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76–486 2012

HEALTHCARE REALIGNMENT AND REGULATION: 

THE DEMISE OF SMALL AND SOLO PRACTICES? 

HEARING 

BEFORE THE

SUBCOMMITTEE ON INVESTIGATIONS, OVERSIGHT, 

AND REGULATION 

COMMITTEE ON SMALL BUSINESS 

UNITED STATES 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED TWELFTH CONGRESS 

SECOND SESSION 

HEARING HELD 

JULY 19, 2012 

Small Business Committee Document Number 112–080 

Available via the GPO Website: www.fdsys.gov 


emcdonald on DSK7TPTVN1PROD with HEARINGE:\Seals\Congress.#13
(II) 

HOUSE COMMITTEE ON SMALL BUSINESS 

SAM GRAVES, Missouri, Chairman 

ROSCOE BARTLETT, Maryland 

STEVE CHABOT, Ohio 

STEVE KING, Iowa 

MIKE COFFMAN, Colorado 

MICK MULVANEY, South Carolina 

SCOTT TIPTON, Colorado 

JEFF LANDRY, Louisiana 

JAIME HERRERA BEUTLER, Washington 

ALLEN WEST, Florida 

RENEE ELLMERS, North Carolina 

JOE WALSH, Illinois 

LOU BARLETTA, Pennsylvania 

RICHARD HANNA, New York 

ROBERT SCHILLING, Illinois 

NYDIA VELA ́ ZQUEZ, New York, Ranking Member 

KURT SCHRADER, Oregon 

MARK CRITZ, Pennsylvania 

JASON ALTMIRE, Pennsylvania 

YVETTE CLARKE, New York 

JUDY CHU, California 

DAVID CICILLINE, Rhode Island 

CEDRIC RICHMOND, Louisiana 

JANICE HAHN, California 

GARY PETERS, Michigan 

BILL OWENS, New York 

BILL KEATING, Massachusetts 

LORI SALLEY, Staff Director 

PAUL SASS, Deputy Staff Director 

BARRY PINELES, Chief Counsel 

MICHAEL DAY, Minority Staff Director 


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C O N T E N T S 

OPENING STATEMENTS 

Page 

Hon. Mike Coffman .................................................................................................. 1 

Hon. Kurt Schrader ................................................................................................. 2 

WITNESSES 

Mark Smith, President, Merritt Hawkins, Irving, TX .......................................... 2 

Louis F. McIntyre, M.D., Westchester Orthopedic Associates, White Plains 

Hospital Physicians, White Plains, NY .............................................................. 4 

Joseph M. Yasso, Jr, D.O., Heritage Physicians Group, Independence, MO ...... 6 

Jerry D. Kennett, M.D., F.A.C.C., Senior Partner, Missouri Cardiovascular 

Specialists, Vice President and Chief Medical Officer, Boone Hospital Center, Columbia MO ................................................................................................ 8 

APPENDIX 

Prepared Statements: 

Mark Smith, President, Merritt Hawkins, Irving, TX .................................. 29 

Louis F. McIntyre, M.D., Westchester Orthopedic Associates, White 

Plains Hospital Physicians, White Plains, NY ........................................... 35 

Joseph M. Yasso, Jr, D.O., Heritage Physicians Group, Independence, 

MO .................................................................................................................. 39 

Jerry D. Kennett, M.D., F.A.C.C., Senior Partner, Missouri Cardiovascular Specialists, Vice President and Chief Medical Officer, Boone 

Hospital Center, Columbia, MO .................................................................. 44 

Additional Materials for the Record: 

‘‘So Long, Marcus Welby: Obamacare, Market Kill the Solo Private Practice,’’ by Bruce Japsen, Forbes ..................................................................... 51 

‘‘Henninger: Obamacare’s Lost Tribe: Doctors,’’ by Daniel Henninger, The 

Wall Street Journal ...................................................................................... 55 

‘‘More Doctors Giving Up Private Practices,’’ by Gardiner Harris, The 

New York Times ............................................................................................ 58 

‘‘Is Private ObGyn Practice on its Way Out?’’ by Lucia DiVenere with 

OBG Management Senior Editor Janelle Yates, OBG Management ....... 64 

‘‘Demise of the Solo Doctor,’’ by Parija Kavilanz, CNN Money .................... 72 

‘‘A Small Business Plan All Can Agree On,’’ Chairman Sam Graves, 

POLITICO ..................................................................................................... 75 


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HEALTH CARE REALIGNMENT AND REGULATION: THE DEMISE OF SMALL AND SOLO 

MEDICAL PRACTICES? 

THURSDAY, JULY 19, 2012 

HOUSE OF REPRESENTATIVES

COMMITTEE ON SMALL BUSINESS, 

SUBCOMMITTEE ON INVESTIGATIONS, 

OVERSIGHT AND REGULATIONS

Washington, D.C. 

The Subcommittee met, pursuant to call, at 10:00 a.m., in Room 

2360, Rayburn House Office Building. Hon. Mike Coffman (chairman of the subcommittee) presiding. 

Present: Representatives Coffman, Tipton, Schrader, and Hahn. 

Chairman COFFMAN. Good morning. The meeting is called to 

order. I want to thank our witness list for being here today. We 

look forward to your testimony. 

Today, we meet to examine the changing landscape of small and 

sole position practices. For many years, newly-licensed physicians 

typically joined a private practice or open one of their own. According to Merritt Hawkins, a national physicians’ recruiting firm, 

whose president is testifying today, only 1 percent of its searches 

in 2011 were for independent practices, the lowest in the firm’s 28– 

year history and down from 22 percent in 2004. Many people believe that small and solo practices in order to survive, they will 

look very different than the medical practices in past years. These 

shifts appear to be rooted in the increasing economic pressures, 

younger physicians, they want freedom from the long hours and administrative burdens of owning a private practice and they need financial help with student loans, medical liability insurance, and 

health information technology. Established physicians have cited 

declining reimbursements and increasing regulations such as the 

reporting requirements for health information technology and the 

push towards accountable care organizations as reasons small and 

solo practices have become economically unsustainable. 

In a recent Wall Street Journal op-ed, Daniel Henninger described practicing medicine as a health care law’s biggest loser. We 

are interested in learning how all of these factors, including the requirement of the health care law which was upheld by the United 

States Supreme Court may affect small practices. 

We have an exceptional panel of witnesses to help us understand 

these issues. Welcome, we look forward to your testimony. 

Dr. Schrader, do you have any opening—— 


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Mr. SCHRADER. I will just submit mine for the record, Mr. Chairman. Thank you. 

Chairman COFFMAN. Thank you. 

The subcommittee members have an opening statement prepared 

and that is within the Senate for the record. I would like to take 

a moment to explain the timing lights to you. 

You will each have five minutes to deliver your testimony. The 

light will start off as green. When you have one minute remaining, 

the light will turn yellow. And, finally, it will turn red at the end 

of your five minutes. I ask that you try to adhere to the time limit. 

Our first witness today is Mark Smith, president of Merritt Hawkins in Irving, Texas, a leading physicians’ recruiting firm for 

small, independent practices, group practices, and hospitals. Mr. 

Smith has over 21 years of experience with Merritt Hawkins and 

is an expert in medical staff planning and physician staffing. He 

is a graduate of Oregon State University. Welcome. You have five 

minutes to present your testimony. 

STATEMENTS OF MARK SMITH, PRESIDENT, MERRITT HAWKINS; LOUIS F. MCINTYRE, M.D., WESTCHESTER ORTHOPEDIC ASSOCIATES, WHITE PLAINS HOSPITAL PHYSICIANS; 

JOSEPH M. YASSO, JR, D.O., HERITAGE PHYSICIANS GROUP; 

JERRY D. KENNETT, M.D., F.A.C.C., SENIOR PARTNER, MISSOURI CARDIOVASCULAR SPECIALISTS, VICE PRESIDENT 

AND CHIEF MEDICAL OFFICER, BOONE HOSPITAL CENTER 

STATEMENT OF MARK SMITH 

Mr. SMITH. Thank you. Mr. Chairman and distinguished subcommittee members, good morning. My name is Mark Smith and 

I am president of Merritt Hawkins Associates, the largest physician search consulting firm in the nation and a member of the 

AMN Health Care. 

In the course of my 22 years at Merritt Hawkins, I consulted 

with thousands of physician practices and my company has produced numerous white papers, surveys and books concerning physician practice pattern related topics. 

I appreciate the opportunity today to address the subcommittee 

on the decline of solo and small physician practices. 

For those who remember the ‘‘Marcus Welby, M.D.’’ nightly TV 

show, we still have an image in the mind of a physician as a small 

business owner running their own practice. This classic model of an 

independent physician practice still exists today, but is rapidly becoming a relic of a bygone era. 

Today, physicians are more likely to be employees than they are 

to be medical practice owners. This is particularly true of medical 

residents completing their training. In the 2011 survey of final-year 

medical residents by Merritt Hawkins, only 1 percent chose to be 

a solo private practice physician. By contrast, 60 percent said they 

would prefer to be either a hospital employee or work for another 

entity. In short, virtually no one wants to be a Marcus Welby anymore. This represents a fundamental transformation and structure 

of physician practices away from the classic private practice model 

and towards employment and an increasing number of other practice options. 


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The five primary reasons for this transformation taking place: 

flat or decline in reimbursement, growing regulatory and administrative burden, malpractice costs, information technology implementation, and the effects of health reform, both the legislative and 

evolutionary. 

First reimbursement. For today’s Marcus Welby, both Medicare 

and private insurers typically pay physicians for usual and customary charges. Physicians generally were paid for services 

invoiced in an amount above the cost of doing business. This system has been repeatedly modified in an effort to reduce cost and 

to manage care. Physician reimbursement in some cases has been 

cut or has not yet faced with inflation. 

