What will it take to reduce Nevada's doctor shortage?

That's this week on Nevada Week .

♪♪♪ Support for Nevada Week is provided by Senator William H. Hernstadt.

-Welcome to Nevada Week .

I'm Amber Renee Dixon.

There's a joke among locals that goes: Where do you go to get good health care in Las Vegas?

The answer: The airport, because you have to leave the state.

There is a doctor shortage in Nevada.

According to the latest data from the Association of American Medical Colleges, Nevada ranks 45th in the country for the number of active physicians per 100,000 people.

Here to discuss how to solve that deficit are Dr. Marc Kahn, Dean of the Kirk Kerkorian School of Medicine at UNLV, and Diego Trujillo, Chief Executive Officer for Las Vegas HEALS, a coalition of healthcare industry professionals.

Gentlemen, thank you so much for joining us.

-Thank you.

-Thank you for having us.

-When you hear that joke, what do you think, doctor?

(Dr. Marc Kahn) You know, it's a joke I'll never tell.

I gotta be candid.

I take it somewhat personally because our job as a relatively new medical school is to improve health care and to take care of our community.

And people have a right in Las Vegas and in Nevada to have the spectrum of health care and the quality of health care that's available everywhere.

-How do you go about reducing the doctor shortage in Nevada?

-So I think there's two things to look at: There is a grow-your-own solution, and there's an import solution.

So to grow our own, you know, we are at UNLV going to increase our class size.

But more-- but more importantly, we need to have an increase in the number of residency programs.

So after a medical student graduates, they have to do further training in order to be Board certified in a specialty or subspecialty.

And the data clearly shows that a medical student who graduates from a medical school in Las Vegas-- I'm sorry, in Nevada, has a 50/50 chance as to whether or not they'll practice in the state.

If they do residency here as well, that number goes up to almost 80%.

So that's the grow-your-own solution.

When we look at the import solution, we need to facilitate getting doctors into our state from other states.

That includes streamlining the licensure process, that includes having rational malpractice regulations, and that includes having reasonable reimbursement from state sources like Medicaid.

-Let's talk about the Medicaid reimbursement.

Why is that necessary in getting doctors here?

(Diego Trujillo) For me, it's a very easy answer.

It's just to remain competitive, at the very least, with the states around us, especially when you're taking into account with the malpractice insurance.

It really depends on how friendly we want to make our state to physicians.

They get a choice as to where they want to go.

And I think it would be very obvious for the rest of us in any industry that if we have better choices in every state around Nevada, then we would make those choices.

Why would the physicians not make those choices as well?

And so I think we need to work hard as a community in Nevada to be able to make this more friendly for physicians so that they do choose to come or stay.

-How does Nevada compare Medicaid ratewise, reimbursement ratewise, compared to other states?

-Yeah, I mean, we're one of the-- we have one of the lower reimbursement rates compared to other states.

Again, that does make it difficult for folks to come into our state to practice.

-What else makes it difficult?

You talked about the licensure.

-So different states have different processes for licensure.

I'm going to be conservative and say ours is not streamlined like it should be.

And when you delay, when you increase the time it takes for a physician to get a license, sometimes they're going to just get frustrated and go to another state.

-Let's also talk about AB404.

And that deals with the medical malpractice, something that you are lobbying against in this year's legislative session.

What does that bill do if it was passed?

-So what we're looking-- Right now from what it appears, they want to raise the cap to two-and-a-half million.

I'm looking at the statute of limitations, how much an attorney is able to charge for their services during the trial.

So it would have severe consequences for the physicians and for our community, in general, and the access to care that we have.

-What is the cap right now for medical malpractice that a patient can get if they are suing?

-I believe it's 350,000, if I'm not mistaken.

-And they are looking to raise that to two-and-a-half million?

-They're looking to raise it to two-and-a-half million.

-What kind of impact would that have on doctors and this issue of the doctor shortage in Nevada?

-So you could look-- This has been done in New Mexico, and you can look at the statistics that are coming out of New Mexico.

And you can see the drop in OB/GYN, pediatric physicians.

