[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.] A P P E N D I X [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] [all]