As a result today, physicians see little connection between their 

costs and the amount to which they are reimbursed. This is a difficult business model to sustain. Some small private practices are 

having trouble keeping their doors open. There have even been reports in recent months of a growing number of practices going out 

of business, something I have not seen in my 24 years with this 

organization. 

By contrast, employment provides physicians safe harbor from 

today’s challenges and from the uncertainties that lie ahead. Regulatory burdens, virtually all businesses are subject to regulatory 

compliance of some kind. Medical practices are no different. As a 

small business owner, physicians must abide by Equal Opportunity 

and worker safety laws, state and local ordinances, and many other 

rules and regulations. Adding a layer of complexity, physicians 

must work in the most highly of all regulated professions, having 

to comply with HIPAA, stark laws, Medicare, and many other regulations. It is concerning to me that a survey conducted by Merritt 

Hawkins stated that physicians spend 26 percent of their time 

doing paperwork. Many physicians see employment as a way to escape the rising tide of risk and regulation and allow them to focus 

on patient care. 

Malpractice. Among the greatest cost of doing business, small 

business owners must pay for their own malpractice insurance, the 

cost of which could be debilitating. 

For example, the annual premium for malpractice in some parts 

of Florida for an obstetrician can exceed $160,000 a year. As malpractice rates remain high, the former becomes an attractive option 

to physicians, as employers typically pay for this benefit. 

For a variety of reasons, physicians are obliged to incorporate a 

growing level of information technology into their practice, particularly EMR or Electronic Medical Records. 

While the federal government has provided reimbursement funds 

for physicians to implement EMR, many still find it difficult due 

to a lack of time and available expertise. EMR implementation is 

the key example of resources, expertise, and time a small medical 

practice are being taxed in today’s increasingly complex medical environment. A growing number of physicians are embracing employment again as potential refuge from these challenging concerns. 

Health reform is a driver of a number of health care trends, including the decline of small, private practices. Health reform encourages the consolidation of physicians into larger entities to be 

economies of scale. 


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In addition, health reform promotes the formation of new delivery models such as Accountable Care Organizations or ACOs which 

depend upon hospital and physician alignment in the use of advanced information technology. ACOs are also risk-bearing entities 

and as such require a high level of administrative and business expertise and it is difficult for a solo and all practice physicians to 

participate in these models, which naturally lend themselves hospital employment for physicians. 

Combined, these factors with others have created conditions in 

which small, private practice is increasingly untenable. This model 

is only likely to survive in small, rural areas, where there are few 

physicians and even in these segments, physicians will need to affiliate with larger entities. Otherwise, physicians are likely to be 

employed by multi-physician groups like hospitals and the era of 

Marcus Welby will rapidly disappear into our rearview mirror. 

Thank you for the opportunity to address the subcommittee for 

examining the challenges facing America’s solo and small practice 

physician. 

Chairman COFFMAN. Thank you for your testimony. 

At this time, our next witness is Louis F. McIntyre, a medical 

doctor, a board-certified orthopedic surgeon practicing in White 

Plains, New York. Dr. McIntyre and his partners had operated a 

small practice since 1994, but in the fall of 2011, they sold their 

partnership to a hospital group and joined the hospital’s employees. 

He earned his medical degree from the New York Medical College 

at Valhalla. How do you say it? 

Mr. MCINTYRE. Valhalla. 

Chairman COFFMAN. Valhalla. 

Mr. MCINTYRE. Land of the gods. 

Chairman COFFMAN. Okay. Dr. McIntyre is a member of the 

American Association of Orthopedic Surgeons and is testifying 

today on their behalf. 

Welcome. You have five minutes to present your testimony. 

STATEMENT OF LOUIS F. MCINTYRE 

Mr. MCINTYRE. Thank you, Mr. Chairman and members of the 

committee to allow me to testify today and tell my little small practice story. 

I joined Westchester Orthopedics in 1994. The practice resided in 

a small office and we had a few employees and we wanted to grow 

the practice and improve the quality of care that we delivered. So, 

in 1995, we moved to a much larger office space, hired more physicians, free parking. Patients love free parking, and added more 

docs. 

The late 1990s brought two challenging trends: decreasing reimbursement and increasing business cost. We needed more employees to handle the clerical demands and by managed care and yearly 

malpractice premiums went from $40,000 to $110,000 per doctor 

from 1994 to 2011. As a small practice, we were unable to negotiate 

favorable rates because we did not have market share. We formed 

a network of orthopedic surgeons to try to change that, but we 

were unable to affect rates because of anti-trust concerns. 

To remain viable, we added more doctors in ancillary services 

and implemented an electronic medical record. Our total cost for 


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the EMR implementation was about $500,000, which represents 

about $100,000 per doctor. Initially, we saved some money with 

EMR, but over time, that was negated by the need to upgrade the 

system and hire data entry personnel. We built an ambulatory surgery center and acquired additional office space to build a physical 

therapy center to standardize the quality of the physical therapy 

that our patients received. 

When completely configured, we had just under 50 employees. 

All had health insurance, all had a generous profit-sharing plan, all 

had paid vacation and leave and sick leave. Patients appreciated 

the convenience of being able to receive all their musculoskeletal 

care in one coordinated and contiguous setting. 

The negative pressure on reimbursement, however, continued. 

The American Academy of Orthopedic Surgeons estimates that orthopedic surgeons with Medicare reimbursement revenue decreased 

28 percent in the last decade alone. Reimbursement from private 

payers has also fallen and practice costs, unfortunately, continue to 

rise. 

Laws recently passed by Congress have further stressed private 

practice. The American Recovery and Reinvestment Act mandated 

the adoption of EMR for all physicians serving Medicare patients. 

Even though we had previously implemented an EMR, the meaningful use criteria accompanying the regulations still represented a 

significant cost burden for us in terms of data collection and quality reporting rules. 

The Patient Protection and Affordable Care Act proposes new, 

complex risk-sharing methodologies that many small practices, if 

not most, will not be able to comply with. The combination of decreased reimbursement, increased reporting requirements, huge 

outlays for technological improvements, and uncertainty about future potential earnings are driving physicians to seek employed positions. Doctors know that they cannot meet all the demands 

placed upon them now and see patients at the same time. According to the AAOS, the employment of orthopedic surgeons by hospitals has increased 300 percent in the last 5 years. 

Last year, we decided to become hospital employees. This year, 

the other orthopedic group in our town also is going to become employees of the same hospital. The multi-specialty group next use, 

WESTMED, has 225 employee positions. Clearly, the employee 

model is winning in Westchester County. 

There are advantages for employee positions. Doctors have more 

financial security with a salary, they do not have to worry about 

losing money taking care of uninsured patients, they are free from 

dealing with some of the troublesome human resources and IT 

issues, but employment, however, significantly decreases physicians’ autonomy and infecting the care environment. Physicians are 

in a unique position to interact with patients on a daily basis and 

identify deficiencies in care. Physicians’ ability to advocate for patients is diminished by employment because they no longer manage 

the care environment. 

As more physicians seek employee positions, there will be a generation of physicians who will never experience private practice 

and the business of taking care of medicine. They will be unaware 

of the costs and management issues of providing care. 


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There is concern that an employed position will see less of a need 

to join medical specialty societies that have added great value to 

patient care. How these concerns will affect the profession is unknown at this time. 

In the future, I fear that physicians may unionize to protect their 

economic interest. I believe this would herald the end of medicine 

as a profession and the start of medicine as trade associations. 

It is rarely mentioned, but private practice employs people and 

pays taxes. A recent study conducted by the Medical Society for the 

State of New York showed that the private practice of medicine 

was the fifth largest employer in Westchester County, second in 

business establishments, third in personal income taxes paid, and 

seventh in corporate sales taxes paid. 

As a hospital employee, our practice is now tax-exempt. The loss 

of employment and tax revenue resulting from private practice 

physicians migrating to hospital employment may be significant 

and worthy of further study. 

Finally, there will not be employed positions for all the doctors 

in Westchester County or the United States. There is and will continue to be an increased need for physicians, especially with the 

implementation of PPACA in 2014. If private practice disappears, 

patient access to care, local employment, and tax revenue will suffer. We need to strengthen private practice as well as other models 

of health care delivery to ensure patient access to quality of care. 

Thank you for the opportunity to share these thoughts. 

Chairman COFFMAN. Thank you, Dr. McIntyre. 

Our next witness is Joseph Yasso, junior doctor of—— 

Mr. YASSO. Osteopathic medicine. 

Chairman COFFMAN. Osteopathic medicine, I am sorry. A boardcertified family physician, medical physician, and medical director 

of the Heritage Physicians Group in Independence, Missouri. He is 

a member of the American Osteopathic Association and is testifying today on their behalf. 

Welcome. You have five minutes to present your testimony. 

STATEMENT OF JOSEPH YASSO 

Mr. YASSO. Thank you. Chairman Coffman, Ranking Member 

Schrader, and members of the subcommittee, on behalf of the 

American Osteopathic Association, thank you for the opportunity to 

testify today. 

As a board-certified osteopathic family physician, I proudly treated patients for over 30 years. My current practice is comprised of 

three physicians, including myself and a family nurse practitioner. 

We are owned by the Hospital Corporation of America. 

Today, I am pleased to share with you my personal experience 

of how impactful health care realignment and regulations are upon 

decisions made by new and established physicians alike. 

