Hearings to examine how Washington's rules drove physicians out of medicine.

[Gavel sounds.] The U.S. Special Committee on Aging will now come to order. Across the nation, older Americans are feeling 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 healthcare system is making that job nearly impossible. This is especially true for doctors who see patients on Medicare or other government-run or subsidized healthcare programs. Federal mandates, 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. Absolutely 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. And 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 healthcare providers, and the regulatory burden is especially tough for those who treat older Americans. It's 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 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'll 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'll 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 are doctors themselves. They will tell us about their real-life experiences navigating and preparing doctors to deal with Washington's top-down, one-size-fits-all approach to regulating medicine. They'll also share their experience working to solve these problems and what steps we can take to help our doctors and the patients they serve put the doctor-patient relationship back at the center of healthcare. I look forward to a productive discussion today with our witnesses. I'd now like to recognize Ranking Member Gillibrand for her opening statement.

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 it 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's clear that the current system has flaws. Requiring physicians to spend clinical time and energy fighting to convince insurance companies that their patient actually does need the procedure, treatment, or drug they prescribed is understandably aggravating and exhausting. And tying 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, improving the usability and interoperability of electronic health records, simplifying or standardizing payer forms would meaningfully reduce administrative burden and 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 healthcare 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 towards profit can undermine the ability of these vital healthcare 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 healthcare 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's a pervasive stigma against seeking mental health support and fear of medical license loss that prevents many from getting the help they actually need. It's 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 have to 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 exhausts, our essential workforce. I look forward to hearing from you and your proposals. Thank you.

Thank you, Ranking Member. Now I'd like to welcome today's 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're excited that you're here. So please begin your testimony.

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've 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 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've 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 is 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. But here's the hopeful part: this crisis is solvable. The medical schools in Florida came together to evaluate the support being provided to address the root causes of burnout. We used this shared 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 on-site 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 hard-wired 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 on-site 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 the key components of the American Medical Association's physician wellness program that includes the reduction of administrative burden, reduction 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.

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 and a national leader in the direct primary care movement. He's spent more than two decades in private practice and 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.

Mr. Chairman, Ranking Member, members of the committee, it's a pleasure to be back here at the Senate to give some testimony. Again, my name is Lee Gross. I'm a practicing family physician in Southwest Florida, have been independent since 2002. And so 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. I do not speak for the state of Florida. So 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 a very strange name for a medical practice, but 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 of diagnostic and billing codes, filing an insurance claim for every single transaction, and then we're disappointed and surprised that it's cumbersome, it's impersonal, it's inflexible, and it's expensive? So 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 run up and down the halls of Congress saying, "Please don't cut our pay. Please don't cut our pay. It's absolutely not survivable if Congress cuts the pay of primary care doctors." And I'd walk out, and behind me the ophthalmologists would walk in and they'd say, "Please don't cut 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 just became obvious to me that we shouldn't be fighting for a larger slice of the pie, but what we should be looking to do is 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 government 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. So 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 it to do. So I had parallel systems: one for compliance and one actually to perform the function that I needed in my office. So it essentially became that the electronic health record became a cash register. I used to get a one-page note from my consultant, and I'd know why my patient was there, what they did, what the recommendations were, what pertinent findings were. Now I get 16 pages of computer-generated rubbish, and I have no idea what the patient was there for, but I know if their pet was spayed or neutered. It's absurd. And so the medical record has become a cash register, the patient has become an ATM, and it had become all about volume. And so 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. And so we kind of joked in my practice that we were just going to go ahead and stop billing Medicare and we're just going to charge $100 for parking. But effectively, that's what we did. In 2009, we created essentially 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 co-pays, no deductibles. I don't bill insurance for any services. Any testing that I do in my office is included: EKGs, Holter monitors, cortisone injections, those are all included. And I have a cash-based relationship for all the services outside of my office, so I buy everything wholesale and pass those savings along to the patient. So I buy labs at 95 percent savings because the lab doesn't have to interact with the insurance company and they don't have to 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. So if you eliminate all that and you just get the lab, it actually gets really cheap. So we've been doing that now for 15 years, operating outside of insurance companies. We've seen near-zero inflation in the actual cost of purchasing healthcare. The cost of coverage has skyrocketed, but our cost of purchasing care and providing care has been nearly flat for 15 years. Since we've 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. And so we are at a point now in our country where we can personalize healthcare down to somebody's individual DNA. Yet we are taking a one-size-fits-all approach to healthcare that has to be a broad brush across a massively enormous country that is so incredibly diverse as the United States of America. But what we don't need is mass production in medicine. We need mass personalization, and that's the kind of care that we deliver. And I'm hoping that we can get to that through removing some of the overregulation in healthcare. Thank you.

