Copyright © 2019 Albuquerque Journal
“I wish there was a quick easy answer,” Gov. Michelle Lujan Grisham lamented last week.
Nevertheless, New Mexico’s new governor is offering a multi-pronged prescription intended to help alleviate the shortage of physicians and other health care professionals in New Mexico.
There’s a price tag and legislative approval is needed for some proposed remedies. Other initiatives rely on political will and cooperation the governor hopes will “change the dynamic.”
For starters: Lujan Grisham wants to increase Medicaid reimbursement rates for medical providers, who have seen cuts in Medicaid payments over the past eight years due to poor state budget conditions. The federal government funds most of Medicaid in New Mexico, but the state’s portion will approach $1 billion in the coming budget year.
Raising those reimbursements to providers would increase patient access, she said. Those who are non-Medicaid or privately insured also would benefit because the higher rates could help expand physician practices, allowing them to take on more patients.
“When you raise rates, then you have more folks accepting new patients because they get their costs covered. They can build their practices,” said Lujan Grisham. ” ‘If I get my Medicaid rates up and I have more nurses who are screening patients before I get in, I can see more patients without minimizing quality.’ All of that changes when we put more money into the system.”
“We can’t ask physicians and other practitioners to stay or come to New Mexico if they lose money in the practice,” she said.
The Legislature, which is now in session, would have to sign off on the additional money.
The state Human Services Department’s legislative Medicaid budget request includes about $6.4 million to rebuild New Mexico’s provider network, said HSD Secretary Dr. David Scrase. That money would be matched nearly 4-1 by the federal government for up to $30 million to try to make these “strategic investments in our network and grow and incentivize providers.”
If the state can make up to $30 million of Medicaid provider improvements, “that will take the pressure off commercial insurers” in New Mexico, Scrase said last week. Private health insurance, which has become increasingly expensive, has had to offset the lower government reimbursements.
Medicaid and Medicare insure well over half of the state’s population, he said, leaving about 41 percent private-pay patients.
“There is help,” Scrase said. “All of the legislation has been focused on the demand side – getting people coverage. But now we’re trying to focus on the supply side.”
The governor also supports leveraging Medicaid dollars to fund more graduate medical residency slots – which are typically three years or longer for primary care physicians.
“You have to use Medicaid as a great tool and equalizer,” Lujan Grisham told the Journal. Paying for graduate medical residencies with Medicaid, combined with loan repayment or forgiveness, “they’ll stay here. Our doctors are all 60 years of age and older. We need to deal with that and that’s how we get younger folks to come and move here.”
Congress has capped federal residency funding at 1997 levels.
So states are finding their own ways to add residency slots, said Kurt Mosley, vice president of Strategic Alliances at the national physician recruiter firm, Merritt Hawkins.
“We’ve found when a doctor is either born, trained or licensed in that state, they tend to stay there,” Mosley said.
Currently, fewer than 40 percent of graduate medical residents in New Mexico end up staying to work as new doctors, according to the most recent data from the American Association of Medical Colleges. States like Colorado, Arizona and Texas do far better at retaining medical residents, according to the 2017 AAMC rankings.
New Mexico ranked 39th, while every state in the western United States excluding Wyoming had greater retention.
“We have to train and recruit,” said Jerry Harrison, executive director of New Mexico Health Resources, which recruits health professionals to come here. “Unfortunately we train a lot of people for export. I don’t care what the discipline is. From nursing through physicians, we train for export to other states, primarily adjoining states and California.”
The latest AAMC ranking did show that nearly 66 percent of those who completed both medical school and residency training in New Mexico opted to practice here.
That’s the case of newly minted Dr. Nathan Prapasiri, who came to Las Cruces from Thailand when he was 9 years old. At age 38, he is finishing up his residency in internal medicine at the University of New Mexico and has a panel of primary care patients at UNM’s Westside Clinic.
“I’m like the golden child,” Prapasiri said of his choice to go into primary care in an outpatient setting in Albuquerque when other internists are following a national trend of working inside hospitals, where they can make more money and have easier one-week-on, one-week-off schedules.
“Having been raised in New Mexico and having obtained my medical education here, my first thing is that I want to give back to our community, and to the underserved population who cannot afford medical care or are marginalized,” he said.
Prapasiri embodies what experts say is New Mexico’s best hope for alleviating the physician shortage: He’s a New Mexican with family in both Santa Fe and Las Cruces who obtained his medical education and residency at the University of New Mexico. And, so far, he has no plans to leave.
Dr. Michael Bay, a gastroenterologist in Albuquerque, said the state also needs to foster a better climate in which to practice medicine.
“I will make the argument that in order to attract physicians to New Mexico, we need to make New Mexico a more attractive environment for the practice of medicine,” Bay told the Journal. “When a young doctor finishes his/her training, we need to make sure New Mexico is an appealing, gratifying and rewarding place to practice medicine.”