After leaving the Army in 1980, I entered a small practice with 

two other physicians that we ultimately chose to sell in 1992, due 

to multiple financial and regulatory concerns similar to those my 

colleagues in practice are facing today. Today, physician practices 

face new demands as required by statute and regulation. These include the adoption of electronic health records and electronic prescribing systems, preparation for coding under ICD–10, implemenVerDate Mar 15 2010 09:06 Nov 16, 2012 Jkt 076486 PO 00000 Frm 00010 Fmt 6633 Sfmt 6602 E:\HR\OC\A486.XXX A486

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tation of quality measures, and adjusting to other changes in the 

health care delivery system. These additional policies and procedures are important and are primarily beneficial to efficiency as 

well as to providing improved patient care. However, each new requirement can be quite costly to the physician practice operating 

as a small business. 

The burden on small practices is particularly disproportionate, 

detracting from the time available for patient care. In addition, the 

looming physician payment cuts under the SGR for small practices 

with limited revenues and narrow margins to make difficult decisions about whether to lay off staff, reduce the Medicare patient 

population, defer investments, opt for early retirement, or sell their 

practice. My first small practice of three buckled to these concerns 

and we opted to sell. 

Today’s medical school graduates are faced with difficult decisions after completing their education and training. The average 

osteopathic medical school graduate has a debt nearing $200,000. 

As you can imagine, this makes the prospect of opening a small 

practice extremely daunting. 

This spring, the American College of Osteopathic Family Physicians conducted a survey of its membership, including questions related to practice types and settings. The survey found that 60 percent of family physicians are employees with no ownership stake 

in the practice. Often, the overwhelming collective burdens I mentioned today are cost prohibitive and outweigh a physician’s desire 

to enter or remain in a small or solo practice. There are also physicians who wholeheartedly embrace the choice of becoming an employee physician. Physicians should not be forced to enter an employed situation out of pure necessity. They should retain their option to choose their ideal practice type absent undue financial considerations and regulatory burdens. 

Medical homes and ACOs provide opportunities for physicians to 

continue managing patient care while still being able to operate as 

a small or solo practitioner. Either model requires a physician to 

be employed by a hospital or large health system in order to be 

successful. Appropriately aligned, incentives can serve to foster success regardless of practice type. Regulators should be cautious in 

creating additional financial burdens on physicians that would inhibit their ability to choose a practice setting that is most appropriate. 

In closing, the transformation of the practice of medicine has undoubtedly impacted the ability of physicians to thrive in a small 

practice or as solo practitioners. However, physicians are adapting 

to the changing practice of medicine by becoming patient-centered 

medical homes and participating in shared savings programs. As 

we work to improve the health care delivery system for patients, 

physicians must be provided appropriate payment and incentive to 

practice effectively in the setting of their choice. Patients deserve 

this level of access. 

I would again like to thank you and the members of the committee for affording me the opportunity to share my experiences 

and the AOA’s perspective regarding this important topic affecting 

osteopathic physicians and our patients. We appreciate the work 

that you do to promote policies that enable physicians to successVerDate Mar 15 2010 09:06 Nov 16, 2012 Jkt 076486 PO 00000 Frm 00011 Fmt 6633 Sfmt 6602 E:\HR\OC\A486.XXX A486

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fully operate as small business absent undue regulatory and financial burdens. We look forward to working with you in the weeks 

and months ahead to ensure that congressional action fosters rather than impedes the physician-patient relationship. 

Chairman COFFMAN. The Chair now yields to Dr. Schrader for 

the introduction of our next guest. 

Mr. SCHRADER. Thank you, Mr. Chairman. It is my pleasure to 

introduce Dr. Jerry Kennett. Dr. Kennett has practiced interventional cardiology in Missouri for the last 30 years as a senior 

partner of Missouri Cardiovascular Specialists and vice president 

and chief medical officer of the Boone Hospital Center. He has 

maintained a busy clinical schedule while also participating in a lot 

of clinical research in education. He is testifying today on behalf of 

American Academy of Cardiology. The college has 40,000 members 

and he has dedicated to enhancing people’s lives through cardiovascular treatment intervention. We welcome Dr. Kennett. 

STATEMENT OF JERRY KENNETT 

Mr. KENNETT. Good morning. Thank you, Member Schrader and 

Chairman Coffman and members of the subcommittee. We appreciate your inviting us to testify here today. 

I am Jerry Kennett, chairman of the American College of Cardiology Advocacy Steering Committee. The ACC, as said, is a 40,000- 

member medical society serving the needs of both providers and 

patients. 

I am a cardiologist with Missouri Cardiovascular Specialists, a 

17-person cardiology and cardiovascular surgery practice in Columbia, Missouri. 

My group was one of those typical office-based practices with 

over 100 employees. Our practice included a cardiac diagnostic center, where patients had easy access to echocardiograms, stress 

tests, and even an outpatient cardiac categorization laboratory. 

A little more than a year ago, our group was an independent 

practice, but now we are integrated with Boone Hospital Center in 

what is termed a professional service agreement. According to the 

2011 Lewin Group report on the economic impact of office-based 

physician practices, these small businesses, such as ours, account 

for 4 million jobs across the United States with $833 billion in 

wages and benefits. These small businesses generate $63 billion in 

state and local tax revenue. 

Physician practices are different from almost any other small 

businesses. The payment for services performed is not controlled by 

free market dynamics, but instead payment is tightly regulated by 

Medicare and Medicaid and private payers who essentially follow 

the lead of the government with the recipient of the services or patient often paying only a fraction of the cost. 

Recent events have had a dramatic effect on private practice cardiology. The ACC estimates that 60 to 70 percent of our current 

physician members have now integrated with hospitals. 

Why has this happened? There are a variety of factors that have 

contributed to this evolution. The prominent reasons relate to 

Medicare physician payment not keeping up with actual practice 

costs, direct cuts in Medicare physician reimbursement, and increased administrative and regulatory burdens. All these add up to 


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tremendous uncertainty among physicians as to what the future 

holds and so many physician practices such as mine see hospital 

integration as their only choice. 

Every year since 2002, physician practices have been threatened 

with significant cuts in Medicare reimbursement, the so-called 

SGR. This uncertainty stifles physician practices from making real 

investments in improving coordination, reducing the current fragmentation of care, and reducing waste. 

Another major turning point for cardiology occurred in 2010 with 

the Medicare Physician Fee Schedule, which reduced payments to 

cardiology practices or some in-office procedures as much as 35 percent. How many small businesses could survive a 35 percent cut in 

payment for the exact same service? Our practice, like many others, could not. 

There are also a significant number of regulatory and administrative burdens that contribute to the uncertainty for physician 

practices and hinder their ability to grow. A few examples are audits. While physician claims for services are generally subject to 

contractor medical review, greater scrutiny in recent years has increased costs and uncertainty. Physician claims must comply with 

multiple edits, as well as recovery audit contractors. 

ICD–10. The Center for Medicare and Medicaid Services will 

soon implement ICD–10, a diagnostic coding system that will increase the number of diagnosis a physician has to choose from 

15,000 to over 87,000. 

Multiple Medicare penalties. Starting in 2011, Medicare began to 

penalize physicians for not meeting the requirements of certain incentive programs. In the coming years, physicians will be penalized 

for not prescribing electronically, not participating in meaningful 

use of an electronic medical record, and not submitting quality data 

through the Physician Quality Reporting System, as well as a yetidentified value-based modifier. 

Finally, physicians have significant anxiety regarding the future 

of Medicare payment reform, as you have heard. The new payment 

methodologies, such as ACOs, bundled payments at medical homes 

will require additional staffing with no assurance they will produce 

any shared savings. Physicians are afraid of being left out. 

In conclusion, the financial pressures associated with declining 

reimbursements and rising operational costs on private cardiology 

practices have resulted in the rapid migration of practices to hospital affiliation. Continued cuts in Medicare reimbursement combined with increasing overhead costs, increased regulation, unfunded mandates, a micromanaged payment system, and an uncertain future are making it difficult for practices to remain viable. 

We believe that a well-functioning Medicare payment system could 

provide opportunities for physicians to practice both independently 

or as employees of a hospital. Increased payments should come 

from increased quality and demonstrate appropriate utilization and 

physicians should be appropriately paid for the increasing expectations associated with the practice of medicine. 

Thank you for the opportunity to share my views and look forward to any questions. 

Chairman COFFMAN. Thank you so much for your testimony. I 

really appreciate all of you taking the time to be here. Let me just 


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open it up with a few questions and then I will defer to my colleagues on the subcommittee. 

All of you had mentioned rising administrative costs as a factor 

in hurting solo and small practices. Back home in my district, I 

was just talking to a woman who is starting a new concept to help 

child care providers by simply doing their administrative work to 

back office work to allow them to focus on child care and her entity 

then focused on the administrative compliance. 

Is there any movement to assist small practices with these third 

party organizations? I know they have existed in say Medicaid, 

Medicare, but just in overall administrative work and all the compliance things that you have to do to—are there such entities 

emerging to relieve some of the cost pressures on small and solo 

practices? 

Mr. SMITH. There are businesses that have evolved to fill that 

need that exists with physicians, I mean, more of these administrative burdens placed on their shoulders and some can work quite 

well. In the new legislation, that intensifies greatly the changes, as 

mentioned, are very significant, but even if you are able to 

outsource that, it comes at a cost and it comes at a cost when you 

are looking at your revenues either being flat invests or declining. 

So, again, it opens up that option to make employment seem much 

more attractive as to transferring that burden to someone else. 

We mentioned in the survey that Merritt Hawkins had that 26 

percent of a physician’s time was in paperwork. And, so, in essence, 

you have a hidden army of about 200,000 physicians out there that 

are doing something other than they were trained. So, anything 

that we can do to relieve that burden outside of just the pure employment option that will allow them to focus on patients which I 

am sure that folks sitting at the table would much prefer to do 

than to do paperwork would be of great assistance. 

Chairman COFFMAN. Dr. McIntyre. 

