[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]




 BURDENSOME RED TAPE: OVERREGULATION IN HEALTH CARE AND THE IMPACT ON 
                            SMALL BUSINESSES

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

                                HEARING

                               before the

       SUBCOMMITTEE ON OVERSIGHT, INVESTIGATIONS, AND REGULATIONS

                                 OF THE

                      COMMITTEE ON SMALL BUSINESS
                             UNITED STATES
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              HEARING HELD
                             JULY 19, 2023
                               __________





                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
                               




            Small Business Committee Document Number 118-021
             Available via the GPO Website: www.govinfo.gov




                               ______
                                 

                 U.S. GOVERNMENT PUBLISHING OFFICE

52-560                    WASHINGTON : 2023















                   HOUSE COMMITTEE ON SMALL BUSINESS

                    ROGER WILLIAMS, Texas, Chairman
                      BLAINE LUETKEMEYER, Missouri
                        PETE STAUBER, Minnesota
                        DAN MEUSER, Pennsylvania
                         BETH VAN DUYNE, Texas
                         MARIA SALAZAR, Florida
                          TRACEY MANN, Kansas
                           JAKE ELLZEY, Texas
                        MARC MOLINARO, New York
                         MARK ALFORD, Missouri
                           ELI CRANE, Arizona
                          AARON BEAN, Florida
                           WESLEY HUNT, Texas
                         NICK LALOTA, New York
               NYDIA VELAZQUEZ, New York, Ranking Member
                          JARED GOLDEN, Maine
                         KWEISI MFUME, Maryland
                        DEAN PHILLIPS, Minnesota
                          GREG LANDSMAN, Ohio
                       MORGAN MCGARVEY, Kentucky
                  MARIE GLUESENKAMP PEREZ, Washington
                       HILLARY SCHOLTEN, Michigan
                        SHRI THANEDAR, Michigan
                          JUDY CHU, California
                         SHARICE DAVIDS, Kansas
                      CHRIS PAPPAS, New Hampshire

                  Ben Johnson, Majority Staff Director
                 Melissa Jung, Minority Staff Director








                            C O N T E N T S

                           OPENING STATEMENTS

                                                                   Page
Hon. Beth Van Duyne..............................................     1
Hon. Kweisi Mfume................................................     3

                               WITNESSES

Dr. Brian Miller, MD, MBA, MPH, Assistant Professor of Medicine, 
  Johns Hopkins University, Nonresident Fellow, American 
  Enterprise Institute, Washington, DC...........................     6
Dr. Henry Anthony Punzi, MD, FCP, FASH, Medical Director, Trinity 
  Hypertension & Metabolic Research Institute, Punzi Medical 
  Center, Carrollton, TX.........................................     7
Mr. Matthew Fiedler, Senior Fellow, Schaeffer Initiative for 
  Health Policy, Economic Studies Program, Brookings Institution, 
  Washington, DC.................................................     9

                                APPENDIX

Prepared Statements:
    Dr. Brian Miller, MD, MBA, MPH, Assistant Professor of 
      Medicine, Johns Hopkins University, Nonresident Fellow, 
      American Enterprise Institute, Washington, DC..............    25
    Dr. Henry Anthony Punzi, MD, FCP, FASH, Medical Director, 
      Trinity Hypertension & Metabolic Research Institute, Punzi 
      Medical Center, Carrollton, TX.............................    32
    Mr. Matthew Fiedler, Senior Fellow, Schaeffer Initiative for 
      Health Policy, Economic Studies Program, Brookings 
      Institution, Washington, DC................................    38
Questions for the Record:
    None.
Answers for the Record:
    None.
Additional Material for the Record:
    APTA Private Practice........................................    50
    ASCO - Association for Clinical Oncology.....................    52
    MGMA - Medical Group Management Association..................    57








