Bacon's Rebellion

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Why the Supply Shortage of Virginia Docs and Nurses?

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by

James A. Bacon
in ,

by James C. Sherlock

Virginia’s political class ignores the severe shortage of doctors and nurses in Virginia — except when it actively works to make the problem worse. This essay will illuminate both the issue and the votes that rejected proven solutions in the 2020 General Assembly.

Virginia data – 2019 State Physician Workforce Report .

Physician Workforce Profile
• Virginia Population: 8,517,685
• Active physicians: 22,419
• Primary care physicians: 7,691
• Total MD or DO students: 3677
• Total Residents: 2457
• General surgeons: 623 / over age 60 – 30%
• Neurosurgeons: 132 / over age 60 – 29%
• Orthopedic surgeons: 461 / over age 60 – 43%
• Plastic surgeons: 189 / over age 60 – 41%
• Thoracic surgeons: 94 / over age 60 – 34%
• Vascular surgeons: 96 / over age 60 – 22%
• Pathologists: 258 / over age 60 – 57%
• Neurologists: 338 / over age 60 – 42%
• Preventive medicine: 229 / over age 60 – 52%
• Pulmonologists: 117 / over age 60 – 71%

Virginia rank among 49 states in active physician density per 100,000 population:
• 26th in physicians;
• 27th in patient care physicians;
• 33rd in patient care general surgeons ; and
• 29th in physicians age 60 or older

Undergraduate Medical Education – rank among states
• MD and DO student enrollment per 100,000 population, AY 2018-2019. Rank:  18.
• Percentage Change in student enrollment at MD and DO Schools, 2008-2018. Rank: 15.
• Percentage of MD students matriculating in-state, FY 2018-2019. Rank: 35.

Graduate Medical Education
• Total residents/fellows in ACGME Programs per 100,000 population as of December 31, 201. Rank: 33.

Retention
• Percentage of physicians retained in state from undergraduate medical education (UME), 2018 – 31.4%. Rank: 32.
• Percentage of physicians retained in state from graduate medical education (GME), 2018 – 38.5%. Rank: 40.

These data are exactly what you think — bad. Two trends jump off the page:

  • Our physician workforce, notably our surgeon workforce, is small relative to the national average and it is aging quickly.
  • We are not attracting enough Virginians to our medical schools and are not retaining enough Virginia medical school graduates and residents at Virginia hospitals.

Let’s address why we cannot retain or attract physicians in Virginia at a higher rate than we do.

Virginia’s Medical Schools. Virginia clearly needs an active program to recruit more Virginians to its medical schools and recruit more medical school graduates and residents to practice in Virginia.

A search of the Department of Health Professions and the Department of Health websites yields the impression that they do not have increasing Virginia’s number of physicians and nurses on their plates. Across the rest of the government, the search terms physician retention and physician recruitment returned no results on virginia.gov.

Based on a search of its website, the Medical Society of Virginia also seems to have no formal program for recruitment or retention of physicians here. I hope I am wrong.

My search of the websites of Virginia’s medical and nursing schools did not encounter any indication that they make an effort to retain their students in Virginia. They may do it and not publicize it or I missed it. I hope so.

Surgeons. The direct cause of our surgeon shortage is the Certificate of Public Need (COPN). Maryland has 2.5 million fewer people than Virginia and yet nearly as many surgeons as the Commonwealth: 1,595 in Virginia, 1,507 in Maryland. Maryland is second among 50 states in active physician density, Virginia 26th.

Maryland, which exempts physician-owned surgical centers from COPN regulation, has well over 500 physician-owned surgical centers (POSCs). Virginia has about 80 ambulatory surgical centers (ASCs), about half of which are owned by hospitals and reimbursed at hospital rates. Physician-owned ASCs compared to hospital outpatient departments are about half the cost to government, commercial and individual payers for the same procedure by the same surgeon, yet the surgeon himself makes more for that procedure in his ASC than he does in the hospital outpatient department. Such is the impact of hospital facility fees on the total bill. That is a self-making case for Virginia to model the Maryland exemption.

Del. Jason Miyares, R-Virginia Beach, introduced HB 1094, which exempts physician-owned ambulatory surgery centers from COPN review, which would emulate the Maryland exemption, and it was defeated. The hospitals, which have paid for the privilege, control the votes many members of the General Assembly. Surgeons, denied any possibility of owning their own surgical centers in Virginia, understandably seek greener pastures.

