The Business of Medicine

The landscape of medicine is rapidly changing, and physicians need to adapt. Jai G. Parekh, MD, speaks with Gary Wörtz, MD, about the business side of ophthalmology, the relationship between physicians and industry, and where he thinks ophthalmologists fit into the overall health care equation.

Gary Wörtz, MD: Open, outspoken. It’s Ophthalmology off the Grid—an honest look at controversial topics in the field. I’m Gary Wörtz, MD.

In today’s health care environment, physicians are increasingly tasked with wearing multiple hats—clinician, researcher, innovator, educator, manager, CEO, advocate … the list goes on. The landscape of medicine is changing, and we too must adapt.

Today’s guest is someone who has embraced this brave new world: Dr. Jai Parekh. As we’ll hear, Jai completed two residencies—in internal medicine and then ophthalmology—and then earned his MBA at Duke. Now, he serves as both a practicing ophthalmologist and the Vice President of Global Medical Affairs for eye care and dermatology at Allergan.

I sat down with Jai to talk about the business of medicine, what he has learned about the physician-industry relationship in his new role, and why eye care providers must step outside the incubator and become part of the overall health care equation.

Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.

Gary: Welcome back to another episode of Ophthalmology off the Grid. I am so excited to have my good friend Dr. Jai Parekh on with us tonight. Jai and I have known each other for quite a while, and every time I'm with Jai he makes me laugh and teaches me something. It's usually something both about medicine and ophthalmology and business. So, that's why love hanging out with Jai. Because it's always fun, and it's always educational. I thought it would be great to have him on tonight. So, with that preamble, Jai, thanks for spending some time with us. I appreciate it, man.

Jai Parekh, MD: Thanks for having me.

Gary: Before we dive in there, I want to just go through your background a little bit because I found it really interesting last time we were together. I always knew that you had an MBA and that you went to Duke, which is a fantastic program, despite my feelings about their basketball program as a UK fan. We have to give them their due academically. As I was looking through your academic history also, I realized that ophthalmology was not your first residency. Did I read that right?

Jai Parekh, MD: You're actually right. So, initially, it goes back years and years. When I was in medical school, I was actually in the combined medical program up at Boston University. My wife, Swati, and I were dating at the time. She wanted to be an OB-GYN, and I actually wanted to be a heart surgeon. Lo and behold, the two of us started thinking about life and where we had our preferences. The two of us were very family-oriented. We came from strong family backgrounds. We're both first generation. So, she said, you know what? I'm gonna go into ophthalmology; it's a great blend of surgery and medicine and long-term care, lasers and technology.

I'm like, you know what? I'm still gonna stick with the heart. But, I'm gonna go into cardiology. So, I actually ended up going into internal medicine and training in internal medicine, where I was Chief Resident up in Boston. I actually had a spot available and ready for me in the Longwood area for cardiology. And during that year, my chief year, I actually ended up spending some time with the folks over at the Johnson Clinic and did a mini diabetes fellowship. I was looking to blow off some time, so they were like, you know what? You should meet this guy named Dr. Lloyd Aiello, who is the father of diabetic retinopathy, and spend some time with him and learn about how these diabetic patients develop retinopathy. So, I spent some time with him. He was the nicest guy, kind as ever, and a savant, and very wise. He goes, "Jai, with your background, you'd be a great retinologist." Next thing you know, I'm thinking about lifestyles and cardiology and interventional. I really had a big focus on ischemia. And I'm like, you know what? I'll be finished up in medicine. I'll be chief in medicine and bored up there. And what I'll do, go into the heart or the eyes? It’s is still the windows to disease.

