    [Senate Hearing 119-360]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 119-360

                               THE DOCTOR IS OUT:
                             HOW WASHINGTON'S RULES
                        DROVE PHYSICIANS OUT OF MEDICINE

    =======================================================================

                                    HEARING

                                   BEFORE THE

                           SPECIAL COMMITTEE ON AGING

                              UNITED STATES SENATE

                        ONE HUNDRED NINETEENTH CONGRESS

                                 SECOND SESSION
                                   __________

                                 WASHINGTON, DC
                                   __________

                               FEBRUARY 11, 2026
                                   __________

                               Serial No. 119-24

             Printed for the use of the Special Committee on Aging

                     [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                                   ______

                     U.S. GOVERNMENT PUBLISHING OFFICE

    63-404 PDF                WASHINGTON : 2026

                           SPECIAL COMMITTEE ON AGING

                         RICK SCOTT, Florida, Chairman

    DAVE McCORMICK, Pennsylvania         KIRSTEN E. GILLIBRAND, New York
    JIM JUSTICE, West Virginia           ELIZABETH WARREN, Massachusetts
    TOMMY TUBERVILLE, Alabama            MARK KELLY, Arizona
    RON JOHNSON, Wisconsin               RAPHAEL WARNOCK, Georgia
    ASHLEY MOODY, Florida                ANDY KIM, New Jersey
    JON HUSTED, Ohio                     ANGELA ALSOBROOKS, Maryland

                                  ----------

                    McKinley Lewis, Majority Staff Director
                    Claire Descamps, Minority Staff Director

                             C  O  N  T  E  N  T  S

                                  ----------

                                                                       Page

    Opening Statement of Senator Rick Scott, Chairman................     1
    Opening Statement of Senator Kirsten E. Gillibrand, Ranking
      Member.........................................................     2

                               PANEL OF WITNESSES

    Alma Littles, M.D., Dean & Chief Academic Officer, Florida State
      University College of Medicine, Tallahassee, Florida...........     4
    Lee Gross, M.D., Founder, Epiphany Health Direct Primary Care,
      North Port, Florida............................................     6
    Jeffrey Smith, CPA, MBA, FACMPE, CGMA, Incoming Board Chair of
      Medical Group Management Association (MGMA), Chief Executive
      Officer, Piedmont Healthcare, PA, Statesville, North Carolina..     8
    Corey Feist, JD, MBA, Co-Founder and Chief Executive Officer,
      Lorna Breen Heroes' Foundation, Charlottesville, Virginia......    10

                                    APPENDIX

                          Prepared Witness Statements

    Alma Littles, M.D., Dean & Chief Academic Officer, Florida State
      University College of Medicine, Tallahassee, Florida...........    28
    Lee Gross, M.D., Founder, Epiphany Health Direct Primary Care,
      North Port, Florida............................................    31
    Jeffrey Smith, CPA, MBA, FACMPE, CGMA, Incoming Board Chair of
      Medical Group Management Association (MGMA), Chief Executive
      Officer, Piedmont Healthcare, PA, Statesville, North Carolina..    38
    Corey Feist, JD, MBA, Co-Founder and Chief Executive Officer,
      Lorna Breen Heroes' Foundation, Charlottesville, Virginia......    48

                            Questions for the Record

    Alma Littles, M.D., Dean & Chief Academic Officer, Florida State
      University College of Medicine, Tallahassee, Florida...........    57
    Lee Gross, M.D., Founder, Epiphany Health Direct Primary Care,
      North Port, Florida............................................    61
    Jeffrey Smith, CPA, MBA, FACMPE, CGMA, Incoming Board Chair of
      Medical Group Management Association (MGMA), Chief Executive
      Officer, Piedmont Healthcare, PA, Statesville, North Carolina..    64
    Corey Feist, JD, MBA, Co-Founder and Chief Executive Officer,
      Lorna Breen Heroes' Foundation, Charlottesville, Virginia......    66

                           Statements for the Record

    American Academy of Dermatology Statement........................    71
    American Academy of Family Physicians Statement..................    75
    American Association of Orthopaedic Surgeons Statement...........    85
    American Clinical Neurophysiology Society Statement..............    88
    American Economic Liberties: Healthcare Middlemen Statement......    90
    American Economic Liberties: Medicare Advantage Statement........    95
    American Economic Liberties: One Big Beautiful Bill Statement....   136
    American Economic Liberties: United Health Group Statement.......   140
    American Hospital Association Statement..........................   143
    American Physcial Therapy Association Statement..................   146
    American Podiatric Medical Association Statement.................   156

                             C  O  N  T  E  N  T  S

                                  ----------

                       Statements for the Record (cont'd)

    American Society of Health-System Pharmacists Statement..........   159
    American Society of Hematology Statement.........................   173
    American Society of Retina Specialists Statement.................   176
    Primary Care Collaborative Statement.............................   184
    Regulatory Relief Coalition Statement............................   187
    Ryan McClenahan Statement........................................   190
    Society of General Internal Medicine Statement...................   194

                               THE DOCTOR IS OUT:
                             HOW WASHINGTON'S RULES
                        DROVE PHYSICIANS OUT OF MEDICINE

                                  ----------

                          Wednesday, February 11, 2026

                                            U.S. Senate
                                     Special Committee on Aging
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 3:35 p.m., Room
    216, Hart Senate Office Building, Hon. Rick Scott, Chairman of
    the Committee, presiding.
        Present: Senator Scott, Moody, Gillibrand, Warnock, and
    Alsobrooks.

                     OPENING STATEMENT OF SENATOR
                          RICK SCOTT, CHAIRMAN

        The Chairman. The U.S. Senate Special Committee on Aging
    will now come to order. Across the country, older Americans are
    feeling that it is harder than ever to get timely access to the
    doctors and care they need to live happy, healthy lives and
    even when seniors do find a doctor, many feel rushed and
    disconnected from them.
        Doctors aren't the villains here. Like their patients, they
    are victims of a broken system. Doctors want to care for and
    connect with their patients, but our rigid, top-down health
    care system is making that job nearly impossible.
        This is especially true for doctors who see patients on
    Medicare or other government-run or subsidized health care
    programs. Federal mandates and administrative requirements pile
    on paperwork and paperwork, and force doctors to spend more and
    more time on compliance than on care, making patients face one
    obstacle after another just to get help. The results? Patients
    can't get the care they need from doctors, and doctors can't
    give patients the care they deserve.
        Actually, no one benefits from this. We are forcing our
    doctors to operate in a system that prioritizes paperwork over
    patients and federal mandates over professional judgment. The
    demands on doctors to focus on compliance over care are higher
    than ever. Doctors must navigate unstable insurance and
    Medicare policies, different reporting standards, and excessive
    administrative burdens just to take care of their patients.
        Again, no one benefits in this situation--not patients, and
    certainly not doctors who got into this profession because they
    want to help patients and the result is less care, less access,
    and worse outcomes.
        This is especially true in rural and underserved areas that
    already struggle to find and maintain health care providers,
    and the regulatory burden is especially tough for those who
    treat older Americans. It is no wonder that doctors regularly
    report feeling higher levels of burnout than other U.S.
    workers.
        That burnout leads to more doctors quitting their jobs,
    which creates more doctor shortages, which leads to increased
    administrative burden, which creates a more disconnection and
    fewer rewarding interactions with patients, which results in
    more burnout. In the most serious cases, this burnout
    contributes to devastating mental health consequences for
    physicians and their families, including serious depression and
    even suicide.
        We owe it to all of our constituents, but especially our
    aging population and those responsible for caring for them to
    stop this cycle. Today we will look at how Washington's
    regulations and red tape play into this crisis and what we can
    do to fix it so that our doctors can spend more time caring for
    patients and less time navigating bureaucracy.
        We will hear from witnesses who interact with physicians at
    all levels. They train our doctors, they manage them in medical
    practices, they treat them, and they work with them as
    colleagues and our doctors themselves. They will tell us about
    their real-life experiences navigating and preparing doctors
    that deal with Washington's top-down, one size fits all
    approach to regulated medicine.
        We will also share their experience working to solve these
    problems, what steps we can take to help our doctors and the
    patients they serve put the doctor-patient relationship back at
    the center of health care.
        I look forward to a productive discussion today with our
    witnesses, and I would like to recognize Ranking Member
    Gillibrand for her opening statement.

                     OPENING STATEMENT OF SENATOR
                 KIRSTEN E. GILLIBRAND, RANKING MEMBER

        Senator Gillibrand. Thank you, Chairman Scott, for holding
    today's hearing. Thank you to our witnesses. I really
    appreciate you being here to give us your testimony. Burnout
    within the health workforce has decreased since its peak during
    the pandemic but remains a prevalent issue plaguing our systems
    of care. It directly impacts the well-being and effectiveness
    of our workforce, and its consequences are grave for the
    patients, particularly older adults and people living in rural
    or underserved areas.
        Burnout, which the American Medical Association defines as
    a long-term stress reaction including emotional exhaustion,
    depersonalization, and feeling of decreased personal
    achievement, causes physicians to leave the profession, making
    workforce shortages even worse and undermining access to care.
        A wide range of factors drive physician burnout, including
    regulatory and administrative requirements, system level
    financial pressures, and realities of the profession's culture.
    Regulatory requirements play an important role in upholding a
    quality standard for patient care, safety, and privacy.
        They allow providers to keep detailed track of patient
    treatment, and they also help prevent waste, fraud, and abuse.
    Simultaneously, it is clear that the current system has flaws.
    Requiring physicians to spend clinical time and energy fighting
    to convince insurance companies that their patient truly needs
    the procedure, treatment, or drug they prescribed is
    understandably aggravating and exhausting.
        Time payment adjustments to extensive patient data entry
    with technology designed for billing compliance instead of
    clinical workflow understandably causes fatigue and
    frustration, especially when it consistently spills beyond
    normal working hours.
        Reforms like streamlining the prior authorization process,
    approving the usability and interoperability of electronic
    health records, simplifying or standardizing payer forms would
    meaningfully reduce administrative burden that drives the
    burnout in physicians.
        This can help delay early exit from the workforce and keep
    independent practices afloat. This is especially important as
    we continue to see unprecedented rise in smaller physician
    owned practices closing their doors, integrating with larger
    health care systems, or receiving private equity investment.
        With these structural changes, physicians can face system
    level financial pressure that drive burnout through diminished
    agency and focus on profit. Under these circumstances,
    physicians can face business-oriented performance targets that
    require an increase in patient volume.
        This means seeing a greater number of patients in shorter
    increased, frequent visits that create even more administrative
    work, which can be compounded by the reduction of clinical and
    administrative support staff. This drive toward profit can
    undermine the ability of these vital health care workers to
    secure their basic psychological or safety needs, and they
    experience less autonomy and input on key decision-making.
        Particularly combined with the inability to practice
    elsewhere due to the rise of strict non-compete agreements,
    many physicians opt to leave the profession entirely. System
    leadership must drive operational level change.
        Employers have an obligation to meet the needs of their
    employees, promote participation in relevant decisions, and
    implement evidence informed actions like those included in the
    NIOSH and the Dr. Lorna Breen Foundation Impact Wellbeing
    Guide.
        Additionally, federal investigation into private equity
    investments in health care entities and federal action to ban
    anti-competitive terms in employment contracts are crucial to
    promoting autonomy at organizational and individual levels and
    reduce burnout. Despite the regulatory, administrative, and
    system level pressures that put enormous stress on the health
    workforce, there is a pervasive stigma against seeking mental
    health support and fear of medical license loss that prevents
    many from getting the help that they need.
        It is important that clinician education includes training
    to handle not only these administrative burdens, but also
    psychological preparation to handle trauma like a patient death
    or distress. We must address burnout. The consequences and
    stakes are too high. Healers are suffering. Providers are
    facing sky-high costs to replace each clinician that leaves.
        Remaining staff are working at reduced capacity, putting
    themselves and their patients at greater risk. Patients are
    losing access to the care they need. These impacts only
    intensify in older, rural, and underserved communities,
    especially combined with enacted cuts to Medicaid that will
    exacerbate the provider closures and create medical deserts.
    There isn't an easy solution to any of this.
        Moving the needle requires buy-in from all sectors that
    shape our workforce. Congress, academic institutions,
    regulators, and health system leaders must work together in a
    bipartisan way to create a system that supports, not exhaust,
    our essential workforce. I look forward to hearing from you and
    your proposals. Thank you.
        The Chairman. Thank you, Ranking Member. Now, I would like
    to welcome today is witnesses. Our first witness leads one of
    the Nation's most mission driven medical schools with a focus
    on training physicians to serve in rural communities.
        Dr. Alma Littles is the Dean and Chief Academic Officer of
    the Florida State University College of Medicine where she
    oversees medical education, workforce development, and
    physician training programs across the State of Florida.
        Under her leadership, the FSU College of Medicine has
    emphasized primary care, community-based training, and
    addressing physician shortages in areas most affected by access
    challenges. Half my office went to FSU, so they are excited
    that you are here, so please begin your testimony.