They just-- We're already at a disadvantage in that we're paying them less, and now they're more liable.

And so again, it's the hostility that they feel within the state.

Would you not rather live somewhere where you just feel like your work is appreciated and you can work a little more freely to your calling, which is what medicine is, right?

And so to support that calling, I think as a community, we need to make a choice.

And Dr. Kahn, I mean, when we look at AB404, he mentions the Medical Board.

I think that we do need to discuss oversight of physicians.

I don't know, or I have not seen any data, any study, that shows that allowing for a larger settlement brings better outcomes to medicine.

And so I think we need to have an honest conversation.

And the important part for me is that we, as a healthcare community, are controlling that dialogue and that narrative and having those discussions.

-Anything you'd like to add to that?

-Just to say whether or not you believe in the sentiment of AB404, the reality is, is that if you increase the malpractice cap, that's going to have a negative effect on our ability to attract and retain physicians.

So it's a choice you have to make.

If you think the malpractice cap should be higher, then you have to be willing to accept that that's going to result in less physicians.

-And if the malpractice cap was raised, physicians would have to respond by paying more insurance premiums?

Is that how it would work?

-That's correct.

-It's interesting you brought up OB/GYNs, because mine just recently told me AB404 might make it, if it were to pass, impossible for me to continue practicing.

-I think it's very unfortunate.

We want to be a state that is competitive, even with small business.

And some of the larger organizations are able to brace for that impact.

My concern is for the smaller primary care offices, for those, for those smaller OB/GYN practices.

How do they survive?

They either go work for a large organization that will pay that insurance for them-- And what will end up happening is you will lose those small practices.

-You could understand, though, from someone who may go to the hospital and suffer something that is life altering, in which they cannot function anymore or are unable to speak.

There was an article in the Review-Journal recently about a woman who suffered from locked-in syndrome after a visit to the hospital and cannot move, can only communicate through blinking.

She got reportedly a $47 million settlement.

But that cap, according to her lawyer, she's only gonna get like $350,000 according to him.

How would you respond to that?

-There's unfortunate circumstances even for me with the care of my father.

I would-- When he was misdiagnosed and mistreated due to a very rare disease, we had to go to Mexicali to actually get a biopsy on his kidney, because nobody wanted to do it for liability issues.

-Here in Nevada?

-Yeah.

And there's very tragic stories that happen.

I think that the end goal is to have better outcomes for patients.

And I don't see that being able to sue for more is going to solve that issue.

I would like to work towards better oversight and supporting in whatever way we can as a community.

I just don't see any data that reflects that that is a solution that, doctors perform better when they know they're more liable.

-We gotta get back to the "growing our own."

The residencies is super important here.

If that's what's needed to reduce the doctor shortage in Nevada, why doesn't Nevada have enough residencies?

-So residencies are primarily funded by the Centers for Medicaid and Medicare Services, CMS, by the federal government.

And a law was passed in 1996 that went into effect in 1997 that effectively capped the number of positions that the federal government was going to pay.

As a result when we look now, Nevada as a state has 404 CMS funded residency positions for the whole state.

You compare that to California that has over 9,000 or New York State that has over 16,000.

So what's happened is the federal funding has been frozen.

And since 1997, the past 25, 26 years, we're a very different state than we were.

-Populationwise.

-So what's happened is we haven't been able to keep up with the times.

That's the problem.

-What has been happening at the federal level, if anything, to address that?

-So several years ago as part of the Balanced Budget Act, the Federal Government did agree to fund 1,000 more positions over five years for the entire country.

So that's 200 positions a year.

We were fortunate at UNLV to get two-and-a-half the first year.

You have to apply every year.

And not that I'm not happy that that happened, that's really a drop in the bucket.

-What do you do with half a residency?

-Well, residents are also paid sometimes by the VA or other sources, but yeah.

-Okay.

So then you are looking to the state, I would imagine?

-We're looking to the state.

And the past two governors have been generous in using state monies to support GME.

What we're looking-- -Which is Graduate Medical Education.

-I'm sorry.

GME is Graduate Medical Education, which are the residencies and fellowships that physicians enter after graduating medical school.

