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. Doctors are deserving, after all, given the importance of their life-saving work and the struggles associated with life in the medical profession.

Not only did the average medical-school graduate leave campus with more than $189,000 of debt in 2016, but 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 and warranting pause from potential whitecoats.

It’s therefore fair to expect a certain measure of difference in terms of the working environments faced by doctors across the nation. So in order to help doctors make the most informed decisions regarding where to practice, WalletHub’s analysts compared the 50 states and the District of Columbia across 14 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 to help local governments identify policy initiatives and our detailed 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="http://ift.tt/2mHkWQE;  

Best States to Practice Medicine

Overall Rank	State	Total Score	‘Opportunity & Competition’ Rank	‘Medical Environment’ Rank
1	Iowa	68.67	2	6
2	Minnesota	66.40	8	1
3	Idaho	66.31	3	11
4	Wisconsin	65.66	10	2
5	Kansas	65.15	6	5
6	South Dakota	63.24	1	42
7	Montana	63.13	4	22
8	Mississippi	62.40	5	23
9	Alabama	61.05	11	9
10	Tennessee	59.56	15	14
11	North Dakota	59.19	14	13
12	Nevada	57.44	17	19
13	Colorado	57.12	16	24
14	Arizona	56.96	13	32
15	Nebraska	56.91	12	34
16	Texas	56.53	23	4
17	Wyoming	55.88	7	47
18	South Carolina	55.60	26	3
19	Utah	54.90	19	11
20	Arkansas	54.75	24	7
21	West Virginia	54.75	9	43
22	Indiana	53.05	25	16
23	North Carolina	52.18	32	10
24	Florida	52.01	22	26
25	Louisiana	51.56	20	35
26	Georgia	51.47	29	21
27	Missouri	50.88	33	20
28	Kentucky	50.01	30	27
29	Washington	49.92	31	25
30	New Mexico	49.89	21	40
31	Pennsylvania	49.08	18	44
32	Virginia	48.81	37	18
33	Oklahoma	47.72	34	33
34	New Hampshire	47.37	28	39
35	Michigan	46.91	36	30
36	Illinois	45.89	27	45
37	Alaska	44.92	40	29
38	Vermont	44.87	39	15
39	Ohio	44.61	38	38
40	California	44.48	46	8
41	Oregon	44.14	45	17
42	Delaware	42.95	35	48
43	Hawaii	41.99	41	31
44	Maine	40.60	42	36
45	Connecticut	38.33	49	28
46	Massachusetts	37.85	47	37
47	Rhode Island	36.84	43	49
48	Maryland	36.45	44	50
49	New Jersey	34.48	48	46
50	District of Columbia	33.72	51	41
51	New York	28.49	50	51

 

Ask the Experts: The Future of the Medical Profession

Medicine is changing rapidly, and the manner in which it is taught and practiced must adapt accordingly. The industry not only faces an aging population as well as new regulations, but it also must keep pace with technological breakthroughs and make sense of hospital reorganization and rebranding. With that in mind, we sought insight from medical professionals, business experts and public-policy researchers into the future of the medical profession. You can check out our panel as well as the questions we asked them below.

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

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• Mark Dame Assistant Professor in the Clinical Services Management Program at Texas Tech University Health Sciences Center
• Holly J. Mattix-Kramer Associate Professor in the Medical Center and in the Stritch School of Medicine at Loyola University Chicago
• Susan Giaimo Visiting Assistant Professor in the Departments of Political Science and Biomedical Sciences at Marquette University
• Joseph White Luxenberg Family Professor of Public Policy in the Department of Political Science, and Director of the Center for Policy Studies at Case Western Reserve University
• Valerie A. Yeager Assistant Professor in the Department of Global Health Management and Policy at Tulane University School of Public Health and Tropical Medicine
• Dennis P. Andrulis Associate Professor of Management, Policy & Community Health at the University of Texas School of Public Health, and Senior Research Scientist at the Texas Health Institute
• Edward Salsberg Research Instructor in the School of Nursing and Director of Health Workforce Studies in the Health Workforce Institute at George Washington University
• Timothy F. Page Associate Professor in the Department of Health Policy and Management at the Florida International University Robert Stempel College of Public Health & Social Work
• Harry J. Heiman Director of Health Policy in the Satcher Health Leadership Institute at Morehouse School of Medicine
• Betty Rambur Professor of Health Policy and Nursing at University of Vermont
• Nicholas K. Iammarino Professor of Health Sciences and Chair of the Department of Kinesiology at Rice University
• David J. Becker Associate Professor in the Department of Health Care Organization and Policy at University of Alabama at Birmingham, School of Public Health

