According to data from the American Association of Medical Colleges, Nevada ranks 45th in the country for active physicians per 100,000 residents, 48th for primary care physicians, and 49th for general surgeons.

These rankings, leaders of Nevada's medical schools are well aware of.

And here to explain what they're doing about them are Dr. Marc J. Kahn, Dean of the Kirk Kerkorian School of Medicine at UNLV; and Dr. Wolfgang Gilliar, Dean of the College of Osteopathic Medicine at Touro University, Nevada.

Gentlemen, thank you both for coming.

I'll start off with you, Dr. Kahn.

How many students are you going to be graduating this semester, and how many of them will be doing their residencies in Nevada?

(Dr. Marc J. Kahn) So actually, Amber, graduation is tomorrow.

We'll be graduating 62 seniors and 57% are staying in Nevada.

-Okay.

Same questions for you, Dr. Gilliar.

(Dr. Wolfgang Gilliar) We have about 160 graduates, and our graduation is on Monday.

And I will give you the total number of students.

That's actually 54 students out of a class of the 160 that are staying in this state.

-54.

Number of students, or just percentage?

-57% of 62 is about 33 students, 33-34.

-Okay.

And you two are representing two of Nevada's three medical schools.

The other is at the University of Nevada, Reno.

They gave a percentage too.

13% of their graduating medical students, about 69 who participated in their match day, are going to be staying in Nevada to do their residencies.

And we bring this up because it has been shown that if you do your residency somewhere, it is likely you will end up practicing there as a physician.

However, it is well documented there are not enough residencies in Nevada.

We'll start with you, Dr. Kahn.

Why is that, and what is the solution?

-Yeah.

So residency positions are in large part funded by the Centers for Medicare and Medicaid Services, the federal government.

And the federal government cap the number of funded residency positions in a law that went into effect in 1997.

We were a very different state then.

So Nevada is capped at about 403 positions for the entire state.

Compared to over 9,000 in California and over 17,000 in New York, we're really woefully under subscribed in the number of CMS funded residency positions.

-What is the chance of that federal funding changing?

-I'm not that optimistic.

I know that Senator Rosen and others have advocated for expansion as part of the pandemic funding.

The state-- the Feds did provide about 2,000 extra spots, but that's over five years and divided by the whole country.

So it's really small potatoes.

-Dr. Gilliar, what's the solution then, state funding?

-I think the solution will have to be much larger than that.

We have to go back to the federal support, and we cannot give up of increasing those numbers.

There is no question.

We just have to keep getting at this because the health of the United States depends on that.

But we have to also get as much funding as we can by the state, and I think we could actually become a model state if we find some solutions that other states have not undertaken, like saying, How can we invest in those residencies?

How can we support them?

I would think a number of million dollars could go a long way if we did this.

Then we need to see if we can get support from philanthropy or how hospitals can pitch in.

-Tell me about hospitals' roll.

I mean, nationwide, they do have a lot of residencies.

-Absolutely.

-Is that different here in Nevada?

-It is different.

And one of the major differences is that in most other states, as Dr. Kahn pointed out, the residencies are linked to the academic health centers or academic medical centers, which means a medical school, they have large hospital and that's where the residencies run.

We don't have this here in this state.

So we have private hospitals who have the residencies and, therefore, there is a mismatch in the way it's being organized.

And this is what Dr. Kahn and I talk about all the time.

How can we assure quality and an increase in numbers both, as us, the medical schools, be a catalyst to that?

-Dr. Kahn, where do you stand on where the money should go?

Would you'd like to see it at your school versus a private hospital?

-Well, so I think that the-- I think that if we're talking about state dollars.

So, in comparison, the state of Texas provides about $200 million in their biennium to fund residency positions.

And, actually, they've calculated.

So they pay for 1.1 times the number of medical school graduates that they have as a state.

We're about a 10th of the size.

So the dean at University of Nevada, Reno and I have been talking to the Governor and elected officials to see if we can get $20 million for that purpose.

I think that, you know, again, Dr. Gilliar, many of his students come to our residency programs.

We welcome them.

And, again, this is really not a school issue as much as a statewide issue.

But I do believe that state taxpayer monies should go to the state entities to grow graduate medical education to care for the community.

-So you wouldn't agree if any state money went to his school, for example, a private not-for-profit?

-Well, so actually, his school doesn't really have residencies.

So we don't-- we're not competing in this fashion.

-I understand you may want to get into that field.

-I, as I said, I would be open to create them.

But the way I like to look at it is have a real public-private, collaborative initiative where we say, What is it that the state needs, and how can we actually save money by doing it correctly?

For instance, I could then, if we were to support, let's say, three or four residences, for instance, I'd love to support a dermatology residency.

