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This is Carly Beam with the Becker Spine

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and Orthopedics podcast. And today, we have two

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wonderful guests.

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Both are experts not only in spine surgery,

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but also just understanding

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health care policy.

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Thank you both for joining us, and can

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you introduce yourselves?

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Thank you, Carly. I'm Morgan Lourio. I'm past

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president of ISAS and, chair emeritus for the,

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coding and reimbursement task force.

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Carly, my name is Kylie VanDofsky. I'm an

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orthopedic spine surgeon in Tucson, Arizona. I'm affiliated

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with the University of Arizona,

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and I'm active with Morgan Loria under the

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ISOS umbrella.

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Great to have both of you on. And

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doctor Loria, I wanna start with you of

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their questions.

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So one of the things I really want

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to discuss with both of you is CMS's

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rural transformation

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model and patient access. And to start, doctor

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L'Oreal,

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why is this conversation so timely

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right now?

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Okay, Carly. Well, this isn't about a scope.

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It's about whether patients can access spine care

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where they live.

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If rural patients have to drive four hours

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for a sixty minute decompression,

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then the system is misaligned.

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Bread and butter spine surgery should be local.

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Sustaining community based private practices

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and complex revision strategies should remain in tertiary

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care centers.

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That's how access and expertise

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coexist.

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Got it. And then, you know, doctor Lewandowski

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want to pivot slightly, and all everything that

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we're talking about right now is gonna converge

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by the end of this podcast. But doctor

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doctor Lewandowski

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want to raise a point of interest,

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with, endoscopic

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decompression.

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Clinic clinically speaking,

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would you say endoscopic decompression is mature enough

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to scale?

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Absolutely, Carly. We spent the last ten, twelve

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years

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developing clinical evidence on the

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application of the endoscopic minimally invasive decompression in

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an outpatient setting. We worked up

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the patient selection criteria. We we published clinical

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protocols.

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Come to find out thinking that was the

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most significant hurdle in terms of insurance authorization,

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but it actually wasn't.

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Yeah. Are

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performing the, endoscopic surgery now, and,

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we've done some survey work that revealed that

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the main hurdle is actually logistical

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and implementation.

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Can you dive deeper into that? This idea

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that the barriers

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implementation,

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and what can surgeons

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do to address that?

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We developed some content to help surgeons with

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the discussions locally in the Wilson Surgery Center.

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But what it comes down to is that

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the cost for the capital equipment is high.

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The endoscopes have, high maintenance costs. They don't

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last that long. They last on average

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35 to 50 surgeries, then they're essentially broken.

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So when you look at all the hidden

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costs,

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which include sterilization,

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reprocessing,

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cleaning,

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they sound like trivial issues, but for small

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surgeons in it, they can turn into real

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problems where they just don't have the staffing

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to, process these scopes on time so that

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this ASC can can make money.

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In a hospital setting, it's it's similar. You

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may be competing with other service lines,

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that

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are racking up costs. So

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integrating the endoscopic

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technique platform is not as trivial, and we've

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learned that from

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multiple service studies that we've done nationally and

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internationally.

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Got it. And thank you for breaking that

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down. And, you know, turning back to you,

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doctor Lorio,

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I wanna pick your brain about this idea

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of access

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fragility. Can you talk about what that looks

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like in real life and why it happens

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to begin with?

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Well, when a spine surgeon leaves a rural

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region,

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care doesn't get delayed. It vanishes.

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A procedure doesn't,

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improve access if it can't fit

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inside the building.

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And can you talk more,

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on

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just kind of what's driving this issue?

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Well, transformation isn't about expanding benefits. It's it's

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about making delivery viable.

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And, rural hospitals don't fail because surgeons lack

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skill.

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They fail because systems lack margins.

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Got it. And doctor Lewandowski, I'd love to

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hear your, perspective on, you know, what's making

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delivery so challenging

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operationally.

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One of the problems, Carly, that we run

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into consistently is

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the endoscopic

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protocol requires

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a targeted diagnostic workup. And, again, we published

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this. It's,

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discoverable in the Journal of Personalized Medicine. There

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are two articles

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that detail how that's being done.

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But it comes down to a lack of

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insurance authorization

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for a diagnostic injection right in the first

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visit.

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Mhmm. The criteria

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for surgical indication

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are not accurate enough to determine what the

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pain generators are.

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Mhmm. And a diagnostic injection is critical in

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determining that to make the case for medical

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necessity for intervention.

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So there's delays

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with formulating a treatment plan that actually will

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work within the framework of a local ASC

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or or hospital setting.

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Yeah. And then, you know, kind of circling

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back to what you're talking about a bit

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earlier about

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endoscopic

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spine, doctor Lundrowski,

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what what actually changes with disposable

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HD endoscopy?

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What basically

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takes place, the cost has been

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shifted out of the ASC. So instead of

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having to buy

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capital equipment on the order of several $100,000,

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you're bringing in a low cost system

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that is able to compete

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with the traditional

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reprocessable

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endoscope

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on a technology level. We now have

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chip on tip camera systems that have high

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resolution,

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four k HD, for example,

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then that comes sterilely packed. So the whole

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processing chain,

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sterilization cleaning

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is eliminated,

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and the equipment essentially arrives in the peel

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pack.

