1 00:00:00,080 --> 00:00:02,240 This is Carly Beam with the Becker Spine 2 00:00:02,240 --> 00:00:04,639 and Orthopedics podcast, and I'm thrilled to be 3 00:00:04,639 --> 00:00:06,580 joined today by doctor Michael Mannagini, 4 00:00:07,040 --> 00:00:10,480 CEO at Indiana Orthopedic Institute. Doctor Mannagini, thank 5 00:00:10,480 --> 00:00:11,779 you for joining us today. 6 00:00:12,335 --> 00:00:14,195 Thank you for having me. It's a pleasure. 7 00:00:14,654 --> 00:00:17,135 So, before we dive into our discussion, can 8 00:00:17,135 --> 00:00:18,975 you just introduce yourself and share a little 9 00:00:18,975 --> 00:00:20,035 bit about your background? 10 00:00:20,734 --> 00:00:22,335 Sure can. Yeah. My name as you said, 11 00:00:22,335 --> 00:00:23,554 my name is Michael Managini. 12 00:00:24,095 --> 00:00:25,170 I'm the founder and 13 00:00:25,649 --> 00:00:27,670 CEO of the Indiana Orthopedic Institute. 14 00:00:28,050 --> 00:00:30,289 Before that, I was a full professor of 15 00:00:30,289 --> 00:00:33,250 orthopedic surgery at Indiana University Health here in 16 00:00:33,250 --> 00:00:35,570 here in Indianapolis, and we started the, Indiana 17 00:00:35,570 --> 00:00:36,549 Orthopedic Institute 18 00:00:37,090 --> 00:00:39,494 about three years ago, just myself and, 19 00:00:40,295 --> 00:00:43,174 an anesthesiologist and a small team. And now 20 00:00:43,174 --> 00:00:45,114 we're up to almost a 100 employees and 21 00:00:45,335 --> 00:00:47,114 14 surgeons and two anesthesiologists 22 00:00:47,494 --> 00:00:50,054 and growing, across the state in three different 23 00:00:50,054 --> 00:00:53,094 markets. So that's Incredible. Yeah. It's been great. 24 00:00:53,094 --> 00:00:55,469 It's been a crazy ride. Healthcare is, as 25 00:00:55,469 --> 00:00:57,390 you know, is in is in a state 26 00:00:57,390 --> 00:00:58,289 of change, 27 00:00:58,670 --> 00:01:00,429 all the time, rapid change, I would say, 28 00:01:00,429 --> 00:01:02,590 and it's been an amazing ride. Yeah. I 29 00:01:02,590 --> 00:01:04,030 mean, it sounds like change is just kind 30 00:01:04,030 --> 00:01:06,369 of the only constant really with health care. 31 00:01:06,829 --> 00:01:09,325 I would agree. Yeah. Well, doctor Meneghenian, first 32 00:01:09,325 --> 00:01:11,004 question I wanted to kind of ask you 33 00:01:11,004 --> 00:01:11,504 is, 34 00:01:11,805 --> 00:01:13,504 where do orthopedic practices 35 00:01:13,884 --> 00:01:16,064 most commonly lose their 36 00:01:16,685 --> 00:01:18,604 efficiency? And can you talk about some of 37 00:01:18,604 --> 00:01:21,689 the operational changes that, you know, can deliver 38 00:01:21,689 --> 00:01:24,890 quickest financial impact without affecting the quality of 39 00:01:24,890 --> 00:01:25,390 care? 40 00:01:26,090 --> 00:01:27,950 Yeah. It's a great question. I think 41 00:01:28,569 --> 00:01:30,349 where I see operational inefficiency, 42 00:01:30,650 --> 00:01:32,650 and it's not just in really orthopedics, but 43 00:01:32,650 --> 00:01:34,189 in all of health care, is the 44 00:01:34,729 --> 00:01:35,629 the progressive, 45 00:01:36,194 --> 00:01:38,354 I would say, the the middle layer of 46 00:01:38,354 --> 00:01:38,854 bureaucratic, 47 00:01:40,034 --> 00:01:40,694 and administrative 48 00:01:41,155 --> 00:01:42,295 bloat that we have. 49 00:01:42,754 --> 00:01:44,995 And I think, you know, traditionally in health 50 00:01:44,995 --> 00:01:47,575 care, we've had we've been very fortunate 51 00:01:48,689 --> 00:01:51,010 to have enough financial resources in this country 52 00:01:51,010 --> 00:01:53,189 over years where that layer got pretty thick. 53 00:01:53,729 --> 00:01:56,609 But it's pretty distant from the doctor patient 54 00:01:56,609 --> 00:01:59,430 relationship, and I think the that's where efficiency 55 00:01:59,489 --> 00:02:01,569 of care has gone down. And we can 56 00:02:01,569 --> 00:02:03,444 talk about in surgery or we can talk 57 00:02:03,444 --> 00:02:05,364 about just in general the practices and that 58 00:02:05,364 --> 00:02:07,204 we're focused anyway, I think, on the just 59 00:02:07,204 --> 00:02:08,985 the general practice of of orthopedics. 