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The Framework to Scale Optometry Across 4 States: Cold Starts, Acquisitions & the Medical Model | Dr. Solomon Gould
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Welcome to the Power Hour, Optometry's biggest and longest running show. I'm your host, Eugene Shotsman, and today's episode is one that a lot of practice owners I think are going to lean in for. So My guest is Dr. Solomon Gould. And Solomon has a really interesting background. He's own private practices, he's consulted hundreds of practices, he's worked in corporate optometry. But this particular episode is going to zoom in on a very specific chapter or maybe a couple chapters of his career. So at one point, Salomon simultaneously owned practices in, get this, four different states. And he built that through a mix of two acquisitions and six cold starts. All of these practices fully independent. And in this conversation, he talks honestly about what that experience actually felt like and how he went from buying his first practice a few years out of optometry school to to starting cold and new markets. And it's not just about the growth, but also about the challenges. People, operations, leadership, and the decisions that worked and ones that didn't. So a big focus of this discussion is how Salomon used a medical model as a true growth lever in his practice. Not just to increase revenue per patient, but fundamentally to kind of change the practice, economics, culture, long term scalability and just overall patient experience. So we dig into how the medical optometry model impacts margins, capex decisions, patient experience, and why sequencing and he talks a lot about this matters so much when you're making this shift. So we also spend time on building this concept of a performance culture. We talked about why people sometimes work out in a practice and why they don't, and how he got people to come along with him. And what does it really take to take to build a team that can scale with you and how to bring people along with a vision instead of forcing change right away way. So we talk about the bottlenecks that come up, whether it's leadership or strategy. And Solomon ties it all together with three pillars that he talks about throughout the episode, which is people, technology and strategy. So it's a really good episode if you're thinking about growth, because you're probably not thinking about growth in four different states. Maybe you are. But whether it's adding medical services, opening another location, or simply building a practice that runs better without you being the bottleneck, think this episode will definitely resonate. So before we jump in, quick reminder, make sure you're subscribed on YouTube, Spotify, Apple Podcasts, or wherever you listen so you don't miss future episodes. And as always, if you have Feedback, questions, ideas for the show reach out to me directly@eugene shotsman.com or on the Power Hour website. I do read, I do respond. And now let's get into it. Solomon Gould, welcome to the Power Hour. Excited to have you on the show.
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Thanks, Eugene. Thanks so much for the opportunity this morning. I'm excited to be here.
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Yeah. And, you know, I think usually we don't do long intros on the, on the show, but you've accomplished so much in your career and you've seen such different sides of our profession and our industry that I thought it would be really good for the audience to get some context about your background. So just give everybody some highlights over what's happened over the last couple decades.
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Oh, sure thing, Eugene. Yeah, no, it's been a. It's been a beautiful career so far. And now I'm 15 years into, well, now 16. I have to remind myself it is 20, 26 of a lot of different things. I mean, I'll start off with what's near and dear to my heart, and that is being a private practice owner. I've had the genuine pleasure of owning eight private practices that are fully independent. And over the course of time, I found myself very, very intrigued and heavily involved in consulting for private practice owners. And so I've had the genuine pleasure of consulting for hundreds, at this point, of private practice owners and groups in the private sector over the past 15 years. And of course, in that experience, I have also been involved in both private equity and corporate ventures. And so I've seen a lot of different sides of every different sector within the industry. So, yeah, it's been a lot, and it's been a genuine pleasure. Yeah.
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And so let's talk about some of the maybe unifying threads and maybe even go back to your first private practices. So some of the private practices that you owned, what were the early lessons that you learned and how did you even come to own those?
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Oh, yeah. So, you know, I come, you know, after graduating from optometry school, which was back in 2012, hard to believe. I was very intrigued and enthralled in the thought of being an entrepreneur. I had always, always loved that, that entrepreneurial spirit and opportunity that comes with being an independent business owner. And so I, you know, two years into private practice, into private practice as an associate optometrist, I was ready. And so how I got into started off with the purchase of a private practice and with a very rich history, 42 years, same doctor, and believe it or not, Eugene, same optician. And so you know, I jumped right in. And I would say the biggest things that I learned is one, not being afraid to really ask a lot of questions and challenge status quo. And by that I mean specifically from the inception of creating a business entity and making sure that, you know, a. I was fully informed of what all I needed to have in place before I hit that execute button. Everything from the business entity itself, accounting, what payers I wanted to and needed to be credentialed with, to how I wanted to structure the platform itself from a patient care standpoint. And specifically, what I mean by that is how much do I want to focus on that retail side? How much do I want to focus on pushing the envelope and getting in more to the medical space? And in that, you know, I'd say the biggest retrospective mistake I made early on was, you know, thinking that I had to just, you know, take whatever plans I could, I could get on, you know, and. Which serves as one of the more strategic levers that enable private practices to be very successful. And that's getting on as many commercial medical payers as well as Medicare, Medicaid and. And other plans as possible.