So the past two governors have been supportive, as is the current governor.

What we're trying to do, though, is increase the amount of funding.

Again, we are woefully behind other states.

And until we're able to catch up, I think that the physician shortages that we see in state are not likely to get better.

-So Governor Joe Lombardo, as part of his budget, is proposing about $8.5 million for residencies and fellowships.

Is that enough?

What will it do?

-You know, realistically, someone asked me, How much money would you like?

I said, How much can you give us?

I mean, we are so behind the eight ball.

We'd like to see the governor consider doubling that amount.

-Okay.

-I think that's going to be really important.

There are specialty training programs, residency programs, that don't even exist in our state.

So we're in the Sun Belt, yet there's not a dermatology training program in the state.

We have an aging population.

There's no training programs in urology or ophthalmology.

So not only do we need in-house growth to increase the size of some of the programs we have, but we also need to expand into important areas that we don't even have training programs in for our medical school graduates.

-If you were to get that double, that funding--so that would be $17 million--how many residences would that create?

How soon?

-So if we were-- So getting a residency program approved requires an accreditation process that at best takes a year and a half, but probably closer to two to three years.

So there is a lead-in period.

A resident, if you look at a resident and you include the salary and you include all the fixed costs to running a residency, it's about $150 a resident.

But what you have to realize is if a residency program is three years and we have two residents in the program, the first year that's two residents.

That's $300,000.

The second year, since those first year residents become second year, now we have four residents.

So now we're up to four times 150, or 600,000.

And the third year, now we have two in each class.

So now we're up to six times 150, or $900,000.

-So that proposed funding wouldn't quite work out for the timeline of a typical residency, which is three to four years?

-We would like the governor and his office and the legislator to consider extending the timeline, recognizing that there's a lead-in period before you even get residents.

Now, admittedly, there are some startup costs, but the cost of a residency program really increases as the program matures.

So it's most expensive when it's full in each of the years.

-Very quickly, how long until this doctor shortage can be solved if you get the money you need for residencies and then Nevada starts seeing those doctors in action?

-If we get the support, the financial support that we need, we can see a difference in three to five years.

To completely fix the problem though, I think we're talking about a considerably longer period of time, because we're starting so far behind.

-Okay.

And Diego, what's it gonna take?

-For me, it's very important that we bring in the right talent.

I'm looking at the schools of medicine.

Dr. Khan, hearing him speak and his knowledge and what he brings to the valley is incredible, but in the same way that we need to worry about our own health, I think as a community, we also need to worry about our own health.

And I think it's important for people to understand these matters so that when they need the support as they go to the governor's office, that we as a population, as a healthcare community, are there right behind them to echo what they're saying and really work to solve this.

We need to invest if we're going to see a return.

It won't just solve itself.

-Gentlemen, thank you so much for joining us.

-Thank you very much.

-38% of medical students graduating from the Kirk Kerkorian School of Medicine this year will remain in Nevada for their residencies.

Meanwhile, 30% of medical students graduating from Touro University Nevada will also stay in the state for their residency program assignments.

Maria Silva joins us now.

And Maria, all of these students learned about their residency locations on March 17, the day known as "Match Day."

(Maria Silva) Yeah, and it's an exciting day.

And on Match Day, not just students here in Nevada, but medical students across the entire country-- -Cool.

- --precisely at 9 a.m.

They have these envelopes with them.

They opened those up, and that's revealing where they'll be doing their residency.

Some of them doing three up to, you know, six, eight years, some of them.

Now, Touro University Nevada, another exciting thing about that is that all of their students, 100% matched, and they had the 100% rate, which is sometimes not unheard of for some schools.

So all of the students were able to match.

162 medical students to be exact.

Even more exciting, out of those 162 students, 50 will complete their residency in state here in Nevada.

Now, I caught up with two medical students, one staying in Nevada and one heading out of state.

Now, both shared what Match Day means and what's in store for these soon-to-be doctors.

(Fabiha Hossain) We were both up in the morning.

We couldn't sleep.

We were just like, Oh my gosh, where are we gonna go?

