Healthcare in Nevada hasn’t always had a stellar reputation. From access and cost to professional burnout, the Silver State has a myriad of challenges. But when a suspicious spot shows up on a CAT scan or a bizarre symptom manifests itself Nevadan’s rely on medical professionals.
Recently, a group of healthcare leaders met at a roundtable sponsored by Nevada State Bank and held in Las Vegas to discuss their industry including the significant shortage of clinicians, a challenged hospice environment, the impact of cybersecurity on medicine and many of the driving factors behind healthcare costs.
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 the Shortage of Healthcare Professionals in Nevada?
Dr. Marc Kahn: Nevada does not reach the 50th percentile in physicians per capita for any specialty. We are short across the board, and that does not even take into account some of the other health professionals like nurses, medical technologists and pharmacists, etcetera.
Dr. Amir Bacchus: There are just not enough physicians or clinicians to do the work that we need to do. It drives all the other issues that we see everywhere. Whether it is quality issues, access issues, mental health illness and management, it is all because we do not have enough clinicians.
Blayne Osborn: We need everybody. We talk a lot about doctors and nurses, but we also need lab techs, RAD techs, CNAS, CRNAS, and MAs. We need everybody.
Dr. David Steinberg: We are struggling to attract doctors and keep doctors, especially in radiology. And because radiology is now a digital specialty, you do not have to get dressed in the morning to make a living. You can work from your living room or den and read studies from states that pay far more than Nevada. We are competing against every other state in the union.
Bacchus: If you look at Dartmouth data, at the end of 2023, Nevada ranked 48th in the country for primary care physicians. For general surgeons, we rank 49th. It is pathetic. And for being such a dynamic city with all the things that we have and the things that we do, not only in Las Vegas, but throughout the state, it is still hard to attract enough good clinicians.
Steinberg: When you look at the healthcare shortage, there is only so much you can do. You can either pay them more, or increase their quality of life. We are still living in this post-COVID reaction, where health care providers and care workers were stressed out and not appreciated. You can’t find someone to work in a nursing home or someone to work in a dementia facility and the idea of working long hours for 15 or 20 bucks an hour does not work. Caring for people is very intense. It is very draining. People are not going into professions that require manual labor with caring.
Barry Duplantis: There are fewer and fewer people even going to school to become healthcare providers.
Kahn: There are two ways to grow your workforce. One is you recruit from outside and the other is that you grow your own. We know that if you graduate from medical school in Nevada, you have about a 40 percent chance of practicing here. If you do your residency or fellowship in Nevada, there is about a 60 percent chance you will practice here. But if you do both, it goes up to 80 percent. The secret to growing your own workforce is not medical students, it is residency programs. And since we were capped in 1997, we have 403 federally funded residency programs in the entire state. That is compared to California with over 9,000 and New York with 18,000. We are woefully undersubscribed. And unless we fix the residency picture, we are not going to be able to improve the “grow your own” strategy and increase our physician workforce.
Are There Barriers to Practicing in Nevada?
Steinberg: To get a medical license in the state of Nevada is very difficult. If you were the top of your class in high school, you did nothing wrong in college, you were the top of your class in medical school, you went to UCLA, and you did not graduate from a foreign medical school or anything else, it could take you six months to a year to get a medical license. But the insult gets worse. Once you get a medical license, it can take you six months to a year to get credentialed on all the different boards. And, by the way, no one will start their credentialing process until you have a medical license. It is adding insult to injury because we are already short.
Renee Coffman: I have been hearing about this for 20 years. This is not a new problem, and it is fixable.
Mason Van Houweling: Nevada has an unfortunate reputation in the medical community of being too much of a hassle. Other states are expediting the process for doctors coming out of a residency or a fellowship. Nevada needs a single application or to reciprocate more what other states are doing. It is fixable, we just need leadership.
Steinberg: It has gotten a little bit better incrementally. But the problem is that Nevada has never emphasized education or healthcare. In Ohio, you have integrated healthcare models that are unbelievable and that provide extraordinary care. It is such a huge engine that the whole state is focused on making that industry happy. Unfortunately, education and healthcare have been a second thought after gaming in Nevada. It needs to change because we are not going to attract physicians and industries that want to have excellent healthcare. We need to let the governor, and state representatives know that we cannot tolerate it taking six months to a year to get a medical license because we need physicians now. I could grow my business another 15 percent tomorrow if I had the providers. In 2026 and 2027 I have doctors coming, but that does not do anything for me now.
