S.Hrg.119-360

1[Senate Hearing 119-360]2[From the U.S. Government Publishing Office]34                                                        S. Hrg. 119-36056                           THE DOCTOR IS OUT:7                         HOW WASHINGTON'S RULES8                    DROVE PHYSICIANS OUT OF MEDICINE910=======================================================================1112                                HEARING1314                               BEFORE THE1516                       SPECIAL COMMITTEE ON AGING1718                          UNITED STATES SENATE1920                    ONE HUNDRED NINETEENTH CONGRESS2122                             SECOND SESSION23                               __________2425                             WASHINGTON, DC26                               __________2728                           FEBRUARY 11, 202629                               __________3031                           Serial No. 119-243233         Printed for the use of the Special Committee on Aging3435                 [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]3637        Available via the World Wide Web: http://www.govinfo.gov3839                               ______4041                 U.S. GOVERNMENT PUBLISHING OFFICE424363-404 PDF                WASHINGTON : 20264445                       SPECIAL COMMITTEE ON AGING4647                     RICK SCOTT, Florida, Chairman4849DAVE McCORMICK, Pennsylvania         KIRSTEN E. GILLIBRAND, New York50JIM JUSTICE, West Virginia           ELIZABETH WARREN, Massachusetts51TOMMY TUBERVILLE, Alabama            MARK KELLY, Arizona52RON JOHNSON, Wisconsin               RAPHAEL WARNOCK, Georgia53ASHLEY MOODY, Florida                ANDY KIM, New Jersey54JON HUSTED, Ohio                     ANGELA ALSOBROOKS, Maryland5556                              ----------5758                McKinley Lewis, Majority Staff Director59                Claire Descamps, Minority Staff Director6061                         C  O  N  T  E  N  T  S6263                              ----------6465                                                                   Page6667Opening Statement of Senator Rick Scott, Chairman................     168Opening Statement of Senator Kirsten E. Gillibrand, Ranking69  Member.........................................................     27071                           PANEL OF WITNESSES7273Alma Littles, M.D., Dean & Chief Academic Officer, Florida State74  University College of Medicine, Tallahassee, Florida...........     475Lee Gross, M.D., Founder, Epiphany Health Direct Primary Care,76  North Port, Florida............................................     677Jeffrey Smith, CPA, MBA, FACMPE, CGMA, Incoming Board Chair of78  Medical Group Management Association (MGMA), Chief Executive79  Officer, Piedmont Healthcare, PA, Statesville, North Carolina..     880Corey Feist, JD, MBA, Co-Founder and Chief Executive Officer,81  Lorna Breen Heroes' Foundation, Charlottesville, Virginia......    108283                                APPENDIX8485                      Prepared Witness Statements8687Alma Littles, M.D., Dean & Chief Academic Officer, Florida State88  University College of Medicine, Tallahassee, Florida...........    2889Lee Gross, M.D., Founder, Epiphany Health Direct Primary Care,90  North Port, Florida............................................    3191Jeffrey Smith, CPA, MBA, FACMPE, CGMA, Incoming Board Chair of92  Medical Group Management Association (MGMA), Chief Executive93  Officer, Piedmont Healthcare, PA, Statesville, North Carolina..    3894Corey Feist, JD, MBA, Co-Founder and Chief Executive Officer,95  Lorna Breen Heroes' Foundation, Charlottesville, Virginia......    489697                        Questions for the Record9899Alma Littles, M.D., Dean & Chief Academic Officer, Florida State100  University College of Medicine, Tallahassee, Florida...........    57101Lee Gross, M.D., Founder, Epiphany Health Direct Primary Care,102  North Port, Florida............................................    61103Jeffrey Smith, CPA, MBA, FACMPE, CGMA, Incoming Board Chair of104  Medical Group Management Association (MGMA), Chief Executive105  Officer, Piedmont Healthcare, PA, Statesville, North Carolina..    64106Corey Feist, JD, MBA, Co-Founder and Chief Executive Officer,107  Lorna Breen Heroes' Foundation, Charlottesville, Virginia......    66108109                       Statements for the Record110111American Academy of Dermatology Statement........................    71112American Academy of Family Physicians Statement..................    75113American Association of Orthopaedic Surgeons Statement...........    85114American Clinical Neurophysiology Society Statement..............    88115American Economic Liberties: Healthcare Middlemen Statement......    90116American Economic Liberties: Medicare Advantage Statement........    95117American Economic Liberties: One Big Beautiful Bill Statement....   136118American Economic Liberties: United Health Group Statement.......   140119American Hospital Association Statement..........................   143120American Physcial Therapy Association Statement..................   146121American Podiatric Medical Association Statement.................   156122123                         C  O  N  T  E  N  T  S124125                              ----------126127                   Statements for the Record (cont'd)128129American Society of Health-System Pharmacists Statement..........   159130American Society of Hematology Statement.........................   173131American Society of Retina Specialists Statement.................   176132Primary Care Collaborative Statement.............................   184133Regulatory Relief Coalition Statement............................   187134Ryan McClenahan Statement........................................   190135Society of General Internal Medicine Statement...................   194136137                           THE DOCTOR IS OUT:138                         HOW WASHINGTON'S RULES139                    DROVE PHYSICIANS OUT OF MEDICINE140141                              ----------142143                      Wednesday, February 11, 2026144145                                        U.S. Senate146                                 Special Committee on Aging147                                                    Washington, DC.148    The Committee met, pursuant to notice, at 3:35 p.m., Room149216, Hart Senate Office Building, Hon. Rick Scott, Chairman of150the Committee, presiding.151    Present: Senator Scott, Moody, Gillibrand, Warnock, and152Alsobrooks.153154                 OPENING STATEMENT OF SENATOR155                      RICK SCOTT, CHAIRMAN156157    The Chairman. The U.S. Senate Special Committee on Aging158will now come to order. Across the country, older Americans are159feeling that it is harder than ever to get timely access to the160doctors and care they need to live happy, healthy lives and161even when seniors do find a doctor, many feel rushed and162disconnected from them.163    Doctors aren't the villains here. Like their patients, they164are victims of a broken system. Doctors want to care for and165connect with their patients, but our rigid, top-down health166care system is making that job nearly impossible.167    This is especially true for doctors who see patients on168Medicare or other government-run or subsidized health care169programs. Federal mandates and administrative requirements pile170on paperwork and paperwork, and force doctors to spend more and171more time on compliance than on care, making patients face one172obstacle after another just to get help. The results? Patients173can't get the care they need from doctors, and doctors can't174give patients the care they deserve.175    Actually, no one benefits from this. We are forcing our176doctors to operate in a system that prioritizes paperwork over177patients and federal mandates over professional judgment. The178demands on doctors to focus on compliance over care are higher179than ever. Doctors must navigate unstable insurance and180Medicare policies, different reporting standards, and excessive181administrative burdens just to take care of their patients.182    Again, no one benefits in this situation--not patients, and183certainly not doctors who got into this profession because they184want to help patients and the result is less care, less access,185and worse outcomes.186    This is especially true in rural and underserved areas that187already struggle to find and maintain health care providers,188and the regulatory burden is especially tough for those who189treat older Americans. It is no wonder that doctors regularly190report feeling higher levels of burnout than other U.S.191workers.192    That burnout leads to more doctors quitting their jobs,193which creates more doctor shortages, which leads to increased194administrative burden, which creates a more disconnection and195fewer rewarding interactions with patients, which results in196more burnout. In the most serious cases, this burnout197contributes to devastating mental health consequences for198physicians and their families, including serious depression and199even suicide.200    We owe it to all of our constituents, but especially our201aging population and those responsible for caring for them to202stop this cycle. Today we will look at how Washington's203regulations and red tape play into this crisis and what we can204do to fix it so that our doctors can spend more time caring for205patients and less time navigating bureaucracy.206    We will hear from witnesses who interact with physicians at207all levels. They train our doctors, they manage them in medical208practices, they treat them, and they work with them as209colleagues and our doctors themselves. They will tell us about210their real-life experiences navigating and preparing doctors211that deal with Washington's top-down, one size fits all212approach to regulated medicine.213    We will also share their experience working to solve these214problems, what steps we can take to help our doctors and the215patients they serve put the doctor-patient relationship back at216the center of health care.217    I look forward to a productive discussion today with our218witnesses, and I would like to recognize Ranking Member219Gillibrand for her opening statement.220221                 OPENING STATEMENT OF SENATOR222             KIRSTEN E. GILLIBRAND, RANKING MEMBER223224    Senator Gillibrand. Thank you, Chairman Scott, for holding225today's hearing. Thank you to our witnesses. I really226appreciate you being here to give us your testimony. Burnout227within the health workforce has decreased since its peak during228the pandemic but remains a prevalent issue plaguing our systems229of care. It directly impacts the well-being and effectiveness230of our workforce, and its consequences are grave for the231patients, particularly older adults and people living in rural232or underserved areas.233    Burnout, which the American Medical Association defines as234a long-term stress reaction including emotional exhaustion,235depersonalization, and feeling of decreased personal236achievement, causes physicians to leave the profession, making237workforce shortages even worse and undermining access to care.238    A wide range of factors drive physician burnout, including239regulatory and administrative requirements, system level240financial pressures, and realities of the profession's culture.241Regulatory requirements play an important role in upholding a242quality standard for patient care, safety, and privacy.243    They allow providers to keep detailed track of patient244treatment, and they also help prevent waste, fraud, and abuse.245Simultaneously, it is clear that the current system has flaws.246Requiring physicians to spend clinical time and energy fighting247to convince insurance companies that their patient truly needs248the procedure, treatment, or drug they prescribed is249understandably aggravating and exhausting.250    Time payment adjustments to extensive patient data entry251with technology designed for billing compliance instead of252clinical workflow understandably causes fatigue and253frustration, especially when it consistently spills beyond254normal working hours.255    Reforms like streamlining the prior authorization process,256approving the usability and interoperability of electronic257health records, simplifying or standardizing payer forms would258meaningfully reduce administrative burden that drives the259burnout in physicians.260    This can help delay early exit from the workforce and keep261independent practices afloat. This is especially important as262we continue to see unprecedented rise in smaller physician263owned practices closing their doors, integrating with larger264health care systems, or receiving private equity investment.265    With these structural changes, physicians can face system266level financial pressure that drive burnout through diminished267agency and focus on profit. Under these circumstances,268physicians can face business-oriented performance targets that269require an increase in patient volume.270    This means seeing a greater number of patients in shorter271increased, frequent visits that create even more administrative272work, which can be compounded by the reduction of clinical and273administrative support staff. This drive toward profit can274undermine the ability of these vital health care workers to275secure their basic psychological or safety needs, and they276experience less autonomy and input on key decision-making.277    Particularly combined with the inability to practice278elsewhere due to the rise of strict non-compete agreements,279many physicians opt to leave the profession entirely. System280leadership must drive operational level change.281    Employers have an obligation to meet the needs of their282employees, promote participation in relevant decisions, and283implement evidence informed actions like those included in the284NIOSH and the Dr. Lorna Breen Foundation Impact Wellbeing285Guide.286    Additionally, federal investigation into private equity287investments in health care entities and federal action to ban288anti-competitive terms in employment contracts are crucial to289promoting autonomy at organizational and individual levels and290reduce burnout. Despite the regulatory, administrative, and291system level pressures that put enormous stress on the health292workforce, there is a pervasive stigma against seeking mental293health support and fear of medical license loss that prevents294many from getting the help that they need.295    It is important that clinician education includes training296to handle not only these administrative burdens, but also297psychological preparation to handle trauma like a patient death298or distress. We must address burnout. The consequences and299stakes are too high. Healers are suffering. Providers are300facing sky-high costs to replace each clinician that leaves.301    Remaining staff are working at reduced capacity, putting302themselves and their patients at greater risk. Patients are303losing access to the care they need. These impacts only304intensify in older, rural, and underserved communities,305especially combined with enacted cuts to Medicaid that will306exacerbate the provider closures and create medical deserts.307There isn't an easy solution to any of this.308    Moving the needle requires buy-in from all sectors that309shape our workforce. Congress, academic institutions,310regulators, and health system leaders must work together in a311bipartisan way to create a system that supports, not exhaust,312our essential workforce. I look forward to hearing from you and313your proposals. Thank you.314    The Chairman. Thank you, Ranking Member. Now, I would like315to welcome today is witnesses. Our first witness leads one of316the Nation's most mission driven medical schools with a focus317on training physicians to serve in rural communities.318    Dr. Alma Littles is the Dean and Chief Academic Officer of319the Florida State University College of Medicine where she320oversees medical education, workforce development, and321physician training programs across the State of Florida.322    Under her leadership, the FSU College of Medicine has323emphasized primary care, community-based training, and324addressing physician shortages in areas most affected by access325challenges. Half my office went to FSU, so they are excited326that you are here, so please begin your testimony.327328         STATEMENT OF ALMA LITTLES, M.D., DEAN & CHIEF329330       ACADEMIC OFFICER, FLORIDA STATE UNIVERSITY COLLEGE331332               OF MEDICINE, TALLAHASSEE, FLORIDA333334    Dr. Littles. Chairman Scott, Ranking Member Gillibrand, and335distinguished Committee members, thank you for the opportunity336to