Latest / Becker’s Healthcare Podcast / Morgan P. Lorio, MD, FACS, Discusses Redefining Spine Care

Transcript

Morgan P. Lorio, MD, FACS, Discusses Redefining Spine Care · Becker’s Healthcare Podcast

• 0:02
  - The playbook for running a successful ASC in
• 0:04
  - 2026
• 0:06
  - looks almost nothing like it did a few
• 0:07
  - years ago.
• 0:08
  - And the one for 2029
• 0:10
  - probably won't look like this one either.
• 0:12
  - Case complexity is increasing. Payer models are shifting.
• 0:16
  - Technology is creating new possibilities
• 0:19
  - and new cost pressures at the same time.
• 0:21
  - The spine and orthopedic leaders who are staying
• 0:24
  - ahead aren't just keeping up with the changes.
• 0:27
  - They are in rooms where the changes get
• 0:29
  - talked about honestly. Becker's twenty third annual Spine
• 0:29
  - Orthopedic and Pain honestly. Becker's twenty third annual
• 0:32
  - Spine Orthopedic and Pain Management Driven ASC Conference
• 0:36
  - is such a space.
• 0:37
  - More than 1,000 attendees,
• 0:39
  - 275
• 0:40
  - plus physician and ASC speakers, three days of
• 0:43
  - programming across the clinical,
• 0:45
  - operational, and strategic
• 0:47
  - with CME credits available.
• 0:49
  - Join us June eleventh through the thirteenth. For
• 0:52
  - the agenda and event details, visit Becker's Hospital
• 0:55
  - Review and click on the events tab in
• 0:57
  - the upper right.
• 1:00
  - Welcome to the Becker Spine Podcast. Today, we're
• 1:03
  - discussing an important question facing modern spine care.
• 1:06
  - How do we better define the roles, responsibilities,
• 1:08
  - and handoffs between operative and nonoperative spine care?
• 1:11
  - Today's discussion is based on a recently published
• 1:13
  - paper defining spine care, a framework for scope,
• 1:17
  - standards, and bidirectional
• 1:18
  - transitions,
• 1:19
  - a collaboration between members of the International Society
• 1:22
  - for the Advancement of Spine Surgery and colleagues
• 1:24
  - from Charite University
• 1:27
  - of Medicine in Berlin.
• 1:29
  - The paper builds upon themes first explored in
• 1:32
  - doctor Morgan Loriaux's earlier reflection for ISAS,
• 1:35
  - navigating the future of spine surgery, a surgeon's
• 1:38
  - reflection on coding, reimbursement, and emerging technologies,
• 1:41
  - and expands those concepts into broader framework for
• 1:44
  - patient navigation,
• 1:45
  - accountability,
• 1:46
  - and care transitions across the spine care spectrum.
• 1:49
  - My guest today is doctor Morgan Laurio, an
• 1:51
  - orthopedic spine surgeon and past president of the
• 1:53
  - International Society for the Advancement of Spine Surgery
• 1:56
  - and one of the paper's coauthors.
• 1:58
  - Doctor L'Oreal, tell us a little bit about
• 2:00
  - yourself and how that evolution occurred.
• 2:03
  - Okay. Well, thank you, Laura.
• 2:05
  - I'm Morgan L'Oreal, an orthopedic spine surgeon, past
• 2:08
  - president of ISAS, and currently an advisory board
• 2:11
  - member of the American Academy of Interventional Spine
• 2:14
  - and Neuromodulation.
• 2:17
  - I think evolution is exactly the right word.
• 2:20
  - In my earlier reflection for ISAS,
• 2:22
  - Navigating the Future of Spine Surgery,
• 2:25
  - I discussed how reimbursement policy,
• 2:27
  - administrative requirements,
• 2:29
  - emerging tech, and changing care models were increasingly
• 2:32
  - influencing
• 2:33
  - how patients access spine care and thus move
• 2:36
  - through the health care system.
• 2:39
  - What began as a discussion about coding, reimbursement,
• 2:41
  - and innovation
• 2:43
  - gradually
• 2:44
  - evolved into a much larger question.
