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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 Lorio, 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.

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Great. And today, we're discussing your recently submitted

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analysis titled the price of silence, and it

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this takes a really hard look at reimbursement

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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

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me about what compelled you to write this?

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Okay.

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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

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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,

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which is now in press at the International

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Journal of Spine Surgery,

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was authored in part

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as a direct response to the send help

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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

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the one I entered.

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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.