Posted by: John S Kiernan

Doctors are among the highest-paid and most educated professionals in the U.S. Just consider the fact that “physician” is the most popular profession within the top 1 percent of earners. And the high salary average makes sense, given the importance of their life-saving work and the struggles that come with life in the medical profession.

But doctors don’t always start out wealthy. The average medical-school graduate left campus with more than $190,000 of debt in 2017. The medical profession has also been undergoing intense transformation in recent years. Health-care reform, the rise of branded hospital networks and the retirement of Baby Boomers are all complicating the lives of doctors.

But working conditions for doctors aren’t the same everywhere in the U.S. In order to help doctors decide where to practice, WalletHub compared the 50 states and the District of Columbia across 16 key metrics. Our data set ranges from average annual wage of physicians to hospitals per capita to quality of public hospital system. Check out the complete ranking, additional expert commentary and a full description of our methodology below.

1. Main Findings
2. Ask the Experts: The Future of the Medical Profession
3. Methodology

Main Findings

Embed on your website<iframe src="//d2e70e9yced57e.cloudfront.net/wallethub/embed/11376/doctors-geochart1.html" width="556" height="347" frameBorder="0" scrolling="no"></iframe> <div style="width:556px;font-size:12px;color:#888;">Source: <a href="https://ift.tt/2pHJfgI>  

Best States to Practice Medicine

Overall Rank	State	Total Score	‘Opportunity & Competition’ Rank	‘Medical Environment’ Rank
1	South Dakota	75.97	3	1
2	Nebraska	70.66	7	3
3	Idaho	70.64	1	17
4	Iowa	70.16	2	16
5	Minnesota	69.94	9	4
6	Wisconsin	69.84	6	7
7	Kansas	68.86	8	9
8	Montana	68.01	5	13
9	North Dakota	65.19	14	11
10	Wyoming	64.88	4	35
11	Alabama	62.50	11	31
12	Mississippi	62.24	10	43
13	Arizona	62.10	12	32
14	Colorado	61.95	18	12
15	Tennessee	61.77	16	24
16	Utah	60.92	17	20
17	Maine	60.70	32	2
18	South Carolina	60.25	19	21
19	Washington	58.59	20	26
20	Georgia	58.31	22	22
21	West Virginia	58.24	13	45
22	Nevada	57.40	15	47
23	Arkansas	56.99	25	25
24	North Carolina	56.86	35	8
25	Indiana	56.82	27	23
26	Alaska	56.37	39	5
27	Louisiana	56.11	21	37
28	Texas	55.55	33	14
29	New Mexico	54.16	24	40
30	Florida	54.08	29	34
31	Missouri	53.90	26	38
32	Pennsylvania	53.25	31	36
33	Kentucky	53.07	23	46
34	Vermont	52.93	42	6
35	Michigan	52.83	36	27
36	Oklahoma	52.53	34	28
37	New Hampshire	52.32	28	44
38	Virginia	51.05	40	29
39	Delaware	49.03	37	39
40	Ohio	48.99	38	42
41	Connecticut	48.94	44	15
42	Illinois	48.86	30	51
43	California	47.82	46	18
44	Maryland	47.82	41	41
45	Oregon	47.71	47	19
46	Massachusetts	46.59	43	33
47	District of Columbia	45.75	51	10
48	Hawaii	43.25	50	30
49	New York	41.39	49	48
50	Rhode Island	40.86	45	50
51	New Jersey	40.24	48	49

 

Ask the Experts: The Future of the Medical Profession

Medicine is changing rapidly, and the way it is taught and practiced has to change too. The industry faces an aging population, new regulations and technological breakthroughs. With that in mind, we asked a panel of experts the following key questions:

1. What are the biggest issues facing doctors today?
2. How do state and local policies influence the lives of doctors and other medical professionals?
3. What tips can you offer current medical students about what specialty to pursue and where to practice?
4. To what extent does the threat of a malpractice lawsuit affect doctors’ ability to do their job?
5. In evaluating the best states for doctors, what are the top five indicators?
6. Taken altogether, has the ACA proven to be a net positive or net negative for physicians?