speak with you today to share a perspective on an issue that337is becoming increasingly urgent across our Nation, physician338burnout. An issue experienced by doctors who want nothing more339than to care for their patients yet find themselves pushed to340the brink by the very system meant to support them.341    Physicians enter medicine with a clear purpose, to heal, to342serve, and to stand with patients in their most vulnerable343moments but today, that purpose is being overshadowed by344unsustainable administrative burdens leading to record345percentages of physician burnout.346    We have already heard definitions of physician burnout, so347I won't repeat that, but we know that physicians have a higher348incidence of suicide when compared with other professionals in349the United States. Around 400 take their lives each year and350just as concerning, medical students and residents have rates351of depression 15 percent to 30 percent higher than the general352public.353    This is a national crisis. To address it, the National354Academy of Medicine, the Association of American Medical355Colleges, and the American Medical Association are all actively356developing resources to help. Physicians are leaving medicine357not because they have lost their passion, but because the358regulatory environment has made it nearly impossible to359practice the way they were trained.360    Physicians lose satisfaction when factors come between them361and their patients. The issue is not regulation itself.362Physicians understand the need for oversight, accountability,363and patient safety. The issue the volume and complexity of364mandates, documentation requirements, reporting systems,365compliance checklists, and insurance rules and regulations that366grow year after year in the face of reduced reimbursement and367without regard for the time they consume or the strain they368impose in the form of the inability to make decisions based on369training.370    The consequences of burnout can be devastating. Think about371this, one physician leaving practice potentially leaves 2,000372to 3,000 patients without access to care. Studies suggest that373more than half of practicing physicians say they are burned374out. We found this to be a real issue in Florida after becoming375aware of several suicides among medical students, residents,376and faculty.377    Here is the hopeful part, this crisis is solvable. The378medical schools in Florida came together to evaluate the379support being to address the root causes of burnout. We use380this data to share experiences and solutions. Programs were381developed that support wellness activities and deliberate382efforts were made to destigmatize seeking help in medical383school, residency training, and practice.384    This included lobbying for a change in the licensure385application regarding how questions about prior mental illness386were asked and addressed. The survey of medical schools and387residency programs confirmed that the schools were actively388engaged in a variety of activities including incorporating389mandatory wellness topics into the curriculum, providing390dedicated onsite counseling services, offering online391resources, hosting financial aid and planning workshops, and392incorporating activities that prepare students for the impact393of administrative burdens.394    Since our founding 25 years ago, Florida State University395College of Medicine has recognized the threat of physician396burnout and we hardwired into our curriculum and397extracurricular activities, programs and activities to address398it.399    We provide resources on sleep and stress management, weekly400fitness classes, campus walks, and improved our onsite fitness401room. A major suicide awareness and prevention program featured402film screenings and a live panel discussion. Our six regional403campuses also developed their wellness programs.404    All of this is helpful, but we cannot lose sight of key405components of the American Medical Association's Physician406Wellness Program that includes the reduction of administrative407burdens, reduce of stress drivers in organizations, and removal408of regulations and technology requirements.409    We need your help. You have the power to make a positive410impact by supporting regulatory reform, promoting411administrative simplification, ensuring that federal policies412strengthen not strain the physician workforce, and by413recognizing that the best way to protect patients is to protect414the people who care for them.415    Addressing this issue is no longer an option. It is416critical to ensuring access to care. I look forward to417continuing the conversation. Thank you.418    The Chairman. Thank you, Dr. Littles. Our next witness is a419practicing family physician who left the traditional insurance420driven system to restore the doctor-patient relationship. Dr.421Lee Gross is the Founder of Epiphany Health Direct Primary Care422in Florida, a national leader in the direct primary care423movement.424    He spent more than two decades in private practice and has425testified before Congress on how federal regulations and CMS426mandates contribute to physician burnout and rising costs.427Thank you for being here. Please begin your testimony.428429        STATEMENT OF LEE GROSS, M.D., FOUNDER, EPIPHANY430        HEALTH DIRECT PRIMARY CARE, NORTH PORT, FLORIDA431432    Dr. Gross. [Technical problems.] Sabotage the Florida guy.433    Mr. Chairman, Ranking Member, members of the Committee, it434is a pleasure to be back here at the Senate to give some435testimony. Again, my name is Lee Gross. I am a practicing436family physician in Southwest Florida--have been independent437since 2002.438    For disclosure, I serve on the Florida Board of Medicine. I439am speaking on my own behalf and not on behalf of the Florida440Board of Medicine, and I do not speak for the State of Florida.441The name of my practice is Epiphany Health and Epiphany Health442is a very strange name for a medical practice--and the timer is443not running here. Epiphany Health is very strange for a very444medical practice.445    In fact, we had an epiphany and the epiphany was, why are446we insuring primary care? Why are we taking relational and447longitudinal care and funneling that through an insurance448product, using tens of thousands of diagnostic codes, hundreds449of thousands diagnostic and billing codes, filing an insurance450claim for every single transaction, and then we are451disappointed and surprised that it is cumbersome, it is452impersonal, it is inflexible, and it is expensive.453    I had a fully insured practice back in 2002. I took454Medicare. I took all the insurances, and this was during the455time of the sustainable growth rate formula and I would come to456run up and down the halls of Congress saying, please don't cut457our pay, please don't our pay. It is absolutely not survivable458if Congress cuts the pay of primary care doctors.459    I would walk out, and behind me the ophthalmologist would460walk in, and they would say, please, don't come our pay and461then behind them, the surgeons were standing there and this462constant battle for a larger slice of a pie that was463continually shrinking. It just became obvious to me that we464shouldn't be fighting for a large piece of the pie, but we465should be looking to explode the pie and looking for a better466way to do this.467    I was an early adopter of electronic health records, and I468should say that in the sustainable growth rate debates, I would469have to take out personal loans to make payroll because of the470brinksmanship that would happen in Washington. I wouldn't know471if we would have money coming in.472    I didn't know how to finance supplies. I didn't know how to473finance equipment purchases because I didn't know what we were474going to get paid and so, the Federal Government became an475unreliable business partner in the practice of medicine, and I476felt like I needed to fire them. I was an early adopter of477electronic health records. I loved that electronic health478record. It maximized operational flow, workflow.479    It was fantastic and then the Federal Governor came in and480certified it and so, the electronic health record I had that481did everything I needed it to do and made me more efficient was482no longer certified, and they couldn't afford to certify.483    I started getting Medicare penalties because I had a system484that was efficient and worked for my practice, but I was485getting penalized, so I had to purchase an additional system486that didn't do anything I needed to do.487    I had parallel systems, one for compliance and one actually488to perform the function that I needed in my office. It489essentially became that the electronic health record became a490cash register. I used to get a one-page note from a consultant491and I would know why my patient was there, what they did, what492their recommendations were, what pertinent findings were.493    I get 16 pages of computer-generated rubbish, and I have no494idea what the patient was there for, but I know their pet was495spayed or neutered. It is absurd and so, the medical record has496become a cash register, the patient has become an ATM, and it497had become all about volume.498    You start rolling out all the alphabet soups of the MACRA499and the MIPS, and the quality metrics, and the reporting. I500would have to find other ways to generate revenue, because I501wasn't going to do those things and so, every time I found a502way to generate and support my practice, Medicare would make a503rule change to undercut that and I was playing whack-a-mole504with Medicare as to how my practice would survive.505    We kind of joked in my practice that we were just going to506go ahead and stop billing Medicare. We are just going charge507$100 for parking but effectively that is what we did. We508created essentially in 2010 what became one of the first direct509primary care practices in the country.510    We charge a subscription for services. We charge $93 a511month right now for adults, $30 for children, and after that we512charge nothing for the services we provide in our office. No513copays, no deductibles. I don't bill insurance for any514services. Any testing that I do in my office is included, EKGs,515halter monitors, cortisone injections, those are all included516and I have a cash-based relationship for all the services517outside of my office.518    I buy everything wholesale and pass those savings along to519the patient. I buy labs at 95 percent savings because the lab520doesn't have to interact with the insurance company, and they521don't have deal with coding and if you ask the lab, the most522expensive thing that they do in the lab is interact with523insurance companies and do the coding. If you eliminate all524that and you just get the lab, it actually gets really cheap.525    We have been doing that now for 15 years, operating outside526of insurance companies. We have seen nearly zero inflation in527the actual cost of purchasing health care. The cost of coverage528has skyrocketed, but our cost of purchasing care and providing529care has been nearly flat for 15 years.530    Since we have started doing that, we were one of the first531few practices in the country that have done that. Now, there532are thousands of doctors around the country in all 50 States533that have stepped away from the system because we can do better534at providing primary care, not going through third-party535systems.536    We are at a point now in our country where we can537personalize health care down to somebody's individual DNA. We538are taking a one size fits all approach to health care that has539to be a broad brush across a massively enormous country that is540so incredibly diverse as the United States of America.541    What we don't need is mass production in medicine. We need542mass personalization, and that is the kind of care that we543deliver, and I am hoping that we can get to that through544removing some of the overregulation in health care. Thank you.545    The Chairman. Thank you. Our next witness brings a546perspective of managing large, multi-specialty physician groups547serving both urban and rural communities. Jeffrey Smith is the548Chief Executive Officer of Piedmont Healthcare in North549Carolina and is the incoming Board Chair for the Medical Group550Management Association.551    In his role, he oversees the operational, financial, and552compliance challenges facing physician practices under Medicare553and CMS regulation. Boy, it sounds like an easy job. Thank you554for being here. Please begin your testimony.555556      STATEMENT OF JEFFREY SMITH, CPA, MBA, FACMPE, CGMA,557558             INCOMING BOARD CHAIR OF MEDICAL GROUP559560              MANAGEMENT ASSOCIATION (MGMA), CHIEF561562           EXECUTIVE OFFICER, PIEDMONT HEALTHCARE, PA563564                  STATESVILLE, NORTH CAROLINA565566    Mr. Smith. Chairman Scott, Ranking Member Gillibrand, and567members of the Committee, thank you for the opportunity to568testify on how administrative and regulatory red tape fuels569physician burnout and undermines patient access to care.570    I am honored to speak on behalf of Medical Group Management571Association, MGMA, as its incoming Board Chair. MGMA has over57270,000 members across the United States representing 15,000573medical group practices and more than 350,000 physicians.574    I am also the CEO of Piedmont Healthcare, a physician owned575and led multi-specialty medical group based in Statesville,576North Carolina, with over 230 physicians and providers and577almost 1,200 employees.578    I have over 40 years of health care experience and I feel579deeply passionate about this issue, in part because I have seen580its impact firsthand while working alongside my daughter, who581is a primary care physician in my practice. MGMA has long582advocated for reducing administrative burden and routinely583surveys our members on administrative hurdles they face.584    Their feedback makes clear the connection between585regulatory burden, a broken payment system, and physician586burnout. In our 2026 survey with over 230 responded physician587practices, more than half of the practices report losing a588physician to burn out in the past three years and among those,589over 75 percent say regulatory burden played a substantial590role.591    This impacts patient access to care as it leads to longer592wait times, shorter visits, and practices becoming unable to593accept new patients. In my own practice, I have increasingly594witnessed more physicians being driven toward early retirement.595Burden related to regulatory impacts, work-life balance as596well, something I have seen with my daughter who often must597complete these tasks at home after her children fall asleep.598    While MGMA supports efforts to strengthen and expand599physician training programs, addressing administrative and600regulatory policies that are leading to physician burnout is601critical to stem the tide on the front end and support602physicians already in practice. I would like to highlight the603following burdens that I and other MGMA members are facing that604significantly contribute to physician burnout.605    Medicare Advantage has allowed beneficiaries to access new606benefits and can serve as an opportunity for innovation.607However, as Medicare Advantage enrollment has increased, it has608created daunting new challenges for many practices. MGMA609members report audits, denials, prior authorization, and down-610coding in Medicare Advantage as some of their top burdens in6112026.612    There is also significant lack of standardization across613Medicare Advantage plans. We have had to hire whole teams614dedicated to value-based care just to interpret what quality615really means.616    For years, one of the top cited regulatory burdens for617medical groups has been prior authorizations due to its impact618on staffing demands, added cost, and impact on patient care. I619oversee over 70 offices in the Charlotte metro area, and each620practice has at least one staff member dedicated to prior621authorizations.622    MGMA members rank Medicare Advantage as the most burdensome623payer. I appreciate the Chairman, Ranking Member, and many624members of the Committee for co-sponsoring the Improving625Seniors Timely Access to Care Act. It is important to pass this626widely supported legislation that would streamline prior627authorization for Medicare Advantage.628    There are numerous additional opportunities to reduce629duplicative and unnecessary regulatory hurdles. Reforming the630Merit-Based Incentive Payment System, or MIPS, in Medicare631would be welcomed. As complying with these requirements is a632time-consuming and laborious process. Further, provider633enrollment and