Seven orthopedic surgeons and a table full of surgical instruments helped Michael Meneghini, MD, establish one of the most important rules at Indiana Orthopedic Institute: Not everyone gets to do things their own way.
As the physician-led organization developed its outpatient surgery model, Dr. Meneghini gathered his colleagues to standardize their equipment. Each surgeon could choose one preferred instrument. The rest had to be standardized.
The exercise captured a tension at the heart of orthopedic ASC growth: The independence that makes physician-led organizations attractive can also undermine the efficiency needed to sustain them.
“Physicians and surgeons are notorious for that,” Dr. Meneghini told Becker’s. “This is the way I do it, and I have this protocol, and I have to have this instrument.”
As founder and CEO of Noblesville-based Indiana Orthopedic Institute, Dr. Meneghini has navigated that tension while expanding the organization beyond joint replacement into multiple orthopedic specialties.
Building a clinical program, not just a surgery center
“Health systems typically can build buildings, but physicians build clinical programs, and they’re very different,” Dr. Meneghini said.
IOI’s model integrates surgeons, perioperative clinicians, anesthesiologists and physical therapists, allowing care teams to coordinate directly rather than navigate multiple administrative layers.
He described a recent day when his team performed four knee revision procedures at its ASC. During one case, he needed a specific postoperative immobilization protocol and communicated it directly to the institute’s physical therapists.
That coordination, he said, illustrates the advantage of keeping clinical decisions close to the people delivering care.
“You can’t design a clinical program by rounding on the unit once a year or once every quarter,” he said. “You’ve got to empower your physician leaders to develop clinical programs and give them the autonomy to do so.”
The financial paradox of growth
Even with a leaner operating structure, IOI faces mounting financial pressures. Dr. Meneghini identified four major challenges: anesthesia expenses, inflation in staffing and supplies, commercial payer contracting and the capital required for expansion.
“We overpay for anesthesia. The market’s out of control. We have no choice,” he said.
For independent organizations without the financial reserves of major health systems, growth presents a difficult calculation.
“In a constrained healthcare environment, you can’t grow by cutting costs. You have to invest,” he said. That reality makes eliminating administrative waste and unnecessary clinical variation particularly important, even as organizations spend to expand their capabilities.
Why specialization wasn’t enough
IOI initially focused on hip and knee replacement, but Dr. Meneghini recognized that a narrower model could limit opportunities with employers and payers.
“We quickly realized that if we were going to work directly with employers and take on full musculoskeletal risk through alternative payment models and payer arrangements, we needed to offer all of orthopedics,” he said.
A major employer seeking comprehensive musculoskeletal care, he reasoned, would still need separate arrangements for shoulder, hand and ankle conditions if IOI remained focused exclusively on joint replacement.
Although some orthopedic groups have doubled down on joint replacement specialization, Dr. Meneghini worries that approach could cost them business as purchasers seek broader services.
For IOI, expanding specialties became a way to position the organization for more comprehensive care arrangements, rather than simply adding surgical volume.
The hardest part of scaling is getting surgeons to agree
Expanding specialties introduces another challenge: maintaining consistency as more physicians bring their own preferences and protocols.
The early instrument-standardization meeting established an expectation that Dr. Meneghini said remains central to IOI’s operating model.
“These sets that we agreed to are the exact same sets that I agreed to,” he said. “I only have my one special instrument.”
As the organization grows, he believes leadership must prevent individual exceptions from gradually undermining efficiency.
“The answer is, it’s the Indiana Orthopedic Institute way, or there is no other way,” he said.
That discipline requires more than physician authority. Dr. Meneghini emphasized the importance of experienced operational leaders, including IOI’s new chief operating officer, Jen Worthy, whose expertise includes revenue optimization and revenue cycle management.
He also sees hospital and payer partnerships as essential, provided they support expansion without adding unnecessary bureaucracy.
“I think getting partnerships that allow you to scale without adding bureaucracy and cost are the key,” he said.
Physician ownership reinforces that alignment by giving surgeons a direct stake in the organization’s performance. “When they’re owners, they become aligned and incentivized on cost and quality,” he said.
The next competitive advantage may be human
Looking ahead, Dr. Meneghini believes technology alone will not determine which orthopedic organizations succeed.
As AI and automation reshape healthcare, he expects patient experience to become an increasingly important differentiator.
He pointed to Ritz-Carlton and Disney as examples of organizations known for attentive, consistent service, arguing that healthcare should aspire to a similar standard without compromising clinical quality.
“I believe the next five to 10 years will be defined by growth through providing an incredible patient experience and top-level patient care,” he said.
Payer restrictions could complicate that vision, but Dr. Meneghini sees an opportunity for organizations that can pair clinical excellence with a more personal approach.
For orthopedic ASCs, growth is about more than how many procedures they can perform or facilities they can open. It is about whether they can preserve the coordination, accountability and patient relationships that made their original model work as they grow.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
