General Considerations
The majority of articles discussing the best state in which to practice medicine have
offered superficial analyses, focusing on physician satisfaction surveys, a handful of broad taxes
(such as income and property), medical liability insurance premiums, and the local weather. A
more in-depth guide is needed to make physicians aware of potential pitfalls associated with
certain practice models in each state.
The best states generally undertake policies designed to reduce the cost of medical care.
Decreased cost leads to increased access, and greater access permits physicians to compete for
patients based on quality. State methods to reduce costs to physicians and patients generally take
the form of lower taxes and fewer regulatory hurdles that interrupt the patient-physician
relationship. Less favorable states have generally taken the opposite approach, and have been
more likely to “double down,” attempting to address perceived inefficiencies with more
regulatory requirements that often fail to achieve desired improvements.
Physicians might first look at each state’s comprehensive ranking, which weights all
categories equally, then evaluate a narrowed list of states on the basis of considerations most
relevant to their practice.
Which State Best Suits Your Medical Practice–
an Analysis and Reference Guide
Philip Eskew, D.O., J.D., M.B.A.
Corporate
Tax
at 0% = +1, above 0% up to 7.99% = 0, at or above 8% = -1
RankingIncome
Methodology
Sales Tax
at 0% = +1, above 0% up to 6% = 0, above 6% = -1
General Gross
Receiptscriteria
Tax for
if present
= -1
Classification
the tiered
are listed in Table 1. Ranked factors
ABSTRACT
concerning
taxas follows:
policy
are= -1ranking
listedsystem
in Table
3, and regulatory
Physician
Grossscores
Receipts
if present
were assigned
+1 if pro-physician
compared to other states, 0 if neutral, or -1
Tax
if anti-physician.
policy
in
Table
4.
Provider States’
Taxes overall ranking if
= +1
bynone
tier ispresent
given in
Table 2. Details concerning tax policy are listed
Medicaid
+1inif Table
opted 4.
not to expand, -1 if expanded, 0 if undecided
in Table Expansion
3, and regulatory policy
In choosing a state to set up a practice, physicians
Certificate of Need
+1 if no certificate requirements, -1 if any type of certificate
should consider tax and regulatory policy, especially those
Table
1. Scoring
Table 1. Scoring
Factors Factors
required
In Office Dispensing
+1 if easily arranged, 0 if difficult to obtain permit, -1 if
regulations most relevant to their specialty or practice
Item
Scoring
prohibited
Individual
Income Tax
at if
0%no=restrictions
+1, above 0%
up to 7.99%
= 0, at amount
or abovein8%
= -1-1 if
Surgical
Restrictions
+1
enacted,
0 if minimal
place,
model. Important issues include: certificate-of-need (CON)
Corporate
Income
Tax
at
= 0,
0, at
at or
or above
above 8%
8%==-1
-1
Corporate Income Tax
at0%
0%==+1,
+1,above
above 0%
0% up
up to
to 7.99%
7.99% =
extensive
Sales
Tax
at
0%
=
+1,
above
0%
up
to
6%
=
0,
above
6%
=
-1
requirements, in-office dispensing regulations, office-based
Sales
TaxIncome Tax
0%==+1,
+1,above
above
0%rapidly
up to
to 7.99%
6%
= 0,=above
6%
= -1data
Pilot
Maintenance
of
no
assignment
given,
changing
limited
Corporate
atat0%
0%
up
0,and
at or
above
8% = -1
General
Gross Receipts Tax if present
= -1
General
present
-1
Licensure
Sales
Tax Gross Receipts Tax atif0%
= +1,= above
0% up to 6% = 0, above 6% = -1
surgical restrictions, pilot maintenance-of-licensure efforts,
Physician
Gross
Receipts
ififpresent
==-1
Physician
Gross
Receipts
present
-1 index <2, 0 if index between 2 to 5, -1 if index >5
Medical
Board
Actions
if per capita
General
Gross
Receipts
Tax +1
if present
= -1
Tax
Tax
Medical
+1
if in top= ten
medical board action climate, medical liability climate,
PhysicianMalpractice
Gross Receipts
if present
-1 states per capita, -1 if in the bottom ten states
Provider
ififnone
ProviderTaxes
Taxes
nonepresent
present == +1
+1
Ranking
Tax
continuing medical education (CME) requirements, and
Medicaid
Expansion
+1
if
opted
not
to
expand,
-1 if
undecided
Medicaid
Expansion
+1
if
opted
notbetween
expand,
expanded,
ifif undecided
Continuing
Medical
+1
if at present
0, 0 if
0 and
50,expanded,
-1 if at 5000 or
above
Provider Taxes
if none
=to+1
Certificate
+1
any type
type of
of certificate
certificate
CertificateofofNeed
Need
+1ififno
nocertificate
certificate requirements,
requirements, -1 if any
Education
Medicaid Expansion
+1 if opted not to expand, -1 if expanded, 0 if undecided
whether the state elected to expand Medicaid. Taxes include:
required
required
Price
Transparency
Grade
No
assignment
given
due
to
difficulty
interpreting
limited data
Certificate of Need
+1 if no certificate requirements, -1 if any type of certificate
Office
Dispensing
+1ifassignment
ifeasily
easilyarranged,
arranged,
InInOffice
Dispensing
+1
obtain permit,
permit, -1
-1ifif
GME
needed
for licensure
No
given 00 if difficult to obtain
individual income, corporate income, sales, gross receipts,
required
prohibited
prohibited
InSurgical
Office Dispensing
+1
if
easily
arranged,
0
if
difficult
to
obtain
permit,
-1 if -1 if
Restrictions
+1ififno
norestrictions
restrictions enacted,
enacted, 0 if minimal
physician gross income, and various provider taxes.
Surgical Restrictions
+1
minimal amount
amount in
inplace,
place, -1 if
prohibited
extensive
extensive
Table
2.