 
 BURDENSOME RED TAPE: OVERREGULATION IN HEALTH CARE AND THE IMPACT ON 
                            SMALL BUSINESSES

                              ----------                              


                        WEDNESDAY, JULY 19, 2023

              House of Representatives,    
               Committee on Small Business,
                         Subcommittee on Oversight,
                           Investigations, and Regulations,
                                                    Washington, DC.
    The Subcommittee met, pursuant to call, at 9:38 a.m. in 
Room 2360, Rayburn House Office Building, Hon. Beth Van Duyne 
[chairwoman of the Subcommittee] presiding.
    Present: Representatives Van Duyne, Williams, Alford, 
Crane, Bean, Mfume, and Gluesenkamp Perez.
    Also Present: Representative Molinaro.
    Chairwoman VAN DUYNE. Good morning, everyone.
    I now call the Committee on Small Business to order.
    Without objection, the Chair is authorized to declare a 
recess of the Committee at any time.
    I will now recognize myself for an opening statement.
    Welcome to today's hearing on the harmful impacts of 
overregulation in healthcare, which is hurting small 
businesses.
    I want to thank our witnesses for joining us today, and I 
am eager to hear from you and discuss how we can cut through 
some of the red tape that I have heard so much about.
    Unfortunately, burdensome reporting requirements and rising 
compliance costs, coupled with an overreaching regulatory 
landscape, have led to small healthcare providers having to 
close their doors for good. This is absolutely unacceptable.
    As we have heard time and time again, overregulation can 
shutter the doors of any small business. But small healthcare 
providers are disproportionately impacted.
    I will never forget the meeting we had--and you may have 
been there. There was a physician who had--had to sell her 
practice.
    She said: You know, I went into so much debt in medical 
school. I know my patients. I know my patients' history. I 
spend time talking to them.
    She said: But I could not afford to have my doors open. So 
I became an employee.
    And she said: With all of these regulations, I am no longer 
practicing medicine. I am now following protocol.
    She said: A monkey could do my job.
    She almost cried. It was that impactful.
    And, during the roundtable that I have hosted with doctors 
in north Texas, I have always made a point of asking them how 
much of their time is in front of a screen versus face to face. 
And I think at the last roundtable, one of the physicians said 
it is about 70 percent of her time is in front of a screen.
    I said: Now keep in mind, when you walk into the exam room 
and you are having to be in front of computer--and we have all 
been there as patients--and your doctor is in front of a 
computer, and he is asking you questions, but he is not looking 
at you; he is typing into his computer.
    And I said: If you consider that time, how much of your 
time is really face to face in front of the patient versus 
being on the computer and a screen.
    And they said: If we do that, it is maybe 10 percent with 
the patient and maybe 90 percent.
    And, you know, it is shocking to hear how much of their 
time is spent on compliance, time that they would strongly 
prefer to be spent with their patients. And I know, as 
patients, we would rather have that one-on-one time with our 
physicians.
    In 2017, a report from the American Hospital Association 
revealed that the massive amount of regulations placed on 
healthcare providers cost them $39 billion each year. And to 
put this number in perspective, if you took an average 
community hospital with about 160 beds, that would be $7.6 
million per year spent on compliance.
    And, moreover, we know that the constantly changing 
regulatory environment causes issues with proper compliance and 
harms patient care. Frustratingly, the regulatory environment 
has only worsened since the AHA's 2017 report.
    The Medical Management Association's 2022 Annual Regulatory 
Burden Report showed that 89 percent of respondents feel the 
regulatory burden has increased in the past year.
    When regulatory costs reach the point that it is no longer 
feasible for small, private healthcare practices to keep their 
doors open, it leads to one thing, and that is consolidation.
    And, when proponents of consolidation claim that healthcare 
mergers decreased costs and improve access to care, the reality 
is quite different. Far too often, consolidation decreases 
quality of care. It eliminates competition, which increases 
costs. And it removes the possibility of physicians owning 
their own businesses, thereby crushing the American dream.
    Small healthcare providers have in recent years been hit on 
all sides. We know that, on top of severe overregulation, the 
COVID-19 pandemic played a significant role in consolidations 
as well. More than 22,000 physicians left independent practice 
to join bigger hospital systems after the onset of the 
pandemic.
    Unfortunately, small providers bear a disproportionate 
amount of the regulatory burdens and administrative costs that 
are associated with healthcare compliance. And this leads to 
rising costs, increased administrative costs, and more 
consolidation. This leads to the elimination of many small 
providers.
    And we cannot continue to allow overregulation to shut the 
doors of small care providers, and I am glad that our Committee 
is focused on finding solutions to provide better and more 
affordable patient care.
    I ask unanimous consent to waive Representative Molinaro 
onto the Subcommittee for the purpose of asking questions in 
today's hearing.
    And, with that, I would now like to yield to our 
distinguished Ranking Member from Maryland, Mr. Mfume.
    Mr. MFUME. Thank you very much, Madam Chair. Good morning. 
Thank you for calling this hearing and for your leadership on 
this issue.
    I want to also thank those witnesses who are here today as 
we try to put in context in a very real way why this is such a 
problem for so many of us.
    As of 2021, healthcare spending consumed about 18 percent 
of the gross domestic product here in the U.S., nearly double 
the 9.6 percent average across other similarly developed 
nations. It also accounted for nearly a quarter, a whole 
quarter, of the government spending.
    Yet, despite these high costs, both independent providers 
and patients have come to us and have complained over and over 
and over again about their situation.
    The U.S. often archives worse health outcomes than many of 
our peer nations, which I still find hard to believe. We stand 
alone among our peers by not guaranteeing healthcare coverage 
as a right. And, while many factors underpin our country's high 
healthcare costs, none of them seem to carry such a healthy 
price tag as the administrative bloat permeating every 
interaction between a patient and their doctor.
    In many ways, our pursuit of extensive healthcare plans and 
choices has given rise to a complex and fragmented multiplayer 
system that is very, very difficult to navigate for patients, 
difficult for doctors, and difficult for small businesses 
alike.
    Our country, as has been stated in a lot of different areas 
and studies, spends between 15 and 30 percent of all national 
medical expenditures on administrative costs primarily through 
billing and insurance-related activity. Nearly half of that 
spending, between $250 billion and $570 billion a year, could 
be avoided through streamlined practices. In fact, one analysis 
found that the United States' administrative costs per capita 
is about $1,055 per year, over five times the average of 
similarly developed nations, those that I had referenced 
earlier.
    Now not only do these costs get passed on to consumers 
through higher premiums, as most of you know, and out-of-pocket 
expenses, they are also passed on to independent physicians 
whose small businesses provide essential healthcare for Members 
of their community. However, and regrettably, this growing 
overhead pushes many physicians away from their private 
practice and toward hospital employment.
    While private practice was once a shining cornerstone of 
the small business community, only 3 in 10 physicians now 
remain independent. And that is in part due to the 
administrative and financial burdens that I referenced a moment 
ago that we continually place on these small firms.
    As a result, hospitals have become increasingly 
consolidated and corporate entities, which have absorbed 
numerous practices all across our nation, every State involved, 
and though this consolidation streamlines administration, it on 
the other hand decreases accountability and further accelerates 
the closure of independent practices.
    It also endows hospitals with a sort of monolithic--excuse 
me--monopolistic pricing power in insurance negotiations. And 
most, if not all, studies show that more concentrated hospital 
markets have 5 percent higher insurance premiums than those 
that are less concentrated. And so, while administration is a 
major reason for growing costs, we can't undervalue regulations 
also in mitigating cost growth.
    The Affordable Care Act made great strides in slowing the 
growth of insurance expenses and keeping small firms in the 
market. Between 2002 and 2012, the rate at which small firms 
offered health insurance declined by over 10 percent. And, 
between 2013 and 2020, that decline was just about 2 percent.
    So, while we are still dealing with complex challenges in 
our healthcare system, it is important to recognize the 
essential role of regulation in ensuring that we provide 
stability to our markets and protection to our consumers, no 
matter where they may be.
    Again, I want to thank the witnesses for coming to testify. 
We look forward to your comments. There will be obviously 
questions or observations, but we all look forward to a 
productive discussion this morning.
    And, Madam Chair, I want to thank you and yield back my 
time.
    Chairwoman VAN DUYNE. Thank you very much.
    I would like to now yield to the Chairman of the full 
committee, Chairman Williams, for an opening statement.
    Mr. WILLIAMS. Good morning--and I want to thank my fellow 
Texan, Congressman Van Duyne--for holding--holding today's 
Subcommittee hearing on regulations within the healthcare 
industry and its impact on small businesses, and to our 
witnesses for being here today.
    Today's hearing is critical in examining the impact of the 
industry's overregulation on small businesses and small 
providers. We are eager to discuss what this committee can do 
to help minimize the regulatory landscape and ease the impact 
on small providers.
    Throughout recent years and especially during the pandemic, 
we have seen how stifling regulations can suffocate any small 
business, especially those in healthcare. I have a business of 
hundreds of employees back in Texas. We supply healthcare. 
There are issues.
    From burdensome reporting requirements to rising compliance 
costs, many small providers have been forced to close their 
doors or be brought by--bought by larger companies. So, far too 
often, consolidation decreases quality of care, eliminates 
competition, which increases costs, and removes the possibility 
of physicians owning their own business.
    So I am looking forward to today's discussion. I hope this 
hearing shines a light on the burdensome red tape currently 
restricting our small healthcare providers.
    So thank you again, Chair Van Duyne, and I yield back.
    Chairwoman VAN DUYNE. Thank you very much, Chairman 
Williams.
    We will now move to the introduction of the witnesses.
    Our first witness here today is Dr. Brian Miller. Dr. 
Miller is a nonresident Fellow with the American Enterprise 
Institute here in Washington, D.C. In addition to his role at 
the American Enterprise Institute, he is a practicing 
hospitalist at the Johns Hopkins Hospital and Assistant 
Professor of Medicine in Business at the Johns Hopkins 
University.
    Dr. Miller has previously served as a medical officer in 
the Office of New Drugs at the Center for Drug Evaluation and 
Research at the FDA and is a special advisor to the FTC's 
Office of Policy Planning.
    Dr. Miller graduated from the University of Washington a 
with Bachelor of Science in Chemistry and Biochemistry and 
completed an internal medicine residency at Georgetown 
University Hospital with a public health residency at Johns 
Hopkins University.
    Dr. Miller, thank you very much for being with us today, 
and we look forward to hearing from you.
    Our second witness is Dr. Henry Punzi. Dr. Punzi is a 
Medical Director of Punzi Medical Center located in Carrollton, 
Texas. With over 40 years of experience, Dr. Punzi has 
firsthand knowledge of the impacts of overregulation within the 
medical industry. Dr. Punzi attended medical school at the 
University of Buenos Aires and completed his residency at the 
University of Texas Southwestern Medical Center.
    I really appreciate you being here. I appreciate you 
participating, as well, in roundtables on healthcare within our 
district. And I look forward to hearing from you today.
    I now recognize the Ranking Member from Maryland, Mr. 
Mfume, to briefly introduce our last witness appearing before 
us today.
    Mr. MFUME. Thank you very much, Madam Chair.
    Matthew Fiedler is a senior fellow at the Brookings 
Schaeffer Initiative on Health Policy. His research examines a 
range of topics in healthcare, economics, and healthcare 
policy.
    Prior to joining Brookings in 2017, he served as chief 
economist of the Council on Economic Advisors where he overall 
the council's work on healthcare policy, including the 
implementation of the Affordable Care Act's health insurance 
and healthcare payment reforms. He holds a Ph.D. in economics 
from Harvard University and a B.A. in mathematics and economics 
from Swarthmore College.
    Mr. Fiedler, thank you very much for joining us today. We 
look forward to your testimony.
    Chairwoman VAN DUYNE. Thank you.
    We appreciate all of you being here today.
    And, before recognizing the witnesses, I would like to 
remind them that their oral testimony is restricted to 5 
minutes in length. And, if you see the light turn red in front 
of you, it means your 5 minutes have concluded and you should 
wrap up your testimony.
    I now recognize Dr. Miller for his 5-minute open remarks.

