Thursday, June 4, 2015

For physicians, is money all that matters in deciding where to practice?

I would think that when physicians decide where to set up practice, there are things that they would want to think about other than how much money they’ll make.  Yet if one reads Medscape’s current list of the best and worst places to practice, it would appear that money trumps everything else (although Medscape said it also considered factors like “cultural attractions”). What Medscape apparently did not consider at all are factors like the percent of the population that is uninsured, mortality and morbidity rates, rates of chronic disease, per capita healthcare spending, that is, anything having to do with patients.

As a result, the locations that Medscape rated as best for practice are, with only a few exceptions , the states with higher physician earnings, lower taxes, and fewer malpractice lawsuits-- but that also have the largest numbers of uninsured people.  The locations that Medscape rated as the worst for practice are, with only a few exceptions, the states with lower physician earnings, higher taxes, and more malpractice lawsuits—but that also have the fewest numbers of uninsured patients.

And I think this is a problem, because it suggests to its mostly physician readership (and to the broader public that may hear about it and get the wrong impression) that all physicians should care about is the money coming in and going out of their practices—without regard to the social, economic, and policy environment affecting the health of their patients.
Here is Medscape’s list of the top 10 best places to practice, and why, ranked in order:

1. Tennessee: low cost of living, good pay for physicians, progressive communities, music and attractions.
2. Mississippi: low taxes, low malpractice payouts, cultural activities.
3. Oklahoma: high physician income, arts and cultural community.
4. Texas: no state income tax, choice of cities and geographies, fewer malpractice lawsuits, excellent medical community.
5. Wyoming: many cultural activities, natural beauty, no state income tax, demand for physicians.
6. Idaho: outdoor recreational activities, reasonable home prices, average tax burden.
7. South Carolina: warm climate and warm people, several museums, good practice environment.
8. New Hampshire: good physician compensation, low taxes, educated populace, proximity to Boston.
9. Nebraska: below average cost of living, wealthy state, strong industry, good schools and low crime.
10. Alaska: no income tax, adventurous lifestyle, wide scope of practice, tight knit community.

Here is their list of Medscape’s 5 worst places to practice, and why:

1. New York: with a special warning “to avoid New York City” because, “At $249,000, average physician compensation is more than $22,000 below the national average. New Yorkers know they pay a premium to live in the city, but they may not be aware of just how hefty it can be.”
2. Rhode Island: “RI physicians responding to the 2015 Medscape Physician Compensation Survey reported lower pay than any other doctors in the country.”
3. Maryland: “a high cost of living and too many doctors”
4. Massachusetts: “high taxes, a high cost of living, exorbitant housing costs, and average physician compensation that is $23,000 below the national average”
5. Connecticut: “It costs a lot to live there, and doctors don't make a lot to compensate”

What if practice locations were instead ranked by the fewest and the most numbers of uninsured patients?  You end up with a very different ranking than Medscape’s:

The top 10 best states based on fewest uninsured (as % of population)

1. Massachusetts (4%)
2. Hawaii (5%)
3. Minnesota (7%)
4. Delaware (7%)
5. Vermont (8%)
6. District of Columbia (8%)
7. South Dakota (9%)
8. Rhode Island (9%)
9. Wisconsin (9%)
10. Iowa (9%)
11. Connecticut (9%)
12. New York (9%)
13. Kansas 10%)
14. Maine (10%)
15. Pennsylvania (10%)

(Nebraska and Maryland also have 10% of their population uninsured).

The bottom 10 worst states based on greatest number of uninsured (as % of population):

1. Texas (20%)
2. Nevada (20%)
3. Arizona (19%)
4. Florida (19%)
5. Wyoming (17%)
6. North Carolina (16%)
7. Georgia (16%)
8. New Mexico (16%)
9. Alabama (16%)
10. Alaska (16%)
11. South Carolina (15%)
12. Montana (15%)
13. California (15%)
14. Arkansas (15%)
15. Idaho (14%)

(Oklahoma and Mississippi are also tied with 14% of their populations uninsured).

