This is Carly Beam with the Becker Spine
and Orthopedics podcast, and I'm thrilled to be
joined today by doctor Michael Mannagini,
CEO at Indiana Orthopedic Institute. Doctor Mannagini, thank
you for joining us today.
Thank you for having me. It's a pleasure.
So, before we dive into our discussion, can
you just introduce yourself and share a little
bit about your background?
Sure can. Yeah. My name as you said,
my name is Michael Managini.
I'm the founder and
CEO of the Indiana Orthopedic Institute.
Before that, I was a full professor of
orthopedic surgery at Indiana University Health here in
here in Indianapolis, and we started the, Indiana
Orthopedic Institute
about three years ago, just myself and,
an anesthesiologist and a small team. And now
we're up to almost a 100 employees and
14 surgeons and two anesthesiologists
and growing, across the state in three different
markets. So that's Incredible. Yeah. It's been great.
It's been a crazy ride. Healthcare is, as
you know, is in is in a state
of change,
all the time, rapid change, I would say,
and it's been an amazing ride. Yeah. I
mean, it sounds like change is just kind
of the only constant really with health care.
I would agree. Yeah. Well, doctor Meneghenian, first
question I wanted to kind of ask you
is
where do orthopedic practices
most commonly lose their
efficiency? And can you talk about some of
the operational changes that, you know, can deliver
quickest financial impact without affecting the quality of
care?
Yeah. It's a great question. I think
where I see operational inefficiency,
and it's not just in really orthopedics, but
in all of health care, is the
the progressive,
I would say, the the middle layer of
bureaucratic,
and administrative
bloat that we have.
And I think, you know, traditionally in health
care, we've had we've been very fortunate
to have enough financial resources in this country
over years where that layer got pretty thick.
But it's pretty distant from the doctor patient
relationship, and I think the that's where efficiency
of care has gone down. And we can
talk about in surgery or we can talk
about just in general the practices and that
we're focused anyway, I think, on the just
the general practice of of orthopedics.
And I think
if you look at how we can improve
that, that layer, that middle layer of of
administrative
work that needs to be done, I think
that can real that's where artificial intelligence and
AI is really gonna play a role. So
if you have a a specific team, like
we have revenue cycle management team of a
few people,
getting them to perform at a higher level,
getting better claims, getting better results, faster results
for the patients
so that they can get their surgeries,
authorized by,
commercial insurance
and Medicare, etcetera.
That's good for patient care. It's good for
patient access,
and it's also helps us be much more
efficient and even keep our costs down. So
I think utilizing technology in that way
is gonna be an advantage,
in the practice and also in the operating
room. Yeah. And I'd love to hear, you
know, what's an example of
AI success that you've seen at your practice
so far?
I think there's a couple places. So one
is definitely on the revenue cycle management side.
The other the other aspect really is is,
I think, the ambient listening that's in, electronic
medical records,
in in the those software programs. So the
fact that you can go into an office
now I mean, physicians
get consumed
with
dictating
and box checking in electronic health record.
And if you look over the last twenty
years as as EMRs have
become
totally ingrained in the health care models, you'll
see a lot more physicians, nurses, providers
staring or typing at a computer,
just documenting which takes away from patient care.
I think the future is allowing the doctor
patient relationship
to get back to its core where you
can focus on the patient and what you're
doing providing care, and all that extra stuff
is waste. I actually
it's funny you mentioned this because, tomorrow, I
give a lecture to orthopedic fellows on being
efficient, and the definition of efficiency isn't moving
faster. It's removing the waste.
And I think, you know, what we've just
talked about here, removing the bureaucratic
waste from the physician
and patient interaction is a way to make
it much more efficient.
That's a great way of putting it. And
then I also wanna touch on just the
clinical aspect as well. What's your strategy for
aligning clinical workflows with financial goals, especially when
it comes to the higher cost areas, like
scheduling, implants, staffing?
Yeah. Those are all those are all key
issues and and great question. I pardon me.
You know, let's take them one by one.
So surgery scheduling, the more you can automate
it, the better.
You still have to have the expertise, the
clinical expertise, to put the surgeries where they
need to be during the day to and
interact with the operating room staff. Do they
know how to supply instrumentation,
you know, OR setup, etcetera? But automating that
with technology as best as possible is gonna
be great. We use we actually use a
program in our operating room that's almost like
air traffic controls, a company called, Osmotec, and
the patients wear a transponder, and it shows
where the patients are real time. It's got
dashboards everywhere.
And and and I think those kinds of
technologies
are gonna allow surgery scheduling, surgery throughput,
and even and even staffing to improve. For
example,
that technology also has a patient engagement app
to it and a family engagement, so it
shows the family where the patient is through
the journey.