STATEMENTS OF BRIAN MILLER, M.D., MBA, MPH, NONRESIDENT FELLOW, 
   AMERICAN ENTERPRISE INSTITUTE, ASSISTANT PROFESSOR, JOHNS 
  HOPKINS SCHOOL OF MEDICINE; ANTHONY PUNZI, M.D., FCP, FASH, 
  MEDICAL DIRECTOR, TRINITY HYPERTENSION & METABOLIC RESEARCH 
 INSTITUTE, PUNZI MEDICAL CENTER; AND MATTHEW FIEDLER, SENIOR 
   FELLOW, SCHAEFFER INITIATIVE FOR HEALTH POLICY, ECONOMIC 
            STUDIES PROGRAM, BROOKINGS INSTITUTION.

       STATEMENT OF BRIAN J. MILLER, M.D., M.B.A, M.P.H.

    Dr. MILLER. Thank you, Chair Van Duyne and Ranking Member 
Mfume and distinguished Members of the Subcommittee on 
Oversight, Investigations, and Regulations.
    I am excited to be here today to talk about red tape and 
overregulation in healthcare. There is so much of it, it is 
actually sort of hard to know where to start, to be completely 
honest.
    I am a practicing hospitalist at Hopkins. I am a 
nonresident fellow at AEI. I previously was a special advisor 
at the FTC. I also worked at the CMS Innovation Center, the 
FDA, the FCC. So I basically worked for every agency that 
regulates our industry.
    Disclaimer, I am here today in my personal capacity. The 
views here are my own and don't necessarily reflect those of 
Hopkins, the American Enterprise Institute, or the Medicare 
Payment Advisory Commission, on which I am a commissioner.
    So, thinking about consolidation, right, I looked up this 
little story because what does consolidation look like?
    In June 2022, MaineHealth decided to remove Maine Medical 
Center from the Anthem, now Elevance, insurance network from a 
contract dispute. The CEO of Maine Medical Center, a physician, 
penned a nice op-ed in the local paper, and so I was curious. 
Right? I looked it up at the time, and the Healthcare Cost 
Institute, a nonpartisan research institute, said that the 
market was highly concentrated by FTC and Department of Justice 
standards.
    A few months later, the plaintiff and the hospital settled. 
And I was like, oh, okay, just another fight between a big 
hospital and, you know, probably a local monopoly, for certain 
a local monopoly, and a big insurance company.
    And then, I started digging into it. And I saw that the 
impoverished hospital that was the local monopolist received 
over $40 million in COVID relief funds and that, during the 
pandemic, they bought the D'Angelo's sandwich shop next door, 
despite crying poverty.
    So that is sort of monopoly in action. Right? You are a 
monopolist, and you can beat up on other businesses or even 
beat up on the government. Consolidation is bad. It raises 
prices, lowers quality, results in a worse patient experience. 
I sort of argue that we did this to ourselves, and it is sort 
of our fault.
    There was a move, and it was successful, to ban physicians 
from owning and operating hospitals. Now we have a concentrated 
hospital market in 90 percent of metropolitan areas. We are 
worried about small practices being able to compete with large 
delivery systems that have bought everything from clinics to 
home care. We banned it through Stark Law. We banned physician 
owned-and-operated integrated care delivery.
    The important thing I think also is, is that, for those 
practices that do remain, we regulate them into the ground. I 
looked this up. CMS has 2,466 quality metrics, over 2,000. 
There aren't even that many days in the year. CMS needs to go 
on a quality diet and actually have a lifecycle for quality 
metrics. Sort of a basic tenet of quality performance for 
running an organization is that for your internal measures, you 
need to see when they top out, when they are no longer working, 
and if they don't have an impact.
    We talked about how physicians don't spend time seeing 
patients. The average physician spends, from a time motion 
study published in JAMA Internal Medicine, 15 percent of their 
day with patients.
    So what does overregulations mean for small business? Well, 
it crushes small business. And, you know, one of the things 
that the American Association of Medical College CEO has 
commented on is a lack of diversity in the medical workforce. 
For physicians being able to own and operate their own 
business, regulating businesses into the ground is another 
barrier to entry.
    Small practices are important. Why are small practices 
important? It is not just an economic concept. It is a real 
concept. I went to Northwestern for medical school. Great 
facility, quaternary care. You can get plastic surgery. You can 
get burns treated, everything, organ transplants. To go from 
one side of the campus to the other is over a quarter of a 
mile, and the outpatient clinic tower is 23 stories tall, not 
exactly easy to navigate.
    A small practice allows greater customization of your care 
and also potential greater customization of the process of your 
care delivery.
    Thank you, and I look forward to questions.
    Chairwoman VAN DUYNE. Thank you very much.
    I now recognize Dr. Punzi for his 5-minute opening remark.

       STATEMENT OF HENRY ANTHONY PUNZI, M.D., FCP, FASH

    Dr. PUNZI. Good morning, Chair Van Duyne, Mr. Mfume, all 
the Congressmen here.
    It is a pleasure and an honor to be here in front of you.
    My name is Henry Punzi, and I have been in the solo private 
practice of internal medicine since 1984 and have firsthand 
knowledge of the changes at CMS, as well as the insurance 
industry. I have also been doing clinical research since 1986 
and have worked closely with the Food and Drug Administration 
and the National Institutes of Health.
    As a result of numerous publications, studies from the--
publications from these trials, I have been a national and 
international speaker and have worked with many pharmaceutical 
companies and have seen the regulatory aspect of the FDA.
    And, lastly, I am also an FAA senior Aviation Medical 
Examiner, performing pilot physicals, and work closely with the 
Federal Aviation Administration.
    Now, as the prior witness said is what do all these 
government entities have in common is that I am surrounded by 
red tape, a lot of regulations. And, as a result of this 
bureaucracy, to many physicians, medicine has lost a lot of 
what made it desirable.
    So the key here is, as a physician in private practice, 
when I take time with my patient, that is the main thing I need 
to do. And there are some research that shows that it takes, 
for an average visit, about 15 minutes--that is kind of what 
has been allotted--of which 5 minutes is specifically about one 
complaint the patient has. And then there is 1 minute for the 
other five complaints that they have.
    So you can imagine that the time I have speaking to all of 
you, I have got to examine a patient who is 77 years of age and 
get their medical history and physical.
    So, as my medical students--I am a clinical assistant 
professor at UT Southwestern. So what I tell my students is 
medicine is an art and a science. So the key there is being 
able to do a good history and physical that allows me to 
identify 80 percent of the problems that the patient has, but I 
have to have time to do that.
    The second thing I tell my students is that patients do not 
go to medical school to tell us what is wrong with them. That 
is the art of medicine. I have got to be able to extract that, 
and you can imagine that, in 5 minutes, that is significantly a 
challenge.
    Now the other issue that plays into all of this is that 
many visits patients come in for certain issues that may not be 
related to their main complaint, and a lot of it has to do with 
mental health. And, within that period of time, it is very 
challenging to extract that from patients.
    Now, on the flip side of that, when you look at the 
electronic medical record, data shows that typically for every 
hour that you are in contact with a patient, it takes about 2 
hours of electronic health records to be able to kind of 
identify that.
    So really we are putting the emphasis in the wrong place 
which is, as Chairman Van Duyne said, is that whenever I have 
gone the VA with my cousin, and the physician is looking at the 
screen, and we are behind him. And that really ends up being 
kind of a big issue for me particularly, since being in 
practice for many, many years.
    Lastly, it is the prior authorizations. Right? There are 
typically about prior authorizations per week. Now that does 
not mean that you get them all resolved. So, from one week the 
another, you have 45 that you add on, and that just can kind of 
stockpiles. And the issue with prior authorizations is that the 
data suggests that patients end up dropping their treatment.
    I have got many diabetic patients. Now with diabetes, a 
chronic disease, one visit does not really allow the patient to 
understand the disease process. So, if they end up dropping 
their medication because of prior authorizations, they 
sometimes don't come back. And that ends up driving the cost of 
healthcare.
    I had a patient that I saw last week actually. And she was 
walking her dog, tripped, injured her right foot, went to the 
minor emergency center, had an X ray done, no fracture. She was 
still hurting 3 days later, saw the orthopedist. He was trying 
to get an MRI. It took about 2 and a half weeks to get that MRI 
approved. Immediately she was called, say put your foot in the 
boot because you have a fracture.
    So those are things that we see on a day-to-day basis in my 
practice and in many practices. So I think the key here is that 
we have to be allowed to talk to the patient. Again, as I 
emphasize with my students, and my medical professor in 
Argentina always said: Henry, the history and physical, if you 
don't know what is going on with the patient, then you do it 
again, because sometimes people, when you talk to them, they 
give you more information that allows you to make the right 
diagnosis.
    And that is what cause--decreases healthcare costs, making 
the correct diagnosis.
    Thank you.
    Chairwoman VAN DUYNE. Thank you very much.
    And I now recognize Mr. Fiedler for his 5-minute opening 
remarks.