Overall
Ranking
by
State
Surgical
Restrictionsof
+1
ifassignment
no restrictions
enacted,
0changing
if minimal
amount
in
place, -1 if
Pilot
Maintenance
no
given,
rapidly
and
limited
data
Pilot Maintenance of
no assignment given, rapidly
and limited data
extensive
Licensure
Licensure
General Considerations
Pilot
Maintenance
of
no
and limited
dataif index >5
Medical
BoardActions
Actions
+1assignment
percapita
capitagiven,
index rapidly
<2, 00 if
if changing
index between
Medical
Board
+1
ififper
index
<2,
index
between 22 to
to 5,
5, -1
-1 if index >5
Licensure
Professional
Liability
Medical
Malpractice
+1ififinintop
topten
ten states
states per
per15.
capita,
-1
states
Medical
Malpractice
+1
capita,
-1 if
if in
in the
the bottom
bottom ten
ten
states
Tier
1
Oklahoma
1
(+2,
-1) >5
Medical
Board Actions
+1 if per capita index <2, 0 if index between 2 to 5, -1
if index
Ranking
Ranking
1.to South
Dakota
88%
(+8,=-0)
16. Georgia
1 (+2, -1)
Corporate
Income
Tax
at
0%
=
+1,
above
0%
up
7.99%
=
0,
at
or
above
-1
Corporate
Corporate
Income
Income
Tax
Tax
at
at
0%
0%
=
=
+1,
+1,
above
above
0%
0%
up
up
to
to
7.99%
7.99%
=
=
0,
0,
at
at
or
or
above
above
8%
8%
=
=
-1
-1
Medical
Malpractice
+1
ifif-1)
inat top
states per
capita,
ifif in
the
bottom
ten
states
The majority of articles discussing
the
best
state
in
which
Continuing
Medical
+1if
0,00ten
if between
between
017.
and
50, -1
-1
at
50
or
above
2.
Wyoming
5
(+6,
Utah
1
(+2,
-1)
Continuing
Medical
+1
at
0,
if
0
and
50,
-1
if
at
50
or
above
SalesTax
Tax
at0%
0%==
=+1,
+1,above
above0%
0%Ranking
upto
to6%
6%==
=0,0,
0,above
above6%
6%==
=-1
-1
Sales
Sales
Tax
atat
0%
+1,
above
0%
up
up
to
6%
above
6%
-1
Education
18. Florida
1 (+3, -2)
Education
GeneralGross
Gross
ReceiptsTax
Tax if
ifpresent
present==
=-1
-1
to practice medicine have offered
superficial
analyses,
Continuing
Medical Grade
+1
at 0, 0 if between
0 19.
and
50, -1Carolina
if at
50 or above1 (+3, -2)
General
General
Gross
Receipts
Receipts
Tax
if
present
-1
Price
Transparency
Noifassignment
assignment
given due
due
to South
difficulty
interpreting
Tier
2 Transparency
Price
Grade
No
given
to
difficulty
interpreting limited
limiteddata
data
PhysicianGross
GrossReceipts
Receipts
ifpresent
present==
=-1
-1
Education
Physician
Physician
Gross
Receipts
if
if
present
-1
3. Idaho
(+4,
-0)
1 (+3, -2)
GME
neededfor
forlicensure
licensure 4 No
Noassignment
assignment
given 20. Kansas
focusing on physician satisfaction
surveys, a handful of
GME
needed
given
Tax
Price
given due21.
to Nevada
difficulty interpreting limited
data
4. Transparency
Wisconsin Grade
4 No
(+5,assignment
-1)
1 (+4, -3)
Tax
Tax
Provider
Taxes
nonepresent
present==
=+1
+1 GME
5. needed
Indianafor licensure
3 No
(+4,assignment
-1)
given
Provider
Taxes
Taxes
none
present
+1
broad taxes (such as income andProvider
property),
medicalifififnone
liability
MedicaidExpansion
Expansion
+1ifif
ifopted
optednot
notto
toexpand,
expand,
-1if
ifexpanded,
expanded,
ifundecided
undecided
6.-1
North
Dakota
(+4, -1)
Tier 4
Medicaid
Medicaid
Expansion
+1
+1
opted
not
to
expand,
-1
if
expanded,
000ifif
undecided
Table
2.
Overall
Ranking
by 3State
Table
Overall
Ranking
by
State
7. 2.Texas
3 (+5, -2)
22. Arizona
0 (+2, -2)
insurance premiums, and the local
weather.
in-depth
Certificate
ofNeed
NeedA more +1
+1ifif
ifno
nocertificate
certificaterequirements,
requirements,
-1ifif
ifany
anytype
typeof
ofcertificate
certificate
Certificate
Certificate
of
of
Need
+1
no
certificate
requirements,
-1
-1
any
type
of
certificate
8.
Alaska
3
(+5,
-2)
23. Tennessee
0 (+3, -3)
required
Table 2. Overall
Ranking by
State
required
required
Table
2. Overall
Ranking
by State 24.
guide is needed to make physicians
aware
of
potential
Virginia
0
(+1, -1)
InOffice
OfficeDispensing
Dispensing
+1ifif
ifeasily
easilyarranged,
arranged,000ifif
if difficult
difficultto
toobtain
obtainpermit,
permit,-1
-1ifif
if
In
In
Office
Dispensing
+1
+1
easily
arranged,
to
obtain
permit,
-1
Tier difficult
3
25. Minnesota
0 (+4, -4)
prohibited
Tier 1
15. Oklahoma
1 (+2, -1)
prohibited
prohibited
pitfalls associated with certain practice models in each
state.
2 (+3,
-1)
26.
West
Virginia
-1(+2,
(+2,-1)
-3)
Tier9.11. Nebraska
15.
-1)
Dakotaamount
(+8, -0)
16. Oklahoma
Georgia
11(+2,
SurgicalRestrictions
Restrictions
+1ifif
ifno
norestrictions
restrictionsenacted,
enacted,
ifminimal
minimal
amountin
in28place,
place,
-1ifif
if
Surgical
Surgical
Restrictions
+1
+1
no
restrictions
enacted,
00South
ifif
minimal
in
-1
-1
10.
Colorado
(+3,
27.
(+2,-1)
-3)
1.2. 0
South
Dakota amount
85place,
(+8,
-0)
16.
Georgia
1 (+2,
-1)
Wyoming
(+6,-1)
-1)
17. Michigan
Utah
1-1
The best states generally undertake policies designed
extensive
Tier11.
15.
Oklahoma
11(+2,
(+2,
-1)
extensive
extensive
25 (+3,
28.
