Okay, so there has been lots of feedback about the new direction I’m taking. First, when I wrote that I was going to be writing future posts “demonizing private practice,” what I was trying to say is that I used to idolize it, but now I have removed solo private practice from a pedestal that it doesn’t deserve. I’ve posted before that I think that this mode of practice is endangered. Large group practice will probably make it since they can offer specialty care not found in commercial, but you can’t just plop a few doctors into the same town all at once, so new group practices will rise up from the ashes of solo practices trying to survive by evolving, and new solo private practice will cease to emerge.
So the message to optometry students is that private practice optometry isn’t the pinnacle of our profession- it’s just another way of practicing. Choose your mode of practice based on your goals. Do you really want to be a “savvy businessperson” with all the headaches of running your own practice? If so, get out of optometry and start a business where you can make some real money since optometrists have a cap on their income potential since we can only see so many patients a day.
Anyway, most of the criticism to my recent post has been words to the effect of “your exam fees are so low it disgraces the profession.” Um…why are your exam fees so high? Oh yeah, your overhead is ridiculous. Let’s say your solo private practice pretax net is $118,800. That means your practice had to gross around $396,000 (a generous 30% net-to-gross ratio), $475,200 (25%), or $594,000 (at 20%).
The Wal-Mart doctor just has to gross $132,000 or $148,500, depending if the lease is 10 or 20 percent. No problem. Oh, and the Wal-Mart doctor can gross $11,000 a month just working 4 days a week. And he doesn’t have to kill himself explaining to every single person that enters his practice why his glasses cost so much and why his exam fees are so high.
So, your ridiculously high exam fee, caused by ridiculously high overhead, is part of the problem with rising health care costs in this country while Wal-Mart optometry is helping people to save money and live better.
Listen to this blog entry
Dr. Langford,
Your explanation that exam fees are so high because of the overhead in private practice is not founded in good reason. The exam fees are higher because those optometrists have the confidence to value their SERVICES accordingly. You’ve been through extensive training, you’ve incurred large educational debt, you’ve sacrificed years in order to achieve your doctorate, and ABOVE ALL ELSE you are an expert in your field. Realizing all of those things will lead you to the conclusion that $45 completely undervalues the SERVICE you give, regardless of your overhead. This is demonstrated in that there are a number of commercial optometrists that charge more than yourself. Their overhead, like yours, is minimal. But they chose to charge more because they believe in the value of their expertise.
As I’ve said to you earlier, your belief that you are helping America through your exam pricing is noble. However, if that is the case, then why stop at $45. Pricing your exams at $25 would provide HUGE health care savings to your patients. It would be even nobler. And including pupil dilation, the most important part of your patient’s evaluation, in the price of your exam would also be very noble of you.
BTW, don’t be some pompous. You are in no way the most hated optometrist in America. Not even that many people know of this site. In fact, your recent surge in traffic is due to the attention Optoblog has been recieving on ODWire.com.
This is certainly a convenient way for you to have a one sided argument on the issues, so I would encourage you to join in a dialogue to defend your points on http://www.ODWire.org
You need to calm down. None of this is very cool or helpful to anyone. Especially you.
Hey, I’m calm. It’s the soar losers wanting to meet me in a back alley that need to calm down.
Oh, and this is MY BLOG, where I get to post anything I want. It’s opinionated because…I’m expressing my opinions. Those who want to champion solo private practice to all the poor unsuspecting optometry students are welcome to start their own blog.
And for the millionth time, I refuse to support the secret society of ODWire in anyway until they allow anyone to read the bulletin board, not just logged in users.
Oh, and pupil dilation is extra since it takes extra time. Time is money, you know.
On a side note, $45 also happens to be the average fee for all Wal-Mart optometrists. It also happens to be about the average reimbursement from vision plans, so those of you who take any vision plans, you haven’t got any grounds tell me my fee is too low when you accept that yourself.
$45 is the average? Where are your facts? Are you quoting a survey by an independent agency? [Yes, the Optometric Business Academy, sponsored and run by the same people at the pro private practice Management and Business Academy.
OD Wire a secret society? It's a forum of discussion amongst professionals. Perhaps you should limit this site to just optometrists considering all the cartoons you have making fun of your patients.
