Industry FocusHealthcare

 

The healthcare industry in Nevada has never been more relied on than it has in recent years. However, despite COVID being in the rearview mirror, the industry is still facing giant problems. From battling a significant shortage of medical professionals, rising costs and burnout to the point that practitioners are leaving the field altogether, the industry has challenges it needs to address – and quickly.

Recently, a group of healthcare experts met at a roundtable sponsored by City National Bank and held in Las Vegas to discuss those challenges and the future of healthcare in Nevada. Connie Brennan, publisher and CEO of Nevada Business Magazine, served as moderator for the event. These monthly roundtables bring together different industries to discuss issues and solutions.

How Severe Is Nevada’s Shortage of Healthcare Professionals?

Dr. Marc Kahn: Nevada ranks 45th for doctors per capita and 48th for primary care.

Dr. Andrew Priest: One of the biggest problems in the valley is simply the number of providers that we have. We are trying to address that by putting out 150 new providers – PAs (physician assistants), nurse practitioners, doctors, therapists, etc. – into the valley every year. Hopefully in the next six or seven years, we will put out another thousand, but that is still not going to meet our needs as the population continues to expand.

Russell Cook: The number one concern that we hear about [in Nevada] is the availability of providers and, in particular, providers who are able to take on new patients. That is especially true in the rural areas of the state.

Priest: As [Las Vegas] has grown and the number of people that are continuing to come into the valley [increases], the number of healthcare providers that follow is not meeting the demand of the number of people.

Dr. John Rhodes: Most of the people coming out of medical schools and out of residencies are not coming out as primary care physicians. A well-trained primary care physician can probably handle about 85 percent of all doctor visits, but only 20 to 25 percent of graduates are going into primary care fields. If we are going to make a difference, we need to figure out how to get medical students to go into primary care fields.

Kahn: We have data that if a medical student graduates in the state of Nevada there is about a 40 percent chance of them practicing here. [Comparatively], a resident, right out of medical school, has about a 60 percent [chance of practicing here]. But [if a person goes to] medical school and [completes their] residency here, that number increases to 80 percent. The solution is, we need more residency positions.

Dr. Fermin Leguen: The lack of resident places is one of the biggest issues in terms of retention [in Nevada], especially for Clark County which is kind of an isolated metro area. It is very difficult [to] bring physicians and other qualified individuals, because whoever decides to work with us has to leave the place where they are today, as opposed to metro areas, where people just drive a few miles and come back home. It is a big decision for people because they [oftentimes] have to move their family.

Kahn: Residency positions were frozen by Congress in 1996, enacted in 1997, and at that time, we were a very different state. We have 403 federally funded CMS (Centers for Medicare and Medicaid Services) residency positions for the entire state. California has over 9,000 and New York has 17,000. What we desperately need is to get more state support for residency programs, because that is how we will get [medical professionals] to stay [in Nevada].

Ty Windfeldt: It is a huge challenge for us because we tell individuals that are looking to locate to Nevada out of residency that we need to have six to nine months prep time. Oftentimes they [will get a job] in a state that [requires] less [prep time] and where they can start working [sooner].

Kahn: There are some real barriers to entry [in Nevada for physicians] with the licensure process. When I came here three and a half years ago, it took me over seven months to get a license. It took my colleague, the dean at the University of Nevada, Reno, over ten months, and the founding dean of the medical school waited over a year. We have to address that issue because if you are going into private practice, you are going to give up [due to the long wait times] and go somewhere else.

Leguen: Another weakness in the system locally is the public school system. It does not offer enough opportunities for people, family members, physicians or other professionals when they move here, to actually improve their capabilities in certain sectors. For example, if somebody wants to come here, and wants to get into nursing school they have to pay [thousands of dollars] because the public system does not offer the number of spots for people to get there. If you go into associate degrees, [it is] even worse. All [of] this contributes to the lack of physicians in the community.

Kahn: It can take 300 plus days to get [credentialed] by the state [for] Medicaid plans. Many states have regulations that say you must have a credentialing decision within 60 to 90 days’ pay date but here [in Nevada] there is no limit. We are [also] one of the minority of states that allow insurance providers to grant exclusivity. The majority of states have “Any Willing Provider” laws which state that if somebody meets credentialing criteria, they can go on a plan. The problem is if [someone] is going to come into town as a cardiologist, there are two groups in town that have the insurance market locked up. [They] can’t get on the plan and it is going to be very difficult for [them] to practice. Those things make real barriers to entry for new physicians coming into the state.

