Ophthalmologist Financial Planning: Cash-Pay Income, Retirement Stacking, and PE Buyouts

Ophthalmology sits in a structurally unusual position in physician finance. The average ophthalmologist earns $350,000–$450,000 annually — solidly high-income by any measure — but the ceiling is dramatically higher for practice owners with significant cash-pay revenue streams: LASIK and other refractive surgery, premium intraocular lens upgrades for cataract patients, and cosmetic oculoplastic procedures can add $200,000–$800,000 or more per year to an ophthalmologist's income above insurance-based clinical revenue.¹ That cash-pay component, combined with a high practice-ownership rate and active private equity consolidation, gives ophthalmologists a set of financial planning challenges and opportunities that differ substantially from employed-physician peers.

Training is relatively efficient for a surgical specialty: four years of ophthalmology residency (including a PGY-1 internship year) puts most general ophthalmologists in practice by age 29–31. Subspecialty fellowship adds one to two years — vitreoretinal surgeons, glaucoma specialists, oculoplastic surgeons, and cornea/refractive specialists are in practice by 31–34. The earlier career launch compared to medicine-based subspecialties means ophthalmologists have a longer window to compound wealth — but the financial decisions made in the first five attending years, particularly around practice structure, loan repayment path, and retirement account setup, have outsized long-term consequences.

Approximately 55–60% of practicing ophthalmologists remain in private or physician-owned group practice — one of the highest private-practice retention rates of any medical specialty.² That means the majority of ophthalmologists have access to practice-owner retirement vehicles — solo 401(k), cash balance plan, S-corp election — that hospital-employed physicians cannot use. Understanding and executing these structures correctly is worth more financially over a career than any investment decision an ophthalmologist is likely to make.

Ophthalmologist Income by Practice Setting

Cash-Pay Income: LASIK, Premium IOLs, and Cosmetic Procedures

The most distinctive financial feature of ophthalmology is the cash-pay revenue stream available to practice owners. Unlike virtually every other medical specialty, ophthalmologists have well-established, high-volume procedures that patients pay for entirely out-of-pocket — not because insurance denies claims but because they exist outside the insurance billing system by design.

LASIK and Refractive Surgery

LASIK and related refractive procedures (PRK, SMILE, phakic IOL implantation for extreme prescriptions) are entirely elective and not covered by any commercial or government insurance. The full procedure fee — typically $1,800–$3,500 per eye in the current market — flows directly to the practice.³ An ophthalmologist who performs refractive surgery and owns the practice entity receives both the surgeon professional fee and the facility fee, combining to generate significantly more revenue per case than an employed LASIK surgeon who receives only the professional component.

A busy refractive surgery practice performing 300–500 cases per year (600–1,000 eyes) generates $1.2M–$3.0M in gross revenue. After facility costs (laser platform service contract or equipment lease, staff, marketing, consumables), a well-run refractive practice can produce $400,000–$1.2M in net practice income to the owner-physician above and beyond their clinical insurance-based ophthalmology income. This income is taxed as ordinary income from practice operations, but it is practice income — eligible for S-corp election, solo 401(k) employer contributions, and cash balance plan deductions in ways that W-2 physician income is not.

Premium Intraocular Lenses

Cataract surgery is the highest-volume surgical procedure in the United States, with over four million procedures annually.⁴ Standard cataract surgery (basic monofocal IOL) is a covered Medicare benefit. However, premium IOL implants — multifocal IOLs, extended depth-of-focus (EDOF) lenses, toric lenses for astigmatism correction, and laser cataract surgery platforms — involve components not covered by Medicare that patients pay out-of-pocket via an Advanced Beneficiary Notice (ABN) process.

A cataract surgeon performing 500–800 cases per year with 25–45% premium IOL adoption generates $250,000–$700,000 in additional cash-pay revenue at $1,500–$3,000 per eye upgrade. This income is significant, relatively predictable (it tracks cataract surgical volume), and increases as the ophthalmologist builds a referral base of patients seeking premium outcomes. Practice-owning cataract surgeons who have developed a premium IOL referral channel have an embedded revenue stream that is a major component of practice value — and a major variable in any PE transaction or practice sale.