                  STATEMENT OF MATTHEW FIEDLER

    Mr. FIEDLER. Madam Chair, Ranking Member Mfume, and Members 
of the Subcommittee, thank you for having me here today.
    My name is Matthew Fiedler, and I am a health economist and 
a senior fellow with the Schaeffer Initiative on Health Policy 
at the Brookings Institution, where I study topics including 
health care provider payment and health insurance regulations.
    My testimony will focus on ways that policymakers can make 
healthcare providers' interactions with health insurers, both 
public and private insurers, less burdensome.
    As the other witnesses have alluded to, providers interact 
with insurance in many ways, including when negotiating 
contracts, collecting information about patients' coverage, 
obtaining prior authorization for care, submitting claims for 
payment, and reporting on quality of care. These activities are 
costly.
    Insurance-related administrative costs are estimated to 
consume 13 percent of physician practices' revenue on average, 
plus somewhat smaller fractions of other providers' revenue. In 
total, that amounts to hundreds of billions of dollars per 
year, costs that are ultimately borne by patients and taxpayers 
in the form of higher prices. Due to economies of scale, these 
burdens probably hit smaller practices harder than larger ones.
    It is important to recognize that administrative activities 
can be valuable. Billing processes are ultimately how providers 
are paid. Prior authorization processes can help prevent 
delivery of inappropriate services, and audit processes can 
help uncover fraud. So, if we are looking to reduce 
administrative burdens, we need to proceed thoughtfully.
    In that spirit, I want to offer three targeted reforms that 
could reduce administrative burdens with relatively few 
tradeoffs. The first is eliminating Medicare's Merit-Based 
Incentive Payment System, or MIPS. Under MIPS, Medicare scores 
clinicians in several domains, including the quality and 
efficiency of their care. Clinicians' payment rates are then 
adjusted up or down based on their scores with the goal of 
encouraging high performance.
    Much of the information used to score clinicians, 
particularly on quality, is reported by clinicians themselves, 
often at high costs. A recent study estimated that practices 
spent nearly $13,000 per physician reporting to MIPS in 2019.
    But, despite these large costs, MIPS is likely not 
improving patient care. One problem is that clinicians can 
choose which measures they are evaluated on, which makes it 
hard to meaningfully compare across clinicians. Plus, studies 
of past programs like MIPS have found little evidence that they 
actually improve care. Since MIPS appears to have large costs 
but few benefits, I suggest eliminating MIPS and, ideally, 
replacing it with a better-designed set of incentives.
    The second reform is changing how provider-insurer payment 
disputes are resolved under the No Surprises Act, the law that 
protects patients from facing large surprise bills when they 
unexpectedly receive out-of-network care. Under the law, 
disputes over payment for out-of-network care are settled via 
arbitration. Unfortunately, arbitration is costly with fees 
that start at $900 per case.
    At the arbitration volumes observed so far, providers and 
insurers will incur hundreds of millions in dollars in fees per 
year, not to mention the direct costs of participating in 
arbitration. Congress could avoid these costs, while still 
ensuring that providers are appropriately compensated for out-
of-network care, by doing away with arbitration and instead 
directly specifying benchmark payment rates.
    The third reform is improving the Medicare Advantage risk 
adjustment system, which adjusts payments to MA plans based on 
what health conditions their enrollees have. This system aims 
to ensure that payments to plans are commensurate with the cost 
of their enrollees' care. But plans have responded to this 
system by working to document evermore enrollee diagnoses. This 
has increased to payments to MA plans well beyond what the 
Medicare statute intends, but it also increases providers' 
administrative costs since MA plans often enlist providers to 
help hunt for diagnoses.
    Reforms to risk adjustment could make it less susceptible 
to this type of gaming. One idea put forward by the Medicare 
Payment Advisory Commission is to increase the number of years 
of diagnosis data used in risk adjustment. This would increase 
how many diagnoses are captured without MA plans' special 
efforts, reducing administrative burdens. It would also reduce 
federal costs by reducing the gap between how many diagnoses 
get captured in MA versus traditional Medicare, the ultimate 
benchmark for MA payments.
    In closing, I want to zoom out and talk briefly about a 
more ambitious potential reform. Providers appear to bear 
larger administrative burdens in the United States than in 
other countries likely at least in part because providers here 
must deal with a menagerie of public and private insurers, all 
of which set different rules.
    Standardizing billing, quality reporting, or other 
processes across insurers could reduce administrative burdens. 
This approach would present real tradeoffs. In some cases, 
different insurers may have good reasons to set different 
rules, and standardization would only work well if the 
standardized processes were well-designed. But requiring 
greater standardization could likely reduce administrative 
burdens by much more than the other approaches I have 
discussed.
    Thank you again for the opportunity to testify. I look 
forward to your questions.
    Chairwoman VAN DUYNE. And I really appreciate all of you 
sticking to the 5-minute rule.
    We are going to now move to Member questions under the 5-
minute rule, and I recognize myself.
    Dr. Punzi, you talked a little bit about this in your 
testimony. I know that we have talked extensively about this 
during our roundtable meetings.
    But can you talk to me a little bit on--on the 
administrative burden that you are seeing in your office? You 
talked specifically about the percentage of time that you spend 
on that, but I am also interested in finding out about your 
staff's work on that----
    Dr. PUNZI. Right.
    Chairwoman VAN DUYNE.--versus actually patient work.
    Dr. PUNZI. So I have five staff Members. One is 
specifically geared towards my research because, through the 
FDA, the amount of paperwork that is utilized for the studies 
has significantly increased. So she does specifically that.
    And I have two employees, two medical assistants that help 
me out. And then they split half and half. So half is being 
able to see the patients. The other half is trying to do either 
prior authorizations with medications or prior authorizations 
with procedures, X-rays. So we are not really heavy procedure 
wise, but we have got to do that.
    Now the advantage I have in my clinic is that I end up 
dictating. We still have to input data into the computer, but 
that is one of the advantages that I have being in practice for 
such a long time is I have got a service. Somebody will 
dictate. So it makes it a lot easier for me to be able to see 
the patient face to face and then do the dictation and get that 
the next day.
    So I think that, when you talk about burden, is--is, yes, 
is it is getting worse from the point of view being able to 
identify whom it is that I need to talk to, especially when you 
do a prior authorization. It takes about three people. It is 
myself, my medical assistant, whoever is on the other side, and 
the insurance company and subsequently to the physician that 
you talk to that may not be an internist.
    So a lot of times it ends up being kind of a challenge from 
that point of view.
    Chairwoman VAN DUYNE. So part of the reason why I had these 
roundtables to hear from you, hear what some of the complaints, 
are but also to figure out solutions.
    Dr. PUNZI. Yes.
    Chairwoman VAN DUYNE. So, from your perspective, how would 
you advise, you know, the Members here, Congress to be able to 
respond to your criticisms----
    Dr. PUNZI. Yes.
    Chairwoman VAN DUYNE. But--also be able to provider better 
patient care, better access, and higher quality?
    Dr. PUNZI. Two things that I can think of.
    One is that, with regards to electronic health records, 
when I have a patient come to my office and request the records 
and when I read them, I really don't quite understand 
completely what the patient had done. And the reason being is 
that a lot of these records are cut and paste. So it is very 
difficult. So it is not that it actually helps, but it helps 
documentation mainly from the point of view, the billing issue.
    The second thing, for the prior authorizations, I think 
that it needs to be somewhat streamlined. They are talking 
about the reduction in waste. But, as a clinician, when I order 
a test or when I order medication, I think that is best 
practice for that particular patient. So I think that there 
needs to be a little bit more leeway.
    I understand insurance companies have to make their profit. 
But I think at the same time is we need to come to consensus on 
