Finances: Cornea vs Retina

[PLA2]

Hello everyone,

I'm a PGY2 resident right now thinking about fellowships. For me, high income potential is important; we have sacrificed years in training while our peers from high school and college are making 300K+ in tech and fintech for years; plus, our work is extremely valuable and worth a lot more than what medicare pays. Anyways, I'm thinking between cornea and retina fellowship and was wondering which would be a better financial decision in the long run.

Cornea: refractive surgery is cash pay + premium lens cataract surgery would shield me from insane medicare cuts. The financial payoff seems to be pretty good for cornea because of the potential for all of this cash pay and avoiding dealing with insurance/medicare.

Retina: I personally find retina more interesting and have published tons of research in retina. However, my mentors have told me it is more profitable for a retina doctor to be in the clinic doing injections than in the OR doing PPVs. Impending medicare cuts would affect retina compensation a lot more, with both exam fees and CPT physician fees (eg. PRP getting cut 70% a couple years back). In addition, there are talks about cuts to medicare part B which would reduce physician offices getting a small percentage of the drug cost for intravitreal injections. By the time I get out of retina fellowship, how many years left of fair compensation for physicians exist?

Which fellowship should I pursue or just do comp??

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[salami bahama]

You have smart friends! None of my non-medicine friends make that much money as far as I'm aware.

I'll be honest that I can't relate to pursuing a fellowship based on strong monetary considerations as I did a glaucoma fellowship because I enjoyed it the best. That being said, here are my thoughts:

-Hard to predict the future, but insurance cuts will certainly continue. It will be interesting (and scary) to see if there is a breaking point where enough ophthalmologists would stop taking Medicare if the reimbursement gets too low for cataract surgery. Unfortunately, you have to be quite established and prominent in the field to be an ophthalmologist who doesn't take insurance...only a handful of ophthalmologists I'm aware of have cash only ophthalmology practices. A huge chunk of our patients are on Medicare, and not surprisingly, they want to use their insurance. So, you will always have to deal with "insurance/medicare," but it is certainly a sizable bump in your income if you offer cash pay upgrades (premium IOLs), elective surgery (LASIK, PRK, ICLs, SMILE, etc), or cosmetic procedures (Botox, etc.).
-Retina arguably has the highest salary potential without having to offer cash pay procedures. The injections in clinic up the $/encounter which really helps the overall revenue. Obviously, insurance cuts are a concern here.
-In my mind, the most important thing in regards to compensation will be the job setting you choose. Will you join an efficiently run practice that will offer you a fair buy-in and have the opportunity to invest in an ASC/optical/building? A busy PE practice that gives you significant volume (there are jobs where you operate 3-4 days/week and optometrists run the clinical side)? Would you be willing to take on the risk and hang your own shingle to have 100% ownership and build up your own practice? Will you practice in a rural setting where there is better insurance reimbursement? The money you make at the end of the day isn't always that first contract salary, so don't get too excited about that. From my perspective, the 'money' is made when you've made partner after buying in, at least a few years after starting your own practice, or building up your volume in a PE setting.
-I don't know which one will be the most lucrative over the next decade, but I would say that being able to offer cash pay services is really nice, so that's +1 for cornea. You may just want to look into refractive fellowships or looking for a job opportunity where you'd have mentorship to teach you refractive surgery. I'm sensing you'd be less interested in EKs, PKs, raging ulcers, etc.

Would be curious to see what others think! Best of luck figuring out which fellowship you want to pursue and finishing residency.

 

[percyeye]

I think the real question is what can make me the most in the area of the country I want to live in. Seeing as I have almost 0 friends in the tech and especially fintech world I'm assuming you like on either West or East coast. It probably doesn't matter if you do lasik and open up shop in Orange County CA due to it being so saturated. I live in the Midwest where it isn't so saturated and I know the Retina and anterior segment Docs make some serious $$$. But they have almost no competition which helps.

