The pitch is always the same. We'll handle the business side and you keep practicing medicine exactly the way you have been. Nothing changes except you stop dealing with payroll, billing, and lease negotiations. After 25 years of running a solo ophthalmology practice, handling every administrative function yourself while maintaining a full surgical schedule, someone finally shows up and says they'll carry the weight for you.

So you sign and for about 90 days, it actually works. The billing gets handled, someone else negotiates with the insurance companies. you show up, see your patients and go home without a stack of paperwork waiting for you at the kitchen table. For the first time in decades, the job feels like what it was supposed to feel like when you finished your fellowship.

Then the staffing changes start.

The First Thing They Touch

The front desk coordinator who's been with you for 15 years gets a call from the regional office asking why your location needs a dedicated coordinator when their other offices share one across two sites. Your lead technician, the person who trained every new hire for the last decade and knew your patients by name, gets reassigned to a higher volume location because the group is optimizing resources across the platform. What that means in practice is that your office costs too much relative to the revenue it generates, and the fastest way to change that number is to cut the people who make it run.

One ophthalmologist described the experience simply. He said the group took a practice that was running well and dismantled it from the inside. He'd built that practice over more than two decades. At peak, he was performing more than 2,000 cataract surgeries and several hundred refractive procedures a year out of an ambulatory surgery center he'd designed and built himself. His staff had been with him for decades and some of them had worked in the same office for longer than most physicians have been in practice.

Within months of the PE acquisition, the group began replacing staff. Long tenured employees were let go and replaced with centralized hires who'd never set foot in the practice. Some of the original staff were fired and then the group tried to rehire them after discovering that the institutional knowledge they carried couldn't be replaced by a training manual. Patients who'd never waited more than 15 minutes were now sitting in the waiting room for over an hour. The practice that had been built on relationships, efficiency, and clinical excellence was being managed by a regional team whose primary metric was margin.

A 2025 study published in Health Affairs examining 200 PE acquired ophthalmology practices found that physician turnover increased 265% relative to baseline after acquisition, with annual turnover roughly quadrupling. That number doesn't capture the full picture because it only measures the physicians who left. It doesn't measure the technicians, coordinators, billing staff, and office managers who were pushed out before the physician decided to follow them.

Volume Pressure and the 12-Minute Window

The volume pressure comes next. The schedule that the physician spent years calibrating to give each patient adequate time gets replaced by a template designed to maximize the number of encounters per day. Cataract evaluations that used to run 45 minutes are blocked at 20. Post operative visits that the physician handled personally get routed to an optometrist hired by the regional team. The physician is told this is about efficiency, when in realitty it's about is billing. More encounters per day means more claims submitted, and the PE group's return model requires revenue growth in the first 12 to 18 months to justify the acquisition multiple.

The physicians who push back learn quickly where the power actually sits. The employment agreement gives the PE group authority over scheduling, staffing, and operational decisions. The physician's clinical autonomy, the thing that was explicitly promised in the recruitment pitch, exists only within the boundaries of a workflow that someone else designed. You can practice medicine however you want, as long as you do it in the 12 minutes you've been allocated.

Research published in the American Journal of Ophthalmology found that 78% of ophthalmology trainees said they wouldn't consider employment at a PE owned practice. The next generation of ophthalmologists is watching what's happening to the current one. They see the volume mandates, staff turnover and non-competes that follow you across state lines. They're choosing hospital systems and academic positions over PE, and the pipeline of physicians willing to work inside these groups is shrinking at the same time the groups need more of them to meet their return targets.

The Non-Compete That Follows You

The non-compete provisions in most PE employment agreements make leaving difficult even when staying is no longer sustainable. Radius restrictions that cover not just current locations but future locations, which means everywhere the group might expand over the next 5 years. One ophthalmologist shut down his own practice to take a PE position. Within a year he left and relocated his family twice trying to get clear of the non-compete so he could practice again. The moment he realized it was wrong was when a patient asked a question during a consultation and the workflow didn't leave time for him to answer it.

Another physician in a PE backed group described being threatened with an extended notice requirement designed to handicap his remaining compensation. The message was clear: You can leave, but we'll make sure it costs you.

The promise was that nothing would change, but what changed was everything. The staff, schedule, workflow, patient experience, and the physician's authority over their own practice. The only thing that stayed the same was the physician's name on the door, and even that serves the group more than it serves the physician.

What the MSO Model Actually Protects

There's a version of management support that doesn't require giving up ownership of your clinical entity or signing a non-compete that controls where you can work for years after you leave. The management services organization model, when structured correctly under state corporate practice of medicine statutes, separates the business operations from the clinical practice entirely. The physician owns the professional corporation. The MSO handles billing, staffing, equipment, marketing, compliance, and vendor management through a management services agreement. The physician keeps full clinical autonomy because the MSO is legally prohibited from directing medical decisions.

That structural separation matters because it preserves the one thing the PE contract took away. The physician can leave and there's no equity rollover locking them in. There's no non-compete tied to locations that don't exist yet. The management support exists because both parties benefit from it continuing, not because one party has leverage over the other.

The ophthalmologists who signed PE contracts weren't making bad decisions. They were solving a real problem with the only solution available to them at the time. The problem is that the solution came with terms designed to protect the investor's return, not the physician's practice. A different structure, built around different incentives, produces a different result.

This article is for general educational purposes and is not legal or financial advice.

Verdira is a healthcare acquisition platform focused on ophthalmology practices. Physician ownership. Transparent structure. No volume quotas. If you are evaluating the ophthalmology market and want to understand how different practice models affect transition planning, we are open to thoughtful conversations.

Contact info@verdira.com | 307-381-3734 | verdira.com