Mr. MCINTYRE. My experience in our practice was that there 

were many entities that could help us with individual things. Billing. We outsourced billing. IT. We could outsource a lot of stuff to 

IT, but there was not any umbrella organization that would come 

in and say we will do it all for you. It sounds like a great business, 

actually. 

So, the hospital assumes all those tasks for you. I think that is 

what makes it attractive to many physicians who are just looking 

for a way out so that they can concentrate on patient care instead 

of regulatory burdens. 

Mr. YASSO. When we sold our practice in 1992, of course, we did 

not have the IT piece to worry about back I those days, but we 

were doing our own billing and managing the practice ourselves 

and doing quite well. 

When we sold to TriSource, they right away started charging us 

a $7,000 a month management fee and a $7,000 a month billing 

fee. That was $14,000 a month of overhead that we did not have 

before. So, all of a sudden, the practice that was in the black was 

now in the red because we had such a tight margin. And, so, if you 

do those kinds of things, that is the cost that you have to bear to 

get those things done. 


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Mr. KENNETT. In private practice, there are always consultants 

and companies that want to come in and do things for you. They 

say they can do it more efficient and better and usually that does 

not have to be the case, that usually the costs are as great as before. 

As you might imagine in these small businesses, the physician 

practices, they are so regulated and so many things we have to 

deal with that your overhead sometimes in small practices can be 

as much as 80 percent. So, it becomes overwhelming and that is 

one of the reasons that as mentioned they tend toward employment. 

Chairman COFFMAN. Most of you mentioned medical malpractice 

as an issue and the small or solo practice dissolving and moving 

into as employees or into a larger physicians’ group or employees 

of a hospital. But those costs do not change. Is it that just as a 

function of cash flow, as you got a small practice and there is a 

bump in cash flow and you have got this big overhead issue like 

paying your premiums on a medical malpractice policy, is that essentially the problem because I do not see where the costs are 

changing. They are very high, obviously, higher than they ought to 

be, but I do not see them materially changing from the individual 

from the small practice to a larger practice or as to employees of 

a hospital. 

Mr. MCINTYRE. Well, personally, my malpractice went from $40,000 a year in 1994 to $110,000 in 2010. We paid that and at 

one time, we had 7 orthopedic surgeons, almost a million dollars 

in malpractice premiums per year. That was a big number. 

Human resources, obviously, was the single most expensive item 

in our budget, but right below that was malpractice and it really 

became a burden to pay the malpractice, so much so that we shifted from doing it in quarterly payments to shifting to monthly payments. It was really a cash flow burden for us. 

Going to the hospital, the hospital assumes that cost. We do not 

see that cost at all and many of the hospitals are self-insured in 

regards to malpractice. 

Chairman COFFMAN. Okay. 

Mr. MCINTYRE. So, that may affect the rates, but my personal experience, my hospital now is paying my malpractice premium for 

the policy that I have. Now, I would imagine at some point in time, 

that is going to be subsumed by their own malpractice policy. 

Chairman COFFMAN. Okay. Does anybody else have any—— 

Mr. SMITH. Well, just keep in mind that with these physicians, 

since Dr. McIntyre joined the hospital-based practice, the hospital 

loses money. There is not a true savings that occurs from him coming over. They typically lose money on these practices, but the hospital has to have physicians in the community. They really have no 

choice but to bear that potential loss. 

Chairman COFFMAN. But is it cheaper if a larger entity can be 

self-insured and manage its own liability or do these hospitals still 

carry third party insurance? 

Mr. YASSO. Well, Hospital Corporation of America in the metropolitan area of Kansas City employs over 250 physicians. I would 

think they get a bit of the economy of scale—— 

Chairman COFFMAN. Okay. 


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Mr. YASSO [continuing]. To some degree if they stick with one insurer and probably get a rate break to some degree. 

Chairman COFFMAN. In looking at the new health care law, the 

Affordable Care Act, there is a movement I think borne of that to 

accountable care organizations. So, there has been a trend prior 

certainly to the Health Care Act, a movement away as you all have 

tried from the solo practice, the small physicians’ group to larger 

practices and to employees at hospitals. How has the current 

health care law or has it accelerated by that process? 

Mr. SMITH. There is no question it has accelerated that process. 

It had the fear of the unknown and I think a lot of wait and see, 

see what would happen from the Supreme Court’s decision. It has 

picked up the pace quite a bit. I would say as ACOs come closer, 

hospitals realize there is bundle payments looking for partners. At 

the same time, you see insurance companies not wanting to be left 

out as you have seen with Highmark in Pennsylvania buying hospital systems. So, there is a bit of a race for that finish line and 

physicians might experience running for cover because of the intensity of the penalties within the system. 

Some information we could provide is there is so much more regulation and the penalties are so great, I find physicians very fearful 

that they will make an honest mistake and being held accountable 

financially. 

Mr. KENNETT. Speaking from my administrative side, I would 

say that probably the health care law has accelerated more on the 

part of the hospitals probably more so than physicians because of 

the fact of the Accountable Care Organizations, the bundle payments, and measures in there that the hospitals want to be sure 

they have enough primary care physicians particularly as well as 

specialists that they can have in their Accountable Care Organizations to being able to participate. I think it has brought about some 

acceleration on the part of physicians just because of uncertainty, 

but as you mentioned, so many of these thing we talked about actually predated the Affordable Care Act. 

Chairman COFFMAN. Sure. I am going to ask one more question 

and then defer to Dr. Schrader and but then I will come back probably and we will go back and forth. Oh, and I am sorry, Ms. Hahn, 

as well, from California. And that is that you talked about the patient-doctor relationship being compromised, if you will, through 

the movement of the solo or small group practice to the larger 

group practice or to employees of a hospital. I wonder if you could 

all elaborate on that and please be specific in terms of examples 

of how you think that changes the patient-doctor relationship, this 

movement. 

Mr. YASSO. I think that one of the ways it change that, when you 

become an employed physician for particularly those physicians 

that come directly out of residency and become employed physicians and have never practiced in solo practice or owned their own 

business, it is more of a business now and it is I work for X number of dollars and I work X number of hours a week and that is 

all I do. I may not stay a little longer to say Ms. Jones, let us work 

her in or see that extra patient because they want to be seen, they 

need to be seen that day and do that. And you hear stories about 

that all the time about how physicians tend to cut it off and say 


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well, I used to see 30 a day. Well, now I see 26 a day or I see 22 

a day and those types of things and it is a problem, I think. 

Mr. MCINTYRE. My practice is two miles from my house, and, so, 

I take care of the people that live in my community. My reputation 

is predicated upon how I do that. So, not only was I very concerned 

about being a good physician, but running a good small business 

in my community. And what I said before in the testimony was 

that I had great ability to affect the atmosphere and the business 

that was there because I ran it. So, if things were brought to my 

attention by patients or staff or whatever, that we were deficient 

in that area, well, you can be sure that we changed that. Now, I 

am really not responsible for the policies of the practice; the hospital is. So, I am a little bit hamstrung in my ability to affect those 

policies. 

Yesterday, a patient came in. Supposedly, one of our doctors was 

not on the insurance panel because the hospital had not gotten us 

all on the various insurance plans yet and the patient was told 

well, you cannot see the doctor that you have seen for 10 years. If 

I were running the practice we would just have seen the patient 

and dealt with the insurance issues later. So, I think that when 

you are vested in your practice as a physician and also as a business man or woman, that lends a whole different color to the way 

you approach it. 

Mr. KENNETT. I might differ slightly because of the fact that I 

do not think being employed has changed my physician-patient relationship. I think I feel the same about my patients as I always 

have in the past 30 years. There is a lot of regulatory and reimbursement issues that have affected relationships because we cannot provide the services we used to provide. That is a real concern. 

And, quite honestly, there is an evolution in medicine that is going 

to change physician-patient relationships in the fact that we now 

have intensivists, we have hospitalists, we have an nocturnist, we 

have shift medicine, and that is what the younger physicians like 

in many instances. And, so, that is changing the physician-patient 

relationship. 

Mr. SMITH. I would add quickly the difference to me, the patient 

is access. Today, we have a shortage of physicians in many parts 

of the country and surveys I have read had shown that employed 

physicians, the risk off the table, they are no longer business owners, see about 7 percent fewer patients and this is at a time we already have a shortage and we are looking to add 30 million people 

for this process. To me, that is a great concern. 

Chairman COFFMAN. Dr. Schrader. 

Mr. SCHRADER. Thank you, Mr. Chairman. Well, thank the panel 

as I guess retired, small business. Been a practitioner for 35 years, 

started my own business from scratch when you could do that sort 

of thing. My humble opinion, much as had been stated here, I 

mean, that is almost impossible to do. I do not care what sort of 

medical practice you are into. I mean, the tax law has gotten byzantine. I actually did my own tax returns when I started my practice. It was actually doable and I felt like I was not committing— 

and the regulatory burden, and certainly those in the medical profession, with all the different regulatory frameworks come out, the 

SGR has been a sword of Damocles hanging over every physician’s 


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head, I do not care who you are, for many years. Sometimes we 

treat it almost cavalierly here in D.C. because we ‘‘never let it happen,’’ but it is still there and it is still disrespectful, I think, of the 

hard work that folks put in. It makes it pretty tough. It makes it 

pretty tough. 

The debt burden now that youngsters came out with, I mean, 

gosh, my tuition, I am embarrassed to say, graduated college a few 

years ago, like $700. Students would kill themselves to do that 

now. I am a dinosaur, but not that much of a dinosaur. 

But the other thing I think the panel has alluded to a little bit 

that did not get brought out is there is a change in attitude among 

the young people. I do not care, and this is not just the medical 

profession, I see this in a lot of my other business friends and associates where the idea of starting a risk-based enterprise, well, there 

are lots of great entrepreneurs in our great country, thank goodness, and that is what is going to make and continue to make our 

country great. In some professions, they are a little less more risk 

diverse for a lot of the reasons you all have just enunciated here. 

