Private Practice or Employment as an Ophthalmologist

The Two Fundamental Models

After completing specialist training, two fundamental pathways are available: independent practice as a self-employed ophthalmologist, or salaried employment in a practice, MVZ, or hospital. The BVA describes independent practice as an occupation offering freedom of organisation, in which the scope of work, working environment, and hierarchies can be shaped according to one's own vision. The range of ophthalmic activities spans basic and specialist diagnostics, conservative therapy, and ophthalmic surgery. Employment, on the other hand, offers fixed structures, lower financial risk, and — in the hospital setting — collectively bargained remuneration, but less entrepreneurial independence.

Pathways to Independent Practice

Self-employment is possible in several forms. The BVA lists the solo practice, the group practice (Gemeinschaftspraxis), the shared-resource practice group (Praxisgemeinschaft), hospital-based admitting physician activity (belegärztliche Tätigkeit), and the outpatient surgical centre. The regional associations of statutory health insurance physicians (Kassenärztliche Vereinigungen) further distinguish between pathways such as founding a new practice, taking over an existing practice, forming a joint practice (Berufsausübungsgemeinschaft), and employed positions within an MVZ.

Statutory Health Insurance Authorisation and Needs Planning

Anyone wishing to treat patients covered by statutory health insurance requires authorisation as a contracted physician. The basic prerequisite is registration in the physician register pursuant to Section 95 SGB V, which requires completion of specialist training. The application is submitted to the locally responsible authorisation committee, which is composed on a parity basis of three representatives each from the medical profession and the health insurance funds. Required documents include, among other things, a curriculum vitae, a certificate of good conduct, an extract from the physician register, and proof of professional indemnity insurance.

Whether authorisation is possible depends on needs planning. According to the KBV, a planning area is generally closed to new authorisations once the supply level reaches 110 percent. Ophthalmologists fall under the category of general specialist care, which is planned at district level. In closed areas, setting up a practice is generally only possible by taking over a vacant position, for which the KV maintains waiting lists. Where the supply level reaches 140 percent or above, the authorisation committee is expected to refuse a succession application if the practice is not necessary for supply reasons.

The Trend Toward Salaried Employment

The professional landscape is shifting. A survey of more than 1,000 ophthalmologists under the age of 49, reported in the Deutsches Ärzteblatt, reveals a clear change: the proportion of self-employed ophthalmologists fell from 60.6 percent in 2016 to 39.1 percent in 2022. Over the same period, the share of ophthalmologists employed in an MVZ rose from 8.3 to 18.9 percent — more than doubling.

The breakdown by gender and preferred working hours is noteworthy. Women were more frequently in salaried employment than self-employed; for men, the reverse was true. The most frequently cited reason against self-employment — at 36 percent — was the time burden involved, followed by a lack of available contracted positions. At the same time, the survey shows a high level of satisfaction among those already self-employed, of whom just under 96 percent stated that they wished to remain in their own practice.

Weighing Up the Models

Independent practice offers entrepreneurial freedom, scope for personal design, and often a high level of earnings, but requires investment — for example in diagnostic and surgical equipment — as well as a willingness to bear financial risk and administrative burden. Salaried employment offers predictable working hours, lower financial risk, and collectively bargained structures in the hospital setting, but less freedom to shape one's working environment. The growing importance of MVZ also creates a spectrum of hybrid forms, such as employed positions in an ophthalmic care centre with a surgical focus.

The long-term outlook is supported by demographic change. The BVA points out that demand for ophthalmic services, and the importance of good vision in old age, will grow substantially over many years to come. This underpins the security of supply for both career pathways.

What Influences the Decision

The choice between independent practice and salaried employment is rarely final — many pathways can be combined or changed over the course of a career. Those who seek responsibility and freedom of organisation early on, and who are prepared to invest in equipment and practice management, will find the right framework in independent practice. Ophthalmic practices are, however, capital-intensive due to their high proportion of equipment and their potential surgical focus, which makes practice takeovers and partnership models attractive as a way of sharing investment and risk. Those who prioritise predictable working hours, lower entrepreneurial risk, and the possibility of part-time work are often better suited to salaried employment or an MVZ. The preferred working hours reported in the Deutsches Ärzteblatt — with a clear tendency toward reduced weekly hours — account for part of the shift toward employment. What matters is making a conscious decision aligned with one's own priorities, and checking the regional supply situation through the needs planning of the responsible KV at an early stage.

Sources

• BVA, Ambulante Augenheilkunde: Niederlassung mit Zukunft — practice forms, scope of ophthalmic activity
• KV Bayern, Zulassung und Praxisstart — physician register, authorisation committee, required documents
• KBV, Bedarfsplanung — supply level, closure from 110 percent
• Deutsches Ärzteblatt, Augenärzte wollen am liebsten eigene Praxis — self-employment and MVZ rates in 2016 and 2022