credentialing in Medicare could be streamlined634to better capture this data and lower practice costs.635    All of this regulatory red tape is exacerbated by the636continued under-reimbursement of Medicare Part B. Financial637stressors were the second largest contributing factor to638physician burnout in our 2026 survey. Given Medicare's639reimbursement's frequent reductions due to outdated budget640neutrality requirements and lack of an inflationary update, it641is vital to pass legislation to comprehensively address these642concerns.643    The challenges discussed throughout this testimony coalesce644to undermine the ability of independent medical groups to645continue to operate and potentially lead many physicians to646sell their practices. One MGMA member relayed selling their647practice after being independent for over 100 years.648    Enacting long-term reforms would help lead to a more robust649practice environment. I sincerely appreciate the opportunity to650testify today and share both my personal experience and other651MGMA members' experiences on how regulatory burden contributes652to physician burnout. I look forward to your questions.653    The Chairman. Thank you. I now recognize Ranking Member654Gillibrand to introduce the next witness.655    Senator Gillibrand. Thank you, Mr. Chairman. I now want to656introduce Corey Feist. Mr. Feist is the CEO and Co-Founder of657the Dr. Lorna Breen Heroes Foundation and recently served as658the CEO of the University of Virginia Physicians Group.659    Mr. Feist has previously testified to support mental health660legislation for health care workers in front of the House661Energy and Commerce Subcommittee on Health. His advocacy662efforts resulted in the passage of the first federal law663focused on improving the well-being of health care workers, Dr.664Lorna Breen Health Care Provider and Protection Act, in honor665of his sister-in-law.666    He was also awarded the Surgeon General's Medallion for667Health in 2023 for the foundation's efforts. Mr. Feist, you can668begin your testimony.669670         STATEMENT OF COREY FEIST, JD, MBA, CO-FOUNDER671672            AND CHIEF EXECUTIVE OFFICER, LORNA BREEN673674         HEROES' FOUNDATION, CHARLOTTESVILLE, VIRGINIA675676    Mr. Feist. Chairman Scott, Ranking Member Gillibrand, and677members of this Committee, thank you. My name is Corey Feist,678CEO of the Dr. Lorna Breen Heroes Foundation.679    On behalf of millions of health workers, thank you for the680introduction and co-sponsorship of the Improving Seniors Timely681Access to Care Act of 2025, and for reauthorizing the Dr. Lorna682Breen Health Care Provider Protection Act. We now seek full683funding of the Lorna Breen Act to ensure life-saving work684continues. This is my third time testifying on this crisis.685    Each time I carry the stories of those lost, not to a lack686of resilience, but to a system that failed them. In 2021, I687shared the story of my sister-in-law, Dr. Lorna Breen. She was688a physician leader during the pandemic's first wave in New York689City. Despite her bravery, she was terrified that seeking690mental health care for her trauma that she witnessed on the job691would cost her career that she spent her life building.692    Lorna took her life April 26, 2020. In 2024, I shared the693story of Tristan Kate Smith, a 28-year-old nurse whose father694found a letter on her computer after her death. She wrote to695the system she felt abused her, noting that instead of respect,696they get pizza parties and pens for the health care heroes.697    Today, I share the story of Dr. William West, a 34-year-old698ophthalmology resident. His family called him Iron Will for his699tenacity in rock climbing and endurance racing. In March 2024,700the information ocean and pressures of medical training broke701even Iron Will. In a devastating final note he wrote, I am702simply exhausted and have nothing more to give.703    He used his final moments to plead with administrators to704support the residents rather than merely push them. William's705story is a warning. Our health care system is claiming our706brightest minds before they even finish their training. When we707lose a resident, we aren't just losing one doctor.708    We are losing 40 years of expertise meant to serve our709aging population. The tragedy of losing clinicians like Lorna,710William, and Tristan is compounded by the looming demographic711shift. The number of Americans over 60 will increase by 46712percent in the next decade. HRSA projects will cause a shortage713of over 500,000 nurses, physicians, dentists, and pharmacists714by 2038.715    These projections do not fully account for those leaving716due to systems failures, many of which you have already heard717from. Forty-five percent of physicians say administrative718pressures are pushing them toward career changes or early719retirement. Administrative tasks like prior authorization are720the number one. driver of physician burnout. Nurses face a721safety crisis with 80 percent experiencing workplace violence.722Last year, 24 percent of Gen Z nurses left their roles.723    Pharmacists are abandoning their roles due to excessively724high workloads and hostile workplace climates. However, this is725not a foregone conclusion. Thanks to the Lorna Breen Act funded726Workplace Change Collaborative, we now have a proven national727framework with several priorities for policy and practice to728avert this crisis.729    The Lorna Breen Act grantees have already supported over730250,000 health workers in states, and the results are731undeniable with 35 percent reductions in staff turnover, 50732percent decreases in mental health conditions. The law also733supported NIOSH's Impact Wellbeing Initiative, which provided73435,000 plus health care leaders with training to address the735operational burdens that drive their workforce's burnout.736    Our foundation created a technical assistance program to737accelerate the initiative. We improved access to mental health738care for more than three million health workers by supporting739over 70 licensing boards and over 20--or 2,000 hospitals and740care facilities and removing intrusive mental health questions741from licensing and credentialing applications. We are also742proving that administrative burden can be reduced while job743satisfaction and patient experience improve.744    One rural hospital decreased their workforce's cognitive745burden addressing EHR alert fatigue. Their traveling nurses now746want to stay in rural Virginia saying that this is the first747place they have worked where they feel healthy, and they748actually can get the help that they need. Reauthorization of749the Lorna Breen Act is a historic win, but without funding, it750is a hollow promise.751    While billions are spent on workforce creation, the Lorna752Breen Act programs are the only ones directly supporting753retention. Investment in the pipeline is squandered if we don't754stop the leaks.755    For example, we currently face a two-year exodus in nurses,756where 50 percent of new nurses leave the profession after two757years.758    This Committee can make a difference by ensuring the Lorna759Breen Act is fully funded in Fiscal Year 2027, and for voting760for the Improving Seniors Timely Access to Care Act.761    I hope to return and report on the lives of health workers762we have saved and how we are serving the aging community in the763United States with the best and brightest among us, the Lornas,764the Tristans, and the Williams. Thank you for your leadership.765    The Chairman. I thank each of you for your testimony, and I766will turn it over to Senator Moody for the first questions.767    Senator Moody. Thank you, Chairman Scott, Ranking Member768Gillibrand for holding this hearing, and welcome to two of our769witnesses that are from Florida, for traveling up here and770braving the ice on the ground. I know you wish you were back771with the palm trees and flamingos. I do too. Welcome. This is772such an important topic for our country, especially Florida. We773have so many seniors in our state.774    Some refer to us as not just the Sunshine State, but the775Silver State. Discussing how we are going to provide efficient,776quality health care is so important and so, this topic is of777great importance and particular interest to me. Florida has778some of the best hospitals and providers in the country.779    We have world-renowned care, education, and training and we780are so proud of these accomplishments, but we know they are781only possible because we have hard working Floridians that have782trained in health care and are part of our health care783structure and show up to work, rain or shine, no matter what is784happening.785    Nationwide, the health care industry employs over 17786million people, making it one of the largest employment sectors787in the United States, so it is understandable that we need a788large health care sector and those that will work in this789industry, but so much of that economy is tied up in billing,790administration, and regulatory compliance and physicians are791increasingly forced to spend nearly twice as much time on792administrative work as they do in providing patient care.793    I hear from Floridians all the time what they are794experiencing on the job in these health care careers, and it is795grinding and it feels burdensome. It is challenging and I think796that is probably why a recent Mayo Clinic study found that 57.1797percent of physicians said they would choose to become a798physician again, down from 72.2 percent just five years ago.799    With endless prior authorization requests, sometimes800combative patients, extreme working hours, it is no wonder that801many providers step away from their traditional practices to802transition to direct primary care practices, also known as803concierge care.804    Many of these practices allow physicians to see patients805for longer, avoid cumbersome administrative processes, all806while delivering a higher quality experience and giving doctors807more time to live their lives.808    We expect that segment of the health care industry to grow809to nearly $36 billion by 2030 and while there is a lot of good810with that, and I certainly understand why there is that811transition, we have to recognize that the exodus of providers812from the mainstream health care system is a symptom of an813underlying problem with that traditional system, and we as a814Government have to figure out why that is.815    I mean, it is no longer a free market in the health care816system. Government has gotten so involved and so regulated, and817we require so many things. Some seem nonsensical, like making818you move to a different computer system when yours is working819just fine, where you have to maintain two computer systems.820    Unbelievably wasteful, and it sounds just like the821Government but we are no longer a free market in our health822care. I mean, supply and demand in health care is not driving823costs anymore, and this is why we are seeing costs drive824through the roof.825    This is why it is so taxing now on consumers of health826care, and I don't blame this mass exodus of people trying to827move into what health care used to be, providing care to828patients in a way where you feel like you have a relationship829with them, you can spend time with them, high quality, maybe830even cost efficient.831    I am supportive of that but I am very nervous that832concierge care or even direct care outside this, what we would833now call the traditional health care or mainstream health care834system, might not be accessible by everyday people who might835not have a really, really high income. I worry about that.836    Obviously, as we are seeing this mass exodus from the837profession in general, I think we are going to have a projected838shortage of 140,000 physicians by 2038. We are seeing a mass839exodus of physicians, period. We have a mass exodus going into840this more direct or concierge care. I am really worried about841what happens for everyday Americans that might not be able to842afford that direct care.843    I think this is a great topic for us to talk about because844I really think what has driven that is this just crazy, over-845regulated, nonsensical approach by Government to--and the more846and more we become involved in health care, the more and more847complex and out of control, and chaotic, and unmanageable, not848working for physicians, not working consumers, it becomes.849    Dr. Gross, thank you for being with us. Congratulations on850a successful career. I wanted to ask you how--you know,851congratulations on all that you have been able to do to852navigate around what we in government have created in the853traditional health care system, but what would be your854recommendations to--from where we find ourselves with a rapidly855declining physician population, and out of that, add to it856those moving out of a health care system that is more857traditional, that many use government services or government858assistance to access.859    What would be your recommendations for those of us on this860Committee to make sure that health care is not only quality,861but cost efficient for Americans?862    Dr. Gross. Thank you, Mr. Chair. A lot to unpack in the863statements there. I think one of the first things that I would864like to do is just clarify a little bit between concierge865medicine and direct primary care, because concierge medicine866typically does charge an access fee and then bills a fee for867service to a third-party payer, whereas the direct primary car868charges a subscription fee, and everything is included in that,869so there is a difference in the price points.870    Senator Moody. Different in the way you charge.871    Dr. Gross. Different in the way you charge and different in872what is included, so we don't bill--it is not like a fast pass873at Disney World, where you pay for access. You know, that is874more of a concierge model.875    Moving past that, I would say that a physician that leaves876practice because they are overburdened, and they have moral877injury sees precisely zero patients, so if you are forcing878somebody out of practice because of the complexities of it,879then you are not comparing it to a doctor that would see 3,000880patients and now they are shrinking it.881    You are comparing it to a doctor that would see zero882patients, so it is not an actual fair comparison, because I883would not be practicing medicine today if I did not change my884practice model. I just wouldn't have done it.885    I would have found something else to do. I am forced by law886to opt out of Medicare when I direct contract with these887patients. That was not my decision. That was federal law that888required----889    The Chairman. Explain that--that you can't do both.890    Dr. Gross. Right. When I directly contract with a Medicare891beneficiary for services that are covered by Medicare, I have892to, by law, opt out. It is not just opt out in my direct care893practice. It is across the board, under everything tied to my894NPI. I can't moonlight as a hospitalist. I can't serve ER895shifts. I can't do telemedicine through a traditional teledoc896type service, because they all bill Medicare.897    That locks me into saying, I can only accomplish this panel898size by statute. I would love to see that change. I want to899work with you to change that statute, because that has a900disproportional impact on rural health care.901    Because if I am putting a panel of a primary care doctor in902rural America, in rural Alaska, rural Utah, I can make a direct903primary care practice work and be profitable with 300 to 500904patients. I can't do that with a fee-for-service practice. If I905come in with 300 to 500 patients, I am going to need massive906federal subsidies.907    I am going to need something to keep that practice afloat,908and there is no way you are going to be able to do it, so and909again, if statute requires me to opt out to do that--I may be910the only doctor in your community serving in your emergency911room.912    I may the only that might be able to care for you in the913hospital, and statute has required me to opt out because I am914providing more affordable and accessible care. It is important915to, again, to have the maximum flexibility for physicians to916shift to the needs of their community directly and not have917that federally dictated.918    For example, when we went into COVID, it took three months919for Medicare to recognize the invention of the telephone, and920we are still fighting over whether the telephone is appropriate921access for physicians and whether the Federal Government should922pay for it.923    Just as recently as two weeks ago we are trying to decide924this. I shifted my practice to a