             STATEMENT OF ALMA LITTLES, M.D., DEAN & CHIEF

           ACADEMIC OFFICER, FLORIDA STATE UNIVERSITY COLLEGE

                   OF MEDICINE, TALLAHASSEE, FLORIDA

        Dr. Littles. Chairman Scott, Ranking Member Gillibrand, and
    distinguished Committee members, thank you for the opportunity
    to speak with you today to share a perspective on an issue that
    is becoming increasingly urgent across our Nation, physician
    burnout. An issue experienced by doctors who want nothing more
    than to care for their patients yet find themselves pushed to
    the brink by the very system meant to support them.
        Physicians enter medicine with a clear purpose, to heal, to
    serve, and to stand with patients in their most vulnerable
    moments but today, that purpose is being overshadowed by
    unsustainable administrative burdens leading to record
    percentages of physician burnout.
        We have already heard definitions of physician burnout, so
    I won't repeat that, but we know that physicians have a higher
    incidence of suicide when compared with other professionals in
    the United States. Around 400 take their lives each year and
    just as concerning, medical students and residents have rates
    of depression 15 percent to 30 percent higher than the general
    public.
        This is a national crisis. To address it, the National
    Academy of Medicine, the Association of American Medical
    Colleges, and the American Medical Association are all actively
    developing resources to help. Physicians are leaving medicine
    not because they have lost their passion, but because the
    regulatory environment has made it nearly impossible to
    practice the way they were trained.
        Physicians lose satisfaction when factors come between them
    and their patients. The issue is not regulation itself.
    Physicians understand the need for oversight, accountability,
    and patient safety. The issue the volume and complexity of
    mandates, documentation requirements, reporting systems,
    compliance checklists, and insurance rules and regulations that
    grow year after year in the face of reduced reimbursement and
    without regard for the time they consume or the strain they
    impose in the form of the inability to make decisions based on
    training.
        The consequences of burnout can be devastating. Think about
    this, one physician leaving practice potentially leaves 2,000
    to 3,000 patients without access to care. Studies suggest that
    more than half of practicing physicians say they are burned
    out. We found this to be a real issue in Florida after becoming
    aware of several suicides among medical students, residents,
    and faculty.
        Here is the hopeful part, this crisis is solvable. The
    medical schools in Florida came together to evaluate the
    support being to address the root causes of burnout. We use
    this data to share experiences and solutions. Programs were
    developed that support wellness activities and deliberate
    efforts were made to destigmatize seeking help in medical
    school, residency training, and practice.
        This included lobbying for a change in the licensure
    application regarding how questions about prior mental illness
    were asked and addressed. The survey of medical schools and
    residency programs confirmed that the schools were actively
    engaged in a variety of activities including incorporating
    mandatory wellness topics into the curriculum, providing
    dedicated onsite counseling services, offering online
    resources, hosting financial aid and planning workshops, and
    incorporating activities that prepare students for the impact
    of administrative burdens.
        Since our founding 25 years ago, Florida State University
    College of Medicine has recognized the threat of physician
    burnout and we hardwired into our curriculum and
    extracurricular activities, programs and activities to address
    it.
        We provide resources on sleep and stress management, weekly
    fitness classes, campus walks, and improved our onsite fitness
    room. A major suicide awareness and prevention program featured
    film screenings and a live panel discussion. Our six regional
    campuses also developed their wellness programs.
        All of this is helpful, but we cannot lose sight of key
    components of the American Medical Association's Physician
    Wellness Program that includes the reduction of administrative
    burdens, reduce of stress drivers in organizations, and removal
    of regulations and technology requirements.
        We need your help. You have the power to make a positive
    impact by supporting regulatory reform, promoting
    administrative simplification, ensuring that federal policies
    strengthen not strain the physician workforce, and by
    recognizing that the best way to protect patients is to protect
    the people who care for them.
        Addressing this issue is no longer an option. It is
    critical to ensuring access to care. I look forward to
    continuing the conversation. Thank you.
        The Chairman. Thank you, Dr. Littles. Our next witness is a
    practicing family physician who left the traditional insurance
    driven system to restore the doctor-patient relationship. Dr.
    Lee Gross is the Founder of Epiphany Health Direct Primary Care
    in Florida, a national leader in the direct primary care
    movement.
        He spent more than two decades in private practice and has
    testified before Congress on how federal regulations and CMS
    mandates contribute to physician burnout and rising costs.
    Thank you for being here. Please begin your testimony.

            STATEMENT OF LEE GROSS, M.D., FOUNDER, EPIPHANY
            HEALTH DIRECT PRIMARY CARE, NORTH PORT, FLORIDA

        Dr. Gross. [Technical problems.] Sabotage the Florida guy.
        Mr. Chairman, Ranking Member, members of the Committee, it
    is a pleasure to be back here at the Senate to give some
    testimony. Again, my name is Lee Gross. I am a practicing
    family physician in Southwest Florida--have been independent
    since 2002.
        For disclosure, I serve on the Florida Board of Medicine. I
    am speaking on my own behalf and not on behalf of the Florida
    Board of Medicine, and I do not speak for the State of Florida.
    The name of my practice is Epiphany Health and Epiphany Health
    is a very strange name for a medical practice--and the timer is
    not running here. Epiphany Health is very strange for a very
    medical practice.
        In fact, we had an epiphany and the epiphany was, why are
    we insuring primary care? Why are we taking relational and
    longitudinal care and funneling that through an insurance
    product, using tens of thousands of diagnostic codes, hundreds
    of thousands diagnostic and billing codes, filing an insurance
    claim for every single transaction, and then we are
    disappointed and surprised that it is cumbersome, it is
    impersonal, it is inflexible, and it is expensive.
        I had a fully insured practice back in 2002. I took
    Medicare. I took all the insurances, and this was during the
    time of the sustainable growth rate formula and I would come to
    run up and down the halls of Congress saying, please don't cut
    our pay, please don't our pay. It is absolutely not survivable
    if Congress cuts the pay of primary care doctors.
        I would walk out, and behind me the ophthalmologist would
    walk in, and they would say, please, don't come our pay and
    then behind them, the surgeons were standing there and this
    constant battle for a larger slice of a pie that was
    continually shrinking. It just became obvious to me that we
    shouldn't be fighting for a large piece of the pie, but we
    should be looking to explode the pie and looking for a better
    way to do this.
        I was an early adopter of electronic health records, and I
    should say that in the sustainable growth rate debates, I would
    have to take out personal loans to make payroll because of the
    brinksmanship that would happen in Washington. I wouldn't know
    if we would have money coming in.
        I didn't know how to finance supplies. I didn't know how to
    finance equipment purchases because I didn't know what we were
    going to get paid and so, the Federal Government became an
    unreliable business partner in the practice of medicine, and I
    felt like I needed to fire them. I was an early adopter of
    electronic health records. I loved that electronic health
    record. It maximized operational flow, workflow.
        It was fantastic and then the Federal Governor came in and
    certified it and so, the electronic health record I had that
    did everything I needed it to do and made me more efficient was
    no longer certified, and they couldn't afford to certify.
        I started getting Medicare penalties because I had a system
    that was efficient and worked for my practice, but I was
    getting penalized, so I had to purchase an additional system
    that didn't do anything I needed to do.
        I had parallel systems, one for compliance and one actually
    to perform the function that I needed in my office. It
    essentially became that the electronic health record became a
    cash register. I used to get a one-page note from a consultant
    and I would know why my patient was there, what they did, what
    their recommendations were, what pertinent findings were.
        I get 16 pages of computer-generated rubbish, and I have no
    idea what the patient was there for, but I know their pet was
    spayed or neutered. It is absurd and so, the medical record has
    become a cash register, the patient has become an ATM, and it
    had become all about volume.
        You start rolling out all the alphabet soups of the MACRA
    and the MIPS, and the quality metrics, and the reporting. I
    would have to find other ways to generate revenue, because I
    wasn't going to do those things and so, every time I found a
    way to generate and support my practice, Medicare would make a
    rule change to undercut that and I was playing whack-a-mole
    with Medicare as to how my practice would survive.
        We kind of joked in my practice that we were just going to
    go ahead and stop billing Medicare. We are just going charge
    $100 for parking but effectively that is what we did. We
    created essentially in 2010 what became one of the first direct
    primary care practices in the country.
        We charge a subscription for services. We charge $93 a
    month right now for adults, $30 for children, and after that we
    charge nothing for the services we provide in our office. No
    copays, no deductibles. I don't bill insurance for any
    services. Any testing that I do in my office is included, EKGs,
    halter monitors, cortisone injections, those are all included
    and I have a cash-based relationship for all the services
    outside of my office.
        I buy everything wholesale and pass those savings along to
    the patient. I buy labs at 95 percent savings because the lab
    doesn't have to interact with the insurance company, and they
    don't have deal with coding and if you ask the lab, the most
    expensive thing that they do in the lab is interact with
    insurance companies and do the coding. If you eliminate all
    that and you just get the lab, it actually gets really cheap.
        We have been doing that now for 15 years, operating outside
    of insurance companies. We have seen nearly zero inflation in
    the actual cost of purchasing health care. The cost of coverage
    has skyrocketed, but our cost of purchasing care and providing
    care has been nearly flat for 15 years.
        Since we have started doing that, we were one of the first
    few practices in the country that have done that. Now, there
    are thousands of doctors around the country in all 50 States
    that have stepped away from the system because we can do better
    at providing primary care, not going through third-party
    systems.
        We are at a point now in our country where we can
    personalize health care down to somebody's individual DNA. We
    are taking a one size fits all approach to health care that has
    to be a broad brush across a massively enormous country that is
    so incredibly diverse as the United States of America.
        What we don't need is mass production in medicine. We need
    mass personalization, and that is the kind of care that we
    deliver, and I am hoping that we can get to that through
    removing some of the overregulation in health care. Thank you.
        The Chairman. Thank you. Our next witness brings a
    perspective of managing large, multi-specialty physician groups
    serving both urban and rural communities. Jeffrey Smith is the
    Chief Executive Officer of Piedmont Healthcare in North
    Carolina and is the incoming Board Chair for the Medical Group
    Management Association.
        In his role, he oversees the operational, financial, and
    compliance challenges facing physician practices under Medicare
    and CMS regulation. Boy, it sounds like an easy job. Thank you
    for being here. Please begin your testimony.