The governor also wants the state and private sector to combine forces to alleviate the shortage, which is only predicted to get worse in the coming years as New Mexico’s baby boomers age and its supply of 60-plus physicians retires.
“One thing that’s not happening enough is a partnership to get out there and universally recruit,” said Lujan Grisham. “It’s got to be a collective.”
The governor recalled how she dealt with agency physician shortages when she served as secretary of the New Mexico Department of Health from 2004 to 2007.
From tapping visa programs for nonresident physicians to offering medical education loan forgiveness incentives, “we were very, very aggressive and we got 30 physicians into rural New Mexico in just over a year because we made it a priority.”
It could take more self-promotion.
Dr. Steve Jenkusky, a psychiatrist and chairman of the New Mexico Medical Board, said the state could launch a New Mexico True-like advertising campaign to show off its strengths to prospective medical students.
He recalls what sold him on locating in New Mexico for his residency as he was finishing medical school in southern Illinois: a vacation guide someone included along with the application he requested from the University of New Mexico.
“Arizona didn’t do that. I looked at that (brochure) and I love the outdoors, I birdwatch, fish and hike. I was like, ‘this was intriguing.’ I came here and fell in love with the state.”
Using our assets
The state should continue expanding the scope of practice for health professionals, Lujan Grisham told the Journal, “without minimizing quality or safety.” “We want to continue to give New Mexicans more opportunities. For instance, we’ve got pretty darn good nurse practitioner and physician assistant programs.”
Currently, there is proposed legislation that would permit New Mexico to license and establish dental therapists as a new type of dental practitioner.
Back in 1993, New Mexico anticipated the coming physician shortage and permitted the licensing of a new type of health care provider, an advance practice pharmacist. Working as part of a team with a physician and others, such pharmacists receive additional training and are especially helpful managing patients who have diabetes, hypertension and other chronic diseases managed through medication, said Joe Anderson, PharmD, PhC, assistant dean for curricular affairs at the UNM College of Pharmacy.
Once patients receive a diagnosis from a physician, the advanced practice pharmacists can be called in to conduct follow-up physical assessments, ensure patients are receiving the proper medication for their condition and avoid adverse drug events, said Melanie Dodd, PharmD, PhC, associate dean for clinical affairs at the UNM College of Pharmacy who also works at the UNM Senior Health Clinic.
“We’re a ready workforce, but we are under-utilized,” Anderson added.
Advanced practice pharmacists aren’t recognized as health care providers under Medicare so such services aren’t reimbursed. But a bill pending in the New Mexico Legislature, HB 578, would require group health plans and Medicaid and its contractors to reimburse advanced practice pharmacists for their services.
In the meantime, some medical providers, like Presbyterian Healthcare Services, already are using advanced practice pharmacists as part of a team approach to ease the burden on their physicians. Presbyterian is also teaming with University of New Mexico so pediatric superspecialists can “all be together and we’ll have a more stable pediatric workforce,” said Dr. Jason Mitchell, chief medical and clinical transformation officer for Presbyterian.
And Presbyterian, which cares for one in three New Mexicans, is trying to combat a shortage of dermatologists by providing additional training in dermatology and equipment for primary care physicians.
“It feels like it takes forever to see a dermatologist. So let’s only send them stuff they really need to do and don’t send them stuff they don’t need them to do,” Mitchell said.
State Rep. Elizabeth “Liz” Thomson, D-Albuquerque, said New Mexico’s health care shortage “has been a long time coming and it will take awhile to fix it. There’s health care shortages throughout the country, but we are in dire straits.”
Though not classified as a health care initiative per se, Thomson said the current legislative emphasis on the “educational moonshot” for public education could help.
“Our high levels of poverty and low levels of educational performance” might put off health care providers thinking about moving to New Mexico, she said. “So I think if we improve our education system … that will hopefully take that out of the equation.”
“New Mexico has so many good things,” Thomson added, “but we also have some black eyes. So it’s going to be ‘all of the above’ kind of approach.”
There are a number of other health provider legislative proposals intended to help ease the shortage, but at least one that physician groups say would hurt. That bill, HB 629 by Rep. Damon Ely, D-Corrales, raises the medical malpractice award caps on damages victims could collect from $600,000 to $2 million.
Opponents of the bill say the current caps help keep liability insurance costs affordable and policies available; and that helps recruit and retain quality physicians in New Mexico
Other health provider legislative bills that are pending include:
⋄ SB 138, sponsored by Sen. Jerry Ortiz y Pino, D-Albuquerque, appropriates $1.2 million for nine additional residency slots for physicians
⋄ SB 296, also sponsored by Ortiz y Pino, offers tax credits for New Mexico health care practitioners who help provide clinical learning experiences for physician, nursing or pharmacy students.
⋄ SB 21, sponsored by Sen. Gay K. Kernan, R-Hobbs, establishes a new Osteopathic Physician Excellence Fund for educational loan repayments. This would be in addition to existing loan repayment programs for health professionals.