 

[LightBox]

Retina makes beaucoup bucks... their patients never go away and their clinics can be made very efficient since they don't have to worry about things like refractions, dry eye management, visual fields, etc -- i.e. things that slow your clinic down as an anterior segment person. Retina clinic visits are very uniform which help improve the throughput of their "factory."

 

[PLA2]

Thank you for the replies @Salami, @percyeye, and @LightBox ! I really appreciate it. I would like to stay on the west coast if I can, but am not opposed to moving to for the ideal job setup.

@LightBox, for retina, do you see the beaucoup bucks continuing? With reimbursements being cut for exams, office visits, diagnostics, and therapeutics. My mentor told me that cataract surgeons produce more money for ASCs than retina surgeons. Will PDS and gene therapy reduce the need for intravitreal injections to the point where retina will no longer make beaucoup bucks?

 

[ophtho838]

Thank you for the replies @Salami, @percyeye, and @LightBox ! I really appreciate it. I would like to stay on the west coast if I can, but am not opposed to moving to for the ideal job setup.

@LightBox, for retina, do you see the beaucoup bucks continuing? With reimbursements being cut for exams, office visits, diagnostics, and therapeutics. My mentor told me that cataract surgeons produce more money for ASCs than retina surgeons. Will PDS and gene therapy reduce the need for intravitreal injections to the point where retina will no longer make beaucoup bucks?

Some of the advances in retina will reduce injection burden down the line (great for patients), but more diseases will fill that vacuum (e.g. treatments for dry AMD). Retina clinics are super efficient so the sheer volume of patients you can see as a retina specialist is just much higher. Your mentors are correct that clinic is more profitable than OR but as a retina specialist you’ll be spending maybe 4-6 days a month in the OR, so that’s a minority of your time. Surgical retina stuff simply doesn’t come up nearly as much as cataracts, so you have to see many more patients in clinic to generate one surgery. Who cares, though? The surgeries are way cooler. I think retina is still going to do very well in the foreseeable future.

The income potential is super high with refractive, but remember it’s very difficult to crack it in the saturated markets like California. For every LASIK surgeon earning $2M, there’s dozens more whose refractive practices are lackluster.

 

[LightBox]

Thank you for the replies @Salami, @percyeye, and @LightBox ! I really appreciate it. I would like to stay on the west coast if I can, but am not opposed to moving to for the ideal job setup.

@LightBox, for retina, do you see the beaucoup bucks continuing? With reimbursements being cut for exams, office visits, diagnostics, and therapeutics. My mentor told me that cataract surgeons produce more money for ASCs than retina surgeons. Will PDS and gene therapy reduce the need for intravitreal injections to the point where retina will no longer make beaucoup bucks?

There will be declining reimbursements across all subspecialties within Ophthalmology over time. If there are cuts in office/diagnostic codes, guess what? Those cuts will also affect cornea/general/glaucoma and not just retina. And expect the same trend of cuts in cataract surgery and ASC fees.

Retina benefits from the sheer volume of patients they see, which is only possible due to the uniformity of their patient visits. You could probably see one retina patient and perform a laser/injection (i.e. higher reimbursement) in the time it takes you to refract a patient (i.e. low reimbursement procedure). Also, your techs in retina only have to focus on a few things (e.g. check vision and IOP) which again increases efficiency. And every patient gets basically the same tests (e.g. OCT) which again increases efficiency.

 

[dantt]

There will be declining reimbursements across all subspecialties within Ophthalmology over time. If there are cuts in office/diagnostic codes, guess what? Those cuts will also affect cornea/general/glaucoma and not just retina. And expect the same trend of cuts in cataract surgery and ASC fees.

Retina benefits from the sheer volume of patients they see, which is only possible due to the uniformity of their patient visits. You could probably see one retina patient and perform a laser/injection (i.e. higher reimbursement) in the time it takes you to refract a patient (i.e. low reimbursement procedure). Also, your techs in retina only have to focus on a few things (e.g. check vision and IOP) which again increases efficiency. And every patient gets basically the same tests (e.g. OCT) which again increases efficiency.

