Welcome back to another installment of Retina Mentor Moments! In this episode, John W. Kitchens, MD, is joined by David G. Miller, MD, to discuss challenges faced by modern retina practices, such as treating patients in rural areas, failed clinical trials, private equity (PE) acquisitions, and hiring doctors.
Dr. Miller is the President of Retina Associates of Cleveland, in Cleveland, Ohio, and serves as the Medical Director of Cleveland Eye and Laser Surgery Center.
Improving access to eyecare in rural communities
Despite the fact that 20% of the US population lives in rural areas, less than 10% of US physicians practice in rural areas.1 Moreover, 61% of counties lack an ophthalmologist and 24% have access to either an optometrist or an ophthalmologist. This translates to 11.7% of Americans living in counties without any ophthalmologists.1
In addition, rural residents are more likely than urban residents to be 65+ years, below the federal poverty level, and uninsured—highlighting a workforce discrepancy that impacts the burden of care faced by rural ophthalmologists.1 To address this growing problem, some retina practices have adopted strategies, such as building expansive referral networks and establishing satellite offices, to better serve patients in rural areas.2
Differences in rural and urban/suburban eyecare
Dr. Miller explained that his practice has 14 main offices and eight satellite offices in more remote locations to provide better access to care for the rural communities surrounding Cleveland. The main offices are open on a weekly rotating schedule, while some of the satellite offices are open every other week.
Dr. Kitchens’ practice has a similar setup with main and satellite offices, and anecdotally, he described differing prevalence in retinal diseases between rural and urban or suburban patients. For example, in Lexington, Kentucky, 80% of his patients have macular degeneration while 20% have diabetic retinopathy, but in eastern Kentucky, this ratio is closer to 60% macular degeneration and 40% diabetic retinopathy.
Dr. Miller added that he has seen similar rates of diabetic retinopathy in rural communities in Ohio. This is likely because glycemic control and eyecare visits can be more difficult to consistently access in rural communities, so there is an overall greater disparity in medical care that leads to worsening diabetic retinopathy.3
To hear insights into the value of failed clinical trials, such as those for submacular surgery and anecortave acetate, watch the full interview!
Private equity in retina
In recent years, private equity has disrupted the classic private practice ownership model in ophthalmology by the acquisition and consolidation of practices by private equity firms.4 Support for and against the sale of private physician groups to larger, privately-owned management groups remains a hot topic of debate in ophthalmology.
Interestingly, industry experts have noted an increase in the number of ophthalmologists who want to maintain or start an independent private practice due to:5
- Profitability
- Dissatisfaction with consolidated management
- Creating a preferred culture
- Greater control of care
Is private equity right for my retina practice?
In the past 6 years, Dr. Miller’s practice has gone through the process twice of evaluating whether PE practice management would be a good fit, but both times, they decided not to move forward with PE. This was in part because concerns were raised by younger doctors who had more recently joined the practice that it may not be an equitable solution for them.
As such, along with financial considerations, the group decided not to pursue PE because it is difficult to recruit new doctors, so they wanted to prioritize keeping the team together to maintain the strength of the practice. He added that PE is tempting for some practices, so for doctors interviewing for jobs, Dr. Miller recommended asking whether the practice has considered joining PE.
If they have considered it and decided not to pursue PE, that practice is less likely to change its position, especially compared to those who haven’t fully considered PE, who may ultimately conclude it is an attractive option.
Watch the interview to learn more about the doctors’ experiences with private equity in ophthalmology!
Tips for interviewing and hiring doctors for a retina practice
Dr. Miller’s technique for interviewing doctors for his practice is to describe an average week at the practice and where/how the doctors typically spend their time, and then watching how the candidate reacts.
For example, one of the founders of the practice worked on Saturdays (and took off Wednesdays), so many of the doctors work half days on Saturdays twice a month. Some people immediately show no interest in working those kinds of hours or on the weekend, which is important to note during interviews.
He added that it is crucial not to overemphasize the unpleasant parts of the practice compared to another practice, while also not covering up any expectations for candidates. With this approach, there have been very few people who have left his practice because they knew what they were getting when they came in.
Conclusion
Between PE acquisitions, new technologies, and offering eyecare services to underserved populations, leading a modern retina practice requires the ability to analyze and adapt to changing conditions.
Fortunately, there are many examples of successful private retina practices, like Retina Associates of Cleveland, that demonstrate private practice is not only sustainable but also potentially a preferable option for doctors.