• 2:47
  - How do we create a spine care system
• 2:50
  - that consistently gets patients
• 2:52
  - to the right expertise
• 2:54
  - at the right time.
• 2:57
  - Through ongoing discussions with colleagues within ISAS and
• 3:00
  - our collaborators at Charite in Berlin,
• 3:02
  - including Doctor. Kiley Wendrowski,
• 3:05
  - Frederick Schoemig,
• 3:06
  - Matthias Pumburger,
• 3:07
  - and Alex Vaccaro,
• 3:09
  - it became clear that the central challenge was
• 3:11
  - not simply surgery,
• 3:13
  - nonoperative care,
• 3:14
  - technology,
• 3:15
  - or even reimbursement.
• 3:17
  - Each of those factors influences behavior within the
• 3:20
  - health care system. As reimbursement pressures increase
• 3:24
  - and administrative requirements grow, clinicians
• 3:27
  - and organizations naturally focus on sustaining
• 3:30
  - their practice
• 3:31
  - and serving their patients.
• 3:33
  - The challenge is ensuring that despite those pressures,
• 3:37
  - patients continue to move efficiently
• 3:39
  - to the right expertise
• 3:41
  - at the right time.
• 3:43
  - The central challenge was transition reliability.
• 3:47
  - The paper we're discussing today
• 3:49
  - represents the maturation of all those earlier ideas
• 3:52
  - into a practical framework
• 3:54
  - for addressing
• 3:55
  - that challenge.
• 3:57
  - Throughout my career, I worked alongside surgeons,
• 4:00
  - pain docs, physiatrists,
• 4:02
  - primary care providers,
• 4:03
  - payers, and policymakers.
• 4:05
  - Over time, it became clear to me that
• 4:08
  - many of the biggest challenges in spine care
• 4:10
  - are not technical problems.
• 4:12
  - Patients generally do well when they reach the
• 4:14
  - right expertise at the right time. They struggle
• 4:17
  - when those transition breakdowns.
• 4:20
  - A fragmented pathway
• 4:21
  - can make even the most excellent clinicians look
• 4:24
  - ineffective.
• 4:26
  - That realization
• 4:27
  - led to this paper, which asked a simple
• 4:30
  - question.
• 4:31
  - How can we create a more reliable,
• 4:35
  - coordinated,
• 4:36
  - and patient centered
• 4:37
  - spine care continuum?
• 4:41
  - Well, that's powerful framing.
• 4:43
  - If you had to distill this entire paper
• 4:45
  - into one sentence, what would it be?
• 4:47
  - Well, the problem in modern spine care is
• 4:49
  - often not the treatment.
• 4:51
  - It's the transition.
• 4:53
  - Patients are not necessarily failed because we lack
• 4:55
  - treatment options.
• 4:57
  - They're they're often failed because they move through
• 4:59
  - fragmented pathways
• 5:01
  - without clear decision points,
• 5:04
  - shared language, or accountable handoffs.
• 5:09
  - Why is this conversation so important right now?
• 5:13
  - Well, imagine a patient who spends eighteen months
• 5:16
  - moving from provider to provider,
• 5:19
  - receiving imaging, therapy, injections, and consultations,
• 5:23
  - and yet never receives a clear answer about
• 5:25
  - who
• 5:26
  - is coordinating their care?
• 5:29
  - That's not necessarily a failure of any one
• 5:31
  - clinician.
• 5:32
  - It's often a failure of transitions.
• 5:35
  - And that's why this conversation matters.
• 5:37
  - Spine care has become increasingly specialized and increasingly
• 5:41
  - fragmented.
• 5:42
  - Patients move through primary care, physical therapy, pain
• 5:45
  - management, physiatry, imaging centers,
• 5:48
  - surgical practices,
• 5:49
  - utilization management systems, and payer requirements
• 5:52
  - before reaching a definitive answer.