Mark Dame Assistant Professor in the Clinical Services Management Program at Texas Tech University Health Sciences Center What are the biggest issues facing doctors today? Reimbursement. The rules continually change and many specialties receive cuts years after year. We are at the infancy of a pay for performance model, but so far, the results have been mixed at best. Many are working longer hours just to keep even with last year’s income. How does state and local policy influence the lives of doctors and other medical professionals? Malpractice laws have some influence on work satisfaction. As insurance is an expense, states with high rates place a burden on the physician. Licensing guidelines can limit care (such as telemedicine) or suppress creativity. Health insurance laws are state-driven and many would prefer more competition. Medicaid is a huge state-led effort. The state influences panel sizes and reimbursement. Many see that the cost of billing for Medicaid exceeds reimbursement. How can localities attract more primary care physicians? One can invest in bright students at the time of undergraduate studies and bring these future graduates home. Frankly, telemedicine and e-medicine may be more of solution than actual on-site physicians. Advanced practitioners can also fill in some gaps. What tips can you offer current medical students about what specialty to pursue and where to practice? One really needs to know oneself. Explore as much as possible while a medical student and talk to as many practicing physicians as possible in order to ascertain what will excite oneself for years to come. Sure, income is important for many. One must be realistic of the tradeoffs with income and lifestyle. All of these determinants apply to specialty and location. Yet, it is easier to change location than specialty. Taken altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians? When one considers a physician is a citizen as well as a physician, the ACA has been a net negative. Incomes have gone down, investment gains have decreased or have gone into the red, and work life balance is increasingly unbalanced to the negative. I have seen frustration and depression on the increase as many seem to think there is nothing they can do to stop the assault on their practice and livelihoods. Despite many have been absorbed by health systems, this has not alleviated root concerns. Holly J. Mattix-Kramer Associate Professor in the Medical Center and in the Stritch School of Medicine at Loyola University Chicago What are the biggest issues facing doctors today? The practice of medicine is changing extremely rapidly and it is very difficult to keep up with these changes. Payments will be based on quality of the care and not just the volume of care delivered. In the long run this is a good thing for patients but the rapidity of these changes and lack of ancillary support for doctors to make these changes is very challenging. How does state and local policy influence the lives of doctors and other medical professionals? States that are reducing support for public health issues such as closing down mental health clinics or senior care services (Illinois) creates a big burden for physicians. These gaps in ambulatory care are then replaced by higher emergency room visits, increased hospitalizations and repeat hospitalizations. How can localities attract more primary care physicians? If the community demonstrates support for physicians and public health, then they may attract primary care physicians. Lifestyle, school quality and pay will always be issues for all physicians. What tips can you offer current medical students about what specialty to pursue and where to practice? Internal medicine is a great specialty and affords a physician the ability to subspecialize in multiple areas. Internal medicine provides physicians training to care for very complex conditions as well as prevention and primary care. Taken altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians? I have witnessed improved access to complex care due to the ACA. I have also noted patients who have obtained insurance through the ACA and ended up not being able to get care because no physicians or medical centers will take the insurance. I still see a lot of patients who have no insurance. Susan Giaimo Visiting Assistant Professor in the Departments of Political Science and Biomedical Sciences at Marquette University What are the biggest issues facing doctors today? The biggest issue is for doctors (particularly primary care doctors) to gain a solid understanding of the social determinants of health and to incorporate this understanding into their practice and treatment of patients. This is critical to achieving good health outcomes. How does state and local policy influence the lives of doctors and other medical professionals? It has a big impact. Decisions about the state budget affect programs like Medicaid and other safety net programs. For instance, reimbursement rates and coverage decisions for Medicaid are determined largely by state actors. If the rates are set too low, then providers will choose not to participate, and many patients with Medicaid insurance will have a difficult time accessing health care in a timely fashion. Wisconsin’s Medicaid reimbursement rate for dental care is one of the lowest in the nation. This has led to long waits to obtain care from dentists for Medicaid patients, since not enough dentists participate in the program due to the low reimbursement rate. The governor’s decision to not accept the federal funds associated with the Medicaid expansion under the Affordable Care Act has led to many more people remaining uninsured. Even with premium subsidies on the state exchange, many of these people still cannot afford the premiums and cost sharing. This means that doctors and other health care providers must continue to treat the uninsured as charity cases, or not at all, or in expensive ER settings. Local governments and city health departments can encourage innovations in coverage and public health, and can fund and partner with nonprofits like United Way and community organizations to reduce infant mortality, obesity, and build safe and healthy neighborhoods. How can localities attract more primary care physicians? I think that working with state and federal programs that offer loan forgiveness programs to graduating med students who practice in underserved areas would be effective. The state and localities should also work with the federal government to establish more community health centers in rural areas. What tips can you offer current medical students about what specialty to pursue and where to practice? I encourage them to go into primary care and to practice in inner cities and rural areas, since these areas have a need for such providers. But at least