Hawaii
-1
(+2,
-3)
2.1 Alabama
Wyoming
(+6, -1)
17.
Utah
(+2,
-1)
18.
Florida
1
(+3,
-2)
1.
South
Dakota
8
(+8,
-0)
16.
Georgia
1
(+2,
-1)
PilotMaintenance
Maintenanceof
of
noassignment
assignmentgiven,
given,rapidly
rapidly
changingand
andlimited
limiteddata
data
29.
(+3,-2)
-4)
18.
Florida
1 (+3,
-2)
Pilot
Maintenance
of
no
no
assignment
rapidly
changing
changing
and
limited
12.2 Missouri
2data
(+3, -1)
Tier
19. New
SouthMexico
Carolina
1-1
to reduce the cost of medical Pilot
care.
Decreased
cost
leads given,
2.
Wyoming
5 (+6, -1)
17.
Utah
11(+3,
(+2,
-1)
Licensure
30.
(+3,-2)
-4)
Tier13.
23. Mississippi
19.
South
(+3,
-2)
Licensure
Licensure
24(+4,
Idaho
(+4,-2)
-0)
20. Pennsylvania
KansasCarolina
1-1
18.
Florida
11(+3,
(+3,
-2)
31.
Delaware
-1
(+3,
-4)
Medical
Board
Actions
+1
if
per
capita
index
<2,
0
if
index
between
2
to
5,
-1
if
index
>5
3.
Idaho
4
(+4,
-0)
20.
Kansas
(+3,
-2)
-2)
Medical
Medical
Board
Boardpermits
Actions
Actions
+1
+1ififper
percapita
capitaindex
indexTier
<2,
<2,14.
0204.ififMontana
index
index
between
between22to
to5,5,2-1
-1
ififindex
index
>5
Wisconsin
4 (+5,
-1) >5
21. South
NevadaCarolina
11(+4,
-3)
to increased access, and greater
access
physicians
19.
33. North
MaineCarolina
32.
-1
(+3,-2)
-4)
4.
4ten
-1)
21.
Nevada
1 (+3,
(+4,
-3)
MedicalMalpractice
Malpractice
+1ifif
ifin
intop
topten
tenstates
statesper
percapita,
capita,
-1ifif
ifin
inthe
thebottom
bottomten
ten
states
5. Wisconsin
Indiana
3(+5,
(+4,
-1)
Medical
Medical
Malpractice
+1
+1
in
top
ten
states
per
capita,
-1
-1
in
the
bottom
states
states
3.
Idaho
(+4,
-0)
20.
Kansas
1-2
34.
Kentucky
(+1,
-3)
33.
Maine
-1(+3,
(+3,-2)
-4)
5.
Indiana
343(+4,
-1)
to compete for patients basedRanking
on
quality.
State
methods
Ranking
6.
North
Dakota
(+4,
-1)
Tier
4
Ranking
4.
Wisconsin
4
(+5,
-1)
21.
Nevada
1
(+4,
-3)
(+1,-2)-3)
34.
Kentucky
6.
Tier35.
4 Arkansas
7. North
Texas
(+5,-1)
-2)
22.
Arizona
0-2(+2,
ContinuingMedical
Medical
+1ifif
ifatat
at0,0,
0,000ifif
ifbetween
between000and
and
50,
-1Dakota
ifatat
at50
50or
orabove
above333(+4,
Continuing
Continuing
Medical
+1
+1
between
and
50,
50,
-1
-1
if
if
50
or
above
5.
Indiana
(+4,
-1)
36.
Iowa
-2
(+2,
-4)
35.
Arkansas
(+1,
-3)
to reduce costs to physicians and
patients
generally
take
7.8. Texas
33(+5,
22.
(+2,-3)
-2)
Alaska
(+5,-2)
-2)
23. Arizona
Tennessee
00(+3,
Education
6. Alaska
North Dakota
(+4, -2)
-1)
Tier23.
4 Louisiana
Education
Education
37.
-2(+3,
(+2,-3)
-4)
36.
Iowa
8.
33 (+5,
24. Tennessee
Virginia
0 (+1, -1)0
PriceTransparency
Transparency
Gradehurdles
Noassignment
assignment
givendue
due7.
todifficulty
difficulty
interpretinglimited
limited
data
Texas
3 (+5, -2)
22.
(+2,
-2)
Price
Price
Transparency
Grade
Grade
No
No
assignment
given
due
to
to
interpreting
interpreting
limited
data
data
the form of lower taxes and fewer
regulatory
that given
38.
Vermont*
(+3,
-5)
37.
Louisiana
(+2,-4)
-4)
24.
Virginia
0-2(+4,
(+1,
-1)
Tier
3 difficulty
25. Arizona
Minnesota
00
8.
Alaska
3
(+5,
-2)
23.
Tennessee
0
(+3,
-3)
GME
needed
for
licensure
No
assignment
given
39.
Washington
(+3,-4)
-5)
38.
Vermont*
GME
GMEneeded
neededfor
forlicensure
licensure
No
Noassignment
assignmentgiven
givenTier 39. Nebraska
25.
0-2(+4,
2 (+3, -1)
26. Minnesota
West Virginia
-1
(+2,
-3)
interrupt the patient-physician relationship. Less favorable
states have generally taken the opposite
approach,
and have
Table2.2.
2.Overall
Overall
Rankingby
byState
State
Table
Table
Overall
Ranking
Ranking
by
State
been more likely to “double down,” attempting to address
perceived inefficiencies with more regulatory requirements
Tier111
Tier
that often fail to achieve desiredTier
improvements.
1. South
SouthDakota
Dakota
(+8,-0)
-0)
1.1.
South
Dakota
888(+8,
(+8,
-0)
2. Wyoming
Wyoming
(+6,-1)
-1)
2.2.
Wyoming
555(+6,
(+6,
-1)
Physicians might first look at each
state’s comprehensive
Tier222
Tier
Tier
ranking, which weights all categories
equally, then4 evaluate
3. Idaho
Idaho
(+4,-0)
-0)
3.3.
Idaho
44(+4,
(+4,
-0)
4.
Wisconsin
(+5,-1)
-1)
4.4. Wisconsin
Wisconsin
444(+5,
(+5,
-1)
a narrowed list of states on the basis
of
considerations
most
5. Indiana
Indiana
(+4,-1)
-1)
5.5.