I came home one day, and I told Swati, guess what? I'm a gonna switch and go into ophthalmology. She couldn't believe it. She was psyched for me, but she's like, don't tell our parents because they're gonna think you're frivolous. So, I matched with a great program. At that time, it was tied academically between BU and Tufts. I was in the BU part of the program, and that was a cornea top-heavy, cataract top-heavy program. And back then, in retina, it was lights on, lights off. I'm just too much of a happy-go-lucky person, as you well know and folks know in the industry. I really had a falling in love with cornea at that time, refractive surgery, transplants, and cataract surgery, with a lot of tough cataracts at Boston City Hospital and the VA. I ended up relinquishing my desire to go into retina, and I actually went into cornea. I actually matched with a New York Eye and Ear and trained under Mark Speaker, MD, PhD, years later.

So, it's been a great trajectory for me since then. But it's funny, I still ask about A1Cs and body mass indexes when people have undergone cancer therapies or whatever therapies we're talking about. I'll always get involved with systemic care. It's really a passion of mine. And luckily enough for me, in terms of hospital leadership, people respect me on both sides of the aisle. So, I'm actually lucky to participate in a hospital level type of leadership outside the industry and outside of eye care. So, it's been great for me. And because I was sort of young going to medical school, I'm now well enough to be mature enough to have done both.

Gary: Well, it's interesting, Jai, because my dad and my namesake, my uncle, Gary Wörtz, MD, they're both internists, and they were partners together. So, I was raised in a family of internists. I did a transitional year internship, and I had 4 months of medicine wards. It was crazy ... it was actually a pretty tough intern year, as far as that goes. I really took that opportunity to realize it was the last chance I was going to have to practice comprehensive medicine. And I loved it. I tried to get as much out of that as possible.

Those are the things you do take with you. It's amazing how you don't waste any time when you're training yourself. You can look at 3 years of internal medicine and think, oh well, it's not directly related. But I would imagine there are so many ways that has served you well. You've already mentioned some: being involved in diabetic care, being involved in hospital leadership. You gained so much credibility having that broad training. I think that is to be commended, and I'm sure your patients have benefited tremendously from your breadth of knowledge.

Jai: Yeah, the practice has benefited. I still teach at New York Eye, here at Mount Sinai. It's been a lot of fun. And I still feel very young. I get bored every couple of years, quite frankly. So, years later, as you well know, I ended up going to business school, and that was a lot of fun, too. You know what? You need to reinvent yourself, like the iPhone does. We're right now in the iPhone 10? By the time you and I are done with our conversation, Gary, we'll have an iPhone 14. You gotta keep reinventing yourself, right?

Gary: Exactly, so that's actually a great segue. You seem like you have more open channels for activity than most people I know. And I know a lot of heavy hitters who are pretty productive. You were telling me about your first week at Duke when you decided, in the midst of being done with ophthalmology residency, having a family, a lovely wife, who I got to meet actually last month, she's just fantastic, and you decided, I'm actually going to fit in a top-level MBA. This is not like a, nothing against the online MBA, but this is a real MBA that you did. Correct me if I'm wrong.

Jai: No, it really was. I was lucky enough to get into some programs in New York and in Philadelphia, which were more geared towards finance. But I always wanted to be a leader. I was chief resident in two specialties. I was captain of the baseball team. I've always lead my whole life without asking to lead. People always look to me lead and so forth. And lucky enough, you and I've been part of Vanguard and folks like there at CEDARS/ASPENS and AECOS. It's been a lot of fun.

But after several years of practicing, I again got the itch to do something more, and I always was thinking about going to business school. In fact, my brother was thinking about an MD/PhD, and he finished up orthopedic surgery down at Penn. I told him what would be more practical would be getting an MBA. So, he spent some time in Boston and then finished up at Wharton in entrepreneurship. We've always been entrepreneurs in the family. And for me, I actually wanted to get a, not one of those health care MBAs, but an MBA in general management, so finance, accounting, leadership strategy. You and I are lucky enough to have some emotional intelligence, but I really wanted some fiscal intelligence to really help lead. And, for me, that sort of catapulted me in the next rung of consulting and opportunities with the industry.

