The Best States to Practice in 2016

Each year Physicians Practice assesses practice conditions across the United States, in search of the best states to practice. We reach out to both public and private organizations to assemble objective datasets that we think are indicative of favorable practice conditions for physicians. Then we whittle our list down to the top five states - no small task, as there is such diversity and breadth of opportunities represented in our nation.

METHODOLOGY

This year for our analysis we changed up the data just a bit. Rather than use physician disciplinary actions by state, we substituted that metric with residency retention rates (the percentage of physicians who chose to stay and practice in the state where they trained, two to 12 years post-residency). The other five state metrics are the same as last year (bit.ly/beststates-2015), with updated data: cost of living, physician density, tax burden per capita, malpractice paid loss (the amount paid in malpractice awards per state), and Medicare's Geographic Practice Cost Index (which adjusts physician reimbursement based on regional variation in the cost to treat patients). Together they paint an economic, regulatory and operational overview of practice conditions for each of the 50 states and the District of Columbia.

Of course, this doesn't account for geographic variation, sense of community, local values, or access to cultural and educational institutions. For that, you might ask your fellow physician where he or she feels most at home. Or you can read the following profiles for the physicians who hail from this year's top-five Best States to Practice: Texas, Idaho, Mississippi, Utah, and Georgia.

*If your state is not highlighted here, find out how it measures up by visiting our Best States to Practice Interactive Map at bit.ly/beststates-map.What states were the worst. Click on the last page for the answer!

TEXAS - the Lone Star State

State Motto: Friendship

Lloyd Van Winkle has practiced family medicine in Castroville, Texas - a small town of 3,800 people, 25 miles from San Antonio - for over 30 years. Van Winkle, who grew up in the state, did his undergraduate training, medical school, and residency in Texas. He says the small-town camaraderie was one of the key draws that kept him in Texas. "Well I know everybody," he says. "So I know when they have diabetes and buy an ice cream at the grocery store, I know it. It's a nice experience to be in a small town. To have that kind of connection with your patients."

Van Winkle also appreciates the climate in Texas, noting, "In December when we are on the back porch barbecuing my brother says, 'You know what people in Minnesota are thinking about right now? Doing this next summer.'"

Because of a low physician density, low cost of living, reasonable tax burden, and high residency retention rate, Texas made the top of our list for the best states to practice. The only sour note was malpractice payouts, which ranked in the bottom-third of our analysis.

Since it is a large state, patients can sometimes have trouble finding a physician, especially in remote areas. Van Winkle says he practices in an underserved area federally designated as a Health Professional Shortage Area (HPSA). However, that can be a bonus for family physicians who are interested in a well-rounded scope of practice. Van Winkle says he delivered 688 babies before he got tired of the 3 a.m. wake-up calls.

Texas is very primary-care friendly, according to Van Winkle, who was past president of the Texas Academy of Family Physicians and former board member for the American Academy of Family Physicians. Because of the large number of family physicians practicing in Texas, he says, "A lot of healthcare in Texas is primary-care driven," rather than specialty directed.

IDAHO - the Gem State

State Motto: Let it be perpetual

Idaho is known for its unspoiled wilderness and varied topography. Located in the northwest, it encompasses mountain ranges, numerous lakes and rivers, waterfalls, and canyons. It is also a great place to raise a family, according to Zachary Warnock, a family medicine physician who practices in a group practice, Intermountain Medical Clinic, based in Pocatello, Idaho. "My wife and I were looking for a place where we felt comfortable raising our children and where we could get out and go camping and hiking and skiing. Just spend time outdoors, because that's a big part of what we love to do," he says. Warnock, who is originally from a small town in Utah, says they decided to settle in Idaho not just for the environment, but also for the freedom to practice medicine the way he wished.

Idaho made our list because it has the second lowest physician density in our analysis, a low tax burden and cost of living, and very low malpractice payouts. Warnock acknowledges that while the dearth of physicians can have a negative effect on patient care, there is a sunny side. "The lack of physicians is both a good thing and a bad thing. The bad side is that we obviously need more people to provide for the needs of patients and the population in Idaho. But it does allow those of us who do family medicine specifically a lot more freedom in our scope of practice," he says. For Warnock, that means caring for all ages of patients - which involves pediatrics, adult medicine, and geriatrics "including and up to taking care of people as they die." He says he strives to have a well-rounded practice and makes the time to interact with his patients, even in their homes if that is where they need treatment.