Indiana
333(+4,
(+4,
-1)
6. North
NorthDakota
Dakota
(+4,-1)
-1)
relevant to their practice.
6.6.
North
Dakota
333(+4,
(+4,
-1)
7.
7.7.
8.
8.8.
Ranking Methodology
Texas
Texas
Texas
Alaska
Alaska
Alaska
Tier333
Tier
Tier
9. Nebraska
Nebraska
9.9.
Nebraska
10. Colorado
Colorado
10.
10.
Colorado
11. Alabama
Alabama
11.
11.
Alabama
12. Missouri
Missouri
12.
12.
Missouri
13. Mississippi
Mississippi
13.
13.
Mississippi
14. Montana
Montana
14.
14.
Montana
(+5,-2)
-2)
333(+5,
(+5,
-2)
(+5,-2)
-2)
333(+5,
(+5,
-2)
(+3,-1)
-1)
222(+3,
(+3,
-1)
(+3,-1)
-1)
222(+3,
(+3,
-1)
(+3,-1)
-1)
222(+3,
(+3,
-1)
(+3,-1)
-1)
222(+3,
(+3,
-1)
(+4,-2)
-2)
222(+4,
(+4,
-2)
(+4,-2)
-2)
222(+4,
(+4,
-2)
Classification criteria for the tiered ranking system are
listed in Table 1. Ranked factors were assigned scores as
follows: +1 if pro-physician compared to other states, 0 if
neutral, or -1 if anti-physician.
States’ overall ranking by tier is given in Table 2. Details
Journal of American Physicians and Surgeons Volume 19 Number 4 Winter 2014
9.10.Nebraska
Colorado
Tier10.
311.Colorado
Alabama
9. Alabama
Nebraska
11.
12. Missouri
10. Colorado
13.Missouri
Mississippi
12.
11. Alabama
14.Mississippi
Montana
13.
12.
Missouri
14.
33. Montana
Maine
13.
Mississippi
15. Oklahoma
Oklahoma
15.
15.
Oklahoma
34.
Kentucky
14.
Montana
16.
Georgia
16.
16.
Georgia
Georgia
35.
Arkansas
33.
Maine
17.
Utah
17.
17.
Utah
Utah
36.
Iowa
34.
Kentucky
18. Florida
Florida
18.
18.
Florida
37.
Louisiana
35.
Arkansas
19. South
SouthCarolina
Carolina
19.
19.
South
Carolina
38.
Vermont*
36.
Iowa
20.
Kansas
20.
20.
Kansas
Kansas
39.
Washington
37.
Louisiana
21.
Nevada
21.
21.
Nevada
40.
New
Hampshire
38. Nevada
Vermont*
22(+3,
(+3,-1)
-1)
22(+3,
(+3,-1)
-1)
(+3, -1)
-1)
222(+3,
(+3, -1)
2 (+3, -1)
(+4,-1)
-2)
22(+3,
2 (+3, -1)
(+4,-2)
-2)
22(+4,
2
(+3,
-1)
2-1(+4,
(+3,-2)
-4)
21 (+4,
-2)
(+2,
-1)
112-2
(+2,
(+2,
-1)
(+1,-1)
-3)
(+4,
-2)
1
(+2,
-1)
11-2
(+2,
(+2,
-1)
(+1,
-3)
-1
(+3,-1)
-4)
1(+2,
(+2,
-1)
11-2
(+2,
-1)
(+2,
-4)
-2
(+1,-1)
-3)
1(+3,
(+3,
-2)
11-2
(+3,
-2)
-2)
(+2,
-4)
-2
(+1,-2)
-3)
1(+3,
(+3,
11-2
(+3,
-2)
(+3,
-5)
-2
(+2,-2)
-4)
1(+3,
(+3,
-2)
11-2
(+3,
-2)
-2)
(+3,
-5)
-2
(+2,
-4)
1 (+4,
(+4,
-3)
11-2
-3)
(+4,
-6)
-2(+4,
(+3,-3)
-5)
45
46
45
47
46
48
47
49
48
49
Tier 6
Tier50
6
51
50
51
24.
0-1
40.
New
Hampshire
-2(+1,
(+4,
-6)
39.
Washington
(+3,-1)
-5)
26.
West
Virginia
(+2,
-3)
27. Virginia
Michigan
-1
(+2,
-3)
25.
0-1
40.
New
Hampshire
-2(+4,
(+4,-4)
-6)
27.
Michigan
(+2,
-3)
28. Minnesota
Hawaii
-1
(+2,
-3)
26.
West
Virginia
-1
(+2,
-3)
29. Hawaii
New Mexico
-1
28.
-1(+3,
(+2,-4)
-3)
-1
(+2,
-3)
Tier27.
5 Michigan
30.
Pennsylvania
-1
29.
New
Mexico
-1(+3,
(+3,-4)
-4)
Hawaii
-1
(+2,
-3)
41.
Connecticut
-3
(+2,
-5)
Tier28.
5
31.
Delaware
-1
(+3,
-4)
30. Pennsylvania
-1 (+3, -4)
29.
-1
(+3,
-4)
42.
Rhode
Island
-3(+3,
(+2,-4)
-5)
32. New
NorthMexico
Carolina
-1
41.
Connecticut
31.
Delaware
-1
(+3,
-4)
45.
Maryland
-4
(+1,
-5)
30.
Pennsylvania
-1
(+3,
-4)
43.
DC
-3 (+3,
(+2, -4)
-5)
* Will
42. North
RhodeCarolina
Island
32.
-1
46.
New
-4
(+1,
-5)
31.
-1
44.
Oregon
-4
(+1,
-5)
43. Delaware
DC York
-3 (+3,
(+2, -4)
*establi
Will
47.
California
-4
(+2,
-6)
32.
Carolina
-1
establis
44.
Oregon
-4 (+3,
(+1, -4)
-5)
45. North
Maryland
48.
-5
46. Ohio
New
York2, the first number
-4 (+1,
(+1,is-6)
-5)
In Table
the state’s total score,
49.