          STATEMENT OF JEFFREY SMITH, CPA, MBA, FACMPE, CGMA,

                 INCOMING BOARD CHAIR OF MEDICAL GROUP

                  MANAGEMENT ASSOCIATION (MGMA), CHIEF

               EXECUTIVE OFFICER, PIEDMONT HEALTHCARE, PA

                      STATESVILLE, NORTH CAROLINA

        Mr. Smith. Chairman Scott, Ranking Member Gillibrand, and
    members of the Committee, thank you for the opportunity to
    testify on how administrative and regulatory red tape fuels
    physician burnout and undermines patient access to care.
        I am honored to speak on behalf of Medical Group Management
    Association, MGMA, as its incoming Board Chair. MGMA has over
    70,000 members across the United States representing 15,000
    medical group practices and more than 350,000 physicians.
        I am also the CEO of Piedmont Healthcare, a physician owned
    and led multi-specialty medical group based in Statesville,
    North Carolina, with over 230 physicians and providers and
    almost 1,200 employees.
        I have over 40 years of health care experience and I feel
    deeply passionate about this issue, in part because I have seen
    its impact firsthand while working alongside my daughter, who
    is a primary care physician in my practice. MGMA has long
    advocated for reducing administrative burden and routinely
    surveys our members on administrative hurdles they face.
        Their feedback makes clear the connection between
    regulatory burden, a broken payment system, and physician
    burnout. In our 2026 survey with over 230 responded physician
    practices, more than half of the practices report losing a
    physician to burn out in the past three years and among those,
    over 75 percent say regulatory burden played a substantial
    role.
        This impacts patient access to care as it leads to longer
    wait times, shorter visits, and practices becoming unable to
    accept new patients. In my own practice, I have increasingly
    witnessed more physicians being driven toward early retirement.
    Burden related to regulatory impacts, work-life balance as
    well, something I have seen with my daughter who often must
    complete these tasks at home after her children fall asleep.
        While MGMA supports efforts to strengthen and expand
    physician training programs, addressing administrative and
    regulatory policies that are leading to physician burnout is
    critical to stem the tide on the front end and support
    physicians already in practice. I would like to highlight the
    following burdens that I and other MGMA members are facing that
    significantly contribute to physician burnout.
        Medicare Advantage has allowed beneficiaries to access new
    benefits and can serve as an opportunity for innovation.
    However, as Medicare Advantage enrollment has increased, it has
    created daunting new challenges for many practices. MGMA
    members report audits, denials, prior authorization, and down-
    coding in Medicare Advantage as some of their top burdens in
    2026.
        There is also significant lack of standardization across
    Medicare Advantage plans. We have had to hire whole teams
    dedicated to value-based care just to interpret what quality
    really means.
        For years, one of the top cited regulatory burdens for
    medical groups has been prior authorizations due to its impact
    on staffing demands, added cost, and impact on patient care. I
    oversee over 70 offices in the Charlotte metro area, and each
    practice has at least one staff member dedicated to prior
    authorizations.
        MGMA members rank Medicare Advantage as the most burdensome
    payer. I appreciate the Chairman, Ranking Member, and many
    members of the Committee for co-sponsoring the Improving
    Seniors Timely Access to Care Act. It is important to pass this
    widely supported legislation that would streamline prior
    authorization for Medicare Advantage.
        There are numerous additional opportunities to reduce
    duplicative and unnecessary regulatory hurdles. Reforming the
    Merit-Based Incentive Payment System, or MIPS, in Medicare
    would be welcomed. As complying with these requirements is a
    time-consuming and laborious process. Further, provider
    enrollment and credentialing in Medicare could be streamlined
    to better capture this data and lower practice costs.
        All of this regulatory red tape is exacerbated by the
    continued under-reimbursement of Medicare Part B. Financial
    stressors were the second largest contributing factor to
    physician burnout in our 2026 survey. Given Medicare's
    reimbursement's frequent reductions due to outdated budget
    neutrality requirements and lack of an inflationary update, it
    is vital to pass legislation to comprehensively address these
    concerns.
        The challenges discussed throughout this testimony coalesce
    to undermine the ability of independent medical groups to
    continue to operate and potentially lead many physicians to
    sell their practices. One MGMA member relayed selling their
    practice after being independent for over 100 years.
        Enacting long-term reforms would help lead to a more robust
    practice environment. I sincerely appreciate the opportunity to
    testify today and share both my personal experience and other
    MGMA members' experiences on how regulatory burden contributes
    to physician burnout. I look forward to your questions.
        The Chairman. Thank you. I now recognize Ranking Member
    Gillibrand to introduce the next witness.
        Senator Gillibrand. Thank you, Mr. Chairman. I now want to
    introduce Corey Feist. Mr. Feist is the CEO and Co-Founder of
    the Dr. Lorna Breen Heroes Foundation and recently served as
    the CEO of the University of Virginia Physicians Group.
        Mr. Feist has previously testified to support mental health
    legislation for health care workers in front of the House
    Energy and Commerce Subcommittee on Health. His advocacy
    efforts resulted in the passage of the first federal law
    focused on improving the well-being of health care workers, Dr.
    Lorna Breen Health Care Provider and Protection Act, in honor
    of his sister-in-law.
        He was also awarded the Surgeon General's Medallion for
    Health in 2023 for the foundation's efforts. Mr. Feist, you can
    begin your testimony.