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B
Yeah. And you know, what were. So when you first took over that practice, you said it had been here, there for over 40 years. You obviously had to make some changes. Did the other OD leave right away or did you. Was he your employee for a while? Did you feel like you were working for him even though you were the owner? And, and what. What were some of the changes that you really wanted to make right away? And I imagine you came up with some resistance as well.
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1000% across the board, Eugene? Yes. So funny enough, I'll never forget the day after, and I did purchase it through a broker. And I'll never forget that we closed the sale at the broker's office and walked out to the parking lot and the former owner handed me the keys and said congratulations, and he was off to retirement. So I started completely on my own with his existing staff, including the optician who had been with him for all 42 years. And then, and then a number of employees. Absolutely correct that there was a big paradigm shift that I, in my vision Inception, you know, conceptually I knew exactly what I wanted to do, but the practice had been almost strictly retail and vision care plans or cash pay for so long. And I myself was very determined to make this a very highly medical private practice. So the resistance came from a360, really starting with the employees. It was a lot of numerous additional implementations, learning, training, a shift in the patients and the loyal patients who had been coming there for a long time and even the vendors that, you know, had, had serviced the practice, shifting that focus more into the medical side and still very, very strongly executing in retail. Even the vendors themselves, you know, got a little bit of resistance too because of course retail drives their business and I'm shifting my focus more into the medical space. But overall it was, you know, a great thing to learn early on in my career. You know, they always say fail, fail early. And I certainly learned very quickly how to create the alliance or the buy in to a vision despite its rich history.
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Yeah, so that's kind of a, and it sounds like that's really been a theme and when we've talked before, that's been a theme throughout your career is trying to figure out what is the vision, whether you're the one creating it or whether there's another leadership team that's creating it and then getting people to buy into that vision across the board. So what are ways not to do that? Like what are mistakes? Like talk, talk about something that that's happened to you personally where you're like, okay, that's definitely not the way to do it. And then let's talk about the way that you would potentially do it and what you've seen to be successful.
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Yes, I think the, the, the most, I would say the, the, the most effective way that I found both with, you know, my own private practices and creating that paradigm shift is, is really bringing the people along the journey, bringing them into the collaborative input and planning process. What I, what I, you know, wouldn't do and unfortunately I never did this. I've had some amazing mentors in the industry that have helped guide me and throughout my career and they taught me going into this, everything that you know, they knew from their own experiences. So it's kind of that cascade down. And so, you know, what I would not recommend is going in with, you know, we'll say a strong handed, strong headed mentality of this is my way or the highway and this is what we're going to do. I think bringing the team. What I did is actually when I first took over my private practice, the first one, we actually did an off site where we, we sat down and we mapped out everything that, you know, I had in my vision and then I had the, the team, you know, contribute to building the roadmap of what we needed to do to get there. And in that inorganically what I found is that we didn't all have the same opinions. We didn't all share the same beliefs at the onset. What ended up happening is that some of the employees who maybe previously weren't as vocal or didn't have as loud of a voice started to really synergize with the vision and create solutions on their own. And ultimately what I found is those were the. They actually became my longtime employees, whereas others, you know, over the course of time, they just, you know, it wasn't in their vision of what they wanted to be a part of. And so, you know, I kept the ones that were, where we'll call it my strong players to this day, you know, dear friends of mine. And, and, and actually that's the team that helped me to scale up to the eight locations over. Over the course of time.
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Yeah. So what did you learn? And when you were talking about eight locations, I always. We had an episode not too long ago where we talked about, you know, moving from 1 to 2, 2 to 4. And in your case, you know, at some point, 48. So let's talk a little bit about some of your early learnings in expanding that business. So you have this one location, presumably it's thriving. If you want share some numbers, talk about, you know, kind of how it changed from when you took over. And then let's talk about what happened when you were getting ready to expand.
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Oh yeah, definitely. Well, I'll start, you know, the practice itself that I first purchased a long rich history and it was is netting roughly around 380k if I remember correctly. And you know what I found when I.
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B
Is that collections or is that ebitda?
