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▶ 0:13:36>> 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 access to the doctor and care they need to live happy and healthy lives and even when seniors do find a doctor, many feel rush and disconnected from them. They're victims of that broken system.
▶ 0:14:02Doctors want to connect to their patients but our rigid top-down health care system is making that nearly impossible. 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 on stackle after another just to get help.
▶ 0:14:29The results, patients can't get the care they need and doctors can't give the patients the care they deserve. No one benefits. We were forcing our doctors to operate in a system that prioritizes paperwork over patients. The reliance on doctors is higher than ever. Doctors must they've great insurance, different reporting standards and excessive administrative burdens just to take care of their patients.
▶ 0:14:58Again, 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. Especially true in rumor and jurisdiction served areas that already struggle to find health care providers. It's no wonder that doctors regularly report to the higher levels of burnout than other U.S. workers.
▶ 0:15:30That leads to more doctors quitting their jobs, creates more doctor shortages, which leads to more administrative burden earn and less interaction with patients. In the most serious cases this burnout results in devastate burnout results in devastating health consequences to patients and their families. Even suicide. We owe it to off of our citizens, especially the older population to stop this cycle.
▶ 0:16:01Today we'll look at how washington regulations and red stay fit into this crisis and how we can fix it. We'll hear from witnesses who interact with fashions at all levels. They train our doctors, manage them, treat them, work with them as colleagues and are doctors themselves.
▶ 0:16:22They'll tell us about their real-life experiences dealing with washington's topdown one size fits all approach to regulative medicine. What we can do to put the doctor/patient relationship back at the center of health care. I'd now like to recognize rank I'd now like to recognize ra ranking member gillibrand for opening statements.
▶ 0:16:47Ranking Member Gillibrand: Thank you, senate scott for holding states hearing. Thank you, witnesses. One-out within the health work forks has increased since its peak during the pandemic but remains a problem. It directly impacts the well-being and affects or workforce and its cobs consequences are grave for patients. Particularly older adults and people living in rural or underserved areas.
▶ 0:17:18Ranking Member Gillibrand: Burnout which is defined as a long-term stress reaction, including emotional exhaustion, depersonalization and feeling of decreased personal achievement causes physicians to leave the profession, making things even worse. A wide range of factors burn in, including regulatory and administrative requirements. System-level financial precious and realities of the profession's culture.
▶ 0:17:48Ranking Member Gillibrand: Regulatory requirements mahan important role in upholding quality care standards. They allow providers to keep detailed track of patient treatment and also help prevent waste, fraud, and abuse.
▶ 0:18:05Ranking Member Gillibrand: Simultaneously, it's clear that the current system has flaws, requiring that signatureses to spend critical time and energy fighting to convince insurance companies that their patient actually does need the procedure, treatment or drug they prejibe is understandably aggravating and exhausting and time payment ape judgments with technology designed for big compliance instead of critical bjork flow understandably causes
▶ 0:18:36Ranking Member Gillibrand: Fatigue and frustration, especially when it consistently spills beyond normal working hours. Reforms like teamlining the process and improving the he tronnic health records, standardsing payer forms would reduce the administrative burn-out that drives the burnout in fashions.
▶ 0:19:02Ranking Member Gillibrand: This can help keep independent practices afloat, especially important as we continue to see unprecedented rise in smaller physician owned practices closing their doors, integrating with larger health care system systems or receiving private equity investment. Physicians can face system-level pressure that drive burnout through diminished agency and focus on profit.
▶ 0:19:28Ranking Member Gillibrand: Under these circumstances, physicians can face business-oriented force targets that require arne increase in patient volume. This means seeing a greater number of patients in shorter, increased free agent visits that create even more administrative work, which can be compounded by the reduction doctor of clinical and administrative support staff this.
▶ 0:19:54Ranking Member Gillibrand: Drive towards profit can undermine the ability of these health care workers to secure their basic psychological or safety needs and affect their decision making. Combined with the inability to practice elsewhere due to the rise of noncompete agreements, many physicians choose to leave the profession entirely.
▶ 0:20:19Ranking Member Gillibrand: Employers have an obligation to meet the needs of their employees, and implement evidence-informed actions like those included in the nysosh and the Dr. lorna breen fun to days well-being guide.
▶ 0:20:41Ranking Member Gillibrand: Additionally, health care entities to ban anti-competitive terms in contracts are crucial to promoting autonomy and reduce burnout. Anxiety 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 need.
▶ 0:21:10Ranking Member Gillibrand: 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.
▶ 0:21:37Ranking Member Gillibrand: 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 jurisdiction served communities, especially combined with enacted cuts to medicaid that will exacerbate provider closers and create medical deserts. There isn't an easy solution to any of this.
▶ 0:22:09Ranking Member Gillibrand: Congress, academic institutions, regulators and health system leaders must work together in a bipartisan way to create a system that intorts, not exhausts our essential workforce. I look forward to hearing from you and your approaches.