What Is the Hospice Environment?
Karen Rubel: The biggest challenge for hospice right now is the proliferation of hospice companies. In southern Nevada, we have over 280 hospices in Clark County alone. What became just counting who our competition was, has now become an issue of elder abuse. We get about 15 to 20 transfers a month from other hospices. And when we track the reasons, it is because people are not receiving care. They have never seen a nurse. They do not know that they are in hospice. They do not get pain medication when they call for help, but are told to go to the emergency room.
Steinberg: The reason there is a proliferation of hospices, just like cannabis stores, is because there must be a good margin. Once the margins in cannabis stores in Colorado disappeared, all the cannabis stores started to disappear. It is as simple as that.
Rubel: In hospice we are paid on a per diem rate and there is a significant difference between a for-profit and a nonprofit when you look at their bottom line. We try to break even every year but we still lose money every year. Some of the hospices in southern Nevada are making a 40 percent margin. That money is not going back into patient care. It is going to make that margin. Until that gets addressed, that is always going to be a problem.
Bacchus: Hospice rates in this area are extremely low. A normal hospice rate should be about 4 per 1,000, 4 percent of your population should be in a hospice. In this market, less than 1 percent of patients actually utilize hospice because a lot of physicians do not ever want to have that conversation. They decide to send them to oncology or decide to continue to treat them on drugs even though they have two months or less of life. They do not want to tell them that no matter what they do, the patient is not going to make it. Instead, they can spend $400- to $500,000 in the last two months of their life. It is a whole dynamic.
Rubel: We are actively seeking some legislation in this next legislative session to try to get some guardrails up in hospice, including maybe a moratorium on issuing hospice business licenses. Something has to change. Seniors and folks that are receiving hospice care do not know that they are not getting good care because they do not necessarily understand what kind of care they should receive. It is headed to the point where it is going to be hard to get the genie back in the bottle, if we do not put some protections in place for the people that are most vulnerable.
Steinberg: Before we put my dad in hospice, he was solicited from eight different hospices. Everyone knew he was sick, and everyone knew he probably did not need that much care. It is horrible.
Rubel: I am cautiously optimistic that we might be able to get some things in the legislation for hospice care, like an advisory group. Currently, if you are a hospice and have a census that is lower than 50 patients, you have no responsibility to report to the Centers for Medicare and Medicaid Services or to the state. There are no guardrails for those little hospices that are providing insufficient care because there is no mechanism to hold them accountable.
Is Cybersecurity an Issue in Healthcare?
Osborn: A challenge that is always on our minds is cybersecurity. It is not really a matter of if you are going to get hit by a cyber-attack, but when.
Steinberg: There is no reimbursement in any government program or any insurance company for jobs that did not exist three or four years ago. [That includes] paying for cybersecurity, the cybersecurity workforce and having a PR plan in place if and when you get hacked.
Osborn: It is only going to continue getting worse as everything becomes more electronic with more AI.
Steinberg: And healthcare is the number one target for cyberattacks.
Van Houweling: From a leadership standpoint, I have been through a lot in my life. First in Afghanistan when I almost lost my life, the October 1st [shooting], a pandemic and lots of stressful things. But going through a cyberattack was the most stressful thing I have ever been through as a leader. You do not know the enemy that you face. They have more resources than you. They do not have ethics. It is not a matter of if, but when you will get attacked.
Steinberg: In radiology, you are basically information storage. Everyone wants your data. We have a whole team of six people who deal with our cybersecurity all day long. Not only that, but when they go home at night, we have a remote team that works 24 hours a day. We did not have cyber insurance five years ago. In fact, I do not even think it existed five years ago.
Van Houweling: Hackers will wait you out. They could be sitting on your system for three years waiting and then casting that net. That is all they do. And here we are trying to take care of patients in the last days of their life or the weakest moments or trauma. And then we have to fight this.
Why Is Healthcare So Expensive?