Like you, Gary, you gotta keep your head down. Keep on working hard, and the opportunities come your way. So, it was tough. I had a couple of kids. I have a thriving practice and an academic practice. I was speaking a lot, doing consulting, working on some phase 4s and some IPs. It was a really busy part of my life. But, I'm like, if I don't do it now, I'm never going to do it. So, I actually flew down for 3 to 4 days every other weekend for 2 years. I had three 2-week segments in a boot camp, and then I spent 2 weeks with my classmates in a wonderful trip because I'm a global guy, like you. We actually went to Korea, we went to the demilitarized zone, and I spent a lot of time in China as well. A couple of years later, I acted as a team physician, as an ambassador with Coach K at the Friendship Games in Dubai and China. All these levels of engagement with reality around you and opportunities, it always comes back to serve you well.

And it was tough. I had a really thick head of hair before business school, and my first weekend I came across some really cool classmates. We had 7% that were physicians. The rest were folks from Google and Goldman Sachs and Pfizer, a lot of really cool companies. I'll never forget my first quiz. I got a 7 out of 20, and I got a letter from the professor saying, “You know what? Are you really sure you want to do this MBA program? This is not just writing a check and getting an MBA. This a real program. The failure rate is up to 10%.” And I was like, scared. Here, I do transplants in my sleep and ruptured globes and tough cataracts, 2-mm light perception pupils on Flomax. I’m about to fail out of stats. So, I turned it on. I turned it on. And that was the turning point for me, early on in my business school career. I turned it on. And my favorite classes were venture capital, private equity, finance, leadership, and strategy. In fact, Coach K taught some of the courses on leadership there. Things that I'll never forget the rest of my life. And they serve me very well. It's really, it's about respect and dignity and leading and being parts of teams. It was great going through Harvard Business Review and going through recruiting. I really realized, hey, I don't want to go to McKinsey or leave full-time medicine. I really love what I do. I want to help. I want to be bigger than the MBA and make it a part of what I do, not part of what we do.

It worked out really, really well for me. I finished after 2 years. A couple of years later, I was elected to go on the board of the alumni counsel. More opportunities, and it was actually one of the best years of my life. I missed four wedding, of which three of them were big Indian weddings. And I'll never be forgiven by aunts and uncles where I missed the weddings. But, it's pretty brutal. It was a huge time commitment. But again, the only thing I'd say is that I should have done it earlier because it really changed the rest of my life. For me, it was like undergoing refractive surgery. I was a -4.00 D, and I became a plano after it.

Gary: You saw things differently.

Jai: You see things differently. Exactly.

Gary: So, you used that pretty, I would imagine, pretty immediately in your practice. You became pretty involved, as I understand, in your surgery center and also in hospital leadership. What were some of the things, maybe as you finished your MBA and you started looking at things with fresh eyes, what are the things that you saw in your surgery center that were the biggest no-brainers, that just seemed completely missed by your physician colleagues maybe that didn't have the same business background?

Jai: You know, we all took the Hippocratic Oath time and time again. Sometimes we lose a focus of why we’re all here: to take care of patients. Now, that may sound mushy, Gary. But, at the end of the day, that's what it's all about. So, really reviving that patient experience, the patient journey, marketing towards that, reducing overhead. It's funny because I was giving so many talks a year for myriad companies on products and disease management issues. I would close the deck and go off the podium and have dinner with colleagues and then talk about overhead management, whether it's in your practice or the surgery center or the hospital. All these simple things, like just shutting off the light and not ordering from certain vendors and ordering from other vendors, watching the books, watching that P and L every week. There are a lot of folks that you and I admire tremendously, who we think have a business sense because they have large volumes; however, they do a very poor job. In fact, doctors in general do a very poor job in overhead management.