▶ 0:22:25Chair Scott: Thank you, ranking member. Our first witness leads one of the nation's most mission-driven medical schools. Dr. alma littles is the dean and chief academic officer of the florida state university of medicine where she oversees medical education, workforce development and physician training programs across florida. Under her relationship, they've emphasized primary care, unity based training and addressing physician shortages.
▶ 0:22:56Chair Scott: Half my offers went for the s.u. So they're excited that you're here. So please begin your testimony.
▶ 0:23:03Dr. 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.
▶ 0:23:34Dr. Littles: Physicians enter medicine with a clear purpose -- to heal, serve and stand with patients in their most vulnerable moments but today that purpose is being overshadowed but unsustainable straiti burden, 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.
▶ 0:24:04Dr. Littles: Around 400 take their lives each year and just as concerning, medical students and residents have rates of depression 15% to 30% 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 physicians leaving medicine, not
▶ 0:24:35Dr. Littles: Because they 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 understood the need for oversight, accountability and patient safety.
▶ 0:24:56Dr. Littles: 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.
▶ 0:25:25Dr. Littles: Think about this -- one physician leaving practice potentially leaves 2,000 to 3,000 patients without achates to care. Studies suggest that more than half of practicing physicians say they're burned out of the we found this to be a real issue in florida. After becoming aware of self-suicide among medical students, residents and faculty. But this crisis is solvable.
▶ 0:25:53Dr. Littles: The medical schools in florida came together to evaluate and address the root causes of burnout. We used this shared data. Programs were develop had in support wellness activities and delicate efforts were made to destigmatize seeking help in mel school, residency training and practice.
▶ 0:26:21Dr. Littles: The survey of medical schools and residency programs confirmed that the schools were actively engaged in a variety of activity, including incorporating mandatory wellness topics into the curriculum. Providing dedicated wellness services. Offline services and corporating activities that prepare students for the impact of administrative burdens. Since our founding 25 years ago.
▶ 0:26:48Dr. Littles: Florida state university college of medicine has recognized the threat of physician burnout and we hard wired into our curriculum and extracurricular activities, perhaps and activities to address it of the we provide resources on sleep and stress management. Weekly fitness classes, campus walked and I'm proofed our on-site finance on-site fin fifthness room. Our six regional campuses also developed third wellness programs.
▶ 0:27:18Dr. Littles: 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, reduce of stress drivers in organizations and removal of organization and technology requirements. We need your help.
▶ 0:27:38Dr. Littles: You have the power to make a positive impact by supporting regulatory reform, promoting administrative simplification, ensuring that face colonel policies strengthen, not strain the workforce and to understand that the best way to serve patients is to present the people who serve them. I look forward to continuing the conversation, thank you.
▶ 0:28:06Chair Scott: Thank you, Dr. littles. Our next witness is a family practicing physician to left the insurance position. Dr. lee gross is the founder of epiphany primary health care in florida. He's spent more than two decades in private practice and testified before congress on physician burnout and rising costs. Thank you for being here.
▶ 0:28:37Chair Scott: Please begin your testimony. [crackling mic] >> use hers.
▶ 0:28:55Dr. Gross: Sabotage the florida guy. [laughter] Mr. chairman, ranking member, members of the committee, it's a pleasure to be back here at the senate to give some testimony. My name is lee gross. I'm a practicing family physician in southwest florida. I've been independent since 2002 so for disclosure, I serve on the florida board of medicine. I'm speaking on my own blach and I do not speak on behalf of the state of florida.
▶ 0:29:24Dr. Gross: Epiphany health is a strange name for a medical practice and the timer is not running here. But, in fact, we had anpitch any and the epiphany was why are we ensuring primary care?
▶ 0:29:38Dr. Gross: Why we taking relational and longitudinal care and funneling that through an insurance product, using hundreds of diagnostic codes and then we realize it's impersonal, inflexible and suspensei. I had a fully insuranced practice in 2002.
▶ 0:30:05Dr. Gross: I took medicare and all the insurances and this was measure during the time of the sustainable growth rate florida and I would run up and down the halls of congress saying please don't cut our pay. It's not survive if congress cuts the pay of primary care doctors.
▶ 0:30:23Dr. Gross: And I'd walk out and between thee the opt apologies was walk in saying, please don't cut our pay and behind them a different doctor. It became obvious we shouldn't be fighting for a larger piece of the pie but looking to explode the pie and looking far better way to do this. I was an early adopter of electronic health records.
▶ 0:30:51Dr. Gross: 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 didn't know how to finance supplies or equipment purchases because I didn't know what we were going to get paid. So the federal government became an unreliable business partner and I felt like I needed to fire them. I loved that electronic health record.
▶ 0:31:20Dr. Gross: It maximize operational and workflow. It was fantastic and then the federal government came in and certified it so the electronic health record I had was no longer certificated and they couldn't amped to certify five so I started getting medicare penalties 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.
▶ 0:31:52Dr. Gross: So it essentially became the electronic health record became a cash register. I used to get a one-page note from my consultability. What pertinent findings were. Now I get 1*6 pages of rushish. I have no idea what the patient was there for but I know if their pet was spade or neutered. It's absurd. It's become an a.t.m.