-5
47. Illinois
California
-4 (+1,
(+2,
-6)
In
firstthe
number
is-6)
the
state’s
total score,
number
ofTable
areas 2,
in the
which
state
was
above
average,
and
48. Ohio
-5 (+1,
-6)below
above average,
number
of
areas
in
which
the
state
was
average. and
Tier49.
6 Illinois
-5
(+1,
-6)
number
of areas in which the state
was
50. Massachusetts
-7 (+0,
-7)below average.
Taxation
-9 (+0, -9)
Tier51.
6 New Jersey
Washington
-2 (+3, -5)
Tier439.
Taxation
Tier
44 New Hampshire
Tier
40.
-2(+2,
(+4,-2)
-6)
50. Massachusetts
-7 (+0, -7)
1
22.
Arizona
[1] corporate,2 [2] a
The highest tiers of individual,
22.
Arizona
(+2,-2)
-2)
000(+2,
Tier22.
5 Arizona
51. New Jersey
-9 (+0, -9)
1
23.
Tennessee
0
(+3,
-3)
The require
highestno
tiers
of individual,
[1] corporate,
23.
Tennessee
(+3,
-3)
23.
00-3(+3,
41. Tennessee
Connecticut
(+2,-3)
-5)
and should
additional
explanation.
Provider2 [2]
taxea
24. Virginia
VirginiaIsland
0(+1,
(+1,
-1)
24.
Virginia
(+1,
-1)
00-3
42.
Rhode
(+2,-1)
-5)
and
should require
no by
additional
Provider taxe
are typically
justified
states asexplanation.
a means of financing
Me
Tier24.
5
25. Minnesota
Minnesota
0(+4,
(+4,
-4)
25.
Minnesota
0
(+4,
-4)
25.
0
-4)
*
Will
likely
be
last
in
2017
when
single
payor
is
43.
DC
-3
(+2,
-5)
are
typically
justified
by
states
as
a
means
of
financing
Me
except
Alaska
levies
some
type
of
provider
tax,
and
the
thr
41.
Connecticut
-3
(+2,
-5)
26. West
WestVirginia
Virginia
-1(+2,
(+2,-3)
-3)
-1
26.
West
Virginia
-1
(+2,
-3)
26.
established—
could
ban
private
medicine
44.
Oregon
-4
(+1,
-5)
except
Alaska
levies
some
type
of
provider
tax,
and
the
thr
generating
provider
tax
revenue
are
hospitals,
intermediate
42.
Rhode
Island
-3
(+2,
-5)
27.
Michigan
-1
(+2,
-3)
27.
27.
Michigan
Michigan
-1
-1
(+2,
(+2,
-3)
-3)
generating
provider
tax
revenue
are hospitals,
*A
Will
likely
be lastofinstates
2017
when
payor
is intermediate
43.
DC
-3
(+2,
-5)
small
minority
have single
enacted
a provider
tax narro
28. Hawaii
Hawaii
-1
(+2,
-3)
28.
28.
Hawaii
-1
-1
(+2,
(+2,
-3)
-3)
In Table 2, the first number
is-5)
the state’s totalestablished—
number
indicates
the a provider tax narro
couldof
ban
private
medicine
44.
Oregon
-4
(+1,
Ascore,
smallthe
minority
states
have
enacted
receipts.
[4]second
29. New
NewMexico
Mexico
-1(+3,
(+3,-4)
-4)
29.
29.
New
Mexico
-1
(+3,
-4)
number
of areas
in which the -1
state
was
above average,
and the[4]
second (negative number) is the
receipts.
30. Pennsylvania
Pennsylvania
-1(+3,
(+3,-4)
-4)
30.
30.
Pennsylvania
-1
-1
(+3,
-4)
number
of
areas
in
which
the
state
was
below
average.
In
Table 2, the first number
the state’s totalRegulations
score, the second number indicates the
31. Delaware
Delaware
-1(+3,
(+3,is-4)
-4)
31.
31.
Delaware
-1
-1
(+3,
-4)
number
of areas
in which the -1
state
was
and the second (negative number) is the
Regulations
32. North
North
Carolina
-1(+3,
(+3,
-4)above average,
32.
32.
North
Carolina
Carolina
-1
(+3,
-4)
-4)
In Table 2, the first number is the state’s total score, the
second
number indicates the number of areas in which the
Taxation
number of areas in which the state was below average.
Certificate of Need (CON)
of (negative
Need (CON)(CON)
Certificate-of-need
laws were initially effec
stateThe
was
above average, and theCertificate
second
number)
[2] and
sales
taxes [3]Act
are
listed
in Table
3 initially
Taxation highest tiers of individual, [1] corporate,Resources
Certificate-of-need
(CON)
laws
werewere
effec
Development
of
1974.
They
designed
andthe
should
require no additional
explanation.
Provider
taxes
can
come
from
many
categories
andwere
is
number
of areas
in which
the
state
was
below
average.
Resources Development
Act
of 1974.
mechanisms
to ensure that
there
was aThey
need
for a designed
specified
1
2
3
1
2 Medicaid programs.
3 4 [4] Every state
are typically
justified
by of
states
as a means
financing
The highest
tiers
individual,
[1]of
corporate,
[2] and
sales
[3]
are
listed
in
3for aAspecified
mechanisms
to taxes
ensure
that
there
was
aTable
need
capital
investment.
The
theory
was
that
hospital
might w
except
Alaska
leviesnosome
type ofexplanation.
provider tax,
and the
threeinvestment.
most
popular
categories
forthat
and should
require
additional
Provider
taxes
can
come
from
many
categories
andbusiness
capital
The
theory
was
hospital
A might
w
hospital
B,
while
the
town
only
has
enough
to sup
4
115
generating
hospitals,
intermediate
care
facilities,
and[4]
nursing
homes.
[4]business
are typicallyprovider
justifiedtax
byrevenue
states asare
a means
of financing
Medicaid
programs.
Every
state
hospital
B,
while
the town
only
has
enough
to sup
hospitals
were
to purchase
machines,
the risk
of over-use
o
A
smallAlaska
minority
of states
a provider
narrowly
tailored
to
gross
except
levies
some have
type enacted
of provider
tax, andtax
the
three
most
categories
for
hospitals
were
topay
purchase
the risk ofStates’
over-use
o
many
MRIs)
topopular
offphysicians’
the machines,
machines
increases.
CON
receipts.