telemedicine on day number925one. When you mentioned the rains falling, when Hurricane Ian926tore the roof off the emergency room next to my office, I927didn't need to wait for the insurance companies to convene a928new code for me to provide parking lot care for my services. I929put a tent in the front of my building.930    We opened up to all comers, whether they were our patients931or not. We provided free care to the community. Why? Because I932am getting paid. I am being paid on a subscription basis and I933have the flexibility and ability to provide the services to the934care, to my community that they need.935    Senator Moody. Thank you.936    The Chairman. Thank you. Ranking Member Gillibrand.937    Senator Gillibrand. Thank you, Mr. Chairman. Mr. Feist, in938your testimony, you discussed how administrative burden is an939underlying cause of physician burnout, impacting time with940patients and pushing doctors beyond even extended working941hours.942    Your foundations, Impact Wellbeing Guide, provides guidance943on how hospitals and health systems can address these burdens944through quality improvement projects. Could you please share a945brief example of how health care providers successfully reduce946physician burnout by using your Impact Wellbeing Guide.947    Mr. Feist. Absolutely. The Lorna Breen Act created the948Impact Wellbeing Guide, and NIOSH partnered with our foundation949and our all-in national coalition of over 37 of the largest950professional associations to create this leader retraining951guide.952    What we have done is we have implemented this guide across953the United States, particularly in Virginia, North Carolina,954now in New Jersey, and as well as in Wisconsin and, what we saw955in Virginia after doing this were decreases in the amount of956time that clinicians were spending in the electronic medical957record before and after work by significant numbers.958    In some cases, three to five minutes per patient, in some959cases ten to fifteen minutes per patients. Huge decreases960there. In addition, standing orders for pharmacy refills.961Things that keep the pharmacists, the patients, as well as the962physicians burdened with bureaucracy. All of those things,963using the Impact Wellbeing Guide, decreased the amount of time964that folks were spending outside of direct patient care,965increased their well-being, increased--and decreased their966burnout967    Senator Gillibrand. Thank you. Dr. Smith, your testimony968describes how Medicare Advantage's burdensome prior969authorization requirements significantly contribute to970physician burnout and can harm patients.971    Over 60 Senators, including myself, are pushing to pass the972Improving Seniors Timely Access to Care Act to streamline the973prior authorization process and help address some of these974widespread concerns.975    Yet, CMS's new Wasteful and Inappropriate Service Reduction976model, also known as the WISeR model, expands prior977authorization into traditional Medicare and utilizes a new non-978standardized approach that is inconsistent with the existing979federal regulations. How will the WISeR model increase980administrative and patient burdens in traditional Medicare, and981how might this drive burnout among physicians in states where982this model is enacted?983    Mr. Smith. I think what you are going to see is more prior984authorizations needed. That is going to add burden to the985staff.986    There will be more denials that will add burden to the987physician to either fight the denial or just to decide it is988just not worth the fight. Now, you have patients not receiving989care. If patients don't receive care, I believe that they will990get sicker, they will end up in the emergency room, and991ultimately the hospital, which will drive the cost of health992care up.993    My dad is 94. He went to the doctor this week while I was994up in Philadelphia visiting him, and the doctor decided that he995needed a CAT scan. I would bet a lot of money that that would996be denied if you did a prior-auth on that.997    Senator Gillibrand. Right.998    Mr. Smith. You know, we spend a lot of time telling999doctors, you know, you are in charge, you are the quarterback1000of care. We actually increased the E&M codes, but every step of1001the way we question what they do. I think we would just be1002contributing to the burnout of doctors if we move forward with1003it.1004    Senator Gillibrand. I agree. Dr. Gross and Dr. Littles. Dr.1005Gross, in your testimony, you highlight the mismatch between1006how physicians are trained and the regulatory environment that1007they practice in.1008    You say that when physicians enter the workforce, they are1009clinically competent but structurally unprepared to operate1010smaller rural practices. How does this mismatch drive physician1011burnout and contribute to consolidation?1012    Dr. Gross. One of the things that I have noted is that when1013people are graduating from training--I am kind of old school.1014When I went into training, I had full practice management1015training in my practice.1016    That doesn't really happen to a degree. I mean, it is still1017sort of required. When people graduate, they do not have the1018full practice manager. How do you have compliance? How do you1019comply with OSHA? How do you hire? How do you fire? How do you1020set up your structure? How do you negotiate contracts?1021    That is all stuff that I learned in my training, but it is1022not really being taught to that degree. Because most people are1023being trained to be employees in an outpatient and ambulatory1024setting.1025    If you are trying to then go from training into a rural1026health care setting delivery where you need to be running your1027own practice, they are not prepared for that. People are just1028not even stepping into that environment, and it is leaving a1029huge void in the rural communities.1030    Senator Gillibrand. Thank you. Dr. Littles, in your1031testimony, you shared how medical schools and residency1032programs in Florida recognize this mismatch and are1033incorporating activities to help students prepare for the1034impact of the profession's administrative burdens. Please1035describe some of these initiatives and discuss how medical1036students and trainees have responded to these trainings.1037    Dr. Littles. Sure. We all know that medical school is a1038stressful environment, going through the process of training to1039become a physician, so we put in support systems, you know, for1040students to help guide them through this because we recognize1041that they are going to be facing stressful situations1042throughout their career, so having, you know, access to onsite1043counseling that they can, you know, access right there at the1044college without feeling that, you know, tension of is this1045going to affect my licensure later on and prohibit me from1046being licensed or practicing medicine, so activities like that.1047    Having wellness activities so that they learn to take1048breaks because at the end of the day we are all humans before1049we are physicians and they need to be able to, you know, to1050take breaks, make sure that they are, you know, eating1051properly, and getting rest, and maintaining connections to1052their support systems that they had even before they came, you1053know, to medical school.1054    Training them with those activities but also recognizing1055that these other stressors that they are going to face as1056practicing physicians are there as well and so, having them1057actually training with those physicians--I mean our students1058and our residents get to see what our attending physicians are1059facing in their practices.1060    When they are having to deal with these issues like, you1061know, prior authorization and denials, and you know, patients1062not being able to access the appropriate lab or the1063appropriate, you know, X-ray facility, they are seeing this as1064a part of their training, even in medical school.1065    As Dr. Gross said, those requirements for that practice1066management training is there for our resident physicians, but a1067lot of them are not focusing on it. Certainly not early on in1068their residencies they are not focusing on it because they are1069not having to be the ones ultimately responsible for it.1070    As they get closer to graduation, they tend to start paying1071a little bit more attention to it but it is true that more1072physicians are employed today than even, you know, 10 years ago1073and certainly more than, you know, 20, 25 years ago. More and1074more of them are entering employed situations which in many1075cases exacerbates a lot of these issues we are talking about.1076    Senator Gillibrand. Thank you.1077    The Chairman. Senator Warnock.1078    Senator Warnock. Thank you Chair Scott and Ranking Member1079Gillibrand. Communities in my state and all across the country1080face dire physician shortages as this panel has demonstrated.1081    Estimates are that in just a couple years we will be short1082by tens of thousands of doctors. Mr. Feist, what effect will1083additional workforce shortages have on our current health1084professionals many of whom are already facing?1085    Mr. Feist. Reduction in staff are a force multiplier on the1086issues that we have been talking about on this Committee today.1087We have to look at what our clinicians are spending their time1088doing right now.1089    When you look at the fact that about 70 percent of a1090primary care physician's time and 50 percent of a nurse's time1091is spent away from the bedside, away from a patient, spending1092that time on administrative burden--as you decrease your staff,1093who else is left to do the administrative work? It is this1094vicious cycle that will impact access. It will impact quality.1095It will affect cost over time.1096    Senator Warnock. It is an impact, obviously, on the1097workers, including the physicians and their workplace, but it1098is a real effect on patients----1099    Mr. Feist. Absolutely.1100    Senator Warnock [continuing]. and the quality of the health1101care that they are able to provide. For decades, Medicaid has1102helped fund doctor residency training through the Graduate1103Medical Education, or GME, Program.1104    This program has played a critical role in addressing1105physician shortages in states like Georgia, where more than 2.71106million Georgians live in a health professional shortage area.1107It is clear we need to do more.1108    That is why I was proud to introduce the bipartisan1109Resident Physician Shortage Reduction Act alongside my friend1110Senator Boozman. This bill would fund 14,000 new resident slots1111over the next seven years.1112    Mr. Smith, how would you increase--how would an increase in1113Medicare-funded graduate medical education slots help improve1114our seniors' access to health care services?1115    Mr. Smith. I think any physician--any addition of1116physicians into the market would increase access to care. There1117would be more appointment time and more availability.1118    The challenge we have is convincing those doctors to go1119into primary care and internal medicine. Most of them,1120nowadays, they say, you know, become a neurosurgeon, or you1121know, I want to become an EP doc in cardiology, because there1122is more money there.1123    They are trying to pay off their student debts. They spend1124another year in fellowship. We don't see a significant amount1125of docs wanting to be family practice doctors anymore. I think1126somehow we have got to incentivize that in this program to make1127that more attractive, and the noble position that it used to1128hold in the community.1129    Take some of this administrative burden off of them and let1130them be doctors again. The numbers are great. We need the1131numbers. We know that the shortage by 38 is going to be1132staggering. I think the bill is----1133    Senator Warnock. They are making decisions then about the1134direction of their career and what they will be able to1135practice, not necessarily based on what they prefer to do. Some1136would love to go into primary care. It is an economic issue.1137    In that regard, Dr. Littles, in your experience, how often1138does the cost of higher education in the health professions1139dissuade people from entering the field?1140    Dr. Littles. Thank you for that question. We certainly1141believe that that is a factor. Because as I said, when students1142come into medical school, they come because they really want to1143be able to provide care and spend that time, you know, with1144their patients but they also need to be to make a living in1145doing that.1146    As has been said, it is the primary care specialties that1147are the hardest hit with that because they tend to be at the1148lower end of the pay scale already and if you are asking them1149to do more and more for less and less, at some point that just1150doesn't work, you know, for them.1151    If we are able to fix some of these other issues with those1152practices, I believe those students who come in wanting to take1153care of patients in a primary care setting will continue to1154want to do that and we will continue to do that.1155    Senator Warnock. Absolutely. I would imagine--well, not1156imagine. I know this is particularly difficult for first1157generation college students who have gone on to medical school1158and are--you know, they have the aptitude, but you have these1159barriers.1160    In the last few months, I have heard from thousands of1161Georgians about changes to federal loan limits under the big1162ugly bill, which capped the maximum amount of federal direct1163loans available to students pursuing a health profession. Most1164medical and nursing students in Georgia rely on federal loans1165to afford their education and when federal loans are capped,1166students seeking advanced degrees in health care still owe the1167rest of their bill.1168    Those who don't come from rich families have to then try1169and get risky private loans from banks, or worse, put their1170tuition balance on high-interest credit cards, or even just1171give up their dreams of being a health professional altogether.1172    This is a concern that all of us share. I appreciate your1173work in this area, Dr. Littles, and also other members of the1174panel. I am deeply concerned that these changes to the federal1175student loans amid a growing health care workforce shortage and1176aging population is the exact wrong move at the exact long1177time. Thank you so much.1178    The Chairman. Thank you, Senator Warnock. Senator1179Alsobrooks.1180    Senator Alsobrooks. Thank you so much, Chair Scott, Ranking1181Member Gillibrand, and thank you so much as well to all of our1182witnesses for being here today. Across the country and in1183communities throughout Maryland, physicians are telling us the1184same story.1185    We hear that they are exhausted, overwhelmed, and1186increasingly unsure how long they can continue practicing in a1187system that demands more from them each year, while giving them1188less time, less support, and less autonomy to focus on patient1189care.1190    You know, I had a medical appointment just last week and1191had that experience. The doctor came in, collapsed basically on1192the chair and said, you know, I don't know what we are doing1193here. You know, one patient after the next.1194    Burnout is not simply about long hours. It is about1195physicians spending more and more of their time navigating1196layers of paperwork and trying to operate around complicated1197processes instead of caring for patients. It is shorter visits,1198heavier caseloads, and constant pressure to do more with less.1199    It is about working in environments where asking for help1200can still feel risky or discouraged. In Maryland, I hear from1201providers who want nothing more than to stay in their community1202and care for their patients, but who are struggling under1203administrative complexity, rising operating costs, and1204workplace structures that prioritize volume over quantity.1205    These pressures are driving talented physicians out of1206medicine, and patients are feeling the consequences.1207Appointments are hard to get, wait times are longer, and rural1208and underserved communities are losing providers altogether and1209exhausted clinicians face higher risks of medical error,1210directly affecting patient safety. This is not just a workforce1211issue.1212    It is a health care issue as well, an access issue. It is1213the quality of care and system sustainability issue. At the1214same time, the drastic Medicaid cuts in H.R. 1 threaten to1215further destabilize clinics and hospitals that serve as the1216backbone of primary and preventative care, forcing more1217patients