Bacchus: If you do not have access to healthcare, then you are going to the ER. And if you are going to the ER and in for observation, it costs significantly more to pay for that versus actually being seen by your physician or having access to a physician that can help monitor or manage you, urgent care or otherwise. We are seeing costs elevate there. Technology has also increased some of the costs and there have been astronomical increases in drug costs across the country. I can tell you from a national perspective, all of the big MCOs (managed care organizations) in 2024 had astronomical increases in [Medicare] Part B drug utilization and they all lost a significant amount of money. Does that mean they are hurting? Of course not. But they are not meeting the margins they think they should be meeting. All of these things are compiling at the same time and are leading to astronomical costs.
Steinberg: We also do not understand what a life is worth or what quality of life is worth. It is a constantly moving target. We did not understand that dementia can be caused by a lack of hearing and now we know that caring for a dementia patient and Alzheimer’s is going to break the healthcare system in America. But where is the money to pay $3,000 now for a hearing aid versus $75,000 to $150,000 a year for extended care four or five years from now? We do not have a global impact where an insurer can agree to spend $3,000 now because they will save that money five or 10 years from now. And part of the problem is that everyone has their own self-interest in mind. Everyone has their cash register in their own little private area, rather than looking at what the totality of cost is, what the quality of life is and what building a healthy society looks like. It is dysfunctional.
Steinberg: Childhood cancer used to be a death sentence, especially the leukemias, and now we can cure them. We can basically cure people from hepatitis C and stop them from getting hepatomas and other long-term costs. The problem is that our ecosystem does not pay people to treat in the short term because the long-term benefits is recognized by someone else. The insurance companies often balk at spending a million dollars on a drug that will give someone a new chance in life. But on the other hand, where are the savings later on? Hepatitis C and HIV treatments have changed our entire country and liberated so many people from death sentences.
Duplantis: In our case, as a 501(C)(3) not-for-profit, 65 percent of all of my expenses are labor. I want to keep paramedics employed, I have to pay a competitive wage because otherwise, they will go work for the fire departments, etcetera. When I build a budget, I am not building it to yield a 35 percent margin. I am generally building it to yield about 8 percent and hoping to get it, knowing that at the end of the day, surprises will happen.
Paul Dieter: One of the other things that is very expensive is treatments. People are living a lot longer. A person getting an expensive therapy for 10 years versus 10 weeks or 10 months, is part of what drives it. What has changed a lot with drugs over the last several years is we used to always negotiate and try to work with the insurance companies. What happens now is, for half of our patients that are commercial, we are dictated which drug we are going to use based on the rebates that the insurance companies are getting on those drugs. We have to constantly fight that. We can lose $5,000 a dose just because the insurance company is getting a $15,000 rebate on the back end.
Duplantis: During this election cycle, people were complaining about groceries but they have no clue what we have experienced in the rising costs of medical supplies in the last three years since COVID. Medical supplies have been up over 25 percent, and some things even more. Some of them have been complete shortages, like the saline after hurricanes.
Bacchus: We see drugs that cost a million dollars a year for one drug. We see things that are astronomical compared to what we saw just two years ago. And everybody is looking to manage their business and create some profit. How much profit is enough? For us, it’s just trying to say, “Okay, let’s practice good guideline medicine and make sure the patients get what they need and maximize care for that.”
Steinberg: In Medicare, we spend 80 to 90 percent of all the healthcare costs for that entire Medicare patient in the last 90 or 120 days of life. Where is the sense? There is probably enough money in the system, it is just not allocated appropriately.
Coffman: The incentives are not aligned to make that happen.
Duplantis: Federal deficits cannot continue on the trajectory that they are on. Our federal government covers 160 million lives and the Centers for Medicare and Medicaid Services is going to use the vast amount of data that they have to essentially harvest and categorize force cost reductions. We are going to see a 4 percent reduction in our Medicare reimbursement rates come January. Every time we turn around, there is something else.
Bacchus: Benefit packages from health plans are drastically being cut in 2025 because dental, hearing, vision and all of these buy-up programs within the insurers are too expensive. They are going to drastically cut benefits and try to put that back on to the consumer. There are all these costs and people demand them. They want to be able to see the dentists especially if they are a senior and have oral difficulty or need dentures. Hearing aids are also very important not only just to help with hearing, but for dementia reasons. All of these things are compiling at one time and are leading to escalations in overall costs.
