Its not exactly a revolution, but you could call it accelerated evolution. As optometrists continue to embrace an expanded scope of practice that requires more expensive instruments, larger offices and bigger staffs, solo practice is on a decline, and group practice is on the rise.

Indeed, surveys by the American Optometric Association (AOA) and Jobson Publishing show that, while self-employment remains dominant among O.D.s, the mix of independent practices is changing. Specifically:

The number of O.D.s practicing in partnerships or groups has doubled in the past eight years, from 20% to 40% of practitioners.

If you define a group practice as three or more optometrists, that number has doubled as well, from 8% to 16% of O.D.s.

The number of O.D.s in solo practice has decreased since 2001, from 59% of practitioners to 53%.

The trend is mirrored in other health-care professions. Back in the 1980s, physicians began to form groups. By 1991, about one-third of physicians were practicing in groups of three or more doctors. The percentage remains the same today, says the American Medical Association.

The American Chiropractic Association says that about one-third of its members share an office with one or more chiropractors. A spokesman for the American Dental Association says its data do not indicate an erosion of solo practice, yet ADA figures from 2002 show that 35% of dentists practice in partnerships or groups.

Their rival, the American Academy of Dental Group Practice (AADGP) says its membership of 240 group practices (with an average of four to five dentists per group) has grown 15% in the past five years.

Dental practices are more profitable in groups, says Robert Hankin, executive director of the AADGP. They have lower operating costs and a more pleasant working environmentpeer review, collegial exchange; youre not just toiling away alone. Groups make more money because theyre good at delegation and more aggressive in marketing.

AOA data show that optometrists who practice in groups have a better bottom line. Its 2006 Caring for the Eyes of America report shows that O.D.s in practices with three to five doctors make the most, with $184,500 in median net income. Solo practitioners have a median net income of $110,000, while the median for a two-doctor practice is $136,000. Doctors in group practices with six or more O.D.s typically make $150,000.

Using AOA research, we can identify the characteristics of the optometrists who have the greatest earnings potential: 15 to 25 years in practice, a private-practice setting, and partnership in a group practice of optometrists, says Richard C. Edlow, O.D., chairman of the AOA Information & Data Committee.

Not That Simple

Given these statistics and the expanded scope of optometric practice, group practice seems to be a slam-dunk. However, conversations with optometrists and consultants reveal that those who have taken the plunge into group practice have found the waters to be brisk and challenging at best and, at worst, murky and fraught with peril.

The more partners you have, the more difficult decision making is, says Greg Kraupa, O.D., the senior partner in a five-optometrist practice in Fridley, Minn. To get all the doctors together in one location, then come to a joint understanding regarding a specific issue, is very challenging. And, after a certain point in size, the doctors cannot continue to manage the prac- tice, he says. When you are trying to see patients, be a good clinician and then wear other hats related to business management, theres not enough of you to go around.

Optometrist Greg Evans recently parted with two ophthalmologists associated with Evans Eye Care, in Palm Desert, Calif. Dr. Evans is left with one busy location, a new, larger office, and a third office in the works. Yep, thats me, working on the chain gang! Im not exactly sure how Im going to run two (maybe three) busy practices, he says. However, my goal is to grow the practice both financially and professionally (nicer office, room for growth) to attract another partner.

Scott Daniels of Practice Concepts, Costa Mesa, Calif., represents practice buyers and sellers, negotiates mergers and advises O.D.s about how to grow their practices. He doubts that group practice is for everyone.

Just because you have more doctors doesnt mean you make more money, he says. Being a partner is very difficult, especially if youre a small business owner who has been doing it for years by yourself.

Sage Advice

If youre thinking about forming or joining a group, heres some advice from those who have already done so.

1. Draw up a legal document. This agreement should spell out in as much detail as possible who owns what in the practice and who is responsible for what. Make sure to clearly delineate an exit procedure for any partner who decides he or she wants out.

2. Get your own lawyer. Although you may feel that youre all on the same side, a time may come when you will not feel so kindly toward your partners. Hire your own attorney to protect your interests as you go in.

3. Do your due diligence. Insist on having access to the books of a practice you may be joining, and turn them over to a certified public accountant for an independent audit. If you get resistance on this, consider it a red flag.

4. Hire a qualified manager. By pooling resources, you can afford to pay a competitive salary for an experienced business manager. This will be well worth it, as running a group practice is much more complex than running a solo practice.