(Amal Noureldine) The most, I think, surreal moment ever.

-Amal Noureldine and Fabiha Hossain, two of the 162 medical students from Touro University Nevada's College of Osteopathic Medicine who gathered in a ballroom at Green Valley Ranch for Match Day 2023.

-We got our envelopes maybe like 20 minutes before we opened them.

And we just had to sit there.

And it's like minutes before I felt like I couldn't even breathe.

-What's inside these envelopes, life changing for the students of Nevada's largest medical school.

How the medical students are paired with their residency programs involves a Nobel-Prize-winning algorithm.

I'll let Dr. Wolfgang Gilliar, Dean and Chief Academic Officer, explain.

(Dr. Wolfgang Gilliar) The graduating senior ranks the programs that they would like to go to in the ranking from 1 to 15, 26, whichever number they would like to do.

Then the various programs, this means the residency, when say, Student X applied there, and they say, Oh, Student X was fantastic.

We make her number one.

Then this gets into the computer and they say, They said 16 here, they said 5.

The computer analyzes it all and then ultimately says, They chose this as number one.

Okay, they can end up here as number one.

-Amal, one of the 50 students who will remain in state to help with the growing demand for quality healthcare providers in Nevada.

-I matched at Sunrise Health here in Las Vegas, but I'm actually going to be training at Southern Hills Hospital, it's like a branch of Sunrise, for psychiatry.

So I will be there for the next four years.

-The other 112 medical students will be entering residencies in 28 other states, with 40 students going to California.

-I'm going to Kaiser Oakland for pediatrics.

I'm super excited.

-The hope is to one day have more graduating medical students stay in Nevada.

-Now, what I like to do is that out of our graduates of about 175-180, about 100 stay in this state.

That's my dream.

Because in 10 years, we have about 1,000 students who would then become physicians and hopefully stay.

Because the data show, if you do medical school and your residency in the area, you will stay 75% in that area.

-Amal does plan to stay in Nevada once she completes her residency.

-We desperately need healthcare providers, especially mental healthcare providers.

I felt like I really enjoyed my time here, and I would like to contribute to that further in my journey.

-As for Fabiha's journey, she hasn't completely ruled out returning to Nevada.

-I did enjoy all my pediatric rotations here, and I would love to come back.

-Dr. Gilliar's advice for these graduating medical students comes from experience and from the heart.

-Know why you're doing this and that in the end it is worth it.

You're doing this for support of the common good for society.

And even though when things look really dark and difficult, you have a mission.

And those values should drive you.

Because in the end, it is really in the beautiful ways we can change the world.

And in medicine, you can really do that.

-The faculty and staff at Touro, so proud of their students.

Check this out.

They took out a full-page ad in the Sunday newspaper to congratulate their medical students who, by the way, they graduate officially, Amber, in May.

So a big congratulations to all of these students.

It's so great to see the video.

They're all smiling and so excited.

And to share that with their families, it's super special.

-It means a lot to their families from that video, right?

So much hard work they've put in.

The majority of these students, what kind of residencies are they going to be doing?

-Well, many of them-- Actually, out of the 162, 90, or about 55%, are going actually into primary care.

And that includes family medicine, internal medicine, and pediatrics as well.

-All right, Maria.

Thank you so much.

And thank you for filling in for me while I've been out.

-It's so wonderful to have you back and precious baby Otto.

Love him.

-Thank you, Maria.

Okay, we continue our healthcare conversation now from the legislative perspective.

Joining us with more on what measures Nevada lawmakers are considering in Carson City right now is Tabitha Mueller of The Nevada Independent .

And Tabitha, you recently wrote about a bill that would impact what Nevadans pay for prescription drugs.

What would that do if passed?

-Right.

So if passed, what this bill would do is it would take what-- So what this bill would do is that it would take, as part of President Joe Biden's Inflation Reduction Act, there was a measure that said Medicare can now negotiate the price of prescription drugs for Medicare recipients.

This bill, what it says is it looks to build upon that and say that these drug price caps would apply statewide regardless of insurance.