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Ebitda, yeah, thank you. Thanks for asking on clarification. So had an ebitda of roughly 380k. And you know, I was hard pressed on building out a medical model. And you know what I found as I started to get very strategic with the payers specifically I had. My business entity was complete. I was contracting and credentialing with very strategically with select payers to ensure that I had as high of an exam reimbursement as possible. So average exam revenue and what I found in doing so. We talked about opposition earlier. You know, I had a hard time getting on some of those payers to start, but I was able to leverage a firm that was able to help me with getting on those panels. They had some good influence and some, some great relationships across the payer, the different payers and was able to get on those payers. And from there it was a quick, we'll say cash flow lever that enabled me to Increase the cash flow to enable a second location very, very quickly over the course of time. And then when I turned the page into a second location, what I found, and this was also an acquisition, I found that everything I had done in that, that first location and that first private practice was more of a, we'll call it rinse and repeat. I like to tell people that first practice is your biggest challenge. When you start to scale up and you have a proven model and a proven strategy, it enables you to move a little quicker. There is one variable in that formula, though, that you always have to be very, very strategic and delicate with, and that's the people. Right. We don't have our businesses if we don't have our people behind us. One of my favorite quotes is, you know, if you're leading people and they're not following you, they're just going, you're just going for a walk. And I found that it was a matter of bringing the people along the journey. So everything I did with that private practice, from creating that roadmap, that strategic roadmap of how we were going to get from status quo to the vision, I did that same thing with that second practice and the second group of employees and had the same experience with that second group, ironically.
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So you mentioned the number of about 300,000 or 380,000 in EBITDA for the first practice before the medical model. What was it after you added the medical model?
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Yeah, two years in after we had successfully. When it comes to the actual patient model, patient care model, once we had a robust patient medical model, we had, we were ebitda roughly around 5.70ish with that first practice and ultimately seeing how.
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B
Many more patients and, and also maybe revenue wise, what did that do to your revenue?
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Yeah, revenue itself, we were actually netting about a two or three multiple in, in the, the revenue itself. The, the, the gross revenue. And then what I found is the operating expenses. After some strategic contracting, we'll call it consolidation of everything from tech stack to, you know, vendor alliance groups, I was able to mitigate the operating expenses down to a very healthy number, which fueled even quicker growth onto the third and beyond locations.
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B
Okay, so I'm not sure I fully understood because I expected it to go a slightly different way. So let's just say, and you know, maybe we use approximate numbers, but let's just say your first, when you first bought the practice, it was 1.1.1 million or something with 380,000 in EBITDA. Totally. I think a solopreneur type of thing. Maybe it was a little bit more. But then I'm assuming, I don't know if you saw more patients when you got the medical model or if you saw the same number of patients, you just drove revenue per patient, or maybe it was both. And so how much did revenue go up? Because we know, so you mentioned, you know, your, your profit almost doubled. Not quite, but you know, double went up by like 70%. So what's the, how much did your revenue go up to facilitate that profit increase?
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Yeah, we saw roughly around a 35% increase in revenue. And that ultimately in combination, you know, with the reduction of the operating expenses will enable, enabled us to get to that healthier EBITDA in a quick, quick period of time.
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So to do that, were you seeing more patients or were you just seeing patients differently?
- [17:46]
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Both. Yeah, it's a good question. Our, our new patient ratio grew significantly once we started really attacking our marketing strategy and being more effective in our marketing strategy. We're able to grow a lot more patients and we had both organic growth internal through our own patient base as well as through external. So through getting new patients. So roughly roughly about a 15% lift in New patient ratio over the prior to the medical model.
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B
Well, and I imagine that. So 15% lift, 35% more revenue and we'll call it 70% more profit. That is, that's pretty substantial, right? Like, that's a, I would say that's a good one liner for this episode and say, here's a guy who was just out of optometry school, practiced for two years, bought a new practice and within two years was able to increase revenue by 35%, new patient outpatient volume by 15%, but profit by 70%. So that is pretty good. And then you were able to add another. And when I say pretty good, I put it like in air quotes, like it's really good. So that now you take, now you take that model and you and you go to replicate it. Now the medical side, we're going to get into this in a little bit, a little bit later in the show, but the medical side sounds like it drove a lot of that growth in revenue per patient because obviously you don't have cost of goods on medical. And as you mentioned, you know, a big part of it was getting the pyramids. Right, but it sounds like you drove down your cost of goods for your retail patients, but then you really didn't have as many retail transactions because you were focused on medical and there your cost of goods, you know, 30% of every dollar isn't necessarily flying out the door for cost of goods.
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Right, right, right, exactly. And on the note of the medical model transformation, to your great point Eugene, Capex of the equipment and the technologies that I brought into my practices was also very strategic. You know, it's easy to go after the shiny objects and to go for state of the art technologies like a Heidelberg OCT or you know, whatever technology one is really excited about. I was really focused on a combination of the key technologies that I knew were good for the patients, good for the clinical care of the patients. But I wanted to provide both that preventative prophylactic care approach, that functional care approach to my patients, things like ERG and other biomarkers for the macula, for example. So I really focused on a new way of approaching eye care. And of course after I had generated enough cash flow from a combination of screening as well as using the existing technologies I had incorporated for diagnostic approach, I was then able to really turn up, we'll say the CAPEX lever and acquire a lot of the big, big instruments, the nice OCTs, the, you know, all the things that optometrists love for patient care.
