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Any readers of this blog entry entitled “The Perks of an Optometry Career” need to read my “Do Not Become an Optometrist” entry or my “Should YOU Open a Private Practice?” entry.

How does the perk of working every Saturday sound? How do you like getting home many nights at 8:00 PM, (just in time to tuck your kids into bed)?

Unless an optometrist is employed by a big chain or there is some extreme emergency, hours are generally restricted to Monday through Friday with no on-call duty needed.

That’s not true in today’s market. Only government workers get Saturdays off now. More and more private practices offer extended hours and Saturday hours to stay competitive in today’s market. People don’t take time off work anymore just for routine eyecare (but of course they’ll do it for the dentist, but not you…a lowly optometrist).

Oh, and other doctors don’t have to worry about their scope of practice being legislated away.

And how do you like having a cap on potential income? You can only see so many patients a day. Get rich selling an unlimited number of widgets that everyone wants. Only become an optometrist because you love it…but, that begs the question how do you find out that you love optometry without going to expensive optometry school? By the way, when I went to optometry school (PUCO 2003), it cost about $22,000 per year for tuition, including fourth year when you’re not even at school because you are on preceptorship. Last I heard it’s up to $27,000 per year.

So my question is, at what price point does optometry school become unfeasible?

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There was an interesting article written at the AmateurEconomist.com about “Why Doctors Are Not Good Businessmen.”

Hat tip to Kevin, M.D. who commented on this story and said,

“This is why the private practice model of medicine is dying. More practices are being bought by hospitals where the physicians are salaried. This relieves the burden of administrative tasks and supervising ancillary staff, so that the doctor can focus on medicine.”

Rob at VSP says that “[private practice doctors] provide the best care.” Well, if I’ve got the weight of a business on my shoulders, doesn’t that detract from patient care? Additionally, in our field where the private practice doctors sell what they prescribe, can you totally rule out any conflicts of interest which potentially detract from patient care?

Again, independent doctors of optometry in a Wal-Mart setting don’t have the conflict of interest and their administrative duties are much less than private practice.

What’s funny to me is that every CE event I’ve been to always has some talk about why optometrists should start the “medical model” in their practice and watch the money role in. Well, how is adding more third party payers going to help you make more money? Primary care medicine is dying according to Kevin M.D., and yet the roboconsultants are telling us to join more insurance panels. I think getting rid of insurance companies in your practice is the way of the future.

The roboconsultant woos you buy saying that for one case of dry eye you can milk an insurance company for $500-$800 in office visits and procedures. Well, do you do that for every dry eye patient, even the poor self pay patient or the patient with insurance but poor benefits? I would think that doing it just for those with good insurance would be unethical as well as probably insurance fraud.

I think the more your appointment book is filled up, the more you should be able to charge for your services. It’s the old supply and demand of free economics. I think a better system would be for patients to have to front the money to pay the doctor for office visits at the time of service. The patient would have to get reimbursed what they can from their insurance company. Maybe then insurance companies would be forced to have a faster turn around time on processing claims for their patients and be watched more closely for just rubber stamping a denial based on some frivolous billing exercise (or at the least the patient has to worry about it instead of me.) I simply provide the best care for the patient, recommending only the products and services that they need, since now I don’t have to worry about getting paid.

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So Rob’s Blog has this to say to people about getting yearly diabetic eye exams. As if optometrists in a commercial setting don’t do the same thing, he tells a big lie here:

…these [private practice] doctors consistently have the longest relationships with their patients and provide the best care.

Rob, people aren’t buying what you’re selling anymore. I see VSP beneficiaries out of network all the time in my Wal-Mart setting. I guess they aren’t loyal to a practice setting, but rather they factor in price and convenience while assuming, correctly, that any doctor they see in my area is competent.

Oh, and I remember when Intel in the Hillsboro/Beaverton, Oregon area was buying your VSP, and then they switched to EyeMed. Does that mean they thought your private practice network of doctors couldn’t “provide the best care?”

But I see what he’s trying to do. Any roboconsultant will tell you that you need to differentiate yourself from the competition; however, I take exception when he lies.

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I keep hearing this type of comment: “I don’t understand you. I’ve read your blog when you were in private practice versus now. I don’t think you know what you want out of life.”

They seem to be saying that I’m a flip flopper and must be some unhappy individual who is lost. You can’t discredit me because I’ve experienced three major forms of practice. Someone who has experienced government, private, and various flavors of commercial is not a lost soul, but rather he is an experienced voice.

I implore all students and new O.D.s to listen to my words. If you would like the security of government work and don’t mind living in remote locations, then by all means be a government optometrist. If you want to be able to live in more populated areas, than choose commercial practice over private and choose Wal-Mart over all other commercial options.

In my previous posts advocating private practice and demonizing commercial, I had been drinking the private practice cool-aid that I’d been served since optometry school. Some of the disparaging remarks against commercial hold true for many brands of opticals, but not Wal-Mart.

