Speaker 0: 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.

Speaker 1: Thank you for having me, Carly.

Speaker 0: And so before we kick things off, if you could just introduce yourself and share a little bit more about your background.

Speaker 1: 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.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: Mhmm.

Speaker 1: 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.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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?

Speaker 1: 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

Speaker 0: loss. Mhmm.

Speaker 1: Carly, this is something to chew on. Surgeons now carry the highest mortality risk of any physician group. That's not coincidence.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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?

Speaker 1: 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.

Speaker 0: 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.

Speaker 1: Thank you, Corley.