5. Focus on communication. Just as in a marriage, communication is the key to working out differences. Invest in behavior profiling to understand each others style of communication, and obtain professional help to work out significant differences.

Grow Your Own

Practitioners report there are several ways to create a group. The most common way: Grow your own. Thats what optometrist Kerry Beebe, of Brainerd, Minn., did.

Fifteen years ago, Kerry Beebe, O.D. (left), of Brainerd, Minn., brought in a young associate. That young associate, Steven Monda, O.D. (right), has since become a partner in the practice.

I started solo 30 years ago, then merged with an older optometrist and practiced with him for 10 years, Dr. Beebe says. When he was nearing retirement, I brought in a young associate [Steve Monda, O.D.], who later became my partner and has been for 15 years. Now we have a young associate who may be coming in as a partner in the next few years.

To those who feel they cannot afford to add a full-time O.D., Dr. Beebe suggests trying a doctor-sharing system thats worked for him twice. Find a colleague, located about 30 miles away, who also needs a part-time associate. Hire the associate to work part-time at each practice. All three doctors have time to get to know each other, and as the two practices grow, they can determine the best full-time situation for the younger O.D. Taking it one step at a time works best for everyone, says Dr. Beebe, who has been both the young guy and the old guy.

Dr. Beebe offers this advice: Start with an employed associate arrangement for several years before entertaining partnership. Then, you work out how to split income, and what to do in the event of death, disability or retirement. Put as much as you can in writing. When you are friends, its easier to agree. Later, if there are big problems, you can simply refer to the contract.

Optometrist Robert Sorrell also built Middletown Eye Care, of Middletown, Ohio, from a solo practice he started more than two decades ago. For about five years, an older O.D. practiced with him. Then, he says, It was time to build a larger office and offer a new graduate a starting spot.

In that case, the associate did not work out as a partner. Still, Dr. Sorrell says, its important not to give up but to continue searching for a potential partner. I then found another young grad who was finishing a disease residency at Cincinnati Eye, he says. That [doctor] has worked well and still does. He is a partner who is buying a percentage of the practice.

Dr. Sorrell says he sought professional advice on the buy-in and extended a package that made it possible for the younger doctor to become a partner. We were advised to do a salary reduction buy-in, he says. We determined the living standard that the associate needed. He then draws that amount against monthly production. Any amount above his percentage of production goes toward the buy-in. It was very important that we put a fair market price on the practice and take the buy-in pressure off by having a flexible payment.

A third doctor is now part of the practice as well. When she is ready, the same buy-in arrangement will be offered, Dr. Sorrell says.

Optometrist Calvin Clarke built his group practice in Wichita Falls, Texas, the old-fashioned way: He brought in his son, Danny, and daughter-in-law, Elizabeth, after they graduated from optometry school. Now in practice together for more than a decade, theyve been able to expand into a 5,000-square-foot building that they designed and built together.

In Wichita Falls, Texas, optometrist Calvin Clarke (right) brought in his son, Danny, and daughter-in-law, Elizabeth, after they graduated from optometry school.

In a group, you can more easily specialize in what you like, says Dr. Danny Clarke. My wife likes pediatrics. That helps us because my dad and I dont want to do that. I am more medically oriented, so I see more of the medical patients. You dont have to do everything like a solo guy does.

Show Me the Money!

Those who have joined groups and formed themeven starting coldsay theres always a way to achieve financing. Sources include:

The practice itself. Create a buy-in agreement that allows a practitioner to make a decent living as he or she acquires ownership over time. Get professional help with the agreement.
Private lenders. Scott Daniels of Practice Concepts says he can locate 110% financing for practices that are profitable. Private lenders also are more willing to take a risk on a new graduate or young O.D., says Robert Steinmetz, O.D., who offers a course for new O.D.s called Business Aspects of Optometry.
Banks. These folks are fairly risk-averse, so recent optometry graduates may not fare so well. But if you have a track record, or if you are associating with an established practitioner who does, the banks may be your best source.

Family financing. Dont be shy about asking family members who have money to invest. Optometry is a very good business, and group practices show some exceptional returns.

Prepare for Opportunity

Some O.D.s describe unique situations that proved to be the right group practice opportunity at the right time. They stress that being prepared helped them to recognize opportunity and seize it.