Why should the uninsured rate matter to physicians when considering the best and worst places to practice?  Because “people without health insurance live sicker and die younger than those with insurance.”

What if one were to rank the states based on their overall performance on composite measures of accessibility and availability, prevention and treatment, avoidable hospital use and cost, healthy lives, and equity?  The Commonwealth Fund did this, and also came up with a much different ranking than Medscape’s:

The top 10 best states based on overall healthcare performance are:

1. Minnesota
2. Massachusetts
3. New Hampshire
4. Vermont
5. Hawaii
6. Connecticut
7. Maine
8. Wisconsin
9. Rhode Island
10. Delaware and Iowa (tied)

The bottom 10 worst states based on overall healthcare performance are:

1. Mississippi
2. Arkansas
3. Oklahoma
4. Louisiana
5. Nevada
6. Alabama
7. Georgia
8. Texas
9. Indiana
10. Kentucky

(The next in order of worst to best are Florida, Tennessee, North and South Carolina).

Now, to be clear, I have no beef with where physicians choose to live and practice: the choice of where one decides to live and work is a highly personal one, weighing a variety of factors that are unique to each physician and his or her loved ones.  Who am I to judge?

Nor do I have a beef with any of the states listed above, no matter where they rank on the respective lists.  I have been fortunate to have traveled to all 50 states, plus Puerto Rico and of course my home in the District of Columbia, many repeated times, and I love the wonderful diversity of this country, the breathtaking beauty, and the hospitality and kindliness of the people I’ve met.  One of the highlights of my job at ACP is to visit physicians at our chapter meetings throughout the country: over the past year I have visited physicians in Rhode Island, Nebraska, Virginia, South Dakota, Kansas, Delaware, Nevada, and California, and I have trips coming up to Missouri, Washington state, and California and Nebraska again.  Universally, I have found that physicians in every state I’ve visited are committed to giving their patients the best possible care.

No, my beef is only with Medscape, and the sources (recruiters, interviews, surveys) they used that looked mostly at the economics of practice, not the environment affecting the care of patients.  As a result, there is an inherently conservative bias built into Medscape’s analysis, because by emphasizing higher physician earnings,  lower cost of living, fewer malpractice suits and lower taxes over health outcomes and the percentage uninsured, its rates more favorably the states that are hostile to government programs to help cover people and reduce healthcare disparities, and less favorably the states that have more activist governmental programs to reduce the ranks of the uninsured and healthcare disparities, often requiring higher taxes to pay for such programs.

And by focusing mostly on the money, isn’t Medscape doing a disservice to the many physicians who have chosen to practice in their so-called “worst” states—even though they may earn less on average?  One Rhode Island internist, a personal  friend of mine, when I told him his state was ranked by Medscape as one of the top 5 worst places to practice,  responded, "No one asked me. While [our] economy took a big hit, we have a great medical community and collaboration with hospitals, insurance companies, government.”

And aren’t they doing a disservice even to physicians in their “best places to practice," who love their states but would like to see them do better on things like covering the uninsured?  I know many Texas physicians, for instance, who for good reason love their state and the favorable practice environment it offers, but are working hard to try to persuade a hostile legislature and governor to expand Medicaid coverage to the poor.  Expanding Medicaid would, in their mind, make Texas an even better place to practice—and even more importantly, a better place for patients to get the healthcare they need.  And to be sure, many physicians have told me they would even be willing to pay higher taxes if it meant that fewer of their patients would be uninsured.

So how about this, Medscape?  Next time you rank the best and worst places to practice, how about looking not only at the economics of practice, but at how well each states does in providing health insurance coverage, in tackling healthcare disparities, and in improving the health of their populations?

Today’s question: What is your opinion of Medscape’s “best and worst places to practice” list and my objections to it?


james gaulte said...

Mr.Doherty, on your last blog in the follow up section you said you had not commented on ABIM's activities that have created a firestorm of criticism from internists because "I as a matter of practice and policy do not express my opinion ...[on] issues that fall outside my direct governmental affairs responsibilities."

Now you offer criticism about how a website ranked the best places to practice medicine. Perhaps you might explain how that critique falls under your direct governmental affairs responsibilities.

