There was a time when ophthalmologists put in 4 years of medical school, completed residency then joined an existing practice or struck out on their own. That model still holds true for most ophthalmologists. But, as fee-for-service care gives way to value-based care, many are forging their own path to professional fulfillment.

Some leave behind the morass of reimbursement paperwork for increasingly popular direct-care models. Some hand over their practice to private equity. And still others partner with optometrists and other eye-care professionals — even in their own family.

Following are four profiles of ophthalmologists who did just that, some of whom left behind their previous eye-care lives to build new ones that meet their needs for greater fulfillment and satisfaction. Their stories may help inspire you to chart your own course from graduation to retirement.

THE DIRECT-CARE MODEL

No longer chasing the insurance dollar

After a year of working for group practices as a corneal and external disease specialist, Laura M. Periman, MD, in June 2020, opened the doors to the Periman Eye Institute, a direct-care practice in Seattle specializing solely on ocular surface disease.

A combination of factors motivated Dr. Periman to pursue direct care: her desires to follow her passion for treating ocular surface disease effectively, to spend more time with patients and to leave behind the complexities of insurance reimbursement.

“My passion is ocular surface disease,” Dr. Periman explains. “The direct-care model saves both the patient and the doctor a lot of headaches. It saves me a lot in overhead costs, so I can have a leaner staff and lower overhead, and those cost of business savings get passed on to the patient [not just as lower costs] but also in the luxury of more time that I can spend with them.”

Similar to the “concierge” model popular among family-care physicians, the direct-care model bypasses insurance reimbursement complexity for out-of-pocket payment simplicity. Unlike concierge care, though, direct care doesn’t rely on retainer or subscription arrangements.

In Dr. Periman’s view, she can now focus exclusively on caring for patients.

“[Ocular surface disease issues] are not something that can be addressed adequately in a 5-minute encounter,” she says. “There are so many pressures that eat away at our values of service to patients. I found myself getting burned out to some extent, where it was all about running through one patient after another. I just began to resent it, and my patients did, too,” she says.

Making it work

Dr. Periman employs a part-time clinical research associate, two full-time office staff and a virtual business accounting manager. She sees up to 20 patients a day and says the practice is booked out 6 weeks ahead. Every new patient gets up to a one-hour telemedicine call followed by 60 to 90 minutes of in-office diagnostics and their first treatments.

Which raises a question: Doesn’t direct-care cater mostly to patients wealthy enough to pay for treatment out of pocket? Dr. Periman believes such a characterization is too simplistic. “It doesn’t take into account what’s valuable to the patient, what’s meaningful for them and what they are willing to spend money on,” she says.

She has witnessed what she calls “a starvation-level appetite for patients to experience connection with their doctors. By cutting the overhead and chasing the insurance dollar out of the equation and just restructuring the business and revenue stream, this model has created enormous satisfaction for my staff, for my patientsand for myself.”

“I get to be a doctor again, the thing I was born to do,” she adds. “That’s beautiful.”

THE FAMILY BUSINESS

First, thoughtful positioning

After 30 years as part of a large, multispecialty practice, Doug Katsev, MD, in 2020 realized a longstanding goal of opening his own practice and working with his family — and enhanced his competitive position at the same time.

“I did this right in the middle of the pandemic,” says Dr. Katsev, owner and operator of Santa Barbara (Calif.) Eye Care. “People thought I was a little bit crazy, but I’d never seen an ophthalmologist go bankrupt, and I had already established my name, so I figured I would make it.”

Sure enough, Dr. Katsev’s practice was “significantly profitable” within 6 months, he says. He partners with his wife, Nina Katsev, OD, and his daughter Cailyn Katsev, OD, in offering a comprehensive range of services, including surgical procedures for glaucoma, cataracts and corneal conditions.

Dr. Katsev says his competitive strength comes from both offering optical services and working with his family.

“I don’t know anything about optical, and optical is something that you need to compete in today’s eye-care environment,” Dr. Katsev says, noting that he recently began partnering with a private optometry practice in Santa Barbara. Offering a combination of ophthalmology and optometric services, he explains, extends his referral base and effectively adds a second location without increasing his overhead — thus providing a competitive advantage in the event he considers selling to private equity in the future.

Santa Barbara Eye Care handles up to 20 cataract procedures a week as well as 15 LASIK surgeries and up to four corneal transplants a month.

The ties that bind — and appeal to patients

Dr. Katsev also attributes his success in large part to the advanced treatment offered by the practice, as well as to the participation of his wife and daughter.

“I always wanted to work with them,” Dr. Katsev says. “My wife doesn’t work a full 40-hour week, but it’s really nice to have her there.”

He believes patients like the familial environment as well. “They’ll say things like, ‘I saw your daughter. She’s so nice.’ It’s another tie that makes them feel like they’re going to someone they know for their eye care.”

The multi-specialty group he had worked in previously did not offer him the control over his practice that he desired. Once he had established a good reputation and patient base in Santa Barbara, he decided it was time to move on. “A year and a half out, my volume is easily what it was at my multi-specialty group,” he says.

VERTICALLY INTEGRATING FOR SUCCESS

‘Grow or die’

Blake Williamson, MD, says his eponymous, third-generation, family-owned ophthalmology practice has one simple and straightforward mission: to provide patients with the best possible care and treatment.

From a purely business perspective, on the other hand, Dr. Williamson says the practice, Williamson Eye Care, operates under one blunt but honest philosophy: Grow or die.

