May 26, 2017
4 min read

Should your next provider be a medical doctor or an optometrist?

Base the decision on the current makeup and future direction of your practice.

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“The only source of knowledge is experience.”
– Albert Einstein

The demand for eye care is rising about 4% annually, or four times the growth rate of the American population — thanks, baby boomers! — and many times the pace of growth of the general economy in recent years.

As a result of this brisk rise in business, leveraged by retiring boomer physicians, the pace of provider recruitment is rising at the same time that ophthalmologists are getting harder and more expensive to recruit. Which leaves a lot of practice boards and administrators asking, “Who should we hire next?”

The answer to this month’s question starts with a simple reminder of how we always make decisions in ophthalmology, whether the issue is clinical, financial or administrative:

1. Is it legal?

2. Is it ethical?

3. Is it profitable?

Let’s take these three questions in order. Right off the bat, we can dismiss the first question, with the sole exception of the state of Nevada, where protectionist interests have made it illegal for an ophthalmologist to directly hire an optometrist. Everywhere else, you have a legal green light.

That leaves question two. Are ODs and MDs ethically equivalent providers of care? Although the answer would have raised some eye rolling a generation ago, most contemporary surgeons are quite comfortable with ODs and MDs practicing within the bounds of their training and skill.

And what of profits? The answer is, “It depends.” In some settings there can be a strong business case for adding optometrists sufficient for a 3:1 or higher OD:MD ratio and a countervailing strategic or boardroom sentiment to remain MD-only.

Here are five arguments on each side of the MD-OD coin for you to consider and apply the next time your practice needs to deepen its provider bench.

Reasons for choosing an MD

1. The first argument can be strictly economic. Surgeons, although harder to find and hire, can generate far more revenue per patient visit, per square foot of office space and per support staff member compared with optometrists. As a result, adding an MD covers more fixed overhead and gives the rest of the providers a pay raise. This is especially so if the MD chosen is a plastics or retinal subspecialist, in which case fees are higher and support resources are comparatively modest.

2. Hiring a fellow physician and surgeon can be more prudent in a small practice, where it allows you to better hedge against the loss of an existing MD. This is especially the case in a solo MD practice with a surgery center. Adding a second surgeon is good insurance against the transient disability or worse of the first surgeon — the clinic and ASC would both be covered. This would not be the case if the soloist hires an optometrist as the next provider.


3. Hiring another MD sustains or grows the MD-owner pool. It is not that optometrists cannot be medical practice owners — they can in an increasing number of states. But the culture of most medical practices is to grant partnership to the highest-producing and hardest-to-recruit providers. Many optometrists are certainly deserving of conjoint partnership in MD practices, but their road to ownership is blocked in most MD practices. Even the most highly qualified ODs are willing to be durable associates. Accordingly, there is no practical incentive for MD-owners to dilute their holdings as the practice’s OD ranks grow.

4. There can be a market-based rationale for adding an MD instead of an OD. In a small community missing a critical subspecialist — let’s say cornea — a surgical practice stuck between choosing an OD or an MD would be wise to add the subspecialist before a competitor does so.

5. And finally, there can be a career-staged incentive to hire another surgeon. You may have a senior physician who is slowing down. His or her surgical case volumes will increasingly have to be taken on by a fellow MD. If the rest of the surgeons in the practice are at full capacity, adding an OD as the next provider may not represent a practical succession strategy.

Reasons for choosing an OD

1. Optometrists — superior ones — are much easier to recruit than even mediocre ophthalmologists. This is less an issue in over-doctored markets such as Los Angeles, where MD recruitment is easier, but can be a profoundly compelling factor in rural America.

2. About 25% or more of the average general ophthalmologist’s clinic day is spent caring for patients who could be readily managed by an experienced medical optometrist. Hiring such a doctor provides several benefits to the employing surgeon, chiefly creating room for more interesting and lucrative patients.

3. You may be wanting to build or grow an optometric co-management referral center; such centers forswear from primary care and optical dispensing and focus on being a comfortable facility for regional optometrists to send their surgical cases. One of the most important success factors in such centers is a so-called “center director,” a senior-level optometrist, often a fixture in the community, well-liked by his or her peers, who is recruited in to oversee operations. Such doctors have a very different job description from a pure clinician and may spend more than half of their week in administration and outreach.


4. One of the chief trends in eye care is the aggregation of MDs and ODs into far-flung, comprehensive care and treatment enterprises. This trend underpins the bloom of private equity companies currently scouting for acquisitions but is also an appropriate strategy for traditionally scaled independent practices. In such centers, one aim is to vertically integrate and provide one-stop eye care. By adding a full complement of primary care and dispensing to a narrow ophthalmic surgery practice, there can be a 20+% passive profit gain to the MD or corporate owners.

5. Your practice, large or small, may not have enough surgery for another surgeon but an increasingly packed clinic schedule. Adding another MD and cannibalizing other surgeons in the group is a recipe for frustration all around. The existing doctors take a double pay cut, first to hire a doctor and then to have their personal surgical rosters lightened. And the new surgeon takes extra years to have a full OR schedule.