• 5:56
  - Each component may function well individually,
• 5:58
  - but without reliable transitions, patients
• 6:01
  - can't experience they can experience duplication,
• 6:04
  - delay,
• 6:05
  - confusion, and prolonged disability.
• 6:08
  - The challenge
• 6:09
  - is no longer simply whether surgery works or
• 6:12
  - whether nonoperative care works. The challenge is whether
• 6:15
  - patients can reliably move
• 6:17
  - between those domains at the right time,
• 6:20
  - for the right reason, and with clear accountability.
• 6:23
  - Patients don't experience health care specialties.
• 6:26
  - They experience it as a journey.
• 6:29
  - Part of the reason has become so important
• 6:31
  - is that the continuum itself has expanded.
• 6:34
  - We now recognize vertebralgenic
• 6:36
  - pain, discogenic pain,
• 6:38
  - sacroiliac disorders,
• 6:40
  - neuromodulation,
• 6:41
  - and other restorative interventions that sit
• 6:43
  - between traditional pain management and traditional surgery.
• 6:47
  - That's good for patients, but every new option
• 6:50
  - creates new decision points, and every new decision
• 6:53
  - point creates another opportunity for transition failure.
• 6:59
  - That's fascinating to hear about. I know some
• 7:01
  - people hear the discussion and assume that it's
• 7:04
  - about defining who should or should not perform
• 7:06
  - certain procedures.
• 7:07
  - Is that what this paper is about?
• 7:10
  - No. The purpose of the paper is not
• 7:12
  - to redefine or restrict
• 7:15
  - any specialty scope of practice. The purpose is
• 7:17
  - to improve transition reliability.
• 7:19
  - Whatever the entry point into the system, patients
• 7:22
  - benefit when expectations, accountability,
• 7:25
  - communication, and handoffs are clear.
• 7:27
  - The goal is not to determine who owns
• 7:30
  - the patient.
• 7:31
  - The goal is to ensure the patient never
• 7:33
  - becomes lost between providers.
• 7:37
  - So this isn't really a paper about surgery
• 7:39
  - versus nonoperative care?
• 7:41
  - Exactly.
• 7:42
  - That's the wrong debate.
• 7:44
  - This paper isn't advocating for more surgery or
• 7:46
  - less surgery.
• 7:47
  - It's advocating for a better orchestration of care.
• 7:51
  - Nonoperative care is essential, and surgery is essential
• 7:54
  - when appropriately indicated.
• 7:56
  - But the value of either depends on whether
• 7:58
  - patients can move between them at the right
• 8:00
  - time for the right reason, the right accountability.
• 8:04
  - The future of spine surgery is not choosing
• 8:06
  - between spine surgery and pain management. It's integrating
• 8:10
  - them.
• 8:12
  - I know the paper uses the phrase bidirectional
• 8:15
  - care transitions.
• 8:16
  - What does this mean in
• 8:18
  - practical terms?
• 8:19
  - Well, it means the handoff has to work
• 8:22
  - both ways.
• 8:23
  - A patient can begin with physical therapy,
• 8:26
  - rehabilitation,
• 8:27
  - pain management, medications or injections.
• 8:29
  - And if there's a progressive neurologic deficit,
• 8:32
  - we can corded imaging findings, instability, deformity of
• 8:36
  - failure
• 8:37
  - of a structured treatment plan. There should be
• 8:39
  - a clear trigger for surgical evaluation.
• 8:43
  - But the reverse is equally important.
• 8:46
  - If a surgeon evaluates a patient and there's
• 8:48
  - no surgical target,
• 8:50
  - the patient shouldn't feel abandoned.
• 8:53
  - There should be a reliable return pathway back
• 8:56
  - to rehabilitation,
• 8:57
  - pain management, behavioral support, rehabilitation,
• 9:00
  - or long term functional restoration.
• 9:02
  - Every handoff
• 9:04
  - is actually a clinical intervention.
• 9:07
  - Patients don't care
• 9:08
  - where the handoff occurs.
• 9:10
  - They care whether it occurs.
• 9:15
  - So the goal isn't escalation. It's appropriate rooting.
