cataract specialist or refractive surgeon.

On the other hand, if you’re willing to live in an underserved area, or provide services to a population such as Native Americans, who are desperate for specialty care, opportunities may abound. And the number and type of opportunities in any location will influence whether you’re able to go into practice for yourself, in a partnership, or as an employee.

For some young ophthalmologists, going into private practice is the goal no matter what the obstacles. For those so driven, the most important issue is capturing patients as quickly as possible and building a revenue base. On the surface, buying an established practice with a file full of managed care contracts and an established managed care patient base appears to be the simple solution. But it’s anything but simple.

Don’t assume if you buy a practice with 10,000 active patient charts that you automatically own that patient base. Some or most of those patients are probably enrolled in managed care plans. In fact, those patients belong to the health maintenance organizations (HMOs), which will decide if and when you can participate in their respective plans.

A health plan is under no obligation to leave its patients with you, the practice purchaser. Those patients could be taken from you overnight if the plan chooses. This means that "goodwill" has much less value these days when making a practice valuation. Don’t be surprised if an HMO decides that the provider panel needs to be downsized and, rather than adding you in place of the retiring doctor, it chooses to transfer your patients to other panel ophthalmologists. That’s a rude shock.

Understand, too, that despite what you might have heard or read, "any-willing-provider" statutes or regulations offer physicians essentially no protections or rights. Though in some cases pharmacy services have fallen under any-willing-provider protections, to this point ophthalmology hasn’t. A health plan or third-party payer is under no obligation to include you or any other doctor in its panel, no matter your qualifications, your facility’s capacity, or your willingness to accept the going reimbursement rates and contractual provisions offered to current panel providers.

Becoming an employee with the intention of "getting experience" with managed care has its own set of pitfalls. Many health plans require that both employed and participating physicians be board-certified or board-eligible. If you’re not, that will mean your application for a position in an HMO won’t even be considered. In fact, if you won’t meet the minimum demands established by third-party payers — even though you’d be providing services to what may be a relatively small slice of a practice’s total patient base — many private practices won’t consider you.

It also happens sometimes that the physician-owners aren’t pulling all the strings; that is, through ignorance or oversight, they don’t do everything possible to enable them to bring in a new physician employee. In this case, you may need to educate yourself on existing laws and regulations so that you can in turn educate your prospective employer.

So how do you get started with managed care plans and their third-party administrators? How do you find out what opportunities are out there, and if you’ll be able to assume care of patients in a practice you may buy or buy into? How do you get onto the local and regional vision care medical surgical panels?

The answers can be found only with hard work and research. You can reach health plans and third-party payers, including vision and eyecare networks, by phone or letter. Decision-makers usually have a title such as Provider Relations Director, Provider Relations Representative, Director of Network Development (or Network Contracting), or Director of Ancillary Services. How do you find these people, their names, addresses and phone numbers?

Some of the major plans dealing with ophthalmologists are listed in the accompanying table. Much of this information also is on the Internet. You can get a list of HMOs, phone numbers, addresses, etc., at http://doctorline.com/hmostate.htm. You can also find an extensive list of useful HMO links at my personal Web site: http://www.gilweber.com/gw_url.htm.

It’s a daunting task and a difficult choice: private practice or employment. Both are filled with opportunity and disappointment, and both are driven and influenced by some factors beyond your control. Your choice will be one of the most important decisions you make. So make it an educated, carefully considered decision.