You can also develop a pretty streamlined clinic if you only do cataract/refractive but it is impossible to start that way and nobody just hands you something like that for nothing (usually a catch like non partner track or capitated patients or some other nonsense). Who actually does their own refractions???

 

[Baller2016]

Honestly you’ll have high income potential in both. I'm still a resident (pgy3) but here are my two cents. With partnership, a cataract/comp/refractive doc probably averages 500k and retina maybe 700k? These are ball parks and obviously change depending on practice settings. But you also have to remember that for retina you may have slightly more hours/call/emergencies/late add ons to clinic + you do a 2 year busy fellowship with a brutal call schedule. So you should probably really love retina to off set all of this.

I probably wouldn't do a cornea fellowship in your case unless you're truly interested in corneal pathology and transplants. You're probably better off doing a cataract/refractive "ant seg" fellowship where you do tons of refractive and get good at it (SMILE, ICL, LASIK, PRK, etc), high volume phacos, MIGS, and whatever else. Or just do comp.

I'm a PGY3 and also struggle with this decision. I agree retina pathology is way, way more interesting but I feel the patients are less "happy" (just an endless amount of injections with marginal changes in vision) versus those patients who had cataract surgery and just love their surgeon, or so it seems.

 

[dantt]

Honestly you’ll have high income potential in both. I'm still a resident (pgy3) but here are my two cents. With partnership, a cataract/comp/refractive doc probably averages 500k and retina maybe 700k? These are ball marks and obviously change depending on practice settings. But you also have to remember that for retina you may have slightly more hours/call/emergencies/late add ons to clinic + you do a 2 year busy fellowship with a brutal call schedule. So you should probably really love retina to off set all of this.

I probably wouldn't do a cornea fellowship in your case unless you're truly interested in corneal pathology and transplants. You're probably better off doing a cataract/refractive "ant seg" fellowship where you do tons of refractive and get good at it (SMILE, ICL, LASIK, PRK, etc), high volume phacos, MIGS, and whatever else. Or just do comp.

I'm a PGY3 and also struggle with this decision. I agree retina pathology is way, way more interesting but I feel the patients are less "happy" (just an endless amount of injections with marginal changes in vision) versus those patients who had cataract surgery and just love their surgeon, or so it seems.

Better to be employed if that is your partnership income. For comparison, when I looked at Kaiser a few years ago, their cash compensation was right around there for comprehensive...with amazing benefits (pension, health insurance, money towards home, etc) without having to run the practice and a $500,000+ buy-in.

 

[PLA2]

@dantt What region of the country were you looking at for Kaiser and what were they offering? Was it a package that included production bonus for procedures/office visits?

 

[dantt]

@dantt What region of the country were you looking at for Kaiser and what were they offering? Was it a package that included production bonus for procedures/office visits?

Northern California. The majority of compensation was set salary and a small percentage was at risk compensation. Small bonuses for premium IOLs.

 

[PLA2]

@dantt How was the pension set up? Was it 1% of your salary for every year working there, or did they have a faster accrual?

 

[mjohnsonets]

@LightBox Do you feel it is viable to do a 1-year medical retina fellowship? Do you feel that injection reimbursements and volume will stay steady for at least 10-15 years?

This will limit your job opportunities. Some retina practices will take medical retina some won't, mostly because of the lack of ability to cover call in my experience. Most of the med retina docs I know on the west coast do med retina+comp.

If you want high compensation, on the west coast, do retina and go to central CA. It should be fairly easy to build yourself a 7 figure income there as a retina surgeon. West coast for cataract/refractive can be done but it will have to be built if you're going to live in a west coast metro. LASIK is nice to offer because of the cash pay but it costs a lot to advertise and build a LASIK practice with any kind of significant volume so that eats profits.

With either specialty, you can join a multi-spec practice and likely buy into a surgery center but in this case your bonus as a retina surgeon will be diminished from an all retina group.

