Why can’t Nevada hang on to its health care providers?
A shortened version of this article was originally published in the Health Care Quarterly, November 2023, page 38.
Here in Nevada, it’s clear that we have a doctor shortage that’s been ongoing for decades. Patients are waiting months before they can see a doctor, physicians have no place to refer their patients who require specialist care, and problems with access to care have not improved despite the addition of two medical schools. If you’ve lived in Nevada long enough, you may have heard the running joke, “If you want good healthcare, go to the airport.” The question is why?
Each year, Nevada gets a little bit bigger in many ways including population growth, business expansions, and the addition of sports teams, just to name a few. However, healthcare continues to struggle to keep up with demand. Mental Health America reports that Nevada ranks 51st nationally in overall mental health and youth mental health. Our doctor numbers are almost just as bad, with just over 218 active physicians available per 100,000 residents (the 6th lowest in the Nation). We rank 48th nationally for primary care and 49th for specialist care, according to a 2022 Kaiser Family Foundation report.
There are many potential reasons why healthcare can’t keep up with demand, including residency programs (or the lack thereof), unnecessary licensing board hoops, inadequate Medicaid reimbursement rates, high insurance rates, and an aging physician population - just to name a few. To see a difference for the patient waiting months for quality care, which is where it matters most, change requires more than just bringing in a new residency program.
Dr. Shivesh Kumar, MD, MBA, FHM, Founder and Director of Reliant Physicians, explains, “I've lived here since I was a young professional and seen incredible growth in housing, entertainment, and sports, all of which should be applauded. But that opportunity has not been mirrored by a good medical system. We can do better.”
A Quick History
Some folks who’ve been in Nevada for over twenty years will remember the healthcare crisis in the early 2000s well. There was a significant doctor shortage, medical malpractice insurance rates went wild, and liability companies actually moved out of the state; it became so unstable for doctors and insurance companies alike. The problem got so bad that the State of Nevada had to step in and create liability options for physicians. Dr. Rudy Manthei, who has been practicing medicine in Nevada for over thirty years, remembers it well. He explains, “The [medical malpractice] awards started getting out of control, and the frequency of claims got out of control too. We don't have a judicial system that is good at hearing medical cases, and those verdicts of enormous amounts just drove the frequency way up and basically drove doctors away. Our liability companies left, and the state had to come in and set up a liability, it got so bad.”
The issue of medical malpractice hit a tipping point in Nevada and that’s when the Keep Our Doctors in Nevada (KODIN) initiative was created. As Dr. Manthei describes, “We created an initiative, we went to the people, and the people voted.” KODIN helped the public understand that medical malpractice laws were needed to stabilize healthcare in the state.
When the issue of medical malpractice landed on the ballot in 2004, the people did vote to cap attorney fees, cap noneconomic damages, eliminate joint liability so providers are only financially responsible for their percentage of fault, allow damages to be paid in installments, and shorten the statute of limitations. The people voted, insurance companies stopped fleeing, and doctors saw malpractice insurance costs drop. But it wasn’t just medical malpractice caps that were preventing doctors from working in Nevada.
Not Enough Residency Options
The road to becoming a doctor doesn’t end with school - all practicing clinical doctors begin as residents. While medical programs have grown here, residency programs have struggled to keep up with demand. Statistically speaking, where doctors do their residency is geographically where they end up practicing — which is bad news because only 15% of UNR’s School of Medicine Class of 2022 chose Nevada for residency.
Down in Las Vegas, the problem isn’t quite as severe but close to half of UNLV med school grads are leaving that state to train elsewhere. It’s not because they want to; It’s because they have to.
Nevada has zero residencies in some specialties and subspecialties. Dr. Marc J Kahn, MD, MBA, MACP, FRCP, Dean and Vice President for Health Affairs at the University of Nevada-Las Vegas, explained in an interview with the Nevada Current that if “two current UNLV students would like to specialize in dermatology, but there is no dermatology training program anywhere in the state, those students will have no choice but to seek opportunities elsewhere.” We lack good opportunities for specialty residency programs. As a direct result, we lack specialty doctors.
Doctors Blocked from Practicing in Nevada
Residency programs aren't the only way to bring doctors to the state. Board-certified physicians moving here face a different challenge. Dr. Khan explains that “not having a nimble licensing process makes it challenging to get new docs into the state.” When Dr. Khan moved to Nevada, he accepted his position in December, applied for his license to practice in Nevada in January, and wasn’t approved until the end of July — seven months later. For one of his colleagues, it took over ten months to get licensed to practice medicine in Nevada. Further, the process is clunky and challenging. Dr. Khan explains, “The [licensing boards] request things through the mail, things that have already been sent, and they ask for things that are not necessary.”
Many pro-Nevadan physicians and CEOs have gone out of their way to recruit outstanding doctors in areas of medicine where we are severely lacking. Dr. Kumar states, “We do everything to recruit doctors and keep them here, and we will pay out of our pocket to keep them in town.” There is nothing more frustrating for these recruiters than spending so much time and effort bringing doctors into the state only to watch them get blocked by licensing boards that have hijacked the process. As Dr. Khan explains, “We need more access to care, which means we need more physicians, which means that we need to get better licensing in our state.”