half of them have already chosen primary care, so I think they know this already. Taken altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians? It is a positive for doctors. More of their patients now have insurance coverage. Primary care doctors receive higher Medicaid reimbursements, and there are several programs that encourage students to pursue primary care careers. Electronic medical records and government encouragement and financing of pilot programs in coordinated care (ACOs, medical homes) will help physicians provide more coordinated care. The dissemination of clinical guidelines will also aid physicians in treating populations and those with chronic diseases. It is an exciting time for physicians, and I think the ACA has set our health care system in the right direction, toward more patient-centered, coordinated, and evidence-based care. Joseph White Luxenberg Family Professor of Public Policy in the Department of Political Science, and Director of the Center for Policy Studies at Case Western Reserve University What are the biggest issues facing doctors today? It seems to me that one of the biggest issues must be the imposition of managerial and economic theory on doctors' work. This means, essentially, that both the government and private payers are trying to make medical care something that can be managed through measurement, and treating doctors also as purely economic actors with no other values. The latter means that there is continual manipulation of payment systems, based on ideas about incentives, on the theory that doctors who are paid by fees per service immorally generate extra services to increase their incomes, in ways that do not help and even harm patients. So Medicare is supposed to make half of its payments to physicians in some other way within a few years, and hospitals are trying to extend the idea of "Accountable Care Organizations" with bundled payments to the non-Medicare population, and this is putting all sorts of pressure on doctors to participate in different contractual arrangements and, somehow, change their care practices. All of these ideas presume that management is possible because of the first idea: that performance can be measured so that it's possible to pay for quality or pay for performance (P4P) rather than for individual services. If you add electronic medical records to the mix, you get a world in which more and more of physicians' work or the work of their offices is dedicated to filling out forms, checking boxes, and dealing with overseers, rather than on relating to patients. A recent paper in Health Affairs suggested that $15 billion per year is being spent on just recording the information for "quality measures." I worry that this will actually make care worse, because the measures are generally pretty weak and checkbox medicine is not a good idea. It also deepens the general trend of the managers of the health care system not trusting physicians. I'm not saying that their economic behavior is always altruistic or that they are always right in their professional judgments or that they should be totally trusted. Some counterbalances to physician power over patients and our pocketbooks are necessary. But what's happening is likely to succeed only in making physicians more miserable. How does state and local policy influence the lives of doctors and other medical professionals? Not all that much, best I can tell. There are scope of practice laws which influence who can compete with them. States are in charge of licensing, but I don't think their policies vary all that much. State laws are the largest influence on the malpractice system, and that system immensely irritates doctors. But most analysts who have looked at the malpractice system think (a) it's terrible but (b) it's not terrible for the reasons physicians claim and (c) doctors hate it and fear it even in states with laws that relatively favor them. How can localities attract more primary care physicians? I can't imagine there is much they could do. The most logical approach would be to pass state laws setting prices for services, and in those laws paying PCPs relatively better, compared to specialists and PCPs in other states, than is currently the case. But it looks like states could not do that, given the recent Supreme Court ruling on even maintaining databases about prices. I guess a state could choose to pay PCPs much better in its Medicaid program. But even if states could do something to make primary care more attractive, they'd basically be taking from other states. The broad national trends discourage physicians from choosing primary care, and it would take a lot of different states finding ways to make primary care more attractive before the career choices would change. What tips can you offer current medical students about what specialty to pursue and where to practice? Geriatrics is really needed, but it still doesn't pay all that well and it's boring. The experts say physicians should learn to do population health because that's what ACOs will want; but nobody knows how physicians could do population health… Taken altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians? That depends on the individual physician's values. Basically it means there are more paying customers, and they can do good for more people. But the people with improved access to medical care come with either quite low fees (if they are in Medicaid) or, usually, restrictive networks of providers and high cost-sharing, so it may be hard to refer to the specialist you want to refer to and there will be a bunch of times when patients do not adhere to recommendations because they aren't really covered because of high deductibles. So there should be some hassles with the new patients, but physicians who value people getting care should still like that part of the ACA. Otherwise, the ACA encourages the emphases on measurement and management and restructuring the delivery system that I mentioned in my first answer. But that would probably be happening to some extent anyway. Virtually the entire health policy world - with rare exceptions, like myself - is for it. It's not just something Obama and his advisers invented. Valerie A. Yeager Assistant Professor in the Department of Global Health Management and Policy at Tulane University School of Public Health and Tropical Medicine What are the biggest issues facing doctors today? The health care environment is rapidly changing. This introduces a number of issues for physicians including costs and processes of implementing technology such as health information systems (e.g., Electronic Health Records) and adjusting to changing payment and delivery systems as well as quality requirements. These changes require that physicians stay up to date on the policies and requirements as they evolve (e.g., meaningful