Cosmetic Oculoplastics

Oculoplastic surgeons who perform cosmetic blepharoplasty, brow lift, ptosis repair (cosmetic indication), and in-office injectables (botox, dermal fillers) have an additional self-pay revenue stream that functions similarly to cosmetic dermatology practices. Functional blepharoplasty (documented visual field impairment from ptosis) is insurance-covered; cosmetic blepharoplasty is entirely self-pay at $2,500–$6,000 per procedure. An oculoplastics practice with a significant cosmetic patient base — particularly in metropolitan markets — can generate $200,000–$500,000 in cosmetic revenue on top of reconstructive surgery and orbital/lacrimal practice income.

PSLF for Ophthalmologists: Eligibility by Setting

Public Service Loan Forgiveness requires full-time employment at a qualifying 501(c)(3) nonprofit, government entity, or other designated public-service employer. For ophthalmologists, PSLF eligibility divides clearly by practice setting:

PSLF-eligible ophthalmology settings:

• Academic medical centers: University ophthalmology faculty employed directly by a qualifying 501(c)(3) academic system are PSLF-eligible. Verify that your W-2 is issued by the academic medical center entity, not by a separately organized professional corporation, which may or may not be nonprofit.
• Nonprofit hospital systems: Ophthalmologists employed by qualifying nonprofit health systems are eligible. The employing entity's 501(c)(3) status determines eligibility — a hospital system that is nonprofit for most purposes but organizes its ophthalmology department as a for-profit subsidiary would break PSLF eligibility.
• VA and government employers: Federal employment qualifies. The VA employs ophthalmologists at many facilities, with clear PSLF eligibility for all VA physicians.

Not PSLF-eligible: Private practice groups, PE-backed platforms (all for-profit), and physicians employed by for-profit hospital entities or management services organizations are ineligible for PSLF regardless of the patients served or clinical mission of the practice.

For ophthalmologists who will enter private practice — the majority — the loan strategy shifts to refinancing. With a residency of only 4 years (shorter than most subspecialty fellows), loan balances have had less time to capitalize compared to surgeons with 7–9 year training periods, but $200,000–$350,000 in accumulated debt arriving at first attending contract is still a meaningful obligation. When PSLF is definitively off the table, refinancing to the lowest available rate and applying the early attending income surplus to principal reduction produces a better outcome than maintaining federal loan flexibility for a forgiveness program you won't qualify for. See the Physician Student Loan Refinancing Guide.

Retirement Account Stacking for Ophthalmology Practice Owners

For ophthalmologists in private practice or partner-track group practice, the 2026 retirement stacking opportunity is substantial — and it scales with cash-pay income in ways that make it exceptionally valuable for high-volume refractive surgeons and cataract surgeons with premium IOL programs:

An ophthalmologist practice owner in their mid-50s earning $700,000 combined (insurance income + LASIK + premium IOL + cosmetic) can realistically shelter $200,000–$300,000 per year in deferred and tax-free accounts through the full stack. Over ten years before a planned practice sale or retirement, this represents $2M–$3M in pre-tax contributions at a 37% marginal federal rate — a tax reduction of $740,000–$1.1M that remains compounding rather than being paid to the IRS. No investment strategy reliably produces comparable after-tax outcomes for high-income physicians.

The December 31 adoption deadline is absolute: both the solo 401(k) and cash balance plan must be established before December 31 of the year in which you want to make contributions. A record year of LASIK volume discovered in a January tax review is too late for that year's deduction. Review plan adoption timing every October. See the Solo 401(k) for Physicians Guide and Cash Balance Plan for Physicians Guide.

Retirement Planning for Hospital-Employed Ophthalmologists

Ophthalmologists employed by nonprofit hospital systems have access to the 403(b) and, often, a governmental 457(b) — a combined deferral of $24,500 + $24,500 = $49,000 in 2026, or higher with age catch-ups. This is substantially less than the practice-owner stack, but it is still $49,000 in pre-tax deferrals that also reduces AGI for IDR payment calculations if PSLF is being pursued.

For hospital-employed ophthalmologists with PSLF eligibility, maximizing both the 403(b) and governmental 457(b) is the first priority: it directly lowers IBR or RAP payments, which lowers total paid over the 120-payment PSLF window, which increases the forgiven balance at month 120. The interaction between retirement contribution decisions and PSLF forgiveness is often worth more than the tax deferral alone. Use the PSLF Payment Tracker to model this for your specific balance and income trajectory.

S-Corp Election for Ophthalmology Practice Owners

For ophthalmologists with meaningful self-employment income — practice owners, partners, and physicians with significant cash-pay revenue — the S-corp election is often the single highest-leverage tax decision available. An ophthalmologist operating as a sole proprietor or single-member LLC pays self-employment tax on all net practice income: 15.3% on the first $184,500 in 2026 (Social Security wage base), then 2.9% Medicare tax above that, plus 0.9% Additional Medicare Tax above $250,000 MFJ. // 2026 SS wage base per SSA; FICA rates per IRC §3101 and §3111.