Thank you. Our next witness brings the 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, sounds like an easy job. Thank you for being here. Please begin your testimony.

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'm 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 healthcare experience and I feel deeply passionate about this issue, in part because I've 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 respondent physician practices, more than half of the practices report losing a physician to burnout 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've increasingly witnessed more physicians being driven toward early retirement. Burden related to regulatory impacts work-life balance as well, something I've 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 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 downcoding in Medicare Advantage as some of their top burdens in 2026. There is also significant lack of standardization across Medicare Advantage plans. We've 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 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 practices to sell. One MGMA member relates 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.

Thank you. Now I'd recognize Ranking Member Gillibrand to introduce the next witness.

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 in support to support mental health legislation for healthcare workers in front of the House Energy and Commerce Committee's Subcommittee on Health. His advocacy efforts resulted in the passage of the first federal law focused on improving and well-being of healthcare workers, the Dr. Lorna Breen Health Care Provider 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.

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 healthcare for her trauma that she witnessed on the job would cost her 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 healthcare 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. But in March of 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 healthcare 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're 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 this 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've already heard from. 45 percent of physicians say administrative pressures are pushing them towards 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... ...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 the United 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 healthcare 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 healthcare for more than three million health workers by supporting over 70 licensing boards and over 2,000 hospital 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've 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's 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 FY 27 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.

Thank each each of you for your testimony. And I'd now like to turn it over to Senator Moody for the first question.

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. So discussing how we're going to provide efficient, quality healthcare is so important. And so this topic is of great importance and in particular interesting to me. Florida has some of the best hospitals and providers in the country. We have world-renowned care, education, and training. We're so proud of these accomplishments, but we know they're only possible because we have hardworking Floridians that have trained in healthcare and are part of our healthcare structure and show up to work, rain or shine, no matter what's happening. Nationwide, the healthcare 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 healthcare 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're experiencing on the job in these healthcare careers and it's grinding. It feels burdensome. It's 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's 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 healthcare 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 healthcare 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's no longer a free market in the healthcare system. Government has gotten so involved and it's 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 healthcare. I mean, supply and demand in healthcare is not driving costs anymore. And this is why we're seeing costs drive through the roof. This is why it's so taxing now on consumers of healthcare. And I don't blame this mass exodus of people trying to move into what healthcare 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. So I'm supportive of that, but I am very nervous that concierge care or even direct care outside this what we would now call the traditional healthcare or mainstream healthcare system might not be accessible by everyday people who might not have a really, really high income. I worry about that. And obviously, as we're seeing this mass exodus from the profession in general, I think we're going to have a projected shortage of 140,000 physicians by 2038. So we're seeing a mass exodus of physicians, period. We have a mass exodus going into this more direct or concierge care. So I'm really worried about what happens for everyday Americans that might not be able to afford that direct care. And I think this is a great topic for us to talk about because I really think what has driven that is this just crazy, overregulated, nonsensical approach by government to and the more and more we become involved in healthcare, the more and more complex and out of control and chaotic and unmanageable, not working for physicians, not working for consumers, it becomes. So Mr. Gross, 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 healthcare system. But what would be your recommendations from where we find ourselves with a rapidly declining physician population and out of that, add to it those moving out of a healthcare 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 healthcare is not only quality but cost-efficient for Americans?