[If I can't read a bulletin board without without logging in, and you have to be special to have an account, then it's a secret. "All the cartoons"- that's a huge misrepresentation of my artistic work. Only a minority of my cartoons make fun of interesting attitudes of a small minority of patients. And no one is saying they are MY patients. You can disrespect my position on Wal-Mart optometry, but you GO TOO FAR when you fail to appreciate my art.]
If I may, I am another Wal Mart OD and also an ODWire user. I can assure you that I rank considerably higher in the “most hated” category than you.
That having been said, I also feel that your fees are too low. When an OD charges such low fees it causes a chain reaction that reaches far beyond his own practice. The reason that most VC plans reimburse such paltry sums is BECAUSE there are so many ODs charging $45 for eye exams. They take an average and cut just a bit off of it. This also empowers those vision care plans and gives them enough clout that it makes it increasingly difficult to utilize medical plans. I’m shocked at how many times I had to talk to different provider relations managers because when applying for provider status they just ASSUME that I meant to call Spectera and not UHC or Eyemed and not Aetna. They almost forget that we are medical providers…
It’s not about ego or overhead, it’s a fact that you provide an incredibly valuable service and it’s worth more than your charging. Even Medicare values your services more than you do.
[Medicare doesn’t pay my bills since I don’t take Medicare. I take cash at the time of service. I can keep my exam fees low since I only minimally bill insurance. Also, take a look at Cache Valley, Utah economics, and you would see that even though I’m at the average exam fee for Wal-Mart optometrists, I’m probably higher than what some sort of adjusted market ratio might say I should be. But I agree that supply and demand economics plays a role in all this. When it gets to the point that I’m scheduled more patients in a day than I can handle or if I’m booked out too far in advance, I’ll have to raise my fees to adjust for being in such high demand.
Do you really believe that exam prices in private practices are higher simply because of increased overhead?
Or that they should be lower in Walmart because there is minimal overhead?
Maybe they should be based upon the expertise that is provided…
How much time is an average patient in your office during their exam?
Do you not value the 7+ years of education you endured to become a DOCTOR and the tuition you paid?
What about what Medicaid says your services are worth? Are you even maximizing that reimbursement? [Medicaid thinks my S0620 is worth $39.27.
I understand that private practice is a tough go and that you may be jaded, but come on!
Dr. Langford.
Just a heads up. Your website http://visionhealtheye.com/ is in violation of Utah state law. You are actively advertising for Walmart and marketing links to Walmart’s contact lens system. In essence you are making advertisments for the sole profit of the mercantile establishment. In the state of Utah, optometrists are strictly prohibited from marketing or advertising for the mercantile establishment. This includes websites. A complaint has been filed with the Utah Board of Optometry. Again, just a heads up.
[Thanks for the heads up, John Smith. I'll be sure to keep everyone update about Link-Gate in future posts. Now is there any doubt that I'm the most hated optometrist in America?
Oh, and I call BS. Provide the link to this alleged rule.]
You wrote on 03/29/07: “I’ve filled in at Big Box opticals where the staff tells me that the usual doctor doesn’t charge for follow ups on things like red eyes. Unbelievable. Not only are these doctors leaving money on the table, they’re making the rest of the profession look bad.
How come patients question optometrist fees so much? When they go to their PCP for a check-up on their HTN, do they expect to walk out without paying? Do they expect their PCP to refill their HTN meds indefinitely without a follow up exam?
Eyecare is healthcare, and I resent the insurance companies for making the illusion that it’s something separate (vision insurance vs. medical insurance).”
You are extremely self-conflicted individual. Do you really have patients question $45 for an eye exam? [Umm...I was a solo private practice doctor back then. My exam fee was $100.]
The fact remains you failed at your venture, for whatever reason. Now you are rolling back every attack you’ve posted about commercial optometry. If you are going to be so opinionated (as you said that this is the one-sided purpose of this website) then plan on getting called out on your blatant hypocrisy and lack of quality reasoning.
[It appears that someone with a doctorate degree needs to look up the definition of hypocrisy. Stay tuned to optoblog for future posts about how and why I became sincerely and honestly converted toward the Wal-Mart optometry mode of practice. Also, my previous attacks on commercial still stand for many chains, but at Wal-Mart, if any of those still hold true, it is that individual doctor partner’s fault. If you disagree that Wal-Mart optometry is way cool, then start your own blog about why optometry students should start their own solo private practice.