60 00:02:09,525 --> 00:02:10,264 And I think 61 00:02:10,884 --> 00:02:12,485 if you look at how we can improve 62 00:02:12,485 --> 00:02:15,044 that, that layer, that middle layer of of 63 00:02:15,044 --> 00:02:15,544 administrative 64 00:02:16,780 --> 00:02:17,979 work that needs to be done, I think 65 00:02:17,979 --> 00:02:20,699 that can real that's where artificial intelligence and 66 00:02:20,699 --> 00:02:21,979 AI is really gonna play a role. So 67 00:02:21,979 --> 00:02:23,500 if you have a a specific team, like 68 00:02:23,500 --> 00:02:25,340 we have revenue cycle management team of a 69 00:02:25,340 --> 00:02:26,080 few people, 70 00:02:26,699 --> 00:02:28,539 getting them to perform at a higher level, 71 00:02:28,539 --> 00:02:31,875 getting better claims, getting better results, faster results 72 00:02:31,875 --> 00:02:32,694 for the patients 73 00:02:32,995 --> 00:02:34,375 so that they can get their surgeries, 74 00:02:35,314 --> 00:02:36,275 authorized by, 75 00:02:36,675 --> 00:02:37,575 commercial insurance 76 00:02:38,034 --> 00:02:39,094 and Medicare, etcetera. 77 00:02:39,875 --> 00:02:42,034 That's good for patient care. It's good for 78 00:02:42,034 --> 00:02:43,015 patient access, 79 00:02:43,319 --> 00:02:45,639 and it's also helps us be much more 80 00:02:45,639 --> 00:02:47,240 efficient and even keep our costs down. So 81 00:02:47,240 --> 00:02:49,580 I think utilizing technology in that way 82 00:02:49,879 --> 00:02:51,340 is gonna be an advantage, 83 00:02:51,800 --> 00:02:53,639 in the practice and also in the operating 84 00:02:53,639 --> 00:02:55,719 room. Yeah. And I'd love to hear, you 85 00:02:55,719 --> 00:02:57,500 know, what's an example of 86 00:02:57,935 --> 00:03:00,675 AI success that you've seen at your practice 87 00:03:00,814 --> 00:03:01,555 so far? 88 00:03:02,014 --> 00:03:04,115 I think there's a couple places. So one 89 00:03:04,175 --> 00:03:06,435 is definitely on the revenue cycle management side. 90 00:03:06,575 --> 00:03:09,135 The other the other aspect really is is, 91 00:03:09,135 --> 00:03:12,034 I think, the ambient listening that's in, electronic 92 00:03:12,580 --> 00:03:13,400 medical records, 93 00:03:14,020 --> 00:03:16,259 in in the those software programs. So the 94 00:03:16,259 --> 00:03:17,699 fact that you can go into an office 95 00:03:17,699 --> 00:03:19,080 now I mean, physicians 96 00:03:19,379 --> 00:03:20,199 get consumed 97 00:03:21,060 --> 00:03:21,560 with 98 00:03:21,860 --> 00:03:22,360 dictating 99 00:03:22,659 --> 00:03:26,039 and box checking in electronic health record. 100 00:03:26,414 --> 00:03:28,094 And if you look over the last twenty 101 00:03:28,094 --> 00:03:30,514 years as as EMRs have 102 00:03:31,215 --> 00:03:31,715 become 103 00:03:32,014 --> 00:03:35,055 totally ingrained in the health care models, you'll 104 00:03:35,055 --> 00:03:37,234 see a lot more physicians, nurses, providers 105 00:03:38,174 --> 00:03:39,794 staring or typing at a computer, 106 00:03:40,580 --> 00:03:43,560 just documenting which takes away from patient care. 107 00:03:43,780 --> 00:03:45,860 I think the future is allowing the doctor 108 00:03:45,860 --> 00:03:46,759 patient relationship 109 00:03:47,219 --> 00:03:48,819 to get back to its core where you 110 00:03:48,819 --> 00:03:50,340 can focus on the patient and what you're 111 00:03:50,340 --> 00:03:53,219 doing providing care, and all that extra stuff 112 00:03:53,219 --> 00:03:54,340 is waste. I actually 113 00:03:55,055 --> 00:03:57,135 it's funny you mentioned this because, tomorrow, I 114 00:03:57,135 --> 00:03:59,855 give a lecture to orthopedic fellows on being 115 00:03:59,855 --> 00:04:02,735 efficient, and the definition of efficiency isn't moving 116 00:04:02,735 --> 00:04:04,995 faster. It's removing the waste. 117 00:04:05,375 --> 00:04:06,814 And I think, you know, what we've just 118 00:04:06,814 --> 00:04:09,419 talked about here, removing the bureaucratic 119 00:04:09,719 --> 00:04:11,180 waste from the physician 120 00:04:11,639 --> 00:04:13,639 and patient interaction is a way to make 121 00:04:13,639 --> 00:04:14,780 it much more efficient. 