             STATEMENT OF COREY FEIST, JD, MBA, CO-FOUNDER

                AND CHIEF EXECUTIVE OFFICER, LORNA BREEN

             HEROES' FOUNDATION, CHARLOTTESVILLE, VIRGINIA

        Mr. Feist. Chairman Scott, Ranking Member Gillibrand, and
    members of this Committee, thank you. My name is Corey Feist,
    CEO of the Dr. Lorna Breen Heroes Foundation.
        On behalf of millions of health workers, thank you for the
    introduction and co-sponsorship of the Improving Seniors Timely
    Access to Care Act of 2025, and for reauthorizing the Dr. Lorna
    Breen Health Care Provider Protection Act. We now seek full
    funding of the Lorna Breen Act to ensure life-saving work
    continues. This is my third time testifying on this crisis.
        Each time I carry the stories of those lost, not to a lack
    of resilience, but to a system that failed them. In 2021, I
    shared the story of my sister-in-law, Dr. Lorna Breen. She was
    a physician leader during the pandemic's first wave in New York
    City. Despite her bravery, she was terrified that seeking
    mental health care for her trauma that she witnessed on the job
    would cost her career that she spent her life building.
        Lorna took her life April 26, 2020. In 2024, I shared the
    story of Tristan Kate Smith, a 28-year-old nurse whose father
    found a letter on her computer after her death. She wrote to
    the system she felt abused her, noting that instead of respect,
    they get pizza parties and pens for the health care heroes.
        Today, I share the story of Dr. William West, a 34-year-old
    ophthalmology resident. His family called him Iron Will for his
    tenacity in rock climbing and endurance racing. In March 2024,
    the information ocean and pressures of medical training broke
    even Iron Will. In a devastating final note he wrote, I am
    simply exhausted and have nothing more to give.
        He used his final moments to plead with administrators to
    support the residents rather than merely push them. William's
    story is a warning. Our health care system is claiming our
    brightest minds before they even finish their training. When we
    lose a resident, we aren't just losing one doctor.
        We are losing 40 years of expertise meant to serve our
    aging population. The tragedy of losing clinicians like Lorna,
    William, and Tristan is compounded by the looming demographic
    shift. The number of Americans over 60 will increase by 46
    percent in the next decade. HRSA projects will cause a shortage
    of over 500,000 nurses, physicians, dentists, and pharmacists
    by 2038.
        These projections do not fully account for those leaving
    due to systems failures, many of which you have already heard
    from. Forty-five percent of physicians say administrative
    pressures are pushing them toward career changes or early
    retirement. Administrative tasks like prior authorization are
    the number one. driver of physician burnout. Nurses face a
    safety crisis with 80 percent experiencing workplace violence.
    Last year, 24 percent of Gen Z nurses left their roles.
        Pharmacists are abandoning their roles due to excessively
    high workloads and hostile workplace climates. However, this is
    not a foregone conclusion. Thanks to the Lorna Breen Act funded
    Workplace Change Collaborative, we now have a proven national
    framework with several priorities for policy and practice to
    avert this crisis.
        The Lorna Breen Act grantees have already supported over
    250,000 health workers in states, and the results are
    undeniable with 35 percent reductions in staff turnover, 50
    percent decreases in mental health conditions. The law also
    supported NIOSH's Impact Wellbeing Initiative, which provided
    35,000 plus health care leaders with training to address the
    operational burdens that drive their workforce's burnout.
        Our foundation created a technical assistance program to
    accelerate the initiative. We improved access to mental health
    care for more than three million health workers by supporting
    over 70 licensing boards and over 20--or 2,000 hospitals and
    care facilities and removing intrusive mental health questions
    from licensing and credentialing applications. We are also
    proving that administrative burden can be reduced while job
    satisfaction and patient experience improve.
        One rural hospital decreased their workforce's cognitive
    burden addressing EHR alert fatigue. Their traveling nurses now
    want to stay in rural Virginia saying that this is the first
    place they have worked where they feel healthy, and they
    actually can get the help that they need. Reauthorization of
    the Lorna Breen Act is a historic win, but without funding, it
    is a hollow promise.
        While billions are spent on workforce creation, the Lorna
    Breen Act programs are the only ones directly supporting
    retention. Investment in the pipeline is squandered if we don't
    stop the leaks.
        For example, we currently face a two-year exodus in nurses,
    where 50 percent of new nurses leave the profession after two
    years.
        This Committee can make a difference by ensuring the Lorna
    Breen Act is fully funded in Fiscal Year 2027, and for voting
    for the Improving Seniors Timely Access to Care Act.
        I hope to return and report on the lives of health workers
    we have saved and how we are serving the aging community in the
    United States with the best and brightest among us, the Lornas,
    the Tristans, and the Williams. Thank you for your leadership.
        The Chairman. I thank each of you for your testimony, and I
    will turn it over to Senator Moody for the first questions.
        Senator Moody. Thank you, Chairman Scott, Ranking Member
    Gillibrand for holding this hearing, and welcome to two of our
    witnesses that are from Florida, for traveling up here and
    braving the ice on the ground. I know you wish you were back
    with the palm trees and flamingos. I do too. Welcome. This is
    such an important topic for our country, especially Florida. We
    have so many seniors in our state.
        Some refer to us as not just the Sunshine State, but the
    Silver State. Discussing how we are going to provide efficient,
    quality health care is so important and so, this topic is of
    great importance and particular interest to me. Florida has
    some of the best hospitals and providers in the country.
        We have world-renowned care, education, and training and we
    are so proud of these accomplishments, but we know they are
    only possible because we have hard working Floridians that have
    trained in health care and are part of our health care
    structure and show up to work, rain or shine, no matter what is
    happening.
        Nationwide, the health care industry employs over 17
    million people, making it one of the largest employment sectors
    in the United States, so it is understandable that we need a
    large health care sector and those that will work in this
    industry, but so much of that economy is tied up in billing,
    administration, and regulatory compliance and physicians are
    increasingly forced to spend nearly twice as much time on
    administrative work as they do in providing patient care.
        I hear from Floridians all the time what they are
    experiencing on the job in these health care careers, and it is
    grinding and it feels burdensome. It is challenging and I think
    that is probably why a recent Mayo Clinic study found that 57.1
    percent of physicians said they would choose to become a
    physician again, down from 72.2 percent just five years ago.
        With endless prior authorization requests, sometimes
    combative patients, extreme working hours, it is no wonder that
    many providers step away from their traditional practices to
    transition to direct primary care practices, also known as
    concierge care.
        Many of these practices allow physicians to see patients
    for longer, avoid cumbersome administrative processes, all
    while delivering a higher quality experience and giving doctors
    more time to live their lives.
        We expect that segment of the health care industry to grow
    to nearly $36 billion by 2030 and while there is a lot of good
    with that, and I certainly understand why there is that
    transition, we have to recognize that the exodus of providers
    from the mainstream health care system is a symptom of an
    underlying problem with that traditional system, and we as a
    Government have to figure out why that is.
        I mean, it is no longer a free market in the health care
    system. Government has gotten so involved and so regulated, and
    we require so many things. Some seem nonsensical, like making
    you move to a different computer system when yours is working
    just fine, where you have to maintain two computer systems.
        Unbelievably wasteful, and it sounds just like the
    Government but we are no longer a free market in our health
    care. I mean, supply and demand in health care is not driving
    costs anymore, and this is why we are seeing costs drive
    through the roof.
        This is why it is so taxing now on consumers of health
    care, and I don't blame this mass exodus of people trying to
    move into what health care used to be, providing care to
    patients in a way where you feel like you have a relationship
    with them, you can spend time with them, high quality, maybe
    even cost efficient.
        I am supportive of that but I am very nervous that
    concierge care or even direct care outside this, what we would
    now call the traditional health care or mainstream health care
    system, might not be accessible by everyday people who might
    not have a really, really high income. I worry about that.
        Obviously, as we are seeing this mass exodus from the
    profession in general, I think we are going to have a projected
    shortage of 140,000 physicians by 2038. We are seeing a mass
    exodus of physicians, period. We have a mass exodus going into
    this more direct or concierge care. I am really worried about
    what happens for everyday Americans that might not be able to
    afford that direct care.
        I think this is a great topic for us to talk about because
    I really think what has driven that is this just crazy, over-
    regulated, nonsensical approach by Government to--and the more
    and more we become involved in health care, the more and more
    complex and out of control, and chaotic, and unmanageable, not
    working for physicians, not working consumers, it becomes.
        Dr. Gross, thank you for being with us. Congratulations on
    a successful career. I wanted to ask you how--you know,
    congratulations on all that you have been able to do to
    navigate around what we in government have created in the
    traditional health care system, but what would be your
    recommendations to--from where we find ourselves with a rapidly
    declining physician population, and out of that, add to it
    those moving out of a health care system that is more
    traditional, that many use government services or government
    assistance to access.
        What would be your recommendations for those of us on this
    Committee to make sure that health care is not only quality,
    but cost efficient for Americans?
        Dr. Gross. Thank you, Mr. Chair. A lot to unpack in the
    statements there. I think one of the first things that I would
    like to do is just clarify a little bit between concierge
    medicine and direct primary care, because concierge medicine
    typically does charge an access fee and then bills a fee for
    service to a third-party payer, whereas the direct primary car
    charges a subscription fee, and everything is included in that,
    so there is a difference in the price points.
        Senator Moody. Different in the way you charge.
        Dr. Gross. Different in the way you charge and different in
    what is included, so we don't bill--it is not like a fast pass
    at Disney World, where you pay for access. You know, that is
    more of a concierge model.
        Moving past that, I would say that a physician that leaves
    practice because they are overburdened, and they have moral
    injury sees precisely zero patients, so if you are forcing
    somebody out of practice because of the complexities of it,
    then you are not comparing it to a doctor that would see 3,000
    patients and now they are shrinking it.
        You are comparing it to a doctor that would see zero
    patients, so it is not an actual fair comparison, because I
    would not be practicing medicine today if I did not change my
    practice model. I just wouldn't have done it.
        I would have found something else to do. I am forced by law
    to opt out of Medicare when I direct contract with these
    patients. That was not my decision. That was federal law that
    required----
        The Chairman. Explain that--that you can't do both.
        Dr. Gross. Right. When I directly contract with a Medicare
    beneficiary for services that are covered by Medicare, I have
    to, by law, opt out. It is not just opt out in my direct care
    practice. It is across the board, under everything tied to my
    NPI. I can't moonlight as a hospitalist. I can't serve ER
    shifts. I can't do telemedicine through a traditional teledoc
    type service, because they all bill Medicare.
        That locks me into saying, I can only accomplish this panel
    size by statute. I would love to see that change. I want to
    work with you to change that statute, because that has a
    disproportional impact on rural health care.
        Because if I am putting a panel of a primary care doctor in
    rural America, in rural Alaska, rural Utah, I can make a direct
    primary care practice work and be profitable with 300 to 500
    patients. I can't do that with a fee-for-service practice. If I
    come in with 300 to 500 patients, I am going to need massive
    federal subsidies.
        I am going to need something to keep that practice afloat,
    and there is no way you are going to be able to do it, so and
    again, if statute requires me to opt out to do that--I may be
    the only doctor in your community serving in your emergency
    room.
        I may the only that might be able to care for you in the
    hospital, and statute has required me to opt out because I am
    providing more affordable and accessible care. It is important
    to, again, to have the maximum flexibility for physicians to
    shift to the needs of their community directly and not have
    that federally dictated.
        For example, when we went into COVID, it took three months
    for Medicare to recognize the invention of the telephone, and
    we are still fighting over whether the telephone is appropriate
    access for physicians and whether the Federal Government should
    pay for it.
        Just as recently as two weeks ago we are trying to decide
    this. I shifted my practice to a telemedicine on day number
    one. When you mentioned the rains falling, when Hurricane Ian
    tore the roof off the emergency room next to my office, I
    didn't need to wait for the insurance companies to convene a
    new code for me to provide parking lot care for my services. I
    put a tent in the front of my building.
        We opened up to all comers, whether they were our patients
    or not. We provided free care to the community. Why? Because I
    am getting paid. I am being paid on a subscription basis and I
    have the flexibility and ability to provide the services to the
    care, to my community that they need.
        Senator Moody. Thank you.
        The Chairman. Thank you. Ranking Member Gillibrand.
        Senator Gillibrand. Thank you, Mr. Chairman. Mr. Feist, in
    your testimony, you discussed how administrative burden is an
    underlying cause of physician burnout, impacting time with
    patients and pushing doctors beyond even extended working
    hours.
        Your foundations, Impact Wellbeing Guide, provides guidance
    on how hospitals and health systems can address these burdens
    through quality improvement projects. Could you please share a
    brief example of how health care providers successfully reduce
    physician burnout by using your Impact Wellbeing Guide.
        Mr. Feist. Absolutely. The Lorna Breen Act created the
    Impact Wellbeing Guide, and NIOSH partnered with our foundation
    and our all-in national coalition of over 37 of the largest
    professional associations to create this leader retraining
    guide.
        What we have done is we have implemented this guide across
    the United States, particularly in Virginia, North Carolina,
    now in New Jersey, and as well as in Wisconsin and, what we saw
    in Virginia after doing this were decreases in the amount of
    time that clinicians were spending in the electronic medical
    record before and after work by significant numbers.
        In some cases, three to five minutes per patient, in some
    cases ten to fifteen minutes per patients. Huge decreases
    there. In addition, standing orders for pharmacy refills.
    Things that keep the pharmacists, the patients, as well as the
    physicians burdened with bureaucracy. All of those things,
    using the Impact Wellbeing Guide, decreased the amount of time
    that folks were spending outside of direct patient care,
    increased their well-being, increased--and decreased their
    burnout
        Senator Gillibrand. Thank you. Dr. Smith, your testimony
    describes how Medicare Advantage's burdensome prior
    authorization requirements significantly contribute to
    physician burnout and can harm patients.
        Over 60 Senators, including myself, are pushing to pass the
    Improving Seniors Timely Access to Care Act to streamline the
    prior authorization process and help address some of these
    widespread concerns.
        Yet, CMS's new Wasteful and Inappropriate Service Reduction
    model, also known as the WISeR model, expands prior
    authorization into traditional Medicare and utilizes a new non-
    standardized approach that is inconsistent with the existing
    federal regulations. How will the WISeR model increase
    administrative and patient burdens in traditional Medicare, and
    how might this drive burnout among physicians in states where
    this model is enacted?
        Mr. Smith. I think what you are going to see is more prior
    authorizations needed. That is going to add burden to the
    staff.
        There will be more denials that will add burden to the
    physician to either fight the denial or just to decide it is
    just not worth the fight. Now, you have patients not receiving
    care. If patients don't receive care, I believe that they will
    get sicker, they will end up in the emergency room, and
    ultimately the hospital, which will drive the cost of health
    care up.
        My dad is 94. He went to the doctor this week while I was
    up in Philadelphia visiting him, and the doctor decided that he
    needed a CAT scan. I would bet a lot of money that that would
    be denied if you did a prior-auth on that.
        Senator Gillibrand. Right.
        Mr. Smith. You know, we spend a lot of time telling
    doctors, you know, you are in charge, you are the quarterback
    of care. We actually increased the E&M codes, but every step of
    the way we question what they do. I think we would just be
    contributing to the burnout of doctors if we move forward with
    it.
        Senator Gillibrand. I agree. Dr. Gross and Dr. Littles. Dr.
    Gross, in your testimony, you highlight the mismatch between
    how physicians are trained and the regulatory environment that
    they practice in.
        You say that when physicians enter the workforce, they are
    clinically competent but structurally unprepared to operate
    smaller rural practices. How does this mismatch drive physician
    burnout and contribute to consolidation?
        Dr. Gross. One of the things that I have noted is that when
    people are graduating from training--I am kind of old school.
    When I went into training, I had full practice management
    training in my practice.
        That doesn't really happen to a degree. I mean, it is still
    sort of required. When people graduate, they do not have the
    full practice manager. How do you have compliance? How do you
    comply with OSHA? How do you hire? How do you fire? How do you
    set up your structure? How do you negotiate contracts?
        That is all stuff that I learned in my training, but it is
    not really being taught to that degree. Because most people are
    being trained to be employees in an outpatient and ambulatory
    setting.
        If you are trying to then go from training into a rural
    health care setting delivery where you need to be running your
    own practice, they are not prepared for that. People are just
    not even stepping into that environment, and it is leaving a
    huge void in the rural communities.
        Senator Gillibrand. Thank you. Dr. Littles, in your
    testimony, you shared how medical schools and residency
    programs in Florida recognize this mismatch and are
    incorporating activities to help students prepare for the
    impact of the profession's administrative burdens. Please
    describe some of these initiatives and discuss how medical
    students and trainees have responded to these trainings.
        Dr. Littles. Sure. We all know that medical school is a
    stressful environment, going through the process of training to
    become a physician, so we put in support systems, you know, for
    students to help guide them through this because we recognize
    that they are going to be facing stressful situations
    throughout their career, so having, you know, access to onsite
    counseling that they can, you know, access right there at the
    college without feeling that, you know, tension of is this
    going to affect my licensure later on and prohibit me from
    being licensed or practicing medicine, so activities like that.
        Having wellness activities so that they learn to take
    breaks because at the end of the day we are all humans before
    we are physicians and they need to be able to, you know, to
    take breaks, make sure that they are, you know, eating
    properly, and getting rest, and maintaining connections to
    their support systems that they had even before they came, you
    know, to medical school.
        Training them with those activities but also recognizing
    that these other stressors that they are going to face as
    practicing physicians are there as well and so, having them
    actually training with those physicians--I mean our students