▶ 0:32:20Dr. Gross: All about volume. You start rolling out all the mips and quality reports. I would have to find other ways to generate revenue because I wasn't going to do those things. Anytime I would, medicare would make a rules change and I was playing what can a mole.
▶ 0:32:46Dr. Gross: I said we're going to stop big medicare and just charge $100 for parking. In 2009 we crete one of the fiers direct primary care services. We charge a prescription for services. $90 for adults, $30 for children. No co-pays, no detectables. I don't bill any insurance.
▶ 0:33:12Dr. Gross: Any testing I do, cortisone injections, e.q.g. Monitors, those are all included. I buy everything wholesale and pass those sales on to the patient. If most expensive they do in the lab is interact with the insurance companies and do the coding. If youeliminate all that and just do the lab it gets really cheap.
▶ 0:33:40Dr. Gross: We've been doing that for nearly 15 years. We've seen near zero inflation in the actually cost of health care. Our costs have been nearly flat for 15 years.
▶ 0:33:57Dr. Gross: Now there are thousands of doctors around the country in all 50 states that have step wad from the system because we can do better at providing primary care, not going through third-party systems so we're at a point now in our country yes we can personalize health care down to somebody's individual d.n.a.
▶ 0:34:17Dr. Gross: We are taking a one size fits all approach to health care that has to be a broad brush cross a massively enormous country that is so diverse as the united states of america. We don't knee pass produced memory. I hope we can get through that by overcoming the overregulation in health care. Thank you.
▶ 0:34:43Chair Scott: Thank you. Our next witness manages large groups serving both urban and cruel communities. Jeffrey smith is the c.e.o. Of piedmont health care in florida. He oversees the operational, financial and challenges facing -- sounds like an easy job. Thank you for being here. These begin your testimony.
▶ 0:35:15Mr. Smith: Chairman scott, rank
▶ 0:35:18Mr. Smith: Chairman scott, ra ranking member gillibrand and members of the committee, thank you for listening to my testimony. I'm honor torreyed to speak on what have of mgma as itself incoming board chair. It has only 70,000 members across the united states prettying more than 350,000 physicians. I'm also the c.e.o. Of piedmont health care based in statesville, north carolina.
▶ 0:35:46Mr. Smith: With over 230 physicianings and providers and almost 1200 employees. I have over 40 years of health care experience and I feel deeply passionate about this issue, in mart because I've seen its impact firsthand while working alongside bidaughter, a primary care physician in my practice. Mgma retunely surveys our physicians on hurdles they face.
▶ 0:36:14Mr. Smith: In our 2026 survey with over 230 responded physician practices. More than half of practices report losing a physician to burnout in the past three years and among those, over 70% say regulatory burden play as substantial role. In my own practice, I've increasingly witnessed more physicians driven toward early retirement.
▶ 0:36:43Mr. Smith: Burden related to regulatory impacts and work balance. My daughter often must complete these tasks at home after their children fall asleep. Addressing administrative or regulatory policies leading to physician burnout is critical to stem tide on the front end and support physicians already in practice.
▶ 0:37:08Mr. Smith: I would like to highlight the burdens that I and others mgn everything many a physicianings are facing. Medicine care can serve as an opportunity for innovation. However, has enrollment has has increased, it has created dauntling challenges. It requires audits, downloading a medicare advantage. There's also significant lack of standardization.
▶ 0:37:38Mr. Smith: We've had to hire whole teams that are dedicated to val-based care just to interpret what quality really means. For years one of the top cited regulatory burdens have been authorizations do to staffing demands and mississippi on care.
▶ 0:38:01Mr. Smith: Each practice has at least one staff member dedicated to prior organizations. I appreciate the chairman, ranking member and many of members of the committee for the senior care act. It is important to pass this legislation that would screamline prior authorization for medicare advantage.
▶ 0:38:29Mr. Smith: Reforming the merit-based and basement system would be welcomed as complying with these requirements is a time-consuming and laborious process, further providing in enrollment could be streamlined to better practice this data and lower regulatory costs. All this is exacerbated by the continued under funding of medicare part b.
▶ 0:39:00Mr. Smith: Given medicare's reimbursement frequent reductions due to knew talltary budgets and lack of inflation update, it is necessary to address this. It coalesces the undermining of medical groups to continue to conglomerate and leading many to sell.
▶ 0:39:28Mr. Smith: One cites the problem after being independent for over 100 years. I sin veerly appreciate the opportunity to testify today and share both my personal experience and others mgma experiences on how regulatory requirements convict to physician burnout.
▶ 0:39:50Chair Scott: I turn it over to ranking member grill brand. Ranking member gillibrand. Thank you. I want to introduce corey feist. He is the c.e.o. Of the larono breen hereos' foundation group. He has previously testified on the subcommittee on health.
▶ 0:40:20Chair Scott: His efforts resulted in the passage of the first federal law, Dr. lorna breen health care protection act in honor of his sister-in-law. He was given the surgeons' honor toward in 20 3.