I am not a ‘Soar’ loser, I worked at walmart about 6 years ago and charged 65 with dfe included, the previous OD charged 35. I went on to make the most that location had seen, but it was still one of the worst practice situations of my career. You can do great in private practice, I work less, make significantly more, and practice the way I would like. You just have to be smart and create a niche. I have patients that go to walmart and the see me for ‘a real exam’ and the majority return and refer friends and family even though my fees are so high you would have a fit if I told you. I also have the same type of patients that come from a local OMD group that has several ‘mills’. If you are seriously interested in excelling in private practice it isn’t easy, it takes brains,work, and determination, but IMHO much better than corporate optometry.
dave
[Oops, I meant sore. I probably didn't type it right because I must have cerebral hypoplasia, which makes me unfit for private practice. By the way, the reason the rest of you have to find a niche is because Wal-Mart optometrists are taking your bread and butter.]
Dr. Langford,
You are manufacturing your own reality. I’d like to know what kind of care is provided for 45.00. What kind of instrumentation do you have? Does your facility look state-of-the-art? Or like a little hole in the wall in the corner of a big box store? Does it look like a successful doctor’s office? Does it look like an office where patients want to be? Does it look like an office that patients would refer others to? Or does it look like a facility for price-conscious individuals? I don’t think my exam fee is ridiculously high any more than I think that your logic is ridiculously sensible.
Pupil dilation doesn’t have to take any more time if your office is properly staffed and your staff is properly trained. Your thinking conflicts with CPT. Maybe you have heard of this…the rest of the profession uses it daily.
Keep up the good work, dude. Just don’t attempt to brainwash the majority. You are in the minority.
Oh, and it’s SORE loser, not SOAR.
Are you an AOA member?
[I used to be, but I couldn't afford it since all my income is going into the money pit you call solo private practice. As soon as I'm back on my feet I plan on rejoining.
"...Don't attempt to brainwash the majority." So...you would have me silenced, denied of my free speech? And should I just go jump off a cliff simply because the majority is also jumping off a cliff?
I think my work area looks pretty good, but you might consider answering your own questions by visiting your competition. This brings up the point that just because your exam fees are high, doesn't mean your practice looks nice. I'm seen some pretty hole-in-the-wall private optometry offices-almost as bad as a certain Utah optical chain.]
When you post baby stuff like that on WalMartOD, it is a poor reflection on all of us. Grow up! I am sure you are not the most hated OD in America. Others more hated than you. There was that OD that killed his neighbor. That Iowa OD who asked his female patients to take their shirts off. Most OD’s that work at America’s Best.
[That's me, a big baby. So,from what you are saying, I'm only the 3rd most hated optometrist?
I hadn't heard about the America's Best optometrists. So, just by working there, they incur the same wrath I've incurred the last week since I merely announced that Wal-Mart practice rules and solo private practice should not be place on a pedestal nor viewed as the pinnacle of our profession?]
What do you do when the district manager calls and tells you that your lease is being terminated for no reason at all?
[I'll bet it means that you had a poor rapport with your DM and your VCM.]
David,
Most hated OD in America? Puh-lease. You are not even on the radar screen bud (thankfully ODwire and Optcom have linked to you, so you will see some more traffic). Not that I completely disagree with what you say, but I will say that as a corporate OD in a big box retailer that is better than Walmart (and who treat their employees, members, Vendors, and leasees with more dignity), I excel and charge what I think my services are worth. I will also add that Wal-Mart ODs that I have met in my travels also share that the fee is based more on Service provided rather than a simple overhead calculation.
Enjoy your hyperbole, and I look forward to speaking with you whenever you want. As a NATIONAL thorn in people’s side, I invite anyone to the table when it comes to discussing the future of Optometry. There are plenty of issues to be worked through, and I guess name calling on both sides will at least set the table for understanding how big the divide can be.
I wish you luck in your mode of practice, adn I hope everyone in any mode of practice practices the fullest scope possible.
Steve Lowinger
(PS. I totally agree with the Insurance reimbursement argument. If Corporate Optometry didn’t exist, the $30 per exam insurance takers would be the pariah’s of the profesion.)
Just out of curiousity, why don’t you take medical insurance? At that point, you charge a reasonable fee for your services, but your patients only have to pay you $25 for a co-pay? Is that not contributing more to the financial wellbeing of your patients? What about those poor folks on Medicare? If you DID file medicare, you would be paid on the order of $100, but your patients would only have to be out of pocket $20 (feel free to comp that refraction fee, just to take one for the team).