122 00:04:15,560 --> 00:04:17,240 That's a great way of putting it. And 123 00:04:17,240 --> 00:04:18,920 then I also wanna touch on just the 124 00:04:18,920 --> 00:04:22,584 clinical aspect as well. What's your strategy for 125 00:04:22,584 --> 00:04:26,264 aligning clinical workflows with financial goals, especially when 126 00:04:26,264 --> 00:04:28,824 it comes to the higher cost areas, like 127 00:04:28,824 --> 00:04:30,685 scheduling, implants, staffing? 128 00:04:31,785 --> 00:04:33,464 Yeah. Those are all those are all key 129 00:04:33,464 --> 00:04:36,089 issues and and great question. I pardon me. 130 00:04:36,169 --> 00:04:37,529 You know, let's take them one by one. 131 00:04:37,529 --> 00:04:39,529 So surgery scheduling, the more you can automate 132 00:04:39,529 --> 00:04:40,269 it, the better. 133 00:04:41,050 --> 00:04:42,810 You still have to have the expertise, the 134 00:04:42,810 --> 00:04:44,970 clinical expertise, to put the surgeries where they 135 00:04:44,970 --> 00:04:46,810 need to be during the day to and 136 00:04:46,810 --> 00:04:49,209 interact with the operating room staff. Do they 137 00:04:49,209 --> 00:04:50,669 know how to supply instrumentation, 138 00:04:51,685 --> 00:04:54,485 you know, OR setup, etcetera? But automating that 139 00:04:54,485 --> 00:04:56,805 with technology as best as possible is gonna 140 00:04:56,805 --> 00:04:58,644 be great. We use we actually use a 141 00:04:58,644 --> 00:05:00,644 program in our operating room that's almost like 142 00:05:00,644 --> 00:05:03,720 air traffic controls, a company called, Osmotec, and 143 00:05:03,959 --> 00:05:06,040 the patients wear a transponder, and it shows 144 00:05:06,040 --> 00:05:07,959 where the patients are real time. It's got 145 00:05:07,959 --> 00:05:09,019 dashboards everywhere. 146 00:05:09,480 --> 00:05:11,240 And and and I think those kinds of 147 00:05:11,240 --> 00:05:11,740 technologies 148 00:05:12,120 --> 00:05:15,579 are gonna allow surgery scheduling, surgery throughput, 149 00:05:16,199 --> 00:05:18,920 and even and even staffing to improve. For 150 00:05:18,920 --> 00:05:19,420 example, 151 00:05:20,175 --> 00:05:23,055 that technology also has a patient engagement app 152 00:05:23,055 --> 00:05:25,055 to it and a family engagement, so it 153 00:05:25,055 --> 00:05:26,814 shows the family where the patient is through 154 00:05:26,814 --> 00:05:27,395 the journey. 155 00:05:27,774 --> 00:05:28,274 So, 156 00:05:28,735 --> 00:05:31,214 you know, our practice has a a front 157 00:05:31,214 --> 00:05:31,714 office, 158 00:05:32,014 --> 00:05:35,120 person. Her name is Jan. And, I say 159 00:05:35,120 --> 00:05:36,020 frequently now, 160 00:05:36,399 --> 00:05:38,560 well, we don't need to hire another Jan 161 00:05:38,560 --> 00:05:39,620 because we have 162 00:05:40,080 --> 00:05:41,459 our Ospotek technology 163 00:05:42,160 --> 00:05:44,500 that's interacting with the family. 164 00:05:45,040 --> 00:05:47,279 Let's save money on personnel because as you 165 00:05:47,279 --> 00:05:48,615 know, people and their benefits 166 00:05:49,654 --> 00:05:51,101 are one of the highest costs in a 167 00:05:51,101 --> 00:05:52,134 practice or any business for that matter. So 168 00:05:52,134 --> 00:05:53,995 if we can have Jan plus technology 169 00:05:54,535 --> 00:05:55,675 rather than two Jans, 170 00:05:56,055 --> 00:05:58,854 that saves, that saves us a fair amount 171 00:05:58,854 --> 00:06:00,214 of money. And so I think that answers 172 00:06:00,214 --> 00:06:01,274 your staffing question. 173 00:06:01,589 --> 00:06:04,230 We we need to use, technology. Now finally, 174 00:06:04,230 --> 00:06:06,569 the implant utilization, that's a tricky one. 175 00:06:06,949 --> 00:06:08,470 That's one we've been trying to solve. And 176 00:06:08,470 --> 00:06:09,990 and I for full disclosure, I've worked with 177 00:06:09,990 --> 00:06:12,550 implant companies. I've been a designer for, fifteen 178 00:06:12,550 --> 00:06:13,370 plus years. 