into emergency rooms while placing even greater strain1218on an already stretched workforce.1219    We cannot afford to continue operating a health care system1220that is burning out the very professionals that we depend on.1221Now, I have a question, Mr. Feist, if I can start with you and1222you have spent years working with hospitals, health care1223systems, and policymakers on efforts like Dr. Lorna Breen1224Health Care Provider Protection Act to address physician mental1225health and burnout.1226    Much of the national conversation focuses on helping1227physicians manage stress, but far less on reforming the1228structural conditions that drive burnout in the first place, so1229based on your work, can you tell us what are the most impactful1230preventative reforms that reduce burnout at its root?1231    Mr. Feist. I appreciate the question because you highlight1232the issue. The well-intended response over the last few years1233to the workforce has been to flood the market with a message of1234you need to be more resilient to health workers, when they need1235the problems addressed at the root cause.1236    What we hear from the workforce by asking them the same1237question you asked me is that the administrative burden is the1238number one driver of their burnout. In addition, for nurses,1239the increasing issues around safety and threats and acts of1240violence against them are also driving them completely out of1241the workforce.1242    The workloads are manageable if you think about the fact1243that if you--I am sorry, the workloads can be manageable if you1244reduce the amount of administrative time that they are spending1245before and after work.1246    That in getting health workers back to the bedside and back1247to getting into the direct patient care that they went into the1248business to do, so we need to return them back to what they1249trained for and eliminate as much of the administrative burden1250and other operational inefficiencies that stand between them1251and their patients every day.1252    Senator Alsobrooks. As to workforce violence, I have heard1253a lot about workforce violence. How important is it that1254occupational safety and health administration develop clear1255federal standards to ensure that physicians, nurses, and other1256health care professionals can practice in environments that are1257physically safe, as well as adequately supported?1258    Mr. Feist. A question back to me?1259    Senator Alsobrooks. Yes.1260    Mr. Feist. I think about the Maslow hierarchy of needs. You1261have your essential needs of being able to be fed and watered,1262if you will, use the restroom but then right above that, you1263have safety and feelings of just being physically safe and1264emotionally safe. It is critically important for our workforce.1265    I mean, we don't walk in here every day without armed1266guards outside and yet, we send our health workers into an1267environment where they can be physically and verbally abused1268every day, and then we ask them to come back tomorrow and do it1269all over again. It is just an unsustainable environment for1270them to work in.1271    Senator Alsobrooks. One last question. My time is going1272here. Prior authorization, and this is for Mr. Smith, has1273become a routine gatekeeper in medical care, often requiring1274extensive paperwork, repeated appeals, and long delays before1275patients can receive treatment that their physicians deem1276medically necessary.1277    From your perspective running medical practices, how does1278the current prior authorization system contribute to physician1279burnout? What consequences do you see for patients when1280medically necessary care is delayed or denied, particularly for1281older adults and those in rural and underserved communities?1282    Mr. Smith. Yes, thank you. Prior authorizations are1283delaying care. There is no doubt about it and just to back up1284for a second, burnout is not restricted to doctors. In some of1285our offices, we have over 40 percent of our staff turnover1286every year because they cannot last in this environment. It is1287that difficult.1288    I try to see every class of incoming employees and I tell1289them, health care is not for the faint of heart. It is1290incredibly difficult, and I believe our front desk folks have1291the toughest job in health care. Not the doctors. It is the1292front desk. They need to be psychiatrists, insurance experts,1293best friends. I mean, it is incredibly challenging, all working1294under HIPAA obviously.1295    Prior authorization slows care. We see that, forcing folks1296to go to urgent care, in a lot of cases to the emergency room,1297because we haven't been able to get the authorization. We see1298delays in care. We haven't been able to quantify what that1299means in terms of additional dollars, but I think that would be1300worth looking at because I think that slowdown--we keep saying1301we need to get rid of the administrative burden, but we also1302recognize that the Government doesn't have unlimited money.1303    How do we work together to reduce those burdens so it1304reduces our costs, so we may not need as much of an increase as1305we had thought we did because now we can get rid some staff or1306rearrange some staff.1307    We can back to taking care of patients, because that is1308really--that is what doctors want to do. That is why they went1309to medical school. I believe that prior-auths are our biggest1310issue and truly need to be addressed quickly.1311    Senator Alsobrooks. Thank you.1312    The Chairman. Thank you, Senator Alsobrooks. Dr. Littles,1313what effect does documentation reporting requirements have on1314the willingness of new physicians to practice in rural or1315underserved areas?1316    Dr. Littles. Thank you. We have been talking about the1317stressor of dealing with the electronic health records and the1318number of electronic health record that physicians often have1319to go through in the course of taking care of their patients.1320    When you extend that out into rural communities, oftentimes1321even access to an electronic, you know, health record in and of1322itself--one, it is costly, but sometimes that is difficult for1323them to even have.1324    When they have that electronic health record, we know that,1325you know, the number of clicks that they have to go through to1326provide the documentation is directly related to the stress1327that they feel from that.1328    When you are asking about how the documentation1329specifically is affecting students wanting to go into rural1330practice, among the whole list of other factors that prevent1331them from doing that, that is certainly one of them.1332    The cost of the electronic health record, the complexity of1333using the electronic health record. The fact that the1334electronic health record isn't communicating with the1335physicians they are referring patients to in nearby urban1336areas.1337    All of that has a negative impact. I hear my faculty1338talking all the time about the pajama time that they are1339spending on their electronic health record, which has also been1340mentioned today. All of those are distractions from the care of1341the patient.1342    The Chairman. Thank you. Dr. Gross, tell me how your1343practice changed. How is your day different now from when you1344are running an insurance driven practice to a patient driven1345practice?1346    Dr. Gross. Yes. When I have a fee for service practice, any1347slot in my schedule when I walk into my office that is not1348already filled is lost revenue, so when I walk in, the schedule1349is already full.1350    As the phones start to ring, then I have to start adding1351double booking, triple booking, quadruple booking, referring to1352the emergency room, sending to physician assistants, nurse1353practitioners, sending to other sites of care, because I don't1354have the capacity built within my schedule to accommodate for1355them. Which requires me to run an hour behind schedule, two1356hours behind schedule.1357    Five minute office visits, three minutes of those which are1358spent clicking the boxes to get paid and then the two-minutes,1359oh, you have got another problem. I am sorry, you got to1360rebook, and by the way, my next available appointment is in1361three months. My schedule that I have right now is I walk into1362my office, I have an hour before lunch blocked out for same day1363appointments an hour before lunch, at the end of my day blocked1364out for same-day appointments. As the phone rings, if you call1365me in the morning, you are seen in the warning. As you call in1366the afternoon, you are seen in the afternoon.1367    If I don't get a phone call, then I do administrative time,1368or I go home and spend some time with my family but people1369aren't referred to the emergency room simply because I am too1370busy and that opens up my schedule to actually practice to the1371full scope of my training.1372    I would argue that a lot of referrals in primary care is1373not because the doctor is not capable of handling the problem.1374It is because the doctor doesn't have time to handle the1375problem, so when the doctor now has the time and the1376administrative burden is lifted to perform the full scope of1377his or her practice, now you are stopping downstream referrals1378for endocrinology, for rheumatology.1379    You are managing things within your practice that are1380clearly within your purview as you are training and we see that1381in our data. That when we implement this into a health plan1382that is built around our practice model, our ER referrals are138335 percent less. Our specialty referrals are 35 percent less.1384    Our cost of total implementation of the health plan built1385around our model is a 52 percent reduction in health care in a1386rural health care setting and we sustain numbers like that over1387seven years because we are--not because we are better than1388anyone.1389    It is the structural design of the practice. It is the1390administrative design of the practice, the intent of that,1391which I think is completely changing how we care for patients.1392    The Chairman. Mr. Smith, how much of your budget goes to1393getting prior authorizations, compliance, paperwork versus1394patient care?1395    Mr. Smith. Well that is a good question. I don't have a1396specific answer. I can tell you that in 75 offices, we have at1397least one employee, average employee, with benefits is making1398$35,000 to $50,000, so it is a significant amount and if we1399could reduce that by a quarter, by a half, it would1400significantly change the budget of the medical group.1401    The Chairman. Is it easy to stay up with all the changes by1402the insurance companies and by Medicare and by Medicaid?1403    Mr. Smith. I am sorry. Say that--?1404    The Chairman. Is it easier to stay with all of the rule1405changes by Medicare, Medicaid, plus all the changes with the1406insurance company?1407    Mr. Smith. It is not easy. I mean we do our best to1408educate. We have great staff. You know, our staff typically is1409high school educated. Working in the medical offices, we have1410in-house programs to allow them to become certified medical1411assistants.1412    We do everything we can to raise them up and to increase1413their knowledge, but it is a lot. You know, a one or two doctor1414practice, can't really have a business manager running that1415practice, so we are running it from afar and hoping that we can1416get information to them to allow them to be successful.1417Honestly, just to get paid for the work they are doing.1418    The Chairman. The people who run Medicare and Medicaid in1419your state, they are just out there to help you every day,1420aren't they?1421    Mr. Smith. Yes, every day they come out. [Laughter.] No. It1422is a challenge.1423    The Chairman. Mr. Feist, how much of today's mental health1424crisis is driven not by patient care itself but by the constant1425pressure of bureaucracy and red tape?1426    Mr. Feist. We hear--as we have discussed today, when you1427think about burnout as an occupational syndrome and burnout as1428driven by the workplace design, I think as we discussed today1429the vast majority of what we are experiencing in burnout is1430within our control to reduce by changing the operational1431environment that our health care workers work in every single1432day.1433    The Chairman. Well, I want to thank everybody for being1434here today. This was eye opening and hope all of our colleagues1435in the Senate see all this.1436    I think it is very difficult what physicians are going1437through and I think more and more physicians are doing what you1438are doing, Dr. Gross. They have got to opt out of the way the1439system is organized because it is just too difficult.1440    I am sure you deal with, Dr. Littles, all the time with,1441you know, the choices people are making, so thanks everybody1442for being here. It is clear that real reforms must start with1443cutting red tape and putting doctor-patient relationships at1444the center of health care so physicians can focus on healing1445rather than compliance.1446    I look forward to continuing to work with members across1447the aisle and down the dais. If any Senators have additional1448questions for the witnesses or statements to be added, the1449hearing record will be open until next Wednesday at 5:00 p.m.1450Thank you very much. It is adjourned.1451    [Whereupon, at 04:45 p.m., the hearing was adjourned.]14521453=======================================================================14541455                                APPENDIX14561457=======================================================================14581459=======================================================================14601461                      Prepared Witness Statements14621463=======================================================================14641465                 U.S. Senate Special Committee on Aging14661467  "The Doctor is Out: How Washington's Rules Drove Physician's Out of1468                               Medicine"14691470                           February 11, 202614711472                       Prepared Witness Statement14731474                            Dr. Alma Littles14751476[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]14771478                 U.S. Senate Special Committee on Aging14791480  "The Doctor is Out: How Washington's Rules Drove Physician's Out of1481                               Medicine"14821483                           February 11, 202614841485                       Prepared Witness Statement14861487                             Dr. Lee Gross14881489[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]14901491                 U.S. Senate Special Committee on Aging14921493  "The Doctor is Out: How Washington's Rules Drove Physician's Out of1494                               Medicine"14951496                           February 11, 202614971498                       Prepared Witness Statement14991500                             Jeffrey Smith15011502[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]15031504                 U.S. Senate Special Committee on Aging15051506  "The Doctor is Out: How Washington's Rules Drove Physician's Out of1507                               Medicine"15081509                           February 11, 202615101511                       Prepared Witness Statement15121513                              Corey Feist15141515[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]15161517=======================================================================15181519                        Questions for the Record15201521=======================================================================15221523                 U.S. Senate Special Committee on Aging15241525  "The Doctor is Out: How Washington's Rules Drove Physician's Out of1526                               Medicine"15271528                           February 11, 202615291530                        Questions for the Record15311532                            Dr. Alma Littles15331534                          Chairman Rick Scott15351536    Question:15371538    You highlighted during the hearing that even modest1539reductions in documentation and administrative workload can1540meaningfully increase patient-facing time and reduce burnout.1541For small, independent, or rural practices that lack large IT1542departments, what types of digital infrastructure or workflow-1543support platforms are most practical and scalable to eliminate1544redundant documentation, streamline prior authorization, and1545improve care coordination?15461547    Response:15481549    For small, independent, or rural practices, the most1550practical approaches are hub and spoke digital infrastructure1551models, where core clinical and administrative capabilities are1552provided through a regional or system-level platform (Health1553System or State Entity), rather than requiring each practice to1554maintain its own IT department.15551556Examples of practical platforms include:15571558      