I would love to have one, and I would love to run one.

And, however, it is also very costly of employing all the physicians for that.

I would love to do cost sharing with UNLV, that the physicians come and stay with us here in Nevada and the state of Nevada benefits, and we will do some cost sharing.

So I really think we can explore some of that potential.

-Actually, the good news is, is that we are really working together: Dr. Gilliar and I in town, myself and my colleague in Reno.

And we recognize that this is not a local problem.

This is really a problem for the entire state, and the solutions are going to have to be statewide.

-Let's see if you both can agree on what the top needs are for residencies in Nevada.

You mentioned dermatology, can you-- I can't imagine that there isn't one already.

-So we-- you'll have on our list, dermatology is high on the list.

We're a sunny state, and there's not a dermatology program in the state.

We're also a state that's getting some older patients, and there's not an ophthalmology or urology program in the state.

So I think there are needs here.

We need to expand some of the programs we have-- pediatrics, women's health, OB/GYN --but we also need to create some new programs that don't exist that are desperately needed by our community.

-Do you disagree with those?

-100% agree.

-Okay.

So last legislative session, there is $8.5 million that is directed towards the government's Office of Technology, Science, Innovation.

I'm saying the order incorrectly.

-Office of Science, Innovation and Technology.

-Also known as OSIT.

-Yeah.

-This money is meant for grants for residencies and fellowships, collectively known as graduate medical education.

Where has that money gone?

-Well, I don't think we know for sure.

We got written into the bill that the deans of the state medical schools would be on the panel.

So Dr. Gilliar and I are both on the panel.

Suffice it to say that committee has yet to meet.

And we're already in [inaudible].

-Yes.

And why I say yes is I think time is really getting urgent that we come together, not just as the medical school deans, because we understand, I think, a lot of these issues as health experts.

I mean, we've been doing this 30-40 years.

And there's no easy solutions to this.

But we would like to branch out together with the Governor, with his office, and say, What else can we do?

There are some brilliant minds in this state.

And you know, if we can get philanthropy to help us, because it ultimately benefits the infrastructure.

If it benefits the infrastructures, it will go to schools, high schools, junior high schools, and then more sports teams and all those can come in with the expansion of people wanting to live here.

So there is this big loop that we are just part of it, but we should be able to close it.

-Your thoughts on this that $8.5 million was written.

And as lawmakers understood it, they thought that if that money was not used in the biennium that it would roll over into another account.

But they learned at a hearing that you were at that, no, if it's not used in these two years prior to the legislature reconvening, it goes back to the general fund.

-Yeah.

So we really do appreciate the money that the states have allocated to GME.

We truly appreciate that.

We think there might be a more efficient way to use those dollars, but we appreciate it.

And the dollars really need to be able to roll over.

If we were going to start a dermatology program today, it would take about 2 1/2 years to actually stand that up by the time we developed a curriculum and by the time we went through the accreditation process.

So a two-year turnover isn't realistic for residency programs.

That has to be extended.

Again, I'm very appreciative of our lawmakers for providing money.

We're both very hopeful that we're going to get more money.

We're both very appreciative that the Governor has seen GME as one of his key points to try to increase the numbers to better care for Nevadans.

And we're very appreciative of that.

We think there's perhaps a more efficient way to use the money, however.

-Speaking of the Governor, he recently issued an executive order, which I'm not quite sure what it will actually accomplish.

It's for the patients' commission to figure out what's going on with the health care shortage?

Do either of you know what that will accomplish?

-Yeah.

My understanding is this was the Patient Protection Commission.

So it's important that in our state we provide safe and effective care, that we do the right thing at the right time for the right reason.

And the Governor really supports such a philosophy.

I believe that that's what this bill was meant to accomplish.

-A statement more so than anything?

-I think so.

-That's how we might interpret that.

But I think it's important for a statement, I think we need to get the basics and base correct so that we all communicate in the same direction.

The first role that Dr. Kahn and Dr. Hauptman in Reno and I have is we have a social contract.

The social contract is to support the provision of physicians that are safe to the state.

And therefore we have to make sure that we have patients that are-- that the patients know the physicians that graduate are safe.

So if we start from there, then we can say, The next step is that the residents must be safe.

And this is not an easy thing to do, because it gets to quality.

And now what are these indicators?

And I think together with more money we can actually work in that direction.

-I know, but then you go back to more money.

$8.5 million, and you don't even know-- -And that's not enough.

-And that's not enough even if it was allocated by the end of the two years.

You said you have spoken to the Governor.

Is he aware of this issue with that bill?

-I can't comment.

I don't know.

Yeah.

-Okay.

Well, that has yet to be worked out.

We had also talked on the phone about incentivizing hospitals who are providing residencies.

What else can hospitals do to retain the residents?

