This is Carly Beam with the Becker Spine
and Orthopedics podcast. And today, we have two
wonderful guests.
Both are experts not only in spine surgery,
but also just understanding
health care policy.
Thank you both for joining us, and can
you introduce yourselves?
Thank you, Carly. I'm Morgan Lourio. I'm past
president of ISAS and, chair emeritus for the,
coding and reimbursement task force.
Carly, my name is Kylie VanDofsky. I'm an
orthopedic spine surgeon in Tucson, Arizona. I'm affiliated
with the University of Arizona,
and I'm active with Morgan Loria under the
ISOS umbrella.
Great to have both of you on. And
doctor Loria, I wanna start with you of
their questions.
So one of the things I really want
to discuss with both of you is CMS's
rural transformation
model and patient access. And to start, doctor
L'Oreal,
why is this conversation so timely
right now?
Okay, Carly. Well, this isn't about a scope.
It's about whether patients can access spine care
where they live.
If rural patients have to drive four hours
for a sixty minute decompression,
then the system is misaligned.
Bread and butter spine surgery should be local.
Sustaining community based private practices
and complex revision strategies should remain in tertiary
care centers.
That's how access and expertise
coexist.
Got it. And then, you know, doctor Lewandowski
want to pivot slightly, and all everything that
we're talking about right now is gonna converge
by the end of this podcast. But doctor
doctor Lewandowski
want to raise a point of interest,
with, endoscopic
decompression.
Clinic clinically speaking,
would you say endoscopic decompression is mature enough
to scale?
Absolutely, Carly. We spent the last ten, twelve
years
developing clinical evidence on the
application of the endoscopic minimally invasive decompression in
an outpatient setting. We worked up
the patient selection criteria. We we published clinical
protocols.
Come to find out thinking that was the
most significant hurdle in terms of insurance authorization,
but it actually wasn't.
Yeah. Are
performing the, endoscopic surgery now, and,
we've done some survey work that revealed that
the main hurdle is actually logistical
and implementation.
Can you dive deeper into that? This idea
that the barriers
implementation,
and what can surgeons
do to address that?
We developed some content to help surgeons with
the discussions locally in the Wilson Surgery Center.
But what it comes down to is that
the cost for the capital equipment is high.
The endoscopes have, high maintenance costs. They don't
last that long. They last on average
35 to 50 surgeries, then they're essentially broken.
So when you look at all the hidden
costs,
which include sterilization,
reprocessing,
cleaning,
they sound like trivial issues, but for small
surgeons in it, they can turn into real
problems where they just don't have the staffing
to, process these scopes on time so that
this ASC can can make money.
In a hospital setting, it's it's similar. You
may be competing with other service lines,
that
are racking up costs. So
integrating the endoscopic
technique platform is not as trivial, and we've
learned that from
multiple service studies that we've done nationally and
internationally.
Got it. And thank you for breaking that
down. And, you know, turning back to you,
doctor Lorio,
I wanna pick your brain about this idea
of access
fragility. Can you talk about what that looks
like in real life and why it happens
to begin with?
Well, when a spine surgeon leaves a rural
region,
care doesn't get delayed. It vanishes.
A procedure doesn't,
improve access if it can't fit
inside the building.
And can you talk more,
on
just kind of what's driving this issue?
Well, transformation isn't about expanding benefits. It's it's
about making delivery viable.
And, rural hospitals don't fail because surgeons lack
skill.
They fail because systems lack margins.
Got it. And doctor Lewandowski, I'd love to
hear your, perspective on, you know, what's making
delivery so challenging
operationally.
One of the problems, Carly, that we run
into consistently is
the endoscopic
protocol requires
a targeted diagnostic workup. And, again, we published
this. It's,
discoverable in the Journal of Personalized Medicine. There
are two articles
that detail how that's being done.
But it comes down to a lack of
insurance authorization
for a diagnostic injection right in the first
visit.
Mhmm. The criteria
for surgical indication
are not accurate enough to determine what the
pain generators are.
Mhmm. And a diagnostic injection is critical in
determining that to make the case for medical
necessity for intervention.
So there's delays
with formulating a treatment plan that actually will
work within the framework of a local ASC
or or hospital setting.
Yeah. And then, you know, kind of circling
back to what you're talking about a bit
earlier about
endoscopic
spine, doctor Lundrowski,
what what actually changes with disposable
HD endoscopy?
What basically
takes place, the cost has been
shifted out of the ASC. So instead of
having to buy
capital equipment on the order of several $100,000,
you're bringing in a low cost system
that is able to compete
with the traditional
reprocessable
endoscope
on a technology level. We now have
chip on tip camera systems that have high
resolution,
four k HD, for example,
then that comes sterilely packed. So the whole
processing chain,
sterilization cleaning
is eliminated,
and the equipment essentially arrives in the peel
pack.