[4]provider tax revenue are hospitals, intermediate
generating
care facilities,
and
nursing
[4] radiology
many
MRIs)
to pay off
the
machines
increases.
States’ equ
CON
Independent
physicians
wishing
tohomes.
purchase
Taxation
The highest tiers of individual,1 corporate,2 and sales
taxes3 are listed in Table 3 and should require no additional
explanation. Provider taxes can come from many categories
and are typically justified by states as a means of financing
Medicaid programs.4 Every state except Alaska levies some
type of provider tax, and the three most popular categories for
generating provider tax revenue are hospitals, intermediate
care facilities, and nursing homes.4 A small minority of states
have enacted a provider tax narrowly tailored to physicians’
gross receipts.4
Regulations
Certificate of Need (CON)
Certificate-of-need (CON) laws were initially effected as
part of the Health Planning and Resources Development
Act of 1974. They were designed as state-sponsored costrestricting mechanisms to ensure that there was a need
for a specified health service prior to approving capital
investment. The theory was that hospital A might want an
MRI machine to compete with hospital B, while the town
only has enough business to support one MRI machine. If
both hospitals were to purchase machines, the risk of overuse of government funds (ordering too many MRIs) to pay
off the machines increases. States’ CON laws vary widely
in severity.5 Independent physicians wishing to purchase
radiology equipment and other items traditionally owned
by hospitals should be more cautious about entering states
with these regulations. Hospitals often use CON laws to
prevent perceived competition from physicians. Only 14
states are entirely free of CON laws, and these deserve special
consideration from radiologists and surgeons.5
In-Office Dispensing of Prescription Medications
These regulations are most important to direct primary
care practices, which often attempt to increase their value
to patients by dispensing prescription medications, often
at cost lower than the pharmacy. Eleven states prohibit
physicians from dispensing even non-narcotic medications
on a monthly basis: Arkansas, Maryland, Massachusetts,
Montana, New Jersey, New Mexico, New York, North Carolina,
Oregon, Texas, and Utah.6 Physicians who have not opted
out of Medicare can easily run afoul of Stark regulations in
this area, and those dispensing medications priced higher
than cost must ensure compliance with anti-kickback
statutes.7 Details have unfortunately not been summarized
in comprehensive fashion in any single location, and further
discussion of this topic would warrant an entire article. The
Jasos Group authored a helpful summary,8 and Progressive
Medical has the best single-page review.9 The Office of the
116
Inspector General issued a summary report in 1989 that is
now outdated.10
Surgical Restrictions
These regulations are complex. The Federation of State
Medical Boards (FSMB) provides a comprehensive overview
of surgical regulations.11 States without specific restrictions
on outpatient surgery obviously provide physicians with
greater practice flexibility. Surgeons should take note of the
10 states with the most severe restrictions: California, Florida,
Kentucky, Louisiana, New Jersey, North Carolina, Ohio,
South Carolina, Tennessee, and Texas. A surgeon desiring
to open an outpatient surgical center in one of these states
should carefully review the regulations prior to making this
investment. The Accreditation Association for Ambulatory
Health Care also provides a helpful summary.12
Pilot Maintenance of Licensure (MOL)
Members of the academic medical community and the
FSMB are concerned about the lack of broad physician
endorsement of the current maintenance-of-certification
(MOC) regime. Physicians have begun to vote with their
feet by opting out of the ever more frequent and more
expensive examinations, arguing that the process has not
been shown to increase quality of care. As a result, efforts
are underway in some states to tie MOC to maintenance
of licensure (MOL), altering what was designed to be a
“feather in your cap” to a new “minimum standard.” These
efforts have been well documented by Paul Kempen, M.D.,
Ph.D.,13 and Kenneth Christman, M.D.,14 in this journal.
MOL proposals were defeated in Ohio, other state medical
associations have been fighting efforts by the FSMB, and
data is gradually being aggregated online.15 While they are
not currently incorporated in the rankings because of lack of
official action in most states, physicians should follow these
developments closely before selecting a new location, and
consider promoting the passage of model legislation on this
issue in their state.16
Medical Licensure Board Actions
The ability to police negligent, corrupt, or otherwise
harmful physicians is an important function of state medical
boards, but most state medical boards operate outside
traditional due process and our court systems’ rules of
evidence, making their investigations of physicians ripe
for potential abuse. Public Citizen’s Health Research Group
historically ranked medical boards based on per capita
(physician) actions.17 While this group favored increased
board action against physicians, their rankings can be
inverted for well-meaning physicians who would like to
minimize their risk of an unwarranted investigation. Public
Citizen gathered its data largely from reports released by
the FSMB, which has now decided to stop releasing the
Journal of American Physicians and Surgeons Volume 19 Number 4 Winter 2014
information.18 For smaller states, the limited number of
physicians can lead to wide variations on an annual basis.