Thank you, Mr. Chair. So a lot to unpack in the statements there. I think one of the first things I'd 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 care charges a subscription fee and everything's included in that. So there is a difference and the price points are...

Different in way you charge.

Different in the way you charge and different what's included. So we don't bill it's not like a fast pass at Disney World where you pay for access. You know, that's more of a concierge model. But so moving past that, I would say that a physician that leaves practice because they're overburdened and they have moral injury sees precisely zero patients. So if you're forcing somebody out of practice because of the complexities of it, then you're not comparing it to a doctor that would see 3,000 patients and now they're shrinking it. You're comparing it to a doctor that would see zero patients. So it's 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...

Explain that. That you can't do both.

Right. So when I directly contract with a Medicare beneficiary for services that are covered by Medicare, I have to by law opt out. And it's not just opt out in my direct care practice, it is across the board under everything tied to my NPI. So 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. And so that locks me into saying I can only accomplish this panel size by statute. I would love to see that change. I would love to work with you to change that statute because that has a disproportionate impact on rural healthcare. So because if I'm 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'm going to need massive federal subsidies, I'm going to need something to keep that practice afloat. And there's no way you're 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 your emergency room. I may be the only doctor that might be able to care for you in the hospital. And statute has required me to opt out because I'm providing more affordable and accessible care. It's important 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're still fighting over whether the telephone is an appropriate access for physicians and whether the federal government should pay for it. Just as recently as two weeks ago, we're still trying to decide this. I shifted my practice to a telemedicine on day number one. When you mentioned the rain's falling, when Hurricane Ian tore the roof off of 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'm getting paid on a subscription basis and I have the flexibility and ability to provide the services and care to my community that they need.

Thank you.

Thank you. Ranking Member 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 foundation's 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 a healthcare provider successfully reduced physician burden by using your Impact Wellbeing Guide?

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. And what we have done is we've 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 work 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 10 to 15 minutes per patient. Huge decreases there. In addition, standing orders for pharmacy refills, things that keep the pharmacist, 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 wellbeing, and decreased their burnout.

Thank you. Mr. 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's 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?

I think what you're going to see is more prior authorizations needed. That's going to add burden to the staff. There'll be more denials. That will add burden to the physician to either fight the denial or just to decide it's just not worth the fight. Now you have patients not receiving care. Patients don't receive care, I believe that they will get sicker, they'll end up in the emergency room, ultimately the hospital, and we're going to drive the cost of healthcare 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. We spend a lot of time telling doctors, you know, you're in charge, you're the quarterback of care. We actually increased the E and M codes. But every step of the way, we question what they do.

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?

So one of the things that I've noted is that when people are graduating from training, I'm kind of old school. When I went into training, I had a full practice management training in my practice. And that doesn't really happen to a degree. I mean, it's still sort of required, but when people graduate, they do not have the full practice management. 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's not really being taught to that degree in most places because most people are being trained to be employees in an outpatient or ambulatory setting. And so if you're trying to then go from training into a rural healthcare setting delivery where you need to be running your own practice, they're not prepared for that. And so people are just not even stepping into that environment and it's leaving a huge void in the rural communities.

Thank you. And 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.

Sure. So 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 for students to help guide them through this because we recognize that they're going to be facing stressful situations throughout their career. So having access to onsite counseling that they can access right there at the college without feeling that 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're all humans before we're physicians and they need to be able to take breaks, make sure they're eating properly and getting rest and maintaining connections to their support systems that they had even before they came to medical school. And with those activities, but also recognizing that these other stressors that they're 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. So when they're having to deal with these issues like prior authorization and denials and patients not being able to access the appropriate lab or the appropriate X-ray facility, they're seeing this as a part of their training even in medical school. And as Dr. Gross said, those requirements for that practice management training is there for our resident physicians to but a lot of them are not focusing on that, certainly not early on in their residencies because they're 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 10 years and certainly more than 20, 25 years ago. More and more of them are entering employment situations which in many cases exacerbates a lot of these issues we're talking about.