being able to diminish either the time or the--or the 
investment in trying to get these things approved.
    Chairwoman VAN DUYNE. So you are--so you are recommending 
that people who actually have medical degrees be the ones who 
are making the decisions on medical care?
    Dr. PUNZI. That would be correct, Chairman.
    Chairwoman VAN DUYNE. Dr. Miller, you know, you have heard 
about some of our conversations that we have had. We have 
talked about a lot about regulatory burden.
    But how are small practices or solo practitioners expected 
to comply with these increased burdens?
    Dr. MILLER. They are expected to comply, and they are 
unable to. And, therefore, they then sell their practice to the 
large health system down the street, which is the consequence. 
That is one of the reasons why I am a big fan that CMS needs to 
have a quality metric lifecycle.
    If you have to comply with hundreds of quality metrics a 
year, you have to hire staff. You have to have IT 
infrastructure that can support that. That then changes how you 
practice, because you are practicing to document rather than 
practicing to treat the patient.
    And so, if we eliminate some of the out-of-date quality 
metrics, put a cap on the number of quality metrics, and 
require CMS to regularly review quality metrics to see if they 
are still performing as intended and actually improving 
clinical practice whereas, in some cases, some of them have 
actually resulted in increased mortality, the Hospital 
Readmissions Reduction Program, for example, we could massively 
improve patient quality, actually allow physicians to spend 
time with their patients, and decrease paperwork.
    Chairwoman VAN DUYNE. Excellent. Thank you very much.
    I now recognize the Ranking Member for 5 minutes of 
questions.
    Mr. MFUME. Thank you, Madam Chair.
    One of you, I don't remember who, said something that I 
thought--should we--that we ought to take a look at in a 
different sort of way and that we are regulating practices into 
the ground.
    Was that you----
    Dr. MILLER. Yes.
    Mr. MFUME. Okay. I just thought it was significant, and I 
didn't want it to go by without some attention. I am going to 
come back to it in a minute.
    On the other side of that, a Kaiser Family Foundation 
survey found customer experiences with a lot of different 
problems of their own. With health insurance, they found that 
the majority of the insured adults said they have experienced 
many problems using their healthcare insurance over the past 
year. Some of those problems are denied claims which, you know, 
debatable one way or the other; provider network problems which 
clearly can be dealt with--I know you talked, Mr. Fiedler, 
about standardization; I want to come back to that to see 
whether there can be some amplification there; and, of course, 
the good, old prior authorization problems.
    Can you, Mr. Fiedler, sort of dive down into these 
authorization problems and network problems and speak also 
about this need for standardization and to some extent audit 
performances?
    Mr. FIEDLER. Starting with prior authorization, I think one 
thing that is important to just recognize as a starting point 
is that----
    Chairwoman VAN DUYNE. Can you speak----
    Mr. FIEDLER.--prior authorization is actually much more 
common in private insurance than it is in Medicare. Traditional 
Medicare, for better and for worse, I would argue, actually 
makes fairly little use of prior authorization. And so it is 
really about Medicare Advantage plans and plans in the private 
market.
    I think one of the challenges with prior authorization is 
there are very real tradeoffs here. There is no question it 
creates very large administrative costs for providers and for 
patients. At the same time, there is evidence that, in some 
cases, it can shift patients toward lower cost treatments or 
prevent delivery of unnecessary care that ultimately saves 
patients money.
    So I think exactly how to strike that balance and how 
policymakers can strike that balance is a hard question that I 
think there are no ready answers to.
    I do think one path you could think about going down is 
trying to standardize these processes across different payers. 
So, rather than every different payer having its own prior 
authorization process that requires submission of slightly 
different information and slightly different forms through a 
slightly different channel, you could think about whether there 
are ways to sort of harmonize these processes across insurers 
so at least, you know, that might reduce the administrative 
burden to some degree.
    Mr. MFUME. And it was your testimony also that, with 
respect to arbitration, I thought I heard you correctly when 
you said you would advocate doing away with it.
    Could you talk about that?
    Mr. FIEDLER. I think the use of arbitration under the No 
Surprises Act is creating a lot of administrative burden for 
both providers and insurers to resolve these payment disputes. 
And we could do that in a much more direct way by setting 
payment benchmarks without compromising the accuracy and the 
appropriateness of the compensation for out-of-network care.
    Mr. MFUME. And what about risk adjustment and the notion of 
changing the number of years, scaling them one way or the 
other? What are the benefits there?
    Mr. FIEDLER. The benefits there are that if you start with 
more years of data, you are more likely to sort of just 
automatically capture the diagnoses that enrollees have rather 
than having MA plans and their providers go out to hunt for all 
these different diagnoses. And so that has the potential to 
reduce the amount of administrative burden involved in the 
risk-adjustment system.
    It also would reduce overpayments to MA plans. We have 
quite a lot of evidence that we are paying MA plans a lot more 
than the Medicare statute intends at the moment, and that is 
ultimately obviously increasing federal costs quite a bit.
    Mr. MFUME. Thank you.
    Dr. Harris, I want to go back to your statement about that 
we are practically running practices in the ground, which I do 
not dispute at all. But I wanted to get your take on the 
concept of standardization, and does that have any value in 
doing just the opposite?
    Dr. MILLER. Standardization of--you mean of the prior 
authorization process or quality metrics or all of the above?
    Mr. MFUME. Of practices.
    Dr. MILLER. Standardization--of the prior authorization 
practices?
    I mean, I think having the insurance industry and 
physicians work together to create an automated or standard 
data interchange would be good. I would be reticent to have the 
government do that, given the history of the government running 
technology programs. Say setting up the ACA exchanges was one 
example that did not go well.
    Mr. MFUME. Let me just jump in real quick because my time 
is just about up.
    What about standardization of billing practices? Any 
thoughts?
    Chairwoman VAN DUYNE. You can answer.
    Dr. MILLER. May I?
    I think standardization--do you mean billing practices like 
the actual claim form, because the claim forms are relatively 
similar already to begin with.
    Mr. MFUME. I am just trying to get you to talk more about 
standardization across a number of different claims. And so, 
yeah, billing would be one of those and anything else, except 
that we are out of time. So I am going to have to come back in 
my next round.
    But thank you very much.
    Chairwoman VAN DUYNE. All right. Thank you.
    I now recognize Mr. Bean from Florida for 5 minutes.
    Mr. BEAN. Thank you very much, Madam Chair. Good morning to 
you.
    And good morning, Small Business Committee.
    You know, if somebody is in the hallway right now, they 
might just be listening to us singing in harmony up here, which 
doesn't happen very often because we are hearing on both sides, 
recognizing there is a problem. There is a problem.
    People forget that doctors are small businesses. I used to 
be a community banker, and I had the privilege of banking 
several doctors and coaching them and trying to become 
efficient and it is tough. They get it from all angles and just 
to juggle what they do.
    I used to have a joke that, you know, I used to say: What 
do doctors need to stay in business a long time? And the answer 
is they have to have lots of patients to stay in business a 
long time.
    Thank you. I will be in town until tomorrow.
    So but they are losing patients. And one of those, it is 
just the other day, one of them lost--sold out, just sold out. 
I talked to him.
    And sure enough, he said: I just couldn't do it anymore. It 
is--it is so good to go home at 6:00 o'clock without having to 
worry.
    And he said: Yeah, there is hoops I have to jump through.
    But so it is just a toss-up question. Are--we seeing that 
we both agree on both sides that we agree that there is a 
problem. Is it always been--are we just saying it has always 
been this or are we seeing a massive pileup of regulations in 
the last couple of years due to COVID?
    Anybody?
    Dr. PUNZI. So I was reading that CMS put out 200 different 
kind of regulations during the time of COVID. And it is very 