Primary Care Physicians
Miyares also introduced HB 608 establishing a Health Enterprise Zone Program and Fund to attract primary care physicians to underserved areas. It also failed. Perhaps the hospital lobby noticed that program has proven in Maryland to significantly reduce emergency room visits.

Nurses
On March 4, 2020, 7861 nursing positions were being actively recruited in the Commonwealth, about 3% of the 264,745 vacancies nationwide. I cross-checked the indeed.com numbers with Virginia healthcare systems’ individual recruiting websites and found them accurate.

Virginia currently has 107,540 active RN licenses in the state, 2.24% of the national total with 2.59% of the nation’s population , a shortage of 14% compared to the average density. That means that even if all of the open positions were filled, Virginia would be short about 6,000 nurses relative to our population.

Accountability
The Governor is a physician. By defeating Miyares’ bills, the General Assembly, primarily the Democrats, has actively discouraged both surgeons and primary care physicians from practicing in Virginia.

The House members who voted to kill Del. Miyares two bills are :
• HB 1094 – Delegates Sickles, Hope, Price, Levine, Aird, Hayes, Adams, D.M., Guzman, Delaney, Tran, Willet, Hodges, Head, and Avoli. The last three are Republicans.
• HB 608 – Delegates Sickles, Carr, Krizek, Hayes, Jones, Cox and Brewer. Cox and Brewer are Republicans.

James C. Sherlock, a Virginia Beach resident, is a retired Navy Captain and a certified enterprise architect. As a private citizen, he has researched and written about the business of healthcare in Virginia. 

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28 responses to “Why the Supply Shortage of Virginia Docs and Nurses?”

  1. Reed Fawell 3rd Avatar
    Reed Fawell 3rd

    Translation:

    Virginia’s political leaders actively work against insuring the health of Virginia’s citizens. To do so, Virginia’s political leaders work to enrich and empower “Virginia health cartels.”

    Virginia political leaders thus insure that these cartels control the market in Virginia for health care, thus insulating those cartels from outside price and quality competition.

    This limits patient choice in Virginia while it also severely increases patient costs, and it severely limits the number of good and excellent doctors and doctor run health facilities in Virginia.

    Why do Virginia’s politicians work so hard to increase Virginian’s health care costs, while limiting their choice, thus lowering the quality and convenience of health care available to Virginians?

    The likely answer is that Virginia’s politicians trade the health of their constituents for the campaign contributions and other political support from a corrupt health care establishment in Virginia. Politicians win. Cartels win. Citizens lose.

    Does this remind anyone here of public education in Virginia, whether it be public K-12 education or public higher education?

  2. Steve Haner Avatar
    Steve Haner

    The parallel with the electricity issues is strong. Campaign dollars flow without limit. There is no state regulator independent of the political winds able to stand up for consumers. There is no strong consumer advocacy movement. The general public remains clueless and captive. Just what did you think “best state for business” means?

    1. djrippert Avatar
      djrippert

      What did Bush say – The Axis of Evil? Dominion, developers and hospitals in Virginia? Oh wait, I forgot Altria, Omega Protein, beer and wine distributors, car dealers ….

      The more I think about it the real Axis of Evil is the General Assembly.

    2. sherlockj Avatar
      sherlockj

      I know Virginia’s Secretary of Health and Human Resources and respect him. I sent this column to him asking if he had any ideas how to turn this around and copied the Governor and the Health Commissioner, physicians all. I hope they will act.

  3. TooManyTaxes Avatar
    TooManyTaxes

    Change the campaign finance laws. No contributions except from a live human being who lives within the boundaries of the district where the candidate is running for office. For statewide races, the donor just needs to live in Virginia. No contributions from any business or non-profit. No bundling. Any person who attempts to create or use a Virginia address who cannot prove domicile in Virginia is guilty of a felony punishable by 5 years in the pen.

    Domicile has been defined as ” the place where a person has his/her permanent principal home to which he/she returns or intends to return. This becomes significant in determining in what state a probate of a dead person’s estate is filed, what state can assess income or inheritance taxes, where a party can begin divorce proceedings, or whether there is “diversity of citizenship” between two parties which may give federal courts jurisdiction over a lawsuit. Where a person has several “residences” it may be a matter of proof as to which is the state of domicile. A business has its domicile in the state where its headquarters is located.’

    1. djrippert Avatar
      djrippert

      The more I think about your proposal the more I like it. One thing – there have to be limits on the donations. Otherwise, a single wealthy individual in a generally poor district could effectively coronate a candidate.

