Published in Non-Clinical

How to Open an Ophthalmology Practice Cold

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13 min read

This article reviews the steps to opening an ophthalmology practice cold based on the experiences of Brian Shafer, MD, in establishing Shafer Vision Institute.

How to Open an Ophthalmology Practice Cold
As a passionate ophthalmologist, the confines of a group practice felt suffocating. Bound by constraints, seeking approvals for basic changes, and being left out of major decisions had become my daily reality.
When a transition plan to a solo ophthalmology practice unexpectedly dissolved, I found myself at a career crossroads, jobless. However, in that moment of uncertainty, the dream of Shafer Vision Institute was born.
Within 4 months, this vision transformed into a full-fledged reality. People often ask, “What are the steps that you took?” In truth, the steps are more like an MC Escher staircase than a ladder.
Apart from a few, most of the “steps” below happened in concert rather than linearly.

Forming the corporation

Before anything could happen, I needed to create the legal entity, Shafer Vision Institute (SVI). In the first days of unemployment, I sat on the phone with my accountant for 2 hours, going through all the necessary documentation. By the end of the day, SVI had a tax identification number (TIN) and was incorporated into the state of Pennsylvania.
A huge step, but in reality, Shafer Vision Institute was still just a dream. I needed money, an office, an electronic medical record, practice management software, multiple types of insurance, a website, a marketing strategy, employees, and, most importantly, patients.

Forming an identity

Differentiation, positioning, and targeting are critical for the success of a start-up. As a full-scale anterior segment surgical specialist, I enjoy providing services ranging from premium refractive cataract surgery, corneal transplants, dislocating intraocular lenses (IOLs), glaucoma surgery, laser in situ keratomileusis (LASIK), EVO implantable collamer lens (ICL), and more.
This is unique in Philadelphia, a city saturated with hyperspecialized ophthalmologists. Thus, the mission of Shafer Vision Institute became clear: to deliver university-caliber care in an intimate private practice setting.

Show me the money: Securing funding

The daunting task of establishing SVI began with drafting a comprehensive business plan. This document spanned over 30 pages, detailing financial projections and outlining the venture's viability. I approached both national and local banks and ultimately found a banker that I enjoyed working with at Provident Bank. After a rigorous due diligence process by the bank, I secured a conventional loan and a line of credit, setting the ball rolling for my dream.
While the corporation was going to be funded, my personal bank account was not. Being willfully unemployed for a few months meant that personal finances became very tight. Thankfully, I have an extremely supportive wife who was willing to tighten our spending with me to make it possible to survive without an income for a few months.
The limited experience in my career meant that I didn't have the financial cushion that seasoned professionals might possess, and this was certainly a risk. Fortunately, I was able to secure a part-time position at Temple University Hospital as their only cornea specialist. This allowed me to have a steady income while working once weekly teaching students and residents.

Finding a home for SVI

I took a systematic approach to finding the perfect location for SVI, factoring in four components:
  1. First, I ensured that I adhered to my former practice’s non-compete clause, staying clear of the 10-mile radius.
  2. Proximity to my residence was equally crucial, ensuring a practical commute.
  3. Furthermore, the site needed highway accessibility, ensuring a broad patient reach.
  4. Equally essential was to ensure the chosen location wasn't oversaturated with specialists in refractive cataract surgery, corneal transplants, or glaucoma surgery. Premium services require a clientele with a disposable income. Hence, regional average income became a pivotal factor in my decision.
After rigorous research and considering all these parameters, Plymouth Meeting, PA, seemed like the optimal choice. Initially, the idea of subleasing from another ophthalmologist or optometrist seemed attractive due to the low startup cost.
However, I recognized that my long-term vision included expanding services, requiring full office control. After an extensive search, I stumbled upon an established ophthalmology practice seeking to centralize its operations to its primary location 10 miles away.
Instead of taking over the practice operations and patient base, we negotiated an asset purchase agreement. This allowed me to acquire tangible assets like slit lamps, furniture, and specific tenant improvements. This negotiation phase, although brief, was intense, culminating in a finalized deal by July 1. The subsequent month became a whirlwind of preparations for the August 1 opening.

Developing a marketing strategy

Marketing is both essential and expensive. I am generally easygoing, but I really am quite particular when it comes to the identity of SVI. I want complete control over my internet presence. Instead of outsourcing, I took the reins myself.
This involved learning the intricacies of website design, graphic software, and more. The month of June involved negotiating my purchase agreement and building my website. After a month-long effort, I had done it. While I had a website, I didn’t have a stream of patients prepared. That’s where practice development comes in.
One thing I take seriously is my relationship with other eyecare providers, both optometrists and ophthalmologists. Given my specialized skill set, referrals will likely make up a large portion of my practice. When meeting with other doctors, I make it clear that I am available for whatever backup they need and will always remain respectful of their patients and practice.

