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EPISODE 14
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20:07
Centralizing operations without erasing the local brand
Jarett Landman
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Former Vice President of Operations,
Jarett Landman started as a physician assistant and spent nearly 15 years in independent practice before running the Massachusetts regional market for Spire Orthopedic Partners — nine locations and 450 employees. He explains why specialty groups are consolidating, what an MSO should centralize versus leave alone, and the three things to check before joining one.
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Nobody Cares Whose Name Is on the Velcro
Healthcare Is Becoming a Game of Super Systems
Top takeaways
1. Consolidation is a margin story, and it has three doors
Jarett's read on why groups are banding together is financial, not strategic. Rent and real estate, the cost of retaining high-quality talent, and the software and technology now required to practice have all risen sharply — while payers apply downward pressure from the other side. What gets squeezed is margin, which in many practices is physician W-2 income.
He sees physicians responding through three pathways:
Capital partners — private equity, creating MSO structures that drive infrastructure changes, synergies and cost reductions.
Physician-led aggregation — similarly situated independent practices banding together for economies of scale through GPO pricing and contract aggregation. In orthopedics he points to the Northeast Orthopaedic Alliance and PELTO.
Hospital employment — increasingly the choice of physicians coming out of residency and fellowship, because it removes the burden of starting and growing a business.
The result he expects over the next 15 to 20 years is a landscape of super systems, whether physician-led, hospital-led or PE-led. He's still a champion of independent practice, but his view is that without some kind of safety net, coexisting with those systems gets very hard.
2. Centralize what's commoditized. Leave alone what physicians actually care about.
This is the line the episode is built around. Physicians care about clinical autonomy, who their PA is, retaining the staff who matter to them, and whether marketing is driving patients to their practice. They do not care about the structure behind the RCM process — they care that they get paid.
His orthopedic example: the brace going on a patient has to be safe and stable and support the injury. But the name printed on the Velcro doesn't much matter. Wherever a product or process is commoditized, that's where an aggregator can drive down cost — and that's leverage a small independent practice negotiating alone with vendors simply doesn't have.
So the MSO's job is infrastructure that doesn't touch patient care and doesn't change how a physician feels about their practice week to week.
3. Don't put a new sticker on the window
Practices joining an MSO often arrive with 20, 30, 40 years of local brand reputation. Rebranding them early, Jarett argues, does more to injure that brand and confuse patients than it does to drive access.
Spire's approach was to accelerate the local brands instead: more marketing behind each practice, more frequent visibility with referring PCPs, expanded commercial and social media marketing for individual physicians. Recognizing that most doctors aren't naturally comfortable on camera, the team built content around subjects those physicians could speak about with genuine enthusiasm, then pushed it out into their communities.
He does think a slow progression toward centralized branding makes sense at sufficient scale. But at the industry's current stage — roughly 19 PE-backed groups and about three physician-owned ones — local brand still beats anything done centrally.
4. Aggregate the data before you consolidate the systems
You don't need every practice on the same EHR on day zero. What you need first is a repository that can extract local data and collate it so like entities can be compared: RCM performance, physician throughput, surgical conversion rates. His rule of thumb — if a metric can be assigned, collect it.
That data then has three separate uses: motivating consistency across the physician base on what's reasonable for patient volume and safe care; supporting payer negotiations with outcomes data; and backing marketing claims about patients successfully treated for a given condition.
System consolidation — EHR, telephony, IT and cybersecurity — comes after, as a synergy play. Notably, he frames it as alignment rather than headcount reduction: if every practice has its own marketer and HR representative, the goal is getting them onto one set of standards, not cutting them.
Bonus: onboarding a practice, and the three things to check before you join one
On bringing a group in, his phrase is eat the elephant bite by bite. A stepwise roadmap over six months to a year keeps it digestible. It starts with extracting their data and mirroring it back — here's how you compare to peers at the same stage of practice — but he's emphatic that this is a conversation starter, never a stick. Be explicit about deliverable timelines and who owns the transition, because how a group comes in sets the tone for what kind of participant it becomes.
And from the practice's side of the table, three things to weigh:
Rightness of fit. He compares it to walking a college campus and being able to picture yourself there. Giving up decision-making that has always rested on your shoulders is daunting, so you need real trust that your people and your partners will be looked after.
How your partner is perceived locally. Different markets have responded differently to hospital, for-profit hospital, private equity and large aggregated groups. You'll still need hospital affiliations, surgical centers and laboratory access, so the partner's reputation should extend your brand, not injure it.