hard to try to keep up with what is going on, let alone in your 
office with whatever's going on regulatorywise.
    But I think if you look at physicians, about 2019, 75 
percent of new graduates are going to be employed. So we are 
seeing a decrease in that. And I think going back to your 
comment is that it is that work-life balance, the only problem 
with that being in private practice. And, if I would get asked, 
``Do you want to sell out,'' you know, the grass is always 
greener on the other side. But the problem with that ends up 
being, all of a sudden, I am working for somebody else and now 
my patients are no longer my patients.
    And I think that is the main key, again, is the art of 
medicine. They are no longer my patients. So now, all of a 
sudden, I have got to do things that I may not find that are 
appropriate at least from my perspective. I have got to see so 
many patients an hour. I have got to do these things.
    And I think that is one of the challenges that you get into 
is that the grass is always greener on the other side.
    Mr. BEAN. That is exactly right, but it is a challenge.
    We--yesterday in a hearing put on by Chair Williams, we 
heard about the current administration, not just medicine but 
all, all small businesses, $375 billion in new compliance 
regulations. That is the cost.
    Are we seeing it, Dr. Brian? Are we seeing the States 
jumping in, too? Is it just----
    Dr. MILLER. Yeah.
    Mr. BEAN.--States getting in on this regulations action, 
too?
    Dr. MILLER. I think it is actually worse than all of what 
we are--it is actually really bad because the problem is every 
time we see a problem the healthcare policy, we design a 
static, regulatory, administrative, agency-driven solution. And 
then, a couple of years later, just like we heard about with 
surprise billing, that problem--that problem is still there. 
And the solution that we had is broken, and the solution is 
another administrative intervention.
    So what we are experiencing now with all these small 
practices leaving is we are seeing the cumulative effect of 30 
years of administrative, state-driven interventions in 
healthcare policy.
    And the problem is that when people design these solutions, 
they are thinking about a static market. They are designing a 
solution that is not dynamic and not flexible over time.
    Mr. BEAN. Very good.
    Madam Chair, without objection, the physical therapists, 
the physical therapists' association of America, APTA, have 
said: Please enter this in the record. The list, they have got 
two pages of bullet points where they are being overloaded.
    And, without objection, I would like to enter that in the 
record.
    Chairwoman VAN DUYNE. Without objection.
    Mr. BEAN. Thank you very much.
    Now some will say: It's great. It is great.
    In fact, let me go on to my last question. I was going to 
say: We--we like choice.
    Americans like choice. And, if we streamlined all 
professions, we lose that choice. So we have got to--this is 
our lightning round. I have only got a few seconds left.
    So, if we were to take out our Small Business lifesaver, 
what is an easy target we need to slash first?
    Dr. Henry.
    Dr. PUNZI. Actually it is going to be the issue of 
reimbursement.
    Mr. BEAN. Very good. Okay.
    Dr. Brian.
    Dr. MILLER. Quality regulations.
    Mr. BEAN. Very good.
    Dr. Matt, jump in.
    Mr. FIEDLER. I am actually going to go outside of 
administrative burden. It is how we pay hospitals when they buy 
up physician practices. We pay them a lot more.
    Mr. BEAN. Very good. Thank you so much.
    Madam Chair, so many questions, so little time.
    So I yield back to you.
    Chairwoman VAN DUYNE. Thank you very much.
    I now recognize Ms. Gluesenkamp Perez from Washington for 5 
minutes.
    Ms. GLUESENKAMP PEREZ. Thank you.
    And thank you to the Chairwoman and Ranking Member for 
holding this hearing.
    We have heard a lot today about the administrative burdens 
that exist for small, independent healthcare providers.
    I guess I would like to focus a little more on how that 
burden impacts particularly rural healthcare providers. Like we 
have seen just a real loss of our providers. We know that they 
are consolidating to bigger or leaving the market entirely.
    So, Mr. Fiedler, if you could explain how the closure of 
independent physician practices might particularly impact 
access for rural and underserved communities.
    Mr. FIEDLER. One of the things I think we know generally 
about administrative burdens is that there are economies of 
scale. And, obviously, if you are in a more rural area, taking 
advantage of those economies at scale is a lot harder.
    And so we would expect these burdens to fall harder on 
smaller practices no matter where they are located. But that is 
going to be a much more acute problem in a rural area relative 
to an urban area in practice.
    And in an urban area, you might end up with the variety of 
problems that come from the consolidation from a small practice 
that gets bought out; in a rural area, you might just end up 
with gaps where there is not care available at all.
    So I think those are respects in which it potentially bites 
a lot harder in that settling.
    Ms. GLUESENKAMP PEREZ. You look like you have something to 
say here.
    Dr. MILLER. Definitely. First of all, I am from Washington 
State. So I am very excited.
    I don't think that there are necessarily administrative 
scale efficiencies in most delivery systems. If anything, I see 
diseconomies of scale with administration where administration 
in large health systems or even moderate health systems just 
begets more administrators, more PowerPoints, more meetings, 
more committees to not actually solve clinical operational 
problems.
    I think it is even harder with regulations in rural areas 
because you are faced with quality regulations. You are faced 
with conditions of participation. Then you have to make sure 
you are in network for all these insurers, and then you have 
new telehealth regulations. And then and it is just like one 
thing after another.
    It makes it impossible to run a business, and so you sell 
out your business to the large health system down the street. 
This has happened in many rural areas. I practiced for a year 
in Cooperstown, New York, a village of 1,200 people with one 
stoplight. So, I know what it's like, and I think that we need 
to decrease regulatory burden so that rural healthcare can 
continue to exist.
    Ms. GLUESENKAMP PEREZ. I guess I am interested in hearing a 
little bit more about what it might look like to take out the 
merit-based incentive program. Yeah, you feel this is a need 
that is already met by other programs?
    Mr. FIEDLER. I think that we have other ways of 
incentivizing improved performance from physicians that 
actually are working in the Medicare program. A substantial 
fraction of Medicare physicians are now in accountable care 
organizations and other types of models where we actually do 
have clear evidence that those models are moving the needle at 
least in improving the efficiency of care and if not improving 
the quality of care.
    I think moving our focus away from MIPS, which is an 
administrative disaster but not really improving patient cares, 
towards these models that are improving care would be the 
direction I would want to move.
    Ms. GLUESENKAMP PEREZ. Uh-huh. I mean, it's striking. 
Right? We spend more and more on healthcare every year, and the 
quality of American health is the lowest. We are just not 
getting--we are not getting wellness out of this system.
    I guess I am curious to anyone who has insight what some of 
the biggest expenses are and how Congress can work to ensure 
smaller firms are able to stay competitive.
    Dr. PUNZI. So I think the biggest expense, as an individual 
practitioner, so I have got to do my rent. I have got to do my 
building maintenance. I have got to pay my employees. But then 
the issue ends up being reimbursement. So I have got to be able 
to make enough money to be able to do that and then maintain 
myself.
    So, if the practitioner is worried about when his next 
payroll is coming and am I getting enough money to do that and 
when you talk about the issue of patients, losing patients, 
then that ends up being a significant challenge for me as a 
small business.
    Ms. GLUESENKAMP PEREZ. So you are saying this is a cash 
flow, as well?
    Dr. PUNZI. Reimbursement. So, basically, we know that, as 
years have gone down, you mentioned that you have had a 
decrease in quality of care, but we have also had a decrease in 
Medicare reimbursement.
    So when I started back in 1984, I am getting paid less for 
Medicare patients now than I did almost 40 years ago.
    Ms. GLUESENKAMP PEREZ. Thank you all so much for your time 
and insight.
    Chairwoman VAN DUYNE. Thank you.
    I now recognize Mr. Crane from Arizona for 5 minutes.
    Mr. CRANE. Thank you, Madam Chairman--Chairwoman. Excuse 
me.
    I appreciate the opportunity to be here today and thank you 
for everybody that has come to testify.
    You know, when I listened to your testimonies, it sounds a 
lot like this place to me. The bureaucracy grows, more 
