Podcast Summary: Acquiring Minds
Episode: Buying to $4m Across 7 Sites in 3 Years
Date: November 13, 2025
Host: Will Smith
Guest: Gail Hamilton Azzotto
Episode Link: YouTube
Overview
This episode features Gail Hamilton Azzotto, who shares her unique and intentional journey acquiring audiology practices—amassing $4 million in revenue across seven locations in less than three years, and with no money out of pocket. Gail details her path from a career in finance and consumer packaged goods (CPG) to building a multi-site healthcare business, her unconventional approach of focusing on “remote” acquisitions, and leveraging manufacturer supply agreements for deal financing. The episode dives deeply into the audiology industry, the business model, operational challenges, industry trends, and how her philosophy of empowering employees shapes everything she does.
Key Discussion Points & Insights
1. Gail’s Background and Path to Entrepreneurship
- Transition from CPG & Finance: Gail describes her early career in finance and brand management for Procter & Gamble (P&G), where she learned P&L management and operational discipline.
Memorable quote:“I wasn’t interested in running someone else’s company… there were things I wanted to do my way.” (12:00 - Gail)
- Foundational ‘Aha’ Moments:
- Realized corporate leadership was not her goal after working at P&G.
- Inspired to build something with direct positive impact on employees’ lives:
“A lot of what I do in building the company is for others.” (14:10 - Gail)
2. Deciding to Buy vs. Start a Business
- Gail’s husband (a radiologist with multi-state licensing and a private practice) inspired her with the possibilities of multi-market healthcare businesses.
- COVID-19 provided downtime to reflect and research buying a business—conversations with Search Fund alumni (notably Bruce, a recurring guest) helped her land on entrepreneurship through acquisition (ETA).
- Why Buying, Not Starting?:
She wanted to be a CEO, but didn’t want to build from scratch or operate someone else’s paradigm.
3. Industry Selection & The Audiology Opportunity
- Initial Focus: Considered vision/optical, but found private equity had already driven up prices and multiples.
“There was a whole bunch of PE just buying these practices… the multiples were crazy.” (20:40) - Pivot to Audiology:
- Noticed audiology shared structural similarities with dental/vision, but lacked private equity penetration— so multiples and acquisition terms were more favorable.
- Direct outreach to audiologists via industry forums and boards provided leads and industry knowledge.
4. A Model Built on Remoteness
- Deliberately Remote: She only acquires practices that are a plane flight away, not drivable—by design, to force the building of systems so she's not tempted to step in as a “key employee.”
“I did not want to be able to drive to the practice… so I could not jump in and be the front desk person or the revenue producer.” (27:59 - Gail)
- Sees herself as a P&L manager, not an operator/producer—a skillset transferable across retail-like health businesses.
5. Deep Dive: Audiology Industry & the Product
- Industry Structure:
- About five global manufacturers control hearing aid supply.
- Key revenue driver: Hearing aid sales, but practices also earn from exams, cleanings, and minor services.
- Demographics: Baby boomer wave benefits industry, but millennials are forecasted to suffer hearing loss earlier (earbuds, phones, noisy urban living).
- Comorbidity insight: Hearing loss is closely correlated with cognitive decline (e.g., dementia, Alzheimer’s).
- The Core Product: Modern hearing aids are high-tech, AI-enabled devices (not outdated “grandma” devices). They improve clarity, filter background noise, and dramatically transform patients’ lives, as witnessed firsthand by Gail.
- Memorable, moving story:
“The audiologist puts hearing aids in a reluctant patient—he breaks down in tears, overcome by how clearly he could hear. I was sold... and also cried.” (51:00 - Gail)
6. Economics & Acquisition Model
- Practice numbers:
- Typical revenue per site: $300k – $500k (some rural locations even higher due to less competition).
- Most revenues accrue to owner/audiologist as salary rather than profit (i.e., “lifestyle practices”).
- The Aggregator’s Edge:
- Pooling locations enables centralization of billing, admin, purchasing—yielding economies of scale and increased leverage with suppliers.
- Multi-site operations can extract cost and drive higher marketing/sales conversion to improve site-level margins.
- Addressing Key Person Risk:
- Providers are licensed in all states in which Gail owns practices.
