The Herd Ran to Texas. The Smart Ophthalmologists Own What It Left.

Talk to enough graduating ophthalmologists and you notice they move as a group. This year the group is heading to Texas, Florida, and the Southeast, and the reasons rhyme every time. Lower cost of living, no state income tax, warmer winters, and everyone else is going too. A friend of ours, an ophthalmologist who spent years running a regional eye trauma center, has a blunter word for it. She calls it sheep, one flock drifting from field to field because the flock is moving.

She's onto something, and here's why it matters to you. The direction the herd runs is the exact direction worth questioning, because a market everyone floods is a market where your leverage disappears. The ownership, the money, and the open door are sitting in the place nobody wants to go.

The Migration Is Real

Physicians really are moving to low-tax states, so this isn't a straw man. When you look at where people relocated in recent Census data, 8 of the 12 states with a single flat income tax gained residents on net, and the no-income-tax states are among the biggest magnets in the country. Layer on the recruiters who lead with a signing bonus and a no-state-tax headline, and the pull toward Texas, Florida, and the Southeast runs strong and constant. Your graduating class feels it, and most of them are following it.

What Happens to a Market Everyone Floods

Here's what nobody mentions about running where the crowd runs. When associates pour into the same handful of desirable metros, the people hiring them collect all the leverage. Supply climbs, so pay gets squeezed, non-competes get tighter, and the private equity groups that already dominate those markets get their pick of candidates on their own terms. In a flooded market you're one of 50 interchangeable applicants competing for the same associate seat, and that seat comes with an associate's pay and an associate's lack of control.

The ownership you actually want gets harder there too. When every young surgeon wants the same sunny metro, practice prices in that metro get bid up, the good ones get taken quickly, and the terms tilt toward the seller and the platform rather than the successor. The crowd lowers your salary and prices you out of the thing you came for at the same time.

And the groups waiting for you in those markets are anything but neutral. Private equity got to the desirable metros first, and got there hard. Nearly 30% of retina specialists nationwide now work under a private-equity-owned group, and in the most popular markets that share runs higher. So the flooded Sun Belt metro you're picturing is mostly a board already carved up by platforms that recruit associates, set quotas, and hold the equity, not a field of independent practices waiting to take you on as a partner. You didn't arrive late to a crowded room. You arrived at a room somebody else already owns.

And those platform seats churn. When a private equity group takes over a practice, physician turnover climbs from roughly 5% to over 20% within 3 years, and most of the doctors who leave are under 60. So the "safe" employed job in the crowded metro is often a revolving door, refilled by the next associate who moved south chasing the same tax break you were. You'd be competing hard for a seat that plenty of people before you already walked away from.

The Market Nobody Wants Is the Market With the Leverage

Now look at the place the herd is leaving. The Northeast is stacked with ophthalmologists in their 60s who built real practices and have nobody lined up to take over, because the young surgeons who would have succeeded them all left for Dallas. New York alone has one of the highest concentrations of ophthalmologists in the country and a large population of solo owners over 55 with no succession plan. Across the tristate, that's thousands of practices quietly heading toward a cliff with no successor in sight.

The workforce math underneath this is stark. A 2024 study in the journal Ophthalmology projected that by 2035 the specialty will meet only about 70% of demand, the second-worst adequacy of 38 specialties studied, as supply falls and an aging population needs more eye care than ever. Demand for a working ophthalmologist has never been higher, and the supply of successors willing to stay in the Northeast has rarely been lower. That combination is the textbook definition of leverage, and it belongs to whoever says yes.

The Wall of Retiring Owners

Zoom in on the scale of what the Northeast is leaving behind. The generation of ophthalmologists who opened solo practices in the 1980s and 1990s is retiring now, nearly all at once, and the pipeline behind them is thin because the young surgeons ran south. Across the New York tristate there are thousands of solo practitioners over 55, most with no succession plan and no obvious buyer, since a single-provider practice is usually too small for a private equity platform to bother with. Each one is a real business with loyal patients, trained staff, and steady cash flow that needs exactly one thing to keep existing, which is a successor. There are far more of those practices than there are successors willing to take them, and that imbalance is the entire opportunity. When the buyers are scarce and the sellers are motivated, the person who shows up ready to own is the one who writes the terms.

Scarcity Is the Whole Game

Think about what scarcity does to your seat at the table. In Texas you're one of many, so you take what's offered. In New York, for a retiring owner with no other successor, you're the only person who can keep the practice alive, and that changes everything about the terms. The solution to a real problem negotiates from strength. An interchangeable applicant negotiates from the bottom of a stack of resumes.

This is the piece the herd never works out. They ran from the high-tax state to escape a cost, and in the process they handed the real opportunity to the few who stayed. The scarcity they created by leaving is the exact thing that makes the place they left valuable.

Put a number on it. A retiring owner with 3 interested associates is running a buyer's market, and that owner sets the terms. A retiring owner with zero successors in sight is the reverse, and the one surgeon who raises a hand gets to name the structure, the timeline, and the size of the ownership stake. The Northeast is full of the second situation, precisely because the associates who would have been your competition all boarded flights to Texas.

Density Is Revenue

There's a revenue side to this, and it cuts the same direction. The dense, wealthy markets people leave for lifestyle reasons are the markets with the highest ceiling for an owner. A city like New York has the population, the income, and the demand to support a serious cash-pay layer, where LASIK runs close to $6,900 for both eyes and premium lens upgrades run into the thousands per eye. That spending is far thinner in the lower-cost exurbs the crowd is chasing. The place that costs more to live in is the place that pays an owner more to practice, and the employee fleeing it never sees that ceiling at all. And that ceiling compounds for an owner. Every premium procedure, every cash-pay upgrade, and every ancillary service runs through a practice you own rather than one you're employed by, so the upside of a rich market lands in your pocket instead of a corporation's. The lower-cost market the crowd chose caps what any practice there can earn, and the employee inside it would never have captured the difference anyway.

The Herd Is Your Signal

So treat the migration as information, and read it the opposite way most of your class is reading it. When everyone runs in one direction, the opportunity is usually behind them, in the market they abandoned. The herd is running to Texas for a tax break and a cheaper house. The ownership, the leverage, and the revenue ceiling stayed in New York, waiting on the ophthalmologist willing to stop following the flock.

You already pay a price for going where everyone goes. Go where they won't, and for the first time you're not competing with anyone. That's the moment owning a practice stops being a someday idea and turns into the thing you step into now.

Educational material only. Figures are illustrative and individual results vary. Images are AI-generated illustrations and don't depict actual Verdira practices, physicians, or patients. See our Disclosures.