I started as a solo practitioner of ophthalmology in Valencia, Spain, in 1982. Today, I am the founder and medical director of Grupo Baviera, a corporate ophthalmology business that encompasses 73 practices spanning four European countries. We employ 900 people, 175 of whom are ophthalmologists.

How did I get from there to here over a span of 35 years? How does a corporate ophthalmology group like ours operate, and what are the advantages and disadvantages? These are some of the questions I address in this article. I hope my perspective on this issue will be instructive to others who are curious about participating in corporate ophthalmology practice.

IN THE BEGINNING

At the time I started practicing ophthalmology, the standard of cataract surgery in Spain and elsewhere was intracapsular cataract extraction without implantation of an IOL. In my country, I was one of the pioneers in implanting lenses and doing extracapsular cataract surgery. I was also a pioneer in refractive surgery in Spain, performing RK at first, then nonfreeze keratomileusis, and later on phakic IOL implantation with the Worst-Fechner Phakic IOL (Ophtec; no longer available). In the 1990s, PRK and LASIK became parts of my armamentarium as well.

In Spain, as in many countries of Europe, we have both surgical ophthalmologists and conservative ophthalmologists who do not do surgery. In my early years of practice, from 1982 to 1995, some conservative colleagues arranged for me to do surgery for their patients when needed. This began a period of cooperation; I did the surgery, and the conservative ophthalmologists did the examinations and follow-ups.

In 1995, several of the doctors who had been cooperating with me in this way joined me in the founding of Clínica Oftalmológica Baviera. We started in Valencia in a clinic of 900 m², with five consultation rooms and two operating rooms. We were doing mainly cataract surgery at that time, but we also had an excimer laser in the operating room.

Our surgical volume grew rapidly, and soon patients from all over Spain were traveling to Valencia to visit our practice. In 1997, we began to expand, opening clinics in other cities including Madrid, Barcelona, Seville, Zaragoza, and Bilbao. Over the next 12 years, from the founding of Clínica Baviera to 2007, we opened on average three new clinics each year, and our surgical volume grew from 2,000 surgeries in 1995 to 50,000 in 2007.

EXPANDING OUR REACH

By 2007, we had 45 branch offices employing about 400 people, 90 of them ophthalmologists. In that year, we did an initial public offering (IPO), and from that time we have been listed in the stock exchange in Madrid.

We had some private investors in Clínica Baviera before the IPO, and at the time of the IPO some of them exited and others retained shares in the company. Our objective in undertaking the IPO was to create value for both the company and the shareholders. Being a public company increases the visibility of the company in the long term and contributes to our brand recognition. For shareholders, our presence on the stock exchange gave them greater liquidity.

One year after the IPO, in 2008, we acquired Care Vision, a corporate ophthalmology group with five established clinics in Germany and Austria. At that time, Care Vision ophthalmologists performed 5,000 surgeries a year (only laser treatments), and employed 60 people, including 10 ophthalmologists. In that same year, we also expanded our reach, opening several Clínica Baviera offices in Italy. Today, Care Vision has 22 clinics and employs 200 people, 34 of whom are ophthalmologists. About 23,000 surgeries—laser, multifocal IOL implantation, and phakic IOL implantation—are performed each year at Care Vision.

Today, the entire Grupo Baviera is responsible for more than 80,000 surgeries per year, predominantly in refractive surgery. Our surgeons perform approximately 60,000 laser treatments and 20,000 cataract/IOL surgeries per year. In Spain, our surgeons also perform plastic surgery. We have 36 consultation clinics and 37 surgical clinics in four countries, serving a total population of 200 million.

KEEP ON GROWING

What motivated the Care Vision acquisition? After we were listed on the Madrid stock exchange, we needed to grow in order to benefit our stockholders. We wanted to keep expanding as we had been, but by that time we had covered all of the most important cities in Spain, and we had to look elsewhere for growth.