Thank you.

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'll 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 burnout?

Reductions in staff are a force multiplier on the issues that we've been talking about on this committee today. We have to look at what our clinicians are spending their time doing right now. And 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 the patient, spending that time on administrative burden, as you decrease your staff, who else is left to do the administrative work? And so it's this vicious cycle that will impact access, it will impact quality, and it will impact cost over time.

So it's an impact obviously on the workers, including the physicians and their workplace, but it's a real effect on patients and the quality of the healthcare that they're able to provide. For decades, Medicaid has helped fund doctor residency training through the Graduate Medical Education or GME program. And this program has played a critical role of addressing physician shortages in states like Georgia, where more than 2.7 million Georgians live in a health professional shortage area. But it's 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 an increase in Medicare-funded graduate medical education slots help improve our seniors' access to healthcare services?

I think any physician, any addition of physicians into the market would increase access to care. There'd be more appointment time and more availability. The challenge we have is convincing those doctors to go into primary care, internal medicine. Most of them nowadays, they say, you know, I want to become a neurosurgeon or, you know, I want to become an EP doc in cardiology because there's more money there. They're trying to pay off their student debts. They spend another year in fellowship. So we don't see a significant number of docs wanting to be family practice doctors anymore. And I think somehow we've got to incentivize that in this program to make that more attractive. Make that 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.

Absolutely. So they're 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's an economic issue. Nevertheless, Dr. Littles, in your experience, how often does the cost of higher education in the health professions dissuade people from entering the field?

Thank you for that question. We strongly 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 with their patients. But they also need to be able to make a living in doing that. And as has been said, it's 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're asking them to do more and more for less and less, at some point that just doesn't work for them. So if we're 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 will continue to do that.

Absolutely. And I would imagine, not imagine, I know this is particularly difficult for first-generation college students who've gone on to medical school and are, you know, they have the aptitude, but you have these barriers. In the last few months, I've 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 healthcare still owe the rest of their bill. And 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. So 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. And I'm deeply concerned that these changes to the federal student loans amid a growing healthcare workforce shortage and aging population is the exact wrong move at the exact wrong time. Thank you so much.

Thank you, Senator Warnock. 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're doing here, you know, one patient after the next. So burnout is not simply about long hours. It's 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's about shorter visits, heavier caseloads, and constant pressure to do more with less. And it's 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 communities 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 isn't just a workforce issue, it's a healthcare issue as well and access issue. It's a quality of care and system sustainability issue. And at the same time, the drastic Medicaid cuts in HR 1 threaten to further destabilize clinics and hospitals that serve as the backbone of primary and preventive care, forcing more patients into emergency rooms while placing even greater strain on an already stretched workforce. So we can't afford to continue operating a healthcare 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. You have spent years working with hospitals, healthcare systems, and policymakers on efforts like the Dr. Lorna Breen Healthcare Provider Protection Act to address physician mental health and burnout. And 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 preventive reforms that reduce burnout at its root?

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 reduce the amount of administrative time that they're spending before and after work so that and 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... ...at other operational inefficiencies that stand between them and their patients every day.

As for workforce violence, I've heard a lot about workforce violence. And so is it, how important is it occupational safety and health administration develop clear federal standards to ensure the positions, nurses, and other healthcare professionals can practice in environments that are physically safe, as well as adequately supported?

Question back to me?

Yes.

Think about the Maslow hierarchy of needs. You have the essential needs of being 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 the 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's just an unsustainable environment for them to work in.

It is unsustainable for them to work in. 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. So from your perspective running medical practices, how does the current prior authorization system contribute to physician burnout? And 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?