It seems almost daunting for these people with the debt they come 

out with, the regulatory burden that is out there, the uncertainty, 

and I will grant that the ACA does create some uncertainty out 

there. It is one of many issues I think face our medical community. 

I would like to get some thoughts about potential solutions going 

forward here. So, I guess one main question I would ask the panel 

here is of the many things you have talked about today from taxes 

to debt, SGR to other regulatory burdens, ICD–10 codes, some of 

the aspects of the ACA, what is the single most or one or top two 

burdens that we should talk about trying to eliminate or change 

and make less burdensome for you guys to get it back to the practice of medicine that we all do so well? 

Mr. KENNETT. So, Congressman, I think that, to me, without a 

doubt, the biggest thing you can do is to eliminate the SGR and 

have a stable platform for physician payment that is fair for the 

appropriate service that they are providing going forward so that 

the physician is on a yearly, monthly sometimes basis, do not know 

what the payment is going to be next year and do not know if their 

claims are going to be held and they have to go borrow money to 

make payroll. So, taking care of the Medicare physician payment 

platform going forward would be a huge step forward. 

Debt, I think, is a very big issue for these kids coming out of 

school today or residency. If we could find a way to either help 

them defer their debt for a while so they have the opportunity to 

go into private practice or if we could find a way, particularly if 

they go into underserved areas and take care of people that truly 

need help, to eliminate their debt so that they can stay in practice 

and stay in areas where people truly need their service. 

Mr. SCHRADER. Very good. Thank you. 

Dr. McIntyre. 

Mr. MCINTYRE. I think as a philosophy, we might want to inject 

some market principles into the physician-patient relationship and 

have providers compete not only on quality issues, but also on price 

issues, which we have not done in decades. I think that might go 

a long way to decreasing costs and increasing quality. If we decide 

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tice, we need to allow private practitioners to band together to negotiate rates without owners’ overhead structures so that they can 

compete with what is becoming monopsony. We have the big medicine, big insurance, and the government, and with consolidation, I 

do not think we are going to get the cost containment we need. I 

think we need more players in the market to do that and facilitating private practice’s ability to negotiate, I think might go a long 

way to contain cost and increase quality. 

Secondly, I think malpractice tort reform will go a long way to 

decreasing the costs not only of private practice, but of medicine in 

general. 

And, lastly, especially with the SGR being such a problem and 

being so expensive and the problems in trying to eliminate it as 

well as deal with Medicare reimbursement cuts that are supposed 

to go through the ACA, perhaps, we might want to think about 

bringing back balanced billing to the Medicare equation that was 

part of the program for the first 20 years of its existence. And I 

think it could be done in a way that would not hurt seniors, but 

would allow private practice to continue to serve Medicare patients. 

Mr. SCHRADER. Mr. Smith. 

Mr. SMITH. Oh, I agree with all three topics mentioned: SGR, 

medical debt, something we hear on a daily basis from the folks 

that we are talking to, and tort reform. I would add to tort reform 

that the impact goes beyond the malpractice. The cost of defensive 

medicine is something that has been calculated in incredible numbers, where physicians are forced, they feel, to protect themselves 

by doing additional tests under normal circumstances they might 

not do. So, that cost is significant. 

The other thing I would mention is to relax some of the regulations that are in Stark II as it implies to recruiting physicians in 

the community. Being a solo practitioner is near impossible. If you 

can get a partner or two partners, you have a chance. Unfortunately, stipulations in Stark II make it difficult because you cannot 

share any of your costs. You have to bear that burden of the cost 

that exists to bring a new associate in and most physicians cannot 

go through that year process to wait for that new person to contribute to their overhead to be able to afford to bring them in. So, 

that would be a real benefit. 

Mr. SCHRADER. Very good. Very good. 

Dr. Yasso, you talked about medical home, and I thought about 

this myself, as maybe being a way to get back to where the physician is ultimately in control, one of the things that is in the ACA 

that maybe needs to be fleshed out more. There was some loan forgiveness over a period of time for new students and that we tried 

to give a little better deal for primary care docs that actually opted 

to go into some sort of—in particular will do that, but primary 

care. 

But I thought that maybe the medical home, and everyone has 

alluded to this. I mean, the doctors have to be in charge of decisionmaking, not the hospital, not the insurance company, not the outfit 

you would hire to run all your books and stuff and can you elaborate a little bit about what would you be looking for, how would 

you be talking to CMS about how to organize this so the docs are 

in control? 


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Mr. YASSO. Well, I think the PCMH is set up in such a fashion 

that it is under the control of the physician. It is a collaborative 

approach to medicine and a team approach where everybody is involved in the care of the patient. That includes the medical assistants in your office, your nursing staff, even the front office staff for 

that matter. Everybody is involved in the care of that patient rather than—an even footing to a degree and things are done for the 

patient by everyone, not just the physician, not just the nurse, but 

everybody gets involved in the care. That is the whole idea behind 

the patient-centered medical home. And then you develop relationships as a primary care physician, you develop relationships with 

specialists that you know are going to provide quality care for your 

patients and you deal with those people and you discuss the care 

so that you know what kind of care that individual is receiving that 

is the best possible care that they can get. 

If you take that a step further and you look at the Accountable 

Care Organizations, I was talking to a physician yesterday who 

practices in the Phoenix area and they have been very successful 

in setting up an ACO down there that is driven by primary care. 

It is not driven by the hospital, it is not driven by the specialist, 

it is driven by primary care, which seems to be very cost effective 

and providing good, quality care. 

So, I think two things. We need to keep in mind when we talk 

about ACOs in particular is they need to be driven by physicians, 

not the hospital. My concern when I first started hearing about 

ACOs was that they were something akin to the old PHOs, Physician Hospital Organizations, which for all intents and purposes 

was driven by the hospitals and that is what we really need to 

avoid because the care, the rubber that meets the road is where the 

patient sees the doctor and that is where the care is delivered. It 

is not by the hospital per se on a daily basis. So, the physicians 

really need to be in control of that. 

Mr. SCHRADER. Dr. Kennett. 

Mr. KENNETT. Just would like to make just two additional comments about medical homes. The first is medical homes, as Dr. 

Yasso said, requires some additional resources within your office. 

People teaching dieticians. So, we have to be sure that they are reimbursed adequately that they are going to be able to provide those 

additional resources. 

And the second is that the medical home needs to be assigned 

to whoever actually should be in control of that patient’s care on 

a regular basis. If that is a patient that is on dialysis, then really 

the nephrologist probably ought to be their medical home, it is the 

patient that has got chronic congestive heart failure, then probably 

a cardiologist. There is a huge majority that should be in the hands 

of the primary care physicians, but it needs to encompass all these 

other specialties, as well. 

Mr. SCHRADER. Just a final comment then, Mr. Chairman. I really appreciate this panel and the topic we are discussing. It is near 

and dear to my heart and very concerned about the future of medicine from all walks of life. 

As a little, old, country veterinarian, I enjoy the opportunity to 

get to know my patients, see them from birth to their passing. It 

is a beautiful thing. But I rely on the specialists. I think we have 


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got a great relationship in the veterinary world where we are not 

afraid to send it out. In the old days, it used to be keep everything 

pretty close and the medicine has changed. Hopefully, physicians, 

veterinarians, and other practitioners of all sorts have come to that 

realization and we will work through that. 

I guess my last point would be that I hope each and every one 

of you are active in making sure that whatever comes out of health 

care evolution, whether it is related to ACA or anything else, that 

some of us are pushing to reform the SGR, this bill out there I am 

cosponsoring with Allyson Schwartz and others to get rid of the 

SGR and get to a smarter level playing field. She is actually like 

a part of the solution and not just a part of the whipping child that 

is out there at the end of the day. But, hopefully, it will be a good 

process, a better process at least going forward and I appreciate 

the Chair bringing this issue to Small Business’ attention. Thank 

you, sir. 

Chairman COFFMAN. Thank you, Dr. Schrader. 

Ms. Hahn from California, and I will relax the five-minute rule. 

Ms. HAHN. Thank you, Chairman Coffman, Ranking Member, Dr. 

Schrader. 

I want to thank the Chairman for holding this hearing. Really 

appreciate the witnesses that are here today, all of you who are involved in some aspect of health care and getting folks healthy. We 

really do appreciate what you are doing. 

It is interesting because, I mean, I know the more Affordable 

Care Act is implemented and this lifestyle, I think a lot of the 

issues as I understand that you brought up today are actually addressed in this new law. 

Loan repayments. There is a lot about helping students repay 

their loans or forgive their loans, particularly if they serve in areas 

that have seen a shortage, talked about, Mr. Smith, the shortage 

of physicians. There is actually a lot in the health care act about 

providing incentives and scholarships to encourage more doctors, 

physician assistants, folks to go into this field. 

I agree with Dr. Schrader, there are many of us who want to 

have a permanent doc fix and I hope we do that in Congress with 

the SGR. 

This is a small business committee, so, it is really interesting to 

hear your views as it relates to being a small business person. I 

am wondering how much training did you get, how much are students in medical school actually getting business training, would be 

partnering with business schools and medical schools. And, again, 

I am always trying to figure out what our Small Business Administration is doing to help small businesses. Is there a better role? Is 

there any role? What is Small Business Administration doing as it 

particularly relates to physicians who are attempting to run a 

small business and what can we do better to help that aspect so 

that—it sounds like we would like to ultimately see more doctors 

continue to be in the role of being a small business owner. 

Mr. MCINTYRE. Training would be zero. On-the-job training 

would be zero. We learned it on the fly. And many of my colleagues 

who I interact with in the regulatory arena have gone on to get 

MBAs. I know a boatload of orthopedic surgeons, MBAs. So, there 


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are a number of people who are doing that. But in terms of the Joe 

lunch bucket doctor, I think that the training is pretty much zero. 