The succession math. If the average physician is in their mid-to-late 50s and you're onboarding fellows in their early-to-mid 30s, ask whether the arrangement is sustainable for them. If it isn't, the MSO has a life cycle and an end, even at scale.
Questions this episode answers
Why are specialty practices joining MSOs and larger groups?
Margin pressure. Rent, talent retention, and the software required to practice have all risen, while payers push from the other direction — and in many practices that margin is physician W-2 income. Jarett Landman sees three responses: private equity capital partners forming MSOs, physician-led aggregation for GPO pricing and contract leverage, and hospital employment, which is increasingly the choice of physicians leaving fellowship.
What should an MSO centralize, and what should stay local?
Centralize what's commoditized — RCM structure, EHR, telephony, IT and cybersecurity, supply contracts. Leave alone what physicians actually care about: clinical autonomy, who their PA is, retaining their own staff, and marketing that drives patients to them. Jarett Landman's shorthand is that a brace has to be safe and stable, but the name on the Velcro doesn't matter — and that's exactly where cost can come out.
Should a practice rebrand when it joins an MSO?
Not early. Practices often join with 20 to 40 years of local brand reputation, and putting a new sticker on the window tends to injure that brand and confuse patients more than it drives access. Spire's approach was to accelerate the local brands instead — more PCP visibility, more commercial and social marketing behind individual physicians. A slow move toward centralized branding makes sense at scale, but not at the outset.
What should a practice check before joining an MSO?
Three things, per Jarett Landman. Rightness of fit — whether you can genuinely picture your group inside that system, since you're giving up decision-making that used to be yours. How the partner is perceived in your local healthcare ecosystem, because you'll still need hospital affiliations, surgical centers and lab access. And the succession math: if the average physician is in their late 50s and you're onboarding fellows in their 30s, the arrangement has to be sustainable for the younger group or the MSO has an end date.
Scale referral operations to drive growth and efficiency
Full transcript
Transcript
[00:00:00] And specialty healthcare growth is not optional, but scaling with operational excellence. That's the hard part. I'm Joe Zboch. This is Scaling Specialty Growth.
[00:00:08] Joe: Thanks for listening. Today's guest is Jarett Landman. He's a former VP of operations at Spire Orthopedic Partners, a PE-backed ortho group where he led the Massachusetts regional market across nine locations and 450 employees. Jarett describes himself as a servant leader, and his career reflects it. He started as a physician assistant treating patients and worked his way into the executive side, which gives him a perspective on operations that's hard to manufacture.
Jarett, welcome.
[00:00:35] Jarett: Thanks, Joe. Appreciate your time here.
[00:00:37] Joe: I wanted to ask the first question just to frame up. Obviously your experience with Spire is unique. So what sort of ways of thinking or philosophy do you have in terms of balancing the operational mindset, the operational needs, to support the growth side of things? Because I know there can always be that struggle, that tension between, hey, we have these goals, we need to hit these goals, and also we need to be able to operationally support it or else we'll be out in front of our skis.
So what kind of process or thinking did you develop over the years to strike that balance and ultimately grow quickly but responsibly?
[00:01:18] Jarett: Yeah, I think it's a good question. I think like anything, great leadership starts with vision — vision and strategy, and aligning the goals of the C-suite and executive team with the local practice level leadership. And I always looked at operations as that bridge of execution, of getting from what's gonna happen dynamically on a day-to-day basis to drive positive patient interactions, positive patient outcomes, increase volume, improve on RCM function, and align that with where the business itself wants to go.
And be that on the independent physician practice level, which I did for nearly 15 years, or on the private equity side, it really is the same. You start with your budgeted and strategic goals for the year, and then you work backwards through your process to say, "Well, what am I gonna do on the local or micro level that's gonna help us achieve that?"
And it's a really fun world, I find operations, because it is truly setting that roadmap as opposed to just the idea.
[00:02:25] Joe: Tell me about the nature of these groups kind of coming together. You see it whether it's an MSO on the independent side, the groups forming a conglomerate in a given region. You've seen it on the PE side. I think there's a lot of commonalities. Can you draw a line on why this motion has picked up so much steam and adoption, and what the thinking behind it is — not just from a growth standpoint, but from preserving the ability to run the business and do the care the way the physicians really envisioned at the onset?