▶ 0:40:40Mr. Feist: Chairman scott, ranking member and members of this committee, thank you. My name is corey feist. Thank you for the introduction and co-sponsorship of the access to care act of 2025 and for rehow authorizing the Dr. lorna breen health care protection act. We now seek full funding of the act. This is my third time testifying on this crisis.
▶ 0:41:09Mr. Feist: 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 leader during the pandemic's first wave in new york city. Despite her bravery, he was terrified that her trauma that she suffered on the job would cost her career.
▶ 0:41:37Mr. Feist: Lorna took her life april 26, 2020. In 2024, I shared the story of kristin smith, a 28-year-old hours in whose father found a note on her computer after her death. Noting that instead of respect, they get pizza parties and pens for the health care heroes. Dr. west, an opthalmology resident definite.
▶ 0:42:04Mr. Feist: In this march of 2024, the information ocean and pressures of medical training broke even iron will. In a devastating final note he wrote I am exhausted and I have nothing more to give. He used his final moments to plead with administrators to support the residents rather than merely push them. His death is a warning. Our health care is claiming our brightest minds before they even finish their training.
▶ 0:42:33Mr. Feist: When we lose a resident we're not just losing one doctor. We're losing 40 years of expertise. 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 in the next decade.
▶ 0:42:56Mr. Feist: It's projected to cause a shortage of over 4500,000 nurses, physicians, dentists and pharmacists by 203. This does not account for those leaving due to systems failures. 45% of physicians say administrative pressures are pushing them towards career changes or early retirement. Administrative tasks like prior authorization is the number one kyrie of physician burnout.
▶ 0:43:25Mr. Feist: Nurses face a workplace crisis with 86% forcing workplace violence. Pharmacists are abandoning their roles due to exively -- -- excessive lie high workloads. We now have a proven national framework with several priorities for policy and practice to avert this crisis.
▶ 0:43:52Mr. Feist: The lorna breen act grantees have already supported over 250,000 health workers in the united states and the results aren undeniable welcomes 35% redid you goes in staff turnover. 50% decreases in mental health. It provided 25,000+ health care leaders with training to drive the support to combat the burnout.
▶ 0:44:22Mr. Feist: We improved access to mental health care 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 credential applications. We have proving that administrative burden can be reduced while patient experience improved.
▶ 0:44:51Mr. Feist: One rural hospital address the offed e.r. Alert fatigue. Their traveling nurses now want to stay in rural virginia, saying this is the first place they've worked where they feel healthy and can get the health they're need. Reauthorization of the lorna breen act is a good start but it has to be continued. Investment in the pipeline is squandered if we don't stop the leaks.
▶ 0:45:21Mr. Feist: For example, we currently face a two-year exodus in nurses where 50% 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 fy27 and for voting in time for the access to care act.
▶ 0:45:47Mr. Feist: I am proud to report on how we are serving the patients to have yeast with the best and brightest among us. Thank you for your leadership.
▶ 0:46:02Chair Scott: Thank you. I turn it over to Sen. moody.
▶ 0:46:05Sen. Moody: Thank you and welcome to two of our witnesses from florida. For traveling up here and braving the ice on the ground. I know you were back with the palm trees and from mingos. I do too. Welcome. This is such an important topic for our country. Especially florida. We have so many seniors in your state.
▶ 0:46:29Sen. Moody: Not just the sunshine state but the silver state so discussing how we're going to provide efficient quality health care is so important and so this topic is of great importance and in particularly interesting to me, florida has some of the best hospitals and providers in the country. We have world renowned care, education and training.
▶ 0:46:54Sen. Moody: We're so proud of these accomplishments but we know they're only possible because we have hard working floridians and a half trained in health care and are part of our health care structure and show up to work rain or shine, no matter what's happening.
▶ 0:47:10Sen. Moody: Nationwide the health care industry employees 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 -- a health care sector and those that will work in this industry but so much of the -- that economy is tied up in big, administration and regulatory compliance and physicianings are increasingly forced to spend nearly twice as much time on
▶ 0:47:40Sen. Moody: Administrative work as they do in providing patient care. I hear from floridians all the time what they're experiencing on the job and these health care careers and it's grinding. Burdensome and challenging. Mayo clinic found that 57.1 physicians said they would choose to become a physician again down from 72% just five years ago.
▶ 0:48:10Sen. Moody: With sometimes combative patients, extreme working hours, it's no wonder that many providers step away from their traditional practices to transition to direct care practices, also known as concierge care. Many of these practices allow physicians to see patients for longer, avoid cumbersome administrative processes, ewell while getting a more quality experience and giving doctors more time to live their lives.
▶ 0:48:40Sen. Moody: 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 system with the underlying problem with that traditional system and we as a government how to figure out how that is. It's no longer a free market in the health care system.
▶ 0:49:08Sen. Moody: Government has gotten so introducive and require so many things. Some seem so nonsensical, like moving to a different commuter structure. It sound just like the government but we are no longer a free market in health care. Supply and demand is not driving costs anymore. This is why we're seeing costs drive through the roof.
