For decades, the standard model of medical succession was the “earn-in.” A younger physician joined a practice, worked hard for low pay for a few years, and eventually bought out the senior partner using future cash flow.

In the MSO era, that path has changed.

Blog 1 explains why successor arrangements exist; this post is the checklist that makes them workable.

Now, when a practice is acquired, the “successor” physician is often stepping into a role that is structurally different from the one the founder held.

The founder was an owner-operator and the successor is often an employed clinical leader with significant responsibility but ambiguous authority.

This transition is often pitched as an opportunity to “take the reins” or “lead the next chapter.”

Without specific structural protections, it often becomes a mismatch: high accountability, high workload, and low decision-making power.

A viable successor role requires alignment between authority, insurance, and economics.

The Risk of Responsibility Without Authority

The most common point of failure for successor physicians is the gap between accountability and control.

In many post-transaction structures, the senior founder steps back into a reduced clinical role or a purely advisory role. The MSO looks to the younger, successor physician to serve as the Medical Director or “Clinical Lead.”

If this title comes with the responsibility to sign off on charts, supervise mid-level providers, and maintain accreditation, but without the authority to hire/fire staff, set schedules, or enforce protocols, the physician is carrying accountability without the tools to manage it.

To avoid this, the role must be scoped in writing, not just in conversation.

The 6-Point Checklist

If you’re evaluating a clinical leadership role inside a platform, or an associate being asked to step up as a founder exits, you should seek clarity on 6 specific structural points.

1. Governance and Authority Definition

If you're the “Medical Director,” what can you actually direct?

• The Check: Do you have veto power over clinical hires? Do you have the final say on patient safety protocols? The agreement should explicitly state which decisions require your approval. Responsibility without authority is risk.

2. Supervision and Coverage Clarity

Platforms often rely on leverage (Nurse Practitioners, Physician Assistants, Optometrists) to scale. As the clinical lead, you're often the supervising physician of record.

• The Check: Is there a hard cap on how many providers you supervise? Are you compensated specifically for this administrative burden? Be cautious with open-ended supervision language (for example: “and other duties as assigned”) unless it’s paired with clear caps, compensation, and scope.

3. Insurance and Indemnity Alignment

If the MSO makes a non-clinical operational error that affects patient care (e.g., failing to send a referral, availability issues with critical supplies), the clinical leader may bear regulatory scrutiny depending on the facts, documentation, and structure.

• The Check: Is there clear indemnity for non-clinical operational errors, and does the agreement match how risk is actually allocated day-to-day? Is the malpractice policy individual or shared? Does it include “tail” coverage if you leave?

4. Workload Expectations

When a founder slows down, the volume has to go somewhere. Often, it flows to the successor.

• The Check: Is your clinical volume capped? If you're taking on administrative leadership, is your clinical template reduced to accommodate it, or are you expected to do administrative work on nights and weekends?

5. Compensation Clarity & Adjustment Logic

Successor comp is often a mix of base, productivity, and sometimes “phantom equity” or profit sharing.

• The Check: If the platform struggles, does your comp drop? If any portion of your comp is tied to EBITDA (or margin), do you have control over the expenses that drive that number? Avoid comp models tied to metrics you cannot influence.

6. The Year 1 Predictability Plan

What happens if the founder leaves earlier than expected?

• The Check: Is there a transition plan documented such as call coverage, supervision expectations, scheduling template, leadership time allocation? Who absorbs the founder’s complex cases? Predictability matters more than reassurance.

Moving from “Employee” to “Stakeholder”

A successor physician doesn't need to be an equity owner to think like a stakeholder. But they do need a contract that treats them as a partner, not just a yield-generating asset.

The goal is to ensure that the physician who is staying for the long haul has the tools, protection, and authority to practice medicine safely.

When the deal is structured correctly, the successor gets a stable platform to build a career, and the MSO gets a committed clinical leader. When it's structured poorly, the relationship often becomes unstable within the first 12–24 months.

How Verdira Approaches This

• Clinical decisions remain with physicians.

• MSO scope is clearly defined in writing and tied to real services.

• Governance is clarified before signing so expectations remain stable after close.

• We build long-duration platforms and do not operate on forced exits.

If you’re evaluating an MSO partnership or successor role and want to sanity-check structure and expectations, we’re open to thoughtful conversations.

This article is for general educational purposes and is not legal advice.