179 00:06:13,829 --> 00:06:16,014 And, you know, I think like everything else, 180 00:06:16,014 --> 00:06:17,455 they're gonna have to be partners with us 181 00:06:17,455 --> 00:06:18,915 and bring their implants down. 182 00:06:19,295 --> 00:06:21,455 But there's a couple strategies to help keep 183 00:06:21,455 --> 00:06:23,935 that cost down. Number one, using sole or 184 00:06:23,935 --> 00:06:26,335 dual source vendors so they can bring their 185 00:06:26,335 --> 00:06:28,254 price down for volume. That takes a lot 186 00:06:28,254 --> 00:06:30,710 of cooperation between you and your and your 187 00:06:30,710 --> 00:06:32,629 colleagues and your partners in the group to 188 00:06:32,629 --> 00:06:34,810 say, can we agree that in this ASC 189 00:06:34,870 --> 00:06:36,250 or this program 190 00:06:36,629 --> 00:06:38,069 to use one or two vendors so we 191 00:06:38,069 --> 00:06:39,830 can keep our cost down? That's one strategy. 192 00:06:39,830 --> 00:06:41,430 The other strategy is on the on the 193 00:06:41,430 --> 00:06:42,410 industry side. 194 00:06:42,865 --> 00:06:44,944 They need to work to bring their inventory 195 00:06:44,944 --> 00:06:45,444 levels 196 00:06:45,824 --> 00:06:47,985 down, be better at designing better implants, and 197 00:06:47,985 --> 00:06:48,805 lower instrumentation 198 00:06:49,185 --> 00:06:50,564 and using technology 199 00:06:51,264 --> 00:06:53,264 in place of the heavy instrument load they 200 00:06:53,264 --> 00:06:55,104 have, which will lower the cost of their 201 00:06:55,104 --> 00:06:57,220 implants. So it's a really on the implant 202 00:06:57,220 --> 00:06:58,579 side, and it's a great point you bring 203 00:06:58,579 --> 00:07:01,139 up, we need we need discipline on the 204 00:07:01,139 --> 00:07:04,120 practice side, and then we need continued development 205 00:07:04,180 --> 00:07:04,919 and evolution 206 00:07:05,779 --> 00:07:08,579 on the on from our industry partners to 207 00:07:08,579 --> 00:07:10,019 help bring down the cost of, 208 00:07:10,774 --> 00:07:13,435 cost of goods as well. Absolutely. 209 00:07:13,814 --> 00:07:16,055 Thank you for breaking that down. And, you 210 00:07:16,055 --> 00:07:17,975 know, I wanna touch on another area that, 211 00:07:17,975 --> 00:07:20,694 you know, was affecting all private practices, just 212 00:07:20,694 --> 00:07:21,915 reimbursement pressures. 213 00:07:22,774 --> 00:07:23,995 How are you approaching 214 00:07:24,375 --> 00:07:26,235 these challenges with other 215 00:07:26,689 --> 00:07:29,329 leaders at, in your practice and then with 216 00:07:29,329 --> 00:07:31,189 other, physicians in your group? 217 00:07:31,970 --> 00:07:35,089 Yeah. It's it's it's definitely affecting, you know, 218 00:07:35,089 --> 00:07:37,490 I think all groups nationwide. And what happened 219 00:07:37,490 --> 00:07:38,709 on January 1 220 00:07:39,235 --> 00:07:41,235 with CMS and, you know, I've been particularly 221 00:07:41,235 --> 00:07:43,074 involved in my role as president of the 222 00:07:43,074 --> 00:07:44,775 American Association of Infiniti Surgeons. 223 00:07:45,235 --> 00:07:46,595 We're dealing with these on a on a 224 00:07:46,595 --> 00:07:49,415 weekly basis, as they roll out from DC. 225 00:07:49,875 --> 00:07:52,134 But, you know, the cuts on the professional 226 00:07:52,355 --> 00:07:53,014 fee side 227 00:07:53,849 --> 00:07:57,229 were mirrored by some increases on the facility 228 00:07:57,610 --> 00:07:59,229 fee side. So you can see 229 00:07:59,689 --> 00:08:02,829 the macro trends here, which is decreasing our 230 00:08:02,889 --> 00:08:03,550 per patient, 231 00:08:04,169 --> 00:08:05,149 sort of fees, 232 00:08:05,689 --> 00:08:06,589 but increasing 233 00:08:07,225 --> 00:08:08,925 the work that we do in facilities, 234 00:08:09,545 --> 00:08:11,144 on the surgical side. So for us, in 235 00:08:11,144 --> 00:08:12,845 a musculoskeletal surgical practice, 236 00:08:13,944 --> 00:08:15,865 we could not have a viable practice if 237 00:08:15,865 --> 00:08:18,125 we didn't own an ambulatory surgery center. And 238 00:08:18,185 --> 00:08:19,920 so we have we have some