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's that difficult. And I try to see every class of incoming employees, and I tell them healthcare is not for the faint of heart. It is incredibly difficult, and I believe our front desk folks have the toughest job in healthcare. Not the doctors. It's the front desk. They need to be psychiatrists, insurance experts, best friend. I mean, it is incredibly challenging, all working under HIPAA obviously. But 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. So how do we work together to reduce those burdens so it reduces our cost, so we may not need as much of an increase as we had thought we did because now we can get rid of some staff or rearrange some staff so we can get back to taking care of patients? Because that's really, that's what doctors want to do. That's why they went to medical school. So I believe that prior auths are our biggest issue and truly need to be addressed quickly.

Thank you.

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?

Thank you. So we've been talking about the stressor of dealing with the electronic health records and the number of electronic health records that physicians often have to go through in the course of taking care of their patients. When you extend that out into rural communities, often times even access to an electronic health record in and of itself is, one, it's costly, but sometimes it's difficult for them to even have. But when they have that electronic health record, we know that the number of clicks that they have to go through to provide that documentation is directly related to the stress that they feel from that. So when you're asking about how that documentation specifically is affecting students wanting to go into rural practice among the list of other factors that prevent them from doing that, that is certainly one of them. And so 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're referring patients to in nearby urban areas, all of that has a negative impact. And I hear my faculty talking all the time about the pajama time that they're spending on that electronic health record, which has also been mentioned today. All of those are distractions from the care of the patient.

Thank you. Dr. Gross, tell me how your practice changed. How is your day different from when you were running an insurance-driven practice to a patient-driven practice?

Yes, so when I have a fee-for-service practice, any slot in my schedule when I walk into my office that's not already filled is lost revenue. So when I walk in, the schedule's already full. And 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've got another problem, I'm sorry you've got to rebook, and by the way my next available appointment's 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, and as the phone rings, if you call me in the morning you're seen in the morning, as you call me in the afternoon you're seen in the afternoon. And 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'm too busy. And that opens up my schedule to actually practice to the full scope of my training. So I would argue that a lot of referrals in primary care are not because the doctor's not capable of handling the problem, it's 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're stopping downstream referrals for endocrinology, for rheumatology, you're managing things within your practice that are clearly within your purview as your training. And we see that in our data that when we implement this into a health plan that's 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 has a 52 percent reduction in healthcare in a rural healthcare setting. And we've sustained numbers like that over seven years because, not because we're better than anyone, it's structural design of the practice. It's the administrative design of the practice, the intent of that, which I think is completely changing how we care for patients.

Thanks. Mr. Smith, how much of your budget goes to getting prior authorizations, compliance, paperwork versus patient care?

Well, that's 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's 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.

Is it easy to stay up with all the changes by the insurance companies and by Medicare and by Medicaid?

I'm sorry, sir?

Is it easy to stay up with all the rule changes by Medicare, Medicaid, plus all the changes with the insurance companies?

It is not easy. I mean, we do our best to educate. You know, we have great staff. 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's a lot. It's a lot. You know, one or two doctor practice can't really have a business manager running that practice. So we're 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're doing.

The people that run Medicare and the Medicaid in your state, they're just out there to help you every day, aren't they? They're just showing up every day.

Every day they come out. No. It's a challenge.

Yeah. 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?

We hear, as we've discussed today, when you think about burnout as an occupational syndrome, and burnout is driven by the workplace design, we, I think as we've discussed today, the vast majority of what we're experiencing in burnout is within our control to reduce by changing the operational environment that our healthcare workers work in every single day.

Okay. Senator Gillibrand, do you have anything else?

No, sir.

Okay. Well, I want to thank everybody for being here today. This was eye-opening, and I 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're doing, Dr. Gross. They've got to opt out of the way the system is organized because it's just too difficult. So, and I'm sure you deal with Dr. Littles all the time, what, you know, the choices people are making. So, thanks everybody for being here. It's clear that real reforms must start with cutting red tape and putting doctor-patient relationships at the center of healthcare so physicians can focus on healing rather than compliance. I look forward to continuing to work with members across the aisle 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 PM. Thank you very much. This is adjourned. [Gavel sounds.]