      Individuals who own multiple residences should be easy. Where are they registered to vote?

      Businesses (and unions) shouldn’t be able to make any contributions to any candidates at all regardless of where they are domiciled.

      1. WayneS Avatar
        WayneS

        How about $50?

      2. TooManyTaxes Avatar
        TooManyTaxes

        Don’t disagree about reasonable limits. Say $1000 to $1500.

    2. djrippert Avatar
      djrippert

      What happened this year to Chap Petersen’s annual attempt to make campaign donations from regulated companies to politicians illegal?

      Oh right … the new Democratic majority killed it.

  4. LarrytheG Avatar
    LarrytheG

    Clearly, many folks are under-impressed with the performance of the GA – even as we hear that what they actually do – do – screws things up!

    I don’t know about the physician and surgeon and other provider numbers but I’d not be surprised that it’s similar to the teacher shortage. but I might be more informed if I saw how those shortages looked on a county or regional basis. Are we well-staffed in places like NoVa and Richmond and under-staffed in places like SW Virginia?

    I’m not sure exactly what the State can or should do about it except that I would support “free” community college for any kid who would get a medical certificate, nurse, etc and agree in return of no-debt to serve in an under-served area but of course someone would have to pay him/her.

    Ditto with nurse practitioners and physician assistants – do incentives to attract them – perhaps do them for kids growing up in those areas so they can have a job and not have to leave to go find a job.

    MedicAid pays on a per patient basis – but a “practice” has to exist first to be able to take MedicAid reimbursements.

    Is this a job for Govt or the private sector?

  5. WayneS Avatar
    WayneS

    “Is this a job for Govt or the private sector?”

    If we as a country declare health care a “basic human right” then won’t it be the government’s responsibility to make sure there are enough doctors for everyone to exercise this “right”?

  6. LarrytheG Avatar
    LarrytheG

    If we actually declared that, and agreed, perhaps……….but it’s sorta like saying you have a right to a job … eh?

    Most all the countries that have universal health care – have private medical practices, save England which actually does have govt doctors.

    And of course we also have govt doctors in the VA.

    But in general, does the govt guarantee a doctor in say SW Va?

    And how would the govt be able to guarantee a doctor would STAY even if sent there for a few years in exchange for their medical schooling?

    Have you seen the 60 minutes segment about two nurses in an RV touring Appalachia to provide care to people who apparently do not have access to a doctor? https://www.cbsnews.com/news/60-minutes-overtime-on-the-road-with-the-health-wagon/

    1. sherlockj Avatar
      sherlockj

      You are getting to the limits of government power, Larry. As long as we are a free people, young men and women will choose the medical profession or not and practice in Virginia or not. All I want the General Assembly to do is to remove the roadblocks (COPN) and make investments (Health Enterprise Zones) that have proven both effective and to reduce costs elsewhere. As for the administration and our state-supported medical schools, even a nod towards attracting more Virginians into medical and nursing schools and retaining graduates would be useful.

      1. LarrytheG Avatar
        LarrytheG

        We, the govt, provides incentives right now for all manner of things to include credits for education of an type.

        Why not give more credit for medical professions to help pay for their debt in exchange for serving in an undeserved area ? I actually thought we might have already done that or had in the past.

        Isn’t that sort of what your enterprise zone idea is? And I agree with and support that also.

        My concern about COPN is that it won’t really help the folks who live in undeserved areas and ma hurt them if it keeps a hospital willing to serve charity cases from opening there.

        I do not think the fact that SOME hospitals that make good profits in Virginia is the reason for higher health care costs per se except for those who do not have insurance. Most who have insurance, have their bills paid for by reimbursement from insurance companies – and Medicare – who set the reimbursement rates from what they believe the cost for that service should be.

        I’m just a skeptic, in general, that unfettered “market” forces have much effect on health care costs in general. I DO believe that the govt CAN set up a framework where competition does occur – for instance, thats how ObamaCare works and Medicare Advantage.

        And it will take the govt to fix “surprise billing” – which basically is some providers who will not participate in a “network” and apparently, few, if any, of that specialty, will not. This happens apparently with anesthesiologists – did in my case but since it was Medicare, they paid only what they calculated was a fair price.

        Once again, I thank you for your articles. They are good, interesting, even compelling and are a particular interest of mine, so I will comment, not always agree, challenge you and provide my own thoughts. But again, I much appreciate your contributions.

        1. WayneS Avatar
          WayneS

          “I’m just a skeptic, in general, that unfettered “market” forces have much effect on health care costs in general.”