So, for me, growing up in a value-oriented family, my parents probably had more money than they let on. We always acted, not frugally, but value-oriented. So, taking that from business school, learning some skill sets, and applying it to the real world and calculating NPV and doing a SWAT analysis, things that you learn in business school, that you don't need an MBA. Usually, MBA screws things up. But, for me, because I was still practicing, is the ability for me to really be part of leadership on a really quick level. I became head of R&D at the hospital level, with all departments, all specialties. Instead of just speaking, I started consulting for a lot of CEOs, SVPs, and VPs that really wanted to know how to elevate their game and get to the next level of engagement with customers and KOLs.

That was a really fun time in my life for me, the next several years. I really enjoyed it. I sort of was someone that no one ever thought about but quickly became part of some big ad boards, those growing ad boards, training programs both in medical affairs and commercial, not only even domestically but worldwide. As I learned about that and that skill set, I became pretty good at it. Just like doing a complex cataract, after a while it becomes a no-brainer at 2:00 in the morning.

Gary: Yeah, that's interesting. The thing I want to dive into a little bit is overhead management because that is one thing that is so vitally important and it gets almost no airtime, especially with regard to its level of importance. Thankfully, my partner, Lance Ferguson, just has an incredible mind. He went to Duke as well; he was a Duke math major. So, I'm surrounded by Duke alums everywhere I turn, it seems. That's OK, great people. Regardless, he has driven home to me the whole concept of cost per case. Every dollar you don't spend in terms of overhead is a dollar that you either get to give to an employee in a bonus, you get to give them better wages, you get to hire better people and keep better people, or at the end of the day that dollar goes into your pocket.

So, the one thing that we know is that reimbursement rates are generally going to go down. But the way you fight against that is constantly trying to get your vendors to be competitive, to look at other quotes, look at the cost of goods. I did a cost-of-goods analysis as part of just him training me to look at the practice. It was a very good exercise. I went through every dollar our practice spent on fixed goods, from Kleenex to Lysol wipes to alcohol pads. Everything we purchased, I put into a spreadsheet and had to put together an analysis of where we could actually save some money based on some spending habits of some of our staff. It was interesting that it was such a, relatively speaking, very low amount that was purchased on cost of goods, outside of the medical cost of goods. But it was still a really good habit to get into to look at every dollar and where it's spent and see if you can find better ways to do that.

Jai: Yeah, and every practice needs one or two people who think like that. I'm not expecting every fellow or resident coming out of Eye and Ear to do that. But you want to be part of a practice that knows exactly where the dollars are going. At the end of the day, it may not go into your pockets; it may go back into the practice. I'm lucky to be part of a group we cofounded, Eye Care Consultants of New Jersey. We took a 45-year-old name, and we changed the name. We changed the mojo. We changed the patient journey. Our overhead actually went up by 3% for a few months, and now we have it back down again. We've created value, more customers coming in.

So, again, if you focus on the patient and talk about enhancing those patient outcomes, but then you also are in the backend and have your management looking at that, there is nothing better than that. That's just the perfect storm. It's the best combination. You and I have friends across the country where their overhead is reaching 65-70%. You know what that means, Gary? Think about that. If your overhead is 66%, that means two-thirds of the year you're working for your overhead.

Gary: That's right.

Jai: Two-thirds of the year. The latter one-third of the year, with all the storms and the hurricanes and Christmas and Hanukkah and Thanksgiving and Halloween, patients don't show up. No-shows. It's cold and so forth. Imagine that. So, I would try to think that people keep their overheads anywhere from 48% to 56%, 57%. Nothing more than 60%. That's a healthy number in specialty medicine. And I've actually convinced a lot of people to do that across the board without cutting value. It actually enhances value. And you gotta think about the money of time but the time of money. If you think about those things in a simple way, like you raise your own household, you can't go wrong.

Gary: Yeah. Alright, I want to switch gears just a little bit and talk about your current role at Allergan. I know that you were presented with an opportunity, was it 2 years ago at this point?