The Texas State Medical Board provides one example of the
misery these entities are capable of inflicting on physicians.19
Medical Liability Actions
A healthy medical liability climate occurs in states that
have lower incidence of nuisance suits, and appears to be
less related to the size of verdicts. Diederich Healthcare has
the most useful comprehensive rankings, on a per-capita
(physician) payout basis.20 Academic studies differ in opinion
about why some states have a more favorable climate than
others. Readers should note that caps (on non-economic
damages) are likely overrated for two reasons: 1) studies
have shown that these made little difference in claims,21 and
2) eight states attempting to impose these non-economic
damage caps have had them overturned on constitutional
grounds at the state supreme court level.22
Continuing Medical Education (CME)
Lifelong learning is a wonderful concept, and physicians
should not attempt to rest on their laurels after residency
or at any other point in their careers. Whether the highly
formalized CME process achieves its purported aims, or
educates physicians better than other less formalized
methods of self-education, is debatable. For physicians who
are confident that they do not need an auditor to ensure they
are consistently furthering their own medical knowledge,
there are five states that have no continuing medical
education requirements: Colorado, Indiana, Montana,
New York, and South Dakota.23 Many states have multiple
subcategories that can make fulfilling these requirements
more onerous.24 Twelve states require 50 CME hours per
year, an especially burdensome number, while the average
for those requiring CME is around 25 hours per year.25 While
physicians with a D.O. degree in Vermont are required to
have an unremarkable 15 hours of CME per year, in the future
physicians with an M.D. degree will have “CME required, with
criteria to be determined by the board,” vague language that
could lead to unpredictable new requirements during future
licensure renewals.26
Price Transparency
This remains an important issue for third-party-free
practices. Many private entities are attempting to aggregate
and disseminate this information, but regulations in this
arena have not had much impact. A study by the Health Care
Incentives Improvement Institute attempted to give each
state a ranking, but the data is limited and rapidly changing.27
The best single resource for a summary in this arena is the
National Conference of State Legislature’s summary; of note,
California, Florida, Maryland, Oregon, and New Jersey all
have online databases representing some attempt at price
Journal of American Physicians and Surgeons Volume 19 Number 4 Winter 2014
transparency.28 All five databases fall well short of the simple
steps taken by Dr. G. Keith Smith at the Surgery Center of
Oklahoma.29
Medicaid Expansion
The states are fairly evenly split regarding Medicaid
expansion.30 Estimates from The New York Times show that
a Medicaid expansion would cause an increase in spending
in most states (but not all).31 Not all levels of expansion are
equivalent, but the decision to expand should generally be
concerning to physicians due to anticipated tax increases
needed to fund the higher levels of state spending. Indiana
and Utah have not yet made official decisions.31
Special Considerations in Various States
Physicians need to be aware of issues unique to individual
states that could not be easily worked into the tiered rankings
above. Remember that “direct primary care” practices charge
a periodic fee for services and do not bill any third parties on
a fee-for-service basis. Any per visit charge must be less than
the monthly equivalent of the periodic fee. Many describe
these practices as “concierge for the masses.”
Florida
Florida had a 1.5% physician gross receipts tax until
around 2001 when the judiciary eliminated it.32
Hawaii
Hawaii has a hybrid between a gross receipts tax and a
sales tax known as a general excise tax of around 4%.33 This
was listed as a sales tax in Table 1 for simplification purposes.
Illinois
The Medicaid climate in Illinois is yet another reason
that it is one of the worst states to practice medicine.
“Attorney General Lisa Madigan filed an antitrust lawsuit in
June against the Carle Clinic Association and Christie Clinic
for declining to enroll new Medicaid patients. The lawsuit
alleges that the medical groups collectively boycotted new
Medicaid patients by adopting identical policies in 2003.”34
Kentucky
Kentucky has experimented with a provider tax in the
past.
Massachusetts
In Massachusetts, a rule to tie licensure to electronic
health record proficiency has been proposed.35
Minnesota
The MinnesotaCare program enacted in the 1990s placed
117
a 2% gross receipts tax on physicians. It was briefly reduced
to 1.5%, and then returned to 2%.32 Efforts to increase the
amount of the tax for specific procedures have thus far been
unsuccessful.32
Missouri
Recently Missouri passed legislation enacting a new class
of healthcare provider—the assistant physician.36 Physicians
who graduate medical school and pass step 1 and 2 of their
national licensure exam (but strangely not step 3), who failed
or elected not to obtain a residency spot, will be eligible for
this new type of medical licensure if they find a physician
willing to sign a collaborative agreement.37 Space precludes
a full discussion here.
New Hampshire
New Hampshire imposes a gross receipts tax, known as a
business profits tax, of 8.5% on organizations with $50,000 or
more gross business income.38 The state also levies a 0.75%
business enterprise tax on all business with gross revenue of
$150,000 or more.38
New Mexico
New Mexico’s general gross receipts tax applies to
physician’s services that are not being delivered by a physician
working for a 501(c)(3) nonprofit or employed by HMOs.32 It
is levied at rates from 5.125% to 8.6875% depending upon
the location of the business.39
New York
A New York law requires all health workers to receive the
influenza vaccination or wear a mask.
New Jersey
New Jersey enacted a 6% gross receipts tax on elective
cosmetic procedures and a 3.5% flat tax on ambulatory
surgical center income greater than $300,000 in 2004.
Studies demonstrated that “for every $1.00 New Jersey
collects from provider taxes the state actually loses $3.39 in
total revenue.”32 Attempts by the legislative authors to later
repeal the taxes were vetoed by the governor.32
Ohio
The first attempt to implement a pilot Maintenance
of Licensure (MOL) program was made in Ohio. Thanks
largely to the efforts of Paul Kempen, M.D., and other
physicians, this effort was blocked. In addition, the former
executive director of the State Medical Board of Ohio,
Richard Whitehouse, has now been ousted. 40 Ohio has a
gross receipts tax, known as the commercial activity tax,
which applies to physicians and most business sectors; it
118
is imposed on businesses with gross receipts of more than
$150,000 and is levied at a rate of 0.26% on gross receipts of
more than $1 million.41
West Virginia
From 1993 to 2010, West Virginia had a 2% physician
gross receipts tax.32 A 10-year sunsetting of the 2% tax
began around 2001.32 In 2009 the legislature betrayed the
trust of the West Virginia State Medical Association and
decided to enact separate legislation authorizing a specific
physician provider tax of “two percent of the gross receipts
derived by the taxpayer from furnishing physicians’ services
in this state.”42 West Virginia places control of pricing and
operational decisions by direct primary care practices in
the hands of the state insurance commissioner and the
body that governs CON issues, the West Virginia Health Care
Authority.43 Direct primary care physicians would be better
off without this legislation.
Texas
Surprisingly, Texas prohibits physicians from dispensing
medications unless they are in a rural area with no pharmacy
within a 15-mile radius.44 To obtain a Texas medical license,
physicians must pass a separate medico-legal examination,
an unnecessary barrier to initial licensure. The Texas Medical
Board has been known for attempting to end physician
careers based on anonymous allegations backed by little
evidence.19
Vermont
The Vermont law enacting single-payer medicine as of
2017 gives the Green Mountain Care Board the authority to
set all prices, and thus the ability to effectively ban private
medicine in Vermont.45
Oregon
Oregon has laws designed to regulate direct primary care
physicians. The motivation for these types of laws in the five
other states with this type of legislation (Washington, West
Virginia, Utah, Arizona, and Louisiana) was to provide explicit
assurance to physicians that this type of practice model
does not amount to the unlawful sale of insurance. Oregon’s
language fails to explicitly state that direct primary care is
“not insurance,” and allows the insurance commissioner
to retain full regulatory control over direct primary care
practices.46 Direct primary care physicians in Oregon are
severely restricted and would be better off without any
legislation at all.