Shared EHR instances or hosted environments (e.g., a1559regional Epic or Cerner/Oracle deployment) that allows rural1560practices and hospitals to plug into enterprise-grade1561documentation, ordering, and care coordination workflows1562without bearing full implementation or maintenance costs.1563      
Embedded workflow automation layers within those1564Electronic Health Records (EHR), such as native AI,1565standardized prior authorization modules, centralized referral1566management, and system-level clinical documentation templates,1567that eliminate duplicative charting and manual handoffs.1568      
Cloud-based care coordination and interoperability tools1569that leverage TEFCA (Trusted Exchange Framework and Common1570AgreementT) and FHIR (Fast Healthcare Interoperability1571Resourcesr) standards to ensure patient information flows1572seamlessly across sites in a regional network.15731574Sample incentives to support this model:15751576      
Federal grants or enhanced matching funds for shared EHR1577hosting arrangements between larger health systems and rural or1578independent practices.1579      
CMS recognition of regional digital health hubs (e.g.,1580"Certified Rural Integration Platforms") that meet1581interoperability, uptime, and governance standards.1582      
Reduced reporting or documentation requirements for1583practices that participate in an approved shared infrastructure1584model.15851586Payer Integration Incentive:15871588      
Provide enhanced reimbursement rates, administrative1589cost-sharing, or preferred network status for payers that1590integrate directly into shared EHR platforms (e.g., Epic's1591Payer Platform) used by regional hubs and rural spokes,1592allowing real-time eligibility, authorization, care gap1593closure, and quality reporting. This reduces payer1594administrative overhead, improves risk adjustment accuracy, and1595lowers avoidable utilization through shared clinical1596visibility.15971598    Question:15991600    What federal policy changes would most accelerate adoption1601of such solutions while maintaining appropriate safeguards for1602patient privacy and program integrity?16031604    Response:16051606Reward integration rather than fragmentation. Examples of1607policy changes:1608      
Clarifying regulatory safe harbors under Stark, Anti-1609Kickback, and Civil Monetary Penalty rules to explicitly allow1610health systems to subsidize or host digital infrastructure for1611affiliated rural or independent practices, provided1612interoperability and patient choice standards are met.1613      
Standardizing privacy and governance frameworks for1614shared EHR and data platforms, so smaller practices are not1615forced to independently interpret HIPAA, state privacy laws, or1616cybersecurity requirements.1617      
Aligning federal quality and reporting programs (e.g.,1618MIPS, Promoting Interoperability) so participation through a1619shared platform satisfies compliance requirements, instead of1620duplicating reporting at each site.16211622Sample incentives:16231624      
A federal "integration bonus" applied to Medicare1625reimbursement for practices participating in validated regional1626digital infrastructure arrangements.1627      
Preferential eligibility for CMS innovation models or1628rural health demonstrations for systems that demonstrate multi-1629site EHR integration and shared workflows across urban and1630rural settings.1631      
Liability and audit protections for practices using1632federally recognized shared platforms that meet predefined1633security and integrity benchmarks.16341635Policy Safe Harbor for Payer Participation:16361637      
Establish explicit federal safe harbors and1638demonstration authority allowing payers to co-invest in shared1639clinical and administrative infrastructure, such as hosted1640EHRs, payer-provider data platforms, or integrated utilization1641management tools, when tied to measurable reductions in1642administrative burden, duplicative services, and total cost of1643care, while maintaining strict governance and patient consent1644standards.16451646    Question:16471648    Additionally, how should federal payment or demonstration1649programs be structured to incentivize adoption of workflow-1650enhancing digital tools, including AI-enabled documentation,1651coding, or administrative support platforms that measurably1652reduce clinician time spent on non-clinical tasks?16531654    Response:16551656    One thing to consider with any demonstration program is1657whether or not small physician practices will be able to1658successfully participate. Physicians in small practices and1659those in rural areas spend inordinate amounts of time just1660requesting and waiting for patient records to reach them.1661Access to patient care documents from consulting physicians1662enhances efficiency and quality of care. Having systems that1663fully integrate between hospitals, consulting physician1664practices and primary care physician practices is critical. For1665that to happen, small practices will need to be able to receive1666adequate funding and support without the fear of costly1667recoupments or excessive program penalties. While costs are a1668crucial and necessary consideration for the government, if1669small practices are not equipped with the resources they need1670to acquire the software and potentially hardware needed, the1671demonstration may be effectively limited to larger hospital1672systems while excluding many smaller practices that could1673benefit the most from measures aimed at reducing administrative1674burdens.16751676Effective program design should move beyond merely "checking1677the box":16781679      
Tie incentives to outcomes, such as reductions in1680clinician documentation time per visit, faster prior1681authorization turnaround, or increased patient-facing minutes,1682rather than simply purchasing the technology.1683      
Encourage system-level deployment of AI-enabled tools1684(e.g., ambient documentation, automated coding, centralized1685prior authorization engines) that benefit multiple sites1686simultaneously.1687      
Allow savings from administrative efficiency to be1688shared between clinicians, practices, and hosting systems,1689reinforcing alignment.16901691Sample incentive structures:16921693      
CMS demonstration programs that provide per-clinician or1694per-visit bonuses when validated AI or automation tools reduce1695time spent on documentation, coding, or administrative tasks.1696      
Shared-savings models where reductions in administrative1697cost or denied claims are partially returned to participating1698practices and hosting health systems.1699      
Temporary expense recognition or add-on payments for the1700first 2-3 years of enterprise-scale implementation of workflow-1701enhancing tools, particularly when deployed across rural1702networks.17031704Shared Payer Administrative Savings & Risk Alignment:17051706      
Structure demonstrations so payers participating in1707integrated EHR and workflow platforms are eligible to share in1708documented reductions in administrative costs, denial rates,1709and unnecessary utilization. For example, CMS could allow1710Medicare Advantage plans or Medicaid MCOs to retain a portion1711of savings generated through real-time clinical integration,1712automated prior authorization, and AI-enabled documentation-1713provided savings are reinvested into provider-facing workflow1714improvements.17151716                        Senator Elizabeth Warren17171718    Question:17191720    Insurance conglomerates and wholesale drug distributors are1721now major employers of physicians. For example, UnitedHealth1722Group (UHG) is the nation's largest employer of physicians, and1723McKesson owns the largest community oncology network.1724    Are you concerned about how these middlemen influence their1725physician employees and independent physician competitors,1726including graduates of your medical school, given their1727incentives to raise prices, lower quality, and drive1728independent providers out of business?17291730    Response:17311732    Organized medicine, in general, opposes the corporate1733practice of medicine because these types of arrangements can1734compromise patient care. Over the past decade or so, physician1735groups have been consolidating at an unprecedented pace.1736Medical groups keep growing larger as physician practices merge1737or sell out in the face of serious economic challenges and, as1738a result, there are now more physicians serving as employes1739than as practice owners. In short, the medical landscape has1740fundamentally changed and there are no signs that this change1741is set to reverse course. One critical reason for this shift is1742that it has become increasingly difficult to manage the cost1743and complexity of running an independent practice, particularly1744due to regulatory red tape and unfair insurance practices.1745    In addition, the conversion factor under the Medicare1746Physician Fee Schedule is not pegged to inflation and has1747fallen around 33% in real value since 2001, which poses a1748serious challenge for physicians who care for seniors. Given1749this reality, it is more important than ever to support1750physicians that want to remain in private practice, so that1751doctors who do not want to work for larger organizations will1752continue to have the opportunity to practice independently. To1753do this, we must cut down on burdens like prior authorization,1754end step-therapy or "fail first" protocols, eliminate unfair1755payment practices such as retroactive denials, ensure that1756payors maintain adequate networks of physicians, and provide1757annual Medicare payment updates that track inflation. Taken1758together, these measures would help make it easier for small1759medical practices to remain economically viable in this1760challenging environment and reduce the spread of the corporate1761practice of medicine.1762    It is important to distinguish care-aligned integration1763from middleman-driven consolidation.1764    Integrated delivery and financial systems like Kaiser1765Permanente and UPMC align insurance, care delivery, and1766population health accountability under unified governance.1767Their success depends on keeping patients healthy, reducing1768unnecessary utilization, and reinvesting in clinical1769infrastructure, creating a fundamentally different incentive1770structure.1771    By contrast, when insurance conglomerates or wholesale drug1772distributors employ physicians or acquire networks without1773direct accountability for care delivery, there is always the1774risk that financial incentives, not patient outcomes, drive1775decisions. That concern is heightened when those entities also1776compete with independent practices or control access points1777like drug purchasing, referrals, prior authorization, or data.1778    The concern is not physician employment itself, but who1779controls clinical decision-making and market leverage. At the1780same time, fragmentation is not the answer.1781    Ultimately, policy should encourage integration models that1782align financing, care, and accountability, while placing1783guardrails around consolidation that narrows competition or1784compromises clinical autonomy.17851786Examples:17871788      
Risk-Bearing Requirement for Advanced Payment Models:1789Limit eligibility for top-tier shared-savings, global budget,1790or capitation programs to organizations that directly deliver1791care and assume downside clinical risk-favoring Integrated1792Delivery and Finance System (IDFS) over administrative1793intermediaries.17941795      
System-Level Quality & Cost Accountability: Attribute1796outcomes, utilization, and total cost of care at the integrated1797system level (not subsidiary or vendor level), advantage1798organizations where financing and clinical operations are1799inseparable.18001801      
Care-First Antitrust Presumption: Apply more permissive1802antitrust treatment to vertically integrated entities that both1803finance and deliver care (e.g., Kaiser), while applying1804stricter scrutiny to entities that control care pathways1805without delivering care themselves.18061807    In addition to the support for physician practices, support1808for patient participation in digital support tools must be1809considered. In many rural areas, connectivity to the internet1810is a problem. Satellite internet is slow and expensive. Many1811patients do not have home internet. Telehealth and tele-1812consults are helpful when patients can get access to the1813internet; however, Medicaid apparently stopped paying for tele-1814consult services after the peak of the COVID-19 Pandemic.18151816                 U.S. Senate Special Committee on Aging18171818  "The Doctor is Out: How Washington's Rules Drove Physician's Out of1819                               Medicine"18201821                           February 11, 202618221823                        Questions for the Record18241825                             Dr. Lee Gross18261827                        Senator Elizabeth Warren18281829    Question:18301831    In 2010, you started a direct primary care practice. Direct1832primary care practices typically charge patients a flat fee to1833cover basic services and do not accept public or private1834insurance. This often requires insured patients to forgo their1835benefits and pay out of pocket.1836    1(a)What role did large insurance conglomerates play in1837your decision to start a direct primary care practice?1838    1(b)Would legislative reform that breaks up Big Medicine1839conglomerates make it easier for you to run your practice?1840    1(c)Would legislative reforms that prohibit prior1841authorization make it easier for you to run your practice?18421843    Response to 1(a):18441845    Large insurance entities were not the only factor in my1846decision, but they were part of a broader structural1847environment that increasingly shaped how care was delivered.1848Over time, payment architecture and administrative requirements1849began to exert growing influence on clinical workflows.1850Utilization management protocols, prior authorization1851requirements, and complex billing rules were originally1852introduced with the stated goal of protecting patients from1853inappropriate or excessive care. In practice, these systems1854gradually evolved into administrative layers that often operate1855independently of the clinical encounter itself.1856    As these processes expanded, they began to consume1857increasing amounts of physician time and practice resources.1858The cumulative effect made it harder to sustain a model1859centered on continuity, access, and individualized decision1860making. Policies intended to address isolated misuse became1861standardized requirements applied across the entire system.1862Tools designed to identify outliers came to shape routine care.1863Over time, the system shifted from targeting rare instances of1864misuse to treating every clinical decision as if it required1865preauthorization, effectively replacing professional trust with1866administrative permission.1867    Direct primary care allowed me to test whether removing1868administrative friction between physician and patient would1869change outcomes. By simplifying payment and eliminating1870intermediated approval requirements for routine care, the model1871reduced overhead and increased time available for clinical1872care. The objective was not to avoid insurers, but to evaluate1873what happens when administrative complexity is minimized and1874clinical decisions occur directly within the physician patient1875relationship.1876    My experience working with DeSoto Memorial Hospital1877illustrates this dynamic. The hospital implemented a self1878funded employee health plan that eliminated prior authorization1879and similar approval barriers for routine care within the1880plan's structure for employees that chose DPC. Removing those1881administrative layers allowed treating physicians to proceed1882based on clinical judgment rather than external authorization.1883The result was a substantial reduction in total health plan1884spending along with improved employee benefits. That outcome1885highlights an important distinction. When administrative1886intermediaries are removed from routine care decisions, both1887cost and access can improve simultaneously. This suggests that1888many inefficiencies attributed to medical care itself may1889instead originate within payment and oversight structures