          Then why not leave health care to the “unfettered” market? Why involve the government at all?

          1. LarrytheG Avatar
            LarrytheG

            well the cow left that barn sometime ago with Medicare, the VA and MedicAid, no?

            But the govt is also the one that subsidizes money spend on employer-provided health insurnce as well as sets the rules for that insurance – guaranteed issue and everyone pays the same premium regardless of age or health status.

            If you too the government out of employer-provided health insurance, the insurance company as a “market” would be free to deny coverage to anyone they deemed a risk and/or charge higher premiums for people who have pre-existing conditions or are older.

    2. WayneS Avatar
      WayneS

      My question was rhetorical. Sherlockj’s comment regarding the limits of government power is exactly what I was driving at.

      There are plenty of people right now (more than just the Bernie-bots) “believe” that health care is a basic human right. I am not one of them.

      But what if that “belief” wins out and becomes the law of the land? How far would our government go in the name of “guaranteeing the right to health care for all”?

      I, for one, do not want to find out.

      1. LarrytheG Avatar
        LarrytheG

        Depending on one’s point of view, government represents the wishes of the governed.

        I’m in the minority on a bunch of issues but I accept it as not what the majority has elected representatives to do.

        It’s not only Bernie-bots – true – it’s the reason the Virginia GA went from GOP to Dem majority, right?

        Health care is a major issue in the upcoming POTUS election also.

  7. Reed Fawell 3rd Avatar
    Reed Fawell 3rd

    Jame’s very fine post provides us with many insights into how Virginia’s government thwarts progress in Virginia and works hard against the interests of most Virginians.

    For example:

    Recall the term “scrappers,” how these scrappers are used to collect vast amounts of information from private individuals who use the web. This private scrapped information is then spliced, resorted and sold by the scrappers to other commercial buyers, who then often use that scraped information to gain advantage over the folks that the information was orginally stolen from.

    This scrapping is also what the government does in Jame’s example regarding health care. The government finds ever more ways to scrape money out of the citizens pockets, beyond simply taxes, to enlarge itself and reward its crony friends and allies.

    For example, the government finds ever more ways to scrape additional money out of sick peoples’ pockets using health care schemes and over billing tricks, which the government then sells to crony non-profit health care companies in return for political campaign contributions and political favors.

    Of course the government’s theft of citizens pockets, and its raid on citizens interests, extends far beyond money. For example, it’s the reason why most smaller towns and smaller cities in Virginia find it very hard to grow, thrive, and become vibrant places. This is because, for one reason, there is a chronic shortage of doctors and health care in these places. All the health care has been scraped into progressive non-profit places like UVa. in Charlottesville where rich get richer off everyone else struggling to live in rest of the state.

    1. Reed Fawell 3rd Avatar
      Reed Fawell 3rd

      To further elaborate on how our government designs legislation and otherwise acts in ways that strips ever more money out of the pockets of its middle class citizens by whatever means that government can contrive, consider these statistics that list the “average costs of college, health insurance, housing, and transportation for a middle class family of four, and how much these costs have increased between 1985 and 2018:

      In 1985, a wage earner could support him or herself, a spouse, and two kids, on $13,227 per year to cover costs of college, housing, health insurance, and transportation, which, at a weekly wage of $443, would require 30 weeks of work to cover all these expenses.

      In 2018, a wage of $54,414 per year, at a weekly wage of $1,026, was needed to cover those same costs – college, transportation, health insurance, and housing. This required 53 weeks of work to cover, but there are only 52 weeks in a year.

      Here is how those costs increased between 1985 and 2018:

      Housing; $45,560 increased to $15,924
      Health insurance:$2,343 to $19,616
      Transportation:$3,484 to $8,842
      College: $1,227 to $10,025

      Obviously, Jame’s post help explain how government drove us health insurance costs. The failures of government, both by action or omission, played large rolls in driving up the average citizen’s cost of housing, college, and transportation.

      And, of course, this does not include the great increase of government, taxes, fees, regulations and add on charges of most everything else under the sun, all as detailed here recently on Bacon’s Rebellion, whether it be cable, WiFi, electricity, or whatever. Government and its crony allies are strangling the middle class American family, draining them of money to redistribute it to buy votes, and reward flavors to government cronies.

      For more details see:
      https://www.manhattan-institute.org/reevaluating-prosperity-of-american-family

      1. Reed Fawell 3rd Avatar
        Reed Fawell 3rd

        Correction to above: Housing costs between 1985 and 2018 went from $5,560 to $15,924.