Private practice is too risky. Sure, you know or have at least heard about successful private practice businesses, but you can’t assume that things would go well for you if you were to hang up a shingle. The money it takes now days to start cold could be better invested in Vegas. It’s a crapshoot, heavy on the crap because the frame vendors, the lens suppliers, ophthalmic equipment companies, the financing company, the advertising people, the landlords, the employees and more all get their money from you. But when do you get paid? Paying all of those people doesn’t automatically bring patients in the door. And when will you actually get enough patients to break even? That could be never, you know. You may just have to close shop when the money dries up, like I did.

Wal-Mart makes it risk free. There will always be patients coming to your door. Your success is only limited by the number of hours you are willing to work. That’s why if you want to be rich, make and sell widgets. If you want to do eyecare, work for the government or Wal-Mart, depending on where you want to live.

Anyway, just because I’m giving advice from my experience doesn’t mean I’m somehow lost or unhappy. I have family, religion, and a great job inside a Wal-Mart Vision Center. Of course I’m happy.

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Here is the scenario. One doctor can own a Wal-Mart contract (or a Sam’s Club contract for that manner) for more than one location at the same time. Wal-Mart usually decides to do this if the locations are struggling with volume and/or having a hard time finding someone to fill the location.

Can the doctor physically be at two places at once or work eight days a week? No, so he hires someone. Let’s call the multi-contract owner Dr. Fingers and the two doctors who work for the contract owner we’ll call Drs. Desperate and Disgruntled. Wal-Mart needs three locations filled: Bountiful, Ghetto, and Rough Diamond.

So let’s say Dr. Fingers works Bountiful and hires Dr. Desperate at the Ghetto location and Dr. Disgruntled at Rough Diamond. The contract is similar to “I’ll pay you 70% of your gross receipts.” Dr. Desperate says fine because she just needs a job and doesn’t care about a long term commitment because she’s willing to relocate in a moments notice. Dr. Disgruntled is in a bind because he really wants to live in the city of Rough Diamond forever, but he doesn’t want to pay Dr. Fingers 30% of his gross receipts, especially when he finds out that Dr. Fingers is only paying Wal-Mart 10% or if the contract is some ridiculously low flat fee not even based on receipts.

So what happens? Usually Dr. Disgruntled will leave and try to find his next best ideal location. Dr. Fingers will probably have to funnel in and out doctors every couple years. The vision centers stagnate and never grow because the doctors who work there have no vested interest in growing the practice since they know they won’t be there long term since Dr. Fingers takes so much of their money.

I believe that it is a mistake for Wal-Mart to give any doctor a contract for more than one location just so he can suck cash from other doctors for no reason other than, “Hey, I own the contract.”

Now, I can see how some of you might say, “But what if you had a multi-doctor parnership share multiple locations equitably?” Well, you’d still have the problem of the last location not growing because the doctors rotate every day, and then which of the doctor partners would volunteer to work at the last location on its poor performing days?

It’s better for the vision centers, the doctors, and even the community to have each doctor own the contract for the vision center that they work in.

“But what about vacation days?” you say. Well, wouldn’t it be cool if each area could have it own full time fill-in person? Maybe the fill in person could always keep 100% of his receipts and not have to pay rent to subsidize the days when there isn’t an opportunity to work? I don’t know, I’m just thinking out loud here. Or you can probably find a private practice doctor who needs supplemental income to work for you.

“But our store needs someone, and we can’t find anyone, so thank Heaven for Dr. Fingers,” you say. Well, that’s a short term solution that defeats you in the long run. None of your sub-contracted doctors would be motivated to grow the practice (an thus increase vision center sales) like a contracted doctor would. This scenario will just stagnate you at mediocrity. If you must hire Doctor Fingers, I think the terms should explicitly say that Wal-Mart has the option to not renew Dr. Fingers contract at the satellite location if they can find a permanent doctor when the contract expires in three years. I don’t care if Dr. Fingers is taking a “risk.” He has three years to recoup his “risk.” Take it or leave it, Fingers.

But let me restate. Multi-location contracts for a lone doctor who invariably gets greedy and pockets cash for not doing any work: BAD. Allowing a doctor to own the contract where he actually works in order to change it from slow to crazy-busy: GOOD.

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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.

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This is what I wish I could say to patients when they ask about private practice glasses prices. Do you ever feel like we’re being sold out by the very lens companies that say they’re looking out for us? For example, Wal-Mart sells lenses for cheaper than I can buy them from my lab. How does that happen?

What if a whole bunch of private practices started a co-op lab so that all profits from the lab go to the doctors? Or is Red Tray Optical the answer?

I like the consignment deal that VSP offers with their line of glasses. Why should I have to pay for frames that haven’t sold? Since frames now days look so freaking wacked, I think all frame vendors should work on consignment.

All I know is that doctors seem to be getting the short end of the stick while the frame and lens makers are assured their cash. I don’t see a profit motive for Big Lenses to help out private practice docs since commercial makes them more money overall.

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