that1890sit between patients and clinicians.18911892[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]18931894    Response to 1(b):18951896    Market concentration in healthcare warrants serious1897scrutiny, particularly when corporate structures combine1898financing, delivery, pharmacy, and utilization oversight within1899the same enterprise. When a single entity is responsible for1900paying for care, determining whether care is approved, and in1901some cases delivering that care, structural conflicts of1902interest are not theoretical. From an incentive design1903standpoint, they are inherent. Such arrangements create1904powerful financial incentives to influence clinical pathways,1905access to services, and treatment approvals in ways that may1906not be transparent to patients or physicians.1907    These vertically integrated models can shift decision1908making authority away from the point of care and toward1909entities whose primary fiduciary obligation is financial1910performance rather than clinical outcomes. That dynamic can1911affect utilization policies, network design, reimbursement1912structures, and approval standards. When those levers are1913controlled within the same organization, the distinction1914between clinical management and financial management can become1915blurred.1916    At the same time, consolidation trends reflect multiple1917reinforcing forces, including regulatory complexity, reporting1918mandates, and compliance costs that disproportionately burden1919smaller practices. Many physicians have entered large systems1920not because of clinical preference, but because scale offers1921protection from administrative overhead that independent1922practices struggle to absorb. In that sense, consolidation is1923not purely a market phenomenon. It is often a rational response1924to policy design.1925    For that reason, structural breakups alone would not1926automatically restore a competitive physician led marketplace.1927If the regulatory environment that favors scale remains1928unchanged, new entities would likely reconsolidate to manage1929the same administrative demands. Structural remedies may1930therefore be necessary, but they will not be sufficient unless1931policymakers also address the underlying policy incentives that1932make consolidation economically rational.19331934    Response to 1(c):19351936    Yes. Prior authorization is among the most resource1937intensive administrative processes in clinical medicine. It1938requires time, staffing, and documentation that do not directly1939contribute to patient care. In many cases it delays treatment1940while approvals are obtained from third parties who are not1941directly involved in the clinical evaluation.1942    Reducing unnecessary prior authorization requirements would1943improve efficiency and timeliness of care. It would also1944redirect clinical staff time toward patient services rather1945than administrative processing. More broadly, it would help1946restore decision making authority to the point of care, where1947physicians are accountable for outcomes. Oversight mechanisms1948are important, but when approval processes become routine1949prerequisites for standard treatment, they can shift control of1950clinical decisions away from those directly responsible for the1951patient and toward entities whose primary role is financial1952administration.19531954Additional Concern: Expansion of Prior Authorization and Risk1955of Administrative Drift19561957    Recent policy developments indicate that prior1958authorization requirements are being introduced into additional1959areas of public coverage through pilot programs that apply1960prospective approval requirements to selected services. These1961initiatives are intended to improve program integrity and1962reduce inappropriate spending. At the same time, they1963illustrate how administrative tools introduced for limited1964purposes can expand over time in both scope and operational1965impact.1966    Historical experience suggests that utilization management1967systems can evolve beyond their initial targets. In the private1968sector, some insurers previously used physician utilization1969scoring programs tied to prescribing or imaging patterns.1970Physicians with higher scores were exempt from certain1971administrative steps, while others faced increasing approval1972requirements. In practice, such systems often affected1973clinicians who treated more complex patients or who practiced1974in fields where higher utilization reflected appropriate care.1975    Another example of clinical guidance evolving into1976administrative constraint is the American Geriatrics Society1977Beers Criteria. Originally intended as a reference tool to help1978clinicians identify potentially inappropriate medications in1979older adults, the criteria have increasingly been incorporated1980into quality metrics, payer policies, and utilization controls.1981In some settings this has effectively turned a clinical1982guideline into a compliance standard, where deviation can1983trigger scrutiny even when medically appropriate. This1984illustrates a recurring policy pattern. Tools created to inform1985physician judgment can gradually be repurposed to regulate it.1986    The concern is not the existence of oversight mechanisms,1987but how they evolve. Safeguards that begin as targeted1988protections can, if not periodically reassessed, become1989generalized administrative requirements that influence routine1990care decisions.19911992Additional Policy Perspective for the Record19931994    The central problem in healthcare is rarely who1995participates in the system. It is how the rules shape their1996incentives.1997    Certain statutory and regulatory structures can1998unintentionally influence institutional behavior through their1999design. Payment rules that tie allowable administrative margins2000to total spending levels, for example, may affect how2001organizations evaluate cost reducing innovations. While such2002policies may limit excessive overhead, they can also create2003situations in which lowering total spending alters financial2004calculations for participating entities.2005    Organizations generally respond predictably to the2006incentives embedded within policy frameworks. When those2007incentives reward volume, complexity, or administrative control2008rather than efficiency and outcomes, system behavior will2009reflect that structure. Policymakers therefore face an2010incentive design challenge rather than a choice between public2011or private delivery models. The key issue is whether payment2012policy aligns institutional incentives with the goals of2013affordability, access, and clinical quality.2014    Sustainable reform is most likely when those incentives are2015calibrated so that patients, physicians, employers, and payers2016all benefit from the same outcome: appropriate care delivered2017efficiently, transparently, and with minimal administrative2018friction.20192020                 U.S. Senate Special Committee on Aging20212022  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2023                               Medicine"20242025                           February 11, 202620262027                        Questions for the Record20282029                             Jeffrey Smith20302031                        Senator Elizabeth Warren20322033    Question:20342035    The passage of the One Big Beautiful Bill Act, coupled with2036the expiration of the Affordable Care Act's enhanced premium2037tax credits, will likely lead to a significant increase in the2038number of uninsured Americans and a concurrent increase in2039uncompensated care, compounding the financial pressures on2040safety-net hospitals and independent physician practices.2041    How do you anticipate providers and safety-net hospitals2042will respond?20432044    Response:20452046    Medical groups will likely provide more uncompensated care2047and face new financial pressures as patients lose coverage due2048to the ACA enhanced premium tax credit expiration and Medicaid2049changes under the One Big Beautiful Bill Act. The response from2050medical group practices will depend on the ability of their2051respective states to intervene and offset some of these costs2052through state-level assistance and policy. Practices,2053especially in underserved and rural areas who serve a diverse2054payer mix, will face financial strain as they absorb more care2055without payment, threatening the stability of safety-net access2056points and independent practices.2057    As uninsured rates increase, medical group practices will2058be forced to take on a substantial administrative burden, such2059as increased eligibility verifications. Front-office staff will2060also shoulder the burden of helping patients who may have lost2061coverage and facilitating out of pocket payment options. As2062financial pressures intensify, group practices may be pushed2063toward selling their practices or closing entirely.20642065    Question:20662067    How will intensifying consolidation further erode2068physicians' autonomy over their patients' medical care?20692070    Response:20712072    Consolidation results from physician owners selling their2073practices and becoming employed in a health system or hospital.2074This change can impact physician autonomy because, unlike2075smaller practices, large health systems often operate in more2076structured environments and may lead to less physician control2077over their schedules, practice structure, and other operational2078activities. By contrast, independent groups can offer2079physicians meaningful control over their work, where partners2080may set their own schedules and adjust workloads, and shape2081operational decision-making.2082    2025 State of Private Medical Practice report speaks to how2083intensifying consolidation impacts autonomy. The survey was2084conducted online from April - May 2025 and received a total of2085240 responses.20862087      
Consolidation is a top driver of declining optimism:2088Among leaders who feel less optimistic about independent2089practice, 54% cite "increasing consolidation of healthcare".2090      
Autonomy is a central component of professional2091independence: 40% of members identify autonomy and independent2092decision-making as a key benefit of private practice, while 47%2093cite quality of care/patient focused as a key benefit of2094working in an independent practice.2095      
Financial and payer pressures are pushing groups toward2096mergers and acquisition, shifting governance away from2097physicians: When asked about necessary changes to ensure2098practices' sustainability, 28% of respondents selected2099"increasing practice size via mergers and acquisitions,"2100signaling that many practices view consolidation as survival.2101    Question:21022103    Following a February 2024 cyberattack on its subsidiary,2104Change Healthcare, UHG extended emergency loans to affected2105providers via its subsidiary bank, Optum Financial. Physician2106borrowers later reported that UHG was acting like a "loan2107shark," abruptly demanding full repayment under threat of yet2108another subsidiary, the insurer UnitedHealthcare, and2109garnishing claim reimbursements as a means of repayment.2110    If applicable, can you provide examples of the way that2111Optum Financial and UHG are treating your members who were2112forced to take these emergency loans?21132114    Response:21152116    While we are aware of ongoing lawsuits related to the2117Change Healthcare cyberattack, we have not heard from members2118about their current interactions with Optum Financial.21192120    Question:21212122    Are any of your members still dealing with the financial2123fallout from this cyberattack and UHG's response to it? If so,2124in what ways are they affected?21252126    Response:21272128    The Change Healthcare cyberattack had wide-ranging2129financial impacts for medical groups beginning in February21302024, that included:21312132      
Substantial billing and cash flow disruptions, such as a2133lack of electronic claims processing. Both paper and electronic2134statements were delayed, with some groups going without any2135outgoing charges or incoming payments immediately following the2136cyberattack.2137      
Limited or no electronic remittance advice from health2138plans, groups had to manually pull and post from payer portals.2139      
Prior authorization submissions were rejected or were2140not transmittable at all.2141      
Lack of connectivity to important data infrastructure.2142      
Lack of ability to perform eligibility checks for2143patients.2144    Members continued to express residual financial concerns2145into 2025 related to unpaid claims, benchmarking and data2146issues, and more. While we have not heard from members recently2147given the amount of time that has passed, all of these2148disruptions amplified underlying systemic financial issues,2149such as staffing shortages and continued inadequate2150reimbursement from Medicare.21512152                 U.S. Senate Special Committee on Aging21532154  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2155                               Medicine"21562157                           February 11, 202621582159                        Questions for the Record21602161                               Cory Feist21622163                          Chairman Rick Scott21642165    Question:21662167    You highlighted during the hearing that even modest2168reductions in documentation and administrative workload can2169meaningfully increase patient-facing time and reduce burnout.2170For small, independent, or rural practices that lack large IT2171departments, what types of digital infrastructure or workflow-2172support platforms are most practical and scalable to eliminate2173redundant documentation, streamline prior authorization, and2174improve care coordination?21752176    Response:21772178    Thank you for the opportunity to respond to Chairman2179Scott's questions regarding the administrative burdens fueling2180the exodus of physicians from the medical profession. For2181small, independent, and rural practices, the "administrative2182tax" is a primary driver of burnout and distress. To support2183clinicians serving in these critical settings, we must2184prioritize digital infrastructure that is interoperable,2185automated, and low-friction.2186    Before implementing specific technologies, I urge all2187practice leaders to review and implement action steps outlined2188in the Impact WellbeingT Guide: Taking Action to Improve2189Healthcare Worker Wellbeing. This transformative resource,2190supported by the Dr. Lorna Breen Health Care Provider2191Protection Act, has already equipped over 35,000 healthcare2192leaders with evidencebased strategies to address the2193operational factors and burdens that drive their workforce's2194burnout.2195    Practice leaders can then take additional steps to reduce2196documentation burden, streamlineworkflow, and improve care2197coordination:21982199    Reducing the Documentation Burden: Ambient Listening AI2200Technology22012202    The Electronic Health Record (EHR) has transitioned from a2203clinical tool to a billing ledger, forcing physicians into2204"pajama time". For small practices, ambient listening AI2205technology or AI-driven scribes represent a significant leap in2206workload reduction. Recent implementation of the Impact2207Wellbeing Guide by one Virginia hospital showed that Ambient2208listening AI technology can reduce documentation time by 10-152209minutes per patient visit while simultaneously improving2210patient experience ratings. Another rural Virginia hospital2211decreased their workforce's cognitive burden by addressing EHR2212alert fatigue-reducing unnecessaryinpatient alerts by 52% and2213unnecessary ambulatory alerts by 73% per month.2214    By automating the generation of structured clinical notes,2215ambient listening AI technology allows physicians and other2216care givers to return their focus to the patient rather than a2217screen.22182219Streamlining Workflow: Electronic Prior Authorization (ePA)22202221    Prior authorizations are a source of profound2222administrative burden as clinicians spend nearly two business2223days a week completing these requirements. Similar to the2224legislative approaches in New Jersey and Virginia, we must move2225toward integrated ePA platforms that reside within the e-2226prescribing workflow. I strongly urge the Committee to support2227S. 1816 The Improving Seniors' Timely Access to Care Act of22282025 to reduce this administrative burden and ensure seniors2229can access the treatments they need.22302231Improving Care Coordination: Asynchronous Communication22322233    Rural health is inherently collaborative, yet clinicians2234are often