Professor Christine Nero Coughlin (JD ’90) quoted in Wallethub’s ’2017 Best & Worst States for Doctors’

Photo of Wake Forest Law Professor Chris Coughlin

Chris Nero Coughlin is a recipient of the Joseph Branch Award for Excellence in Teaching and a two-time recipient of the Graham Award for Excellence in Teaching Legal Research and Writing.

Professor Christine Nero Coughlin (JD ’90) , who is director of the law school’s Legal Analysis, Writing and Research (LAWR) Program, is featured in the following story, “2017’s Best & Worst States for Doctors,”  written by John S. Keirnan and published by Wallethub on March 27, 2017.  Professor Coughlin is one of the experts discussing the biggest issues facing doctors today as well as the top five indicators in evaluating the best states for doctors, among others.

Following is her excerpt:

What are the biggest issues facing doctors today?

Doctors face many issues today.  Of course, the “elephant in the room” is the significant uncertainty that doctors face with what the structure of healthcare will look like in the United States — specifically, whether the Affordable Care Act (the ACA) will be repealed, and whether it will be replaced by the proposed American Health Care Act (the AHCA), or another proposed health care model.

This, of course, raises myriad concerns about the uninsured (or projected to be uninsured), and the underinsured. Regardless of the outcome of the current healthcare debate, doctors will continue to face issues involving billing and declining reimbursement, along with the host of other problems related to getting paid for the care they provide.

With respect to billing and reimbursement, one important change in the way medicine will be practiced on a day to day basis is the Medical Access and CHIP Reauthorization Act of 2015 (MACRA), which repeals the Medicare sustainable growth rate formula used to calculate payments to doctors by changing the focus of payments from “volume to value.”

While full implementation has been delayed until 2018, changing medical practices from fee for service to a quality valuation structure may create a significant shift in management practices. Even absent MACRA, billing and reimbursement issues affect the administration of almost every aspect of patient care. For example, depending on their specialty, doctors commonly face issues even with patients with insurance.

For example, many patients do not understand their deductibles, or are not aware that they have a high deductible and cannot afford (or ultimately do not pay) for recommended tests, preventative care, or needed treatments. Many doctors commonly face situations where a patient’s prescription drug plan or insurance plan fail to cover the medication or treatment the doctor believes to be in the patient’s best interest. In addition, doctors are still facing billing and reimbursement issues relating to demands imposed by electronic health records (EHR) and medical coding, and the complex requirements surrounding the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Doctors express further concerns that they no longer even have the ability to negotiate with narrowing provider networks. The list goes on and on.

Compliance with billing and reimbursement issues is extremely risky, costly, and creates anxiety, as many healthcare laws are complex and broadly written. It is a given that mistakes in the healthcare system bring devastating consequences, particularly when mistakes cause patient harm.  However, Jeff Bendix, et. al, writes mistakes in the arena of billing and reimbursement come with dire personal consequences for physicians, including the threat of criminal prosecution for what many doctors are concerned are honest billing mistakes (or at the most regulatory violations) under the False Claims Act (FCA).  For most doctors, the resources needed to ensure compliance with the FCA, HIPAA, and the many other applicable healthcare laws and regulations are daunting.

How does state and local policy influence the lives of doctors and other medical professionals?

State and local policies influence the lives of doctors and other medical professionals in many ways. While the amount of influence state and local policy have are affected by the factors such as a doctor’s specialty, and whether the doctor practices in an urban or rural setting, an area of concern for many doctors, particularly those involved in community health or primary care setting in the South, is the 2.6 million people affected by the “coverage gap” in states that did not participate in the Medicaid expansion program.

Under the ACA, Medicaid eligibility was intended to be expanded to individuals with incomes of 138 percent or less of poverty.  Nineteen states (10 of those states in the South), declined to expand their Medicaid programs, which resulted in a coverage gap for approximately 2.6 million of the working poor who have incomes above the state’s Medicaid (non-expanded) eligibility requirements, but below the ACA’s marketplace subsidies.  Studies surrounding the coverage gap have identified that the coverage gap disproportionately affects people of color.

What tips can you offer current medical students about what specialty to pursue and where to practice?

The only certainty that medical students can embrace is that the practice of healthcare is evolving and constantly changing. So, when considering important decisions about practice specialty and where to practice, students need to identify what factors are most important in their lives personally, as well as factors such as workload, salary, and amount of professional control that will be important to them in their future medical practice. For example, if economic security is most important factor, the medical student should seek opportunities in areas of the country where physician salaries tend to be higher and cost of living tends to be lower, like the Midwest. If practicing “cutting edge” medicine is important, medical students may want to explore a specialty or subspecialty, and employment or association with a renowned medical schools or teaching hospitals — generally located in larger cities such as Cleveland, Boston, or New York.  If having a long-term professional relationship with patients is rewarding to the student, he or she may consider primary care, or a medical practice in a rural or less urban setting.

To what extent does the threat of a malpractice lawsuit affect doctors ability to do their job? 

Despite the fact that many states have worked toward medical malpractice reform, the threat of medical malpractice directly affects most doctors’ (whether consciously or unconsciously) ability to perform their job. One primary way the threat of malpractice affects a doctor’s practice is with the “defensive” practice of medicine, that is practicing medicine and ordering additional medical tests, imaging procedures, or immediate referrals to specialists. The defensive practice of medicine, however, can also take the opposite route with doctors avoiding complex procedures or even treatment for people whom they are concerned may bring a lawsuit. Given the incredible financial and personal stresses associated with a medical malpractice lawsuit, it is easy to see how this practice has proliferated. Some individuals, however, think it has also contributed to unrealistic patient expectations as to what medical treatment and/or the standard of care should entail. These unrealistic expectations are many times seen in areas where a patient’s family demands continued, intensive, and invasive medical treatment that a doctor deems to be medically futile. The threat of malpractice may also contribute to a breakdown of mutual trust in the physician-patient relationship, and negative factor in the shift to a patient or relationship model of patient care.

In evaluating the best states for doctors, what are the top five indicators? 

Like the answer to most health care questions, the response to the top five indicators for the best states for doctors is “it depends.”  Specifically, it depends on the physician’s specialty, quality of life factors, and economic factors such as average physician compensation, cost of living, and tax burden. It also depends on other factors including whether the doctor is looking for an urban practice versus a rural practice, or an academic setting versus a community setting.

However, when evaluating which state is the best place to locate, physicians should also consider the following common indicators: (1) whether the state is considered friendly to physicians in terms of their malpractice laws, premiums, licensure standards; (2) whether there exists easy access to teaching hospitals and tertiary care facilities; (3) what type of medical system are involved in or dominate the economic base and/or healthcare market; (4) how the state ranks in terms of the overall health of its citizens; and (5) physician density within the state.