    and our residents get to see what our attending physicians are
    facing in their practices.
        When they are having to deal with these issues like, you
    know, prior authorization and denials, and you know, patients
    not being able to access the appropriate lab or the
    appropriate, you know, X-ray facility, they are seeing this as
    a part of their training, even in medical school.
        As Dr. Gross said, those requirements for that practice
    management training is there for our resident physicians, but a
    lot of them are not focusing on it. Certainly not early on in
    their residencies they are not focusing on it because they are
    not having to be the ones ultimately responsible for it.
        As they get closer to graduation, they tend to start paying
    a little bit more attention to it but it is true that more
    physicians are employed today than even, you know, 10 years ago
    and certainly more than, you know, 20, 25 years ago. More and
    more of them are entering employed situations which in many
    cases exacerbates a lot of these issues we are talking about.
        Senator Gillibrand. Thank you.
        The Chairman. Senator Warnock.
        Senator Warnock. Thank you Chair Scott and Ranking Member
    Gillibrand. Communities in my state and all across the country
    face dire physician shortages as this panel has demonstrated.
        Estimates are that in just a couple years we will be short
    by tens of thousands of doctors. Mr. Feist, what effect will
    additional workforce shortages have on our current health
    professionals many of whom are already facing?
        Mr. Feist. Reduction in staff are a force multiplier on the
    issues that we have been talking about on this Committee today.
    We have to look at what our clinicians are spending their time
    doing right now.
        When you look at the fact that about 70 percent of a
    primary care physician's time and 50 percent of a nurse's time
    is spent away from the bedside, away from a patient, spending
    that time on administrative burden--as you decrease your staff,
    who else is left to do the administrative work? It is this
    vicious cycle that will impact access. It will impact quality.
    It will affect cost over time.
        Senator Warnock. It is an impact, obviously, on the
    workers, including the physicians and their workplace, but it
    is a real effect on patients----
        Mr. Feist. Absolutely.
        Senator Warnock [continuing]. and the quality of the health
    care that they are able to provide. For decades, Medicaid has
    helped fund doctor residency training through the Graduate
    Medical Education, or GME, Program.
        This program has played a critical role in addressing
    physician shortages in states like Georgia, where more than 2.7
    million Georgians live in a health professional shortage area.
    It is clear we need to do more.
        That is why I was proud to introduce the bipartisan
    Resident Physician Shortage Reduction Act alongside my friend
    Senator Boozman. This bill would fund 14,000 new resident slots
    over the next seven years.
        Mr. Smith, how would you increase--how would an increase in
    Medicare-funded graduate medical education slots help improve
    our seniors' access to health care services?
        Mr. Smith. I think any physician--any addition of
    physicians into the market would increase access to care. There
    would be more appointment time and more availability.
        The challenge we have is convincing those doctors to go
    into primary care and internal medicine. Most of them,
    nowadays, they say, you know, become a neurosurgeon, or you
    know, I want to become an EP doc in cardiology, because there
    is more money there.
        They are trying to pay off their student debts. They spend
    another year in fellowship. We don't see a significant amount
    of docs wanting to be family practice doctors anymore. I think
    somehow we have got to incentivize that in this program to make
    that more attractive, and the noble position that it used to
    hold in the community.
        Take some of this administrative burden off of them and let
    them be doctors again. The numbers are great. We need the
    numbers. We know that the shortage by 38 is going to be
    staggering. I think the bill is----
        Senator Warnock. They are making decisions then about the
    direction of their career and what they will be able to
    practice, not necessarily based on what they prefer to do. Some
    would love to go into primary care. It is an economic issue.
        In that regard, Dr. Littles, in your experience, how often
    does the cost of higher education in the health professions
    dissuade people from entering the field?
        Dr. Littles. Thank you for that question. We certainly
    believe that that is a factor. Because as I said, when students
    come into medical school, they come because they really want to
    be able to provide care and spend that time, you know, with
    their patients but they also need to be to make a living in
    doing that.
        As has been said, it is the primary care specialties that
    are the hardest hit with that because they tend to be at the
    lower end of the pay scale already and if you are asking them
    to do more and more for less and less, at some point that just
    doesn't work, you know, for them.
        If we are able to fix some of these other issues with those
    practices, I believe those students who come in wanting to take
    care of patients in a primary care setting will continue to
    want to do that and we will continue to do that.
        Senator Warnock. Absolutely. I would imagine--well, not
    imagine. I know this is particularly difficult for first
    generation college students who have gone on to medical school
    and are--you know, they have the aptitude, but you have these
    barriers.
        In the last few months, I have heard from thousands of
    Georgians about changes to federal loan limits under the big
    ugly bill, which capped the maximum amount of federal direct
    loans available to students pursuing a health profession. Most
    medical and nursing students in Georgia rely on federal loans
    to afford their education and when federal loans are capped,
    students seeking advanced degrees in health care still owe the
    rest of their bill.
        Those who don't come from rich families have to then try
    and get risky private loans from banks, or worse, put their
    tuition balance on high-interest credit cards, or even just
    give up their dreams of being a health professional altogether.
        This is a concern that all of us share. I appreciate your
    work in this area, Dr. Littles, and also other members of the
    panel. I am deeply concerned that these changes to the federal
    student loans amid a growing health care workforce shortage and
    aging population is the exact wrong move at the exact long
    time. Thank you so much.
        The Chairman. Thank you, Senator Warnock. Senator
    Alsobrooks.
        Senator Alsobrooks. Thank you so much, Chair Scott, Ranking
    Member Gillibrand, and thank you so much as well to all of our
    witnesses for being here today. Across the country and in
    communities throughout Maryland, physicians are telling us the
    same story.
        We hear that they are exhausted, overwhelmed, and
    increasingly unsure how long they can continue practicing in a
    system that demands more from them each year, while giving them
    less time, less support, and less autonomy to focus on patient
    care.
        You know, I had a medical appointment just last week and
    had that experience. The doctor came in, collapsed basically on
    the chair and said, you know, I don't know what we are doing
    here. You know, one patient after the next.
        Burnout is not simply about long hours. It is about
    physicians spending more and more of their time navigating
    layers of paperwork and trying to operate around complicated
    processes instead of caring for patients. It is shorter visits,
    heavier caseloads, and constant pressure to do more with less.
        It is about working in environments where asking for help
    can still feel risky or discouraged. In Maryland, I hear from
    providers who want nothing more than to stay in their community
    and care for their patients, but who are struggling under
    administrative complexity, rising operating costs, and
    workplace structures that prioritize volume over quantity.
        These pressures are driving talented physicians out of
    medicine, and patients are feeling the consequences.
    Appointments are hard to get, wait times are longer, and rural
    and underserved communities are losing providers altogether and
    exhausted clinicians face higher risks of medical error,
    directly affecting patient safety. This is not just a workforce
    issue.
        It is a health care issue as well, an access issue. It is
    the quality of care and system sustainability issue. At the
    same time, the drastic Medicaid cuts in H.R. 1 threaten to
    further destabilize clinics and hospitals that serve as the
    backbone of primary and preventative care, forcing more
    patients into emergency rooms while placing even greater strain
    on an already stretched workforce.
        We cannot afford to continue operating a health care system
    that is burning out the very professionals that we depend on.
    Now, I have a question, Mr. Feist, if I can start with you and
    you have spent years working with hospitals, health care
    systems, and policymakers on efforts like Dr. Lorna Breen
    Health Care Provider Protection Act to address physician mental
    health and burnout.
        Much of the national conversation focuses on helping
    physicians manage stress, but far less on reforming the
    structural conditions that drive burnout in the first place, so
    based on your work, can you tell us what are the most impactful
    preventative reforms that reduce burnout at its root?
        Mr. Feist. I appreciate the question because you highlight
    the issue. The well-intended response over the last few years
    to the workforce has been to flood the market with a message of
    you need to be more resilient to health workers, when they need
    the problems addressed at the root cause.
        What we hear from the workforce by asking them the same
    question you asked me is that the administrative burden is the
    number one driver of their burnout. In addition, for nurses,
    the increasing issues around safety and threats and acts of
    violence against them are also driving them completely out of
    the workforce.
        The workloads are manageable if you think about the fact
    that if you--I am sorry, the workloads can be manageable if you
    reduce the amount of administrative time that they are spending
    before and after work.
        That in getting health workers back to the bedside and back
    to getting into the direct patient care that they went into the
    business to do, so we need to return them back to what they
    trained for and eliminate as much of the administrative burden
    and other operational inefficiencies that stand between them
    and their patients every day.
        Senator Alsobrooks. As to workforce violence, I have heard
    a lot about workforce violence. How important is it that
    occupational safety and health administration develop clear
    federal standards to ensure that physicians, nurses, and other
    health care professionals can practice in environments that are
    physically safe, as well as adequately supported?
        Mr. Feist. A question back to me?
        Senator Alsobrooks. Yes.
        Mr. Feist. I think about the Maslow hierarchy of needs. You
    have your essential needs of being able to be fed and watered,
    if you will, use the restroom but then right above that, you
    have safety and feelings of just being physically safe and
    emotionally safe. It is critically important for our workforce.
        I mean, we don't walk in here every day without armed
    guards outside and yet, we send our health workers into an
    environment where they can be physically and verbally abused
    every day, and then we ask them to come back tomorrow and do it
    all over again. It is just an unsustainable environment for
    them to work in.
        Senator Alsobrooks. One last question. My time is going
    here. Prior authorization, and this is for Mr. Smith, has
    become a routine gatekeeper in medical care, often requiring
    extensive paperwork, repeated appeals, and long delays before
    patients can receive treatment that their physicians deem
    medically necessary.
        From your perspective running medical practices, how does
    the current prior authorization system contribute to physician
    burnout? What consequences do you see for patients when
    medically necessary care is delayed or denied, particularly for
    older adults and those in rural and underserved communities?
        Mr. Smith. Yes, thank you. Prior authorizations are
    delaying care. There is no doubt about it and just to back up
    for a second, burnout is not restricted to doctors. In some of
    our offices, we have over 40 percent of our staff turnover
    every year because they cannot last in this environment. It is
    that difficult.
        I try to see every class of incoming employees and I tell
    them, health care is not for the faint of heart. It is
    incredibly difficult, and I believe our front desk folks have
    the toughest job in health care. Not the doctors. It is the
    front desk. They need to be psychiatrists, insurance experts,
    best friends. I mean, it is incredibly challenging, all working
    under HIPAA obviously.
        Prior authorization slows care. We see that, forcing folks
    to go to urgent care, in a lot of cases to the emergency room,
    because we haven't been able to get the authorization. We see
    delays in care. We haven't been able to quantify what that
    means in terms of additional dollars, but I think that would be
    worth looking at because I think that slowdown--we keep saying
    we need to get rid of the administrative burden, but we also
    recognize that the Government doesn't have unlimited money.
        How do we work together to reduce those burdens so it
    reduces our costs, so we may not need as much of an increase as
    we had thought we did because now we can get rid some staff or
    rearrange some staff.
        We can back to taking care of patients, because that is
    really--that is what doctors want to do. That is why they went
    to medical school. I believe that prior-auths are our biggest
    issue and truly need to be addressed quickly.
        Senator Alsobrooks. Thank you.
        The Chairman. Thank you, Senator Alsobrooks. Dr. Littles,
    what effect does documentation reporting requirements have on
    the willingness of new physicians to practice in rural or
    underserved areas?
        Dr. Littles. Thank you. We have been talking about the
    stressor of dealing with the electronic health records and the
    number of electronic health record that physicians often have
    to go through in the course of taking care of their patients.
        When you extend that out into rural communities, oftentimes
    even access to an electronic, you know, health record in and of
    itself--one, it is costly, but sometimes that is difficult for
    them to even have.
        When they have that electronic health record, we know that,
    you know, the number of clicks that they have to go through to
    provide the documentation is directly related to the stress
    that they feel from that.
        When you are asking about how the documentation
    specifically is affecting students wanting to go into rural
    practice, among the whole list of other factors that prevent
    them from doing that, that is certainly one of them.
        The cost of the electronic health record, the complexity of
    using the electronic health record. The fact that the
    electronic health record isn't communicating with the
    physicians they are referring patients to in nearby urban
    areas.
        All of that has a negative impact. I hear my faculty
    talking all the time about the pajama time that they are
    spending on their electronic health record, which has also been
    mentioned today. All of those are distractions from the care of
    the patient.
        The Chairman. Thank you. Dr. Gross, tell me how your
    practice changed. How is your day different now from when you
    are running an insurance driven practice to a patient driven
    practice?
        Dr. Gross. Yes. When I have a fee for service practice, any
    slot in my schedule when I walk into my office that is not
    already filled is lost revenue, so when I walk in, the schedule
    is already full.
        As the phones start to ring, then I have to start adding
    double booking, triple booking, quadruple booking, referring to
    the emergency room, sending to physician assistants, nurse
    practitioners, sending to other sites of care, because I don't
    have the capacity built within my schedule to accommodate for
    them. Which requires me to run an hour behind schedule, two
    hours behind schedule.
        Five minute office visits, three minutes of those which are
    spent clicking the boxes to get paid and then the two-minutes,
    oh, you have got another problem. I am sorry, you got to
    rebook, and by the way, my next available appointment is in
    three months. My schedule that I have right now is I walk into
    my office, I have an hour before lunch blocked out for same day
    appointments an hour before lunch, at the end of my day blocked
    out for same-day appointments. As the phone rings, if you call
    me in the morning, you are seen in the warning. As you call in
    the afternoon, you are seen in the afternoon.
        If I don't get a phone call, then I do administrative time,
    or I go home and spend some time with my family but people
    aren't referred to the emergency room simply because I am too
    busy and that opens up my schedule to actually practice to the
    full scope of my training.
        I would argue that a lot of referrals in primary care is
    not because the doctor is not capable of handling the problem.
    It is because the doctor doesn't have time to handle the
    problem, so when the doctor now has the time and the
    administrative burden is lifted to perform the full scope of
    his or her practice, now you are stopping downstream referrals
    for endocrinology, for rheumatology.
        You are managing things within your practice that are
    clearly within your purview as you are training and we see that
    in our data. That when we implement this into a health plan
    that is built around our practice model, our ER referrals are
    35 percent less. Our specialty referrals are 35 percent less.
        Our cost of total implementation of the health plan built
    around our model is a 52 percent reduction in health care in a
    rural health care setting and we sustain numbers like that over
    seven years because we are--not because we are better than
    anyone.
        It is the structural design of the practice. It is the
    administrative design of the practice, the intent of that,
    which I think is completely changing how we care for patients.
        The Chairman. Mr. Smith, how much of your budget goes to
    getting prior authorizations, compliance, paperwork versus
    patient care?
        Mr. Smith. Well that is a good question. I don't have a
    specific answer. I can tell you that in 75 offices, we have at
    least one employee, average employee, with benefits is making
    $35,000 to $50,000, so it is a significant amount and if we
    could reduce that by a quarter, by a half, it would
    significantly change the budget of the medical group.
        The Chairman. Is it easy to stay up with all the changes by
    the insurance companies and by Medicare and by Medicaid?
        Mr. Smith. I am sorry. Say that--?
        The Chairman. Is it easier to stay with all of the rule
    changes by Medicare, Medicaid, plus all the changes with the
    insurance company?
        Mr. Smith. It is not easy. I mean we do our best to
    educate. We have great staff. You know, our staff typically is
    high school educated. Working in the medical offices, we have
    in-house programs to allow them to become certified medical
    assistants.
        We do everything we can to raise them up and to increase
    their knowledge, but it is a lot. You know, a one or two doctor
    practice, can't really have a business manager running that
    practice, so we are running it from afar and hoping that we can
    get information to them to allow them to be successful.
    Honestly, just to get paid for the work they are doing.
        The Chairman. The people who run Medicare and Medicaid in
    your state, they are just out there to help you every day,
    aren't they?
        Mr. Smith. Yes, every day they come out. [Laughter.] No. It
    is a challenge.
        The Chairman. Mr. Feist, how much of today's mental health
    crisis is driven not by patient care itself but by the constant
    pressure of bureaucracy and red tape?
        Mr. Feist. We hear--as we have discussed today, when you
    think about burnout as an occupational syndrome and burnout as
    driven by the workplace design, I think as we discussed today
    the vast majority of what we are experiencing in burnout is
    within our control to reduce by changing the operational
    environment that our health care workers work in every single
    day.
        The Chairman. Well, I want to thank everybody for being
    here today. This was eye opening and hope all of our colleagues
    in the Senate see all this.
        I think it is very difficult what physicians are going
    through and I think more and more physicians are doing what you
    are doing, Dr. Gross. They have got to opt out of the way the
    system is organized because it is just too difficult.
        I am sure you deal with, Dr. Littles, all the time with,
    you know, the choices people are making, so thanks everybody
    for being here. It is clear that real reforms must start with
    cutting red tape and putting doctor-patient relationships at
    the center of health care so physicians can focus on healing
    rather than compliance.
        I look forward to continuing to work with members across
    the aisle and down the dais. If any Senators have additional
    questions for the witnesses or statements to be added, the
    hearing record will be open until next Wednesday at 5:00 p.m.
    Thank you very much. It is adjourned.
        [Whereupon, at 04:45 p.m., the hearing was adjourned.]

