[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
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McKinley Lewis, Majority Staff Director
Claire Descamps, Minority Staff Director
C O N T E N T S
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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.
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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
Statements for the Record
American Academy of Family Physicians Statement
[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
Statements for the Record
American Association of Orthopaedic Surgeons Statement
[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
Statements for the Record
American Clinical Neurophysiology Society Statement
[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
Statements for the Record
American Economic Liberties: Healthcare Middlemen Statement
[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
Statements for the Record
American Economic Liberties: Medicare Advantage Statement
[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
Statements for the Record
American Economic Liberties: One Big Beautiful Bill Statement
[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
Statements for the Record
American Economic Liberties: United Health Group Statement
[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
Statements for the Record
American Hospital Association Statement
[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
Statements for the Record
American Physical Therapy Association Statement
[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
Statements for the Record
American Podiatric Medical Association Statement
[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
Statements for the Record
The American Society of Health-System Pharmacists Statement
[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
Statements for the Record
American Society of Hematology Statement
[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
Statements for the Record
American Society of Retina Specialists Statement
[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
Statements for the Record
Primary Care Collaborative Statement
[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
Statements for the Record
Regulatory Relief Coalition Statement
[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
Statements for the Record
Ryan McClenahan Statement
[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
Statements for the Record
Society of General Internal Medicine Statement
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