Fly Over This!

Folks who live in the Midwestern and Plains states have grown accustomed to defending their homes against the coastal residents who tend to refer to America's great middle as "flyover country" -- as in, that big, flat emptiness one looks down upon while en route from New York to Los Angeles.

So it should come as no surprise, then, that family physician William Mohr -- who was born and raised in Indiana and has practiced there almost all his life -- easily rattles off the benefits of living and working in his state, while acknowledging the preconceptions.

"We have a good healthcare system in terms of the hospitals and the specialists who are here, and we have a very good medical school," says the affable Mohr, who practices in Kokomo and is president of the Indiana State Medical Society. "At the same time, it's true that we don't have oceans and mountains, but we have good public schools, safe streets, and a good quality of life."

And that's to say nothing of the favorable business climate there for physicians, which has made Indiana, for the second time, one of the five best states to practice in, according to Physicians Practice.

We researched the business, regulatory, and legal climates for doctors around the country to compile our second list of the friendliest states in which to hang a shingle.

The results may surprise you.

You haven't stopped reacting to our first listing of the physician-friendliest states two years ago -- we still get calls and e-mails requesting reprints and more information -- so we thought it was time for an update.

Some important things have happened since Indiana was named, along with Michigan, Wisconsin, South Carolina, and Oklahoma, to our list of best states in 2003. For one thing, Medicare has stopped penalizing poor and rural states for being poor and rural. No longer is the Geographic Practice Cost Indices (GPCI) --basically a regional multiplier that determines how much Medicare will pay you for a given service -- set below 1 for any state or metro area.

In other words, while Medicare hasn't abandoned its logic that if you work in a place where it's more expensive to live and practice, you ought to get a little extra, it no longer dings you quite as much just because you live in Mississippi or rural New Mexico. That was an important change, because the GPCI is one of the key data sets that help us decide who makes the cut, and that change alone helped two Southern states -- Louisiana and Alabama -- make the list this year. Oklahoma and South Carolina, along with Indiana, made return appearances this time around. Alaska, Tennessee, and New Mexico deserve honorable mentions.

No glamour

Notice something about this year's list? Like its predecessor, it's missing the likes of Hawaii, California, Florida, and other "glamour" states. See the sidebar "About Our Methodology" to learn the specifics, but suffice it to say we ignored all those subjective factors that people use in deciding where they want to live, like weather, cultural activities, and good schools. We're not trying to tell you where to live; we're trying to give you a good idea of where to find the most favorable conditions to practice under.

Besides, who's to say you'd rather spend your vacation windsurfing off the coast of San Diego than camping in Alabama's Bankhead National Forest? How are we to decide you'd value low cost of living and low taxes over a well-regarded public school system? We wouldn't dream of presuming to set your priorities on such personal issues. And for what it's worth, those quality-of-life measurements are available, ad nauseum, all over the Internet.

But our friendliest states rankings? We've seen nothing else like it.
And we think we know you well enough to know that what's really important to you, professionally at least, is the ability to practice medicine your way -- without fear of a malpractice lawsuit bankrupting you, without having to be a marketing genius to attract patients, and without having an army of insurance payers breathing down your neck. And it would be nice, while you're at it, if you could make a decent living, no?

We've got you covered. Those are the priorities we designed our list to reflect.

In no particular order, the best states in which to be a doctor are:

Alabama

"We're so used to being on near the bottom of every list," remarked a surprised Alabama booster when told of the state's selection. OK, this one caught us a little off guard, too. But you can't argue with the facts: only 2.2 doctors per resident; a decent malpractice climate; and a favorable combination of cost of living and reimbursement.

"In the rural areas, there is no managed care in Alabama," says family physician Bob Mullins, who practices in Valley and is the president of the state medical society. And he says the physicians have a good relationship with the state's major private payer, Blue Cross and Blue Shield of Alabama.

"I think as far the economy is concerned, we're on the upswing," he adds, noting an influx of auto manufacturing jobs. Moreover, Alabama offers generous tax incentives to physicians willing to hang a shingle in one of its many rural areas.

If you're considering the state, here is Mullins' best pitch:
"There's money to be made here. Not a lot, maybe, but you can make a decent living, you're independent, and there's a sense of adventure. I think that combination of factors would be appealing to a lot of doctors."

Oklahoma

The Sooner State had the lowest physician-to-population ratio of the states that made our short list, with only 1.84 doctors per 1,000 residents. That means physicians there can, far more than their counterparts in say, New York, set their own rules, practice standards, and fees. It also had the second-lowest cost of living, with a score of 90.4 on the common cost of living index where 100 is the median. Cheap to live there. Easy to practice there. What more could you ask for?

South Carolina

With its warm climate, Southern hospitality, and legendary golf courses and beaches, South Carolina is often considered a nice place to live after retiring. But for physicians, it's also a great place to live before retiring. Its cost of living (96.2) and physician density (2.4/1,000) are both fairly low and its malpractice climate is fair, if not spectacular.

Louisiana

Forget the gumbo. Doctors in the Bayou State rave about its malpractice climate, an island paradise in a sea of states in crisis. Bill Cassidy, a Baton Rouge gastroenterologist, says Louisiana had the foresight to deal with a previous malpractice crisis 15 years ago and has been reaping the benefits ever since. The state has a $500,000 cap on damages -- both economic and noneconomic combined.

"The state's been very proactive," says Cassidy. His friend, New Orleans gastroenterologist William Anderson, adds: "That doesn't stop people from suing. They still sue. But it means you don't have to worry about losing your life savings on one lawsuit."

Indiana

The Hoosier State is becoming something of a Midwestern refugee camp for physicians feeling intolerable malpractice insurance premiums in neighboring jurisdictions, says Mohr.

"We have noticed in the last year or two that doctors are starting to move here precisely because of the malpractice issue in other states," he says, noting that Indiana borders Illinois, Ohio, and Kentucky -- all crisis states, according to the American Medical Association. Indiana is given a clean bill of health by the AMA.

In addition, only 10 percent of its population is covered by managed care, according to Mohr, and it has fewer than 2.3 physicians per 1,000 residents. And with a cost-of-living index score of only 94.6, you can live well.

Bob Keaveney, acting managing editor for Physicians Practice, last wrote about speech recognition technology in the January issue. He can be reached at
bkeaveney@physicianspractice.com.

This article originally appeared in the April 2005 issue of Physicians Practice.