use requirements), all of which requires a notable investment of time. How does state and local policy influence the lives of doctors and other medical professionals? In the context of Medicaid expansion, state policy has the potential to influence the number of insured patients seen in physician practices and hospitals. There are still 2.9 million people who fall into the ‘coverage gap’ in states that have not expanded Medicaid. This means that when/if these individuals are seen by physicians and hospitals (most likely in the emergency room), unless they can afford to pay out-of-pocket, their care will be uncompensated. This may mean more hospital closures in states that have not expanded Medicaid – already 52 rural hospitals have closed across non-expansion states (77% of rural hospital closures nationally). What tips can you offer current medical students about what specialty to pursue and where to practice? As an academic who studies health systems and health policy, I may not be the best person to answer this question. That being said, population health models, the aging population, and reimbursement models, all seem to be moving toward integrated care. As the population ages, the prevalence of chronic illnesses (e.g., cancer, heart disease, diabetes) will also increase. Thus, one could predict that as baby boomers grow older, the demand for oncologists, cardiologists, endocrinologists will increase, as well as the need for primary care providers to assist in the management of these conditions. Taken altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians? I strongly believe the ACA is a net positive for physicians and the population. The biggest gains from the ACA have been in relation to access to insurance. We’ve witnessed a drop from 18% uninsurance before the ACA to 11.4% in the second quarter of 2015, the lowest it has been in most of our lifetimes. A recent survey of physicians found that they are happier when their patients have more insurance – patients come more regularly and physicians get compensated for the care they provide. A 2015 national survey of primary care providers found that most providers reported no change in their ability to provide quality care, although providers with a larger share of Medicaid patients were more likely to say they’ve been positively impacted in terms of the ability to provide quality care. This doesn’t mean that a number of health system challenges do not remain, but in general, the ACA is a net positive for the US health system and it’s a move in the right direction for both physicians and patients. Dennis P. Andrulis Associate Professor of Management, Policy & Community Health at the University of Texas School of Public Health, and Senior Research Scientist at the Texas Health Institute What are the biggest issues facing doctors today? The biggest issues facing doctors are reflective of the changing nature of the way care is delivered. Accountability for cost effective, quality care has taken center stage, with hospitals, for example, being penalized for inappropriate readmissions and greater scrutiny around patient safety and medical error. Accountable Care Organizations, where practitioners and health care teams take fuller responsibility for care coordination and delivery as well as outcomes in return for sharing financial risk, are gaining more attention from health care provider organizations and government. Finally, as greater pressure is placed on managing care and controlling costs, the era of the single or small group practitioner is, for the most part, receding. Instead, practitioners are finding that their future is most likely tied to their participation in networks-managed care and otherwise. These settings represent the future for many physicians. How does state and local policy influence the lives of doctors and other medical professionals? State and local policymakers have the power to bring attention to and address changing population health dynamics. Whether and how they choose to use that power, varies greatly. Some have taken advantage of federal programs such as Medicare and Medicaid waivers to transform how care is delivered and how practitioners and health care settings meet changing needs of individuals and communities. Such state impact grants in California, New York, Texas and elsewhere offer the opportunity to innovate and in so doing encourage practitioners to adapt practices. Finally, the states who have taken advantage of the ACA’s option to expand Medicaid have opened new doors to financing care to low income populations and, with the federal government covering 100% of costs in the first years of expansion and 90% thereafter, bringing hundreds of millions of dollars to providers and their organizations. States that have chosen not to expand leave practitioners who want to care for these populations at the mercy of charity care sources. How can localities attract more primary care physicians? Localities with medical schools should review their commitment to primary care. Local areas can use the requirement for nonprofit hospitals to conduct Community Health Needs Assessments (under the ACA) and action plans to address needs as a lever to press for increasing primary care in these settings. They should also look to federal programs that support placement of physicians in underserved areas and related loan forgiveness programs in return for service. Finally, local foundations and businesses that recognize the importance of employee health care can work to support efforts to increase the number of practitioners in primary care. What tips can you offer current medical students about what specialty to pursue and where to practice? The medical and health care worlds are moving in multiple directions today. For example, on the one hand, greater emphasis on preventive and “whole person” care — care that takes into account community, circumstance and individual factors such as race, ethnicity, language and culture that influence adherence and outcomes places increasing value on practitioner knowledge and understanding of what affects health and where to intervene. At the same time, an aging population, increased prevalence of chronic disease and advances in treatment will create greater demand for specialists. So choices for students will depend, among other things, on what path attracts the most. But another point to consider is the changing demographics of the country. Diversity is rapidly increasing in many areas across the US and will lead to “majority-minority” communities in cities and towns alike. At the same time urban sprawl continues unabated and will offer new markets for health care organizations and practitioners. Taken altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians? The ACA has open many doors for physicians it at least four ways:

• By significantly increasing the numbers of insured through state-based and administered Marketplaces and Medicaid expansion - in states that have opted to expand - it has greatly increased the number of patients not relying on charity care and covering patient debt.
• The law has authorized several programs to support training — through reinforcing the National Health Service Corps, Primary Care Training and Enhancement Programs, State Healthcare Workforce grants and others - in several medical disciplines, including family medicine, general, internal medicine and general pediatrics, with a special emphasis on primary care.
• It has elevated the importance of and supported efforts to reinforce the importance of health care teams and medical homes that can alleviate some of the responsibility that practitioners feel has fallen primarily and historically on their shoulders.
• The ACA, in recognizing the increasing diversity of the country, has included over 60 provisions intended to reduce disparities, promote equity and improve linguistic and cultural competence, with training, education and workforce support provisions intended to assist physicians in assuring quality of care for all patients.

Edward Salsberg Research Instructor in the School of Nursing and Director of Health Workforce Studies in the Health Workforce Institute at George Washington University What are the biggest issues facing doctors today? It can be a challenging time for physicians as the delivery system and the organization of health care is undergoing substantial change. The changes in organization with hospitals, group practices and ACOs playing a greater role, changes in reimbursement policies, many with a focus on outcomes and value, the expanded use of teams, the growing use of the electronic health record, the expansion of quality metrics and more informed patients, are all impacting on the practice of medicine, and often in a negative way. These developments appear to be impacting on older physicians who see and feel the changes more than younger physicians who have different expectations and experiences. Much of this reflects the fact that we are in a period of change which in and of itself can be unsettling. Hopefully, most of these changes will serve both physicians and patients in the future. The EMR, the use of teams, a greater role for larger health care organizations, revised payment policies etc. should actually make the practice of medicine more satisfying and rewarding. These changes have the potential to allow the physician more time to use his/her skills and knowledge. The physician may not be the king of the mountain in the future health care system but they will be part of a team of other health professionals and informed patients providing high quality care. How does state and local policy influence the lives of doctors and other medical professionals? States play an important role in not only the licensure of physicians but also in the regulation of many of the places physicians work, like hospitals and group practices, and the regulation of insurers. States may be able to encourage greater consistency on the part of insurers, the lack of which is very annoying and time consuming to physicians. States can assure fair hospital and insurer policies. States can also assure reasonable payment rates for Medicaid patients. Nurse practitioners, physician assistants, pharmacists and other clinicians are playing an increasing role in teams caring for patients. States can help by allowing these non-physician practitioners to play a greater role. While there has been some limited resistance on the part of organized medicine to these expanded roles, most physicians at the front lines appreciate the collaboration and assistance of these practitioners. How can localities attract more primary care physicians? States can, and many do, provide loan repayment for physicians entering practice in underserved areas in their state; localities can do the same. They can also encourage local hospitals to provide support for primary care physicians who locate in their communities. Some states support primary care residency program development or expansion of existing programs. Some states provide scholarship support for state residents to go to medical school. The combination of attending medical and doing your training in the same state is very powerful: nearly 70% of the physicians who went to medical school and residency training in a state ended up staying and practicing in the state. So a community that provides scholarships to schools in the state and supports training in community based settings in their locality, is very likely to build a pipeline for future physicians interested in their community. What tips can you offer current medical students about what specialty to pursue and where to practice? There are many wonderful opportunities in most specialties, although it is very competitive in some specialties and in some communities. In general, physicians often like to stay around the sites where they trained; so areas around academic health centers are often the most competitive. But in almost every specialty there are opportunities in smaller communities and in under-served areas. In general, specialties serving the elderly are likely to see rising demand in the coming years. This is not just geriatrics but all specialties serving the elderly, from cardiology to hospice and palliative medicine to orthopedics to physical medicine and rehabilitation. Most important, medical students should select specialties based on what they enjoy doing, but they need to be conscious of the competition for the most competitive specialties and the potential that their practice choices may be more limited in some specialties. Taken altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians? A net positive! As noted above, we are in a period of transition in health care delivery; while this change is challenging, we are moving in the right direction. Health care had to change; we could not afford continued long run cost increases for uncoordinated, fragmented care, with poor outcomes and that was not evidence based. The ACA has not only covered millions of additional Americans, it has also provided billions of dollars to support innovations and evaluation. Other legislation also provided billions for the conversion to EHRs. To be clear, many of the changes were inevitable. The nation could not afford the long term increases of costs; larger organizations were becoming more dominant regardless of the ACA; changes in reimbursement were inevitable. There is certainly room for improvement, but the ACA has provided a direction and stimulus. Timothy F. Page Associate Professor in the Department of Health Policy and Management at the Florida International University Robert Stempel College of Public Health & Social Work What are the biggest issues facing doctors today? Payment reform is one of the biggest issues facing doctors today. Primary care reimbursements are low, and malpractice premiums make it difficult for family physicians to remain in independent private practice. This has led to a shortage of physicians in primary care, as many prospective physicians enter specialties. In an environment of constrained resources, bundled payments and value-based purchasing, initiatives are putting more pressure on physicians to deliver care not only effectively but also efficiently. How does state and local policy influence the lives of doctors and other medical professionals? Following the passage of the Affordable Care Act, healthcare providers are being affected by states' decisions on whether or not to expand their Medicaid programs. Some states, such as Florida, have chosen not to expand their Medicaid program, and this has left a large number of people uninsured because they do not qualify for other coverage under the Affordable Care Act. This means that uncompensated care is still a problem for hospitals, and with federal funds for low income pools set to be reduced, this problem will grow. How can localities attract more primary care physicians? Physician shortages continue to be problematic in rural areas where the market demand for physician services is not as high as in more densely populated, less rural areas. There are some federal initiatives in place to provide financial incentives for physicians to practice in rural areas. With reimbursements for primary care being below that for specialties, similar financial incentives will be needed to incent physicians into primary care. What tips can you offer current medical students about what specialty to pursue and where to practice? There's no sense in doing something for 40 or more hours per week that isn't fulfilling both personally and financially. There is a field out there for everyone that can fulfill both of these goals. Taken altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians? This remains to be seen. Generally speaking, having access to 30 million more insured customers should be a good thing for physicians. However, with reimbursements being scrutinized and with a continued emphasis on efficiency, additional pressure is being put on physicians to demonstrate not only good outcomes but also value to the health system in the care that they provide. Harry J. Heiman Director of Health Policy in the Satcher Health Leadership Institute at Morehouse School of Medicine What are the biggest issues facing doctors today?

