← Becker’s Healthcare Podcast
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- [00:01]
Alan Condon
This is Alan Condon back on the Beckers healthcare podcast and today I'm thrilled to be joined by Dr. Craig McMains, a fellowship trained spine surgeon who specializes in minimally invasive and complex spine surgery at Ortho Indy. Dr. Maines, pleasure to have you back on the podcast with us today. Before we dive into some questions that I'd love to get to, I'd love to hand the floor over to you just to tell us a little bit more about your, your role and your background at Orthoindi.
- [00:31]
Dr. Craig McMains
Absolutely. Thanks for having me on, Alan. Appreciate the time today. As you said, I'm Craig McMains, I am a orthopedic spine surgeon. I've been in practice close to a decade now. I'm currently a partner at Orthoindy specializing in minimally invasive and complex spinal procedures. So Orthoindy is a Indiana's first physician, known like orthopedic hospital. We founded the hospital and I think it was around 2005. The group's been together for about 50 years and so that kind of innovative approach has been part of the DNA of the group and that's what attracted me to joining the group. And so for my individual practice, kind of leveraging that, you know, physician ownership and kind of top down control into my care for my spine patients and incorporating kind of forward thinking technologies to get better outcomes at a, at a good value.
- [01:32]
Alan Condon
So excited to dive in and kind of learn a little bit more about your practice, kind of where you're headed, what you're planning for this year. Dr. McMains, I think certainly no secret to you, to me, to many of our audience, the big headwinds that healthcare across the board is facing, but I guess specific to your practice, specific to spine surgery at Orthoindi, what are the, the big headwinds that you're really planning for this year?
- [01:57]
Dr. Craig McMains
Yeah, so you know, that's a great question and I think I'm going to sound like a broken record for everybody else, you know, in terms of the kind of group level headwinds. I, I'll talk about my individual practice first though. You know, I, I'm, we started a, a little over a year, year and a half ago, an endoscopic spine program at Ortho Indy. And that's been something that's really kind of caused me to see a paradigm shift in how I view patients. Right. Historically the foundations of spine surgery are stabilized, decompressed. Correct. And now I don't have to approach that with a kind of anatomy altering approach anymore. I don't have to do a spinal fusion to get an adequate decompression or to preserve integrity. Being able to have these ultra minimally invasive approaches to the spine where we can decompress the neuro elements and kind of preserve anatomy has been kind of a real boon in my practice. Patients love it. They're getting back to activity faster and just really having great recoveries. The, the analogy I kind of always bring up is, you know, my orthopedic background is look at the. Where shoulder arthroscopy went and the treatment for rotator cuffs, right? We used to do these open approaches. Historically, they were highly disfiguring and highly, you know, morbid for patients to undergo. Well, we got better. We developed these less invasive, or you call minimally invasive techniques and many open deltoid sparing, you know, deltoid splitting approach, we got some good visualization with that. Some people would advocate it was superior for a long time, even after arthroscopy got introduced, right? Because historically, arthroscopy was really challenging and cumbersome and expensive for shoulders. But now if you look at the current landscape, that's the gold standard. Nobody would tell you that you should go backwards and have these open approaches, even in a less invasive fashion. So I think spine is going to go through that paradigm shift as a field and we're going to do better of preserving normal anatomy while alleviating pathology. So that's kind of my big headwind is just kind of change I see in my practice individually is like, how do I keep leveraging that? How do I get that to go forward from a group standpoint? You know, we're facing these, you know, as always, kind of regulatory and financial headwinds, right? We have trouble with our payers, you know, giving surgeons and individual physicians an appropriate compared to say, like a big hospital system, right? And there's all kinds of data out there showing that the reimbursement for facilities is going up or whereas physician rates are flat if not dropping. And, you know, if you look at it from like comparing it to like inflationary data, you know, physicians have not kept up from a pay standpoint and a pay quality standpoint versus kind of what these large healthcare systems do. So just trying to make sure that we remain patient focused, right? We want to get good outcomes because, you know, it's kind of like a field of dreams thing. If you, if you build it, if you build it, they will come, like, if we're doing good work, patients will come see us. But we have to, we have to be lean, we have to make sure that we're not, you know, becoming bloated with, you know, excessive cost. We try to be, you know, consciousness on our implants that we're using, making sure that we're doing things that don't add significant delays in care or cost to the system. So I mean, that's a complicated answer, but that's kind of the thousand foot view of our practice level.