Bob Doherty said...

This post is about governmental affairs and public policy; my criticism of the Medscape ranking is that by emphasizing low taxes, higher earnings and fewer lawsuits, it is biased against states that have more activist governmental policies to reduce the numbers of uninsured, improve access and quality, and reduce healthcare disparities. These government interventions, by making healthcare more accessible for patients, should be one of the factors that physicians may want to consider in deciding where to practice.

james gaulte said...

Thanks for your reply and explanation.If one's philosophical rudder typically steers toward more government actions and programs it is hard to find anything that cannot be shoved into government affairs and public policy.Your argument also assumes that outcomes necessarily follow purported intentions and that states with those programs in fact improve quality of care.Your reply is one more example of how your blog regularly promotes views that conform with a progressive mind set and the views of internists(including some ACP members)with a conservative or libertarian viewpoint only see the light of day in the comments section of your blog.However, I do appreciate your tolerance in allowing contrary view to be published.

W. Bond said...

The tortured logic employed above to justify commenting on a survey of “best places for doctors to live” - or some such thing - as being an opinion related to your “direct governmental affairs responsibilities" is hardly cogent. However, I, personally, think it fine for you to comment on many areas of Medicine in general, as you do. For example, this post from last year on a column you disagreed with: Now, whatever one thinks of Dr. Drake’s piece or your response to it, it is certainly an opinion on a topic that is no more related to the medical-regulatory system we work under than is ABIM and its MOC process. Nonetheless, this is the reason you give (in response to my comment on your last post) for your silence on the ABIM and its financial scandal. Namely, that it is outside of these “direct governmental affairs responsibilities.”

Dr. Gaulte is correct, I suspect, also on the politics.

However, the ABIM financial scandal is not a right/left issue, nor a town/gown issue. Physicians who might have to agree to disagree on many other policy positions are united in their opposition to the revelations of egregious waste, greed, and possibly fraud at the ABIM and its Foundation. To pretend at this late stage that the controversy surrounding the ABIM is only about how and whether to have a MOC process is disingenuous at best.

Now, ACP has an organizational Conflict of Interest regarding the ABIM. First, it has a financial interest in selling test prep courses, material, MOC modules, etc. Second, it has the interest of its members whose fees are those being allegedly misused by the ABIM.

Yet, the presence of this Conflict itself does not mean that the ACP cannot do the right thing. Indeed, the dues-paying members are counting on it – and watching.

Jay Larson MD said...

In the United States, success is often determined by salary, so along this line of logic, the more money you make, the more successful you are. And who does not want to be successful? When I get recruiting flyers in the mail, the place looking to hire tempts one with high salary, good quality of living, low taxes, and low malpractice. I have never seen a flyer that states that the quality of medicine is high and that is the reason one should relocate. We live in American. It is what it is. More concerning than the Medscape survey on where to practice is a Medscape survey on physician burnout. From 2013 to 2015 the rate of physician burnout has increased in general medicine from 43% to 50%. With family practice, general medicine is third from the top for most physician burnout. Perhaps Medscape should combine the surveys and rank states with the lowest burnout rate.

PCP said...