It seems to me that you could easily double your fees and more importantly cut your patients fees in half (just to appeal to your altruism). How is this not a win?
To the doctor above referring to whether or not your office looks like a successful doctors office, he should take a look at some of the newer offices. I’d stack my WM office against most private practices in terms of equipment, asthetic and most importantly…bottom line.
FWIW, DMs don’t cancel a contract for no reason. It’s a pain in the behind having to find ODs anyway and they’re always at a premium. That having been said, you really have to screw up a lot and for a long time to lose a contract or just generally be hard to get along with.
Dr. Langford,
Dr. Nelson’s comments are well-intentioned and are very useful. I suggest you listen to them rather than just discounting in a confrontational manner EVERYTHING that anyone posts on this “blog.”
Wow,
I guess when someone posts a good thought you just outright delete it…
Interesting.
Steve
Keep on deleting my posts, and I’ll keep replying and noting how you delete things when they prove you wrong or make you look bad.
(nice going)
[Umm...Steven, there is something called "Comment Moderation." I don't check my site every second of every day because I'm too busy seeing patients or having a family life.]
I don’t see why there would be any reason that an eye exam at a Wal-Mart doctors office couldn’t be every bit as good as the exam at a private practice. Isn’t the equipment just the same? Can a Wal-Mart doctor not own an OCT and a retinal camera just like the private doctor who… by the way couldn’t have one until he reached 400-500K gross? Wal-Mart’s OBA is rightly encouraging their doctors in company-paid continuing education seminars to increase their medical eye care model. In this model, doctors would bill the same insurances private practice models bill, with the exception of those vision plans who discriminate against corporate-associated doctors. I’ve seen a taste of both worlds, and right now have no immediate preference. The numbers have been reported a little off though…. although 30% is an expected net/gross for private practice, they can gross 33% easily, or up to 40% if they have their own surfacing lab (again this was a doc I knew who grossed over 700K) – but that’s the BEST you can expect from private practice. AVERAGE net/gross reported by the Wal-Mart Optometric Business Academy was 75%. There is more to overhead at a Wal-Mart than rent. If you have your own staff, which I beleive is unique to Wal-Mart leases, your rent is 10%, then payroll could be between 10-15% usually, and then filing/paper expenses. The average Wal-Mart OD spends 1.7% on advertisement according to the OBA. And then, if you follow the medical model, average a percent or two for buying higher tech diagnostic equipment.
Still, with a net to gross difference that high, you can extrapolate the true compensation per patient by caluclating the average revenue per patient. At an average private practice this might be around $250. This equates to around $75-85 per patient that they NET. Using the same math backwards, at a Wal-Mart, you will need to gross $100-113 per patient to take in the same amount of money per patient.
BUT at a private practice, and again I speak from experience, you will deal with a lot more hassle with the optical, patients coming for adjustments, complaints, training and re-training staff how to fit and adjust and repair glasses. AND if you own your own building heaven help you if your air conditioner dies or equipment or something else in your office needs repair. It would be difficult to calculate the actual time spent on each patient, but I would argue it would indeed be less, even with the same quality of care, at Wal-Mart. Not because the exam is any less thorough or the doctor doesn’t chat with patients as much, but because the doctor is involved in managing ALL facets of private practice.
As far as exam fees go… it would be slightly difficult to acheive $100/patient on exam fees only. But you could approach that level by billing using an S code or using a cash/prompt pay discount (up to 25% is widely acceptable and legal with insurance companies), and then billing the insurances a rate that may be that much higher. Also, adding screening retinal photography can increase that revenue by $15-20 per patient (if you charge $25-$35 for the photos, and a good portion of patients elect that though good patient education. – again I’ve seen this done successfully by a corporate doc who averaged $18/pt in increased revenues) I have a plan at my corporate practice where I expect a $95 average revenue per patient.
Now with all of that said…. you can’t discard market economics. Doctors discussing and changing exam fees as a group is illegal, and a Wal-Mart doctor would hurt severely for suddenly and drastically increasing exam fees. Again the OBA reported an average 7% increase/patient in their doctors offices from 05-06. In my area, corporate doctors charge around $70. I’m further out in the country and feel that I offer a very thorough exam. Noone is complaining about my fees, so I plan to increase mine to be higher than that. Next year, if no-one complains, I will increase again. One ophthalmologist told me once… if people aren’t walking away, and noone’s complaining, and you’re getting paid your exam fee, you’re not charging enough. I think this applies next to a corporate entity too, and it’s a good rule of market economics.