- [05:53]
Alan Condon
Yeah, absolutely. And it kind of ties kind of into the next question that I wanted to pick your brains on. I think in terms of what we're seeing across the board in spine and orthopedics, some of the key trends are going to play into that. Seeing a sharp rise in, it seems like orthopedic MSOs, management services, organizations, increased private equity investment coming into the field. On the other hand, increased consolidation. Also a ton of excitement in terms of what we see in spine technology, orthopedic technology. Some of the key trends across the board here on a broad level, but with some of these in mind, how do you see spine orthopedics? How do you see the field evolving over the next two to three years? Curious to kind of get your thoughts there as of how you're looking at the future.
- [06:40]
Dr. Craig McMains
Yeah, the way I, you know, in my perspective is it's, it's like this pendulum and swinging back and forth. Right. We used to have all these private practices and then basically, you know, the Affordable Care act came in and changed the landscape. Physician ownership became much, increasingly rare from a hospital standpoint. And with insurance is putting downward pressure on physician pay. You know, the, and the, the regulatory burden of, you know, documentation and everything else that was required, kind of increasing it, you know, it became overwhelming for physicians to manage all this. Right. We're trained to do patient care, to do medicine. Our, our experience in business is lacking in that regard. And so you saw this pendulum swing where physicians were becoming hospital employed. Like we're joining large groups. I think what we have seen now, decade plus into that kind of change is that these large groups have realized they're not great at managing subspecialists like spine surgeons. Right. And so I get the sense that we're kind of getting, and the surgeons are getting really frustrated and we have, at the end of the day, we have the biggest card to play at this table, which is the power of the pen. Right. Nothing goes through a healthcare system pretty much without a physician order. And I think physicians forget that kind of power they wield in this, in these discussions. We'll call it. And so physicians are starting to increasingly pull away from these large health care organizations. And you know, right now we're seeing this trend towards, as an alternative, you know, private equity involvement and maybe MSOs to try to diminish cost with an economy of scale. At Ortho Indy, we're, we're expanding, we're trying to, we think we have a good solution independently of those two options and we're trying to become a larger brand around the state. But it's the same thing we're trying to, everybody's trying to increase economy scale. So I, I think that you're going to kind of continue to see the pendulum swing in that direction. I, I don't foresee private equity. I'd like to be wrong on this. I don't see them being a long term solution. I, maybe I'm, I'm going to be proven wrong. But you know, at the end of the day, those groups are primarily focused with profitability. And I think the historic perception of them is that they're going to come in, they're going to make an organization lean and then the minute it's hitting its profit margins, they're going to try to flip it and sell it. So that might, I guess, benefit a group if they can buy it off the private equity firm, maybe. But I think for physicians, those are going to be the trends we see moving forward over the next, you know, several years, five years plus. And I think that in that regard, if you can get, and as a subspecialist, if you can get in control of your facility. Right, because we just talked about it a second ago. The facility reimbursements are doing well. Spine surgery getting pushed in the way that joints was before. It's, we want to ratchet down implant cost. You know, we're going to push everybody to outpatient surgery. We want to leverage things like minimally invasive endoscopy to get people kind of up and back to life faster. And so if you can get in on, you know, an asc, that's going to be huge because there's a strong push from all sides, both physician, you know, large organizations to move spine surgery in that direction. The days of having a surgery and staying a week in the hospital are going to become increasingly rare outside of a really few special tertiary facilities, in my opinion.
- [10:25]
Alan Condon
Yeah, it's certainly interesting to see that trend developed to your point earlier when we talked about the traditional spine surgery and how kind of morbid it used to be. What also wasn't that long ago when spine Patients or even total knee, total hip patients are staying 2, 3, 4 days in the hospital. Now to your point, with the help of these minimally invasive surgical techniques, open, ambulated, out the door in an hour, two hours. So currently certainly interesting to see what happens to the traditional inpatient environment as it relates to spine surgery, orthopedic surgery and some of those territory environments like you'd mentioned. Dr. McBain's last question I have for you and you kind of alluded to it earlier, certainly interesting to see the growth of orthoindia over the years. Really fascinating. Interesting. It seems maybe hub and spoke model there. Where are Ortho Indy's best opportunities for growth? To your point, is it acquiring ASCs, building ASCs, partnering, more referrals, kind of really expanding your footprint in that area. New physicians in the group kind of love to get your kind of the group's game plan and kind of how you're thinking about growth there.