What Factors Impact the Cost of Healthcare in Nevada?

Rhodes: Across the industry, affordability is a huge issue for healthcare. And it plays a lot into access because you must have the providers be able to provide it. A lot of people do not even look for providers because of the cost of healthcare in our community and in our country.

Oscar Delgado: From a community standpoint, over the last four years our general costs have increased by more than 15 percent.

Cook: We have been seeing in years past about a 7 to 8 percent average increase year-over-year [in health insurance]. As for what the contributing factors were, we can’t really say. The Division of Insurance works very closely with these insurance carriers to make sure they are reasonable, good faith actuarial studies that back up the cost increases. But as for whether this year is an anomaly or we can expect to see similar increases in future years, only time will tell.

Kahn: We are the only country in the world where insurance companies are allowed to make a margin on healthcare. We have a very different model than many other countries. Dr. Sherif Abdou: Capitalism is important. And profit is not a four-letter word as long as it has centered the patient in the process.

Leguen: You only see proper funding in public health when there is a very specific issue [targeting a] community. In the early 90s with the rising tuberculosis [rates] across the country, there was a lot of money thrown into tuberculosis [care and research] and more recently [we saw that] with COVID.

Cook: The Affordable Care Act places a limit on the profitability of insurance carriers relative to their medical loss ratio. It stipulates that they need to pay out at least 80 percent of the money they get in monthly premiums for medical services. And in the second quarter of 2020, following the enactment of the public health emergency, we saw elective primary care bids fall off to such a great extent that for the first time ever in Nevada, CMS had to order refunds to be issued from insurance carriers to consumers because they exceeded that 80 percent threshold.

Leguen: Nevada is close to being the worst in the country [for public health]. The state of Nevada does allocate [limited] funds for public health. In the latest legislature, they approved the SB 118 law, which provides about $50 million to support public health infrastructure. That is like throwing a coin in the middle of a garden. That is nothing. And it is limited funding for two years [which is] even worse. But that program is not unique to Nevada, it is across the country. But Nevada is one of the worst states in terms of public health support and infrastructure.

Kahn: [Concerning the] healthcare dollar, hospital care is the biggest part. Physician service [costs] are getting smaller as pharma is getting bigger, but physician services are still bigger than pharma. The three big [expenses] in order are hospitals, physicians, and then pharma. Those really drive costs.

Rhodes: We tend to train our doctors in the hospital, which is probably the most expensive place to deliver care. We need to retrain our physicians on how to be efficient and affordable in what they do and how to do a lot of it outpatient and shift the cost to where we can [provide care] in an affordable way.

Abdou: In my day [practicing medicine] we saw our patients in the office. We [only] stopped by the hospital to see patients [when necessary] or when they needed care in the middle of the night. I either went down [to the hospital myself] or called one of my colleagues [to go in my stead]. I was able to take care of a significant number of patients. Now, [a patient has] three or four providers that are seeing them. Somebody is sitting in the office and somebody is in the hospital. There is a hospitalist that takes care of the patient during the day, and there is a hospitalist that takes care of the patient during [the night] and there are doctors that are assigned [to work weekends]. There are four providers that provide the same exact care that was provided [as individual doctors] in the late 90 and early 2000. That is the cost in the system.

Rhodes: There is a lot of testing that goes on that is probably not necessary. Back around 2011, it was estimated that about 30 percent of the dollar spent in healthcare is wasted and is not bringing value to the patient or the patient’s illness. Most of us who have been on the floors in the hospitals and been in hallways of clinics would say it is probably more than that. Some of [the testing in healthcare] may be to protect yourself from liability. It also is an easier process if you need to see more patients [because you] get paid by how many patients you see in that day. We have a system that many times encourages those tests and they become easily justifiable. But ultimately, the person who works benefits from that and that adds to some of the waste that is in the system.

