In a traditional private practice, the physician-owner is the final decision-maker on nearly everything. Clinical decisions and operational decisions live in the same room, and the same person can override both.
In an MSO partnership, those lanes separate and this is where many partnerships get tested early.
Most friction in the first year is caused by moments where the boundaries between clinical authority and business operations weren’t clear, documented, or followed consistently.
Lane discipline is the operating principle that keeps clinical judgment distinct from non-clinical management. When it works, operations become predictable and the practice can scale without clinical drift. When it breaks, you get “lane violations” and the MSO starts pressuring clinical decisions, or physicians start trying to micromanage operational systems.
Defining the Lanes
To prevent conflict, the lanes have to be defined in writing and reinforced in day-to-day behavior.
The clinical lane belongs to physicians. It includes clinical judgment and supervision, diagnosis and treatment, patient safety standards, clinical protocols, credentialing, peer review, and clinical quality.
Operational goals should not override patient safety standards or clinical decision-making.
The operational lane belongs to the MSO. It includes non-clinical staffing administration, payroll and benefits administration, billing operations support, scheduling systems, equipment purchase and maintenance, patient intake workflows, call center operations, marketing operations, technology infrastructure, vendor management, procurement, and facilities support.
The objective of the operational lane is predictability, efficiency, and consistent execution; without crossing into clinical control.
6 Common Collision Points
In theory, the separation is clear, but in practice, the lines can blur. Most friction shows up at the same intersection points where clinical preferences meet operational constraints. Here are 6 common collision points and what lane discipline looks like in each.
1. Scheduling Templates
The friction: A physician wants longer consult slots to ensure time for education and clinical judgment and the MSO sees unused capacity, long lead times, or backlogs that affect access.
The fix: The MSO brings data on capacity and output and the physician leadership defines the minimum clinical time required for safety and quality. Scheduling is then built around the overlap, clinical minimums plus operational efficiency, rather than one side’s preference alone.
2. Staffing Models
The friction: A physician wants a particular tech or front-desk person because “they work well with me" and the MSO is trying to standardize staffing levels based on volume and workflow needs.
The fix: The MSO owns staffing plans and staffing processes and the physicians own competency standards and clinical-facing requirements. In practice the MSO determines staffing structure and physicians help define what “qualified” means.
3. Marketing Operations
The friction: Physicians want marketing that emphasizes reputation and clinical identity and the MSO wants marketing that reliably generates demand and can be measured and improved.
The fix: The MSO owns channels, operations, spend, and reporting and physicians review clinical accuracy to ensure messaging stays within appropriate boundaries. Physicians should not be asked to run marketing and the MSO should not write medical advice.
4. Call Center Scripts and Intake Workflows
The friction: A practice has historically handled intake informally and the MSO introduces a more standardized intake process to reduce missed calls, improve conversion, and improve scheduling consistency.
The fix: Standardization is operational while triage rules are clinical. Operational staff can follow scripts, but the underlying rules, what requires urgent escalation, what can be scheduled, and what questions should be asked, should be defined by physicians.
5. Vendor Selection and Supplies
The friction: Physicians may prefer certain supplies or vendors based on familiarity. The MSO may want to consolidate purchasing and standardize vendors to reduce cost and improve reliability.
The fix: The MSO should present options and the operational implications (cost, availability, consistency). Physician leadership determines whether alternatives are clinically equivalent. If they are clinically equivalent, standardization usually makes sense. If something is clinically necessary, that should be documented, and the operational impact should be understood upfront.
6. Capital Equipment Decisions
The friction: A physician wants a new diagnostic device or surgical equipment and the MSO wants to ensure equipment decisions match actual utilization and a staged operating plan.
The fix: Equipment upgrades should be scoped and documented and the MSO evaluates utilization and operational feasibility. Physicians evaluate clinical necessity and quality implications. If the equipment is clinically essential, that should be clear and if it’s primarily a growth investment, it should be tied to a realistic plan, timing, and accountability.
A Simple Escalation Ladder
Even with good lane discipline, gray areas exist. A functional partnership needs a way to resolve disagreements without turning every issue into a crisis.
A practical escalation ladder looks like this:
Site-level discussion: Lead physician and operational lead review the issue against documented scope, budget, and existing protocols. Most issues resolve here.
Structured review: If unresolved, the issue is reviewed using the same inputs every time such as clinical necessity, operational impact, timing, and alternatives.
Documented decision: If a decision is made, the rationale and any constraints are documented so the issue doesn’t repeat every quarter.
The goal is not bureaucracy, it's consistency.
Why Boring Is Good
The purpose of lane discipline is to make operations predictable. When a surgeon walks into the clinic, they shouldn't have to wonder if supplies were ordered. And the MSO shouldn't have to guess whether a physician will bypass supply ordering protocols.
When both sides stay in their lanes, the practice becomes “boring” in the best way which is stable, predictable, and focused on patient care.
How Verdira Approaches This
Clinical decisions remain with physicians.
MSO scope is clearly defined in writing and tied to real services.
Governance is clarified before signing so expectations remain stable after close.
We build long-duration platforms and do not operate on forced exits.
If you’re evaluating an MSO partnership or successor role and want to sanity-check structure and expectations, we’re open to thoughtful conversations.
This article is for general educational purposes and is not legal advice.