So if it passes, the measure would go into effect in 2026 and make it so that any drug price negotiated by Medicare would be the drug price for all Nevada consumers.

-What were some of the arguments for and against it that stood out to you?

-So I think one of the arguments from, you know, lawmakers who are supporting this bill is saying, Look, we're in a time where cost of living is rising, drug prices are incredibly high and often out of reach for most families.

However, on the other side, you had, you know, pharmaceutical companies saying that this would be basically-- pharmaceutical companies saying that these federally-- this is a federally made decision; that we're now applying to the state level, and it's sort of arbitrary.

They're also saying that it unfairly targets manufacturers of the drug and not other parts of the supply chain, like insurance companies or other organizations.

-And the Culinary Union, where did it stand on this?

-Right.

And so, interestingly enough, the Culinary Union actually testified in opposition to the bill, saying that they weren't brought to the table when discussions were happening.

Now, lawmakers did include a carve-out for unions that negotiate their own drug prices and, you know, set their own healthcare stuff.

But it was really interesting in that hearing where they said, Look, we weren't brought to the table.

We are always supportive of lowering drug prices, but this is too soon, too quick, and we need more time to discuss this.

-All right.

And there were some other healthcare bills that were discussed, two of which Governor Joe Lombardo had prior said, I'm not going to support these.

But lawmakers went ahead and heard them anyway.

What does that indicate to you about this legislative session and the makeup of the body?

-I mean, what you have to understand about this legislative session is that there's Democratic majority in the Senate and a Democratic supermajority in the Assembly.

And those lawmakers are not necessarily in lockstep with the governor.

And this shows some of the tensions that are happening between the governor's office and, you know, the Assembly and Senate.

And I think one of-- What you need to keep in mind is the governor does have veto power unless bills are passed with two-thirds of majority out of both Houses.

So I think that's something that we're gonna have to keep watching.

Obviously, Lombardo said, Hey, don't hear these bills.

The lawmakers did hear them.

And so it'll be interesting to see whether they move forward in the process.

-And I'm curious what those bills were that he did not have support for.

-So the first one is AB6.

And that would basically establish into law an executive order that says Sisolak, that Governor Steve Sisolak, put in place saying, Hey, we need to have a healthcare cost growth benchmark.

So we'd like to keep healthcare costs below a certain percentage year over year.

It's more of a goal than a set, you know, If we don't make this, then people are going to be penalized.

The other one is AB11.

And that seeks to prohibit a hospital or psychiatric hospital from employing a full-time doctor.

Basically, a lot of doctors practice medicine as independent contractors for hospitals.

And this law, proponents say, would make it so that, you know, one hospital couldn't have a specialized care provider that other hospitals then wouldn't have access to.

-And the bill that he may support, what did that entail?

-So that measure basically-- That measure looks like it has support from members of the healthcare industry and from, you know, healthcare advocates as well.

And essentially, it would make it so that electronic records that were part of your, you know-- Your electronic healthcare records could be shared easily between different doctors and, you know, medical groups with your consent.

-And then one more bill relating to health care, Assembly Bill 108.

Proponents say that it could help address the state's nursing shortage.

How so?

-So essentially, Nevada has roughly a three-- has a shortage.

We would need about 3,000 new nurses.

Maybe a little bit more depending on some estimates.

And what that bill says is that we would join a nurse licensure compact.

It's a little like a driver's license, right?

If you get a driver's license here in Nevada, you can drive in Connecticut, you can drive in Oregon.

But what this would say is that if you are a nurse and you have a licensure with this compact, you can operate in Nevada, and I believe it's 37 other states that are also part of the compact.

-Tabitha Mueller of The Nevada -- -In-- -Oh, I'm sorry.

One more thing?

-No.

I was just gonna say that proponents are saying this would allow the state to have access to more nurses and make it easier to become a nurse here and practice.

-And as you mentioned, there's quite the nursing shortage here in addition to doctors.

Tabitha Mueller of The Nevada Independent , thank you so much for joining us.

And thank you for watching.

For any of the resources discussed here, go to vegaspbs.org/nevadaweek.

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