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• Daniel Skinner Assistant Professor of Health Policy in the Heritage College of Osteopathic Medicine at Ohio University
• Fahd Ahmad Instructor in Pediatrics in the Division of Pediatric Emergency Medicine at Washington University School of Medicine in St. Louis & St. Louis Children’s Hospital
• Howard P. Forman Professor of Diagnostic Radiology, Public Health, Economics & Management and Director of the YSPH Health Care Management Program at Yale University
• Adam Wilk Assistant Professor of Health Policy and Management in the Rollins School of Public Health at Emory University
• Arthur Garson, Jr. Director of the Texas Medical Center Health Policy Institute

Daniel Skinner Assistant Professor of Health Policy in the Heritage College of Osteopathic Medicine at Ohio University

What are the biggest issues facing doctors today?

Almost all medical professionals are concerned, above all, with the overwhelming uncertainty of the American health care system. Many physicians, for example, had just begun to settle into understanding the Affordable Care Act and adjusting to changes that it brought about. But now, access points for patients -- in Medicaid, especially -- are being put into question.

How does state and local policy influence the lives of doctors and other medical professionals?

In the United States, private insurance for individuals is regulated on the state level. Each state is different and the level of oversight is uneven. The decline in employer health care plans, the uncertain future of Medicaid, and fast-changing employment sectors have a range of consequences for state and local government, both of which must address the consequences of these changes.

What tips can you offer current medical students about what specialty to pursue and where to practice?

Do what you are interested in. Even despite debt, physicians do well over time. The only thing worse than making a little less money over one’s career is doing something you don’t enjoy. If you are more civic-minded, consider entering into primary care or a high-need specialty in an underserved geographic area.

To what extent does the threat of a malpractice lawsuit affect doctors ability to do their job?

The evidence is mixed. What I can say is that the problem is real, especially in certain specialties such as obstetrics. It’s my sense, and the data seem to confirm it, that physicians’ fears are often worse than the problem itself. A big part of being socialized into physician communities is taking on a great deal of anxiety about malpractice. We are learning, however, that physicians who take the time to develop superior communication skills, and who are honest and direct with their patients, tend to get sued less.

In evaluating the best states for doctors, what are the top five indicators?

This question cannot be answered in the abstract. What I will say from my own context is that Ohio has some of the best and most innovative health institutions in the nation. It is also a state that has some of the biggest health challenges. New physicians looking to make a real difference and practice as part of a hardworking and passionate workforce should consider Ohio.

Looked at altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians?

Physicians who are truly patient-centered must acknowledge the ACA’s accomplishments in the areas of access, research and technological innovation, cost containment, and quality. That said, no policy is perfect. I’m hopeful that physicians will be part of improving the ACA instead of participating in less thoughtful efforts, such as calling for repeal. I’m hopeful that we are entering into a more hospitable political climate for serious thinking about the future of the American health care system.

Fahd Ahmad Instructor in Pediatrics in the Division of Pediatric Emergency Medicine at Washington University School of Medicine in St. Louis & St. Louis Children’s Hospital

What are the biggest issues facing doctors today?

The changing employment landscape, with fewer independent practicing physicians, and more dictates from insurance companies and benefits managers, is greatly reducing physician autonomy. Both related to this but also from separate forces, declining reimbursements in some fields, shortages in some specialties, and “burnout” are increasing challenges.

How does state and local policy influence the lives of doctors and other medical professionals?

The legal climate and tort reform are ongoing issues in many states. Malpractice insurance is high in some states as to make practicing some specialties prohibitive. Patient access to health insurance can vary dramatically by state depending on Medicaid expansion, and other factors which can impact patient care and outcomes are major issues. Some states have dramatically different views on the doctor-patient relationship -- Florida passing laws trying to prevent doctors from discussing gun violence with patients is one example that should be highlighted in the current political climate.

