Latest / Becker’s Healthcare Podcast / The Price of Silence and the Future of Spine Surgery with Dr. Morgan Lorio

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The Price of Silence and the Future of Spine Surgery with Dr. Morgan Lorio · Becker’s Healthcare Podcast

0:00
This is Carly Beam with the Becker Spine
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and Orthopedics podcast, and I'm thrilled to be
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joined today by doctor Morgan L'Oreal, a spine
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surgeon and past president of the International Society
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for the Advancement of Spine Surgery.
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He's been keeping a close eye on all
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the latest policy shifts happening in health care
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and specifically how they relate to spine care.
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So I'm really excited to to discuss with
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him today. Doctor L'Oreal, thank you so much
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for being here.
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Thank you for having me, Carly.
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And so before we kick things off, if
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you could just introduce yourself and share a
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little bit more about your background.
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I'm Morgan Lorio. I'm an orthopedic spine and
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hand surgeon. I've been working,
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for decades now with, ISAS,
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chairing the coding and reimbursement task force
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and,
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very
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much involved with what's happening in policy,
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nationally.
0:52
Great. And today, we're discussing your recently submitted
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analysis titled the price of silence, and it
0:58
this takes a really hard look at reimbursement
1:01
policy,
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consolidation,
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and the future of spine surgery as a
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whole. To start off, can you just tell
1:06
me about what compelled you to write this?
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Okay.
1:10
Well, this piece was written out of necessity,
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not theory.
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In other words, I felt compelled to break
1:17
a silence that policy
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has enforced for years.
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I should also say this clearly at the
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outset that this article,
1:25
which is now in press at the International
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Journal of Spine Surgery,
1:30
was authored in part
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as a direct response to the send help
1:33
committee's current request
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for input on AMA CPT codes.
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Mhmm. I felt it was important that this
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analysis exists in the public record while those
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discussions are actively underway now.
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Over the last twenty years, spine surgery has
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experienced a quiet but relentless evaluation of physician
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work,
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and the data now make that undeniable.
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Add the pandemic
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as an accelerant,
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and what we're seeing isn't cyclical pressure.
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It's structural transformation.
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I wrote this
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as a surgeon,
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not as an economist.
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Someone who lived through COVID,
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nearly died from it, and woke up to
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a profession that no longer resembled
2:19
the one I entered.
2:21
Yeah. And in your paper, you cite this
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nearly 34%
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inflation
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adjusted decline in Medicare reimbursement for some of
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the most common spine procedures since, 2,000.
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Can you talk more about what's driving this
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erosion?
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Certainly.
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Well, the short answer is budget neutrality
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without reality testing.
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When CMS
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insist
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that the pie is fixed,
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any upward adjustment
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must be offset elsewhere,
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often from procedural medicine.
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Budget neutrality
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doesn't control cost.
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It just decides who absorbs them.
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Surgeons, unfortunately,
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are the scapegoats.
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There's been no meaningful cost of living adjustment
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since 2001.
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While practice costs have risen more than 60%,
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What's framed as efficiency is in practice,
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systematic attrition.
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What's being sold
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as efficiency,
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cost savings, streamlining,
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optimization,
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modernization
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has the real effect of gradually eliminating
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people,
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capacity,
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and function
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rather than genuinely improving performance.
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It doesn't make the system work better.
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It makes the system smaller by quietly
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wearing it down.
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In this case,
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efficiency is just attrition with better branding.
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Rome didn't collapse from lack of manpower.
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It collapsed when experience was replaced with cheaper
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substitutes.
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That's not efficiency.
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That's slow
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institutional
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decay.
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Yeah. And you're kind of hooking on what
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you're saying about efficiency. I know you are
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particularly critical about CMS's 20 '26
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efficiency adjustment.
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Can you just kind of dive in deeper
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on why that's such a red flag?
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Yeah. Well, because it breaks a foundational
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assumption.
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This is something we surgeons were taught and
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made to believe
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that physician work
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equals time times intensity.
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CMS is now assuming efficiency gains without observing
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actual clinical practice.
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Spine surgery, meanwhile, is becoming more complex.
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We have older patients with more comorbidities,
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and we're using minimally invasive techniques that require
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higher cognitive load.
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When time goes down
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and intensity goes up,
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only the time gets counted now, and the
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surgeon
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eats the rest.
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Got it. And, you know, I'm interested in
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kind of hearing more about how this is
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affecting,
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just kind of the employment landscape as well.
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You described this idea of the vanishing independent
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surgeon. And, you know, how significant are you
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seeing this shift?
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Well, Carly, it's historic.
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Fewer than half of physicians are now in
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private practice.
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Among physicians
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45,
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self employment dropped to roughly one third.
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Mhmm. This isn't about preference.
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It's about economic unsustainability.
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Administrative burden and pair leverage
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have made independence
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structurally unviable.
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Carly, I'm a slow learner.
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After two decades immersed in policy,
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I've come to understand that physicians didn't abandon
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independence.
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Policy made independence
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mathematically impossible.
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Got it. So it sounds like a real
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real frustration with the system and everything.
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And, you know, I was wondering, you know,
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your paper also
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focuses a lot on CPT governance and particularly
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senator Bill Cassidy's inquiry. Can you talk about
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why this matters to frontline surgeons?
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Well,
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because CPT is no longer just a communication
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tool.