Medicaid and Funding Problems
Getting doctors to practice in Nevada is half the battle. Getting them to stay for less money is the other half. “Nevada has ranked 50th in the nation for public health funding for decades,” according to the Nevada Independent. Dr. Kumar has seen physicians leave the state due to lack of decent pay. If you want to start understanding the problems with pay, Dr. Kumar explains, “You really need to look at how much the reimbursement rates are here when compared to other states.” Reimbursement rates are the rates healthcare providers are paid for the services they provide, and the reimbursement rates in Nevada are much lower for Medicaid and commercial insurance companies when compared to other states. The lack of fair and competitive reimbursement rates makes it “really difficult to attract specialists and to attract the specific services that we need,” Dr. Kumar states.
To be clear, it’s not just about paying physicians more. It’s about the patients. Dr. Kumar says, “The patients [may] have a specific diagnosis that only a specialist can treat, but they have to seek treatment out of state or wait for months.” In mental health, the problems are even worse. The Nevada Current reports that more than half of the 169 behavioral health clinics do not accept Medicaid due to low reimbursement rates or insurance problems. Some providers only accept cash, which continues to limit patient access. It is no wonder Nevada regularly ranks among the worst in the nation for mental health services.
Charles Perry with the Perry Foundation has stated multiple times that our State has forfeited millions of dollars in Federal Matching Funds due to inadequate support for its Medicaid Budget. Even the State is recognizing the problems with Medicaid reimbursement rates. Lombardo’s Chief of Staff Ben Kieckhefer said in May, 2023 that, “[Existing Medicaid reimbursement rates] provide significant challenges for Medicaid enrollees to access care, and makes it incredibly difficult for physicians, hospitals, care providers to provide service to Nevada’s lowest-income families.”
Medicaid is only one piece of the puzzle when it comes to how Nevada handles money in healthcare. In fact, “Nevada has ranked 50th in the nation for public health funding for decades,” according to the Nevada Independent. Elko’s Family Medicine Residency Program is closing for lack of funding. The end of a Covid-era Medicaid policy and subsequent loss of federal revenue is expected to hit rural hospitals in the state particularly hard. New bills have been passed, but many are saying that it’s not enough. And other bills were also passed that can potentially undo the work that’s been done.
Results from the 2023 Legislative Session
Many were hopeful that healthcare and mental health would get some much-needed attention at the legislative session earlier this year, and it did in both good and bad ways. Governor Lombardo vetoed no less than 12 health-related bills, but he did not veto the one that has Nevada doctors most concerned: AB 404, which tips medical malpractice laws back in favor of attorneys.
AB 404 was brought forth by trial lawyer Justin Watkins, who works with Nevada Speaker of the House Steve Yaeger at Battle Born Injury Lawyers. Results of the law allow attorneys to collect a flat fee totaling 35 percent of the amount recovered, which can equal a lot more money for attorneys than the tiered system that was previously in place. AB 404 changed medical malpractice noneconomic damage caps from $350,000 to $750,000 by 2028 and will continue increasing at a rate of 2.1% per year moving forward. AB 404 also extends the statute of limitations for filing a medical malpractice lawsuit, giving patients more time to make a claim.
At first glance, AB 404 looks to be good for patients, lawyers, insurance companies, and (some even claim) healthcare providers. However, healthcare providers will likely suffer the most, as they did before medical malpractice laws were put in place in the early 2000s. While attorneys say that raising the caps leads to better medical oversight, research shows that the effects do not lead to better healthcare outcomes, but rather, an exodus of physicians. For example, after med malpractice laws were overhauled in New Mexico, they saw 700 fewer primary care physicians in 2021 than in 2017.
Here in Nevada, Dr. Mantheis explains that what we can expect to see from AB404 is “the frequency of claims against physicians will go up, and they will drive physicians out or keep them from coming here… As the numbers go up, the attorneys [will] get a larger percentage, but not the patients.”
Diego Trujillo also drove the point home, saying “With AB 404, I could not find any articles, any data, any white papers that would show that if doctors are sued for more money then the outcome is better medicine. The data I saw from other states is that it will actually make doctors leave the state.”
Dr. Mantheis has seen the healthcare struggles in Nevada for over thirty years. He explains that “nothing is more frustrating than to have a patient sit and not be able to treat them or refer them to specialty services.”
Some healthcare providers are disheartened by the results of the 2023 legislative session. Diego Trujillo has a more optimistic outlook, saying, “I don't see our role as waiting until it gets worse but rather getting ready for the next legislative session and work towards a better outcome.” Diego goes on to explain, “We don't control the narrative as a healthcare industry in Nevada… Until we are able to organize, we are not going to be able to move the needle.”
What We Can Do About It
To put a visual to the problem, Diego Trujillo explains, “If we want to bring more birds in our yard, we don't bring in cats and cacti, and other things that will push them away.” It’s time to work together to figure out how to bring more doctors to the state and keep them here. That’s where organization, collaboration, and innovation can help. In Dr. Kumar’s words, “Las Vegas rewards independent thinking and it rewards hard work.”
Improving health care in the state is an uphill battle, but we Nevadans are Battle-Born and we can take on any challenge.
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Contributions from:
Dr. Shivesh Kumar, MD, MBA, FHM, Founder and Director of Reliant Physicians
Dr. Rudy Manthei, DO
Dr. Marc J Kahn, MD, MBA, MACP, FRCP, Dean and Vice President for Health Affairs at the University of Nevada-Las Vegas
Diego Trujillo, CEO of Las Vegas HEALS