What tips can you offer current medical students about what specialty to pursue and where to practice?

I’ll give contrarian advice -- instead of going after what you love, make sure you avoid what you hate. If the idea of going to clinic every day makes you want to vomit, then maybe you shouldn’t go into primary care.

To what extent does the threat of a malpractice lawsuit affect doctors ability to do their job?

It unfortunately impacts many physicians in many specialties. While malpractice claims against OB physicians are an obvious indicator of physicians avoiding practicing in certain areas, sometimes these effects are difficult to quantify. The threat of a lawsuit can lead to ordering tests a doctor may otherwise not order or drive decision-making in other ways, however I don’t believe this is pervasive.

In evaluating the best states for doctors, what are the top five indicators?

This is incredibly specialty- and individual-dependent, but in no particular order:

• Cost of living;
• Income;
• Job opportunities;
• Legal climate;
• Geography preferences for family/leisure.

Looked at altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians?

This may depend on your specialty. Expanded access to health insurance, as well as mandated coverage for preventive care (such as vaccines) are huge improvements for pediatricians.

Howard P. Forman Professor of Diagnostic Radiology, Public Health, Economics & Management and Director of the YSPH Health Care Management Program at Yale University

What are the biggest issues facing doctors today?

Much like the rest of the world, medicine is not nearly as monolithic as it once was. But the common issues are:

• Increasing demands for productivity;
• Increasing costs to both patients and the practices for better (sometimes not) technologies;
• Burnout and work-life balance;
• Fragmentation of care and an increasing reliance on ED and urgent care for off-hours coverage.

How does state and local policy influence the lives of doctors and other medical professionals?

Most of the biggest impacts on physicians have come from federal law and private payers. State and local government policy setting is important, but not nearly of the magnitude or impact as federal law. Having said that, Medicaid reimbursement can have a big impact on access and physician participation with the Medicaid population.

What tips can you offer current medical students about what specialty to pursue and where to practice?

While there will always be pay disparities, all physicians are well-paid, and the happiest physicians I know are not the best paid. So, I would strongly urge medical students to choose a field that they are passionate about: they will be in it for 40 or more years, so they might as well enjoy it. As to location, I think the same thing. There are, unquestionably, better and worse areas to work if you are looking to maximize your standard of living. But for some people, there is no dollar figure that would make living in North Dakota worthwhile. For others, there is no dollar figure that would get them to leave North Dakota.

To what extent does the threat of a malpractice lawsuit affect doctors ability to do their job?

I think physicians think about this more than they probably should. The magnitude of the impact is less than popular press would have you believe. But there is no question that most physicians consider liability when making medical decisions. And that is not in the patient’s best interest.

In evaluating the best states for doctors, what are the top five indicators?

• Standard of living (relative income versus costs);
• Demography -- whether population is growing, aging, etc. more or less than other states;
• Tax burden;
• Schools for your children and work for your spouse or partner;
• Cultural fit.

Looked at altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians?

All evidence suggests it has been a net positive. Incomes have more than kept up with inflation; payment reform mostly started before the ACA and accelerated with MACRA. So, while many physicians may want to blame the ACA for changes to their practices, very little flowed directly from the ACA.

Adam Wilk Assistant Professor of Health Policy and Management in the Rollins School of Public Health at Emory University

What are the biggest issues facing doctors today?