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And so give me some example and some examples and maybe, you know, I think I understand what you're talking about when it comes to Capex, but just give me some examples of what really your you mean here and maybe break down that formula a little bit on the Capex side.
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Yep, absolutely. Start with the technologies. I've always been a big fan of erg and at the time of my private practices, the only ERG technology on the market was the Diopsis. And the Diopsis technology was at that point in time a game changer. This allowed us as doctors of optometry to quantify the functional health and integrity of the retina, which can be applied both as a screening tool as well as a diagnostic tool. And the CAPEX on that at the time was on the higher side. I want to say it was around 60k back in 2012. Over the course of time I started to identify other prophylactic technologies, things like the dark adaptation with the VR headsets. And I'll never forget when they first came out with the VR headsets. That was a game changer for us as doctors of optometry. So leveraging, you know, a few different instruments, you know, Radius xr, all eyes, and incorporated those into the pre, pre test experience. Same thing with those. We, we leveraged that as both screening and also for diagnostic purposes. And, and that at the time I was, it was roughly around 15k ish for a VR headset. And um, there was a lot of emphasis on that pre test at my private practices for a reason. It was we wanted to create a new experience for the patients that provided them, our patients and our loyal customers a new and a much richer experience going to their eye doctor. And then over the course of time, as I started to get more adoption of just, you know, simply because of the fact that those first two private practices were acquisitions and I was creating a paradigm shift, I had to first start with that low hanging fruit and things that would give them a better experience before I brought in the, we'll call it the more mainstream diagnostic technologies like you know, oct, visual field, et cetera. And so, and then you get into those Capexes which, you know, for an oct, which is very, very profitable. You know, you can spend anywhere from on the very low end in the 40s up to over 100k if you want the best model for an oct. Yeah.
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B
And you know, I think the, as I think about this, as you're talking through this. So like let's take a VR headset. So that's like 10 or 15K. Now there's obviously a patient mix that needs visual field. Are there other tests and would you bill. So talk about how the billing would work if you in that particular case. And also, do you feel like we don't do enough visual fields as an industry? Are there some patients that we just don't necessarily recommend it, even though clinically we probably should?
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A
Yeah, no, first and foremost on just the overall implementation of a VR headset. To answer your question first, visual fields are a fantastic way to screen for a number of things. You know, visual field is most commonly at a private practice or in many private practices done with what we call the finger counting. So you're basically using your fingers and you're assessing the peripheral vision manually with your fingers. And in that, as you can imagine, just human error or just the, we'll call it the gross methodology of assessing peripheral vision, a lot of things can be missed. The VR headset itself provides a very quick, efficient way for us to be able to identify areas that either flag us as doctors to be able to say, we should probably do a much more thorough workup of that patient. And if nothing else, it provides that patient with a new fun and experience of experiencing technology in the space of optometry. Something that they, you know, would otherwise only see whether it's a video game or, or on, you know, on tv. So, but then on to other tests and, and I'll I'll wrap it up here. You know, now they've evolved and even at the, as I was still had my private practice, they were evolving to a number of things. Movement of the eyes or ocular motility and others. And these are a lot of those things that, you know, if not, you know, executed correctly, you know, by the, by the employees or the doctors themselves can, you know, lead to, you know, not catching something important or, or even just patients don't have that wow experience as I like to try to provide. Yeah.
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B
And that, that would be the headset, for example. But you're, are you saying that then every patient in your practice, as they're going through their workup, is getting, is getting to put on the visual field headset, whether they clinically are required to do that or not? In your opinion, is it just standard of care to just have every patient do that or what, what percentage of patients would do that? And again, how do you bill for that?
- [26:50]
A
Yeah, yeah. To answer the billing question, and I'll, I'll make sure I touch on that as well. But we did offer it as the primary modality for us to do the pre test. Um, and we would, you know, we had a, an acknowledgement form and an opt out form for patients. If they didn't want to try the VR headset, they were not required to, in which case we would of course utilize a different test. But you know, as far as the billing aspect, we leveraged the visual field specifically as a pre test. We didn't bill for the visual field with the VR headset at the time. They only had a screening option. But then over the course of time, they were able to get in a couple different tests, the 24, 2, the 32, at which point we were then able to still use as a screener for patients and we wouldn't charge for the visual field pretest. And then if we did detect there was something that the patient had some form of ocular pathology, we could then bill that patient after we repeated a second test, we could bill that patient, patient's medical insurance accordingly. But early in the inception of all, it was very much a screener and a way for us to provide our patients with a good experience.