▶ 0:49:34Sen. Moody: This is why it's so taxing now on consumers of health care and I don't blame in max exodus of people trying to move into what health care used to be. Providing care for patients in a way where you feel like off relationship with them, you can spend time with them. High quality, maybe even cost first fircost efficient.
▶ 0:49:59Sen. Moody: I'm supportive of that by I'm nervous that con certainly care or even direct care outside of what we would 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 until. I worry about that.
▶ 0:50:21Sen. Moody: And obviously as we're seeing this max 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 max exodus of if a I guess so ises, period.
▶ 0:50:39Sen. Moody: We have a max exodus going into the more direct or concierge care so I'm really worried about what happens for what happens for everyday americans that might not be able to amped 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 crazy overregulated nonsensical approach bring government, and the more and more we become involved in health care, the more and more complex and out of
▶ 0:51:09Sen. Moody: 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 across.
▶ 0:51:26Sen. Moody: 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 from where we find ourselves with a rapidly declining physician population and out of it, 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.
▶ 0:51:54Sen. Moody: 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?
▶ 0:52:07Dr. Gross: Thank you, Mr. chair. So, a lot to unpack in statements there. I think one of the first things I'd like to do is clarify a little bit between concierge medicine and direct primary care because concierge medicine thinkically charges an access fee and then a fee to a third perfect party payer. So there is a d. In price points.
▶ 0:52:38Dr. Gross: >> different in the way you charge?
▶ 0:52:40Dr. Gross: And theway it's included. It's not like a fast pass to disney world. I would say that a physician that leaves practice because they're you're burdenened and have moral injury sees prix sighsly zero patient so if you're forcing someone out of practice because of the complexities of it you're comparing it to a doctor that sees zero patients so it's not an actual fair comparison.
▶ 0:53:07Dr. Gross: I would not be practicing medicine today if I did not change my practice model. 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 my decision. That was federal law that required --
▶ 0:53:30Chair Scott: Explain that.
▶ 0:53:31Dr. Gross: When I directly contract for services offered by medicare, I have to opt out. It is across the board so I can't moonlight as a hospitallist. I can't seven e.r. Shifts. I can't do tell medicine because they -- tele medicine because they all bill medicare. I can only accomplish this side by statute.
▶ 0:53:58Dr. Gross: I would love or you to change that statute. That has a disproportionate affect on primary health care. If I'm putting a doctor in rural alaska, rural utah. Ic make it work and be profitable with 300 to 500 patients. I can't do that with a fee for service practice.
▶ 0:54:25Dr. Gross: I'm going to need massive central subsidies to keep that practice afloat and there's no way you're going to be able to do it. If statute requires needing to opt out to be able to do that. I may be only doctor serving your emergency room. Staff utes provide the opt-out because I'm providing more affordable and accessible care.
▶ 0:54:51Dr. Gross: 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 thee months for the government to recognize the invention of the telephone. As recently as two weeks ago we're trying to decide this.
▶ 0:55:20Dr. Gross: Itchiested my practice to a tele medicine on day number one. When hurricane ian tore the roofs off the buildings next to my office, I didn't need to wait for the federal building to put a tent in my building. We opened up and 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 the community that they need.
▶ 0:55:52Dr. Gross: >> thank you.
▶ 0:55:53Chair Scott: Touch ranking member gill grand?
▶ 0:55:56Ranking Member Gillibrand: Thank you, Mr. chairman. Mr. feist, you described our administrative burden is an eurodollar lying cost of physician burnout. Your foundations impact well-being guide provides guidance on how hospitals and health systems can address these burden, through quality improvements and quality improvement properties.
▶ 0:56:20Ranking Member Gillibrand: Could you share a brief example of how health care providers successfully reduced that by your well-being guide?
▶ 0:56:34Mr. Feist: Slut. Loren ai breen foundation created this leader retraining guide. And what we've done is implement and what we've done is imple 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.
▶ 0:57:02Mr. Feist: In some cases three to five minutes her patient. In some cases 10 to 15 minutes per patient. 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 well-being guide reduced the amount of time that phoenix were spending on that. Increased their care and decreased their burnout.
▶ 0:57:33Ranking Member Gillibrand: Thank you. And Mr. smith. Dr. smith. Your testimony describes how medicare magazine things that significantly result in burnout. Many of us are pushing to pass the seniors care act to help address widespread concerns. Yet c.m.s.
▶ 0:58:02Ranking Member Gillibrand: New model expands prioritization into traditional medicare and utilizes the new non-standard approach inconsistent with the new federal regulations. How might this reduce burnout among physicians in states where this model is enacted?
▶ 0:58:27Mr. Smith: I think what you'll see is more prior authorization is needed. That's going to add burdens to the staph and add burdens for the physician to either fight the denial or just decide it's not worth the fight. Now you have patients not receiving care. Patients not receiving care I believe will get sicker, ends up in the emergency room, ultimately the hospital and we're going to drive the costs of health care up. My dad is 94.
▶ 0:58:54Mr. Smith: He went to the doctor this week while I was up in philadelphia visiting him and the doctor decided he needed a cat scan. I would bet a lot of money that that would be denied if you did a prior off on that. We spend a lot of time telling doctors you're in charge. The quarterback of care. We increased the effort m.n. Codes but every step of the way we question what they do so I think we would be contributing to the burnout of the doctors with that.