Ms. HAHN. So, in medical school, there is no sense that it could 

be an important part of your success as a doctor who wants to be 

also a small business man? 

Mr. YASSO. Some of the schools, my alma mater being one, offers 

an MBA degree, but not to everybody. They keep it to a very small 

number of students that can get involved in that. So, there is some, 

but as far as any kind of formal training for everybody else or even 

just basic business courses, no. There really is not. 

As far as what can you all do, promote some of the things we 

talked about, I guess, and some of the things that you mentioned 

that are in the Affordable Care Act that might be helpful to make 

sure that those things come to fruition. If they are unfunded mandates, they do not do us any good. So, that is really the key to see 

that some of those things come out and really give us what we 

need to promote people to at least consider going into solo practice 

or small practices. 

Mr. KENNETT. Congresswoman, I would say that certainty going 

forward is what these small businesses need and that relates to 

what we said. Reimbursement, knowing what you are going to get 

paid down the road, and reducing the regulatory burden, which is 

huge. If you could help those two, they would have a lot more businesses staying in practice. 

Ms. HAHN. I am going to follow-up because the Affordable Care 

law also aims to reduce paperwork and administrative costs by 

standardizing billing, and between 2013 and 2016, the rules will be 

implemented to standardize health insurance processing requirements. 

Mr. Smith, you worked on this Merritt Hawkins whitepaper 

where ‘‘Physician practices should benefit from improved revenue 

cycles and save time and money tracking claims.’’ So, I am thinking 

since these rules are not finalized yet, maybe this is an opportunity. Your whitepaper suggests that this is a potential cost savings. So, while we are considering these rules, what should we be 

keeping in mind to maximize these potential cost savings within 

this particular realm? 

Mr. SMITH. Well, anything we can do to keep it as simple as possible would be a plus, which obviously we solve the depth and the 

weight of Affordable Care Act to just pay for a loan and people are 

just really digesting all the areas and attempting to refine some of 

those areas. And to lessen the penalties in certain areas where 

things are unknown. There is an example of which if there is a 

whistleblower situation, the Medicare can suspend payment to the 

physician for that whistleblower act if verified. So, in essence, you 

could have a disgruntled employee who makes a claim, Medicare 

suspends payment to the physician, and it’s over. And I would bet 

that three physicians on this panel, if you had zero Medicare revenue from guilty to proven innocent could crush any of their practices and several examples like that, again, unintended consequences. 

Ms. HAHN. Thank you very much. 

Mr. MCINTYRE. I think that to standardize the billing process as 

you alluded to in the ACA would go a long way. For example, MediVerDate Mar 15 2010 09:06 Nov 16, 2012 Jkt 076486 PO 00000 Frm 00022 Fmt 6633 Sfmt 6602 E:\HR\OC\A486.XXX A486

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care is about 23 percent of our business, but was our most prompt 

payer. We could anticipate Medicare reimbursement within 18 days 

of the bill being sent out as long as it was a clean claim. 

Managed care companies on the other hand, had an average AR 

timeframe of 45 days. And we got much more runaround and hassle from the managed care companies in regards to them saying a 

claim was not clean, them wanting more information. 

So, a standardization of that process, I think, would go a long 

way to help the private practice. 

Mr. KENNETT. Congresswoman, I can give you one quick example 

of one of the regulatory things that happened to physicians that 

make no sense. So, the rack auditors, which I am sure you are 

probably familiar with that can go in and take money back from 

hospitals for whether the patient inpatient or outpatient. So, now, 

a patient can be in the hospital and just because there are some 

regulations of you tell them that they are inpatient or you call it 

inpatient or outpatient, same exact service is provided in the hospital, but then the rack auditor comes in and says no, they should 

have been called outpatient. They can take back the physician’s reimbursement any services that are provided during that hospitalization. It really makes no sense. 

Ms. HAHN. Thank you. 

Mr. MCINTYRE. So, there is one additional program, too, the 

Medicare Administrative Contractors, which is also retroactively 

denying services for lack of paperwork. For example, in orthopedics, the MAC are denying payment for total joint replacements 

unless there is documentation of unsuccessful treatment with physical therapy for three months prior to the procedure. Not only is 

this very costly but there is nothing in the literature that supports 

that such treatment is efficacious. In addition, the rules of these 

programs are unknown and they are enacted retroactively, making 

them impossible to comply with. This really will affect patient care 

negatively. 

Chairman COFFMAN. Thank you, Ms. Hahn. 

The Chair recognizes Mr. Tipton of Colorado. 

Mr. TIPTON. Thank you, Mr. Chairman, and I apologize for being 

late. We had a natural resources meeting, as well. So, I sent your 

regards to that meeting. I know you could not be there because of 

here. 

I would like to thank our panel for being here. Incredibly important issue, particularly for districts like mine, rural Colorado, 

54,000 square miles, and as I have traveled through those 54,000 

square miles, just held a town hall meeting with senior citizens in 

Pueblo, Colorado, last week, they are worried about the president’s 

health care mandate and how it is going to impact them. I have 

got senior citizens in Del Norte, Mono Vista, Alamosa, Cortez, 

Crawford, Hodgkiss, Edgar, some towns a lot of people have not 

even heard of, they cannot find a doctor that is willing to take 

Medicare. 

So, I guess, Mr. Smith, I would like to be able to start with you. 

With a number of small business and a lot of our doctors are small 

business people, solo practices, what effects will the president’s 

health care mandate have on rural Americans, rural citizens’ access to health care in your perception? 


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Mr. SMITH. My perception, the impact I look at first is of the patient. As you mentioned, very difficult as a patient. A new patient, 

physician practice, could be seen if you have Medicare, especially 

if you have Medicare without any kind of gap insurance. A physician has to limit the amount of Medicare that they see in their 

practice to be financially viable. If you have pure financial to procure practice, it is not viable. The reimbursements are too low to 

be able to do that. 

Most physicians that I work with, we conduct about 3,000 

searches a year around the country so we have an excellent of information will tell me that Medicare rates, they generally break 

even as a cost of doing business. So, you have to keep that to onethird of your practice. 

Some specialists, such as internal medicine, you might get it to 

half, but you cannot have that happen. You see physicians as they 

get older, their patients get older, and more and more Medicare 

and you can look at their financials and they slowly dwindle until 

such a day that the decision is I am working for free, I have to get 

out of practice. 

So, now, as we look at this, we have patients that could come 

onto the system, was going to pay Medicaid rates and we are elevating them to Medicare, thinking that is going to be a driver for 

physicians to see them. One, that is a temporary rate. Two, it is 

not a factor and those patients, 30 million people we are adding to 

the system, will have a card that gives them insurance or a version 

thereof. What they will not have is access. 

The second expense, the legislation does address some areas of 

need, attracting people to the system. The shifting of unfilled primary care spots, that really is resulting in a few hundred positions, 

but the issue is we can add as many people as we want to the medical schools, but we have not added a single dollar as it comes to 

residency. And, so, all you will be doing is shifting foreign positions 

out of the system and replacing them with American-trained physicians, but at the end of the day, there is the same number of physicians coming out of the machine and in places like Russia and 

Trinidad and Serbia will still not be able to find a doctor because 

there will be more attractive options in large states. 

Mr. TIPTON. If we could, Mr. Smith, I would like to explore that 

a little bit because you were focusing a little bit on the economic—— 

Mr. SMITH. Okay. 

Mr. TIPTON. From the doctor’s perspective—the majority of doctors I know actually went into health care because they truly care 

about people. They are going to limit the number of patients that 

they can see simply because they want to be able to provide quality 

health care. If you are trying to run them through like an assembly 

line, is that going to reduce the quality of health care? 

Mr. SMITH. Well, there is no doubt. I mean, the physician-patient 

relationship is the most critical thing we can talk about and the 

colleagues here, I am sure, would completely agree with that. But 

the only choice is to do more and I would bet that each of these 

physicians here see a few more patients each year to be able to 

make their practice viable. Not so much as just financial reward, 

but just to make it a viable business that employees will be able 


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to count on and you want income, but the patient will be left on 

the sideline. 

Mr. TIPTON. You just mentioned doctor-patient relationship. We 

should not be getting between that, but if there is going to be a 

medical decision that is to be made, let us have the family patient 

doctor do that in the doctor’s office. Do you have some concern 

about the IPAB Board? 

Mr. SMITH. Well, yes, to answer your question. We have seen this 

in other countries. We have seen some of the impact it has had. 

I saw recently in Europe where epidural injections were taken off 

the list of care to be provided, other decisions that are being made, 

but in each of these decisions that you see along the way, the majority of these decisions are made without physicians involved. We 

speak to thousands of physicians on a monthly basis, and I have 

yet to find any of the ones that had the lab coat that were on the 

front line during these conversations. But anything we can do, it 

has to come down to the physician-patient relationship. 

Mr. TIPTON. Dr. Yasso, I saw your head nodding. Would you like 

to make a comment on that? 

Mr. YASSO. I would agree and the American Osteopathic Association adamantly opposes the IPAB. We think that is just wrongheaded for no other way to say it. 

The other thing that is concerning to me in regards to Medicare, 

as Mr. Smith said, you are almost getting to a point where you are 

just barely breaking even as far as reimbursement is concerned. 

What happens in the next 10 years when they cut $500 billion out 

of Medicare because of ACA? Does anybody know? I mean, obviously, reimbursement is going to take a hit. It has to take a hit. 

I do not see how else you are going to reach that number. 