Then that is something that works really well
for low volume sites
that are trying to see,
does this even work for our local payer
mix? What is the patient volume? So there's
a lot of unpredictable
variables at the beginning when somebody starts this
where an institution or facility can find themselves
trapped with a lot of equipment expense that
they then are not able to amortize.
And then doctor Laurier, I'd like to hear
your perspective on what doctor Lewandowski
said and, you know, why predictability is so
important.
Well, because disposable platforms behave like access enablers,
not cost drivers.
They lower the minimum volume needed to sustain
a program.
So the future of spine is in hospital
versus ASC.
It's variable cost
versus
fixed cost.
Yeah. And then can you kind of dive
into this economic reframe you're talking about here?
Sure.
Well, reusable platforms carry fixed capital and repair
volatility.
Disposable models flatten that into a predictable per
case economics.
ASCs aren't replacing hospitals.
They're replacing hospital overhead.
Got it. And doctor Lewandowski,
from your standpoint, what does this all mean,
practically?
So if we're having a
disposable endoscopic platform, that that means that administrators
can confidently schedule
surgeries. They can put days together.
They don't have to worry about that the
scope might be damaged or there may be
the chain may be down for weeks on
end. So this works particularly well in low
volume surgery center
where a single equipment failure doesn't delay a
case or destabilizes
the entire spine program.
So the
reliability isn't convenience. It's the difference between
a practice surviving and access disappearing.
Got it. And, you know, doctor Loria, do
you think this is a technology
problem or a system problem?
Well, it's a systems issue.
The CPT six two three eight o is
defined by optics,
not surgical intensity,
and ASC payment
must absorb over time, staff,
supplies, and equipment.
What does this mean? Well,
when equipment dominates the margin,
adoption slows
not due to clinical value,
but because low volume economics become fragile.
The problem
isn't endoscopy.
It's how the system values the work.
Mhmm.
Budget neutrality
punishes efficiency
unless efficiency lowers
total cost.
And doctor Lewandowski, you know, thinking about what
doctor Laurier was saying here. Does this change
how surgeons like yourself are thinking about corridor
choice or platform adoption?
It it does. Absolutely.
When infrastructure determines feasibility,
it inevitably influences which techniques
scale
regardless of clinical maturity.
Surgeons adapt to constraints.
If the infrastructure is fragile, technique selection follows
that fragility.
That's not preference. It's survivability.
Got it. And, you know,
tying all this together now, how do you
how is this all connecting
when you think about the rural modernization
efforts?
Well, CMS has announced a 50,000,000,000
rural health transformation program, a five year initiative
aimed at strengthening rural
infrastructure,
workforce capacity,
and care delivery modernization.
That's a recognition that access problems aren't solved
by coverage alone.
They're solved by making delivery
viable.
CMS isn't asking for better surgery.
It's asking for sustainable surgery.
And rural transformation
isn't about geography.
It's about cost structure.
It's a great way to think about it.
And doctor Lewandowski?
Well, if CMS
wants rule modernization
to succeed,
the technologies deployed
have to function without layered dependency.
Otherwise, transformation
remains theoretical.
That's exactly the kind of technology CMS rule
transformation is designed to support,
deployable,
measurable,
and infrastructure light.
Absolutely. And, doctor Lewandowski, I want to,
circle back on something you're talking about earlier,
just imaging skepticism and the whole kind of,
like, chip on tip versus
rod lens. Can you dive more into that?
The chip on tip technology is on par
with
the traditional rod lens system.
In fact, a lot of the video chain
that we use in the operating room does
not have the ability to
display high definition imaging at true four k
level.
Mhmm.
So what that means is the surgeon is
not looking at a worse image.
The question is, does it fit the workflow?
So in fact, then test it the way
the surgeon actually works,
not on a dry demo model in real
cases
with blood in the field, continuous irrigation,
close neural
structures, and so forth.
Measures what matters,
visually qual visualization quality, conversion rates,
rescue scope use, and whether the surgeon completes
the case as planned. Those are all things
we need to study and evaluate in the
future.
When performance holds under those condition,
the conversation moves beyond optics preference.
It becomes about reliability,
especially in environments where access is limited.
Thank you for breaking that down. And, before
we wrap up this podcast, I'd love to
hear from each of you just final takeaways
that our listeners should,
should leave with.
When access disappears, innovation isn't optional. It becomes
infrastructure.
In rural environments, reliability is access.
If a platform can function consistently without heavy
capital or layered support, it won't survive.
Mhmm. That's not a clinical debate. That's a
system reality.
Well, the real innovation isn't the scope. It's
putting surgery back where patients live.
If we want rural patients treated where they
live,
we have to design technology
that can live there too.
Alright. Well, doctor L'Oreal, doctor Lewandowski,
thank you again for joining us on today's
podcast.
This is a great conversation, and I look
forward to connecting again in the future.
Thank you, Carly.