At this point, I would tell you both types of practices are likely to be pursued by private equity.

Also, there is a difference in purchasing power between a $300K and $400K income. Once these numbers get more like $800K/$900K, not so much.

 

[airplanes]

Northern California. The majority of compensation was set salary and a small percentage was at risk compensation. Small bonuses for premium IOLs.

Interesting, Kaiser in the bay area was mid 300s for comprehensive. This was a couple years ago.

 

[dantt]

Interesting, Kaiser in the bay area was mid 300s for comprehensive. This was a couple years ago.

I am referring to the projected year 5 compensation. Not bad for a minimal buy-in. Now if your average is closer to 700k or higher, that's a different story.

 

[i-doctor]

Comprehensive ophthalmologist here with a high cataract volume in a midwestern city…
My advice is simple:
1) If you want to live on or near the coasts, do retina. More opportunity, high income potential, slightly less competitive. (The general/ant segment guys in the big cities on the coasts are all competing for cases. Some only do 250-350 cataract surgeries per year.)
2) Anywhere else (except maybe Chicago, etc) it’s a toss up. Can make a great living doing either.

 

[LightBox]

Better to be employed if that is your partnership income. For comparison, when I looked at Kaiser a few years ago, their cash compensation was right around there for comprehensive...with amazing benefits (pension, health insurance, money towards home, etc) without having to run the practice and a $500,000+ buy-in.

Kaiser is where entrepreneurial minds go to die. I've lapped my Kaiser friends several times financially. I can't imagine dealing with all of the b.s. Kaiser bureaucracy and lack of control. If you want to go to a place where you have to enter your vacation dates 1 year in advance (or else suffer the wrath of a physician-administrator), go to Kaiser.

 

[dantt]

Kaiser is where entrepreneurial minds go to die. I've lapped my Kaiser friends several times financially. I can't imagine dealing with all of the b.s. Kaiser bureaucracy and lack of control. If you want to go to a place where you have to enter your vacation dates 1 year in advance (or else suffer the wrath of a physician-administrator), go to Kaiser.

That is true. OP is comparing it to partnerships where comp/cornea is making 500k and retina is making 700k after possibly getting partnership and paying a whole bunch to buy in. Those are suboptimal but very common.

 

[CECFellow2018]

Hello everyone,

I'm a PGY2 resident right now thinking about fellowships. For me, high income potential is important; we have sacrificed years in training while our peers from high school and college are making 300K+ in tech and fintech for years; plus, our work is extremely valuable and worth a lot more than what medicare pays. Anyways, I'm thinking between cornea and retina fellowship and was wondering which would be a better financial decision in the long run.

Cornea: refractive surgery is cash pay + premium lens cataract surgery would shield me from insane medicare cuts. The financial payoff seems to be pretty good for cornea because of the potential for all of this cash pay and avoiding dealing with insurance/medicare.

Retina: I personally find retina more interesting and have published tons of research in retina. However, my mentors have told me it is more profitable for a retina doctor to be in the clinic doing injections than in the OR doing PPVs. Impending medicare cuts would affect retina compensation a lot more, with both exam fees and CPT physician fees (eg. PRP getting cut 70% a couple years back). In addition, there are talks about cuts to medicare part B which would reduce physician offices getting a small percentage of the drug cost for intravitreal injections. By the time I get out of retina fellowship, how many years left of fair compensation for physicians exist?

Which fellowship should I pursue or just do comp??

don’t confuse cornea and refractive. you need to own your practice and you can achieve the numbers you’re aspiring to

 

[Openglobetrotters]

Comprehensive ophthalmologist here with a high cataract volume in a midwestern city…
My advice is simple:
1) If you want to live on or near the coasts, do retina. More opportunity, high income potential, slightly less competitive. (The general/ant segment guys in the big cities on the coasts are all competing for cases. Some only do 250-350 cataract surgeries per year.)
2) Anywhere else (except maybe Chicago, etc) it’s a toss up. Can make a great living doing either.