Cook: Every year we track the increase in exchange wide [healthcare] rates relative to the previous year and we saw our lowest percentage increase year-over-year from 2023 to 2024. We saw exchange wide about a 2.8 percent average increase, which seems to be far less than the corresponding increase in actual cost of medical services. That is good news for our patients. They are going to see a fairly negligible increase in their premiums for 2023 to 2024.

What Role Does Technology Play in Healthcare?

Rhodes: When we went through the pandemic, a lot of us thought that [telemedicine] was going to create a great shift [in medicine]. [But] most of my patients did not want to give up face to face time in the exam room with their provider if they had a relationship with their provider.

Cook: We see telehealth as a way to potentially increase access to care in the rural areas of Nevada. In many parts of the state, our enrollees have to drive several hours to see a primary care physician. Abdou: [The use of technology in medicine] is a tool that is a sign of the times and can enhance patient engagement significantly.

Delgado: That is what we have seen. [We see technology as an] opportunity to establish care, especially with a lot of our primary care demographics that we serve. Seventy percent of our patients are Spanish speaking. And so [we use technology to] build and gain the trust of a patient. Once we have established care with [a patient’s] parents or the children, they tend to bring in their families and [develop a] relationship with their primary care [physician]. The hope is that starts to trickle and ripple across not only their families, but of course their immediate community.

Windfeldt: Telemedicine is not taking off at [a extreme] level from the evaluation side of it, but it is definitely helping us keep track of patients and what they are doing. That level of technology is really helping [our] understanding [of the patients habits]. Are they exercising? Are they doing the things they should be doing? Without everybody wearing devices that track [their movement], that information is significantly valuable from a healthcare team perspective to see and understand what is going on with our patients on a day-to-day basis.

Kahn: When I was a medical student, the way I learned how to do a lumbar puncture was, I saw one, I did one, and I taught the next. In medical schools now, we have simulation centers, and students are not asked to do something on a patient before they have done many supervised, simulated procedures, and then they move to patients in a supervised fashion. The training that medical students get today is certainly more thorough than what I got because of simulation and because of technology.

Cook: The Centers for Medicare and Medicaid Services promulgate new proposed regulations every year. Among the proposed regulations this year they are proposing a number of network adequacy standard changes, including distance to primary care providers and requiring primary care providers throughout the state to offer telemedicine. I would have thought that was a no brainer if they are out in the rural parts of Nevada, but many of them are not. In order to be considered part of an adequate network, they are going to have to start providing these services potentially as early 2025. That is a positive sign that at least at the federal level, they are recognizing the need, particularly in the rural areas of the country, for provider clinics, not just primary care specialists as well, to provide access to telemedicine.

How Is Physician Burnout Affecting Healthcare?

Abdou: The biggest challenge [in healthcare] continues to be the moral injury that all healthcare professionals experience. There is no going around it. You can increase the number of students and residents by double, but if they all create the same burnout, you are not going to get any improvement in the outcome. It is reaching a public health crisis level.

Kahn: Young people today are different than we were [when we were practicing]. I was on call every third night for three years. That does not happen anymore. I am not saying what we did was better, necessarily, but it was just different. And when you look at the current generation and their expectations, their concept of work life equilibrium is very different than ours. Abdou: The burnout starts in residency. Before they go into real life, they start getting burnout and not only the providers [but the nurses too].

Kahn: The constant fight with medical records, the constant fight with pre approvals, and pre-authorizations and the constant fight to get what you need for your patient leads to this burnout and moral injury.

Rhodes: Many times [the burnout is because] the system lets [the doctors] down. Many times, they chose to jump into a seat that does not allow them to also perform in that area. And sometimes they need to relook at what they are doing within the profession. That does not mean that they need to leave the profession, but maybe they need to relook at how they are addressing it or where they are working to find it.

Abdou: [Doctors enter the field with] a high level of moral expectation and [then they realize that] it is all about the numbers. [The focus is on] the numbers of residents, the number of students, the number of visits per day, the number of operation expenses, etc. Even the quality [of care] has been turned into a number.

Rhodes: When you are burnt out and you walk into an exam room with a patient, that same care, compassion, and passion that you wrote about in your personal statement [when applying to get] into medical school, [likely will not be there].

Kahn: When people leave the profession, you do not have quality [care]. And if people are burnt out, they are not at the top of their game.