regulation, more red tape, and the focus is no longer where it 
should be on the very people we are supposed to be taking care 
of.
    Would you gentlemen say that that is accurate?
    Dr. PUNZI. I agree.
    Dr. MILLER. Yes, sir.
    Mr. CRANE. My question to start with is for all three of 
you. Is it possible in your opinion to shift back from this 
model that seems bent on consolidation, monopolization, topdown 
control, and back towards a healthcare system that is focused 
on our patients?
    Sir, we will start with you.
    Dr. PUNZI. I think we can. And, again, we go back to, as a 
small business, being able to survive and stay afloat. So I 
think that, if the issue of reimbursement really kind of 
improves, especially with the issue of CMS, I think that would 
be very helpful to allow individual physicians to stay in 
practice.
    Mr. CRANE. Mr. Miller, Dr. Miller.
    Dr. MILLER. Absolutely. We have to dive down into the deep 
regulatory weeds and sort of clean out the garden. We also have 
to look at sort of big-picture market dynamic questions like 
physician-owned hospitals and Stark Law.
    Mr. CRANE. Sir.
    Mr. FIEDLER. I think it is actually possible to make 
progress on these questions. I think part of that is reducing 
administrative burdens. I think part of that is addressing 
other problems in our system like the fact that if a hospital 
buys up the local physician practice, it can now charge more 
for those services than it could before, which is a powerful 
incentive pushing towards consolidation.
    Mr. CRANE. Dr. Miller, which--if--and Mr. Bean was talking 
about this a second ago. If you had to take this light saber 
that he referred to and start with the top three regulations 
that you would like to see slashed, what would those be?
    Dr. MILLER. The ban on physician-owned hospitals is number 
one. I would said CMS quality regulations in the fee-for-
service practice program is number two. And then the third, 
because you asked about--Mr. Bean asked--or Representative Bean 
asked about the State level--is certificate of need.
    Mr. CRANE. What about you, Dr. Punzi?
    Dr. PUNZI. Again, I think the regulatory burden from the 
prior authorizations, I think that is number one. Number two is 
the issue of reimbursement. And third is the issue also that we 
have to keep in mind as a physician, which is going to be 
medical liability.
    Mr. CRANE. Dr. Miller, I thought it was sad when you 
pointed out that that study that showed that only 15 percent of 
a doc's time is spent each day with their patients.
    Have you--how has that changed since you started 
practicing?
    Dr. MILLER. It has gotten worse. As a hospitalist, I refer 
to myself as a desk jockey because I spend most of my time 
typing. And, in fact, when I was a resident, one of my 
colleagues was already planning their retirement.
    Mr. CRANE. Wow. And you also said, sir, that you-all are 
now practicing to document and not practicing to treat 
patients. Is that correct?
    Dr. MILLER. Absolutely.
    Mr. CRANE. Do you feel the same way, Doc?
    Dr. PUNZI. Yes, sir, same way.
    Mr. CRANE. How do you think that that affects the accuracy 
at which you are able to treat your patients?
    Dr. PUNZI. Again, going back to my professor, medicine is 
an art and a science. And I think that the ability to be able 
to do a good history and physical, and if you look at the time 
constraints, we can't do that.
    As I tell my patient--as I tell my students, 80 percent of 
the diagnosis you can make by doing a good history and 
physical. And what that does is it allows me to identify what 
the problem is, take care of the patient at a much lower cost 
and within that one visit.
    Dr. MILLER. I was just going to say it means I have two 
jobs: One, the hospital gets paid for, which is the 
documentation, and that is how the system gets reimbursed; and 
the other is treating the patients. So it means I have to 
divide my time.
    Mr. CRANE. Thank you.
    Sir, would you like to comment on any of those question?
    Mr. FIEDLER. I agree. I think some of the quality reporting 
burdens are not generating value and are generating a lot of 
costs. So streamlining those, both in public programs and in 
private insurance, I think would be a high-value step.
    Mr. CRANE. Thank you. I yield back my time.
    Chairwoman VAN DUYNE. Thank you very much.
    I recognize Chairman Williams from the great State of Texas 
for 5 minutes.
    Mr. WILLIAMS. Thank you, Madam Chair.
    And I am interested in two things. First of all, Dr. 
Miller, have you been to the Hall of Fame?
    Dr. MILLER. I have not.
    Mr. WILLIAMS. You need to go, go with Beth Van Duyne. She 
is going up there. I played with the Atlanta Braves, but I am 
not in the Hall of Fame. Let that clear out.
    And also, listening to this testimony, back home in Texas--
I am a car dealer. I own car dealerships. And it is almost like 
we are in the same business. You know, I am fixing cars. You 
are fixing bodies.
    But I see that the same thing is happening in our 
industries: Margins are getting squeezed, more regulations, 
telling you what to charge. It is a disaster, and we need to 
fix it.
    And so, Dr. Miller, you are not only practicing medicine at 
Johns Hopkins, but you have extensive experience working for 
government agencies.
    As I am sure you are aware, when agencies pass regulations, 
they are supposed to be taking into account the impact on small 
business and take steps to lessen the additional burdens. Many 
times you hire somebody for compliance that has nothing to do 
with you--creating income for you.
    Now, on this Committee, we have been looking to how 
seriously agencies are taking this important responsibility to 
insulate small businesses from government overreach. And, 
unfortunately, it seems like many agencies are falling short.
    For example, earlier this year, we wrote a letter to the 
FTC about a rule that would have imposed significant new costs 
on eye doctors and hurt many small practitioners.
    So, Dr. Miller, a question. Given your past experience with 
government agencies--and you have talked some about this 
today--again, how do you think we can ensure agencies take 
their responsibility to lessen the impact on small business as 
they develop new regulations, understanding that less 
regulation means more margins, more service, better business?
    Dr. MILLER. I think aggressive, healthy, and intellectually 
curious oversight, especially of CMS. The rules are 2,000 pages 
long, and I think that that in and of itself says how 
challenging the space is.
    Mr. WILLIAMS. Well, you have heard today this past 
administration has imposed $375 billion worth of regulations on 
small businesses. And to take care of that is $220 million man-
hours. And we have got to fix that.
    So today small providers, like all small businesses, are 
facing significant economic challenges: Inflation--we know 
about that--supply chain issues; and labor shortage, to name 
only a few.
    And, unlike additional small businesses, however, small 
providers face an even heavier regulatory burden with distinct 
requirements to comply with Medicare, to comply with Medicaid, 
and private insurance companies, and all this while you are 
trying to provide quality to your patient, have a 
relationships, and foster meaningful physician-patient 
connections.
    So, Dr. Punzi, can you walk us through how challenging it 
is to balance these various demands on your practice? You have 
done that, but just remind us what a problem it is.
    Dr. PUNZI. So, again, the issue is right now--whenever you 
do a visit, just a regular visit, the average time is about 15 
minutes, of which 5 minutes is one complaint. And then in some 
clinics is one complaint per visit. In this study, they had six 
complaints, of which five 1-minute address. And, again, I have 
5 minutes here.
    And you can imagine, as I mentioned earlier, if I have a 
74-year-old patient that I have got to do a history on, it 
definitely ends up being challenging.
    The other thing, too, is the administrative burden that 
comes after you see the patient. Instead of identifying what is 
wrong with the patient, now you have got to go and try to 
document what you have just done in a timely manner. And then 
the issue also ends up being billing. So now you have got to 
send the billing, and then you may not get paid for 30 days, 60 
days, sometimes 90 days. So those are the big challenges that I 
identify in my practice.
    Mr. WILLIAMS. A lot of fix to this is competition.
    Dr. PUNZI. Yes.
    Mr. WILLIAMS. And whether it be my business or your 
business or your, it is competition. None of us shy away from 
that.
    Dr. PUNZI. Uh-huh.
    Mr. WILLIAMS. Competition will drive prices down, services 
up every time, won't it?
    Dr. PUNZI. Absolutely correct.
    Mr. WILLIAMS. Without government regulation.
    So my last question, Dr. Miller, the consolidation of 
healthcare practices is on the rise, and small providers are 
becoming rarer and rarer. In rural America--and I have a rural 
district, Fort Worth. You know where it is, out West. In rural 
America, oftentimes small providers are the only healthcare 
option.
    So what do you see, quickly, as the long-term consequences 