There are lots of important issues physicians and the practice of medicine these days. One of the biggest is MIPS (MACRA), which starting in 2019, will begin to adjust Medicare payments to physicians. There are a lot of forces coalescing in opposition to MIPS, importantly including MedPAC, out of concerns that the system will reward physicians who have a more favorable (e.g., less complex, more adherent) mix of patients rather than physicians who deliver higher-quality care. Consequently, there is still a possibility that Medicare will hit the brakes on the system before it kicks in. Until that time, many physician practices -- particularly smaller practices in rural areas -- are struggling with MIPS’s reporting requirements. These systems’ complex reporting requirements, along with the upfront fixed costs of implementing electronic medical record systems and a few other factors, are among the leading reasons why growing proportions of physicians choose to be employed by larger physician groups, hospitals, or health systems.

Regardless as to MIPS’s ultimate fate, the broad shift from fee-for-service reimbursement (with or without pay-for-performance structures to incentivize higher-quality care) to more value-based care and integrating principles of population health management into care delivery models is another major issue these days. Both providers and payer organizations (e.g., insurance plans) are still figuring out how to take meaningful steps in these directions and who should hold the risk for which patients in these setups. Aside from a few stand-out delivery systems making bold investments along these lines, I do not get the sense that we see more than incremental steps in this direction for most physician practices over the next decade.

And no matter what these systems ultimately look like, the consequences for physician practices will be pressures to deliver care more efficiently without harming patient care. Some of the strategies being pushed now to contain costs include deferring would-be emergency department patients to lower-acuity settings (e.g., urgent care centers, physician offices), adopting the use of lower-cost medical devices for joint replacement surgeries, and substituting nurse practitioners’ and physician assistants’ care for physicians’ care, especially in primary care settings. For established physicians and delivery models, these transitions are often difficult, while younger physicians tend to acclimate to these new care models quite readily.

Many other significant issues facing physicians are more operational in nature -- figuring out how to coordinate care across provider organizations through integrated electronic medical record systems, for example -- but I cannot speak well to these.

How does state and local policy influence the lives of doctors and other medical professionals?

Some of the state and local policies that affect physicians most directly are Medicaid policies, including eligibility levels (i.e., whether the state has expanded Medicaid under the Affordable Care Act), levels of payment for services to Medicaid beneficiaries, and terms of coverage and utilization management (as administered by private Medicaid managed care plans). These policies are particularly important when practicing in communities where a disproportionate share of the population is eligible for Medicaid or Children’s Health Insurance Programs (CHIP), but overall Medicaid covers almost 20 percent of the population, and nearly 40 percent of children. About 30 percent of physicians do not accept Medicaid patients, but the shares of the population covered through these public programs is growing -- not shrinking. Thus, most physicians see at least some Medicaid patients and experiencing how the state administers these programs.

Moreover, as health systems move to emphasize population health in their care delivery models, physicians will find themselves increasingly coordinating with entities and individuals who are not traditionally part of most health care teams in order to address patients’ social and environmental determinants of health. The capabilities of these entities and individuals, which may include social workers, housing authorities, and social services agencies, are determined significantly by state and local policymakers, budgets, and advocacy efforts. We do not hear a lot of frustrations from physicians yet about the way these entities operate -- not nearly as much as we hear about Medicaid -- but I anticipate this will come, and so physicians will soon engage in greater advocacy about them as well.

What tips can you offer current medical students about what specialty to pursue and where to practice?

In the current market and with the aging of the baby boomer generation, the incentives are stacked up in favor of specializing, rather than entering primary care. Specialists command much higher payment and salaries -- useful for paying off enormous medical school debts -- and there will be particularly strong demand for the specialties that serve disproportionately elderly populations (e.g., gerontology, oncology, cardiology, nephrology) for the next few decades.

Moreover, the work of primary care physicians is in the midst of a transition, as a growing fraction of services historically provided by primary care physicians are now being delivered by nurse practitioners, physician assistants, and walk-in clinics (urgent care centers and retail clinics). Thus, the role of the primary care physician is becoming more of a care team manager and less of a direct care provider. I have seen growing numbers of primary care physicians express concern that they have been inadequately trained for this different role, and growing shares of physicians getting a second degree (e.g., MBA, MPH, MHA) to prepare for it. It is not clear to me that your medical school will train you appropriately for your career if you choose a primary care specialty.