We explored the European market and decided that Germany and Italy were the two countries most interesting to us for expansion. We then looked for ophthalmology groups in Germany that were open to a joint venture, and that is how we came in contact with Care Vision. We found that their corporate philosophy was similar to our own, in that it focused on patient satisfaction.

CORPORATE MANAGEMENT

The name of the overall group, including Clínica Baviera in Spain and Italy and Care Vision in Germany and Austria, is Grupo Baviera. The chief executive officer, headquartered in Madrid, is Eduardo Baviera, and he has led the group for more than 10 years. I, as the founder of Grupo Baviera, am the medical director of the group. Fernando Llovet, MD, with more than 20 years of experience in ophthalmology in general and refractive surgery specifically, is deputy medical director of ophthalmology.

Each clinic has its own group manager to oversee the staff, opticians, and other personnel. Approximately half of our branches are surgical, and the other satellite branches are used only for preoperative workups and postoperative follow-ups (Figure 1).

One of the issues that must be addressed with a large corporate ophthalmology group like ours is standardization and quality control across multiple offices and clinics. Our medical board oversees the training of our young medical professionals and our research and development (R&D) team.

The R&D department in Valencia helps us to maintain quality control and track the proficiency and outcomes of our surgeons. We receive a report every morning showing the outcomes, including complications, of all surgeries performed the day before. This allows us to monitor the skills of our surgeons and to address any problems that we see arising.

We also provide training for all of our doctors, in Frankfurt, Hamburg, and Nuremberg for those in Germany and Austria and in Valencia for those in Spain and Italy. We are not geographically close to many of our doctors, so we cannot easily look in on them and observe their surgeries on a regular basis. Therefore, the best way to have some control over their approach to surgery is to provide 6 months of training, concentrating on refractive surgery techniques, for new surgeons at the outset of their careers with Grupo Baviera.

Usually, during residency, surgeons are trained in all subspecialties in ophthalmology except refractive surgery. We complete our surgeons’ training by providing theoretical and practical training in refractive surgery. New surgeons see patients, and they learn by collaborating with experienced surgeons in consultations and in the operating room.

Techniques covered in this initial training include LASIK, PRK, arcuate keratotomy, and intraocular surgery. We also provide training in the nuances of premium IOLs. In addition to the initial training of new surgeons, we also hold internal seminars on an ongoing basis to keep our medical team current with the most recent developments in the field.

PLUSES AND MINUSES

With a corporate approach to patient care, we have certain economies of scale that reduce the cost of doing business. When we can buy equipment and disposables not for one or two offices, but for 70, we can negotiate better prices. This allows us to offer surgery options with high quality and high value for patients.

For young surgeons, there are also advantages to joining a corporate practice. For example, if they come out of residency with no experience in refractive surgery, they can get good training from their corporate employer before they come to do surgery. Another advantage is that we provide all surgeons with an internal communication tool we call Baviera Online, an internet connection within the whole group. If a surgeon has a question, he or she can receive advice in real time from other Baviera practitioners.

Doctors who join a corporate practice are relieved of the pressures of owning the practice themselves, which for some is another advantage of this style of ophthalmology practice. For instance, when I started as a solo private practitioner, I had to buy a practice, pay a mortgage, acquire a laser and other equipment, and pay the salaries of staff members—not to mention build a clientele from the ground up.

When a surgeon joins a corporate entity, on the other hand, usually he or she works for a salary or for a rate that is adjusted relative to the number of surgeries performed. As a result, generally there is less pressure for a corporate surgeon than for a solo practitioner. The surgeon can concentrate on surgical and medical treatment, rather than worrying about practice management. He or she can also learn from more experienced colleagues and benefit from contact with a network of doctors that can share their skills and their knowledge.

From my perspective, I see more advantages than disadvantages in corporate ophthalmology, although, as I mentioned, there are challenges in quality control when a large group of innovative individuals is involved.

CONCLUSION

I have come a long way since I opened my solo practice in 1982, and I think Grupo Baviera has a lot to offer to enthusiastic surgeons who are attracted to this type of practice.