    =======================================================================

                                    APPENDIX

    =======================================================================

    =======================================================================

                          Prepared Witness Statements

    =======================================================================

                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

                           Prepared Witness Statement

                                Dr. Alma Littles

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

                           Prepared Witness Statement

                                 Dr. Lee Gross

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

                           Prepared Witness Statement

                                 Jeffrey Smith

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

                           Prepared Witness Statement

                                  Corey Feist

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    =======================================================================

                            Questions for the Record

    =======================================================================

                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

                            Questions for the Record

                                Dr. Alma Littles

                              Chairman Rick Scott

        Question:

        You highlighted during the hearing that even modest
    reductions in documentation and administrative workload can
    meaningfully increase patient-facing time and reduce burnout.
    For small, independent, or rural practices that lack large IT
    departments, what types of digital infrastructure or workflow-
    support platforms are most practical and scalable to eliminate
    redundant documentation, streamline prior authorization, and
    improve care coordination?

        Response:

        For small, independent, or rural practices, the most
    practical approaches are hub and spoke digital infrastructure
    models, where core clinical and administrative capabilities are
    provided through a regional or system-level platform (Health
    System or State Entity), rather than requiring each practice to
    maintain its own IT department.

    Examples of practical platforms include:

          Shared EHR instances or hosted environments (e.g., a
    regional Epic or Cerner/Oracle deployment) that allows rural
    practices and hospitals to plug into enterprise-grade
    documentation, ordering, and care coordination workflows
    without bearing full implementation or maintenance costs.
          Embedded workflow automation layers within those
    Electronic Health Records (EHR), such as native AI,
    standardized prior authorization modules, centralized referral
    management, and system-level clinical documentation templates,
    that eliminate duplicative charting and manual handoffs.
          Cloud-based care coordination and interoperability tools
    that leverage TEFCA (Trusted Exchange Framework and Common
    AgreementT) and FHIR (Fast Healthcare Interoperability
    Resourcesr) standards to ensure patient information flows
    seamlessly across sites in a regional network.

    Sample incentives to support this model:

          Federal grants or enhanced matching funds for shared EHR
    hosting arrangements between larger health systems and rural or
    independent practices.
          CMS recognition of regional digital health hubs (e.g.,
    "Certified Rural Integration Platforms") that meet
    interoperability, uptime, and governance standards.
          Reduced reporting or documentation requirements for
    practices that participate in an approved shared infrastructure
    model.

    Payer Integration Incentive:

          Provide enhanced reimbursement rates, administrative
    cost-sharing, or preferred network status for payers that
    integrate directly into shared EHR platforms (e.g., Epic's
    Payer Platform) used by regional hubs and rural spokes,
    allowing real-time eligibility, authorization, care gap
    closure, and quality reporting. This reduces payer
    administrative overhead, improves risk adjustment accuracy, and
    lowers avoidable utilization through shared clinical
    visibility.

        Question:

        What federal policy changes would most accelerate adoption
    of such solutions while maintaining appropriate safeguards for
    patient privacy and program integrity?

        Response:

    Reward integration rather than fragmentation. Examples of
    policy changes:
          Clarifying regulatory safe harbors under Stark, Anti-
    Kickback, and Civil Monetary Penalty rules to explicitly allow
    health systems to subsidize or host digital infrastructure for
    affiliated rural or independent practices, provided
    interoperability and patient choice standards are met.
          Standardizing privacy and governance frameworks for
    shared EHR and data platforms, so smaller practices are not
    forced to independently interpret HIPAA, state privacy laws, or
    cybersecurity requirements.
          Aligning federal quality and reporting programs (e.g.,
    MIPS, Promoting Interoperability) so participation through a
    shared platform satisfies compliance requirements, instead of
    duplicating reporting at each site.

    Sample incentives:

          A federal "integration bonus" applied to Medicare
    reimbursement for practices participating in validated regional
    digital infrastructure arrangements.
          Preferential eligibility for CMS innovation models or
    rural health demonstrations for systems that demonstrate multi-
    site EHR integration and shared workflows across urban and
    rural settings.
          Liability and audit protections for practices using
    federally recognized shared platforms that meet predefined
    security and integrity benchmarks.

    Policy Safe Harbor for Payer Participation:

          Establish explicit federal safe harbors and
    demonstration authority allowing payers to co-invest in shared
    clinical and administrative infrastructure, such as hosted
    EHRs, payer-provider data platforms, or integrated utilization
    management tools, when tied to measurable reductions in
    administrative burden, duplicative services, and total cost of
    care, while maintaining strict governance and patient consent
    standards.

        Question:

        Additionally, how should federal payment or demonstration
    programs be structured to incentivize adoption of workflow-
    enhancing digital tools, including AI-enabled documentation,
    coding, or administrative support platforms that measurably
    reduce clinician time spent on non-clinical tasks?

        Response:

        One thing to consider with any demonstration program is
    whether or not small physician practices will be able to
    successfully participate. Physicians in small practices and
    those in rural areas spend inordinate amounts of time just
    requesting and waiting for patient records to reach them.
    Access to patient care documents from consulting physicians
    enhances efficiency and quality of care. Having systems that
    fully integrate between hospitals, consulting physician
    practices and primary care physician practices is critical. For
    that to happen, small practices will need to be able to receive
    adequate funding and support without the fear of costly
    recoupments or excessive program penalties. While costs are a
    crucial and necessary consideration for the government, if
    small practices are not equipped with the resources they need
    to acquire the software and potentially hardware needed, the
    demonstration may be effectively limited to larger hospital
    systems while excluding many smaller practices that could
    benefit the most from measures aimed at reducing administrative
    burdens.

    Effective program design should move beyond merely "checking
    the box":

          Tie incentives to outcomes, such as reductions in
    clinician documentation time per visit, faster prior
    authorization turnaround, or increased patient-facing minutes,
    rather than simply purchasing the technology.
          Encourage system-level deployment of AI-enabled tools
    (e.g., ambient documentation, automated coding, centralized
    prior authorization engines) that benefit multiple sites
    simultaneously.
          Allow savings from administrative efficiency to be
    shared between clinicians, practices, and hosting systems,
    reinforcing alignment.

    Sample incentive structures:

          CMS demonstration programs that provide per-clinician or
    per-visit bonuses when validated AI or automation tools reduce
    time spent on documentation, coding, or administrative tasks.
          Shared-savings models where reductions in administrative
    cost or denied claims are partially returned to participating
    practices and hosting health systems.
          Temporary expense recognition or add-on payments for the
    first 2-3 years of enterprise-scale implementation of workflow-
    enhancing tools, particularly when deployed across rural
    networks.

    Shared Payer Administrative Savings & Risk Alignment:

          Structure demonstrations so payers participating in
    integrated EHR and workflow platforms are eligible to share in
    documented reductions in administrative costs, denial rates,
    and unnecessary utilization. For example, CMS could allow
    Medicare Advantage plans or Medicaid MCOs to retain a portion
    of savings generated through real-time clinical integration,
    automated prior authorization, and AI-enabled documentation-
    provided savings are reinvested into provider-facing workflow
    improvements.

                            Senator Elizabeth Warren

        Question:

        Insurance conglomerates and wholesale drug distributors are
    now major employers of physicians. For example, UnitedHealth
    Group (UHG) is the nation's largest employer of physicians, and
    McKesson owns the largest community oncology network.
        Are you concerned about how these middlemen influence their
    physician employees and independent physician competitors,
    including graduates of your medical school, given their
    incentives to raise prices, lower quality, and drive
    independent providers out of business?

        Response:

        Organized medicine, in general, opposes the corporate
    practice of medicine because these types of arrangements can
    compromise patient care. Over the past decade or so, physician
    groups have been consolidating at an unprecedented pace.
    Medical groups keep growing larger as physician practices merge
    or sell out in the face of serious economic challenges and, as
    a result, there are now more physicians serving as employes
    than as practice owners. In short, the medical landscape has
    fundamentally changed and there are no signs that this change
    is set to reverse course. One critical reason for this shift is
    that it has become increasingly difficult to manage the cost
    and complexity of running an independent practice, particularly
    due to regulatory red tape and unfair insurance practices.
        In addition, the conversion factor under the Medicare
    Physician Fee Schedule is not pegged to inflation and has
    fallen around 33% in real value since 2001, which poses a
    serious challenge for physicians who care for seniors. Given
    this reality, it is more important than ever to support
    physicians that want to remain in private practice, so that
    doctors who do not want to work for larger organizations will
    continue to have the opportunity to practice independently. To
    do this, we must cut down on burdens like prior authorization,
    end step-therapy or "fail first" protocols, eliminate unfair
    payment practices such as retroactive denials, ensure that
    payors maintain adequate networks of physicians, and provide
    annual Medicare payment updates that track inflation. Taken
    together, these measures would help make it easier for small
    medical practices to remain economically viable in this
    challenging environment and reduce the spread of the corporate
    practice of medicine.
        It is important to distinguish care-aligned integration
    from middleman-driven consolidation.
        Integrated delivery and financial systems like Kaiser
    Permanente and UPMC align insurance, care delivery, and
    population health accountability under unified governance.
    Their success depends on keeping patients healthy, reducing
    unnecessary utilization, and reinvesting in clinical
    infrastructure, creating a fundamentally different incentive
    structure.
        By contrast, when insurance conglomerates or wholesale drug
    distributors employ physicians or acquire networks without
    direct accountability for care delivery, there is always the
    risk that financial incentives, not patient outcomes, drive
    decisions. That concern is heightened when those entities also
    compete with independent practices or control access points
    like drug purchasing, referrals, prior authorization, or data.
        The concern is not physician employment itself, but who
    controls clinical decision-making and market leverage. At the
    same time, fragmentation is not the answer.
        Ultimately, policy should encourage integration models that
    align financing, care, and accountability, while placing
    guardrails around consolidation that narrows competition or
    compromises clinical autonomy.

    Examples:

          Risk-Bearing Requirement for Advanced Payment Models:
    Limit eligibility for top-tier shared-savings, global budget,
    or capitation programs to organizations that directly deliver
    care and assume downside clinical risk-favoring Integrated
    Delivery and Finance System (IDFS) over administrative
    intermediaries.