All that said, if value-based payment models and population health management activities start to take the effects they are supposed to take, then the hope is that fewer patients will require specialty care, and the demand for specialist physicians will fall (as will their take-home pay). If this happens, it will probably take us 10-20 years to get there, so it may not be a major consideration for medical school students just yet.

As for where to practice, the inclination to practice as an employee of a health system makes more sense to me than choosing to practice independently because of the fixed costs of electronic medical record systems, managing ever-changing reporting requirements, taking care of the other dimensions of running a small business, etc.

To what extent does the threat of a malpractice lawsuit affect doctors ability to do their job?

The threat of a malpractice lawsuit could affect a physician’s practice through two mechanisms. One is malpractice premiums, which can amount to a large, annual practice expense. The other is defensive medicine, whereby physicians deliver more conservative care and administer additional diagnostic tests and order more imaging tests to avoid “missing something” that could be the basis of a lawsuit.

Malpractice premiums vary regionally and by state to a degree, and they vary more by specialty. This variation is large enough that it almost certainly affects the supply of certain specialists (e.g., OB/GYN, neurosurgery) in many communities.

As for defensive medicine, health economists and health services researchers have effectively reached the conclusion that, while it is difficult to measure, defensive medicine is likely only an important issue at the margins, and maybe only 1-2 percent of total medical costs could be cut out of the system if defensive medicine were eliminated. Thus, it does not appear to meaningfully affect physicians’ capacity to practice medicine.

In evaluating the best states for doctors, what are the top five indicators?

• Where you want to live. Physicians are well-respected and well-compensated nationwide. But since a large proportion of physicians’ lives are spent outside the clinic, what they or their families want to do in their spare time should be major factor.
• Where your family’s needs will be met. Most physicians have families they go home to. And so, meeting their needs may mean choosing to live and work near where your partner has employment opportunities, in a safe neighborhood with good schools, near other family members, etc. The same reasoning follows as above.
• Where the population you want to serve lives. Many physicians enter the profession with a goal of helping patients with particular profiles (e.g., older patients or children, racial/ethnic minorities, complex, interesting patients). While you can find patients with these qualities mostly everywhere, physicians with more targeted missions along these lines would be well-served to choose a community where they can work with this population most of the time.
• Where demographic trends suggest demand for your chosen specialty will be growing, moving forward.
• Where hospitals do not dominate local health system leadership. Hospital care is expensive, and so the push toward value-based care has led to increasing provision of historically inpatient care in outpatient settings (e.g., urgent care centers, ambulatory surgical centers). Many hospital systems have struggled under these pressures. Rather than developing new, more efficient delivery models, they have often instead looked to mergers and acquisitions to bring greater market power to the table in negotiations with insurance companies. They have raised prices rather than cutting costs. Many hospitals, particularly rural hospitals, have closed amidst these difficulties. The push toward value-based care is not going to slow down anytime soon, and so I expect communities where hospitals remain the dominant local players will continue to struggle and may experience some difficult transitions of leadership in the coming 5-10 years.

Looked at altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians?

Clearly a net positive. Lower levels of uninsured patients (and thus lower levels of bad debt written off by providers), higher payment levels in Medicare (2011-2015) and Medicaid (2013-2014) for primary care services, and other financial incentives to boost physician supply are all positives. The trade-offs -- some reduced payments under Medicare, greater exploration of alternative payment models and accountable care organizations (requiring some reorganization) -- are reflections of where the U.S. health care system has been progressing anyway. The ACA just gave these dimensions of the system a nudge forward.

Arthur Garson, Jr. Director of the Texas Medical Center Health Policy Institute

What are the biggest issues facing doctors today?