Jai: It's been actually close to 3 years. Time goes pretty quickly. So, yeah. I'm the Vice President of Global Medical Affairs and the Chief Medical Office for both eye care and now recently dermatology. Obviously, both fields have a lot of overlap, same kind of customer base, same kind of surgeons. So, it's just been a wonderful trajectory for me. I've learned so much in Medical Affairs and R&D, and then cross-pollinating with my commercial colleagues, our marketing colleagues, business development. This is something that I've always wanted to do, and yes, I had to curtail all my other consulting engagements. I've been pure about what I'm doing. I am full-time here at the company. I'm lucky enough to still retain a good practice, where other partners, including Swati, have really taken on more of a leadership role in the practice.

I still practice a couple of days a month. I still do a lot of surgery. I stopped doing transplants and LASIK. I'm pretty much now focused on cataracts, MIGS, ocular surface, and pretty much comprehensive eye care, especially with glaucoma. But my trajectory at Allergan has been great for me. I’ve learned so much and really learned how to share my vision with really 15,000, 16,000 people, not only across the country but across the world. So, I am just so happy where I'm at. And hopefully the trajectory for me continues as we continue to build out our portfolio, not only in eye care but in other aspects of health care.

Gary: Now you're a little bit on the other side of the industry-physician relationship, what has surprised you, if anything? I guess the lead-up to that is, I'm running a startup, or co-running a startup, and I, in my journey, have realized that developing something that seems like a good idea and seems really easy is actually really, really difficult. It's doable, but you learn along the way that, man, everything is a lot harder than you think it would be. What are some of the things that you've found being on the other side of that relationship that maybe folks don't really appreciate?

Jai: So, by the way, I was in a similar spot like you, Gary, several years ago. I was actually the cofounder for Eye Trans Technologies. We worked on nano particles. My partners and I, there were four of us in the company, we were the servants, we were the kings, and the queens. We did everything, and scalability was an issue. Then I was part of a company called Ocuhub that was looking at digital telemedicine and eye care. That worked out really too, but, again, we realized that scalability was always something that kept us down. I was also the Chief Medical Officer for another company called 1-800-Doctors, and that too, scalability, at times, was a problem.

Here at Allergan, it's not an issue. It's been a giant company. 70 years in eye care. Obviously, aesthetics. And now seven to eight different therapeutic areas across the board, if you divvy things up. I've learned so much in a cross-functional way with my colleagues. There's bureaucracy everywhere. There's bureaucracy at home, there's bureaucracy at our kids’ schools, there's bureaucracy at the surgery center, and there’s bureaucracy at big companies. At the end of the day, you have to be selfless. You have to smile. You have to have balance. You have to think about your colleagues and your customers and the myriad stakeholders. You take care of that, Gary. It all takes care of itself. So, it's just part of being a team.

I didn't grow up playing golf and tennis, which are great sports. But, that's really about me. I grew up playing baseball and then, in college, playing club football. That's really about the team and getting the ball in the end zone. Or hitting a double to clear the bases in the 8th inning. So, it's been a lot of fun for me. I learned just so much from so many people. There's a lot of smart people in this company, a lot of assets the people don't tap into. I'll visit the Irvine campuses and the Madison campuses, and the campuses we have out in Asia as well as Marlow. It's been a lot of fun.

Gary: You have a pretty unique perspective on the landscape, I think, of ophthalmology. You can see it both from a clinician’s point of view. You can see it from a corporate point of view in the industry. What threats do you think are out there? I mean, if you look at the baby boom population that's exploding, you see providers that maybe are getting busier and busier. What do you see on the landscape that either really excites you or maybe is concerning? You can take that any way you want.

Jai: Wow, I'm also on the supplier’s side at the hospital, and in practice. I'll tell you that I'm incredibly bullish. I'm guarded, right? I want to be guarded in general because, at the end of the day, we don't know what next conflict may occur, how they may affect the markets and affect the access to companies that are doing business with physicians in a great symbiosis called industry and the physician.