          System-Level Quality & Cost Accountability: Attribute
    outcomes, utilization, and total cost of care at the integrated
    system level (not subsidiary or vendor level), advantage
    organizations where financing and clinical operations are
    inseparable.

          Care-First Antitrust Presumption: Apply more permissive
    antitrust treatment to vertically integrated entities that both
    finance and deliver care (e.g., Kaiser), while applying
    stricter scrutiny to entities that control care pathways
    without delivering care themselves.

        In addition to the support for physician practices, support
    for patient participation in digital support tools must be
    considered. In many rural areas, connectivity to the internet
    is a problem. Satellite internet is slow and expensive. Many
    patients do not have home internet. Telehealth and tele-
    consults are helpful when patients can get access to the
    internet; however, Medicaid apparently stopped paying for tele-
    consult services after the peak of the COVID-19 Pandemic.

                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

                            Questions for the Record

                                 Dr. Lee Gross

                            Senator Elizabeth Warren

        Question:

        In 2010, you started a direct primary care practice. Direct
    primary care practices typically charge patients a flat fee to
    cover basic services and do not accept public or private
    insurance. This often requires insured patients to forgo their
    benefits and pay out of pocket.
        1(a)What role did large insurance conglomerates play in
    your decision to start a direct primary care practice?
        1(b)Would legislative reform that breaks up Big Medicine
    conglomerates make it easier for you to run your practice?
        1(c)Would legislative reforms that prohibit prior
    authorization make it easier for you to run your practice?

        Response to 1(a):

        Large insurance entities were not the only factor in my
    decision, but they were part of a broader structural
    environment that increasingly shaped how care was delivered.
    Over time, payment architecture and administrative requirements
    began to exert growing influence on clinical workflows.
    Utilization management protocols, prior authorization
    requirements, and complex billing rules were originally
    introduced with the stated goal of protecting patients from
    inappropriate or excessive care. In practice, these systems
    gradually evolved into administrative layers that often operate
    independently of the clinical encounter itself.
        As these processes expanded, they began to consume
    increasing amounts of physician time and practice resources.
    The cumulative effect made it harder to sustain a model
    centered on continuity, access, and individualized decision
    making. Policies intended to address isolated misuse became
    standardized requirements applied across the entire system.
    Tools designed to identify outliers came to shape routine care.
    Over time, the system shifted from targeting rare instances of
    misuse to treating every clinical decision as if it required
    preauthorization, effectively replacing professional trust with
    administrative permission.
        Direct primary care allowed me to test whether removing
    administrative friction between physician and patient would
    change outcomes. By simplifying payment and eliminating
    intermediated approval requirements for routine care, the model
    reduced overhead and increased time available for clinical
    care. The objective was not to avoid insurers, but to evaluate
    what happens when administrative complexity is minimized and
    clinical decisions occur directly within the physician patient
    relationship.
        My experience working with DeSoto Memorial Hospital
    illustrates this dynamic. The hospital implemented a self
    funded employee health plan that eliminated prior authorization
    and similar approval barriers for routine care within the
    plan's structure for employees that chose DPC. Removing those
    administrative layers allowed treating physicians to proceed
    based on clinical judgment rather than external authorization.
    The result was a substantial reduction in total health plan
    spending along with improved employee benefits. That outcome
    highlights an important distinction. When administrative
    intermediaries are removed from routine care decisions, both
    cost and access can improve simultaneously. This suggests that
    many inefficiencies attributed to medical care itself may
    instead originate within payment and oversight structures that
    sit between patients and clinicians.

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Response to 1(b):

        Market concentration in healthcare warrants serious
    scrutiny, particularly when corporate structures combine
    financing, delivery, pharmacy, and utilization oversight within
    the same enterprise. When a single entity is responsible for
    paying for care, determining whether care is approved, and in
    some cases delivering that care, structural conflicts of
    interest are not theoretical. From an incentive design
    standpoint, they are inherent. Such arrangements create
    powerful financial incentives to influence clinical pathways,
    access to services, and treatment approvals in ways that may
    not be transparent to patients or physicians.
        These vertically integrated models can shift decision
    making authority away from the point of care and toward
    entities whose primary fiduciary obligation is financial
    performance rather than clinical outcomes. That dynamic can
    affect utilization policies, network design, reimbursement
    structures, and approval standards. When those levers are
    controlled within the same organization, the distinction
    between clinical management and financial management can become
    blurred.
        At the same time, consolidation trends reflect multiple
    reinforcing forces, including regulatory complexity, reporting
    mandates, and compliance costs that disproportionately burden
    smaller practices. Many physicians have entered large systems
    not because of clinical preference, but because scale offers
    protection from administrative overhead that independent
    practices struggle to absorb. In that sense, consolidation is
    not purely a market phenomenon. It is often a rational response
    to policy design.
        For that reason, structural breakups alone would not
    automatically restore a competitive physician led marketplace.
    If the regulatory environment that favors scale remains
    unchanged, new entities would likely reconsolidate to manage
    the same administrative demands. Structural remedies may
    therefore be necessary, but they will not be sufficient unless
    policymakers also address the underlying policy incentives that
    make consolidation economically rational.

        Response to 1(c):

        Yes. Prior authorization is among the most resource
    intensive administrative processes in clinical medicine. It
    requires time, staffing, and documentation that do not directly
    contribute to patient care. In many cases it delays treatment
    while approvals are obtained from third parties who are not
    directly involved in the clinical evaluation.
        Reducing unnecessary prior authorization requirements would
    improve efficiency and timeliness of care. It would also
    redirect clinical staff time toward patient services rather
    than administrative processing. More broadly, it would help
    restore decision making authority to the point of care, where
    physicians are accountable for outcomes. Oversight mechanisms
    are important, but when approval processes become routine
    prerequisites for standard treatment, they can shift control of
    clinical decisions away from those directly responsible for the
    patient and toward entities whose primary role is financial
    administration.

    Additional Concern: Expansion of Prior Authorization and Risk
    of Administrative Drift

        Recent policy developments indicate that prior
    authorization requirements are being introduced into additional
    areas of public coverage through pilot programs that apply
    prospective approval requirements to selected services. These
    initiatives are intended to improve program integrity and
    reduce inappropriate spending. At the same time, they
    illustrate how administrative tools introduced for limited
    purposes can expand over time in both scope and operational
    impact.
        Historical experience suggests that utilization management
    systems can evolve beyond their initial targets. In the private
    sector, some insurers previously used physician utilization
    scoring programs tied to prescribing or imaging patterns.
    Physicians with higher scores were exempt from certain
    administrative steps, while others faced increasing approval
    requirements. In practice, such systems often affected
    clinicians who treated more complex patients or who practiced
    in fields where higher utilization reflected appropriate care.
        Another example of clinical guidance evolving into
    administrative constraint is the American Geriatrics Society
    Beers Criteria. Originally intended as a reference tool to help
    clinicians identify potentially inappropriate medications in
    older adults, the criteria have increasingly been incorporated
    into quality metrics, payer policies, and utilization controls.
    In some settings this has effectively turned a clinical
    guideline into a compliance standard, where deviation can
    trigger scrutiny even when medically appropriate. This
    illustrates a recurring policy pattern. Tools created to inform
    physician judgment can gradually be repurposed to regulate it.
        The concern is not the existence of oversight mechanisms,
    but how they evolve. Safeguards that begin as targeted
    protections can, if not periodically reassessed, become
    generalized administrative requirements that influence routine
    care decisions.

    Additional Policy Perspective for the Record

        The central problem in healthcare is rarely who
    participates in the system. It is how the rules shape their
    incentives.
        Certain statutory and regulatory structures can
    unintentionally influence institutional behavior through their
    design. Payment rules that tie allowable administrative margins
    to total spending levels, for example, may affect how
    organizations evaluate cost reducing innovations. While such
    policies may limit excessive overhead, they can also create
    situations in which lowering total spending alters financial
    calculations for participating entities.
        Organizations generally respond predictably to the
    incentives embedded within policy frameworks. When those
    incentives reward volume, complexity, or administrative control
    rather than efficiency and outcomes, system behavior will
    reflect that structure. Policymakers therefore face an
    incentive design challenge rather than a choice between public
    or private delivery models. The key issue is whether payment
    policy aligns institutional incentives with the goals of
    affordability, access, and clinical quality.
        Sustainable reform is most likely when those incentives are
    calibrated so that patients, physicians, employers, and payers
    all benefit from the same outcome: appropriate care delivered
    efficiently, transparently, and with minimal administrative
    friction.

                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

                            Questions for the Record

                                 Jeffrey Smith

                            Senator Elizabeth Warren

        Question:

        The passage of the One Big Beautiful Bill Act, coupled with
    the expiration of the Affordable Care Act's enhanced premium
    tax credits, will likely lead to a significant increase in the
    number of uninsured Americans and a concurrent increase in
    uncompensated care, compounding the financial pressures on
    safety-net hospitals and independent physician practices.
        How do you anticipate providers and safety-net hospitals
    will respond?

        Response:

        Medical groups will likely provide more uncompensated care
    and face new financial pressures as patients lose coverage due
    to the ACA enhanced premium tax credit expiration and Medicaid
    changes under the One Big Beautiful Bill Act. The response from
    medical group practices will depend on the ability of their
    respective states to intervene and offset some of these costs
    through state-level assistance and policy. Practices,
    especially in underserved and rural areas who serve a diverse
    payer mix, will face financial strain as they absorb more care
    without payment, threatening the stability of safety-net access
    points and independent practices.
        As uninsured rates increase, medical group practices will
    be forced to take on a substantial administrative burden, such
    as increased eligibility verifications. Front-office staff will
    also shoulder the burden of helping patients who may have lost
    coverage and facilitating out of pocket payment options. As
    financial pressures intensify, group practices may be pushed
    toward selling their practices or closing entirely.

        Question:

        How will intensifying consolidation further erode
    physicians' autonomy over their patients' medical care?

        Response:

        Consolidation results from physician owners selling their
    practices and becoming employed in a health system or hospital.
    This change can impact physician autonomy because, unlike
    smaller practices, large health systems often operate in more
    structured environments and may lead to less physician control
    over their schedules, practice structure, and other operational
    activities. By contrast, independent groups can offer
    physicians meaningful control over their work, where partners
    may set their own schedules and adjust workloads, and shape
    operational decision-making.
        2025 State of Private Medical Practice report speaks to how
    intensifying consolidation impacts autonomy. The survey was
    conducted online from April - May 2025 and received a total of
    240 responses.

          Consolidation is a top driver of declining optimism:
    Among leaders who feel less optimistic about independent
    practice, 54% cite "increasing consolidation of healthcare".
          Autonomy is a central component of professional
    independence: 40% of members identify autonomy and independent
    decision-making as a key benefit of private practice, while 47%
    cite quality of care/patient focused as a key benefit of
    working in an independent practice.
          Financial and payer pressures are pushing groups toward
    mergers and acquisition, shifting governance away from
    physicians: When asked about necessary changes to ensure
    practices' sustainability, 28% of respondents selected
    "increasing practice size via mergers and acquisitions,"
    signaling that many practices view consolidation as survival.
        Question:

        Following a February 2024 cyberattack on its subsidiary,
    Change Healthcare, UHG extended emergency loans to affected
    providers via its subsidiary bank, Optum Financial. Physician
    borrowers later reported that UHG was acting like a "loan
    shark," abruptly demanding full repayment under threat of yet
    another subsidiary, the insurer UnitedHealthcare, and
    garnishing claim reimbursements as a means of repayment.
        If applicable, can you provide examples of the way that
    Optum Financial and UHG are treating your members who were
    forced to take these emergency loans?

        Response:

        While we are aware of ongoing lawsuits related to the
    Change Healthcare cyberattack, we have not heard from members
    about their current interactions with Optum Financial.

        Question:

        Are any of your members still dealing with the financial
    fallout from this cyberattack and UHG's response to it? If so,
    in what ways are they affected?

