During the 2026 ASCRS annual meeting in Washington, DC, Isabelle Bibet-Kalinyak, JD, MBA, and Rajesh U. Kothari, MBA discussed how an aging physician population and the changing business of health care make planning for the future an imperative. The following transcript has been edited for clarity.

Isabelle Bibet-Kalinyak, JD, MBA: Hi, Raj. Great to see you after our presentation about planning for succession before it's too late. We didn't want this to be doom and gloom and participation was essential and it was fun to see everybody chime in on this important topic. I think why it's so critical to talk about this today is because of the changing demographics and also a little bit of a downside in private equity activity. Planning for succession remains critical though, because we have the aging physician population and the business of health care has really evolved. So what did you think were some of the key takeaways about that?

Rajesh U. Kothari, MBA: As we talked about, it's harder and harder to run a small physician practice or even a medium-sized physician practice. And that's driving folks to look at the succession planning and the complications and the challenges of bringing young doctors on. Dealing with private equity and managing against hospital systems is forcing in a good way, I think, practices to think more about their future. And part of that future is what is that succession looking like. And I think as we've talked about and as we shared, they've got a lot of options. They can keep doing what they've been doing, doing it independently. They can just try to stay status quo. I think most are realizing that this is not going to work. And then they can look at: could we do our physician-led consolidation and growth? And then we talked a little bit about what does the PE world look like and why are they so interested?

So, I think that overview of options was really good, but I know you talked a lot about some great points around how do you execute those things, even balancing those things out between the different factors that help you to figure out which one's right for you.

Ms. Bibet-Kalinyak: So, you're right. The number of options is unlimited if you count hybrid propositions. But like you said, there are 4 main buckets. But the main factors that should help you decide which option or hybrid option is the best for you really rely on 5. I have a 5-factor equation in my head. I'm thinking about cash. What does that mean in terms of cash flow, income level? What do I want? Do I want to put money in? The need to borrow, all that. And then the second one is really my appetite for risk. If I'm a practice owner in terms of planning for succession, how much certainty do I want? What does that look like in terms of bringing new partners? How much do I know them? The size of these partners. All that is guided by your appetite for risk. Who bears the risk? Do you take on debt and everything related to risk? The third criteria is the return on investment. When you're thinking about what the future for that practice is, how much do you still want in terms of return investment, and also when do you want that to take place? And then I think the other ones are linked to control. It's the clinical control on one side and then the business control. Some of us can never really give up the control and become employees. So that I think will definitely limit the number of options or option hybrids that you should consider. And if you need to do that internal analysis of these 5 factors and jot them down and really assess them, you will see a much clearer path of what your options are out there.

Mr. Kothari: And when we talked about that, we talked about one of the critical elements is creating alignment—aligning your partners, aligning the other providers in your organization. That when you define those risks and those options and those parameters, if you don't create good alignment internally and understand people are going to have differences (we talked a lot about those differences, but oftentimes you can create the right structure) but if you don't get them out on the table, it is very difficult to execute that succession plan to be able to engage that. If your plan is, "Hey, I want to do A, B, and C," and they're thinking about F and G, you have to get alignment around those. And that was a critical element of what we've talked about. And part of that is changing the mindset of a practice.

Ms. Bibet-Kalinyak: Remember, in the slide deck also in the appendix session, we provided a questionnaire of things people should be looking into, but the alignment sometimes is definitely a factor of the age of the physicians in the practice. And whether you are beginning your career or nearing the end of your career or just in the middle, you have different needs—both from a clinical control or clinical growth and clinical learning standpoint, as well as business, whether you still have a lot of debt from medical school or whether you have other debt—a big mortgage, starting a family, kids in college. So that alignment is critical. And if you don't get it out on the table, you will run into some really tense situations and that's when practices can literally fall apart. And that's the opposite side of what you're trying to achieve if you're planning for succession.

But what do you anticipate are some of the internal roadblocks in a practice when you're thinking about succession planning and the retooling maybe for the future, whether that's a long future or a short runway?

Mr. Kothari: Well, it ties right into what we were talking about in our presentation. When we talked about alignment, it also went to alignment of incentives. So if I'm going to motivate a provider to join my group so I have enough providers so I can retire. I have to create alignment with those different objectives and their incentives, whether it's compensation, where it's balancing work life, which we know is a bigger deal with the younger physicians—how are they getting buy-in? We talked about one of our other sessions—they've got to buy-in to an ASC at fair market value, but maybe I can be more flexible and creative on the practice side to create that incentive to align. And then valuation expectations. Every seller thinks their practice is worth a bazillion dollars and every buyer thinks it's worth $5.50. Getting real and pragmatic about what are the capital costs, the returns, and the risks, allows everybody to get to the right place to say, "What are my options?" So we talked a lot about aligning incentives and aligning incentives becomes important, but anytime we talk about incentives and compensation and buy-in and transition, in health care, we have a lot of extra rules and compliance.

And Isabelle, you talked a lot about critical elements of being compliant as we do those things. Maybe discuss a couple of those highlights on compliance issues and incentives and buy-ins that are important to share.

Ms. Bibet-Kalinyak: I think the incentives come also at different levels that we discussed, whether it's on compensation, but also on the price at which physicians can buy in. So you can motivate partners to buy in over time, investing schedules. We have tools available to design a packet that is attractive to younger physicians, and physicians are also very lucky to have a lot of options for outside financing. So the current owners can help finance and buying in over time by decreasing compensation, but you can also borrow money if you want to accelerate this. That's always an option. And this way, maybe you are more in control as well. You get more shares upfront. But the one thing that we discussed also that was important if you're going to plan for the future is to assess everybody's strengths. Physicians are great at clinical matters, but not all of them are always the best at wearing the CEO hat.

And it's not that they can't, it's that there are only so many hours in the day. You can't be a full-time clinician and a full-time CEO. At one point something has to give. So it's that change of mindset and hiring the right professionals for that. And no need to pitch here at ASCRS/ASOA; we have great leadership tracks and all the training for the administrators here that is needed. But Physicians also need to relinquish some of that power in a sense on the operations and business decisions and realize that every person in the team, including at the operations level, can bring great competence and help further the enterprise. At the governance level, so we can do a lot with the control. Percentage of ownership doesn't necessarily create a control. It's not the only way to create control. I know we discussed some of that during our session. And how can you also control things at the governance level in the operating agreement?

Mr. Kothari: We talked a lot about separating economics from control and control over what decisions and as that mindset changes and evolves. We talked a lot about the different roles of shareholders vs boards vs CEOs and administrators and the changing role and the responsibility. So you can have control in different places at critical junctures while the economics can flow differently and your structure can help you. Are you set up as a PLLC or are you set up as an S Corp? All can help you create more creative economic flow. And those are some of the things that we talked about. This topic is very tailored to the individual and the dynamics, and hopefully this gave a good oversight and perspective to help people think through. But I am always happy to get offline and talk about the unique circumstances of individual practices to help folks think through the regulatory, the legal, the structural, and the economic ways of approaching it.

Thanks for having us for a quick recap of our session.

Ms. Bibet-Kalinyak: Thank you so much.