An S-corp election allows the physician to split income between a W-2 salary — subject to FICA — and K-1 distributions, which are not subject to FICA or self-employment tax. For an ophthalmologist earning $600,000 net from practice (including cash-pay revenue), setting a W-2 of $280,000 and taking the remaining $320,000 as distributions saves approximately $9,000–$12,000 in annual FICA — but the more important benefit is the employer profit-sharing contribution: 25% of $280,000 W-2 = $70,000 employer solo 401(k) contribution, which when combined with the $24,500 employee deferral approaches the $72,000 §415 cap and creates substantial deductions at the 37% marginal rate.

The S-corp must pay the physician a "reasonable compensation" W-2 — the IRS scrutinizes S-corps where too much income flows as distributions relative to compensation for actual services. For physician practice owners, a W-2 of 40–60% of total practice income is generally defensible, depending on specialty, market rates, and how much the income reflects the physician's personal services vs. passive returns. Consult a CPA who specializes in physician practice structures before implementing. Use the S-Corp Election Calculator to estimate savings.

Private Equity Consolidation in Ophthalmology

Ophthalmology has become one of the most actively consolidated physician specialties in private equity. The structural appeal is clear: cataract surgery is the highest-volume surgical procedure in the country (4M+ cases annually), procedure volume grows predictably with an aging population, premium IOL and refractive surgery provide cash-pay upside uncorrelated with insurance reimbursement changes, and the market remains fragmented — the majority of ophthalmology practices are still independent.²

Major PE-backed ophthalmology platforms include EyeCare Partners (one of the largest multi-state platforms, operating across 35+ states), Retina Consultants of America (focused on vitreoretinal and medical retina subspecialty practices), and multiple regional consolidators building scale in specific geographic markets. The PE-to-ophthalmology consolidation wave that began in 2015–2018 has accelerated, and independent ophthalmologists — particularly those approaching retirement age or with valueable premium IOL/LASIK revenue streams — are receiving regular acquisition inquiries.

The MSO Structure and Personal Goodwill

Most ophthalmology PE transactions follow the Management Services Organization model: the PE-backed MSO acquires the non-clinical assets and management function of the practice while the physician retains the PLLC that employs them and provides medical services. At close, the physician receives cash consideration for a portion of the practice value and rolls a minority equity stake (typically 15–30%) into the acquiring platform entity.

The allocation of practice value between enterprise goodwill and personal goodwill is particularly important for ophthalmologists with significant cash-pay practices. A LASIK practice or premium IOL program is largely personal goodwill — the volume follows the surgeon's reputation, skills, and referral relationships, not the practice entity itself. Personal goodwill can be sold directly by the physician as capital gain (23.8% LTCG + NIIT for high earners) rather than ordinary income (up to 37%), potentially saving $150,000–$400,000 in federal taxes on a mid-market transaction. This allocation must be established before the letter of intent is signed — retroactive restructuring after LOI execution is extremely difficult without renegotiating the entire deal. Engage a healthcare M&A attorney and independent CPA before any PE discussion, not after the term sheet arrives. See the Physician Private Equity Buyout Guide and Practice Sale and Exit Planning Guide.

QSBS on Rollover Equity

Rollover equity received in an ophthalmology PE transaction may qualify for Qualified Small Business Stock treatment under IRC §1202. After OBBBA (effective July 2025), the QSBS exclusion is permanently $15 million per taxpayer, with a tiered structure: 50% exclusion at 3-year hold, 75% at 4 years, 100% exclusion at 5 years. For an ophthalmologist who rolls $400,000–$800,000 of equity into a qualifying PE platform, holding the rollover equity through a second liquidity event (platform recapitalization or sale) with QSBS eligibility can convert a large taxable capital gain into a fully or substantially tax-free event. QSBS eligibility must be structured correctly at issuance — confirm with a tax attorney before any transaction closes.