▶ 0:59:27Mr. Smith: I-agreement Dr. gross and Dr. littles -- Dr. gross in your testimony up highlight the mismatch between how physicians are trained and the regulatory environment they practice in. You say when they enter the workforce that are unprepared for this. How does this drive physician burnout and contribute to consolidation?
▶ 0:59:54Dr. Littles: I'm kind of old school. When I went into training I had full practice management training in my practice and that doesn't really happen to a degree. It's still sort of required but when people graduate they don't have the full practice middleweights. How do you have compliance, comply with osha, fire, hire, set up your structure, negotiate contracts?
▶ 1:00:17Dr. Littles: That is all stuff I learned in my training but it's not really being taught to that degree in most places because most are terrained to be employees and not in that setting. If you're going from training into a rarely health care setting where you need to run your own practice, they're not prepared for that and people are not stepping into that environment.
▶ 1:00:42Ranking Member Gillibrand: Thank you. Dr. littles, the you are shared how medical schools and residency programs in florida recognized this and are helping students learn these things. Please respond to that.
▶ 1:01:02Dr. Littles: Sure, we all know that medical school is a stressful environment, going there rut process of training to become a physician so we putt in support systems to help guide students through this because we recognize that they're going to be facing stressful situations throughout their career so having access to on-site counseling that they can access right there at the college
▶ 1:01:35Dr. Littles: Without feeling that tension is just going to affect my license sure later on and prohibit me from being licensed or practicing medicine.
▶ 1:01:50Dr. Littles: Activities like that, having wellness activity so 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 training with those activities but also recognizing that these other stressors that they're going to face as practicing physicians are there
▶ 1:02:22Dr. Littles: As well so having them actually training with those physicians, our students and residents get to see what our attending physicians are facing in their practices so when they're having to deal with issues like prior authorization and denials and patients not being able to access the appropriate lab or x-ray facility, they're seeing this as a part of their training even in medical school and as
▶ 1:02:52Dr. Littles: Dr. gross said, those requirements for that practice management training is there for resident physicians to -- but a lot of them are not focusing on that, certainly not focusing that, certainly not foc early on in their residencies because they're not the ones ultimately responsible for it.
▶ 1:03:13Dr. Littles: 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 situation which is in cases exacerbates a lot of these issues.
▶ 1:03:40Ranking Member Gillibrand: Thank you.
▶ 1:03:41Chair Scott: Senator warren?
▶ 1:03:49Sen.: Thank you. Physicians all across my state face dire physician hornets. Estimates are that in just a couple of years we'll be short by tens of thousands of doctors. Mr. feist, what affect will additional workforce shortages have on our currently health professionals, many of whole are already facing burn-out?
▶ 1:04:20Dr. Gross: Reductions in statue are a force multiplier. We have to look at what our clinicians are spending their time doing. About 70% of a primary care physicians time and 50% of a nurse's time is spent on administrative burden. As you decrease your staff, who else is left to do the administrative work?
▶ 1:04:44Dr. Gross: So it's this vicious cycle that will impact access, quality and cost over time.
▶ 1:04:53Sen. Warnock: So it's an impact on the workers and their workplace but it's a real effect on patients and the quality of health care. For decades medicaid has helped fund doctor residency training through the g.m.e.
▶ 1:05:11Sen. Warnock: Program and it's played a critical role of addressing physician hornets in states like georgia where more than 2.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 residents reduction act alongside my friend senator bozeman.
▶ 1:05:41Sen. Warnock: This bill would fill 14,000 new residents 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 health care services? >> I think any addition of physicians into the market would increase access to care.
▶ 1:06:09Sen. Warnock: The challenge we have is convincing those doctors to go into primary care, internal medicine. Most of them nowadays they say I want to become a neurocurrentlien or an effort p. Doc in cardiologist because there's more money there. They're trying to pay off their student debts. They spend another year in fellowship.
▶ 1:06:37Sen. Warnock: So we don't see a significant number of docs wanting to be family doctors anymore. I think we need to incentivize that to make that more attractive. Take some of the administrative burden off of them and let them be doctors again. The numbers are great. We nope that the shortage by 2038 is going to be staggering.
▶ 1:07:03Sen. Warnock: They're making decisions about the direction of their career and what they will be able to practice, not necessarily what they would 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 and other factors dissuade people from entering the feet?
▶ 1:07:33Dr. Littles: Thank you, we strongly believe that is a factor. When students come to medical school, they come because they really want to provide care and spends their 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 pay scale already and if you're asking them to do more and more for less and less at some point that
▶ 1:08:05Dr. Littles: 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.
▶ 1:08:23Sen. Warnock: Absolutely and I know this is particularly difficult for first-generation college students who gone on to medical school and you have the aptitude but you have barriers. In the last few months I've heard from thousands of georgians about exchanges to federal loan limits under the big ugly bill when capped the amount for those pursuing a health profession.