core financial 239 00:08:20,160 --> 00:08:22,080 principles in the Indiana Orthoped Institute, which is 240 00:08:22,080 --> 00:08:23,360 we will not be in a market where 241 00:08:23,360 --> 00:08:25,199 we don't own our own ambulatory surgery center 242 00:08:25,199 --> 00:08:25,699 because 243 00:08:26,240 --> 00:08:28,480 we use those facility fees to augment the 244 00:08:28,480 --> 00:08:30,400 decline in the professional fees for the work 245 00:08:30,400 --> 00:08:32,720 that we do. So that's how and and 246 00:08:32,720 --> 00:08:34,639 and then there's another piece to it in 247 00:08:34,639 --> 00:08:35,774 my partnership with, 248 00:08:36,175 --> 00:08:36,675 HOPCO. 249 00:08:37,375 --> 00:08:39,615 They're they were so innovative and continue to 250 00:08:39,615 --> 00:08:41,075 be in value based care. 251 00:08:41,774 --> 00:08:42,434 We're using 252 00:08:43,375 --> 00:08:44,195 risk models 253 00:08:44,575 --> 00:08:46,035 and going to employers 254 00:08:46,495 --> 00:08:49,215 and taking risk on patients with great patient 255 00:08:49,215 --> 00:08:51,154 care and keeping costs down 256 00:08:51,629 --> 00:08:53,629 to succeed in value based care. And I 257 00:08:53,629 --> 00:08:55,870 think that's the second frontier. It's not as 258 00:08:55,870 --> 00:08:58,590 mature in every market, but value based care 259 00:08:58,590 --> 00:09:01,470 models are coming quickly as evidenced by the 260 00:09:01,470 --> 00:09:01,970 mandatory 261 00:09:02,509 --> 00:09:05,309 team program, which also started January 1, from 262 00:09:05,309 --> 00:09:07,090 CMS in in many markets. 263 00:09:07,404 --> 00:09:08,845 So I think it's a combination of those 264 00:09:08,845 --> 00:09:11,964 two things, capitalizing on the facility fees and 265 00:09:11,964 --> 00:09:12,464 also 266 00:09:13,004 --> 00:09:14,865 really embracing value based care. 267 00:09:15,644 --> 00:09:17,404 Got it. And, you know, I'd love to 268 00:09:17,404 --> 00:09:19,745 hear some lessons that you've learned about balancing 269 00:09:19,804 --> 00:09:22,360 physician autonomy with standardized processes 270 00:09:23,139 --> 00:09:25,000 and what they mean for, you know, margins 271 00:09:25,059 --> 00:09:26,200 and patient experience. 272 00:09:27,379 --> 00:09:28,820 You know, it's really timely because we just 273 00:09:28,820 --> 00:09:30,259 had our physician meeting on Tuesday, and we 274 00:09:30,259 --> 00:09:31,779 were we were talking we had to cover 275 00:09:31,779 --> 00:09:33,940 the the topic of implants cost. I mean, 276 00:09:33,940 --> 00:09:36,825 it's your your your topics are spot on 277 00:09:36,825 --> 00:09:38,665 and so timely. And what we did was 278 00:09:38,665 --> 00:09:40,024 we all sat in a room together, and 279 00:09:40,024 --> 00:09:41,325 then we put up the data. 280 00:09:41,705 --> 00:09:42,764 And so I think, 281 00:09:43,225 --> 00:09:45,004 you know, physician autonomy 282 00:09:45,544 --> 00:09:47,144 is gonna have to be different than what 283 00:09:47,144 --> 00:09:49,799 it was twenty years ago when I graduated 284 00:09:49,940 --> 00:09:52,659 fellowship from Mayo Clinic, which was you went 285 00:09:52,659 --> 00:09:53,159 out, 286 00:09:53,620 --> 00:09:56,259 you thought about everything, you know, academic, and 287 00:09:56,259 --> 00:09:58,100 you're like, I wanna treat patients. I'm gonna 288 00:09:58,100 --> 00:09:59,080 make all my choices. 289 00:09:59,700 --> 00:10:02,279 Well, now we can't make those choices 290 00:10:02,934 --> 00:10:04,455 just as black and white as we did 291 00:10:04,455 --> 00:10:07,175 back then. So we still have autonomy, but 292 00:10:07,175 --> 00:10:08,934 I would say it's more collective autonomy. So 293 00:10:08,934 --> 00:10:10,295 we get in a room together. We all 294 00:10:10,295 --> 00:10:12,795 look at each other. We put up everybody's 295 00:10:12,855 --> 00:10:15,434 variable direct cost. We put up the utilization 296 00:10:15,495 --> 00:10:17,434 of implants and the price of those implants, 297 00:10:17,970 --> 00:10:20,209 and then we together make decisions. So we 298 00:10:20,209 --> 00:10:21,029 have autonomy, 299 00:10:21,569 --> 00:10:23,169 but we have to make autonomy not in 300 00:10:23,169 --> 00:10:25,649 our own clinical vacuum, but rather as it 301 00:10:25,649 --> 00:10:27,649 relates to the business and making a viable 302 00:10:27,649 --> 00:10:28,629 orthopedic practice. 