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B
Yeah, and it makes sense because I bet your patients were pretty impressed to say, oh, I've never done this at the eye doctor before. And that kind of creates a different perception of the value of the eye exam as well. So after the break, I want to talk a little bit more about your experience in growing from 1 to 22 to 4, 4 to 8, whatever that looks like. And then I want to also maybe tie it all together with some lessons that you learned along the way and maybe a methodology that others thinking about growth and these types of success, successful results that others could possibly implement. So we'll be right back on the power hour. And we're back on the Power Hour with Dr. Solomon Gold. And I wanted to. So where we left, the story is you opened or you bought a practice in Iowa, you increased profitability, you got a second practice in Iowa, and you kind of did the same thing. And then what happened?
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A
Yeah, you know, at that point in time, I, you know, I decided, you know, I moved out to the east coast, to the beautiful city of Boston, near and dear to my heart to this day. And, you know, after I had experienced, you know, we'll call it creating a paradigm shift in existing private practices and implementing a very different model than what the practice was used to and bringing the people along the journey like we were talking about before those. Those three key pillars, you know, I was really excited to try my first de novo. And so I had the opportunity of doing so in. In the city of Boston. And what I did is I was very strategic about bringing in, you know, we'll say, a minority, Minority partner who happened to be an optician. And, you know, it was in a really fantastic part of the city, in the North End, Little Italy, as they call it. And this was my first de novo. And essentially it was a replication of what I had done in the first two practices and in a very different market where there was a lot more competition than I was accustomed to. And what that enabled me to do is really sharpen the blade with how strategic and how granular I needed to be on every facet of the business. And. And was able to turn that practice into a very successful position over the course of a year, actually. So we broke the 1 million mark within the year through a combination of the model itself being in the right location, having the right partner at the time, and really just doing everything we could from a marketing and an outreach perspective. And then from there, it just became a spiral.
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B
Did you see any patients yourself, or were you always focused? It seems to me. And obviously, the fact that you moved away from your two practices is clear testament to the fact that you're a business owner, you're a business mind, rather than necessarily focused on how many patients can I see myself? So when you open the Boston location, so you opened a cold, you partnered with an optician, and then you Said you brought in the same medical model. So you got a optician partner who's trying to make sure that you have a medical model as well as a retail component to the practice. And I'm going to ask you maybe three questions and feel free to answer whatever order. But number one is, what was the greatest. What was the greatest tool that you used to get patients to show up to a new practice in a new city without any reputation there? Number two is what percentage of your business was the medical billing, so to speak, and what percentage was retail? And number three is, did you see patients? Did you have to recruit an od? How did that all go? And were you. What were some of the biggest challenges?
- [32:24]
A
Yeah. Yeah. I'll start with how much I was involved in the patient care itself, if you don't mind, Eugene. Largely because for me, it was near and dear to my heart that I protected the brand and I protected the integrity of the vision that I had. So I would actually see patients at least one day a week at each location. And for the locations in Iowa, I would actually fly back, believe it or not. And I would do one weekend every month for each location. So two of the weekends, I was actually back in Iowa, and I would see patients on Saturdays. And that was important to me. And that. That enabled all those patients who really, really wanted to see me still to see me on those Saturdays. And then, you know, going into the forefront, the first question of, you know, what did we have to do for that first de novo? Quite honestly, I mentioned outreach. Outreach was one of the best things that I could have ever done. I was boots on the ground, going all around and spreading the word with within, not just the local community. I did join Rotary. I actually, you know, I was involved in Lions Club, but more importantly, I actually went to all the emergency room departments. I went to, you know, the clinics, and I shared my information. I offered presentations, some of which I was invited to actually present. Others said, no, thanks. But I was really aggressive on local awareness. And then I paralleled that with a very, very successful target marketing campaign and a lot of. A lot of social media posting. So I learned in those days, early on, that organic social media presence, being authentic and being real and not necessarily providing idealism was a key strategy for that at that time, the Gen Xers and some of the Millennials. And so I leveraged that and we did a lot of social media posting and really just fun, fun moments behind the scenes. Like, for example, we had a nickname for every device in our office, our HP printer, Faxer was Huey. We had a Keurig, his name was Buzz. You know, we would do little fun posts like, you know, hey, Huey's having a bad day today. We can't send your prescription, but we'll put it in your portal or something along those lines. But it was really just a combination of, you know, boots on the ground, grassroots efforts, and really leveraging the marketing aspect.
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B
Got it. So then you started this location cold. You. What percentage of. So a year later you were at a million. What percentage of that revenue was medical? What percentage of that was retail?
- [35:10]
A
Yeah, we actually started out roughly around that 30, 25, 30% on the medical side. And then we grew it to roughly around 40% medical within that practice. And then over the course of time, I actually scaled up on the medical split with the future practices.