1. How to transform the health care system in a way that provides value — improves care, lowers costs, and is patient-centered, providing care to patients in a way that is culturally and linguistically appropriate, takes into account the context and circumstances of their lives and meets their needs.
2. How do we move our focus from treating disease to creating opportunities at the community level for patients to live healthier lives.

I would ask, what are the most important changes doctors need to make to improve the health of their patients and the communities they serve. Unfortunately, provider-centric questions tend to get provider-centric answers and thinking; part of the reason our current system performs so poorly. How does state and local policy influence the lives of doctors and other medical professionals? Policy decisions that create barriers to care or worsen existing barriers create a lose-lose situation for providers and their patients. For example, states choosing not to expand Medicaid, not adequately reimbursing providers in State Medicaid programs, not aligning training resources with the projected workforce needs, are all misaligned with creating the health care system that both providers and communities need. How can localities attract more primary care physicians? States need to preferentially support medical schools that train more primary care physicians, including primary care residency programs. Local communities need to support coordinated systems of care, leveraging patient centered medical homes, Accountable Care Organizations, and collaboration with community-based providers to create an inviting and supportive environment for primary care providers. What tips can you offer current medical students about what specialty to pursue and where to practice? “It’s not just about you.” Think about where the opportunities are to have the greatest impact. Taken altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians? Unequivocally, the ACA is one of the most important policies for reducing the numbers of uninsured, improving access to care, slowing the rate of growth in health care costs, and pushing the health care delivery system away from our toxic volume based reimbursement toward value-based and outcome based reimbursement systems. The system is moving in a better direction and more people having coverage and access to care is a net positive for everyone — including providers. Betty Rambur Professor of Health Policy and Nursing at University of Vermont There is a growing recognition of the role of social determinants - housing and education, for example - in the health of individuals, families, and communities. Traditionally, what is termed health care has actually focused on medical care, even though it is projected that as little as 10% of health status is impacted by such services. Other estimates suggest that roughly one-third of the nation’s $2.9 trillion dollars in health care expenditures is unnecessary, wasteful, uncoordinated, or represents overtreatment. This orientation has been fueled by fee-for-service reimbursement, the “more is better” instinct. Payment reform, particularly models in which providers take accountability for the outcomes and cost of care (Accountable Care Organizations, bundled payments, and fixed revenue all-inclusive care, for example) dramatically changes the incentives toward a focus on health. Strong primary care is essential to the effectiveness of these models, as well as other payment innovations that build on fee-for-service, such as patient centered medical homes, or, more appropriately, person centered health neighborhoods. To serve the nation’s health, fresh thinking that uses the full range of health care workforce talent, skills, and abilities is crucial. As just one example, the high quality of the work of primary care nurse practitioners is well documented. There is also research that finds when compared to physicians, nurse practitioners are more likely to work in rural and urban underserved areas, accept Medicaid patients, and provide excellent care at an overall lower cost. Registered nurses have also been underutilized and are key to reconceptualized and redesigned primary care. For example, predictive and prescriptive analytics using “big data” to serve individual and population health are exciting innovations that are well aligned with the incentives within emerging payment models. One thing health professional schools and professionals continuing education can do to encourage greater career satisfaction among providers is to require health policy, economics and “ethinomics” - the intersection of ethics and economics - as foundational educational material. Most of the current generation of providers has been socialized almost exclusively in a fee-for-service milieu, and the necessary corrective changes the nation is undergoing can seem bewildering or just plain wrong. Conversely, greater understanding creates an appreciation of the ethical imperatives of population health, a focus on the person inclusive of social determinants of health, cost containment, and reduction of overtreatment. In other words, as Einstein famously noted, we can’t solve our problems by using the same kinds of thinking we used when we created them. Nicholas K. Iammarino Professor of Health Sciences and Chair of the Department of Kinesiology at Rice University What are the biggest issues facing doctors today? In many ways, the biggest issues facing doctors today are the same ones that have been around for a number of years. Doctors are frustrated by the changing models of healthcare delivery and ultimately how to best treat their patients. With health insurance companies changing not only the amount of reimbursements but what is covered, physicians increasingly have to see more patients in a shorter time frame. So, physicians must make conscious decisions on how to best use their 10-20 minutes in the examination room. How can localities attract more primary care physicians? Some smaller communities have gotten pretty creative in their attempts to attract physicians to move and practice