I'll tell you that, in eye care, again, the word is really eye care these days. It's really about ophthalmology and optometry and everyone really taking care of patients. I think complacency and stagnation is the enemy of the future. I think you have to keep on invigorating yourself, keep on innovating, looking for the best outcomes for our patients in a really cost-controlled, value-oriented way, with the best output possible. That's what we're seeing with reimbursement at the level of heart failure and hip replacements. We're going to see that in cataract surgery. We're going to see that in glaucoma care. We may see that in retina care as well and how you manage patients that have wet AMD throughout the years or diabetic macular edema. So, I think, in general, any leader or leaders knows that value orientation towards patient care, enhancing outcomes is the most important thing.

I do see consolidation. Right now, everyone's jumping on the bandwagon, the private equity, and everyone wants to be in Wall Street and so forth. Yeah, I think it's a great idea. A lot of our mentors have done that, and perhaps it's akin to people that may be that stage of life, where they’re thinking of slowing down or retiring or pseudo-retiring. Because the next step, after surgical eye care, is medical eye care. In fact, my old partner practiced medical eye care for a good 10 years, where he was pretty much just doing lasers and focusing on the ocular surface and glaucoma.

So, I do see consolidation occurring. Private equity may be the answer for some people, or not. But I definitely see the days of onesie, twosie groups really going by the wayside. I think we got to be part of the equation at the hospital level. Folks have got to be part of the grand rounds, part of the hospital boards, really impacting care. Because, you know this, you know this really well, one insurance company at a blip second, right, can say, you know what, Dr. Jai or Dr. Wörtz? You're no longer part of this panel. And now you lose 15-20% of your patients, plus their relatives, plus their referrals. So, I think you’ve got to be akin to what's going on in the market. We can't be in this incubator called eye care. We can't just be operating at surgery centers. Of course, I think those are where you have the most efficient outcomes. You have to be omnipresent. You have to be all-present. And I think, at the of the day, there's enough envy towards eye care, dermatology, ENT, neurology—we've always been part or outside of the health care equation. Most of the health care equations gone towards cancer care and orthopedics and heart. Now we're seeing hospitals saying, hey, we're going buy this surgery center. Or private equity saying, we're going to fuse a Dr. Wörtz practice and a Dr. Jai's practice in Jersey and control cost of goods. And the way to avoid that is to control your own cost of goods and your own destiny.

Reading The Wall Street Journal, The New York Times, having folks in a practice go business school or a business course or a weekend course, and staying in tune to the market is incredibly, incredibly important, more so than ever. There's a time my partners made $3,000-plus for cataract surgery. They saw X number of patients a week. They took 2, 3 months’ vacation. Those days are gone. Then we all shifted to high volume, high volume, high volume without outcomes. Those days are gone. Now looking at volumes, and outcomes, and taking care of the patient in the best way possible in a confined way. I think population health is going to impact us in how we take care of cataract disease, diabetic retinopathy, glaucoma, even ocular surface disease. As long as you have a payer system, whether it's Medicare or commercial care, you're going to be studied and analyzed in these ways.

Gary: So, let me ask you a couple of questions because you brought up some interesting points. You seem strongly in favor of ophthalmology reintegrating or becoming a more crucial, integrated part of the overall health care equation. And that's something that I've seen, especially in my market, really the exact opposite. Ophthalmology is more on an island than it's ever been, at least in my area. I don't know what it's like in every different market, but are your feelings in that regard that, if ophthalmology continues to isolate itself or becomes more isolated, we will have a harder time advocating for our piece of the overall pie in terms of the CMS valuations, etc.?

Jai: Absolutely. At the end of the day, Gary, there's a finite number of dollars, and the hospital sees you as an asset; they don't see you as a pariah. And whether we have an ACO or post-ACO or an ACO-esque kind of system, no matter how busy you are in your community 5, 10 miles away from the hospital, at the end of the day, they're consolidating a bunch of internal medicine doctors, and family practitioners, and OB-GYNs, and so forth. Once it gets to critical mass and control 10,000 lives, to control costs, if you're not controlling costs at their sites, they're going to hire their own ophthalmologist coming out of fellowship or residency. They're going to hire their own dermatologist. They're going to hire their own ENT. Some cousins of mine, by the way, have gotten those kind of jobs in those specialties that I listed before.