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B
Okay, and you're in, in this, in that location, how much revenue? What was at its height? I know you exited and you sold your whole enterprise, but before you sold, what was the height in terms of revenue for that location?
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A
That particular location, we got to roughly 1.7 in revenue. Got it.
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B
And that was with one full time od, or did you have more than one?
- [36:02]
A
Yeah, we. I actually found a phenomenal doctor. She was, she was five days a week. And then I did have a weekend doctor as well. And, you know, I would fill in for the weekend doctor whenever they wanted time off. And that enabled me to still maintain some patient care at that location as well, but had a phenomenal, phenomenal two associate doctors there. And it was one single lane. And what enabled us to be so profitable was implementation of that medical model.
- [36:34]
B
Got it. That makes perfect sense. And revenue. So you mentioned revenue was 1.7. What was profit at its height?
- [36:44]
A
We had roughly 35% profit within that location.
- [36:51]
B
35% profit margin. Wow. Okay, great. And that is. It sounds like if you're doing 40% medical, that does make a lot of sense because again, you don't have cost of goods on that. You may have to pay your ODs a little bit more. But you're. But, but that does make perfect sense. And so then you basically cash flowed yourself to more de novos. Is that how the rest of the organization got built? And where did you build those de novos? Also in Boston or in other places?
- [37:21]
A
Yeah, yeah, I know that. The adventure continued from there, my friend. You know, I had a great experience in Boston, but I then had moved into the state of Vermont of all places. And, you know, exactly like you described it was taking that same concept and Applying it to another de novo in Vermont. And I was located in a small town called Middlebury. And it was a really beautiful terrain, absolutely beautiful community. And why I moved there, I was actually wanting to stay somewhat near to where my wife was doing her postdoc fellowship. She actually moved to Boston. And I wanted to change the scenery and I wanted to create, I wanted to try creation of a private de novo in a location that didn't have as much competition and was more in that rural setting. Just to really test my model. My first two practices were also urban. Third practice was urban. I wanted to test that, you know, we'll call it more of a suburban, rural aspect. And so I took that and created another de novo in Vermont, same concept, same strategy. And that one is where we actually started to increase the medical model even more from 40% to 60%. And we were servicing patients from two or two or three hour radius, you know, would come all over to see us, which was absolutely wonderful. And we only had one other eye care practice in the, in the, you know, the local community. So it enabled us to be very effective within that, within that zip code.
- [39:00]
B
So when you opened de novos, because it sounds like you opened at least six de novos. When you opened de novos, what was the. How do you decide where you should locate the practice? And then you just mentioned you had a significant patient draw. What were some of the things you did in order to get that patient draw? I'll stop there. Yeah. So how do you decide which location? I have so many. I probably could probably make this episode four hours long because this is a super interesting journey. But I'm going to try to keep myself under control.
- [39:35]
A
Yeah, no, absolutely. I'm a big believer of the worst house on the best block. And so even with my first private practices, my spaces were very efficient and small. It was very. It's very tempting to go for the bigger equals better. But I've always been a lean machine kind of, you know, person. And so when I did the same thing in Boston and in Vermont, I actually increased my office footprint slightly. I think my. That practice was roughly 2000 square feet, which was a step up from my roughly 1500 square feet. And but I was, you know, to answer your question about how I was able to get the patients in, it really is. I use that same lever at each load, each de novo, boots on the ground, community involvement, getting the name out there, putting myself out there to present and create alliance within the OMD community. I can't tell you the number of Bags of goodies I've handed out to emergency departments and how many conversations with physicians I've had about why optometry is important and why I could be of benefit to them and to their patients. But between that and our marketing, which by that time we had really perfected our spend, our allocation, what platforms, and we had a better idea of what our ROI would be in the early stages. You're really kind of cast netting out there, right? You're really testing to see how it works. But once you got to that, once you got to even number three, we knew, well, three was a little challenging because it was a new city. But once we were able to pinpoint the formula, the spend and the allocation, that was it. And then just staying diligent in the community, that really paid off.
- [41:19]
B
Yeah. And I've heard you say this now multiple times about the emergency rooms. So I don't think a lot of people think about emergency rooms as a great place to get patients. So what would be your pitch? What are you telling them, what are you bringing them and who are you even talking to there?