[00:03:04] Jarett: Sure. I think that really irrespective of physician specialty — and of course I cut my teeth in orthopedics, but I think this is paralleled in all of the various subspecialties throughout medicine — there is a certain need for brothers and sisters in arms right now. I think most people are feeling the financial strain on the practice level of trying to run the mom-and-pop business that they historically ran 20, 30 years ago.
I think the costs of everything have risen so greatly, be it the rent and the real estate in which those physicians practice, the costs of keeping and retaining high-quality talent, the costs driven by additional software and technology that's necessary to practice every single day. And unfortunately, we have this downward pressure that's come from the payer side of the equation as well, which has really cut into the ability to create margin, which in many cases is W-2 income for physicians.
So physicians have started to band together and have really looked for three pathways to do that. They've looked for capital partners on the private equity side to help create these MSO structures which drive infrastructural changes, synergies, and ultimately cost reductions for the practices.
They have tried to band together and do that themselves as aggregating independent practices. In the orthopedic space, we get groups like the Northeast Orthopaedic Alliance, PELTO, other groups that have come together similarly situated to try to create those economies of scale, be it through GPO pricing and contract aggregation to create that advantage. And then you have hospital-based groups — and as we know, more and more physicians coming out of their residencies and fellowships are choosing to be employed by hospital systems, because it's taking the pressure off of them having to start a business, grow a business themselves, grow a patient base.
So what we're seeing is this growth of super systems, be it physician-led or hospital-led or private equity-led, and I think that's really what we're gonna continue to see over the next 15 to 20 years in healthcare. I've always been a big champion of the independent practice, and I still am, but I think without creating some sort of safety net for those practices, it's gonna be very hard to coexist with these larger systems as they develop and grow.
[00:05:17] Joe: Yeah. So take me back to some of the major operational wins that you've had, your time at Spire within these groups, to maintain that balance of that nimbleness, that independent type thinking, to be able to really own and establish your place within a given market, given all of the competitive dynamics, the consolidation on the health system side.
Tell me a little bit about what are some of the highest leverage things that you were a part of at your time at Spire, and tell me the story about how those came about.
[00:05:47] Jarett: Yeah. I think first and foremost, be it Spire, be it any sort of major aggregator of physician talent, you want to make sure that you're incenting your physicians appropriately by giving them the clinical autonomy and the ability to make the decisions on the things that really matter to them. Who's their PA in their clinic with them?
How are they retaining and keeping the staff that's valuable to them? How are we helping to drive patients to their practice, marketing effectively for them? And outside of the nine to five of what it is to be a physician — and sometimes the five to nine on the other end when they're stuck in ORs late at night and away from their family — they want everything else made facile for them.
So I think the MSO's responsibility is to really drive that infrastructure which doesn't impact the patient care, which doesn't impact how the physicians feel about their practice week in and week out. They care that they get paid, but they certainly don't care about the structure behind the RCM processes.
They care about making sure that the braces, in the case of orthopedics, that we're putting on patients are safe and stable and are gonna create the support that the patients need. But the name on the Velcro, that doesn't necessarily matter as much. So taking advantage of the wins where products or processes are commoditized, and being able to drive down and reduce costs in those areas, is really where these private equity and private practice aggregators are excelling these days.
And again, that's a huge opportunity compared to what many independent small practices are able to do on their own independently as they negotiate with various vendors in the products or medical supply spaces. So making sure that what matters to the physician stays local and relevant is hugely important, and I think is for the most part adopted by most of these MSOs irrespective of what the financer is behind it.
[00:07:41] Joe: Yeah. So what was your approach to really maintaining and driving new patient volume? Because I don't know the exact history of how practices join this Spire group, but I know from previous conversations with an approach like this, there is some of that local brand. If it's not in the practice name, it's certainly in the physician name. I see you nodding your head.
And so that balance there is like, "Hey, we're gonna grow, we're gonna invest more." Where does that trust come from? How do you cultivate that over time?
[00:08:13] Jarett: Yeah, and again, I think many of these groups take a similar approach to what we did. We really focused on that local brand reputation. In some cases, these practices that are coming together under these MSOs have 20, 30, 40 years of local brand reputation in their markets. So to come in and put a new sticker on the window probably does more to injure brand, does more to confuse patients, than it really does to drive access.
And we were very cognizant of that, certainly. So all of the local brands, we accelerated the marketing for them. We were able to get them out in front of the PCPs more frequently. We were able to get them more commercial marketing efforts. We were able to increase the social media marketing for these doctors.