So,
you know, our practice has a a front
office,
person. Her name is Jan. And, I say
frequently now,
well, we don't need to hire another Jan
because we have
our Ospotek technology
that's interacting with the family.
Let's save money on personnel because as you
know, people and their benefits
are one of the highest costs in a
practice or any business for that matter. So
if we can have Jan plus technology
rather than two Jans,
that saves, that saves us a fair amount
of money. And so I think that answers
your staffing question.
We we need to use, technology. Now finally,
the implant utilization, that's a tricky one.
That's one we've been trying to solve. And
and I for full disclosure, I've worked with
implant companies. I've been a designer for, fifteen
plus years.
And, you know, I think like everything else,
they're gonna have to be partners with us
and bring their implants down.
But there's a couple strategies to help keep
that cost down. Number one, using sole or
dual source vendors so they can bring their
price down for volume. That takes a lot
of cooperation between you and your and your
colleagues and your partners in the group to
say, can we agree that in this ASC
or this program
to use one or two vendors so we
can keep our cost down? That's one strategy.
The other strategy is on the on the
industry side.
They need to work to bring their inventory
levels
down, be better at designing better implants, and
lower instrumentation
and using technology
in place of the heavy instrument load they
have, which will lower the cost of their
implants. So it's a really on the implant
side, and it's a great point you bring
up, we need we need discipline on the
practice side, and then we need continued development
and evolution
on the on from our industry partners to
help bring down the cost of,
cost of goods as well. Absolutely.
Thank you for breaking that down. And, you
know, I wanna touch on another area that,
you know, was affecting all private practices, just
reimbursement pressures.
How are you approaching
these challenges with other
leaders at, in your practice and then with
other, physicians in your group?
Yeah. It's it's it's definitely affecting, you know,
I think all groups nationwide. And what happened
on January 1
with CMS and, you know, I've been particularly
involved in my role as president of the
American Association of Infiniti Surgeons.
We're dealing with these on a on a
weekly basis, as they roll out from DC.
But, you know, the cuts on the professional
fee side
were mirrored by some increases on the facility
fee side. So you can see
the macro trends here, which is decreasing our
per patient,
sort of fees,
but increasing
the work that we do in facilities,
on the surgical side. So for us, in
a musculoskeletal surgical practice,
we could not have a viable practice if
we didn't own an ambulatory surgery center. And
so we have we have some core financial
principles in the Indiana Orthoped Institute, which is
we will not be in a market where
we don't own our own ambulatory surgery center
because
we use those facility fees to augment the
decline in the professional fees for the work
that we do. So that's how and and
and then there's another piece to it in
my partnership with, HOPCO.
They're they were so innovative and continue to
be in value based care.
We're using
risk models
and going to employers
and taking risk on patients with great patient
care and keeping costs down
to succeed in value based care. And I
think that's the second frontier. It's not as
mature in every market, but value based care
models are coming quickly as evidenced by the
mandatory
team program, which also started January 1, from
CMS in in many markets.
So I think it's a combination of those
two things, capitalizing on the facility fees and
also
really embracing value based care.
Got it. And, you know, I'd love to
hear some lessons that you've learned about balancing
physician autonomy with standardized processes
and what they mean for, you know, margins
and patient experience.
You know, it's really timely because we just
had our physician meeting on Tuesday, and we
were we were talking we had to cover
the the topic of implants cost. I mean,
it's your your your topics are spot on
and so timely. And what we did was
we all sat in a room together, and
then we put up the data.
And so I think,
you know, physician autonomy
is gonna have to be different than what
it was twenty years ago when I graduated
fellowship from Mayo Clinic, which was you went
out,
you thought about everything, you know, academic, and
you're like, I wanna treat patients. I'm gonna
make all my choices.
Well, now we can't make those choices
just as black and white as we did
back then. So we still have autonomy, but
I would say it's more collective autonomy. So
we get in a room together. We all
look at each other. We put up everybody's
variable direct cost. We put up the utilization
of implants and the price of those implants,
and then we together make decisions. So we
have autonomy,
but we have to make autonomy not in
our own clinical vacuum, but rather as it
relates to the business and making a viable
orthopedic practice.
And that can be challenging for some. I
mean, that really some physicians don't like that.
They're like, I'm forced
to do x, y, and z. Well, they're
not being forced.
It's the macroeconomics
that are forcing us to do it together.
But if you don't,
there's really no way out of it because
we we're in private practice. But even if
our physician said, well, I don't wanna do
this. I wanna go be employed.
Well, as an employed surgeon,
many times that decision is made by a
committee or someone that the physicians have almost
no autonomy.