- Cross-train and sponsor career development for support staff to become certified hearing instrument specialists (can cover ~90% of audiologist tasks in many states).
- Practices are structured so a “key man” departure doesn’t cripple operations.
7. Unique Zero-Money-Down Deal Structure
- Supply Agreements with Manufacturers:
- Instead of SBA financing, she leverages supply agreements: manufacturers (motivated by future product sales) loan 100% of acquisition costs, to be repaid with an agreed level of product purchases/sales over 7-10 years.
- Not exclusive—her practices sell products from multiple suppliers, though one manufacturer is the primary.
- Personal Financial Requirements:
- No cash (equity) out of pocket, but Gail’s net worth must be sufficient to guarantee the obligation.
- Due Diligence:
- Practices must show historical sales close to threshold agreed in supply agreements—if sales lag, make-up payments are required, but, so far, performance has met or exceeded targets.
8. Organizational Structure: The MSO
- What’s an MSO?: Management Services Organization—a sidecar entity (separate from the holding company) that centralizes all HR, operations, billing, vendor/payroll, benefits, etc.
“The MSO does not own the locations. They supply the things the locations need… Practices pay the MSO.” (90:17 – Gail)
This offers liability protection, centralized scale, and clear value to a future acquirer.
9. Expansion, Operations, and Team Building
- Rapid Growth: Built to 6 practices, 7 locations, over $4 million annual revenue in less than three years.
- Team Structure:
- Lead audiologists manage teams—providers are multi-state licensed to facilitate resource sharing across sites.
- Dedicated ops manager, significant training investment in front-desk-to-specialist career paths.
- Gail’s Role:
- Travels to locations about twice a month (generally more for business ops, team building, and supplier meetings than daily operations).
“I do fly to my practices, but not to work… maybe once a year to each one.” (105:57 – Gail)
10. Ambition and Vision
- Open to Expansion: Gail envisions hundreds of sites; believes audiology is primed for the kind of roll-up seen in dental and veterinary medicine.
- On Bringing in Capital: She may pursue outside investment in future, but for now, remains unlevered with no outside/investor capital.
- Willing to Collaborate:
“Yes, searchers should pursue this… but do it with me! I’d love to partner to expand the model.” (111:47 – Gail)
Notable Quotes & Memorable Moments
- “It’s a clear, concise journey: you come in, we evaluate for hearing loss, and if you need amplification, the technology is incredible.” (35:54 – Gail)
- On hearing loss and social isolation:
“As you lose your hearing, you withdraw. You just naturally withdraw… and that accelerates decline.” (43:43 – Bruce)
- On technology and product:
“The product is not just sound up or down…It has the same technology, if not better, than what’s in your phone or AirPods. Hearing aids are probably letting people live a more amplified life than you and I without them.” (113:24 – Gail)
- On building internal career pathways:
“We’ve sent front desk staff to school to become specialists. If I could do more of that, that’s what I’d want to do.” (70:55 – Gail)
Important Timestamps
- Gail’s journey from P&G to entrepreneurship: 04:20 – 12:22
- Why buy, not build? The road to ETA: 21:51 – 23:13
- Intentional remote ownership model: 27:47 – 30:19
- Audiology industry, product & technology: 33:47 – 43:43
- Powerful patient story—life-changing impact: 47:52 – 51:35
- Economics of audiology practices, roll-up rationale: 58:21 – 62:00
- Addressing key person/practitioner risk: 64:48 – 72:58
- Supply agreement/zero cash down model explained: 77:04 – 84:53
- Organizational structure—MSO / why it matters: 88:16 – 92:28
- Sample acquisition stories (challenges, rural/urban): 93:07 – 101:10
- Advice to searchers, vision for the future: 111:26 – 113:24
Conclusion
Gail Hamilton Azzotto offers a blueprint for searchers and entrepreneurs interested in health services, multi-site roll-ups, and alternative deal financing. Her disciplined, systems-first, and people-focused approach—combined with smart deal structuring and a willingness to buck conventional wisdom—yielded not just business growth, but real, observable impact on both employees and patients. She welcomes collaboration and expansion—and makes a strong case that audiology remains one of the last, best unsaturated healthcare roll-up opportunities.
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