• 9:19
  - Precisely. The goal is purposeful movement through the
• 9:22
  - system. The future of spine care is not
• 9:24
  - simply better procedures, it's better navigation.
• 9:27
  - We wanna avoid two failures. One is premature
• 9:29
  - surgery without a clear anatomical or biomechanical
• 9:32
  - target. The other is endless conservative care without
• 9:35
  - reassessment,
• 9:36
  - where patients cycle through repeated interventions while disability
• 9:40
  - persists.
• 9:41
  - Both are low value care. The shortest path
• 9:44
  - to value
• 9:45
  - is not the least expensive path. It's the
• 9:48
  - path that gets the patient to the right
• 9:49
  - expertise sooner. The solution isn't ideology.
• 9:53
  - The solution is structure.
• 9:55
  - Yeah. The the paper talks about rules of
• 9:57
  - engagement. What does that mean?
• 9:59
  - They're actually very practical. First, define the roles
• 10:02
  - and accountability.
• 10:03
  - Second, make care episodes goal directed and time
• 10:06
  - bound.
• 10:07
  - Third, standardized procedural language.
• 10:10
  - Fourth, create explicit handoff triggers. And finally, establish
• 10:14
  - accountability for interventions that may have durable
• 10:17
  - biomechanical
• 10:18
  - consequences.
• 10:19
  - The objective is clarity, not control.
• 10:22
  - The goal is to ensure patients know where
• 10:25
  - they are in the process,
• 10:28
  - who is responsible for the next step,
• 10:31
  - and when a transition should occur.
• 10:36
  - That idea of accountability seems central to the
• 10:38
  - paper. Why?
• 10:40
  - Because some interventions don't simply relieve symptoms. They
• 10:42
  - may alter biomechanics
• 10:44
  - and create downstream consequences.
• 10:47
  - When an intervention
• 10:48
  - carries foreseeable need for rescue, revision, or long
• 10:51
  - term accountability, the pathway should include someone trained
• 10:54
  - to manage those consequences.
• 10:57
  - That's not about turf.
• 10:59
  - That's about patient safety.
• 11:01
  - Accountability
• 11:02
  - should follow consequence.
• 11:06
  - One thing that struck me while reading this
• 11:08
  - paper is that it seems less like a
• 11:10
  - clinical guideline and more like a blueprint for
• 11:13
  - coordinated care. Is that fair? I I think
• 11:15
  - that's exactly right. This isn't a paper about
• 11:18
  - proving that one treatment is superior to another.
• 11:20
  - This is not a surgery paper. This is
• 11:22
  - a system
• 11:24
  - engineering paper.
• 11:25
  - Historically,
• 11:26
  - we focused on whether surgery works or whether
• 11:29
  - nonoperative
• 11:30
  - care works. And those are important questions, but
• 11:33
  - increasingly,
• 11:34
  - the larger opportunity may be found in how
• 11:36
  - patients move between those domains.
• 11:38
  - The paper argues that high performance spine care
• 11:41
  - depends on clear decision points, shared accountability,
• 11:44
  - standardized language, and reliable
• 11:47
  - bidirectional
• 11:48
  - transitions. In many way,
• 11:50
  - the future of spine care may be defined
• 11:52
  - less by new procedures
• 11:54
  - and more by
• 11:56
  - how effectively we
• 11:58
  - coordinate existing expertise
• 12:00
  - across the continuum of care.
• 12:04
  - What does this framework mean for patients?
• 12:07
  - Well, patients should know three things. Who is
• 12:09
  - leading the care?
• 12:12
  - Why a treatment is being performed?
• 12:14
  - And what happens next
• 12:16
  - if that treatment succeeds or fails.
• 12:19
  - Patients shouldn't have to navigate a fragmented spine
• 12:22
  - care system on their own.
• 12:24
  - Better spine care begins when op and when
• 12:26
  - those transitions are reliable,
• 12:28
  - patients are more likely to reach the right
• 12:29
  - expertise
• 12:30
  - at the right time.
