Health care has an administrative crisis, with Anders Gilberg of MGMA

A new Medical Group Management Association (MGMA) report found that 95% of practices say the administrative and regulatory burden has increased over the past several years. Anders Gilberg, MGMA's senior vice president of government affairs, says the data tell a clear story about why.

In this episode, Gilberg joins Physicians Practice Managing Editor Keith Reynolds to walk through the biggest drivers, from the explosive growth of Medicare Advantage and its abusive prior authorization tactics to the persistent failure of the MIPS-to-APM transition that was supposed to have happened a decade ago. He explains why practices are now staffing three or more full-time administrative employees per physician just to manage payer requirements, and why a full 25% of all U.S. health care spending goes toward administrative burden, higher than anywhere else in the free world. 

Don’t miss our recent episodes on the legal risks of AI, CMS’ WISeR Model, fraud enforcement trends and medical device tariffs.

Music Credits:
Healing Breeze by Cephas - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:22 | Sponsor message Copic Medical Liability Insurance.

0:22 – 0:44 | Cold open Gilberg previews the episode's central stat: 25% of all U.S. health care spending goes toward administrative burden — higher than anywhere else in the free world.

0:44 – 1:40 | Introduction Austin Littrell introduces the episode and previews the conversation with Gilberg.

1:40 – 3:01 | Setting the stage: 95% Gilberg explains the MGMA regulatory burden report and confirms the headline finding: 95% of member practices say administrative and regulatory burden has increased in recent years.

3:01 – 5:07 | What's driving the surge Gilberg traces the growth of Medicare Advantage — now covering over half of all Medicare beneficiaries — as the primary culprit, bringing commercial insurer frustrations into what used to be a simpler government program. He also flags the 90% of practices reporting increased prior authorization burden, and the two-thirds still stuck in MIPS with no viable alternative.

5:07 – 7:07 | Is Medicare Advantage broken? Gilberg draws a distinction between Medicare Advantage as a model — which can enable innovative, patient-friendly care — and the commercial administration of Medicare Advantage, which has brought take-it-or-leave-it contracting, utilization review abuse, denials and audits to the top of MGMA's burden survey.

7:07 – 9:13 | What prior authorization actually looks like day to day Gilberg describes the real-world experience: delayed authorizations, denials, phone calls with clinicians who don't match the requesting specialty, and a patchwork of dozens of separate insurer portals — each with its own workflow — that practices must navigate simultaneously. He notes CMS is moving toward standardization, but the problem is nowhere near resolved.

9:13 – 11:00 | The cost in dollars and staff Gilberg puts a number on the problem: upward of three full-time administrative staff per physician, devoted entirely to prior authorization, audits and billing — while a full quarter of all U.S. health care spending goes to administrative overhead, the highest of any country in the free world.

11:00 – 12:20 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

12:20 – 13:56 | The WISeR model: a foot in the door Gilberg explains why the WISeR model — which introduces prior authorization into traditional Medicare across six states and 17 services — is alarming even for practices not yet affected. He notes the irony that CMS is simultaneously pushing for prior authorization standardization while rolling out WISeR on a separate, non-standardized portal. The concern: a slippery slope toward broader expansion.

13:56 – 15:54 | Why practices are still stuck in MIPS Gilberg explains the original promise of MIPS — a bridge to alternative payment models — and why it failed. Over a decade later, not a single APM has been produced by the Physician Technical Advisory Committee, leaving the vast majority of practices trapped in a reporting exercise that doesn't function as a meaningful quality improvement program.

15:54 – 17:33 | Burnout, access and the human cost 77% of MGMA members link regulatory burden directly to burnout. Gilberg explains what that means in practice: physicians retiring early, leaving rural communities, or moving into employed roles to escape the paperwork — leaving patients without access to care that can't easily be replaced.

17:33 – 19:19 | If Congress could do one thing Gilberg's answer: physician payment reform. Specifically, eliminating the tournament model in MIPS — which requires some physicians to be cut to fund quality bonuses for others — and aligning Medicare payments with inflation. He calls it an oldie but goodie that the system can no longer afford to delay.

19:19 – 20:50 | Closing remarks and outro Gilberg closes with a note of cautious optimism — hoping for progress on prior authorization and payment reform by year's end. Littrell thanks listeners and reminds the audience to subscribe and visit MedicalEconomics.com and PhysiciansPractice.com.