MISSISSIPPI - the Magnolia State

State Motto: By valor and arms

Mississippi has once again made our list of top states, holding the top ranking for lowest physician density and lowest cost of living this year. It also does well in post-residency retention rates. Family physician Carlos A. Latorre can attest to that. He says after completing his residency at the University of Mississippi Medical Center, nine of out eleven residents in his cycle stayed to set up practice in in the state. Latorre is an employed physician with Merit Health River Region, practicing in Vicksburg, Miss., a city within a greater metropolitan area in the southwestern part of the state that encompasses 50,000 people, situated 40 miles west of Jackson, Miss. It is located just beyond the border between Mississippi and Louisiana, separated by the Mississippi River. While Vicksburg is not considered a rural area, Latorre says many of the surrounding towns are more rustic. "When you cross into Louisiana, as soon as you cross the river, it is also rural because there there's nothing for another 70 miles."

It is that small town hominess that Latorre finds most satisfying. He says he is well-known in his community, having resided there before he attended medical school. Patients feel comfortable entrusting their care to him and tell him, "We are glad you are here."

Latorre, who is a board member with the Mississippi Academy of Family Physicians, is also the president of the MAFP Foundation, which promotes public health educational initiatives like tobacco cessation programs. The foundation also sends medical students into the community to work with grade school students to promote healthy living.

In addition to a supportive medical association, Latorre notes "the cost of living is low, the salaries are very decent, there is a lot of work in terms of patients to be seen, and good collaboration between physicians. It is a very harmonious place to work."

UTAH - the Beehive State

State Motto: Industry

Anesthesiologist Paul N. Clayton, president of the Utah Medical Association, started his medical internship in Detroit, Mich., but soon realized that he wanted to return to his home state of Utah. "Considering all of the things that go into the equation of where do we want to practice [and] where do we want to raise a family, we just felt drawn back to Salt Lake City," he says. He and his wife both had extended families in Salt Lake and appreciated the natural environment in Utah, with its changing weather and diverse geography.

Our analysis placed Utah in the top quartile for low physician density, low cost of living, low tax burden, and low malpractice payouts. It also does well in residency retention rates.

Utah enjoys a spirit of collegiality among its physicians and has a strong relationship with its medical associations and government, according to Clayton. "I think in general, in Utah, physicians are well thought of, are respected. We have a very effective state medical association that is effective in lobbying for us with the legislature," he says.

But there are some tradeoffs. As the most populous city in Utah, Salt Lake draws many physicians looking to set up practice in the city. Unfortunately, in Clayton's experience, that competition can limit opportunities for physicians to become part of narrow payer panels, effectively curtailing referrals and practice growth.

But that doesn't mean there aren't opportunities in other areas of the state. Since the population is highly concentrated in the Salt Lake area, along the Wasatch Front, there is a great need for primary-care physicians in the less populous, more rural areas of the state. As Clayton notes, many of those small communities don't have their own hospital, just "incredible, wonderful physicians that practice in those communities."

GEORGIA - the Peach State

State Motto: Wisdom, justice, moderation

With a low cost of living, low physician density, and very low tax burden, Georgia is a great place to settle down. It scored well on five of our six metrics - with high malpractice payouts being the only outlier. Mitzi Rubin, a family physician who is employed by WellStar Health System in Marietta, Ga., agrees. "The nice thing about practicing in Georgia is that we are fairly close to everything. We are a few hours from the beach, you have the lakes, you have the mountains," she says. Rubin attended medical school in Chicago, and while she says both she and her husband enjoyed living there, there was never a doubt about returning to Georgia. The lower cost of living and the many opportunities to get out and enjoy nature convinced them to come back.

Rubin, who is president of the Georgia Academy of Family Physicians, characterizes the state as family-medicine friendly. As a family-medicine physician she says she can treat 95 percent of patient complaints, at least in the initial phase. And, she says, her patients know that, which means they come to her directly, rather than asking to see a specialist first. That willingness to entrust patient care to the home-town doc allows physicians the freedom to define their own practice. "We have some family docs in Georgia who still deliver babies. And some that do colonoscopies or C-sections. And some that do more lifestyle medicine … everything from birth through geriatrics …," Rubin notes.

There is also freedom to choose practice models. Many new physicians are turning to employment with health systems, but Rubin says first they should ask themselves what type of practice they want. Rubin initially practiced in an independent medical group for close to nine years and became a full partner. The decision to become employed, she says, was more about the synergies she found with WellStar through advocacy and committee work, as well as the changes she saw on the horizon for medicine.

2016 HALL OF SHAME

We would be negligent if we didn't write about our "non-fabulous five" - the worst states to practice in our analysis. This year we looked at the states which had a preponderance of negative financial metrics; such as a high tax burden, high cost of living, and excessive malpractice payouts. In years past, our analysis had singled out wealthy states with high physician densities clustered in the Mid-Atlantic or Northeast, like Maryland and Massachusetts. But this year, we believe this slightly different view of the data more accurately represents overall negative practice conditions for physicians. Our bottom five states in descending order, from bad to worse, are:

• Ohio

• West Virginia

• Maine

• Minnesota

• Illinois

Erica Spreyis associate editor for Physicians Practice. She may be reached at erica.sprey@ubm.com.