Mr. TIPTON. Excellent point, and Dr. McIntyre, maybe you would 

like to jump in a little bit on this because I think Mr. Smith said 

it very well. We can insure everyone in the country, but there is 

a quantitative difference between insure and health care. Two completely different things. And if we are wanting to be able to get at 

health care, are you seeing a real problem with the president’s 

health care mandate when it gets down to actual delivery of health 

care? 

And I am speaking primarily for rural America, rural Colorado. 

I know some of our metropolitan areas have an abundance of doctors and specialties, but let us talk about rural America. 

Mr. MCINTYRE. I do not know that a mandate in itself creates an 

access issue. I think the access issue is really driven more by reimbursement level. So, if your reimbursement level falls below the 

level of your ability to deliver the care—— 

Mr. TIPTON. But the reimbursement level is actually via the 

mandate. That is part of the program. 

Mr. MCINTYRE. Well, my understanding of the ACA is that it 

does cut $500 billion out of Medicare—— 

Mr. TIPTON. Five hundred seventy-five billion. 

Mr. MCINTYRE. Over 10 years and does fail to correct the SGR, which is another $300 billion. So, I think that is the access issue. 

I think I certainly have a philosophical and constitutional issue 

with the mandate myself personally, but, perhaps, I am not sophisticated enough to realize how it will impact access other than the 


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issues we spoke of. It is possible to provide someone with insurance, but if that insurance does not pay costs, then you are basically uninsured. 

For example, if you put people on Medicaid, I think it is something like 40 percent of all physicians will not accept the Medicaid 

patient because the reimbursement is so low and I believe my understanding of the ACA is that by 2019, Medicare rates will be 

around what Medicaid reimbursements are now. So, I think that 

is a huge issue and a potentially devastating one for access to care 

for Medicare patients going forward. 

Mr. TIPTON. So, effectively, our senior citizens, people who have 

run the race are walking in the door with their Medicaid card, putting it on the table, it is insurance and they are not able to get a 

doctor. 

Mr. MCINTYRE. I think you could definitely see that problem. 

Mr. TIPTON. That is a real challenge. 

Mr. Smith. 

Mr. SMITH. To add to it, one of the things that my firm does, we 

do studies on wait times. How long does it take to get to see a physician? An unintended outcome that we discovered was the greatest 

increase in wait times of any metropolitan market was Boston and 

the difference between what occurred between our first wait time 

survey and our second was the implementation of universal health 

care. 

So, a place that I think any of our colleagues would probably 

have the most physicians, the most training programs, the environment you would not expect to have that issue are having that 

issue. So, if that is happening in Boston, what is going to happen? 

I do not think that is a difficult question to ask. 

Mr. TIPTON. Right. 

Dr. McIntyre, maybe if you would like to, we have got to be able 

to address some of the accessibility. Every American, I think that 

we can all agree, we want affordability, accessibility. The president’s health care mandate fails on both accounts. 

What can we do? What should be done to be able to increase the 

number of physicians that are going to be able to get into some of 

these rural areas to be able to provide that access to health care? 

Mr. MCINTYRE. In answering a similar question, I thought perhaps injecting a market-based solution to this problem would go a 

long way to improving quality, decreasing costs, and improving access. I think if the patients have some skin in the game, then they 

are more likely to seek health care that is of quality to them. If 

somebody is paying for their health care, especially if it is first dollar coverage, they are less likely to become shoppers, they are less 

likely to search for quality. They are much more likely to search 

for volume. 

So, I think in the current situation, we have a volume-driven 

process that is going to be exacerbated by the health care law instead of one where we will be looking for quality. 

The health care law does attempt to impose quality on the system through comparative effectiveness research and on other 

things, but that is sort of a top-down approach. 

Mr. TIPTON. Ultimately, and I would just kind of like to get your 

thoughts on this, original CBO estimates on the president’s health 


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care mandate stated it was going to cost $900 billion. In the White 

House, there was dancing in the hallways over that number. I am 

a small business guy and I know $1 billion is a lot of money. CBO 

just rescored this. It is going to be $1 trillion and $787 billion. With 

administrative costs, we are going over $2 trillion. Is there a better way to be able to spend $2 trillion? 

Mr. KENNETT. Congressman, if I could, I would like to just comment a little bit on before and then this question, as well, and that 

is that if we are going to increase access, we have to be able to pay 

for it. And, so, that is a concern. We have to appropriately pay physicians for the services they perform. So, if we are going to reduce 

costs within the system, I think if you get any larger number of 

physicians in a room and talk about how we are going to reduce 

costs, that you will come to the issue of utilization. 

And, so, the American College of Cardiology for years has been 

working on the perfect use criteria and our registries and I think 

that we as a profession are going to have to look at the appropriate 

utilization and cut out the utilization that is inappropriate and 

that could save possibly as much as one-third of what we are 

spending right now on health care. 

Mr. TIPTON. Would tort reform be a good idea? 

Mr. YASSO. Absolutely, and I was going to just mention that. The 

patient comes in with back pain, let us say, and you may send 

them for X-rays of their back, let us say low back pain. They come 

back and they say well, doc, you gave me some medicine, it really 

did not help, I still have the back pain. And the next thing you 

know, you are ordering an MRI. Why do you do that? Is it because 

it is really a necessary test or is it because you are worried about 

the liability of the situation? Am I missing something? Is there 

something else going on here that I will pick up with the MRI? And 

you are thinking about the legality of the situation more than you 

are—is this really appropriate care for the patient? And medical liability is what is perceived a lot of times and I think that is really 

true in the ER setting. You wonder how much money is spent needlessly in the emergency room on CTs of the head, stress tests for 

chest pain, all those kinds of things where they may not necessarily be needed. 

Mr. TIPTON. I mean, I thought it was curious that the administration and the 111th Congress, we are in the 112th, would not 

even consider tort reform because I have actually held meetings 

with physicians. I just met with about 24 physicians over in Brentwood, Colorado. Tort reform came up as one of the number one cost 

drivers and it is fear factor that if the patient is not totally forthcoming and you did not catch it, you can be sued. We have got to 

be able to bring some common sense into that portion of the equation, as well. So, certainly thank our panel for taking the time to 

be able to be here. We would love to be able to hear more from you. 

This is about affordability, it is about accessibility, and as I travel 

through rural Colorado in my district, I am talking senior citizens 

right now who are frightened about what the consequences are 

going to be to their health care going forward as we continue to see 

the president’s health care mandate put into place and I think 

maybe we should have started with you at the very beginning, talk 

to the physicians before they started writing a 2,000-plus-page bill 


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that many of them did not read, yet passed, and Minority Leader 

Pelosi was correct. She said we will find out what is in it once it 

has passed, and, unfortunately, that discovery is still continuing. 

We are seeing increased costs, increased control, and reduced access to health care in this country. Thank you for coming in today. 

I yield back, Mr. Chairman. 

Chairman COFFMAN. Thank you, Mr. Tipton. I have got a few 

other questions. I want to make sure that we have everything done 

on record. 

Dr. Yasso and Dr. Kennett, in your written testimony, you both 

mentioned a burden of complying with statutory and regulatory requirements, particularly electronic health records, electronic prescribing, and physician quality of reporting, which will carry significant penalties for non-compliance in future years. 

Would you elaborate on how these burdens disproportionately 

impact a small or solo practice physician’s time and revenue? 

Mr. YASSO. I have a friend that practices in Kansas City and has 

a predominately Medicaid practice. She has chosen to date not to 

implement the electronic health record because of the expense. I 

mean, she is barely breaking even paying her help, taking a salary, 

and those types of things and she is a very altruistic person and 

she wants to take care of her patient population, but she cannot 

afford—and even though the government says well, we will reimburse you if you put in a system that is compatible or I forget what 

the terminology is for that, but, anyway, she has made the decision 

that in 2014, she is going to retire. And the community is going to 

lose one darn good doctor because of that. And it is those types of 

things. It is just a heavy burden in situations like that and it takes 

good people out of the practice of medicine. 

Mr. KENNETT. With our group of physicians, there were only 11 at the time, we spent about $700,000 on electronic health record 

and you do not recoup very much. On an ongoing basis, you had 

that expense of maintaining it on a regular basis and the other bad 

part of that, when you first institute an electronic health record, 

actually it reduces your productivity pretty dramatically for the 

first six months or so and then you come back, but you are never 

going to get back to where you were before. 

So, you are going to have to have electronic health record to demonstrate meaningful use, and if you do not, you get penalized for 

all your Medicare, funds will be cut—you are not participating in 

meaningful use and you are not e-prescribing, and it goes on and 

on. So, that is one of the drivers to hospitals is because the hospital 

can better afford—they still had to lower costs involved, yet they 

can better afford to absorb those costs in the small physician practices. 

Chairman COFFMAN. Mr. Smith, your testimony mentioned the 

high cost of malpractice insurance. Do you think malpractice reform will help a small practice physician to shoulder the burden 

and how so? 

Mr. SMITH. Well, I think if tort reform would be part of the legislation, you would have seen a much greater acceptance of the physicians of this legislation, of the changes that were coming, but we 

have seen in states that apply tort reform, that it is a significant 

cost savings to the physicians and, of course, what I mentioned beVerDate Mar 15 2010 09:06 Nov 16, 2012 Jkt 076486 PO 00000 Frm 00028 Fmt 6633 Sfmt 6602 E:\HR\OC\A486.XXX A486

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fore, the cost of defensive medicine, which is an intangible cost that 

is significant, would be impacted, as well. 

Chairman COFFMAN. Dr. McIntyre, some health care mandates, 

such as the reporting requirements for health information technology and establishing Accountable Care Organizations are first 

instituting with ‘‘incentive payments,’’ but involved penalties later. 

Do you think that the inability to comply with mandates may be 

contributing to the disappearance of small medical practice? 