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Then that is something that works really well

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for low volume sites

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that are trying to see,

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does this even work for our local payer

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mix? What is the patient volume? So there's

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a lot of unpredictable

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variables at the beginning when somebody starts this

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where an institution or facility can find themselves

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trapped with a lot of equipment expense that

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they then are not able to amortize.

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And then doctor Laurier, I'd like to hear

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your perspective on what doctor Lewandowski

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said and, you know, why predictability is so

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important.

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Well, because disposable platforms behave like access enablers,

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not cost drivers.

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They lower the minimum volume needed to sustain

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a program.

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So the future of spine is in hospital

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versus ASC.

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It's variable cost

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versus

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fixed cost.

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Yeah. And then can you kind of dive

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into this economic reframe you're talking about here?

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Sure.

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Well, reusable platforms carry fixed capital and repair

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volatility.

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Disposable models flatten that into a predictable per

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case economics.

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ASCs aren't replacing hospitals.

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They're replacing hospital overhead.

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Got it. And doctor Lewandowski,

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from your standpoint, what does this all mean,

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practically?

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So if we're having a

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disposable endoscopic platform, that that means that administrators

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can confidently schedule

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surgeries. They can put days together.

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They don't have to worry about that the

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scope might be damaged or there may be

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the chain may be down for weeks on

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end. So this works particularly well in low

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volume surgery center

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where a single equipment failure doesn't delay a

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case or destabilizes

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the entire spine program.

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So the

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reliability isn't convenience. It's the difference between

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a practice surviving and access disappearing.

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Got it. And, you know, doctor Loria, do

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you think this is a technology

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problem or a system problem?

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Well, it's a systems issue.

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The CPT six two three eight o is

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defined by optics,

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not surgical intensity,

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and ASC payment

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must absorb over time, staff,

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supplies, and equipment.

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What does this mean? Well,

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when equipment dominates the margin,

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adoption slows

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not due to clinical value,

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but because low volume economics become fragile.

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The problem

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isn't endoscopy.

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It's how the system values the work.

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Mhmm.

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Budget neutrality

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punishes efficiency

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unless efficiency lowers

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total cost.

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And doctor Lewandowski, you know, thinking about what

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doctor Laurier was saying here. Does this change

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how surgeons like yourself are thinking about corridor

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choice or platform adoption?

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It it does. Absolutely.

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When infrastructure determines feasibility,

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it inevitably influences which techniques

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scale

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regardless of clinical maturity.

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Surgeons adapt to constraints.

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If the infrastructure is fragile, technique selection follows

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that fragility.

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That's not preference. It's survivability.

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Got it. And, you know,

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tying all this together now, how do you

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how is this all connecting

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when you think about the rural modernization

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efforts?

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Well, CMS has announced a 50,000,000,000

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rural health transformation program, a five year initiative

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aimed at strengthening rural

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infrastructure,

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workforce capacity,

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and care delivery modernization.

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That's a recognition that access problems aren't solved

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by coverage alone.

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They're solved by making delivery

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viable.

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CMS isn't asking for better surgery.

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It's asking for sustainable surgery.

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And rural transformation

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isn't about geography.

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It's about cost structure.

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It's a great way to think about it.

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And doctor Lewandowski?

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Well, if CMS

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wants rule modernization

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to succeed,

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the technologies deployed

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have to function without layered dependency.

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Otherwise, transformation

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remains theoretical.

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That's exactly the kind of technology CMS rule

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transformation is designed to support,

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deployable,

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measurable,

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and infrastructure light.

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Absolutely. And, doctor Lewandowski, I want to,

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circle back on something you're talking about earlier,

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just imaging skepticism and the whole kind of,

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like, chip on tip versus

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rod lens. Can you dive more into that?

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The chip on tip technology is on par

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with

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the traditional rod lens system.

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In fact, a lot of the video chain

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that we use in the operating room does

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not have the ability to

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display high definition imaging at true four k

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level.

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Mhmm.

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So what that means is the surgeon is

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not looking at a worse image.

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The question is, does it fit the workflow?

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So in fact, then test it the way

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the surgeon actually works,

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not on a dry demo model in real

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cases

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with blood in the field, continuous irrigation,

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close neural

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structures, and so forth.

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Measures what matters,

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visually qual visualization quality, conversion rates,

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rescue scope use, and whether the surgeon completes

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the case as planned. Those are all things

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we need to study and evaluate in the

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future.

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When performance holds under those condition,

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the conversation moves beyond optics preference.

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It becomes about reliability,

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especially in environments where access is limited.

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Thank you for breaking that down. And, before

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we wrap up this podcast, I'd love to

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hear from each of you just final takeaways

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that our listeners should,

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should leave with.

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When access disappears, innovation isn't optional. It becomes

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infrastructure.

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In rural environments, reliability is access.

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If a platform can function consistently without heavy

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capital or layered support, it won't survive.

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Mhmm. That's not a clinical debate. That's a

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system reality.

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Well, the real innovation isn't the scope. It's

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putting surgery back where patients live.

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If we want rural patients treated where they

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live,

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we have to design technology

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that can live there too.

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Alright. Well, doctor L'Oreal, doctor Lewandowski,

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thank you again for joining us on today's

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podcast.

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This is a great conversation, and I look

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forward to connecting again in the future.

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Thank you, Carly.

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Thank you, Carly.