So, to control your destiny for your group—I don't care how many years you been there, it could be fourth-generation eye care—you've got to be part of the hospital equation. You've got to go to their golf charity events. Go to their charity balls. Be part of grand rounds. I'm not saying go there and see consults every day on dry eye for the rest of your life, but be part of the equation. Because ophthalmologist, in general, are skewed and are seen as people that don't want to see patients. They don't want to see a herpes consult with herpetic neuralgia or don't want to see anything but a ruptured globe, which they refer out to a tertiary care facility anyway. We have to reverse that trend because, if we don't, those same people will buck us out of the system and then you have loss of control. You do that, you may have your surgery center. You lose two or three contracts. You're out of the game.

Gary: Interesting, That's a very interesting perspective.

One other thing I want to dive into real quick, and I don't want to spend too much time on this, but is really the private equity side of this. I just see myself, if I'm a private equity guy and I'm looking at a practice, the last thing I think I would want would be a practice with people who are looking to gear down or maybe slow down in the latter parts of their career unless they have a rock-solid replacement plan coming through. So, if they've got a young guy or gal who shows a lot of promise, then clearly that's a pathway forward. But, it seems also like those younger people may not have the same incentive to work as hard and perform, perhaps, as the founders did.

To me, it just seems there may be a little bit of a misalignment of stakeholders in this, and that's why I'm having a hard time wrapping my head around, is that I'm hearing, that this private equity deal is great and people are getting great multiples. It sort of seems like it is almost too good to be true. But then I think, how are they going to add value when they are already paying out a big payday to the owners and then I assume they're trying to package goods together, consolidate, control costs of goods, invest maybe in other growth areas, and maybe flip that to someone who is larger 5 years down the road. So, I see danger. For some reason, this whole thing ... I sort of have that caution flag in my mind. Is that wrong to think that way?

Jai: You already answered your own questions. Listen, private equity is a solution to what the market dictated, right? Again, it's about population health, controlling lives, having multiple practices. And you know what? You're right. They look to the principals. It's usually a very good day for the principals. It may be a good day for a practice if it's not very well-oiled. But then, for the rest of the folks who are still 5, 7, 8, 10, 15 years out of fellowship or residency, there is no change. There may be loss of control. There may be loss of destiny, and I would say for some people it's like teeth whitening. It's for some people. It's not for everyone, right? It's not for everyone, no matter what Groupon says. It's not for everyone. So, I do think, and I loved private equity back in business school and a couple of the companies that actually contacted me for my inside advice on how to run things better and so forth, but, at the end of the day, when you have consolidation, you are marrying two different kinds of groups, two different thought bases.

Gary: Two cultures.

Jai: Two cultures. You may reduce some of those costs up front and see how it pans out the next 4 to 5 years, but then what happens is that's going to be flipped very quickly. So, I know a lot of friends that have done it, and I'm very happy they've done it. I think it's great for them, later on in their third or fourth decade of practice. But for the rest of us that are in our first or second decade of practice, I really think you got to be very cautious. I'm not going say it's alarming. But, you got to be very cautious about it. I know in cardiology practices across the country and GI practices, this model has not necessarily worked. And often times things go awry after 3 to 5 years. Let's see what happens right now in eye care. I'm guarded about it, but I definitely embrace it. I think there's a role for it in the market. At the end of the day, you can want what you want. I can want what I want. But the market dictates exactly, Gary, what happens. And that's what we'll see in 3, 4 years; we'll know which ones succeeded, which ones have not. You go to all these big meetings, you talk to our friends that have been part of it, and maybe for the principals, it worked out well, but for the rest, they'll say yes, you've got to see more patients, see less patients, have controlled hours.