Non-Governmental 457(b) Risk at PE Platforms

Many PE-backed ophthalmology platforms offer deferred compensation arrangements. Unlike governmental 457(b) plans at nonprofit hospital systems — which hold assets in a trust separate from employer assets — non-governmental deferred compensation assets are general assets of the employer corporation. If the platform encounters financial difficulty (a leveraged buyout with high debt service is vulnerable to rising interest rates, reimbursement pressure, and operational setbacks), deferred compensation participants become unsecured creditors. EyeCare Partners underwent a debt restructuring in 2023 as rising rates stressed its LBO capital structure — a public reminder that leveraged ophthalmology PE platforms carry real financial risk. Do not accumulate large non-governmental deferred compensation balances without evaluating the platform's current credit quality. See the Physician 457(b) Deferred Compensation Guide.

Pre-Close Retirement Stacking

The year before a practice sale closes is typically the highest-income year of an ophthalmologist's career — full practice income, no reduced production from transition, plus close-year distributions. If a cash balance plan is already in place, the final year's actuarially calculated contribution (often the largest, given age-based scaling) can be made before the plan must be terminated. Solo 401(k) employer contributions should be maximized before December 31. Pre-close contributions of $150,000–$350,000 in deductible retirement plan contributions in a year that also generates $1M–$4M in transaction income materially reduces the effective tax rate on the sale. These plans must have been established years in advance — you cannot set up a cash balance plan in the year of sale and capture meaningful deductions. See the Cash Balance Plan Guide and Solo 401(k) Guide.

Disability Insurance for Ophthalmologists

Ophthalmology is a fine-surgery specialty. Cataract surgery involves making millimeter-scale incisions and inserting and manipulating IOLs inside the eye under a surgical microscope. Vitreoretinal surgery requires operating under high magnification with instruments inserted through sub-millimeter sclerotomies, performing delicate manipulations on retinal tissue. LASIK and refractive surgery require steady hands, precise positioning, and the ability to direct laser platforms accurately. The own-occupation definition in disability insurance is critical for ophthalmic surgeons.

Own-Occupation Coverage for Ophthalmic Surgeons

A true own-occupation disability policy pays benefits if you cannot perform the material and substantial duties of your specific occupation as an ophthalmologist — even if you can work in another capacity. A condition affecting fine motor control — essential tremor, a hand or wrist injury, early Parkinson's symptoms, or a cervical radiculopathy limiting surgical positioning — could make ophthalmic surgery impossible while leaving other medical work intact. Under a true own-occupation policy, you could receive full or partial disability benefits while continuing non-surgical practice activity.

The visual acuity paradox: ophthalmologists, whose professional work centers on the visual system, face the occupational irony that a progressive visual condition affecting their own vision could impair surgical performance before becoming apparent to others. Surgeons who depend on stereoscopic visualization under a microscope are uniquely sensitive to conditions affecting depth perception or binocular vision. A true own-occupation policy that specifies the ophthalmic subspecialty protects against this scenario.

Key riders for ophthalmologists:

• Future Increase Option (FIO): Buy during residency or early attending years while you are young and healthy, locking in the ophthalmic subspecialty classification before any health issues arise. Coverage can be increased without new medical underwriting as income grows. The FIO window closes — do not let it lapse.
• Residual/Partial Disability: Particularly valuable for ophthalmologists with significant surgical volume. A partial disability reducing surgical capacity by 40% reduces total income by much more if surgical fees represent a premium component of practice revenue. Proportional partial disability benefits cover the income reduction even when you continue working in a reduced capacity.
• COLA Rider: Indexes the disability benefit to inflation during a claim. An ophthalmologist who becomes disabled at 45 may collect benefits for 20+ years; inflation protection is meaningful over that horizon.

Use the Physician Disability Coverage Calculator to estimate your coverage gap. See the Physician Disability Insurance Guide for own-occupation policy structures and carrier comparison.

Malpractice Insurance for Ophthalmologists

Ophthalmology has below-average malpractice risk compared to high-risk surgical specialties like neurosurgery, obstetrics, and trauma surgery — but malpractice exposure is not trivial, and it varies considerably by subspecialty and practice mix. Annual premiums for a general ophthalmologist in private practice typically range from $5,000 to $18,000 depending on state, coverage limits, surgical volume, and procedure mix.⁵

Refractive surgery creates a disproportionate malpractice footprint relative to its complication rate. LASIK complications are rare — serious visual loss from LASIK is estimated below 0.1% — but when patients who had elective surgery for cosmetic vision correction experience an outcome below their expectations, litigation is more likely than in covered-procedure settings where surgical complications are accepted as risk. High patient expectations for purely elective, cash-pay refractive surgery translate to more claims relative to the complication rate.

Vitreoretinal surgeons typically carry higher premiums than general ophthalmologists, reflecting the stakes of retinal detachment and macular surgical repair where vision loss outcomes are more common and expected in complex cases.