        Response:

        The Change Healthcare cyberattack had wide-ranging
    financial impacts for medical groups beginning in February
    2024, that included:

          Substantial billing and cash flow disruptions, such as a
    lack of electronic claims processing. Both paper and electronic
    statements were delayed, with some groups going without any
    outgoing charges or incoming payments immediately following the
    cyberattack.
          Limited or no electronic remittance advice from health
    plans, groups had to manually pull and post from payer portals.
          Prior authorization submissions were rejected or were
    not transmittable at all.
          Lack of connectivity to important data infrastructure.
          Lack of ability to perform eligibility checks for
    patients.
        Members continued to express residual financial concerns
    into 2025 related to unpaid claims, benchmarking and data
    issues, and more. While we have not heard from members recently
    given the amount of time that has passed, all of these
    disruptions amplified underlying systemic financial issues,
    such as staffing shortages and continued inadequate
    reimbursement from Medicare.

                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

                            Questions for the Record

                                   Cory Feist

                              Chairman Rick Scott

        Question:

        You highlighted during the hearing that even modest
    reductions in documentation and administrative workload can
    meaningfully increase patient-facing time and reduce burnout.
    For small, independent, or rural practices that lack large IT
    departments, what types of digital infrastructure or workflow-
    support platforms are most practical and scalable to eliminate
    redundant documentation, streamline prior authorization, and
    improve care coordination?

        Response:

        Thank you for the opportunity to respond to Chairman
    Scott's questions regarding the administrative burdens fueling
    the exodus of physicians from the medical profession. For
    small, independent, and rural practices, the "administrative
    tax" is a primary driver of burnout and distress. To support
    clinicians serving in these critical settings, we must
    prioritize digital infrastructure that is interoperable,
    automated, and low-friction.
        Before implementing specific technologies, I urge all
    practice leaders to review and implement action steps outlined
    in the Impact WellbeingT Guide: Taking Action to Improve
    Healthcare Worker Wellbeing. This transformative resource,
    supported by the Dr. Lorna Breen Health Care Provider
    Protection Act, has already equipped over 35,000 healthcare
    leaders with evidencebased strategies to address the
    operational factors and burdens that drive their workforce's
    burnout.
        Practice leaders can then take additional steps to reduce
    documentation burden, streamlineworkflow, and improve care
    coordination:

        Reducing the Documentation Burden: Ambient Listening AI
    Technology

        The Electronic Health Record (EHR) has transitioned from a
    clinical tool to a billing ledger, forcing physicians into
    "pajama time". For small practices, ambient listening AI
    technology or AI-driven scribes represent a significant leap in
    workload reduction. Recent implementation of the Impact
    Wellbeing Guide by one Virginia hospital showed that Ambient
    listening AI technology can reduce documentation time by 10-15
    minutes per patient visit while simultaneously improving
    patient experience ratings. Another rural Virginia hospital
    decreased their workforce's cognitive burden by addressing EHR
    alert fatigue-reducing unnecessaryinpatient alerts by 52% and
    unnecessary ambulatory alerts by 73% per month.
        By automating the generation of structured clinical notes,
    ambient listening AI technology allows physicians and other
    care givers to return their focus to the patient rather than a
    screen.

    Streamlining Workflow: Electronic Prior Authorization (ePA)

        Prior authorizations are a source of profound
    administrative burden as clinicians spend nearly two business
    days a week completing these requirements. Similar to the
    legislative approaches in New Jersey and Virginia, we must move
    toward integrated ePA platforms that reside within the e-
    prescribing workflow. I strongly urge the Committee to support
    S. 1816 The Improving Seniors' Timely Access to Care Act of
    2025 to reduce this administrative burden and ensure seniors
    can access the treatments they need.

    Improving Care Coordination: Asynchronous Communication

        Rural health is inherently collaborative, yet clinicians
    are often underwater with documentation and coordination tasks.
    We recommend the adoption of HIPAA-compliant asynchronous
    messaging hubs to replace the inefficiency of "phone tag".
    Furthermore, practices should address EHR alert fatigue. As
    noted above, we have seen evidence in Virginia that targeted
    quality improvement projects can reduce unnecessary ambulatory
    alerts by up to 73% per month, significantly decreasing the
    cognitive burden on the workforce.
        Beyond technical infrastructure, we must address the
    "invisible" administrative barriers that prevent clinicians
    from seeking help. Many legacy licensing and credentialing
    applications ask intrusive, stigmatizing questions about a
    clinician's mental health history. Consistent with
    recommendations in the Impact Wellbeing Guide, our Foundation
    and its coalition of national healthcare organizations has
    supported 70 licensure boards and 2,115 health care facilities
    in auditing and removing these questions, improving access to
    mental health care for more than 2.64 million licensed health
    workers. By shifting the focus from past diagnosis to current
    impairment, we create a culture where getting mental health
    support is treated as a normal, healthy part of the job.
        For the independent physician, time is the most precious
    resource. The newly reauthorized Lorna Breen Act prioritizes
    projects that reduce administrative burden, freeing up
    clinicians to focus on patient care while supporting their
    wellbeing. I urge Congress to provide full funding of $45M in
    FY27 for Lorna Breen Act programs. By funding these programs
    now and in the future, and by taking the steps outlined above,
    we can protect the backbone of our healthcare system. We must
    move from a system that depletes our workforce to one that
    sustains them with safety and operational support.

        Question:

        What federal policy changes would most accelerate adoption
    of such solutions while maintaining appropriate safeguards for
    patient privacy and program integrity?

        Response:

        To most effectively accelerate the adoption of these
    burnout-reducing technologies while maintaining program
    integrity and patient privacy, federal policy must transition
    from permissive to proactive support.
        Based on the evidence-based framework of the National
    Academy of Medicine (NAM) National Plan for Health Workforce
    Well-Being and the operational successes of the Dr. Lorna Breen
    Health Care Provider Protection Act, we recommend the following
    federal policy changes:

    Sustained Funding for Workforce Retention

        Federal investment has historically focused on the pipeline
    (creating new clinicians) while ignoring the leaks (losing
    existing clinicians). As I referenced in my written testimony,
    tens of billions of dollars are directed annually for
    healthcare workforce creation initiatives, but the Lorna Breen
    Act programs are the only ones to directly support workforce
    retention. Congress must provide full and consistent annual
    funding for the newly reauthorized Lorna Breen Act, which
    ensures federal dollars are used for proven operational
    improvements rather than superficial wellness programs.

    Standardizing Electronic Prior Authorization (ePA)

        The administrative burden of prior authorizations currently
    consumes nearly two business days a week for physicians. By
    passing and implementing S. 1816 The Improving Seniors' Timely
    Access to Care Act, we can ensure a standardized, real-time
    electronic prior authorization process for Medicare Advantage
    plans. Utilizing the HL7 FHIR (Fast Healthcare Interoperability
    Resources) standard will ensure secure and transparent data
    exchange that does not create new avenues for "upcoding" or
    fraudulent claims.

    Codifying Documentation Relief through AI "Safe Harbors"

        While Ambient Notes AI can reduce documentation time by 10-
    15 minutes per patient visit, small practices often hesitate to
    adopt it due to concerns over future audit scrutiny. By
    establishing CMS "Safe Harbor" guidelines that explicitly
    recognize AI-generated, physicianvalidated ambient notes as
    meeting medical necessity and documentation requirements for
    Medicare/Medicaid reimbursement, will give small practices the
    peace of mind they need to adopt this transformative
    technology. Requiring these platforms to maintain HIPAA-
    compliant, SOC2-certified data encryption will ensure patient
    conversations remain private and are not used for unauthorized
    secondary purposes.

    Incentivizing "Low-Burden" EHR Configurations

        Small practices often suffer from "EHR alert fatigue," yet
    they lack the IT staff to optimize these systems. By
    establishing federal grants or "Wellbeing Meaningful Use"
    incentives for EHR vendors and practices that successfully
    reduce cognitive load, we can help small practices make the
    most of these systems, perhaps even achieving benchmarks like
    the 73% reduction in ambulatory alerts as demonstrated by
    quality improvement projects implemented in Virginia using the
    Lorna Breen Act resources. This shifts the focus of technology
    from a billing ledger to a clinical tool that supports-rather
    than depletes-the workforce.
        We cannot care for our aging population if we do not care
    for those who care for them. By removing the red tape and
    making technology work for people, we preserve the 30 to 40
    years of expertise each clinician provides to the American
    public - an urgent priority given projected workforce
    shortages.

        Question:

        Additionally, how should federal payment or demonstration
    programs be structured to incentivize adoption of workflow-
    enhancing digital tools, including AIenabled documentation,
    coding, or administrative support platforms that measurably
    reduce clinician time spent on non-clinical tasks?

        Response:

        To move the needle on clinician burnout, federal payment
    and demonstration programs must shift from rewarding volume of
    documentation to rewarding quality of care for patients and
    clinicians.
        By funding newly reauthorized Lorna Breen Act grants,
    Congress can help support operational changes that reduce
    administrative burden. With resources from the Lorna Breen Act,
    hospitals have successfully improved the wellbeing of health
    workers by decreasing administrative burden. They have seen
    significant decreases in both diagnosed mental health
    conditions like depression and turnover.
        Federal demonstrations should require the use of evidence-
    based or evidence-informed resources like the Impact WellbeingT
    Guide to ensure that digital tools are integrated into a
    supportive, safe workplace culture rather than simply added to
    existing workloads.

    Mandating Interoperability for Prior Authorization

        Federal policy must accelerate the adoption of electronic
    Prior Authorization (ePA) to eliminate the "clerical detective
    work" that currently consumes nearly two business days a week
    for physician staff.
        Immediate passage and implementation of S. 1816 The
    Improving Seniors' Timely Access to Care Act of 2025 would
    mandate a standardized electronic process for Medicare
    Advantage plans. Future payment models should penalize "manual-
    only" authorization processes that delay care and increase
    clinician distress.

    Removing Legal and Regulatory Barriers to Wellbeing

        Incentivizing use of effective technological tools is only
    half the battle; we must also ensure thatclinicians feel safe
    enough to seek support while they manage these system
    transitions.
        Federal programs should require participating health
    systems to audit and remove stigmatizingmental health questions
    from their credentialing applications. To date, this initiative
    has alreadyimproved access to care for more than 438,000
    credentialed health workers.

    Tiered Reimbursement Incentives for "Burden-Reduced" Care

        Federal payment programs, particularly those within CMS,
    should provide enhancedreimbursement or bonus payments for
    practices that utilize certified ambient listening AItechnology
    and other AI-enabled administrative tools.
        A "Wellbeing Tier" within the Merit-based Incentive Payment
    System (MIPS) or AlternativePayment Models (APMs) could reward
    practices based on a number of factors such as measurably
    reducing time spent on non-clinical tasks. For one rural
    hospital in Virginia, the use of ambient listening AI has been
    shown to reduce documentation time by 10-15 minutes per patient
    visit, directly allowing for more patient-facing time.
        Implementing these and other similar programs, we need to
    balance the federal investment between focusing exclusively on
    pipeline creation to prioritizing workforce retention. By
    providing full and consistent annual funding for Lorna Breen
    Act programs in FY27 and beyond, Congress can ensure that
    technology works for people, preserving our health workforce to
    care for our aging population.

    =======================================================================

                           Statements for the Record

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                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

                           Statements for the Record

                        American Academy of Dermatology

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                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

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                American Academy of Family Physicians Statement

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                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
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                               February 11, 2026

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             American Association of Orthopaedic Surgeons Statement

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      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

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              American Clinical Neurophysiology Society Statement

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      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

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      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
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                               February 11, 2026

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           American Economic Liberties: Medicare Advantage Statement

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      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

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         American Economic Liberties: One Big Beautiful Bill Statement

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      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

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      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
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                               February 11, 2026

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                    American Hospital Association Statement

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                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

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                American Physical Therapy Association Statement

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                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

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                American Podiatric Medical Association Statement

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                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

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          The American Society of Health-System Pharmacists Statement

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      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

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                    American Society of Hematology Statement

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                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
                                   Medicine"

                               February 11, 2026

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                American Society of Retina Specialists Statement

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                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
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                               February 11, 2026

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                      Primary Care Collaborative Statement

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                     U.S. Senate Special Committee on Aging

      "The Doctor is Out: How Washington's Rules Drove Physician's Out of
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                     Regulatory Relief Coalition Statement

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                     U.S. Senate Special Committee on Aging

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                           Ryan McClenahan Statement

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                 Society of General Internal Medicine Statement

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