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It's mandatory infrastructure.
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It's federally designated under HIPAA yet owned and
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commercialized by a private organization.
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That same ecosystem
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participates in valuation
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through the RUC,
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the relative value scale update committee.
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So when language,
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valuation, and revenue were intertwined,
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you create self reinforcing
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downward pressure on physician work.
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I'll try to provide an analogy.
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A vice grip requires someone to keep turning
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the screw.
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A pressure cooker tightens itself. In this case,
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once assumption replaces observation,
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the system applies downward pressure automatically,
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silently,
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continuously,
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and without accountability.
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Got it. And I like I like that,
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analogy you're using, the vice grip versus
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the pressure cooker.
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And, you know, I you mentioned earlier, this
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is also very deeply personal paper, and you
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talk about your own experience
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with surviving COVID nineteen and returning to this
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transformed profession.
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Could you talk about why your own perspective
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was really important to include in this paper?
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Okay. Well, because policy's never abstracted the people
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living under it.
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I survived a COVID nineteen coma, woke up
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to a system
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where physicians had become employees,
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not advocates.
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Burnout isn't just emotional. It's economic,
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moral,
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and physical.
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Burnout isn't a personal failure.
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It's what happens when professional obligation
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meets structural
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loss. Mhmm. Carly,
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this is something to chew on.
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Surgeons now carry the highest mortality risk of
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any physician group.
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That's not coincidence.
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Got it.
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And, you know, obviously,
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beyond physicians, this is all affecting
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patients
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as well. You make this argument that patients
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are experiencing a parallel illusion, this idea of
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coverage without care. Can you dive deeper into
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that?
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Well, Carly, we really been in the matrix
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literally.
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Patients technically have insurance, but access is mediated
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by delay, denial, and complexity.
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Physicians, meanwhile, technically have licenses
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but lack autonomy.
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That dissonance erodes trust on both sides of
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the exam table.
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Both
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are trapped in a system where the promise
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of protection
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is written in someone else's language.
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Protection
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here
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isn't safety in the live sense.
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It's administrative shelter granted conditionally
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and revoked silently.
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Protection is written as coverage,
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authorization,
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policy alignment, and quality metrics.
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It sounds like care, but it functions like
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distance.
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Someone else defined the threat, the remedy,
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and
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acceptable risk using a vocabulary the protected party
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did not create
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and cannot fully contest or even understand.
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What's protected
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is not the person or the profession,
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but the system's exposure, financial, legal, and political.
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For patients,
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protection becomes prior authorization,
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formularies,
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step therapy,
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ostensibly shielding them from harm, but often shielding
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payers from cost.
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Care is delayed or diluted in the name
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of safety.
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For professionals,
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protection becomes compliance.
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Guidelines replace judgment.
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Metrics replace meanings.
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And independence is traded for the illusion of
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security.
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Follow the rules and you'll be
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safe until the rules change without warning. In
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both cases,
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protection is externalized. It's not something you possess.
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It's something
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you're allowed to borrow. And because it's written
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in someone else's language, you cannot fully name
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what's actually at risk,
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dignity,
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vocation, trust, time, and moral agency.
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Those losses
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don't appear in policy text, so they're treated
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as accepted acceptable, collateral.
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That's the trap.
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A system that promises protection while quietly redefining
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what
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and who
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it's protecting against.
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Got it. And, know, you raised concerns about
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replacing physicians with nonphysician
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providers. Can you talk a bit about what's
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being lost in that transition?
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Okay. Well, experience,
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continuity, and accountability.
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When you have mid or late career physicians
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leaving early,
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they take with them clinical memory and judgment
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that cannot be rapidly reproduced.
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Substitution
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may increase headcount,
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but it does not restore expertise.
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A sustainable
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workforce strategy begins with retention,
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not replacement.
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You can replace labor faster
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than you can replace wisdom. Mhmm. And that
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gap is where patients get hurt.
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Yeah. And when it comes to reform, you
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you're very clear that incrementalism
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isn't enough.
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What does meaningful reform
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look like to you?
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Well, to name a few off the top
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of my head,
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transparency interrupt deliberations,
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valuation index to mean work, not the bottom
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quartile,
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restoration
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of a real cost of living adjustment tied
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to the Medicare economic index
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and a truly modernized geographic practice cost index
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that recognizes
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equal pay for equal work.
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If we paid physicians the same for the
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same work everywhere,
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we would stop driving experienced doctors out of
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underserved areas.
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Right now, the system does the opposite.
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And then it acts surprise
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when access
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disappears.
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And most importantly,
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recognition that professional autonomy itself
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is a quality metric.
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It's very well said. And then my last
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question for you, doctor L'Oreal, if there's one
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message you want policymakers
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and health system leaders to take away from
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this conversation, what is it?
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Well, kicking the can has been the strategy,
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and it's time that someone other than the
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surgeon paid the piper.
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Silence has been the most expensive code of
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all.
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Reimbursement reflects what society believes physician judgment is
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worth.
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And when that value collapses,
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something far greater than income is lost.
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These are policy choices,
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and because they are choices,
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they can be changed.
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Great. Well, doctor Lorio, thank you so much
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for joining us on today's podcast. Look forward
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to connecting again in the future, and I
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hope you have a great rest of your
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day. Thank you, Corley.