in their towns and rural locales. Offering financial incentives seems to be the primary way. Helping new physicians pay off their loan debt continues to be a strong incentive however, other creative strategies like purchasing a home or setting up an office are also popular. What tips can you offer current medical students about what specialty to pursue and where to practice? There has been a push by the American Association of Medical Colleges and other organizations to increase the number of primary care physicians in the US. These have been somewhat successful. Premedical students are eager to embrace this and learn that it “may” be helpful to their admission if they indicate a desire to enter a primary care field. By way of comparison, virtually every other industrialized nation focuses and, in some cases, mandates, a new physician train in primary care (i.e., as a General Practitioner or GP’s). Thus, approximately 75-80% of physicians are GP’s while only 20-25% are Specialists. In the US, it is opposite as most new physicians end up going into specialty residency programs. Something happens from the time they are undergraduate premedical students espousing the love of, and need for, primary care. I think the answer is quite simple. Besides the fact that our younger generation loves high tech and equipment, once in medical school they quickly learn that the real money is in “procedures” that most often require them to pursue a specialty area. Those lofty and humanitarian goals of serving and helping others in need of care, public health interests, the new focus on global health and infectious disease control quickly go out the window and fade as they are replaced with newer goals like a bigger home, fancier automobiles and the like. Taken altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians? The Affordable Care Act has proven to be a mixed bag for physicians. While not perfect, it is a step in the right direction in my opinion. It has taken a significant chunk out of the group of uninsured Americans and offers a new level of preventive medicine. Some physicians, those that would like to see a national health system, obviously see this as a step in the right direction. Groups like the PNHP, Physicians for a National Health Program, acknowledge this but ultimately feel it falls short of achieving their goal of fully nationalized health care system as most other industrialized nations. The other opposing view is that physicians want to be left alone and allowed to practice medicine in the best way that will benefit their patients, and thus see the Affordable Care Act as just another way of interfering in their business. Unfortunately, this antiquated approach to medical practice is more myth than reality today. Whether they like it or not, the ACA and new laws that will most certainly come, will force physicians to rethink how they practice their craft and, along with the medical insurance industry that is constantly changing, require them to find ways to offer quality care to their patients. David J. Becker Associate Professor in the Department of Health Care Organization and Policy at University of Alabama at Birmingham, School of Public Health What are the biggest issues facing doctors today? Physicians will face an array of challenges in the coming years as we take stronger steps to control the growth of health care spending in the US. Although draconian cuts in reimbursements under the Medicare sustainable growth rate were averted with the so-called doc-fix, physicians will face stronger incentives for quality and efficiency under the Merit-Based Payment Incentive Program (MIPS). This is one of the early steps in the long awaited move from a health care system that rewards volume to one that rewards quality and appropriateness. How does state and local policy influence the lives of doctors and other medical professionals? One huge area is state decisions to expand Medicaid. Physicians in states that have not elected to expand, continue to treat uninsured patients and deliver care for which they may or may not be compensated. Related to this is the growth of high-deductible health insurance plans which is encouraged by various features of the ACA. With patients facing larger out of pocket costs, providers face greater risk of patient non-payment. Physician practices may need to devote more resources to bill collection. They will also be required to report more and more data. Related to efforts to control health care costs, physicians will face increased opposition to restrictive scope of practice laws that limit the activity of nurse practitioners and other non-MD providers. How can localities attract more primary care physicians? This is a significant challenge, and a variety of programs are being used, including incentive payments and recruiting students from these underserved areas. The financial pull of specialized medicine and urban environments makes this a challenging issue to address. The role of non-MD primary care providers is again relevant to these discussions. What tips can you offer current medical students about what specialty to pursue and where to practice? Like all of us, current medical students should pursue something that they are passionate about. It's not my position to impose my vision of self-actualization on anyone. From society's point of view however, I do have concerns about students who aspire for a part-time career as a physician given the significant public investments that are made in GME. Taken altogether, has the Affordable Care Act (ACA) proven to be a net positive or net negative for physicians? I think the effects have largely been positive, as the ACA has expanded coverage, expanded covered services and, in the case of primary care, has provided for enhanced reimbursements. There are challenges on the horizon with P4P, a changing role within ACOs, and increased out-of-pocket costs to collect from patients. The ACA was not a radical transformation of the US health care system, and as such, is the best providers could have hoped for from a landmark piece of health care legislation.