The ACP for aome time has lost its way. Its advocacy is failing because it is resulting in an ever more untenable practice environment for the practicing IM physician. Their strategy has been an utter and miserable failure and they are too arrogant to admit it. Or perhaps they were never there to represent the practicing physician.
Their advocacy and stances are are basically liberal talking points. Pushing everything from Universal healthcare, to the LGBT agenda, to Gun control etc. they are every last one Democratic talking points and initiatives. They have sold the profession down the river.
The sheer disgraceful behaviour of the ABIM in fleecing its captive audience was tacitly supported by the ACP while it did its own bolt on fleecing by selling test prep. products, conferences etc. Now that the rebellion has started we are getting deafening silence.
Their support and entrenchment with liberal think tanks in washington has made its way into gov't policy. The systematic eradication of the small IM practice and their support of policies that increase administrative burden is sinful. Everything ACP claims to do to assist the profession is nothing but paying lip service when you actually analyze their actions.
I long said if you follow the ACP's agenda, we will all be working at CHC/FQHCs or some such employed setting, with more administrators and ancillary staff doing a bunch of head scratching jobs, have a "collaborative" ANP or DNP medical director, who pushed CMS mandates and directives in your face be your boss, you will be working at a clinic collecting vast gov't subsidies yet be getting a salary that is about 15-20% more than the average Nurse practitioner. That's the socialist way and the ACP way. They think it's right and they won't stop till they have finished the job. Efficiency and quality have no role in this, they are just the talking points. Whatever the result will be claimed to be a victory and transformative change.
I was a fee paying member of the ACP until 2010 for 12 yrs. once I realised what their agenda represented, i could not in good conscience continue remaining a member of such an entity. Their views have only gotten more extreme since then.
For those like my friend Harrison who espouse both liberal views as well as a independent physician practice streak, i wish to say something quite simple. You cannot serve your patients the way you have previously once you have lost your practice. You may not care about your income, or perhaps you feel Doctors are overpaid. However when you small business is wrecked, you too will be an employee and taking instructions from the said "collaborators".Whatever it is that makes you support the ACP, realise that independent practices are going the way of the dodo bird. Do you not think the hostile policies from CMS are behind this? Whenever I raise issues like differential payments for the same service based on facility, there is a deafening silence. Apparently such things pushing independent practices into hospital hands is free market competition. Yet ACP has the time to draft a policy on the Transgender community(whatever your view on that, likely represent less than 1% of the population).
The deep infestation of this organization with such views and convictions at the expense of advocacy for the profession like every other lobby is irreparable. Only replacable. The deep hypocricy of posts claiming to represent the profession is maddening. Actions and results Mr Doherty speak far louder than words. Medical students are shunning primary care IM in droves. It has amongst the lowest specialty fill rates by US MD graduates. Then those that enter want to go to specialty medicine or hospitalist medicine. Your advocacy for the past 2 decades has been a miserable failure. How well is putting patient advocacy above that of professional advocacy working? Each of the readers can decide that for themselves.

Bob Doherty said...

Well, PCP has a lot to say, not surprisingly. Let me respond to some of his premises.
On ACP’s advocacy to improve healthcare for LGBT persons: does PCP believe that denial of healthcare and basic human rights is okay if it "only" affects 1 %, or 5%, or 10% of our population? What % threshold is okay when it comes to tolerating discrimination? The evidence is clear (please read our entire paper in Annals) that LGBT persons face barriers to healthcare that are the result of public policies that marginalize, discriminate, and exclude them because of their gender identity and sexual orientation. How can physicians and ACP not speak out for changing such discriminatory policies? Discriminatory policies are morally and ethically wrong, not matter what percentage they make up of our population.
Advocacy to reduce preventable death and injuries from is not an appropriate focus for ACP? The evidence is clear that tens of thousands of Americans are killed and injured by firearms each year, and that reasonable restrictions—such as universal background checks—can reduce them. ACP's positions on firearms have been endorsed by the American College of Surgeons, American Public Health Association, American Academy of Family Physicians, American College of Obstetrics and Gynecology, American Academy of Pediatrics, American College of Emergency Medicine, the American Bar Association, and more than 30 other organizations representing consumers, physicians and other healthcare professionals, lawyers, victims of gun violence, and the list of supporters is growing.
Advocacy for providing health insurance coverage to all legal U.S. residents is not an appropriate focus for us? How so, when we know from the IOM that lack of health insurance is associated with tens of thousands of preventable deaths and suffering (people without health insurance live sicker and die younger).
ACP's views, by the way, are well in line with the overwhelming majority of Americans-- recent polls show, for instance, that more than 60% Americans favor civil same sex marriages and more than 80% support background checks on firearms, two of ACP's so-called "liberal" positions. (The Annals also recently published a survey of internists' views on firearms, which also found that overwhelming majorities agree with the positions ACP has advocated). And while a narrow plurality of Americans express disapproval of the ACA, more than 80% of people who have actually obtained coverage through the ACA like their coverage, according to a new poll.
So I have to ask PCP, who is out of touch with the views of most Americans on policies to reduce deaths and injuries from firearms, and on extending basic human rights to LGBT persons? If this is a "socialist" agenda, than is PCP suggesting that the majority of Americans who agree with us on these issues are "socialist"?

