For Morgan Lorio, MD, speaking out about healthcare policy is a necessity, not a theory. He recently published an analysis in the International Journal of Spine Surgery focusing on evolving trends.
Dr. Lorio’s paper, “The Price of Silence: What 2 Decades of Policy—and a Pandemic—Have Taken From Spine Surgeons: An Independent Analysis,” examines challenges to independent physicians and healthcare policy reform.
Dr. Lorio spoke about how these changes are affecting the landscape for surgeons during an upcoming episode of “Becker’s Spine and Orthopedic Podcast.”
Note: This is an edited excerpt.
Question: In your paper, you cite a nearly 34% inflation adjusted decline in Medicare reimbursement for some most common spine procedures since 2000. Can you talk more about what’s driving this erosion?
Dr. Morgan Lorio: The short answer is budget neutrality without reality testing. When CMS insists 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 and 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.
Q: This is affecting the employment landscape as well, and you describe this idea of the vanishing independent surgeon. How significantly are you seeing this shift?
ML: It’s historic. Fewer than half of physicians are now in private practice among those under 45. Self employment dropped to roughly one-third. This isn’t about preference. It’s about economic unsustainability. Administrative burden and peer leverage have made independence structurally unviable. After two decades immersed in policy, I’ve come to understand that physicians didn’t abandon independence. Policy made independence mathematically impossible.
Q: This is all affecting patients as well. You make this argument that patients are experiencing a parallel illusion. Can you dive deeper into that?
ML: We’ve been in the matrix. Patients technically have insurance, but access is mediated by delay, denial and complexity. Physicians 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 the 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 and formularies 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 that 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 is protecting against.