Because again, doctors wanna skate in their lane. They're not necessarily the best in front of a camera, or doing sound bites. But we worked with them to put together relevant content that mattered to them, that they could speak excitedly about, and we were able to leverage that out in the communities to help drive additional visibility for those physicians.
So keeping the brand, the physicians, and the access locally relevant was super important to us. I think for most groups over time, as you aggregate, the goal is to make a slow progression to a centralized branding, and I think that makes a lot of sense at a certain scale. But early on, as many of these groups currently are — the 19 plus that are private equity backed and the three or so that are physician owned — right now the local brand certainly trumps what can be done centrally.
[00:09:50] Joe: Yeah. You talked earlier about this — you didn't say hidden, but kind of this hidden infrastructure layer, in terms of the docs don't really care what name is ultimately on the Velcro. Is there any, from a technology standpoint, centralization? What's the centralization playbook there? Do you try to get everybody on the same EHR or the same this or the same that, to where you're able to develop, for lack of a better word at the corporate level, a pulse of data across these practices to say, "Hey, in this market we need to really up our marketing spend," or, "Hey, in this market there's bottlenecks in this aspect of access or care"?
What does that playbook look like in terms of the maturation of centralization, if that seems to be a central part of the value prop that banding together as an MSO or a PE-backed roll-up works?
[00:10:39] Jarett: No question. And I think it starts with data aggregation, irrespective of day zero having all groups on the same EHR or same set of systems. You have to have a repository where you're able to extract all of the local data to be able to collate it effectively, be able to compare like entities across a variety of different content areas.
RCM performance, physician throughput, surgical conversion rates. I mean, if there's a metric that can be assigned, you should be trying to collect it and leveraging it going forward. And that data is infinite in terms of its application.
It's applied on the local level to help motivate and keep consistency across your physician base in terms of what's a reasonable expectation for patients to be seen in a clinic and deliver safe and effective care. It might be utilized with the payers as you're negotiating a contract to say, "Hey, look at our outcomes, scores, and studies that we're able to drive centrally here."
It might be used in marketing ploys — X number of patients treated successfully for this condition. And so you need to pull all of that data somewhere centrally. And then I think once you've done that, then just best business practices to create those synergies and to be able to reduce the costs is ultimately what you're trying to look for when you put together these centralized programs — things like EHR, telephony systems, IT and cybersecurity.
And while we're not interested necessarily in reducing headcounts anywhere, we certainly want to align the individuals. So if you have a marketer internal to each of the practices, an HR representative internal to the practices, you wanna get on one set of standards that you're driving across those businesses locally.
So again, the more you can centralize, the more you can create consistency in the framework and the architecture, the better the local businesses are gonna feel supported and perform. And ultimately, that's really attractive then to future practices wanting to come into the MSO.
[00:12:40] Joe: Yeah, that's where I was heading next — future practices coming into the MSO. Because I'm sure there's gonna be hesitation across a variety of things. But when you do bring in a new practice and you're beginning the rollout, what are the key data points that you are paying attention to that you perhaps have already created standards around?
Where are you starting? What are you paying the most attention to at the outset versus maybe later down the road?
[00:13:07] Jarett: Yeah. I'm gonna reframe that question just a little bit, because I think what's really important for new groups that are joining an MSO is to feel that while they're coming into a system, and that system may be preordained, that you're not swallowing an elephant as that new physician group — taking on a brand new EHR and a new system of marketing and a new set of FTEs that are gonna be weighing in on your metrics and your performance.
I think you wanna still kind of eat that elephant bite by bite. And so I think you put together a really good strategic roadmap of how you're onboarding a physician group, and I think it's stepwise progressional, and it's over the course of typically somewhere between six months and a year, so it's digestible for the physician group.
And it starts again with being able to extract their data, because then you can reflect that data mirrored back to them to be able to say, "Hey, here you are compared to your peers and within the rest of the organization." But you never wanna use that as the stick. You wanna use it as a starting point for, "Hey, let's have a conversation about how you're performing on surgical conversion rate compared to people who are also 10 years into practice, like in class."
In terms of patient outcomes data versus your peer class that's performing the same set of total knee, total hip surgeries — that we're trying to get to a best-in-class center of excellence level. But in that early stage, I think you want to be upfront with whoever you're onboarding as a new practice.
I think you want to be very clear in terms of the deliverable timelines. You want to be able to tell them exactly what that roadmap and process looks like and who's gonna help support that transition. Nobody should ever feel like they're in the lurch, because how they come into the group is gonna set the tone for what kind of participant they're gonna be when they are homogenized within the infrastructure. And again, we want best in class, but to do that, you need your physicians aligned and best players.