of this trend of consolidation continues? And how do you see 
telehealth potentially filling the void?
    Dr. MILLER. The answer is that folks will have to drive 3, 
4, 5 hours to see the doctor. Telehealth can help, but you 
can't--we are not technologically in a space where we can do 
remote surgery from 5 hours away. So that--the Star Wars/Star 
Trek world is probably about 40 years away. So we need to 
preserve rural options.
    I think looking at repealing the ban on physician-owned 
hospitals or looking at Stark Law to allow physicians to own 
integrated care delivery is a great potential solution.
    Mr. WILLIAMS. Free markets are--the start of business 
America is what the country was built on.
    Thank you all for coming.
    I yield back, Chairman.
    Chairwoman VAN DUYNE. We do have a little bit of time left. 
So I want to run through a second round of questions if anybody 
has them.
    When were you in Cooperstown?
    Dr. MILLER. 2013.
    Chairwoman VAN DUYNE. You have not--I actually--my dad did 
his internship and residency at Imogene Bassett Hospital in 
Cooperstown.
    Dr. MILLER. That is where I was.
    Chairwoman VAN DUYNE. So we were there for 3 years. It is a 
great community.
    I don't have any further question. I am going to ask you. I 
am going to give everybody an opportunity: Was there a request 
that you prepared for that was not asked today that you want 
to--I am just going to go down the line.
    Dr. PUNZI. I think, when you talk about rural healthcare, 
there is about 64 million patients that live in areas that are 
underserved. And two-thirds of the lack of physicians are in 
those particular areas.
    And, again, as you had mentioned, the issue of getting to a 
physician, they are talking about drive time. So I think that 
is challenging. Hospitals in that scenario, the turnover rate 
for staff is about 20 percent.
    So they have got many challenges, but the big thing is we 
have got to allow those patients to have access. And I think 
that physicians in private practice, in rural areas, if you 
make it attainable, if you make it viable from a financial 
point of view would definitely go a long way.
    Chairwoman VAN DUYNE. Excellent. Thank you.
    Dr. Miller.
    Dr. MILLER. I would say the biggest regulation that we 
haven't addressed is Stark Law or physicians' self-referral 
law. So, if I am an orthopedist and I work for MedStar Health 
as an employee, I can self-refer for an MRI or a physical 
therapist or whatever within the MedStar system. But, if a 
physician does that, that is statutorily prohibited.
    Stark Law is over--and rules are over 900 pages long. I 
know that because I fell asleep by the pool on vacation in 
Florida one year trying to get through it. And so I think that 
that is something that needs to be addressed, and taken apart 
to allow physician-owned-and-operated care delivery to compete 
fairly with these massive tax-exempt hospitals which have 
bought literally every part of the healthcare supply chain, 
from home care to ambulatory surgery centers to clinics to 
imaging centers to critical access hospitals to urban 
hospitals.
    We should allow physicians to compete fairly on an equal 
playing field.
    Chairwoman VAN DUYNE. Thank you.
    Mr. Fiedler.
    Mr. FIEDLER. As we talk about consolidation in the health 
care sector, I think one thing that is also driving that is 
that whoever buys up a bunch of physician practices can often 
charge a much higher price for the services than those 
practices were charging before. And so figuring out what the 
policy solutions are to that problem I think is a very real 
one.
    This may be a place actually where regulations has not been 
aggressive enough. I think antitrust enforcement in particular 
should probably be taking a more careful look at some of these 
types of combinations than it does today.
    Chairwoman VAN DUYNE. Thank you. I appreciate your 
testimony.
    I now recognize Ranking Member Mfume from Maryland for 5 
minutes.
    Mr. MFUME. Thank you mister--Madam Chair.
    Just a couple of quick things and I am going to ask both 
Dr. Miller and Dr. Fiedler to, if you can communicate back to 
the committee or to me, because it is going to require a longer 
response, and it is probably going to be a much more thoughtful 
subject that I am sure you would want to expand on.
    But beginning with you, Dr. Miller--and by the way, I am--I 
am glad that you indicated that your views are your own, and 
they don't represent Johns Hopkins or anybody else. Sometimes 
we get into a position where that is not always the case, and 
things leave out of this room that are not always factual.
    And, you know, I served as a trustee at Johns Hopkins over 
top of the hospital and the university for 12 years. And so I 
know there are a lot of different views and visions and 
positions. So I am glad that you indicated that yours today 
were your own thoughts on that matter.
    I want to talk about what I thought was an interesting 
comment you made about the fact that we don't design responses 
the way we should to problems, and I think you said that most 
of them are being designed as state-sponsored or static. Is 
that--did you use the word ``static''?
    Dr. MILLER. I used the word ``static,'' not ``state-
sponsored.''
    Mr. MFUME. Okay. Well, derived from a state activity or----
    Dr. MILLER. No. Static versus dynamic.
    Mr. MFUME. Okay.
    Dr. MILLER. Thinking about whether a system is changing 
over time versus a system in place.
    Mr. MFUME. Right. And you also said that the better systems 
would be the more dynamic and the flexible ones, as you just 
said, over time.
    If you could just write back briefly to the Committee your 
thoughts, lay out how that would--should look if we were going 
down that path and trying to create more dynamic and flexible 
policies and practices and approaches, it would be helpful. It 
really would, and I would appreciate it.
    And you also indicated that, as I think I--Mr. Punzi, you 
may have also--that more regulation was not the way to go. Am I 
paraphrasing correctly there?
    Dr. PUNZI. It is kind of like my patients. A lot of times 
what they do is they add more medication on top of other 
medication without identifying what the old medication was for. 
Patients end up on 12, 13 medications. And they don't know why.
    And I think, similar, regulations. We have got regulations 
on top of regulations, but we don't realize why the first one 
was done to begin with.
    Mr. MFUME. And we don't have regulations that regulate the 
bad regulations. That is really the bottom line. I don't know 
that it is the numerical difference. I think it is the fact 
that some of these have just come about over time and have 
never gone away and so they add to the overall aggregate 
number.
    Dr. Fiedler, can you explain on the other side of that how 
more regulation in health insurance space, in particular, could 
lead to better experiences for the population most affected? 
And, again, I am not advocating fewer regulations. I am 
advocating a consolidation or policing of the regulations that 
we have so that we can kind of get rid of the ones that are not 
working and, if we have to add good ones, then add them in.
    Mr. FIEDLER. Everything is about tradeoffs. And so we want 
the good, and we don't want the bad, and exactly as you are 
asking, how do we get there?
    And I think one of the ways to get rid of bad regulations 
is exactly the conversation we are having right now, bringing 
attention to these things.
    As a process matter, I think that is probably the most 
effective way is having people both inside of government and 
outside of government who are bringing attention to where the 
problems are and identifying them.
    I think the challenge is that, for any given regulation, 
there is someone who is on the losing side of it, even if 
consumers and other people are benefiting from that regulation.
    So I think one of the challenges in some of these debates, 
maybe less so in healthcare but in healthcare, as well, is 
there are lots of people who want to tell you that any 
regulation, including the good ones, are bad and costing them 
money, even when they are generating a lot of value.
    Mr. MFUME. Kind of like government programs. Once they get 
started, they just never go away, even if they are not 
effective.
    So I am going to ask, as I asked one of your colleagues 
here, if you can jot down some thoughts that further expand on 
that and could submit them back to the Committee, that would be 
great.
    Mr. FIEDLER. Thank you.
    Mr. MFUME. Thank you, Madam Chair.
    Chairwoman VAN DUYNE. Well, seeing no other further 
questions, I would like to thank our witnesses for their 
testimony and for appearing before us today.
    Without objection, Members have 5 legislative days to 
submit additional materials and written questions for the 
witnesses to the Chair, which will be forwarded to the 
witnesses. I ask the witnesses to please respond promptly.
    If there is no further business, without objection, the 
committee is adjourned.
    [Whereupon, at 10:45 a.m., the Subcommittee was adjourned.]


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