underwater with documentation and coordination tasks.2235We recommend the adoption of HIPAA-compliant asynchronous2236messaging hubs to replace the inefficiency of "phone tag".2237Furthermore, practices should address EHR alert fatigue. As2238noted above, we have seen evidence in Virginia that targeted2239quality improvement projects can reduce unnecessary ambulatory2240alerts by up to 73% per month, significantly decreasing the2241cognitive burden on the workforce.2242    Beyond technical infrastructure, we must address the2243"invisible" administrative barriers that prevent clinicians2244from seeking help. Many legacy licensing and credentialing2245applications ask intrusive, stigmatizing questions about a2246clinician's mental health history. Consistent with2247recommendations in the Impact Wellbeing Guide, our Foundation2248and its coalition of national healthcare organizations has2249supported 70 licensure boards and 2,115 health care facilities2250in auditing and removing these questions, improving access to2251mental health care for more than 2.64 million licensed health2252workers. By shifting the focus from past diagnosis to current2253impairment, we create a culture where getting mental health2254support is treated as a normal, healthy part of the job.2255    For the independent physician, time is the most precious2256resource. The newly reauthorized Lorna Breen Act prioritizes2257projects that reduce administrative burden, freeing up2258clinicians to focus on patient care while supporting their2259wellbeing. I urge Congress to provide full funding of $45M in2260FY27 for Lorna Breen Act programs. By funding these programs2261now and in the future, and by taking the steps outlined above,2262we can protect the backbone of our healthcare system. We must2263move from a system that depletes our workforce to one that2264sustains them with safety and operational support.22652266    Question:22672268    What federal policy changes would most accelerate adoption2269of such solutions while maintaining appropriate safeguards for2270patient privacy and program integrity?22712272    Response:22732274    To most effectively accelerate the adoption of these2275burnout-reducing technologies while maintaining program2276integrity and patient privacy, federal policy must transition2277from permissive to proactive support.2278    Based on the evidence-based framework of the National2279Academy of Medicine (NAM) National Plan for Health Workforce2280Well-Being and the operational successes of the Dr. Lorna Breen2281Health Care Provider Protection Act, we recommend the following2282federal policy changes:22832284Sustained Funding for Workforce Retention22852286    Federal investment has historically focused on the pipeline2287(creating new clinicians) while ignoring the leaks (losing2288existing clinicians). As I referenced in my written testimony,2289tens of billions of dollars are directed annually for2290healthcare workforce creation initiatives, but the Lorna Breen2291Act programs are the only ones to directly support workforce2292retention. Congress must provide full and consistent annual2293funding for the newly reauthorized Lorna Breen Act, which2294ensures federal dollars are used for proven operational2295improvements rather than superficial wellness programs.22962297Standardizing Electronic Prior Authorization (ePA)22982299    The administrative burden of prior authorizations currently2300consumes nearly two business days a week for physicians. By2301passing and implementing S. 1816 The Improving Seniors' Timely2302Access to Care Act, we can ensure a standardized, real-time2303electronic prior authorization process for Medicare Advantage2304plans. Utilizing the HL7 FHIR (Fast Healthcare Interoperability2305Resources) standard will ensure secure and transparent data2306exchange that does not create new avenues for "upcoding" or2307fraudulent claims.23082309Codifying Documentation Relief through AI "Safe Harbors"23102311    While Ambient Notes AI can reduce documentation time by 10-231215 minutes per patient visit, small practices often hesitate to2313adopt it due to concerns over future audit scrutiny. By2314establishing CMS "Safe Harbor" guidelines that explicitly2315recognize AI-generated, physicianvalidated ambient notes as2316meeting medical necessity and documentation requirements for2317Medicare/Medicaid reimbursement, will give small practices the2318peace of mind they need to adopt this transformative2319technology. Requiring these platforms to maintain HIPAA-2320compliant, SOC2-certified data encryption will ensure patient2321conversations remain private and are not used for unauthorized2322secondary purposes.23232324Incentivizing "Low-Burden" EHR Configurations23252326    Small practices often suffer from "EHR alert fatigue," yet2327they lack the IT staff to optimize these systems. By2328establishing federal grants or "Wellbeing Meaningful Use"2329incentives for EHR vendors and practices that successfully2330reduce cognitive load, we can help small practices make the2331most of these systems, perhaps even achieving benchmarks like2332the 73% reduction in ambulatory alerts as demonstrated by2333quality improvement projects implemented in Virginia using the2334Lorna Breen Act resources. This shifts the focus of technology2335from a billing ledger to a clinical tool that supports-rather2336than depletes-the workforce.2337    We cannot care for our aging population if we do not care2338for those who care for them. By removing the red tape and2339making technology work for people, we preserve the 30 to 402340years of expertise each clinician provides to the American2341public - an urgent priority given projected workforce2342shortages.23432344    Question:23452346    Additionally, how should federal payment or demonstration2347programs be structured to incentivize adoption of workflow-2348enhancing digital tools, including AIenabled documentation,2349coding, or administrative support platforms that measurably2350reduce clinician time spent on non-clinical tasks?23512352    Response:23532354    To move the needle on clinician burnout, federal payment2355and demonstration programs must shift from rewarding volume of2356documentation to rewarding quality of care for patients and2357clinicians.2358    By funding newly reauthorized Lorna Breen Act grants,2359Congress can help support operational changes that reduce2360administrative burden. With resources from the Lorna Breen Act,2361hospitals have successfully improved the wellbeing of health2362workers by decreasing administrative burden. They have seen2363significant decreases in both diagnosed mental health2364conditions like depression and turnover.2365    Federal demonstrations should require the use of evidence-2366based or evidence-informed resources like the Impact WellbeingT2367Guide to ensure that digital tools are integrated into a2368supportive, safe workplace culture rather than simply added to2369existing workloads.23702371Mandating Interoperability for Prior Authorization23722373    Federal policy must accelerate the adoption of electronic2374Prior Authorization (ePA) to eliminate the "clerical detective2375work" that currently consumes nearly two business days a week2376for physician staff.2377    Immediate passage and implementation of S. 1816 The2378Improving Seniors' Timely Access to Care Act of 2025 would2379mandate a standardized electronic process for Medicare2380Advantage plans. Future payment models should penalize "manual-2381only" authorization processes that delay care and increase2382clinician distress.23832384Removing Legal and Regulatory Barriers to Wellbeing23852386    Incentivizing use of effective technological tools is only2387half the battle; we must also ensure thatclinicians feel safe2388enough to seek support while they manage these system2389transitions.2390    Federal programs should require participating health2391systems to audit and remove stigmatizingmental health questions2392from their credentialing applications. To date, this initiative2393has alreadyimproved access to care for more than 438,0002394credentialed health workers.23952396Tiered Reimbursement Incentives for "Burden-Reduced" Care23972398    Federal payment programs, particularly those within CMS,2399should provide enhancedreimbursement or bonus payments for2400practices that utilize certified ambient listening AItechnology2401and other AI-enabled administrative tools.2402    A "Wellbeing Tier" within the Merit-based Incentive Payment2403System (MIPS) or AlternativePayment Models (APMs) could reward2404practices based on a number of factors such as measurably2405reducing time spent on non-clinical tasks. For one rural2406hospital in Virginia, the use of ambient listening AI has been2407shown to reduce documentation time by 10-15 minutes per patient2408visit, directly allowing for more patient-facing time.2409    Implementing these and other similar programs, we need to2410balance the federal investment between focusing exclusively on2411pipeline creation to prioritizing workforce retention. By2412providing full and consistent annual funding for Lorna Breen2413Act programs in FY27 and beyond, Congress can ensure that2414technology works for people, preserving our health workforce to2415care for our aging population.24162417=======================================================================24182419                       Statements for the Record24202421=======================================================================24222423                 U.S. Senate Special Committee on Aging24242425  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2426                               Medicine"24272428                           February 11, 202624292430                       Statements for the Record24312432                    American Academy of Dermatology24332434[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]24352436                 U.S. Senate Special Committee on Aging24372438  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2439                               Medicine"24402441                           February 11, 202624422443                       Statements for the Record24442445            American Academy of Family Physicians Statement24462447[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]24482449                 U.S. Senate Special Committee on Aging24502451  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2452                               Medicine"24532454                           February 11, 202624552456                       Statements for the Record24572458         American Association of Orthopaedic Surgeons Statement24592460[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]24612462                 U.S. Senate Special Committee on Aging24632464  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2465                               Medicine"24662467                           February 11, 202624682469                       Statements for the Record24702471          American Clinical Neurophysiology Society Statement24722473[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]24742475                 U.S. Senate Special Committee on Aging24762477  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2478                               Medicine"24792480                           February 11, 202624812482                       Statements for the Record24832484      American Economic Liberties: Healthcare Middlemen Statement24852486[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]24872488                 U.S. Senate Special Committee on Aging24892490  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2491                               Medicine"24922493                           February 11, 202624942495                       Statements for the Record24962497       American Economic Liberties: Medicare Advantage Statement24982499[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]25002501                 U.S. Senate Special Committee on Aging25022503  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2504                               Medicine"25052506                           February 11, 202625072508                       Statements for the Record25092510     American Economic Liberties: One Big Beautiful Bill Statement25112512[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]25132514                 U.S. Senate Special Committee on Aging25152516  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2517                               Medicine"25182519                           February 11, 202625202521                       Statements for the Record25222523       American Economic Liberties: United Health Group Statement25242525[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]25262527                 U.S. Senate Special Committee on Aging25282529  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2530                               Medicine"25312532                           February 11, 202625332534                       Statements for the Record25352536                American Hospital Association Statement25372538[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]25392540                 U.S. Senate Special Committee on Aging25412542  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2543                               Medicine"25442545                           February 11, 202625462547                       Statements for the Record25482549            American Physical Therapy Association Statement25502551[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]25522553                 U.S. Senate Special Committee on Aging25542555  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2556                               Medicine"25572558                           February 11, 202625592560                       Statements for the Record25612562            American Podiatric Medical Association Statement25632564[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]25652566                 U.S. Senate Special Committee on Aging25672568  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2569                               Medicine"25702571                           February 11, 202625722573                       Statements for the Record25742575      The American Society of Health-System Pharmacists Statement25762577[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]25782579                 U.S. Senate Special Committee on Aging25802581  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2582                               Medicine"25832584                           February 11, 202625852586                       Statements for the Record25872588                American Society of Hematology Statement25892590[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]25912592                 U.S. Senate Special Committee on Aging25932594  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2595                               Medicine"25962597                           February 11, 202625982599                       Statements for the Record26002601            American Society of Retina Specialists Statement26022603[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]26042605                 U.S. Senate Special Committee on Aging26062607  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2608                               Medicine"26092610                           February 11, 202626112612                       Statements for the Record26132614                  Primary Care Collaborative Statement26152616[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]26172618                 U.S. Senate Special Committee on Aging26192620  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2621                               Medicine"26222623                           February 11, 202626242625                       Statements for the Record26262627                 Regulatory Relief Coalition Statement26282629[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]26302631                 U.S. Senate Special Committee on Aging26322633  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2634                               Medicine"26352636                           February 11, 202626372638                       Statements for the Record26392640                       Ryan McClenahan Statement26412642[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]26432644                 U.S. Senate Special Committee on Aging26452646  "The Doctor is Out: How Washington's Rules Drove Physician's Out of2647                               Medicine"26482649                           February 11, 202626502651                       Statements for the Record26522653             Society of General Internal Medicine Statement26542655[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]