▶ 1:08:52Sen. Warnock: Most medical students in georgia rely on frailness and when they're capped, students seeking advanced degrees in health care still owe the rest of their bill and those who don't come from rich families have to then try to get risky private loans from banks or worst. Put their tuition 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.
▶ 1:09:22Sen. Warnock: I appreciate your work in this area, Dr. little and also other members of the panel and I'm deeply concerned that these changes to the federal student loans is is the wrong move at the wrong time.
▶ 1:09:42Sen. Scott: Senator alsobrooks.
▶ 1:09:44Sen. Alsobrooks: Thank you, to all of our witnesses for being here today. As the country and communities throughout maryland physicians tell us they are exhausted and increasingly unsure how long they can continue to sing in a system the demands more from them each year while giving them less time and somea doctor collr
▶ 1:10:20Sen. Alsobrooks: And said I don't know what we are doing. Burnout is not simply long hours. It is about physicians spending more and more time navigating layers of paperwork and trying to operate around complicated processes instead of caring for patients. It is about have your caseloads and pressure to do more -- heavier caseloads and pressure to do more with less.
▶ 1:10:47Sen. Alsobrooks: In maryland I hear from providers who what to stay in their communities and care for patients, but 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 underserved communities are losing providers altogether.
▶ 1:11:15Sen. Alsobrooks: Exhausted clinicians face higher risk of medical error affecting patient safety. This isn't just a workforce issue. It is a health care issue as well. It is a quality of care and systems sustainability issue.
▶ 1:11:31Sen. Alsobrooks: At the same time, the drastic medicaid cuts in hr one threaten to destabilize clinics and hospitals that are the backbone the primary and preventive care, forcing patients into emergency rooms while placing greater strain on an already stretched workforce. We can't afford to continue operating a health care system that is burning out the professionals we depend on. I'm requesting, Mr. feist, if I can start with you.
▶ 1:11:59Sen. Alsobrooks: You have spent years working with hospitals, health care systems and policy makers on efforts like the lorna breen health care provider prepared -- protection act. Much of the conversation focuses on helping physicians manage stress. Far less on reforming the structural conditions that drive burnout in the first place. Can you tell us the most impactful preventive reforms that reduce burnout at its root?
▶ 1:12:27Mr. Feist: You highlight the issue, the well intended response over the last few years to the workforce has been to flood the market be more resilient when health workers need the problems addressed at the root cause. We ask them the same question. The administrative burden is the number one driver of burnout.
▶ 1:12:49Mr. Feist: 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, sorry, the workloads can be manageable if you reduce the administrative time they spend before and after work getting health workers back to the bedside and back to the direct patient care they went into the
▶ 1:13:20Mr. Feist: Business to do. We need to return them to what they train for and eliminate as much of the administrative burden and other operational inefficiencies that stand between them and their patients.
▶ 1:13:31Sen. Alsobrooks: As for workforce violence, how important is it occupational safety to develop a clear federal standards to ensure the positions nurses and health care professionals can practice in environments that are physically safe, as well as adequately supported?
▶ 1:13:51Mr. Feist: Think about the maslow hierarchy of needs. You have the essential needs of being fed and watered and using the restroom. Above that you have safety and feelings of being physically and emotionally safe. It is critically important for our workforce. We don't walk in here every day without armed guards outside.
▶ 1:14:15Mr. Feist: Yet we send our health workers into an environment where they could be physically and verbally abused every day, and we ask them to come back tomorrow and do it again. It is unsustainable for them to work in.
▶ 1:14:26Sen. Alsobrooks: One last question, my time is going. Prior authorization. This is for Mr. smith. It has become a gatekeeper in medical care, often requiring extensive paperwork, repeated appeals and delays before patients can receive treatment that their physicians deemed medically necessary. . From your perspective, how does the current prior authorization system in to physician burnout?
▶ 1:14:56Sen. Alsobrooks: What consequences do you see from patients with medically necessary care that is delayed or denied particularly for older adults and those in rural or underserved communities?
▶ 1:15:04Mr. Smith: Thank you. Prior authorization is delaying care. . There is no doubt about it. The backup for a second, burnout is not restricted to doctors. In some offices we have over 40% of staff turnover every year because they can't last in this environment. It is that difficult.
▶ 1:15:29Mr. Smith: 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 on desk folks have the toughest job in health care, not the doctors. The front desks need to be insurance experts, psychiatrist. It is incredibly challenging, working under hipaa obviously. But prior authorization slows care.
▶ 1:15:58Mr. Smith: If forces folks to go to urgent care in a lot of cases, to the emergency room because we haven't gotten 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. We keep saying we need to get rid of the administrative burden. We recognize the government doesn't have unlimited money. How do we work together to reduce the burden so it produces, our costs so we may not need -- reduces our costs?
▶ 1:16:30Mr. Smith: We can get rid of or rearrange staff and we can get back to taking care of patients because that is what doctors want to do. That is why they went to medical school. I believe prior authorization is the biggest issue I need to be addressed quickly.