303 00:10:29,089 --> 00:10:30,929 And that can be challenging for some. I 304 00:10:30,929 --> 00:10:32,929 mean, that really some physicians don't like that. 305 00:10:32,929 --> 00:10:33,945 They're like, I'm forced 306 00:10:35,945 --> 00:10:36,009 to do x, y, and z. Well, they're 307 00:10:36,009 --> 00:10:36,524 not being forced. 308 00:10:36,904 --> 00:10:37,884 It's the macroeconomics 309 00:10:38,504 --> 00:10:40,745 that are forcing us to do it together. 310 00:10:40,745 --> 00:10:41,804 But if you don't, 311 00:10:42,424 --> 00:10:43,705 there's really no way out of it because 312 00:10:43,705 --> 00:10:45,625 we we're in private practice. But even if 313 00:10:45,625 --> 00:10:47,065 our physician said, well, I don't wanna do 314 00:10:47,065 --> 00:10:48,365 this. I wanna go be employed. 315 00:10:48,839 --> 00:10:50,539 Well, as an employed surgeon, 316 00:10:51,079 --> 00:10:52,919 many times that decision is made by a 317 00:10:52,919 --> 00:10:55,720 committee or someone that the physicians have almost 318 00:10:55,720 --> 00:10:56,459 no autonomy. 319 00:10:56,839 --> 00:10:58,360 So I would say the new term would 320 00:10:58,360 --> 00:11:01,100 probably be collective autonomy versus individual autonomy 321 00:11:01,754 --> 00:11:04,815 for, private practices and orthopedic enterprises 322 00:11:05,355 --> 00:11:08,335 to survive and thrive in 2026 and beyond. 323 00:11:08,955 --> 00:11:10,715 That's a really that's a really interesting shift 324 00:11:10,715 --> 00:11:12,975 you're describing here, this shift to collective, 325 00:11:13,355 --> 00:11:13,855 autonomy. 326 00:11:14,235 --> 00:11:15,535 And do you think that it'll, 327 00:11:15,879 --> 00:11:18,360 you know, continue stay kind of like the 328 00:11:18,360 --> 00:11:20,939 the the staying trend in this? 329 00:11:21,399 --> 00:11:23,319 I think it'll have to. I mean, you 330 00:11:23,319 --> 00:11:25,740 know, for for things in or like, orthopedics 331 00:11:25,879 --> 00:11:29,079 and musculoskeletal care, many of the procedures are 332 00:11:29,319 --> 00:11:30,779 can be relatively standardized. 333 00:11:31,524 --> 00:11:34,504 So take carpal tunnel, take shoulder replacement, take, 334 00:11:35,044 --> 00:11:35,865 you know, lumbar 335 00:11:36,485 --> 00:11:37,225 spine surgery, 336 00:11:38,004 --> 00:11:39,764 single or two levels fusions, or hip or 337 00:11:39,764 --> 00:11:40,424 knee replacement. 338 00:11:41,044 --> 00:11:43,524 You shouldn't have a wide variability, and sometimes 339 00:11:43,524 --> 00:11:45,284 surgeons don't like that because they have their 340 00:11:45,284 --> 00:11:47,100 own nuance they wanna impart on. But 341 00:11:48,059 --> 00:11:49,360 you're gonna have to justify 342 00:11:50,139 --> 00:11:52,399 anything that is sort of 343 00:11:53,339 --> 00:11:56,379 outside of a standardized value based and evidence 344 00:11:56,379 --> 00:11:56,879 based, 345 00:11:57,740 --> 00:11:58,240 protocol. 346 00:11:58,699 --> 00:12:00,554 And I and I think that that will 347 00:12:00,554 --> 00:12:01,855 be hard for some 348 00:12:02,315 --> 00:12:04,715 surgeons who really like the, you know or 349 00:12:04,715 --> 00:12:07,434 physicians in general who like the, quote, unquote, 350 00:12:07,434 --> 00:12:09,294 art of medicine, their own stylistic, 351 00:12:10,394 --> 00:12:12,235 things they wanna do. So I think that'll 352 00:12:12,235 --> 00:12:12,735 be 353 00:12:13,040 --> 00:12:14,639 it'll be tough, but I think that's the 354 00:12:14,639 --> 00:12:16,480 way forward. And I think that's that's here 355 00:12:16,480 --> 00:12:18,559 to stay if I'm if I'm really honest. 