When Chris Browning, O.D., graduated from Indiana University School of Optometry in 2002, he was determined to go into private practice in his hometown of Indianapolis. He could not find full-time employment with an optometric practice, so he took two part-time positions. After a time, it looked as though he would be able to buy into one of the practices. Once he entered negotiations, however, he concluded that he and the practice owner would never agree on a valuation.

In the other practice, a group at which Dr. Browning filled in, a partner decided to retire. The failed negotiations with the previous employer proved to be a valuable experience, Dr. Browning says.

In the group practice, each doctor had his or her own location, he says. The doctor who was retiring wanted me to make an offer. Since I had learned a lot about practice valuation, I felt I could do that. I also felt I could buy low, improve productivity and increase revenue.

Not long after Chris Browning, O.D. (left), graduated in 2002, he tried to buy into a group practice, but negotiations failed. Still, this experience proved valuable when he joined the group practice of VisionQuest Eyecare, in Indianapolis.
(Below) The optometrists in the practice are Dr. Terry Null, Dr. Alma Noreika, Dr. Browning and Dr. Kathleen Ammel. Not pictured: Michael Jeffirs, O.D.

His confidence is paying off. In his first year as a partner in VisionQuest Eyecare, P.C., in Indianapolis, Dr. Browning says hes improved his locations gross by 25% and his net by 91%. In the second year, the gross was up by another 20% (the net was stagnant due to a $250,000 reinvestment in instrumentation).

Kind of Like Dating

Nevada Vision Group, a three-doctor group in Reno, Nev., was formed after several years of preparation and upheaval that proved invaluable to its success. Jim Conkey, O.D., says he led the merger of three solo practices into a group located in a large building that he owned. The three practices had undertaken the merger when one of the optometrists decided the group was not for him.

We had a lot of issues to work through, but the one we couldnt resolve really was one of visionwhere did we see the group practice heading? It became apparent that two of us were in agreement, but the third partner wanted to go in a different direction, Dr. Conkey says.

When that doctor returned to solo practice, Dr. Conkey and the remaining partner, Paul Wilson, O.D., felt the practice still had room for a third O.D. Meanwhile, optometrist Tamara Old, then employed by an ophthalmology group, indicated that she had enjoyed the exposure to pathology, but that she did not enjoy being an employee. Since she had been looking for a practice ownership opportunity, she connected with Drs. Conkey and Wilson.

Because of Drs. Conkey and Wilsons recent experience, they started slowly. Dr. Old actually started a solo practice in their building, and then merged it into the group practice.

Starting a practice was hard, even though my partners gave me breaks on overhead, Dr. Old says. I learned a lot, though, and it has helped me as we face challenges with the group.

Two such challenges: staffing and communication. When the three partners merged their four-member staffs into a single 12-member staff, Dr. Old says, it became an entirely different beast. And because the partners have very different personalities (a plus in group practice, doctors say), they put extra effort into discussing issues and resolving them.

Its ideal to work with the practitioners before joining the group to see how you will work together, she says. Its kind of like dating. You may notice some things, but you dismiss it; you dont take it seriously. When you become married to it, those things can make you crazy.

Start Fresh

Mr. Daniels observes that partners seem to clash the most when they have been solo O.D.s for years and attempt to merge established practices. Its easier if the partners are new or recent graduates who do not have set operational habits.

Thats certainly what optometrists Robert Steinmetz and Casey Hogan found when they started cold in Chicago in 2003. Both were determined to succeed in private practice and found their way together as business owners.

Im the kind of guy who wants all the toys, and Casey is someone who is conservative. She keeps me under control, Dr. Steinmetz says.

They started humbly, in just 500 square feet of space and with one employee (who is still with them). Both optometrists worked outside of the practice part-time to bring in cash until their practice got on its feet. The surprise was not how long that took, but how quickly they achieved growth.

When we took the lease on this small space, it was attractive because it was inexpensive. Now, we need more space, and we see that we could have afforded it from the beginning, Dr. Hogan says.

(Above) Optometrists Casey Hogan (left) and Robert Steinmetz (center) started cold in Chicago in 2003 with a mere 500-square-foot office. To their surprise, their practice grew more quickly than they expected. So, they opened up a second office and brought in the experience of Roberts uncle, Stephen Steinmentz, O.D. (right).