Bob Doherty said...

PCP says "Whenever I raise issues like differential payments for the same service based on facility, there is a deafening silence." Really? ACP came out with a policy over a year ago opposing the facility fee charges by hospitals when a service is provided in the physician office. And we are part of a "site of service" coalition to eliminate such differentials.

As far as advocacy for independent practices, ACP actually spends at least as much of its resources on influencing payment and regulatory policies to improve the practice environment for internists, in all type of practice, than we do on the larger societal issues described above. I just met this morning with the ACP Vice President responsible for regulatory affairs and the number of such issues that we are engaged with are outstanding--from easing meaningful use requirements, to providing a two-year grace period for ICD-10, to influencing implementation of the new MACRA law that repealed the SGR to ensure that there are pathways available for all practices of all types to succeed, to responding to a Senate request for our ideas on how to reduce barriers to chronic care coordination, to continued advocacy to improve the new Chronic Care Management and Transitions of Care Management codes (which we had a big role in getting CMS to approve in the first place), to influencing the latest CMS rule on Accountable Care Organizations, we are engaged in all of these, and many more, issues that affect the day-to-day practice of medicine. Had PCP remained a member and attended our annual Leadership Day on Capitol Hill a few weeks ago, where more than 300 of his colleagues took the time out of their practices to make a difference by bringing their voices to Washington, he might have had a different view of ACP's advocacy agenda. The issues that they were taking to Congress--continuing the Medicare 10% primary care bonus program, restoring primary care Medicaid pay parity, allocating GME dollars to support primary care, funding for Title VII, NHSC, and other primary care workforce programs, providing safe medical liability harbors for physicians who follow evidence-based practice guidelines, are all directly relevant to, and supportive of, physicians in practice and especially, primary care. We have scored major wins on everything from easing Meaningful Use regulations to getting Medicare to pay for chronic care management to eliminating the Medicare SGR and on many, many more issues, but I don't think PCP is really interested in hearing about these wins, having already made up his mind that we aren't doing anything for physicians in independent practice.

There is no contradiction between advocating for what is best for individual and population health--as ACP does when we advocate to eliminate discrimination against LGBT persons, to reduce firearms-related injuries and deaths, and to provide coverage to all Americans--and advocating to improve the practice environment for internists. ACP does both, and we are proud of it.

victorgettinger said...

And yet not one word about the imposition of foolish MOC requirements or the misaligned association with ABIM. ACP surely does good things but they are not as closely aligned with the needs of the mass of working (and shrinking) population of IM Docs as we would find desirable to protect a living wage commensurate with the amount of work we do!

Harrison said...

What did you write that prompted so much response from B. Doherty?

As for me.
I do hold liberal views and I am in a practice with one other partner.
We lost a partner recently to pancreatic cancer.
That was hard.

I certainly know what it is like to practice in the current environment. I'm not sheltered from it.

I know that practices around us have sold to bigger entities.
We have been courted by bigger entities.
We do not like their practice models, and prefer to stick with our own.
We did manage to recruit someone last year, an MD, and that doctor chose us over the VA system and two big entities who were recruiting her with enticements we can't hold a candle to.
Yet she chose us.
We're pretty happy with that.

I don't know how Medscape picks practice sites.
I don't know how doctors and med students make personal choices.
I know that it can be analyzed, and there is probably a regression plot that allows it all to be characterized.
But I doubt that Medscape hires mathematicians to help them.
Probably just some marketing guys who voted.

I'm generally happy with the current practice environment.
And I work in Southern California.
But then, if I'm unhappy, I can go surfing, right?
(maybe I'll learn one day, I know a cardiologist locally who learned when he was 60, so I've got 4 years to go).

I see a couple of medical students, first years, for shadowing each year.
I am impressed.
I think the future is bright.

And I think the ACP is generally helpful to practicing internists, and it represents us well.