Methodology

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

We evaluated those dimensions using 14 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 calculated the overall score for each state and the District based on its weighted average across all metrics and used the resulting scores to construct our final ranking.

Opportunity & Competition – Total Points: 70

• Physicians’ Average Annual Wage: Double Weight (~12.72 Points)Note: Data for this metric were adjusted for the cost of living.
• Physicians’ Average Monthly Starting Salary: Full Weight (~6.36 Points)Note: Data for this metric were adjusted for the cost of living.
• Hospitals per Capita: Full Weight (~6.36 Points)
• Insured Population Rate: Full Weight (~6.36 Points)Note: “Population” includes noninstitutionalized civilians aged 16 and older.
• Primary-Care Provider Shortage: Full Weight (~6.36 Points)Note: This metric measures the percentage of the population living in a primary-care HPSA, or Health Professional Shortage Area. HPSAs, as defined by the Health Resources & Services Administration, “are designations that indicate health care provider shortages in: Primary care; Dental health; or Mental Health” and “may be geographic-, population-, or facility-based.”.
• Projected Share of Elderly Population: Full Weight (~6.36 Points)Note: This metric measures the projected percentage of the population aged 65 and older by 2030.
• Current Competition: Full Weight (~6.36 Points)Note: This metric measures the number of physicians per 1,000 Residents.
• Projected Competition: Full Weight (~6.36 Points)Note: This metric measures the projected number of physicians per 1,000 Residents by 2024.
• Number of CME Credits Required: Full Weight (~6.36 Points)Note: “CME” stands for Continuing Medical Education, credits for which the state may require medical professionals to earn in order to maintain their licenses.
• Presence of Interstate Medical Licensure Compact Law: Full Weight (~6.36 Points)Note: This metric is based on data from the Interstate Medical Licensure Compact and considers whether compact legislation has been enacted, introduced or not been introduced.

Medical Environment – Total Points: 30

• Quality of Public Hospital System: Full Weight (~7.50 Points)Note: This metric is based on data from the Centers for Medicare & Medicaid Services.
• Punitiveness of State Medical Board: Full Weight (~7.50 Points)Note: This metric measures the number of serious disciplinary actions (per 1,000 physicians) taken by the state medical board.
• Malpractice Award Payout Amount per Capita: Full Weight (~7.50 Points)
• Annual Malpractice Liability Insurance Rate: Full Weight (~7.50 Points)

 

Sources: Data used to create this ranking were collected from the U.S. Census Bureau, Bureau of Labor Statistics, Council for Community and Economic Research, Health Resources & Services Administration, Projections Central’s State Occupational Projections, WebMD, Interstate Medical Licensure Compact, Public Citizen, Arthur J. Gallagher & Co., Centers for Medicare & Medicaid Services and Diederich Healthcare.

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