(Below) Drs. Hogan, Steinmetz and Steinmetz established a new three-doctor office, SoLo Eye Care, which takes its name from the redeveloped Chicago neighborhood of South Loop. This office has a more upscale optical focus than their original, smaller office.

The practice, Advanced Eye Care Professionals, is now moving into a 1,200-square-foot officespacious by their current standards, they say. Drs. Steinmetz and Hogan have also opened a second practice, this one a three-doctor group, with Dr. Steinmetzs uncle, Stephen Steinmetz, O.D. Located in the newly revived neighborhood of South Loop, SoLo Eye Care has more of an upscale optical focus than their original space could handle, they say.

We saw opportunity in this growing neighborhood full of art galleries and trendy restaurants, Dr. Robert Steinmetz says. All of us wanted to start something here, but we didnt want to give up the practices we already had. Being in a group allows us to do that.

Because all three doctors never practice in the same location on the same day (Dr. Stephen Steinmetz also has another practice), it is a challenge is to get all three O.D.s together to make decisions regarding SoLo Eye Care. So, the three doctors have a monthly dinner meeting.

Its not always easy reaching an agreement, and we try to be unanimous. But, we have a rule that if two out of three agree, we will go that way, Dr. Robert Steinmetz says.

Both he and Dr. Hogan had significant school debt and little practice experience prior to opening cold, yet they still succeeded in a highly competitive area of a major city. If we can do it, anyone can, Dr. Steinmetz says.

Stay Solo

Given the challenges acknowledged by optometrists in group practice, staying solo might be the best choice for some personalities. In medicine, dentistry and chiropractic, some two-thirds of doctors still practice solo or in partnership with just one person.

I would love to remind everyone that solo practice is a very feasible, lucrative and immensely satisfying mode of practice. I answer to no one but the patients, and I am free to manage, market, promote and practice exactly how I see fit, says optometrist and practice-management consultant Travis Adlington, of Reno, Nev. Whats more, I really enjoy what I am doing.

Dr. Adlington says he teaches other O.D.s how to gross $1 million a year in a solo practice while working just four days a week. His wife, Cheryl, is an O.D. as well, but he says that she does not see patients; she manages staff and supervises practice promotion, much as an office manager might do.

For my personality, this is the best way to go, he says. I dont want to answer to anyone else. Group setting is like being married to several spouses. You are dealing with money all the time, and its very difficult to get others to think like you.

That certainly was the experience of Al Dufur, O.D., the partner who left Nevada Vision Group to return to solo practice. He professes no rancor toward his former partners (nor they toward him), but he says that hes happier being on his own.

Solo practice is great for me now, he says. It is more work than group practice and not as much flexibility, but you get to call your shots. In a group practice, you have multiple people making decisions, and you cant have that.

Dr. Dufur believes that one of the major challenges of having a group practice was that all three O.D.s in the group had been practicing solo for a significant amount of time. Each of you tends to have a strong idea that your idea is the way to do it, he says.

Now about 18 months into his new solo practice, he is very pleased with the result. When he left the group practice, he took his equipment and staff with him. He says his new location is better than his previous solo practice, and the assets he received when he cashed out of the group enabled him to purchase a building, which was one of the reasons he entered the group.

There was a penalty for exiting; I took a $50,000 hit so that I could cash out. But we had a good agreement with provisions for exiting, he says. Its very important to have a legal document like that.

Future Payoff

Those who successfully practice in groups believe they have put themselves in the best position in the marketplace.

Group practices are increasing in numbers for the same reasons theyve always existed: economies of scale. Its tougher than ever to remain profitable, says optometrist Gary Gerber, president of The Power Practice, a practice management consulting firm.

But doctors in group practice say its well worth it, despite the challenges. Building a group practice with partners takes patience, Dr. Sorrell says. But group practices are more likely to realize that they must grow and change. Often, a doctor in solo practice fails to make the changes needed to advance the practice.

And the bottom line is that its not just good for the bottom line. It may be the key to survival for some independent practices. Says Dr. Beebe: Unless you are independently wealthy, its difficult to compete by yourself in the eye-care market. To deliver full-scope medical care, you need multiple visual fields instruments, digital cameras, GDx, OCT, multiple treatment rooms and a big staff. Its hard for one optometrist to generate enough cash flow to support it all.

Vol. No: 143:11Issue: 11/15/2006