Claims-Made Policies and Tail Coverage

Most ophthalmologists carry claims-made policies. When leaving a practice for a PE transaction, retirement, or a new employment setting, tail coverage is required to cover future claims from prior work. Tail coverage typically costs 150–250% of the final claims-made year premium paid as a lump sum. On a $12,000/year policy, that is a $18,000–$30,000 lump-sum expense at practice departure. In any PE transaction, the responsibility for tail coverage — who pays, what amounts — should be explicitly negotiated in the purchase agreement. See the Physician Malpractice Insurance Guide.

7 Financial Mistakes Ophthalmologists Make

1. Operating as a sole proprietor on significant cash-pay income without S-corp election. An ophthalmologist earning $500,000 net from combined insurance and cash-pay practice income as a sole proprietor pays full SE tax on the excess above the SS wage base: 2.9% Medicare on all income and 0.9% Additional Medicare Tax above $250K MFJ. An S-corp election, executed correctly with a reasonable W-2, can save $10,000–$18,000 per year in FICA on the distribution component and maximizes the employer profit-sharing contribution to the solo 401(k). This is an annual recurring cost most ophthalmology sole proprietors absorb unnecessarily, often for years.
2. Not establishing a cash balance plan at peak earning years. Ophthalmologists with high cash-pay revenue reach income levels — $600,000–$1.2M — where the solo 401(k) alone ($72,000 §415 cap) captures only 6–12% of income in tax-deferred contributions. A cash balance plan stacked on top can shelter an additional $100,000–$260,000+ per year. Many ophthalmologists have never been told this option exists or have generalist CPAs unfamiliar with physician-specific pension plan design. The missed deduction at 37% marginal rates over five years of peak production represents a $500,000–$900,000 lost compounding opportunity.
3. Refinancing student loans before confirming PSLF is definitely off the table. An ophthalmologist who refinances during residency and then takes a first attending job at an academic medical center has eliminated all PSLF eligibility for that training period. The four residency years at a nonprofit hospital represent 4 years × 12 = 48 qualifying PSLF payments at IBR rates often under $100–$200/month. Refinancing before knowing your attending employer forfeits those credits. Hold off on refinancing until you have accepted an offer and confirmed whether the employer qualifies.
4. Entering a PE letter of intent without independent legal and tax counsel on personal goodwill. Ophthalmologists with premium IOL programs, LASIK practices, or established cosmetic oculoplastics businesses have practice value that is predominantly personal goodwill. The tax rate differential — 23.8% LTCG on personal goodwill versus 37% ordinary income on corporate-allocated practice value — on a $1.5M–$3M personal goodwill component can mean $200,000–$500,000 in tax savings. This allocation must be negotiated before the LOI is signed, not after. Many ophthalmologists sign LOIs without understanding this and lose the opportunity permanently.
5. Underestimating the disability coverage gap on cash-pay income. An ophthalmologist earning $350,000 in insurance-based clinical income and $300,000 in LASIK/premium IOL cash-pay income has total compensation of $650,000. Employer group LTD, if available, may cover 60% of base salary — perhaps $180,000/year. Individual disability insurance coverage based on earned income might extend that to $300,000/year. That still leaves a $350,000/year gap relative to total income. Review total income coverage, not just the coverage number on the policy, when evaluating disability risk.
6. Neglecting December 31 retirement plan adoption deadlines. The solo 401(k) and cash balance plan must be adopted before December 31 of the contribution year. Ophthalmologists who have a record LASIK or cataract surgery year and discover it in January's tax review miss the entire year's deduction opportunity — permanently. These are not deductions that can be carried back. Set a calendar reminder every October to review plan adoption status, funding capacity, and whether a cash balance plan should be established or terminated based on income trajectory and retirement horizon.
7. Accumulating large non-governmental deferred compensation balances at leveraged PE platforms. EyeCare Partners' 2023 debt restructuring is a recent reminder that ophthalmology PE platforms carry the same financial risks as any highly leveraged acquisition vehicle. Non-governmental deferred compensation assets held at a PE-backed MSO are general corporate assets. Concentrating $200,000–$500,000 in non-governmental deferred compensation at a platform with $500M–$1B+ in acquisition debt is a material unsecured credit exposure. If offered a non-governmental deferred compensation arrangement at a PE-backed employer, evaluate the platform's financial health and bond ratings before contributing more than a modest amount.