What’s considered high volume for cataracts?

 

[i-doctor]

I would say anywhere in the 4 digits…

 

[MstaKing10]

Hello everyone,

I'm a PGY2 resident right now thinking about fellowships. For me, high income potential is important; we have sacrificed years in training while our peers from high school and college are making 300K+ in tech and fintech for years; plus, our work is extremely valuable and worth a lot more than what medicare pays. Anyways, I'm thinking between cornea and retina fellowship and was wondering which would be a better financial decision in the long run.

Cornea: refractive surgery is cash pay + premium lens cataract surgery would shield me from insane medicare cuts. The financial payoff seems to be pretty good for cornea because of the potential for all of this cash pay and avoiding dealing with insurance/medicare.

Retina: I personally find retina more interesting and have published tons of research in retina. However, my mentors have told me it is more profitable for a retina doctor to be in the clinic doing injections than in the OR doing PPVs. Impending medicare cuts would affect retina compensation a lot more, with both exam fees and CPT physician fees (eg. PRP getting cut 70% a couple years back). In addition, there are talks about cuts to medicare part B which would reduce physician offices getting a small percentage of the drug cost for intravitreal injections. By the time I get out of retina fellowship, how many years left of fair compensation for physicians exist?

Which fellowship should I pursue or just do comp??

Lot of great comments here. Just wanted to come back to the original questions regarding retina specifically.
Yes, its more profitable to be in the clinic. Surgical volume is less but, in my opinion, far more varied and involved than routine cataract surgery. Thus, lower volume does not necessarily mean less interesting or challenging (in fact, one could argue the opposite is true but that's besides the point). Impending cuts will affect all doctors, not just retina docs or even ophthalmologist for that matter. True, PRP, and more recently retinal tear laser fees were slashed (to name a few). But this was offset by a reduction in the post op period (now 10 days instead of 90 days), thus, you can bill for follow up exams which depending on the frequency may be at least a break even if not a net gain. So this is more nuanced than just a slash in reimbursement. I'll agree that drug costs are being targeted and this may affect retina docs, but there are many other ways to keep the drug margin in the green. Obviously retina docs cannot benefit as much from direct cash/fee based services that allow general ophthalmologist to remain quite profitable (ie. premium IOLs/Lasik etc), however, there are many other revenue streams that retina docs can take advantage off and these will continue to evolve over the coming years. I would finish by pointing out that a successful and lucrative career can be had in any ophthalmic subspecialty (yes...even my pediatric ophthalmology colleague in town is killing it!). Keeping a relatively business savvy and entrepreneurial sense will help. I find the employed style physicians, while having a better "lifestyle" end up lagging behind financially. But there are pros and cons to any career choice.

 

[PLA2]

@MstaKing10 Thank you so much for providing this perspective!! I really appreciate it. With the global period being set at 10 days for PRP, are you splitting each eye into 2 or 4 visits? Also, with so many retina practices sold to private equity, are the opportunities to own a practice down the line dwindling?

 

[RetinaDude]

You see a lot of practices being sold to PE, but not everyone. We are not even considering PE within my group. Oh, I’d love the big fat upfront payout but it’s not worth the loss of control.

As far as PRP is concerned, I’ve never planned my PRP based on the global period. Truthfully, with anti-VEGF, the amount of PRP I perform has drastically reduced compared to 20 years ago. When I do PRP, and get as many shots as I can (safely), then I’ll bring the pt back a few months later to see how they’ve responded.

Retina has so many options for treatment coming down the pipeline. The PDS (port delivery system) has just been FDA approved and we should have injections for dry AMD (atrophy) coming out within the next year or so.

Ive been in PP for 22+ years, and have heard I’d be making less money since my fellowship days. It’s a constant rotating statement “this is only going to last another five years and then our incomes will be slashed!” Well, that keeps being stated but I’ve done nothing but make more money each year. So, do what you love and the money will be there.