-I think it can.

It's a long-term proposition.

For instance, hospitals could be incentivized that the residents who do a residency at their spot will actually be hired by them.

What could this incentivization look like?

That they either get money from the state or some either tax benefits or something in that direction that they say because-- that they say the resident is actually supported staying in the state.

75% of those residents who do it, do the residency, stay in the area where they do the residency.

-But do they actually end up at the specific organization or office or-- -And that then comes to competition.

And then it comes to will they stay in the area.

And I would love to say 95%, because there's always movement.

95% of residents who train in Nevada stay in Nevada.

And I think that would be a real outcome measure that we can say, Let's see how this looks like in five years.

-I think you had also mentioned loan forgiveness.

What do you think about that?

-So I think, you know, one of the things that we've been trying to work on is to get our students who leave the state to incentivize them to come back.

And we're working on raising some money for something that we call reverse scholarships.

So maybe rather than getting a scholarship up front, when you've finished your training, wherever you finish training, we'll pay back 20% of your student loan debt each year for five years.

Our hope is, is that at the end of five years, you either fall in love with Nevada or fall in love with someone in Nevada, it doesn't really matter, and that you stay here.

So I think incentivize that on the back end, I think, can help to retain some of the folks at stake.

-How friendly is Nevada to physicians?

Who wants to start?

-Tough question.

-And we only have five minutes.

-That's a tough question.

-Well, I know when we all spoke prior, your top issue, I think, was licensing, correct?

-Yeah.

So I know there has been some motion to improve the-- some movement, excuse me, to improve the licensure process.

But when I came here in 2020, it took me over seven months to get a license with a clean application.

My colleague in Reno, it took him over 10 months to get a license.

Now, the allopathic licenses, the MD, are different than the osteopathic physician licenses.

So Dr. Gilliar went through a slightly different process.

But if we need more doctors, we need to minimize the barriers to entry that we have to becoming a physician in state.

-Yep.

And there's so many little things in action, for instance, not just the ability to practice in the state of Nevada, but, for instance, to get onto insurances.

And it's tough to get onto some insurances because they say their panels are full.

And so how could you try to come in here if they say, Hey, we will not accept you onto that panel by insurance X, Y, and Z?

And that's another difficult thing, because it keeps some of the physicians out.

They don't want to come here until they know they can go there.

-Is this the insurance that would cover malpractice claims?

-No.

-No.

-Just to be able to be reimbursed for their activities as a physician.

Let's say if you have seen patients and they are with insurance X, that insurance says, But we don't need any internist anymore because we already have enough in our system.

-Okay.

Well, I brought up malpractice insurance because some doctors have had to increase that here in Nevada as the result of a law from last session in which the cap was raised on how much someone can be awarded.

It was $350,000.

Now it's going to be increased by $80,000 each year until it reaches $750,000.

You testified against this bill, but it was originally for $2.5 million.

-Right.

That's when I testified.

I thought that was just absurd.

-Have you heard of it having any impact on local doctors so far?

-I have not heard that.

-Okay.

-I'm afraid we might hear it, or we might hear it quietly.

And that's the fear.

We really don't know what the fallout is.

California may have seen some of the negative action there, but I really need to see numbers.

And so I don't want to fence in the dark.

But if we do a good job, it wouldn't really have to matter to us too much.

-Do you want to add anything?

-Just to say, look, in a physician-shortage state, like Nevada, anything that decreases the supply of physicians is potentially problematic.

Raising the cap on malpractice can potentially impact the supply of physicians that we have.

So I think we have to be careful.

Making licensure difficult, again, is going to impact the supply of physicians.

And making access to the third-party payers difficult is going to adversely impact our supply of physicians.

So if we're to increase the numbers you talked about at the beginning of our talk today, we have to (A) grow our own physicians, and (B) make it easy for physicians outside of the state to come and to practice.

-And the last thing I'll bring up is Medicaid reimbursement rates.

There has been some improvement in that area as a result of the last legislative session.

But historically, Nevada has been known to have low rates, correct?

-Yes.

-Okay.

-Yeah.

And there has been movement, and there have been for practices, especially the academic practices in state that see a large number of Medicaid patients.

You know, for example, our practice, we don't turn anybody away.

Right?

We will see anybody who has a need to see us.

There have been some improvements in rates that have been actually pretty substantial for us.

Again, when you look at the rest of the state, anything that will increase the attractiveness for people to come in the state, I think we need to work towards.

-Do you want to add anything to that?

-I think it's absolutely important that we work on that.

Because if we don't get that base up, we will lose, I think, the overall care that we do for the state of Nevada.

-All right.

Dr. Gilliar, Dr. Kahn, thank you so much for taking the time to join Nevada Week.