- [11:33]
Dr. Craig McMains
Sure. So like you said, we, you know, individually and I would say to some degree as a group, I'm not speaking for the group here, but you know, we recognize the value of ASCs and the expansion of ASCs. Right. For all of orthopedics, not just spine surgery. And you know, there's a, there's a strong current out there, like I said, of these smaller practices feeling pressure, not being happy or able to maybe manage the modern pressures of management. And we think that we've kind of developed a pretty good model in Indianapolis here. And so the, the idea is that maybe we're an alternative to all three of those previous options. Right. To big healthcare organizations like, you know, the big, you know, hospital chains that were an alternative to MSOs or an alternative to PE. We can, we can provide those services but allow surgeons to maintain control and to guide the patient experience on a individual kind of hands on practice level. But we can also kind of, by pooling our resources, generate that economy of scale that lets us then, you know, manage these in rising costs and, and you know, manage these overhead issues that we're all having because that's like the biggest barrier to growth. So like, you know, you can try to expand but you know, we don't want people to, we don't want patients to go out there and have more problems to some degree. Right. Like we don't want, we don't want there to be more business. Instead the way that we can get growth is by diminishing our overhead and our cost. I think that the way that orthoindy and other practices should look at this the most is the best opportunity for growth is data monetization. Right. So like we're all generating this impressive data and with some of these AI tools that are available, we finally have a way of processing big data. Right. Which we never had, you know, 10 plus years ago. And so if, if you as a, if we can as a practice figure out, okay, what's the most efficient pathway through our system that generates the best outcome for a patient and you know, with the implants that we're using and our utilization, you know, what, what's the optimal construct or you know, what's the optimal surgery to get the best outcome? Like those are those data monetization questions that if we can start to capture that and act on it, that's going to lead to the biggest growth changes. And I think, you know, we're doing that. We're, we're working with you know, an AI driven, basically call center that kind of manages all of our scheduling now. And that's, that's going to make a boon. We're starting to do that with some of our pro data, like our outcomes data. We, we have our own research foundation. We're gonna, we're gonna turn this, you know, lens to implants here. And so I think that as we figure out how we can diminish our cost going forward, that's how we can drive more volume towards us because patients will, and patients payers. Employers. Right, Direct employers. A whole nother discussion we can go down a rabbit hole with. They'll all start to realize that hey, orthoindy is, you know, approaching this from a patient centric, patient first standpoint. And they're also forward thinking enough that they're trying to get ahead of these challenges. And I think we're, we're that perfect size of mass but nimbleness that we can make these changes rapidly and we're not burdened by bureaucracy.
- [15:08]
Alan Condon
Yeah, no, and I guess I told a lie because you did bring up such an interesting point there as it relates to kind of potential direct to employer contracting and whatnot. In my recent conversations with orthopedic groups across the country, it seems like, particularly around the size and scope of Orthoindi, it seems like more independent orthopedic groups like yours are taking a harder look at potentially some of these direct employer contracts. Is that something that's top of mind for Orthoindi as you consider or tackle some of these headwinds? I'd love to kind of get your perspective there before we wrap up.
- [15:43]
Dr. Craig McMains
Yeah, Once again, this is like an individual perspective. I don't speak for the group in this regard, but, you know, I think it's. It's one of those scenarios where, you know, if you're a large enough group that you can handle a large influx of volume and you have a geographic footprint that, you know, an employer with, you know, a bit of a geographic spread needs, you know, has maybe employees all over the place. And, you know, insurance companies are becoming, you know, they're. They're combative, they're. They're challenging to work with from, as an individual physician standpoint. Right. They. They cave to these big groups because of that old economy of scale discussion. Well, if you can offer a superior outcome and a, you know, a superior patient experience, why can't you go to that employer and, you know, maybe pass along some kind of savings to them by offering that kind of direct employer negotiation for their. For their employees? I mean, everybody wins then, right? The employer is saving money. The patients get a better experience. And, you know, the reason why we're pushing that is because, hey, we don't have the mass of. Of negotiators to chase after, you know, a big national insurance company with. So I think that's something that, like, you know, is going to become. Not something maybe as a solution for every group to pull off, but if you have a group that is of a certain size, you know, it's something that we can. It definitely would be. It's definitely in our radar, and I think it's becoming something that we're hearing this discussion occur around the country more and more frequently.
- [17:27]
Alan Condon
Yeah, no, fascinating to get your perspectives there, and I know, indeed, speaking from. For yourself, a member of the group, but not for the group. I really appreciate your perspectives. Dr. McMahain, so great to have you back on the podcast. Really, really enjoyed this conversation and look forward to speaking with you again down the line.
- [17:44]
Dr. Craig McMains
Really appreciate it. Thank you so much.