So I would say the new term would
probably be collective autonomy versus individual autonomy
for, private practices and orthopedic enterprises
to survive and thrive in 2026 and beyond.
That's a really that's a really interesting shift
you're describing here, this shift to collective,
autonomy.
And do you think that it'll,
you know, continue stay kind of like the
the the staying trend in this?
I think it'll have to. I mean, you
know, for for things in or like, orthopedics
and musculoskeletal care, many of the procedures are
can be relatively standardized.
So take carpal tunnel, take shoulder replacement, take,
you know, lumbar
spine surgery,
single or two levels fusions, or hip or
knee replacement.
You shouldn't have a wide variability, and sometimes
surgeons don't like that because they have their
own nuance they wanna impart on. But
you're gonna have to justify
anything that is sort of
outside of a standardized value based and evidence
based,
protocol.
And I and I think that that will
be hard for some
surgeons who really like the, you know or
physicians in general who like the, quote, unquote,
art of medicine, their own stylistic,
things they wanna do. So I think that'll
be
it'll be tough, but I think that's the
way forward. And I think that's that's here
to stay if I'm if I'm really honest.
I think that's we're gonna be making decisions
together,
and that's okay. It's more of a team
approach. I kinda I kinda like it. It's
just harder. It's more difficult.
Yeah. And then you I I guess to
sort of challenge you a little bit,
what would you say needs to be done
to kind of balance
things out between the,
you know, the collective thinking and autonomy, but
then also still embracing
the that art of medicine
type of approach.
Is there a middle
ground or somewhere we can balance that? Yeah.
I think no. It's a great point. I
think that I think that the your individual
autonomy is gonna be how you interact with
the patient. It's gonna be how you care
for the patient.
But, like, as in a protocol, like hip
and knee replacement, everybody uses tranexamic acid now.
For a period of time, you know, people
did or did not, but the evidence is
so strong.
It's really standard of care, and that's and
that's a good thing. So I think many
of these will become more like standard of
care, and you'll have to use
certain places in the doctor patient relationship and
the entire care continuum to impart your little
nuance or whatever you wanna do differently. So,
like, I would say, we all interact with
patients differently.
I I, you know, I have certain phrases
that I use and certain things that I
discuss with patients that are different than my
colleagues, and that's where you can get your
autonomy. Same thing with your post op visits,
and and whatnot. Things that don't dramatically impact
the bottom line
is probably where you can get some of
that autonomy. And then finally, though,
I would say,
if if it's a good collective
if good collective autonomy
has mutual respect of all the individuals in
their in their autonomy. So, for example, if
there's 14 we have 14 surgeons. We're all
in a room together.
Everybody's voice should be, heard and and
good ideas received well and considered,
and then the collective
values each individual. So I think it I
think what could go wrong, what what the
employee doctors are frustrated with right now
is when their voice isn't even heard or
when there's a committee.
You know, call it the value committee or
the, you know, implant purchasing committee, and they
have zero say in it. And they're told,
hey. You're using this vendor.
And they're like, well, I didn't have a
say in it. The answer is too bad.
That's what I think they don't like. I
think people will be okay
with a team based approach as long as
they understand they're valued and respected, if that
makes sense. Yeah. Absolutely.
And then last question for you. How are
you thinking about growth in your practice this
year?
Yeah. You know, it's, so we're a disruptive,
type of practice because we're,
growing so fast and we it's it's fun
to grow. It's one of the things I
love doing. I've learned as about myself as
being with affiliated and running growth companies is
is,
is exciting.
And I think the market for example, I'm
a hip and knee surgeon, so the market
grows about three to 4% per year.
We wanna be, you know, double, triple,
triple that. And the way to do that
from what we do on the particularly on
the patient care side is to provide
a top tier experience for patients, one that
they go out and tell their neighbors about.
Because there's all these you know, a lot
of people approach growth with fancy marketing and
blogs and getting on the Internet and search
engine optimization, and I think that's gonna become
with AI, it's gonna become a little bit
harder.
So I think we're gonna actually take a
different step, and we're gonna provide authentic
customer service,
patient centered experience where the family and the
patient are wowed when they come get treated
by us at the Indiana Orthopedic Institute,
and we're gonna grow that way. Because the
rest of the world's gonna start going towards
artificial intelligence and the Internet and what have
you. And I I think we can be
disruptive by going you can call you could
almost call it going a little old school,
and actually providing
great patient I know it sounds wild. Right?
Authentic great patient care. It it still will
work.
And I think as people head towards these
other things,
I think that can be disruptive growth.
Absolutely. Well, doctor Menagini, thank you so much
for joining us on our podcast, and I
look forward to connecting again in the future.
Thanks. An honor to be here.