As ophthalmology practices fall victim to challenging payer reimbursement policies, consolidation and private equity, Dr. Williamson says being a vertically integrated practice that encompasses eye care, eyewear and eye surgery enables Williamson Eye to remain independent.

“Our method is to be like (Mahatma) Gandhi,” he says. “We want to be all things to all people.”

Opened by Dr. Williamson’s grandfather in 1946, the practice encompasses nearly 200 ophthalmologists, optometrists, nurses, technicians and office staff in six locations in and around Baton Rouge, La. All levels of eye care are offered: general exams, eyeglass and contact lens fittings, laser correction and other surgical procedures, along with treatment for glaucoma, diabetic retinopathy and other diseases of the eye. The practice posted some 84,000 patient visits in 2020 and averages more than 5,000 cataract surgeries a year.

“My grandfather was actually an optometrist, so our model has always been to offer a full range of medical and optical,” Dr. Williamson says. The practice employs four surgeons, plus 11 optometrists who seeing most of the primary care patients.

Williamson Eye’s approach to growth consists of a continuing assessment of the market for opportunities to broaden its scope.

“We ask, ‘Where are we not currently that we could be [with] a certain density of households?’” They then determine which providers already serve the area and which services Williamson Eye can bring to the region.

“We feel like we have to grow or die,” he explains. “In today’s environment, you see a lot of consolidation, you see private equity (PE) gobbling up practices. We feel we’re already the platform practice in our community, but to make that even more firm, we have to keep growing.”

Buy or partner

Williamson Eye recently opened a new flagship center in Baton Rouge that includes a surgery center where most premium services are done. They also acquired a practice in New Roads, La., and aligned with Baton Rouge General Hospital.

“A lot of small practices are being bought out by hospitals, and we don’t want to do that. Our interest is in partnering,” he says. “We find value in being closely aligned with a market leader hospital group that doesn’t have an ophthalmology department. It’s a mutually beneficial relationship.”

Dr. Williamson doesn’t foresee embarking on alternative practice models, such as concierge or direct care.

“Boutique practices can work great in certain markets, but in a smaller market like Baton Rouge, it’s more difficult to only do LASIK or advanced IOLs or just do cash-pay procedures,” he says.

As for selling to private equity, “We’ve functioned as our own private equity company, just from our cashflow and our status with our local lenders,” Dr. Williamson says. “We’ve been able to buy practices in the past and integrate them into our system. That’s how we grow and operate.”

THE PRIVATE EQUITY MODEL

Relieving the burden, leaving a legacy

Nearly 30 years after opening Eyes of York in York, Pa., Denise Visco, MD, sold her multispecialty practice in December 2020 to Vision Innovation Partners (VIP), a private equity firm that operates 19 ophthalmology and optometry practices in the mid-Atlantic United States.

It was a move, Dr. Visco says, designed to relieve her of the business burden so she and her partner can focus on patient care and help the practice continue growing through an increasingly challenging health-care environment.

“Reimbursements are continuing to erode. Costs are continuing to go up. We were maxed out with the economies of scale that we could achieve,” Dr. Visco says. “That doesn’t just affect the ability of the physicians to earn money. It affects the ability for us to upgrade services and equipment; so, the quality of care then inevitably goes down as the profit margin is squeezed. That’s the war we fight, and we felt this was the best strategy for us.”

Dr. Visco and Eyes of York are not alone in pursuing private equity investments.

According to a 2020 analysis in Ophthalmology, 228 ophthalmology/optometry practices were acquired by 29 PE-backed companies between 2012 and 2019. Of these, 127, 9 and 92 were comprehensive or multispecialty, retina and optometry practices, respectively. In addition, Chen et al showed, acquisitions have picked up speed: 42 practices were acquired between 2012 and 2016 compared to 186 from 2017 through 2019.

Benefits for clinical and business sides

Dr. Visco says not much has changed with patient care delivery under VIP. On the business side, however, various processes and technologies have been changed and/or upgraded. There are also new health insurance and retirement plans and other benefits. New electronic health records and practice management systems have been implemented to tie into the larger organization.

But the clinical side operates essentially the same way it always has.

“I still have decision-making capabilities in the practice, but I don’t have to deal with the everyday staffing, compliance, payroll, accounts receivable, accounts payable issues, cashflow,” she says. “All of that has been taken away, happily. Our schedules are very similar, and from our doctors’ perspective, after getting through the initial integration process, nothing has changed dramatically.”

Eyes of York consists of one office and surgery center staffed by five physicians specializing in refractive surgery, laser vision correction, dry eye treatment, glaucoma management, diabetic eye care and other procedures and conditions. Patient volume reached 12,000 encounters in 2019, and Dr. Visco expects the practice to exceed 13,000 in 2022, including 3,000 cataract surgeries.

Dr. Visco says one major benefit of selling to a PE firm, specifically for herself and other operators of legacy practices, is that they can rest assured their practice will live on even after they leave. She has no doubt that she made the right decision to take the private equity route.

“I’m absolutely, 100% sure that this was the best thing to ensure the future success of the practice in the medical climate that we have,” Dr. Visco says. “I know that patients will continue to receive high-quality eye care long after I’m gone.”

NO SINGLE WAY TO SUCCESS

As these profiles illustrate, ophthalmology practice is no longer one-size-fits-all. Ophthalmologists are finding new and creative ways to negotiate the increasingly tricky terrain of the eye care landscape. Indeed, these physicians recognize there’s no one best way to practice ophthalmology — except for the one that works for you. OM