356 00:12:18,559 --> 00:12:20,559 I think that's we're gonna be making decisions 357 00:12:20,559 --> 00:12:21,059 together, 358 00:12:21,679 --> 00:12:23,120 and that's okay. It's more of a team 359 00:12:23,120 --> 00:12:24,639 approach. I kinda I kinda like it. It's 360 00:12:24,639 --> 00:12:26,019 just harder. It's more difficult. 361 00:12:26,345 --> 00:12:27,945 Yeah. And then you I I guess to 362 00:12:27,945 --> 00:12:29,644 sort of challenge you a little bit, 363 00:12:30,264 --> 00:12:32,024 what would you say needs to be done 364 00:12:32,024 --> 00:12:33,085 to kind of balance 365 00:12:33,785 --> 00:12:35,325 things out between the, 366 00:12:35,785 --> 00:12:38,105 you know, the collective thinking and autonomy, but 367 00:12:38,105 --> 00:12:39,725 then also still embracing 368 00:12:40,105 --> 00:12:41,644 the that art of medicine 369 00:12:41,980 --> 00:12:42,879 type of approach. 370 00:12:43,419 --> 00:12:44,399 Is there a middle 371 00:12:44,860 --> 00:12:47,820 ground or somewhere we can balance that? Yeah. 372 00:12:47,820 --> 00:12:49,340 I think no. It's a great point. I 373 00:12:49,340 --> 00:12:52,080 think that I think that the your individual 374 00:12:52,139 --> 00:12:53,899 autonomy is gonna be how you interact with 375 00:12:53,899 --> 00:12:56,024 the patient. It's gonna be how you care 376 00:12:56,024 --> 00:12:56,845 for the patient. 377 00:12:57,225 --> 00:12:59,705 But, like, as in a protocol, like hip 378 00:12:59,705 --> 00:13:02,264 and knee replacement, everybody uses tranexamic acid now. 379 00:13:02,264 --> 00:13:03,705 For a period of time, you know, people 380 00:13:03,705 --> 00:13:05,225 did or did not, but the evidence is 381 00:13:05,225 --> 00:13:05,965 so strong. 382 00:13:06,745 --> 00:13:09,059 It's really standard of care, and that's and 383 00:13:09,059 --> 00:13:10,580 that's a good thing. So I think many 384 00:13:10,580 --> 00:13:12,100 of these will become more like standard of 385 00:13:12,100 --> 00:13:13,559 care, and you'll have to use 386 00:13:14,340 --> 00:13:16,740 certain places in the doctor patient relationship and 387 00:13:16,740 --> 00:13:19,700 the entire care continuum to impart your little 388 00:13:19,700 --> 00:13:21,940 nuance or whatever you wanna do differently. So, 389 00:13:21,940 --> 00:13:23,460 like, I would say, we all interact with 390 00:13:23,460 --> 00:13:24,440 patients differently. 391 00:13:25,034 --> 00:13:26,875 I I, you know, I have certain phrases 392 00:13:26,875 --> 00:13:28,475 that I use and certain things that I 393 00:13:28,475 --> 00:13:30,154 discuss with patients that are different than my 394 00:13:30,154 --> 00:13:32,475 colleagues, and that's where you can get your 395 00:13:32,475 --> 00:13:34,575 autonomy. Same thing with your post op visits, 396 00:13:35,434 --> 00:13:38,460 and and whatnot. Things that don't dramatically impact 397 00:13:38,460 --> 00:13:39,360 the bottom line 398 00:13:39,740 --> 00:13:41,340 is probably where you can get some of 399 00:13:41,340 --> 00:13:43,279 that autonomy. And then finally, though, 400 00:13:43,660 --> 00:13:44,559 I would say, 401 00:13:45,259 --> 00:13:46,960 if if it's a good collective 402 00:13:47,820 --> 00:13:49,519 if good collective autonomy 403 00:13:50,325 --> 00:13:52,485 has mutual respect of all the individuals in 404 00:13:52,485 --> 00:13:54,325 their in their autonomy. So, for example, if 405 00:13:54,325 --> 00:13:57,045 there's 14 we have 14 surgeons. We're all 406 00:13:57,045 --> 00:13:58,024 in a room together. 407 00:13:58,404 --> 00:14:01,304 Everybody's voice should be, heard and and 408 00:14:01,605 --> 00:14:04,024 good ideas received well and considered, 409 00:14:04,440 --> 00:14:05,419 and then the collective 410 00:14:06,039 --> 00:14:08,200 values each individual. So I think it I 411 00:14:08,200 --> 00:14:10,039 think what could go wrong, what what the 412 00:14:10,039 --> 00:14:12,139 employee doctors are frustrated with right now 413 00:14:12,679 --> 00:14:14,600 is when their voice isn't even heard or 414 00:14:14,600 --> 00:14:15,659 when there's a committee. 415 00:14:16,279 --> 00:14:18,120 You know, call it the value committee or 416 00:14:18,120 --> 00:14:20,325 the, you know, implant purchasing committee, and they 417 00:14:20,325 --> 00:14:22,085 have zero say in it. And they're told, 418 00:14:22,085 --> 00:14:23,465 hey. You're using this vendor. 