- [41:37]
A
Yeah, you know, quite honestly, you know, every, we'll say every market, every city has it, we'll say a different level of influence from the OND community. And so the first thing is just putting yourself out there and introducing yourself and what you do and testing each interaction, you know, is this one that I, you know, I feel comfortable going back and, you know, trying to put myself out there again. And you know, there are some cities, some markets where the optometric community doesn't have the full buy in and support from the OMD community. And that's a very generalized statement. But what I found is by continuously circling back and providing the value I could provide to them, ultimately I was able to win a lot of those conversations. Not all, but a lot. And specifically at the beginning I was offering, hey, I can just be a resource to you. You can call my cell phone anytime you have a patient that has something in the eye and I'm just here to help you. And then if you do happen to know of anybody who needs an eye doctor, just send them my way. But otherwise my consultations are free of charge. And then it became, wow, this guy has all that is needed for eye emergencies. Let's send our patients in that come with eye emergency, because oftentimes they get an eye drop and then they refer to an optometrist anyway. And so it really is, you know, being able to eat some of the, we'll call, value of your time and some humanitarian efforts to first build up that relationship and prove the value, and then it becomes an inherent natural referral relationship.
- [43:15]
B
Is the general reality is that, like, the ophthalmologist on call is just too busy and they're, you know, that they don't have an ophthalmologist. Like, if a patient comes into an emergency room and they have something in the eye, it would seem to me, and I live in Cleveland, so everything is dominated by a really big medical enterprise that is the Cleveland Clinic. So it would seem to me that if I walk into an emergency room and more than half of the emergency rooms in my town are owned by the Cleveland Clinic, um, then I would be likely referred to an ophthalmologist or something within the network. You're saying that in some communities that's not the case. And the, and, and the, the treating physician who is in the, who's in the room gets to make a decision and say, you know what, I want you to go see this optometrist because you can get into him tomorrow or right now versus, you know, the ophthalmologist who you might have to make an appointment and wait three weeks to get in. Is that the value prop?
- [44:20]
A
Yeah, that is part of it. And the other part is a lot of times when patients come into the emergency room, if they have an eye ailment, the only time they'll really page in or bring in ophthalmology is if there's like a major, you know, trauma, you know, whether the eye itself has been, you know, lacerated or penetrated with an object, or they have the need for sutures that are, you know, too close into the anexia of the eye, where the emergency physician doesn't feel quite comfortable. So oftentimes, you know, they'll get an eye drop and they'll try to assess the surface of the eye with what they call a burton lamp. But ultimately they're then referred to an optometrist or to an ophthalmologist after the fact. So by being a good consultative contact for the emergency room physicians, that enables us to prove our value within the community.
- [45:15]
B
Yeah, And I imagine that in the rural community, you were also seeing more older patients where the medical model might be even more attractive. Right, though, versus your urban settings.
- [45:26]
A
Correct, that's exactly it. And, and what I found, even in the urban settings, Eugene, was once consumers or once patients know that you are doing everything all at the same place, they're, you know, you're not just servicing their once a year visit. Hey, If I have something I can call that same doctor and I can go back and see that team that actually really created what I like to call the sticky factor for patient loyalty. You know, patients came back every year, we had a higher return rate, we had an increase in the new patient ratio as well. So it's really proving the value of all in house approach to patient care.
- [46:04]
B
Yeah, that's super interesting. And so then your next four locations, were they rural, were they urban and were they also in Vermont?
- [46:13]
A
No, no, no. Actually then I went back to the urban setting, so back into the beautiful Midwest. So Minnesota, where I reside now, and definitely I would say Minnesota is one of the states that has the most complex medical commercial payer mix, but also the richest from an opportunity perspective. And you know, it's, it's hard to get on some medical plans in certain states and Minnesota was one of those. But they do have very rich plans for optometrists.
- [46:51]
B
Yeah. And it's interesting as you talk about it is that you're managing practices in four, in four different states and at some point in your career. So what were the biggest challenges you encountered when managing an enterprise of that size? Geographically?
- [47:10]
A
Yeah, I think it all starts, I'd say I'll start with a lever that I, you know, I think is probably the most, the best investment I could have made is really making sure that I had the good tech stack and a good power dashboard to be able to, you know, watch and monitor the metrics of the practices on a weekly basis, on a daily basis. But also having the right partners in place with, we'll call it skin in the game. You know, they had equity in the practice and you know, the biggest challenge I found over the course of time was so I had a good, I had a good pulse on, you know, who I had watching the locations and managing the teams on a day by day basis. But what I did find over the course of time, Eugene, is that, you know, the labor itself, the operating, the cost of labor became, you know, very, very high, much higher than I had been accustomed to. But you know, with challenge comes opportunity. So I use that as an opportunity to pivot with how I was paying the teams in all different positions, optometrists, the technicians, the managers and I created in a way that they were actually able to make more money, but they had to, you know, create the value to earn that money. And for some doctors, for example, where the more the higher incentive based structure is not as appealing, you know, I would lose doctors who wanted just a guaranteed base you know, pay with a nominal bonus structure. But I would gain doctors who were really driven based on opportunity. And, you know, so I'd say overall, the biggest challenge ultimately came down to the labor aspect. Yeah.