• 12:34
  - That makes sense. So in many ways, this
• 12:36
  - is a systems paper. Exactly. If we can
• 12:39
  - make the interface between operative and nonoperative care
• 12:41
  - reliable,
• 12:43
  - transport transparent,
• 12:44
  - and accountable,
• 12:46
  - we can improve value, safety,
• 12:48
  - patient trust, and, ultimately,
• 12:51
  - outcomes.
• 12:53
  - You've served in a leadership position across organized
• 12:56
  - spine surgery. What is one thing that you've
• 12:58
  - learned from that experience?
• 13:00
  - Well, I've come to believe that the future
• 13:02
  - of spine care will be determined
• 13:04
  - less
• 13:05
  - by what procedure we perform
• 13:08
  - and more
• 13:09
  - by how well we coordinate the patient's journey
• 13:12
  - to that procedure
• 13:14
  - or away from it.
• 13:15
  - After years of working with surgeons, payers, policymakers,
• 13:19
  - multidisciplinary
• 13:20
  - providers, I've realized that being the biggest problems
• 13:22
  - in spine care are not technical problems,
• 13:25
  - they're navigation problems.
• 13:27
  - When I entered practice, the central question was,
• 13:30
  - does this patient need surgery?
• 13:32
  - Today,
• 13:33
  - the the more important question may be, where
• 13:36
  - is this patient on the con continuum,
• 13:38
  - and what
• 13:40
  - is the next best intervention?
• 13:42
  - That
• 13:43
  - is a fundamentally different way of thinking about
• 13:45
  - spine care.
• 13:46
  - The problem is not the people.
• 13:49
  - The problem is the pathway.
• 13:51
  - Value is not created by denying care. It's
• 13:53
  - not created by delaying care, and it's not
• 13:55
  - created by forcing patients through more steps.
• 13:58
  - Value is created when the right patients reaches
• 14:00
  - the right expertise at the right time.
• 14:03
  - Policies, payment systems, and clinical pathways should support
• 14:06
  - clinically intelligent transitions,
• 14:08
  - not obstruct them.
• 14:12
  - Oh, wow. That that's incredible. Final question. If
• 14:15
  - listeners remember the conversation in a nutshell, what
• 14:18
  - would you want it to be?
• 14:20
  - Well, patients are not lost because we lack
• 14:23
  - treatments.
• 14:24
  - They're lost
• 14:25
  - because we lack reliable pathways between them.
• 14:28
  - And when those pathways break down, trust can
• 14:30
  - erode. The doctor patient relationship can suffer, and
• 14:34
  - even the most excellent clinical
• 14:36
  - clinician
• 14:37
  - can appear ineffective.
• 14:39
  - The problem is not the people. The problem
• 14:42
  - is the pathway. As the spine care continuum
• 14:45
  - continues to expand,
• 14:46
  - stewardship becomes increasingly important.
• 14:49
  - For decades, we've defined spine care by what
• 14:51
  - we could remove,
• 14:53
  - decompress,
• 14:54
  - stabilize, or fuse.
• 14:56
  - Increasingly now, we are defining spine care by
• 14:58
  - what we can restore.
• 15:01
  - The future of spine care is simply not
• 15:03
  - better procedures.
• 15:04
  - It's better stewardship of pain across the entire
• 15:07
  - continuum of care.
• 15:08
  - The problem is the transition,
• 15:10
  - and the opportunity
• 15:12
  - is the continuum.
• 15:15
  - A perfect end. Doctor L'Oreal, thank you so
• 15:17
  - much for joining us. Thank you, Laura, for
• 15:19
  - this opportunity.
• 15:21
  - And thank you to our listeners. This has
• 15:23
  - been a conversation about redefining spine care, not
• 15:26
  - by choosing sides, but by building better bridges
• 15:28
  - across the continuum.
• 15:30
  - The future of spine care may not depend
• 15:31
  - on choosing between surgery and nonoperative treatment. It
• 15:34
  - may depend on how effectively we can connect
• 15:36
  - them. Until next time. Thanks for listening.