  8. sherlockj Avatar
    sherlockj

    Errata: I just noticed that I wrote “emergency room visits” at the end of the Primary Care Physicians section. Correct that to “inpatient admissions”. Same issue. That will drive the hospitals to continue to oppose it.

  9. LarrytheG Avatar
    LarrytheG

    I see where the GA took action on balanced billing!

  10. Izzo Avatar
    Izzo

    The AMA cartel significantly controls supply of doctors. U.S. has significantly fewer doctors per capita than other OECD countries. 50% less than Germany for instance. Our doctors are paid far more than any other country, and they work shorter hours and see fewer patients per month than most. We have only about 55% as many medical school spots per capita as the OECD average.

    I’m sure Larry will attribute the high cost and low supply of doctors to unfettered market forces (after all, it makes perfect sense that in a free market there would be very few people trying to get high paying jobs), but I would argue that this really very similar to what Dominion has done in energy.

    1. Reed Fawell 3rd Avatar
      Reed Fawell 3rd

      Izzo – How refreshing it is to read again your highly informed and knowledgeable words and numbers that so often provide us with insights into otherwise complex and opaque issues of great public interest – first on the toxic American higher education cartel in Virginia and now also on the health care cartel in Virginia. Thanks to your help and also Jame’s, we here on Bacon’s Rebellion are breaking into the otherwise secret codes, strategies and tactics these cartels deploy to deepen their toxic stranglehold over the health, wealth, and education of Virginians.

      Hopefully too we are on our way to doing the same with the chronically toxic zoning and land use, energy, and identity and race politics in Virginia.

  11. LarrytheG Avatar
    LarrytheG

    So, why do other developed countries where the govt insures universal coverage and low drug prices also have more doctors than the USA which prides itself on a less-govt, more unfettered market approach?

    Is the cure to cartels – govt intervention?

    I’m not sure what the “mix” of doctors verses para-professionals like Physician Assistants and Nurse Practitioners is in other OECD countries verses this country – but both are much more cost-effective that Doctors in performing many roles and leaving other roles that only doctors can do.

    And one more – next time you do a provider search for various medical specialities – note the abundance of foreign surnames. In my own case – my dentist is from a Caribbean country, my endocrinologist is Pakistani and the guy who did my Colonoscopy last name is Pai.

    They tend to be foreign-educated but gain American medical credentials despite the “cartel”. Of course, I have to pay extra attention listening because of “accents” but all are top-notch in my view and all of them use Physician Assistants and Nurse practitioners so my time with them is limited primarily to their particular skill set.

    I also seek out providers can or will or do who share electronic records so that when I go to one – they can see my complete medical history, my current issues and common drug list.

    Health Care in the US is enormously complicated in no small way because of enormous number of players – insurance, networks, etc.

    Other countries are like our Medicare – there are no “networks” and the rules for deductibles and out-of-pocket, etc are simple. And no “balance billings” – all providers work to the same rules.

    And despite claims to the contrary – I’ve personally never run into a Doctor that did not take Medicare. I’m sure there may be some – but the vast majority do as do most all hospitals.

    Our own VA works that way also – as does Medicaid.

    As Jim says – the health industry is a powerful force that does tend to have influence and control to protect their interests – even if it harms patients interests.

    But I see “profitable” hospitals as successful hospitals – hospitals that have figure out how to deal with things like uncompensated care and low Medicare/Medicaid reimbursements and still make money.

    And I see the loss of rural hospitals and loss of near access to health care as one of the reasons why our country compares badly against others in terms of longevity. You can see this in life-expectancy numbers in places like Nova compared to places like SW Va where – on average -10 years is normal. That much lower life expectancy in the rural areas is what drags us down in international comparisons of longevity – as well as costs because people who do not get regular care to manage disease – eventually do end up in a hospital with heroic and expensive late state care trying to save people who did not get good care and now are in their final stages – often times, barely kept alive with terrible quality of life until they do expire leaving mountains of costs.

  12. Izzo Avatar
    Izzo

    “So, why do other developed countries where the govt insures universal coverage and low drug prices also have more doctors than the USA which prides itself on a less-govt, more unfettered market approach?

    Is the cure to cartels – govt intervention?”

    Larry, the reason the AMA acts as a cartel is because the government has “intervened” to allow it to do so.

  13. LarrytheG Avatar
    LarrytheG

    Izzo – can you name countries that do health care better than us that are not developed countries where the govt controls health care?

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