Action Plan by Career Stage

Ophthalmology Residents and Fellows

• Certify PSLF employment from your first year if your residency program is at a nonprofit hospital or academic medical center. Four years of qualifying residency payments at IBR rates cost almost nothing and preserve all options for a first attending position that may turn out to be PSLF-eligible.
• Open a Roth IRA every year of training while income is in the 22% bracket or below. As a resident or fellow, you are well below the 2026 direct Roth IRA phase-out threshold ($146,000 single / $236,000 MFJ). Contributions made during training compound for decades at tax-free rates.
• Buy own-occupation disability insurance with the FIO rider before completing fellowship. Lock in the ophthalmic subspecialty classification while you are young and healthy. Do not defer past the first attending year — the FIO window closes and premiums increase with age.
• Subspecialty fellows pursuing cornea/refractive or oculoplastics fellowships should understand the cash-pay income mechanics of their intended practice setting before accepting a first offer. A position at an established refractive surgery practice with a mentor's referral pipeline and existing cash-pay revenue offers a meaningfully different financial trajectory than joining a hospital employment model.

Early-Career Attending Ophthalmologist (Years 1–5)

• If joining a nonprofit hospital system or academic center with PSLF eligibility: certify PSLF employment immediately. Max the 403(b) and governmental 457(b) to reduce AGI and lower IBR or RAP payments simultaneously, increasing the ultimately forgiven balance.
• If entering private practice: establish an S-corp or review existing entity structure, open a solo 401(k) in year one (adopted before December 31), and begin making maximum contributions. Do not defer this — one year of missed solo 401(k) contributions is a permanent loss of $72,000 in tax-deferred contributions at a 37% marginal rate.
• If joining a practice with an existing LASIK or premium IOL program, negotiate for partnership track that includes participation in cash-pay revenue — the difference between being a W-2 employed surgeon and a partner sharing in facility and cash-pay revenue can double your effective compensation over five years.
• Read the New Attending Physician Financial Checklist at least six months before signing your first contract. Review the Physician Employment Contract Financial Review Guide before accepting any offer.

Mid-Career Ophthalmologist (Years 5–15)

• If you haven't established a cash balance plan, evaluate it now. The actuarial contribution capacity at ages 45–55 is highest relative to remaining compounding runway before retirement. A practice-owning ophthalmologist at 50 earning $700,000 combined can shelter $160,000–$240,000/year in a well-designed cash balance plan stacked on the solo 401(k). Model this annually with a CPA and actuary who specialize in physician practice structures.
• If PE acquisition discussions are beginning, engage independent counsel before any LOI. Personal goodwill allocation, QSBS eligibility on rollover equity, tail coverage responsibility, and pre-close retirement stacking all require planning that cannot be compressed after term sheets are exchanged.
• Evaluate practice expansion carefully. Adding a LASIK suite, premium IOL program, or cosmetic oculoplastics capability has high upside — but it requires capital investment, marketing, and operational expertise. Model the economics including equipment depreciation (100% bonus depreciation is permanently available under OBBBA for qualifying property placed in service after January 19, 2025), facility costs, and the cash flow ramp before committing.

Late-Career Ophthalmologist (Years 15+)

• Cash balance plan contributions peak in the late 50s and early 60s. A 62-year-old ophthalmologist in active practice can contribute $250,000+ per year to a cash balance plan, accumulating $1M+ in tax-deferred assets in the final five years before retirement. Pair this with full solo 401(k) stacking, backdoor Roth for both spouses, and HSA contributions if HDHP-eligible.
• Update estate planning documents. The current $15 million estate exemption (permanently set by OBBBA) means federal estate tax may not apply to most physician estates, but practice buy-sell agreements, succession planning for cash-pay practice value, and beneficiary designations on qualified plans require current review. See Physician Estate Planning Guide.
• Model Roth conversion windows. A practice exit at 62 creates 5–8 years of Roth conversion opportunity before RMDs begin at age 73 (born 1951–1959) or 75 (born 1960+). With no practice income and before Social Security, the marginal rate on conversions can be materially lower than the 37% rate during peak earning years. Use this window to reduce the future RMD burden from large IRAs accumulated over a high-income career.
• Verify non-governmental 457(b) distribution timing if you have deferred compensation at a PE-backed employer. Distribution schedules must be set under §409A at the time of initial deferral election — you cannot retroactively change them. Confirm your distribution schedule does not coincide with a practice sale year or other high-income events that would create compounding IRMAA surcharges or bracket compression. See Physician IRMAA Medicare Planning.