419 00:14:24,085 --> 00:14:25,285 And they're like, well, I didn't have a 420 00:14:25,285 --> 00:14:26,644 say in it. The answer is too bad. 421 00:14:26,644 --> 00:14:28,165 That's what I think they don't like. I 422 00:14:28,165 --> 00:14:29,625 think people will be okay 423 00:14:30,485 --> 00:14:33,210 with a team based approach as long as 424 00:14:33,269 --> 00:14:35,509 they understand they're valued and respected, if that 425 00:14:35,509 --> 00:14:37,370 makes sense. Yeah. Absolutely. 426 00:14:37,830 --> 00:14:39,990 And then last question for you. How are 427 00:14:39,990 --> 00:14:42,629 you thinking about growth in your practice this 428 00:14:42,629 --> 00:14:43,129 year? 429 00:14:44,149 --> 00:14:46,649 Yeah. You know, it's, so we're a disruptive, 430 00:14:47,794 --> 00:14:49,414 type of practice because we're, 431 00:14:49,954 --> 00:14:52,834 growing so fast and we it's it's fun 432 00:14:52,834 --> 00:14:54,274 to grow. It's one of the things I 433 00:14:54,274 --> 00:14:56,595 love doing. I've learned as about myself as 434 00:14:56,595 --> 00:15:00,274 being with affiliated and running growth companies is 435 00:15:00,274 --> 00:15:00,674 is, 436 00:15:01,315 --> 00:15:02,054 is exciting. 437 00:15:02,460 --> 00:15:04,300 And I think the market for example, I'm 438 00:15:04,300 --> 00:15:05,899 a hip and knee surgeon, so the market 439 00:15:05,899 --> 00:15:08,000 grows about three to 4% per year. 440 00:15:08,300 --> 00:15:10,320 We wanna be, you know, double, triple, 441 00:15:11,100 --> 00:15:12,860 triple that. And the way to do that 442 00:15:12,860 --> 00:15:15,019 from what we do on the particularly on 443 00:15:15,019 --> 00:15:17,684 the patient care side is to provide 444 00:15:18,065 --> 00:15:20,384 a top tier experience for patients, one that 445 00:15:20,384 --> 00:15:22,144 they go out and tell their neighbors about. 446 00:15:22,144 --> 00:15:23,985 Because there's all these you know, a lot 447 00:15:23,985 --> 00:15:26,704 of people approach growth with fancy marketing and 448 00:15:26,704 --> 00:15:29,105 blogs and getting on the Internet and search 449 00:15:29,105 --> 00:15:31,820 engine optimization, and I think that's gonna become 450 00:15:31,980 --> 00:15:35,259 with AI, it's gonna become a little bit 451 00:15:35,259 --> 00:15:35,759 harder. 452 00:15:36,139 --> 00:15:38,139 So I think we're gonna actually take a 453 00:15:38,139 --> 00:15:41,199 different step, and we're gonna provide authentic 454 00:15:41,579 --> 00:15:42,639 customer service, 455 00:15:43,445 --> 00:15:45,445 patient centered experience where the family and the 456 00:15:45,445 --> 00:15:47,764 patient are wowed when they come get treated 457 00:15:47,764 --> 00:15:49,705 by us at the Indiana Orthopedic Institute, 458 00:15:50,084 --> 00:15:51,605 and we're gonna grow that way. Because the 459 00:15:51,605 --> 00:15:53,384 rest of the world's gonna start going towards 460 00:15:53,445 --> 00:15:56,245 artificial intelligence and the Internet and what have 461 00:15:56,245 --> 00:15:58,220 you. And I I think we can be 462 00:15:58,220 --> 00:16:01,179 disruptive by going you can call you could 463 00:16:01,179 --> 00:16:03,019 almost call it going a little old school, 464 00:16:03,340 --> 00:16:04,480 and actually providing 465 00:16:04,779 --> 00:16:06,700 great patient I know it sounds wild. Right? 466 00:16:06,700 --> 00:16:09,659 Authentic great patient care. It it still will 467 00:16:09,659 --> 00:16:10,159 work. 468 00:16:10,735 --> 00:16:12,254 And I think as people head towards these 469 00:16:12,254 --> 00:16:13,075 other things, 470 00:16:13,774 --> 00:16:15,634 I think that can be disruptive growth. 471 00:16:16,335 --> 00:16:19,054 Absolutely. Well, doctor Menagini, thank you so much 472 00:16:19,054 --> 00:16:21,615 for joining us on our podcast, and I 473 00:16:21,615 --> 00:16:23,475 look forward to connecting again in the future. 474 00:16:23,695 --> 00:16:25,315 Thanks. An honor to be here.