▶ 1:16:48Sen. Scott: What effect does documentation have in physicians practicing in rural or underserved areas?
▶ 1:16:59Dr. Littles: We have been talking about the stressor of dealing with the electronic health records, and the number of electronic health records physicians often have to go through in the course of taking care of their patients. Stand that out into rural communities, you often -- when you extend that out into rural communities, you have, access to electronic health records is costly.
▶ 1:17:30Dr. Littles: Sometimes it is difficult for them to have. When they have the electronic health record, we know the number of clicks they have to go through to provide documentation is directly related to the stress they feel from that.
▶ 1:17:47Dr. Littles: When you are asking about how the 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.
▶ 1:18:07Dr. Littles: The cost of the electronic health records, the complexity of using the electronic health records, the fact that the records aren't communicating with the physicians, they are referring patients to in nearby urban areas. All of that has a negative impact. My faculty talks about the pajama time they are spending on the electronic health record, which has been mentioned today. All of those are distractions from the care of the patient.
▶ 1:18:38Sen. Scott: Dr. gross, tell me how you practice -- your practice changed how. Is your day different from an insurance different -- driven practice?
▶ 1:18:50Dr. Gross: And he slept in my schedule when I walk into my office that isn't already filled, is lost revenue. When I walk in, the schedule is full. As the phones ring I have to start adding double and triple booking, referring to emergency rooms, sending to physician assistants and nurse practitioners and other sites of care because I don't have the capacity built in my schedule to accommodate for them.
▶ 1:19:19Dr. Gross: It requires me to run an hour or two behind schedule, five-minute visits, three minutes of those are spent clicking boxes to get paid and the two minutes, you have another problem? You have to rebook and the next available appointment in three months. The schedule I have now is, I walk into my office and have one hour before lunch for same-day appointments, one hour at the end of my day for same-day appointments and as the phone rings, if you call in the morning you are seen in the morning. If you call in the afternoon you are seen in the afternoon.
▶ 1:19:50Dr. Gross: If I don't get a call I do administrative time or spend time with my family. People are preferred to the emergency rooms simply because I'm too busy. That opens up my schedule to actually practice to the full scope of my training. A lot of referrals in primary care aren't because the doctors aren't capable of handling the problems, it is because they don't have time.
▶ 1:20:14Dr. Gross: When the doctor has the time and the administrative burden is lifted to perform the full scope of his or her practice, you are stopping downstream referrals and managing things within your practice that are within your purview and training.
▶ 1:20:28Dr. Gross: We see that within our data, that when we implement this into a health plan that is built around the practice model, our er referrals are 35% less, specialty referrals are 35% less, the cost of total implementation of the health plan built around our model is 52% reduction in rural health care settings. We sustained numbers like that over seven years because, not because we are better than anyone.
▶ 1:20:57Dr. Gross: It is the structural design of the practice and the administrative design of the practice, the intent of that is, I think completely changing health care.
▶ 1:21:06Sen. Scott: How much of your budget, Mr. smith, goes to getting prior authorizations, compliance, paperwork versus patient care?
▶ 1:21:16Mr. Smith: That is a good question. I don't have a specific answer. In 75 offices, we have at least one employee with benefits who is making 35-50,000 dollars. It is a significant amount. If we could reduce that by a quarter or a half, it would significantly change the budget of the medical group.
▶ 1:21:42Sen. Scott: Is it easy with all the changes by the insurance companies and medicare and medicaid? Is it easy to stay up with the rule changes by medicare and medicaid and the changes with insurance companies?
▶ 1:21:57Mr. Smith: It is not easy. We do our best to educate. You know, we have great staff. Our staff typically is high school educated, working in medical offices. We have in-house programs to allow them to become certified medical assistance. We do everything we can to raise them up and increase their knowledge. But it is a lot. It is a lot.
▶ 1:22:25Mr. Smith: One or two doctor practices can't really have a business manager running the practice. We are running it from afar and hoping we can get information to them to allow them to be successful. Just to get paid for the work they are doing.
▶ 1:22:40Sen. Scott: The people who run medicare and medicaid are out there to help you every day?
▶ 1:22:43Mr. Smith: Every day they come out. It is a challenge.
▶ 1:22:50Sen. Scott: Mr. feist, how much of today's mental health crisis is driven not by patient care but the constant pressure of bureaucracy?
▶ 1:22:58Mr. Feist: As we have discussed today, when you think about burnout as an occupational syndrome, driven by the workplace design, we have discussed today, the majority of what we experience in burnout is within our control to reduce by changing the operational environment health care workers work in every day.
▶ 1:23:22Sen. Scott: Ok. I want to thank everybody for being here today. This was eye-opening and I hope our colleagues in the senate see this. I think it is difficult what physicians are going through and more and more physicians are doing what you are doing, Dr. gross, they opt out of the wake the system is organized because it is too difficult. I'm sure you deal with those all the time, with the choices people are making. Thanks everybody for being here.
▶ 1:23:51Sen. Scott: It is good, 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 working with members across the aisle. . Senators have statements, the record will be open until next wednesday at 5:00 p.m.. The hearing is adjourned.