Purchasing equipment

The practice's purchase agreement included fundamental equipment like slit lamps and exam chairs. However, technological advancements were required, meaning updating outdated systems. The Herculean task involved transitioning from Windows 7 to Windows 11, replacing AV cables with HDMI and DisplayPort, and countless hours of manual labor. I will never forget standing chairs and fishing wires through the ceiling and walls to upgrade the visual acuity charts!
I ultimately decided to purchase the diagnostics that I truly needed and then one that I frankly just wanted. I needed an optical coherence tomography (OCT) machine that could do anterior and segment, including epithelial mapping. This made the Zeiss Cirrus 500 HD-OCT the perfect choice. I needed a biometer that could measure posterior corneal astigmatism, so I bought the Zeiss IOLMaster 700. By purchasing together, the Zeiss equipment was bundled and cheaper than the sum of their individual parts.
As a cornea specialist, I need a topographer. I chose to upgrade my topographer to the iTrace so that I effectively measure aberrations and manage all IOL issues that come my way. I ultimately decided that for convenience, I would get the Optos. Wide-field fundus photography is a luxury, not a necessity, but for my ultimate patient workflow, it will add to the experience.

Electronic health records and practice management

While I’ve used most of the big electronic health records (EHRs), I used Modernizing Medicine in my last job and really liked it. While I knew it worked as an EHR and practice management (PM) software, I did not realize they also had an add-on called BOOST that could function as your billing team. This allowed me to integrate my EHR, PM, and revenue cycle management (RCM) all in one!

Acquiring practice insurance

Establishing an ophthalmology practice requires multiple insurance coverages, including malpractice, business, cybersecurity, and workers' comp insurance. Generally, this was the easiest part of the process as insurance brokers are very eager to enroll businesses into their plans.

Credentialing

Ambulatory surgery center (ASC) accreditation

The moment I realized that I would be remaining local, I started to research where to operate. I obviously could not operate at my former ASCs due to my restrictive non-compete.
Pennsylvania is not a certificate of need (CON) state, and therefore ASCs are plentiful. As such, I began the credentialing process with two centers, each 10 miles from my office in different directions. This was to account for patients from diverse geographies.

Insurance

While I am individually on par with most insurance plans from my academic jobs and prior private practice positions, it takes insurance companies a very long time to recognize a new professional corporation. Unfortunately, this has been the aspect of practice creation that is most out of my control, and, consequently, the biggest hassle.
In general, Medicare will not begin the credentialing process until 30 days prior to the opening of the new practice, and the new practice must have proper signage on the door first. This posed a challenge, as I did not have a lease secured until exactly 1 month before I hoped to open the doors.
The timing was critical, and although I met all the criteria, the delays remain. There was nothing I could have done differently in this aspect, but to date, I am still not on par with all insurance companies.

The art of hiring employees

Starting a new venture inevitably led to some past colleagues reaching out. One such serendipitous connection led to hiring an old associate as my office manager. The power of networking further expanded my team, with the office manager's friend joining as the clinical coordinator. For added efficiency, I collaborated with MyTeem for an access center to streamline communication channels.
Ensuring consistent patient care quality is paramount. To achieve this, I spent the 2 weeks before opening the doors doing rapid-fire education and planning with my team. These sessions, spanning an hour or more, involved in-depth discussions on various topics, ensuring the entire team was aligned with our core mission.
This also helps to ensure that any patient who calls in can have their questions answered. Most importantly, I let my team know daily that I deeply care for them, their families, and their career satisfaction.

Legal considerations

I never thought that I would speak to so many lawyers in such a short period of time. Legal counsel is expensive, arduous, and frankly frustrating but completely necessary.
I hired an employment attorney to protect me from violating any of the clauses from my former contract and to review my employee handbook, a healthcare attorney to assist me in the asset purchase agreement and to prevent me from violating the Stark Law or Anti-Kickback Statute, and a real estate attorney to assist me with my lease.

Challenges and solutions

The journey, although rewarding, came with its set of challenges. The unexpected job loss, the financial strain of unemployment, the complexities of IT services, and the tedious credentialing process tested my resilience. However, each challenge offered a lesson, from deepening family bonds, financial discipline, upskilling in IT, to patience during administrative processes.

Final thoughts

Embarking on this venture taught me that dreams are achievable with determination, support, and adaptability. The challenges faced in establishing a practice pale in comparison to the rigorous journey to become an ophthalmologist.
Potential entrepreneurs must harness the vast support network available, listen to varied opinions, and then chart their unique path. At Shafer Vision Institute, our essence remains: Delivering university-caliber care in an intimate private practice setting. And guess what? The doors have opened!
Brian Shafer, MD
About Brian Shafer, MD

Dr. Shafer is a board-certified, fellowship trained cataract, refractive, cornea and glaucoma surgeon. He completed medical school at Temple University School of Medicine and ophthalmology residency at the University of Pennsylvania, Scheie Eye Institute.

After residency, Dr. Shafer spent a year as the cornea, refractive, glaucoma, and anterior segment fellow at Vance Thompson Vision in Sioux Falls, South Dakota. Dr. Shafer is the Founder and CEO of SVI, Shafer Vision Institute, a premier private practice in the Philadelphia area that is committed to providing university-caliber care in an intimate private practice setting.

He is an adjunct assistant professor of Ophthalmology at the University of Pennsylvania and a clinical assistant professor (adjunct) of ophthalmology at Temple University Hospital. He is passionate about providing meaningful improvements in quality of life by giving patients the care they need and deserve. His professional interests include advanced technology IOLs, sustained drug delivery in glaucoma, and the patient experience.

Outside of medicine, Dr. Shafer is a loving husband and father and enjoys fishing, gardening, and seeing live music.

Brian Shafer, MD
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