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