As rising costs, consolidation, and succession challenges reshape ophthalmology, independent practices still have options, as Isabelle Bibet-Kalinyak, ESQ, BBA, JD, MBA, discusses in her American Academy of Ophthalmology 2026 presentation, "The Independence Blueprint: Build a Scalable Ophthalmic Practice Without Private Equity." 

This transcript has been edited for clarity.

Bonjour everyone. My name is Isabelle Bibet-Kalinyak. I am a health care attorney specialized in representing physician groups as well as suppliers along the supply chain. Today, I'm going to talk about what we covered at the American Academy of Ophthalmology during our presentation with 2 ophthalmologists [Cynthia Matossian, MD, FACS, and Ravi D Goel, MD] and an experienced investment banker [Rajesh U. Kothari, BA, MBA]. And the topic was really, really important. It's about how to maintain an independent practice even though costs are going up and building a scalable ophthalmologic practice without the help of private equity.

We're facing some dire numbers in ophthalmology. We know that today at least 35% of ophthalmologists have reached the age of 65 years old. So that creates a high demand for thinking beyond the numbers and how we reconcile what's going on with the influx of private equity, ophthalmology, and eye care generally, with the desire, perhaps, for some physicians who have gone to work for private equity and are currently employed by private equity-backed practices.

What is coming next? Is the independent practice dying slowly or not? I think when we look at those numbers and the conversations of senior physicians who have been successful in bringing on junior partners to revive and invigorate their practice, we have some answers there, and we can help others achieve that. When you think about independence today, the imperatives are clinical, cultural, and economic in value. You have to reconcile the rising costs out there with some cultural and converging trends, but with a lot more competition, primarily because we've had consolidation, and you have huge competitors out there. But whether they've been successful or not at gaining market share, we know that the private equity model or private equity-backed practice model does not work for everyone. Physicians tend to love their independence, and how to remain independent is what we addressed. So with rising costs, there is more and more pressure to create new revenue flows or capitalize on the existing structure to grow, but also cut costs.

Of course, I couldn't be truthful without saying that artificial intelligence (AI) is throwing a little bit of a wrench in the equation. We don't know exactly where we're going with AI, but there are certain things that we know: First, because of laws created at the state level governing entities, we know that the importance of updating the corporate governance of an entity is going to be critical. When you want to attract new physicians who will eventually become partners and invest the same sweat equity that you have in your practice, you need to think ahead of time, and you cannot use the same structure in your corporate governance. You're going to need to attract new talent but retain it. How do you do that? Many times, fellows who graduate and physicians who have been in practice—they have different experiences because they also have risen through perhaps the private equity model or even hospital-based employment. However, they also have rising bills, whether from medical school, their personal lives, mortgages, student loans—you name it. Unless you become knowledgeable about how to speak with them about investing not just time, but also capital, in a practice, and what that looks like from a financial standpoint, you're not going to be successful in retaining them.

So today, successful practice leaders—and whether it's on the administrative side or on the clinical side—need to have some understanding about this business. What we also know is that there are really not that many options, but there are many, many combinations of options if you want to grow your practice. So if you do nothing, your practice is likely to decline, but you can remain independent, and we can chart the path. Not everybody is cut out to have their own ambulatory surgery center, but a surgery center certainly can make sense, or ownership in a surgery center with others can make sense for growth. Similarly, consolidation, adding practice lines, and adding different subspecialties can make sense in a certain geographic area. Not everybody is in the same situation, and here, the facts and circumstances depend greatly. So once you are able to look at this, weigh all your options, and better understand what the pros and cons of each option are, then you'll be able to chart the course for your own practice.

We really look at a 5-factor equation here (see table below). One is the revenue of cash. Two is determining the risks involved with each option that you and your partners are willing to take on. And many times, the correlation between the risk and how much investment you've put in will definitely guide what your returns are. And then you always have the issue of control, whether it is the clinical control or the operational control. We can then help you to analyze this through your own lens so that you’re able to track your own progress.

We covered a lot of material during our presentation, but you can definitely reach out to us for more information. Thank you to Ophthalmology Management for allowing us to spread the word. Find us online at the law firm Pullman & Conley. My full name is Isabelle Bibet-Kalinyak, and we'll gladly answer your questions. Thank you very much.