• Getting back to being able to spend time with patients and having trusting relationships with them, rather than the 8-minute doctor’s visit.
• Being able to practice the type of medicine that the doctor wants, despite having huge loans to pay for university and medical school (i.e., choice of specialty now is very much related to amount of loans).
• Reducing paperwork and administrative work -- only 55 percent of GPs' time is spent seeing patients.

How does state and local policy influence the lives of doctors and other medical professionals?

The most important state policies are around Medicaid and reimbursement. Many physicians cannot keep their doors open -- i.e., they do not make enough -- based on how much Medicaid pays. Therefore, they do not see Medicaid patients, reducing access to care.

What tips can you offer current medical students about what specialty to pursue and where to practice?

• Find a way to do the specialty that you want to do. You may not make as much money as you would like, but do not let specialty choice be driven by economics. Remember, your income is likely to at least double or even triple from residency to your first job. It is OK to live frugally for the first several years while repaying loans -- as long as you are doing what you want to do.
• Take time for your family.
• Love being with patients.

To what extent does the threat of a malpractice lawsuit affect doctors ability to do their job?

The data show that malpractice is less of a factor than it once was, as the awards are capped in many circumstances. Physicians should do their best to keep up on guidelines for care of their patients (usually published by their own physician specialty). Many lawsuits come from ignorance of the current guidelines. Be all you can be to patients -- and communicate. Most lawsuits are not against physicians that the patients like.

In evaluating the best states for doctors, what are the top five indicators?

The indicators should be about what is important to the physician and her or his family. The choice should be mainly about living conditions, schools, etc. Certainly, if the support by the state for the uninsured is important, it may be that the physician will want to practice in a blue state.

Looked at altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians?

I give it a net positive -- but with some real problems. The ACA decreased the number of uninsured people, and that is extremely important. Those who look to reverse Medicaid expansion should realize that the cost of care for the uninsured in those states will be covered by increasing private insurance premiums. The uninsured still get care.

The major failure of ACA was that it paid no attention to the increase in health care costs. The U.S. must decrease the cost of health care. If it doesn't, from the patients' perspective, they will be unable to afford insurance. From the physicians' standpoint, if fewer people will be able to afford health insurance, physicians will receive less income.

Methodology

In order to identify the best states for doctors, WalletHub compared the 50 states and the District of Columbia across two key dimensions, “Opportunity & Competition” and “Medical Environment.”

We evaluated those dimensions using 16 relevant metrics, which are listed below with their corresponding weights. Each metric was graded on a 100-point scale, with a score of 100 representing the most favorable conditions for practicing doctors.

We then determined each state and the District’s weighted average across all metrics to calculate its overall score and used the resulting scores to rank-order our sample.

Opportunity & Competition – Total Points: 70

• Physicians’ Average Annual Wage: Double Weight (~11.68 Points)
• Physicians’ Average Monthly Starting Salary: Full Weight (~5.83 Points)
• Hospitals per Capita: Full Weight (~5.83 Points)
• Insured Population Rate: Full Weight (~5.83 Points)
• Employer-Based Insurance Rate: Full Weight (~5.83 Points)
• Projected Share of Elderly Population: Full Weight (~5.83 Points)
• Current Competition: Full Weight (~5.83 Points)
• Share of Medical Residents Retained: Full Weight (~5.83 Points)
• Projected Competition: Full Weight (~5.83 Points)
• Number of CME Credits Required: Full Weight (~5.83 Points)
• Presence of Interstate Medical Licensure Compact Law: Full Weight (~5.83 Points)

Medical Environment – Total Points: 30

• Quality of Public Hospital System: Full Weight (~6.00 Points)
• Physician Assistants per Capita: Full Weight (~6.00 Points)
• Punitiveness of State Medical Board: Full Weight (~6.00 Points)
• Malpractice Award Payout Amount per Capita: Full Weight (~6.00 Points)
• Annual Malpractice Liability Insurance Rate: Full Weight (~6.00 Points)

 

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