Mr. MCINTYRE. The short answer is yes. We implemented an 

electronic medical record in 2002. So, we were early adopters. Totally, we spent $500,000, which was about $100,000 per doctor. We 

initially saw some savings because we were able to get rid of file 

clerks and paper costs and transcription costs, but going forward 

with upgrades and having to hire new staff to enter data, those 

cost savings went away. So, basically, it’s a huge cost for a small 

business. The HITECH Act leaves physicians $44,000 over 5 years 

to implement a record as long as they comply with meaningful use. 

So, that would not even cover half of our investment per doctor. 

In addition, the quality reporting in much of the act is very difficult to comply with because the quality reporting criteria have 

been developed by National Quality Forum and places like that of 

the I think it is 44 quality measures, only 3 of them apply to orthopedics at all. So, we were trying to fish around for what we are 

going to start reporting on to comply with the mandate. Asking 

people about looking at things sometimes had nothing to do with 

what they were seeing us for. We have to report those things, even 

though they are not in the scope of our practice, just because of the 

reporting regulations. 

Chairman COFFMAN. Dr. Kennett. 

Mr. KENNETT. Chairman Coffman, I will just give you a quick 

personal anecdote about tort reforms. Missouri has a tort reform 

law with a cap on non-income damages of $350,000. So, my insurance says an interventional cardiologist dropped from $35,000 to 

$14,000. 

Chairman COFFMAN. Right, okay. 

Mr. Tipton. 

Mr. TIPTON. Thank you, Mr. Chairman. I just did have one follow-up question. 

Dr. McIntyre, you had brought it to mind and it is not in regards 

to the electronic medical records, but going back to Medicare, being 

able to fill out compliance forms to be able to get paid. 

Has it been your experience many in all of your professions—I 

talked to a good family practice doc in my hometown, finally just 

pretty much quit simply out of frustration from the standpoint that 

they had moving bars when it came to being able to fill out the 

forms, make sure they filled in the right dots, and it was constantly 

changing. 

Have you written any analysis in terms of the costs, how much 

you were spending rather than spending time with patients, you 

are paying people to be filling out more records when it comes to 

Medicare? 

Mr. MCINTYRE. Well, certainly, our costs in general increased significantly to the point where they were about 80 percent of revenue 

for our clinical practice. We had other portions of the practice that 


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had a lower overhead figure but even with those figured in, our 

total overhead cost was about 63 percent, but that had increased 

hugely since the earlier part of the 1990s. We never culled out 

Medicare specifically to analyze the cost just for Medicare patients, 

but overall, it increased tremendously. When I started, we had one 

billing person. When I left, we had six. When I started, we had one 

person to do pre-certifications and things like that. When we sold 

the practice, we had one person per physician. So, all these things 

added up over time. 

Mr. TIPTON. I am sorry, I apologize for interrupting, but just so 

that I am clear on that, you did not mean you were seeing more 

patients, that you were putting out more bills, it was just compliance? 

Mr. MCINTYRE. Right, just compliance, correct. 

Mr. TIPTON. Just strictly compliance. 

Mr. MCINTYRE. We did have to ramp up volume, too, because we 

could not—— 

Mr. TIPTON. Pay for it. 

Mr. MCINTYRE. Since we were getting a set fee, the only way 

for—there are two ways for a private practice to increase income 

in a set-fee market and that is to see more volume or to add ancillary services. You can decrease costs, but the quality of your service suffers to the point where you are not worth going to see. 

Chairman COFFMAN. Dr. Kennett. 

Mr. KENNETT. Congressman, I would just say that I hope CMS 

is not listening or the Department of Justice, but if on a regular 

basis a physician actually read all the documents which you are 

supposed to sign every day, it would add hours to your day. There 

is no way. You have reams of documents that you go through every 

day you sign your signature on, whether it is home health or hospice or Medicare documentation, it is huge; there is just no way 

you can actually read it all. 

Mr. YASSO. When I first started in private practice in 1980, there 

were three of us, three physicians, and we had four people working 

for us, two in the front office, two in the back, and that was it and 

we did just fine. Today, with four providers, three physicians, one 

nurse practitioner, we have an office manager, four people working 

in the front office, and four people working in the back office. So, 

I mean, realizing we have got one more provider than we did 30 

years ago, but, still, all this regulation and all the things that we 

need to do, the precertification of everything, you just have to have 

more bodies. You cannot get by without them. 

Mr. TIPTON. It is no consolation, but in this country, businesses 

are paying $1 trillion 750 billion per year on just regulatory compliance. Small businesses are paying $10,685 per employee in regulatory compliance. We all know there needs to be some regulations, 

but I think we have certainly seen an overreach in the complexity 

that is inhibiting the very important work that I know you physicians in particular want to do, and that is to be able to provide 

quality health care at an affordable price. So, thank you. 

Thank you, Mr. Chairman. I yield back. 

Chairman COFFMAN. Thank you. 


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Dr. Yasso, I have got a question. Do you think small or solo practices may survive, but only if they fill a particular niche such as 

concierge care? 

Mr. YASSO. I think that could be the way that this goes. I have 

a friend of mine that has started a concierge practice, at least part 

of what he does. He does not do 100 percent of that yet, although, 

he may very well move into that direction at some point in time. 

It is my understanding that you see a lot of that and Mr. Smith 

could speak to that, I am sure, on the east and the west coast and 

I am sure that eventually, that is going to move towards us. It only 

makes sense from the private practitioner if he wants to stay private that he does something like that because now he controls his 

income. It is not controlled by the government, it is not controlled 

by any regulator, he controls his income and that makes sense. 

Mr. SMITH. I would like to just simply with that, because concierge medicine, people think of it as the billionaire’s medicine, the 

doctor follows them around, and that does exist, but if you were a 

primary care provider in solo practice, you are going to have three 

to four employees, you are going to have 50 to 70 percent overhead 

costs, and you are questioning what do you do? Do I join a hospital? If you can today become a concierge physician, you can take 

that panel, which could be as low as 2,500, 4,000 patients and if 

you had 500 of them agree to pay you $50 a month and you would 

see them just in their office and take care of all their needs, you 

would make about 20 percent more money than you made the other 

way. So, you can survive, but from a small business perspective, 

you would trim your staff one or two people. So, very lean and 

those are good-paying jobs, jobs that we hear talk about our health 

insurance, a big part of the opportunity, but these are smart individuals, they will find a way to adapt and coming off the grid and 

doing that is one way. 

And the second thing I would keep in mind is what if you are not one of the 2,500 that can afford the $50 a month? So, we have 

taken that FTE from a full position down to about 15 to 20 percent 

of an FTE and in environment we already have a supply challenge. 

Chairman COFFMAN. My final question involves seniors, seniors 

on Medicare, seniors in my district and across the country. And 

seniors on basic Medicare had a very challenging time, an increasingly difficult time finding physicians that will see them and with 

the Independent Payment Advisory Board that will be fully online 

I think in 2015 according to the Affordable Care Act, is that not 

going to make this situation all that much worse when the new 

way of controlling spending is to have this 15-member board control spending through restricting reimbursement levels. It seems 

essential, that is how we are controlling spending in the Medicare 

system. And, so, I wondered if any of you have any comments on 

where you see senior care going under Medicare. 

Mr. MCINTYRE. In addition, I believe that the IPAB not only is 

tasked with cutting costs significantly, but also with maintaining 

access at the same time. So, I do not know how they can do that. 

And I do not know how central planning is going to be able to affect a fair reduction or program, especially without any input from 

anyone. I believe there is no input from physicians, there is no 

input from the Congress, they basically just give Congress a report 


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and Congress can accept it or not. Currently, at least now, we have 

some input to our reimbursement via some certain committees of 

the AMA. That will go away with the IPAB. 

Mr. KENNETT. Certainly, the environment we are in where there 

is uncertainty on Medicare reimbursement, seniors are going to 

have increasing difficulty getting access, you are exactly right. I 

think we all here could agree that the IPAB is not a good thing 

and it is really not a good thing and that the only people that they 

are going to cut between now and 2019 are providers. 

And, so, the good news is I think that the current congressional 

environment, it seems very unlikely you are going to get 15 people 

to approve by the Senate to be on the board, so, it is not going to 

be implemented. 

Mr. SMITH. And I would argue that they are regulating and controlling prices for services in large—because they cannot get access. 

Chairman COFFMAN. Did anyone have any further comments? 

Well, thank you, all, for participating today. I ask unanimous 

consent that the following articles be admitted to the hearing 

record. A New York Times article dated March 25, 2012, entitled 

‘‘More Doctors Giving Up Private Practices,’’ a CNNMoney article 

dated July 11, 2012, entitled ‘‘The Mind of a Solo Doctor,’’ a Wall 

Street op-ed dated July 5, 2012, entitled ‘‘Obama Care’s Lost Tribe: 

Doctors,’’ a Forbes article dated July 2, 2012, entitled ‘‘So Long 

Marcus Welby: Obama Care, Market Kill the Solo Private Practice.’’ 

Without objection, so ordered. I ask unanimous consent that 

members submit statements and supporting materials for the 

record. Without objection, so ordered. 

This hearing is now adjourned. Thank you very much for your 

testimony. 

[Whereupon, at 11:33 a.m., the Subcommittee was adjourned.] 


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71 


emcdonald on DSK7TPTVN1PROD with HEARINGInsert graphic folio 118 76486A.043
72 


emcdonald on DSK7TPTVN1PROD with HEARINGInsert graphic folio 119 76486A.044
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emcdonald on DSK7TPTVN1PROD with HEARINGInsert graphic folio 120 76486A.045
74 


emcdonald on DSK7TPTVN1PROD with HEARINGInsert graphic folio 121 76486A.046
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emcdonald on DSK7TPTVN1PROD with HEARINGInsert graphic folio 122 76486A.047