[00:14:59] Joe: Yeah. So when it goes wrong, which inevitably it will in some ways, what are usually the top things to be looking out for, if you are looking to grow by either joining a group or creating one of your own, to unlock some of the benefits that we talked about earlier in the conversation?
[00:15:14] Jarett: Yeah. I think the first is alignment and rightness of fit. If you are out looking for a strategic partner — be it private equity, be it hospital, be it other physicians that are like-minded — much like when you were going to college and you walked on the college campus and you said, "I could see myself there."
There is a little bit of a feeling about trusting the suitors, trusting the system that's been created, and just feeling like, yeah, my group could assimilate into this world, and we could be really confident we're gonna have successful outcomes and be happy in this new world. Again, a lot of physicians who have started their own practices or built large groups on their own — that giving up of some level of control, be it entire control, or even just the feeling of some of the decision-making that historically always rested on their shoulders, can be somewhat daunting.
So you wanna make sure that you have absolute and complete trust that as you're coming into a new organizational structure, that you are going to be taking care of your people that you have historically treated and taken care of, and as well taking care of your partners.
So that's the first piece. I think the second piece is just to be mindful of the healthcare ecosystem that's currently out there and maybe what some of the perceptions are. In different markets, there have been different responses to hospital infrastructure versus for-profit hospital versus private equity versus some of these larger aggregated groups coming together.
I think you should know who your partners are and how they're perceived out there in that healthcare ecosystem, because it will matter — we all work interchangeably. It doesn't matter if you're a private equity-backed group of independent physician practices, ultimately you're gonna have local affiliations with hospitals. You're gonna need access to surgical centers. You're gonna need access to laboratory. And so you wanna know that the team you're coming together with is well thought of in the communities in which you work, which is gonna expand and extend your brand reputation, not injure it.
And then the last thing is, you should have some foresight as to what you want to gain from this partnership — not just for the short term, but for the long term. Because many groups that are coming together, the average age of the physician population may be in their mid to late 50s, but you have to think about what that succession plan is gonna look like as you start onboarding new physicians coming out of fellowship in their early to mid-30s.
And is it sustainable for them long term? Because if it's not, then there's a life cycle and end to the MSO even at its scale. And so I think those three factors are really important, both in the preliminary phase of joining a larger MSO, to make sure that it's right for the local business, but also right for the partner you're eventually joining.
[00:17:54] Joe: What's next? You've had a very successful career at Spire. You're maybe looking and working on what's next for Jarett. So I'm curious what you wanna share, or what you've been thinking on, what you've been working on.
[00:18:08] Jarett: I mean, I'm a lifelong healthcare executive. I see no reason why that's not gonna be where my career ends over the next 15 to 20 years. I care about the system. I care about the mission behind why we do what we do. I used to always joke with our physicians that we could open a McDonald's and probably make money.
But at the end of the day, we're in this business because the mission is clear. It's about taking care of our parents and our children, and setting the tone for other people to get the care that they need and deserve. And look, we've all been patients. It is hard out there financially for people.
Healthcare is not viewed in the best light, probably in the last 10 or 15 years. You don't have to look far in the news to hear about insurance companies and fraud and abuse and waste, and maligned physicians and Medicare fraud. And you're not really hearing about what really matters, which is who's taking care of the patients that come through the ER on a free care basis because they broke a bone in their ankle and they need it fixed.
And at its core, I believe all the people that are still tied to healthcare on the provider side believe in that mission, even though sometimes they feel a little browbeaten. And I think on the executive side, it matters to have that empathy and that care too. And so I can't think of another industry I'd want to be in.
I know that there's a lot of growing interest from groups that are out there that are Spire-like on the MSO side and various subspecialties. And so right now, I'm gonna await my suitors, but I know that in the interim, I'm gonna enjoy the time I'm having with my family and enjoy the beautiful weather we're getting this summer, and I'm sure we'll find a landing spot shortly.
[00:19:47] Joe: Jarett, I appreciate the time and I appreciate the wisdom. Thank you so much for being on the show.
[00:19:51] Jarett: Joe, thanks for hosting. Really appreciate it.
[00:19:53] Hey, it's Joe. Thanks for listening. If you like what you hear, share with the peer, and if you're looking to scale referral operations to drive growth and efficiency, visit hatchcare.com.