Just my two cents… take them for what their worth, if it helps. but these are actual facts that I’ve seen in other people’s practices, and reported by the walmart oba.
[Wow, Brian, this is the most thought out comment I've seen on my site. You have won the Optoblog Comment of the Quarter Award, 2Q08. Feel free to print yourself out a certificate of achievement. My only comment is that I once heard an exam fee/billing guru say at GWCO that a 20% prompt pay discount was bordering on getting you into trouble, so I just had a 10% in my private practice because that is what many physician's offices in my area do.
So, how does everyone feel about changing my Wal-Mart exam fees to $Y where Y=X*Z, where X is the full fee fee (what is billed to insurance), Z is the prompt pay discount fraction, and Y is the actual fee my cash paying customers pay.?]
Dr. Langford, have you seen a psychiatrist?
[No, but that would be a good question to ask any new grad thinking of opening up their own solo private practice...]
Very Interesting indeed. I did a google on Walmart Optometry because I have been in private practice as an associate for the last two years and wondered if the headaches, hassles, complaints would be less and the income would be significantly more.
I am exploring contracting with a local Walmart. Dave, your cynicism runs deep and wit runs long for sure. I understand most of your points.
I think Brian is right about having the scope of practice that would be what is considered a “thorough” exam. I think you can have your cake and eat it too. Prove all the private OD’s wrong. Practice to the highest extent of your training and state law, and reap the financial benefits while doing what’s best for the patients (thorough eye care with advanced technological benefits). Brian, we need to talk. One thing I disagree with though is the S-code. You can’t charge an S-code to the patient then turn around and file it to insurance. That is fraud. The S-code is designed to be charged to patients for ‘routine’ services (ie. refractive Dx only) who do not have or choose not to use their routine vision insurance.
Currently in the practice I am in, we charge $150 for a Comp NP, $60 for a refraction, and are Contact evaluations start at $59 (usually discounted 15% due to insurance or prompt pay if pt is paying out of pocket). Since I came on, we have added retinal photography (avg med ins reimbursment is $55) and GDx which has a screening mode on it. Last month we made $3.5K in cash screening fees and $4K on insurance billings for the testing mode. We have Humphrey’s VF, a scout topographer for Wave lenses, fitting Synergeyes hybrid lenses, have an Ophthonix WaveFront Analyzer for correcting higher order abberations and am next going to convince the owner he should had a divice that measures macular pigment density (another great service to patients that brings in money on the screening and Nutritional products to decrease risks for developing AMD).
How many of these services do you think I would be able to offer my patients at Wal-mart? That is a serious question. I know Wal-mart’s marketing strategy has been price so is it realistic to expect to offer the highest quality services and technology (which makes their lives better——clear, comfortable vision makes people more productive and nicer
when that is not the kind of patients that they have traditionally attracted?
How do I find out more about this OBA? (are they related to Obi Wan Kenobe?)
My challenge for all OD’s reading this blog is to have a civil conversation about what is realistic and acheivable without personal attacks.
Thanks
[I posted a link to them in another post, but you have to have a user name and password to access their site. A really useful thing they have is the "Key Metrics of Optometric Practice at Wal-Mart and Sam's Club" which I will mirror here until someone's legal department sends a cease and desist letter, but I do so not having seen or read anywhere that this information is confidential.
If you are thinking about signing a Wal-Mart contract, I would ask the District Manager for a way to log into this website so that you can see all the great resources they have. -DJL]
Clint,
The answer to your question about what tech you can realistically have at WM is that you can have whatever you want. I treat a reasonable amount of glc so advanced tech is a must. The only issue that sometimes comes up is space, but generally there are ways to overcome those problems.
What I don’t like to see is ODs sell themselves short on their fees because it does tend to limit the amount of technology you can actually afford to put in. I charge $85 for an s-code and a medical exam is $120 plus $25 refraction. I consider my fees to actually be a little on the low side, but there are a lot of ODs out there that consider those fees just unacheivable.
“If I may, I am another Wal Mart OD and also an ODWire user. I can assure you that I rank considerably higher in the “most hated” category than you.”
I’ve heard this imbecile raving on ODwire. I would agree…he (Stephen Nelson) probably is the most hated OD in America.