- [49:02]
B
And again, I want to be respectful of the fact that we don't necessarily have hours and hours, and maybe we'll do a Part 2 episode if the audience requests it. Just jumping into how you manage that and how you manage incentives and all of those types of things. I think, you know, where I want to probably end this particular episode is you came back to your three pillars a couple times, and so maybe just speak to that a little bit more. The strategy, the technology, and the. And the people. And what. And I know that you also had consulted hundreds of practices throughout your career as well. So what are some of the common unifying lessons from. From all of this experience that you had that, I mean, really, maybe you wish you knew ahead of time, but what were some of the things that you really think account for some of your success across those three pillars?
- [49:59]
A
Yeah, definitely, Gene. Thank you. I'd start, you know, with people. Over the course of time, we all change, society changes, and we have different generations that are, you know, provide. That are our employees, that are our colleagues. And I would very. I was always very diligent about keeping on top of the generational differences and how to be more effective with the different generations. So when it comes to doing anything, it's really making sure the people are at the forefront. Without your people, you don't have your team and you don't have your businesses. So maintaining a pulse and being very strategic in how I interacted with them, both as my employees as well as with the patients. The technology piece, you know, technology in optometry specifically has. Has come a long way. We have now the opportunity. And I did experience this solely over the course of time. I mentioned diopsis earlier in our. In the interview when erg behemoth thing, that was a way for us as optometrists to prevent, you know, kind of that prophylactic or propensity to develop, you know, complications. Here's where you're at with this condition, and here's where you're trending. So technology became not just a way to react, but also a way to predict and giving the patients who, again, going back to people shifting. The consumers were changing and shifting. They wanted to take their health into their own hands and have responsibility over it. So things like the macular health, the retinal health, being able to say, okay, what can I do? To, to overcorrect this and then the last part, the strategy. I think the best thing I ever did, Eugene, was sitting that first team down and mapping out the vision of how we get to where we wanted to go with that first transformation. Solomon knew exactly what he wanted to do and how he wanted to get there. But I really needed to open, you know, open my heart and open my mind to what do other people think? And I got that recommendation from a mentor. But also, you know, Steve Jobs always talks about, you know, we hire the smart, you know, the smartest people to be better what we do. I learned a lot from my teams along the journeys and I had insights from them that I wouldn't have thought of myself. And so the strategy, although inception was Solomon's strategy, became every team member along the way helped to form my strategy, which I then carried over into industry and, and to my various roles.
- [52:31]
B
Yeah, that's fantastic. And I think a really important lesson, again, kind of those three pillars being technology, people and strategy, in no particular order, but it seems to me like that that was a big maximizing component. My last question to you is, you mentioned this whole, you're going to monitor metrics every day, every week, every whatever. And so those three pillars only work together if they're measured, if they're accountable. So aside from watching, I don't know, the revenue or something, as you log into your dashboard with your enterprise across multiple states, what are the key metrics that you think, you know, maybe people wouldn't even expect to monitor whether they have one location or multiple. And what are the, what are the things you learn from looking at those numbers?
- [53:21]
A
Yeah, I would say the biggest ones for me have always been, you know, collections per full time equivalent. Looking at what each individual employee is. And we're speaking on, you know, start with the doctors looking at, you know, what are their collections, you know, how are they benchmarking against, you know, where they started, what is their goal and how can I help, you know, guide them on how they get to their goal. And then of course, on the retail side, we're looking at multiples, upsells, and really ultimately the ratio of full time support to the doctor, making sure that we have labor at an efficient standpoint and that we're being effective with the team as well. Those are the big, big ones on a daily basis.
- [54:15]
B
What I heard you say, which ties all this so nicely together, is that when I asked you about the numbers, you didn't just say the numbers, you said the numbers and how the person who I assigned the number to, what their goal is and how they're trending towards their goal. So I assume behind that, and this is where a future episode could exist as well. Behind that is the conversation that you have to have with the individual to get them bought in to the fact that they want to be better off tomorrow than they are today. And in order to be better off tomorrow than they are today, we're both watching this number and we're both going to talk about this number. And the number isn't going to be something that we review once a year. It's a number that we're paying attention to because you, you, that employee, set the goal that I really want you to hit so that. I love that with that. I think we've covered so much in this episode. You had such an incredible journey. Honored to spare an hour to spend an hour with you, Solomon, in such a. Such an insightful conversation. And I appreciate you being on the Power Hour.
- [55:18]
A
Well, thanks for the opportunity, Eugene. Lots of respect for you and everything you do for us in the industry. So, again, thank you so much and hope to be back someday soon.
- [55:27]
B
Of course.