It is somewhat loss of control. But, that said, a lot of doctors don't want that control. They don’t want to worry about overhead management. They don't want to worry about marketing and hiring and firing. So, for some people, it's not a bad avenue. For some people, hospital employment is not a bad avenue. There are hospitals now employing ophthalmologists to be part of their two- or three-person group to take care of 100,000 patients for population health. So, this is what's happening in our specialty. We need to embrace it. These solutions aren't for everyone. But they are certainly for some people, some decades ophthalmic surgeons that have been doing this for years that just want to really play around for 5 more years but have someone else do it better for them. So, I do embrace it. But I think for someone like you or me, I'd resist the temptation.

Gary: Alright, so I'm going to ask you one more question, and answer however you want. I like to look at mega trends and themes, and one thing that has sort of bothered me—and this is like a true confessional time now—but one thing that does kind of bother me is I feel like, in many ways, the physician is the little guy and the little guy seems to always be controlled by the powers that be. And the powers that be are either the government, so CMS sets rates, or insurance panels determine whether you can be on the panel or not, or it's the private equity guys who come in, purchase things, and then tell how things are gonna be. Where and when and how do physicians regain control of their own destiny. Is the horse out of the barn?

Jai: I think that, yes, there has been loss of control overall systemically, not just for ophthalmologists or optometrists, for that matter, and all eye care professionals, but in general. Medicine now is one nth of the equation; before it was the equation. It was the primary variable. Now, as providers, we're just one nth because, in general, we've not done a very good job of controlling costs. We haven't done a very good job as a society at looking at outcomes. I think there is entropy in the market. I think we have to work on a local level. As I've told you before, go back to the hospital, go on the board, give to the hospital, at the golf events and charitable events, be part of the equation. Go back to your state societies to help them. Prevent some of the things that are coming down the pike. And going back to ASCRS or Academy or ASRS and voicing an opinion.

I think part of your destiny is part of the equation, is part of the leadership, and folks like you and myself and others around us that are doing that. I think that's what you gotta do because, otherwise, it's very fatalistic and that's incredibly guarded. When I go and teach the residents in New York, I still get a glimmer of hope that, yes, we took care of a corneal ulcer today or Acanthamoeba keratitis. People are always going to need us. Robots will not replace us. All that is going to be replaced is our power. As long as you have dignity and integrity and balance within our lives, and I think balance is very important, all of us went into eye care to have balanced life. I saw your beautiful family in pictures, and we talked about it in December at that great wedding in Florida, where you met Swati and myself. I think it's really important for us to keep that balance. But, no, we have to engage our congressmen, our congresswomen, our leaders of our own specialty, and really be part of the equation. That's all I can tell you. And for that reason, I'm guardedly bullish but not overly bullish.

Gary: Got it. Jai, thank you so much for spending some time with me tonight. I love, like I said at the beginning, I always laugh, I always learn something, and that has definitely happened tonight. So, thank you so much for coming on the program.

Jai: Gary, thanks for having me.

Gary: Absolutely. This has been Dr. Gary Wörtz and Dr. Jai Parekh with Ophthalmology off the Grid. ‘Til next time.

Gary: From reimbursement, to consolidation, to population health, the practice of ophthalmology is undeniably changing. As Jai mentions, ophthalmologists will increasingly be held accountable for providing the best outcomes in a cost-controlled, value-oriented way. And I think he makes a good case for the importance of evaluating and evolving the role we play in the overall health care equation. Taking an active rather than passive role helps ensure that our common goal—to provide the best possible care for our patients—remains at the top of the agenda.

So, once again, this has been Ophthalmology off the Grid with Dr. Gary Wörtz. For more episodes like this, visit eyetube.net/podcasts, and be sure to rate, review, and subscribe wherever you get your podcasts. Catch you next time.

Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.