I have been to almost every ACP annual meeting for the last 15 years, or more.
I think I missed once.
I was in Boston not long ago.
I think that the energy among practicing interists is great.

Can't think of a negative thing to say.
Except about pancreatic cancer.
I can think of lots of bad things to say about that.


PCP said...


I'm rooting for you and your practice colleagues. May you thrive and multiply a hundred fold. The country would be well served.
Me and my wife will grow old one day and I would hope to have access to a well trained and compassionate Internist with good judgement, bedside manner and clinical skills. And what I want for myself I want for every american, even if I do differ on how we get there.
I see the same current environment as you and draw a somewhat different conclusion, I compare it to that of 20 yrs ago and see the change in the trajectory for the profession. I don't see that the ACP has helped with their advocacy or positions. I judge the results on the basis of how mnay young doctors are starting up private practices like Harrison did or atleast joining like his more recent colleague.
What I instead see is that young internists are running. Running to subspecialty fellowships, to hospital medicine, employment by large corporate entities with their deep and agenda driven pockets etc.
I don't argue with you for a second that medicine will continue to fill its schools, what I do think is that they won't represent the very best like it has historically done.

I do see that the ACP have spent a disproportionate amount of their energy on issues not beneficial to their members and that take a decidedly liberal political slant. I also see them finding all sorts of tangential justifications for that advocacy. It is easy to rationalize everything one does. I think Bob's post assumes my views on these social issues even though I haven't said what those are. The point I made and continue to make remains the same. The ACP is devoting more energies to hot button political issues rather than practicing physician issues, even as the practice environment deteriorates materially. Arguably their policy positions are aiding and abetting that deterioration. Likewise the mischaracterizarion of my use of the term "socialist". I used it in reference to their support of a pay scale that eventually settles us 20% above Nurse Practitioners(and yes it is CMS thats sets NP pay at 85% of physician pay for the same service code, and you should hear their lobby's call for parity). To my mind that is very socialist, centrally planned and implemented. Perhaps ACP has another rationalization for that one.

On the issue of differential payment rates. This problem has been in place for decades. Even now, the issue is not just physician offices owned by physicians vs hospital owned practices. Why should an echo done at place X cost 4x that of place Y? Would you pay 4x for a tube of toothpaste at Target vs Walmart? Hospitals have a strong lobby that looks after their interests, thats why they get paid the way they do. Health care doesn't cost what it does in the US due to physician pay. The elephant in the room is hospital costs, pharma costs, imaging and other costs, insurance and administrative costs, all of which are all inflated far beyond reasonable. Intead of focussing on the $5000 MRI that should cost $500 leaving rhe physician and patient to decide. The system is focussed on reducing the number lf these MRIs by endlessly interfering in that relationship, so that noone has to pay. I believe the system gets far more success with the first approach. The sad truth is that these entities are now swallowing up ailing small practices due to said policy and hence consolidating power and even exerting their influence on the profession.


PCP said...

What of the cost based reimbursement model for primary care at FQHCs and CHCs Bob? Why is it that it can be 2-3x what medicare is prepared to pay a private practitioner who sets up an office there? Why is it that if I'm employed by the said entity medicare sees 2-3x value in my work Bob? These are cardinal questions. This is no longer about just a push here or there for this and that. Internists and their representatives should be asking these hard questions about why corporate and solely profit driven entities are being handed such complete control of the system, and why are physicians and their patients being marginalised? I certainly don't expect the ACP to ask them however

Jay Larson MD said...

Harrison was very lucky to find an internist willing to go into small group practice. The last time an internist came to our town and go into private practice was 15 years ago. I agree with PCP. The practice environment has deteriorated over the past 20 years. So much more paperwork and regulations and much less time with patients, unless of course you purposely settle for a much lower income and spend as much time with patients as they need. That is what I did and have not regretted it one bit. I too am disturbed by physicians being employed by profit driven corporate entities. Sure ethical standards are applied to physicians, but the same standards are not applied to corporate boards or CEO's, the ones that decide how much salary physicians get and how much time they can spend with their patients.