Washington
Washington’s gross receipts tax, known as the business
and occupations tax, has a 1.5% service sector rate.47
Journal of American Physicians and Surgeons Volume 19 Number 4 Winter 2014
service Washington’s
sector rate.47 gross receipts tax, known as the business and occupations tax, has a 1.5%
service sector rate.47
Table 3. Tax Climate Comparison
Table3.3.Tax
TaxClimate
Climate
Comparison
Table
Comparison
Individual Corporate Sales
Gross
Dr Tax Provider Taxes Medicaid
Individual
Corporate
Sales
Gross
Income
Income
Tax
Receipt Dr Tax Provider Taxes Medicaid
Expansion
Income
Income
Tax
Receipt
Expansion
Tax
Tax
Tax
Tax
Tax
Tax
Alabama
5.00%
6.50%
4.00%
Hosp
NH No
Alabama
5.00%
6.50%
4.00%
Hosp
NH No
No
Alaska
0.00%
9.40%
0.00%
None
Alaska
0.00%
9.40%
0.00%
None
No
Arizona
4.54%
6.50%
6.60%
others
Yes
Arizona
4.54%
6.50%
6.60%
others ICF NH Yes
Yes
Arkansas
7.00%
6.50%
6.00%
Hosp
Arkansas
7.00%
6.50%
6.00%
Hosp
ICF
NH
Yes
California
10.30%
8.84%
7.50%
Hosp ICF NH Yes
California
10.30%
8.84%
7.50%
Hosp ICF NH
NH Yes
Yes
Colorado
4.63%
4.63%
2.90%
Hosp
Colorado
4.63%
4.63%
2.90%
Hosp
NH
Yes
Connecticut
6.70%
9.00%
6.35%
Hosp ICF NH Yes
Connecticut
6.70%
9.00%
6.35%
Hosp ICF NH Yes
Yes
Delaware
6.75%
8.70%
0.00%
others
Delaware
6.75%
8.70%
0.00%
others
Yes
District of
District
of
D.C.
Columbia
8.95%
9.98%
6.00%
Hosp ICF NH Yes
Columbia
8.95%
9.98%
6.00%
Hosp ICF
ICF NH
NH No
Yes
Florida
0.00%
5.50%
6.00%
Hosp
Florida
0.00%
5.50%
6.00%
Hosp
ICF
NH
No
Georgia
6.00%
6.00%
4.00%
Hosp
NH No
Georgia
6.00%
6.00%
4.00%
Hosp
NH No
Hawaii
11.00%
6.40%
4.00%
others
Yes
Hawaii
11.00%
6.40%
4.00%
others
Yes
Idaho
7.40%
7.40%
6.00%
Hosp ICF NH No
Idaho
7.40%
7.40%
6.00%
Hosp
ICF
NH
No
Illinois
5.00%
9.50%
6.25%
Hosp ICF NH Yes
Illinois
5.00%
9.50%
6.25%
Hosp ICF
ICF NH
NH Undecided
Yes
Indiana
3.40%
7.50%
7.00%
Hosp
Indiana
3.40%
7.50%
7.00%
Hosp
ICF
NH
Undecided
Iowa
8.98%
12.00%
6.00%
Hosp ICF NH Yes
Iowa
8.98%
12.00%
6.00%
Hosp ICF NH
NH No
Yes
Kansas
6.45%
7.00%
6.30%
Hosp
Maryland
5.75%
8.25%
6.00%
ICF
Yes
Kansas
6.45%
7.00%
6.30%
Hosp
NH
No
Kentucky
6.00%
6.00%
6.00%
Hosp ICF NH Yes
Maryland
5.75%
8.25%
6.00%
Hosp ICF
ICF NH
NH Yes
Yes
Massachusetts
5.25%
8.00%
6.25%
Kentucky
6.00%
6.00%
6.00%
Hosp
Louisiana
6.00%
8.00%
4.00%
Maryland
5.75%
8.25%
6.00%
Hosp ICF
ICF NH
NH No
Yes
Massachusetts
5.25%
8.00%
6.25%
Hosp
NH
Yes
Michigan
4.35%
6.00%
6.00%
Hosp
Yes
Louisiana
6.00%
8.00%
4.00%
ICF
NH
No
Maine
8.50%
8.93%
5.00%
Hosp
ICF NH
No
Maryland
5.75%
8.25%
6.00%
Yes
Massachusetts
5.25%
8.00%
6.25%
Hosp
NH
Yes
Michigan
4.35%
6.00%
6.00%
Hosp ICF NH
NH No
Yes
2%
Maine
8.50%
8.93%
5.00%
Hosp
Massachusetts
5.25%
8.00%
6.25%
Hosp
NH
Yes
Michigan
4.35%
6.00%
6.00%
Hosp ICF NH
NH Yes
Yes
2%
Minnesota
7.85%
9.80%
6.88%
gross
Hosp
Michigan
4.35%
6.00%
6.00%
Hosp
NH
Yes
2%
Minnesota
7.85%
9.80%
6.88%
gross
Hosp ICF
ICF NH
NH No
Yes
Mississippi
5.00%
5.00%
7.00%
Hosp
2%
2%
gross Hosp
Minnesota
7.85%
9.80%
6.88%
gross
Hosp ICF
ICF NH
NH No
Yes
Mississippi
5.00%
5.00%
7.00%
Missouri
6.00%
6.25%
4.23%
Hosp
Minnesota
7.85%
9.80%
6.88%
gross
Hosp ICF
ICF NH
NH No
Yes
Mississippi
5.00%
5.00%
7.00%
Hosp
ICF
NH
No
Missouri
6.00%
6.25%
4.23%
Hosp ICF
ICF NH
NH No
No
Montana
6.90%
6.75%
0.00%
Hosp
Mississippi
5.00%
5.00%
7.00%
Hosp ICF
ICF NH
NH No
No
Missouri
6.00%
6.25%
4.23%
Hosp
Montana
6.90%
6.75%
0.00%
Hosp
ICF
NH
No
Nebraska
6.84%
7.81%
5.50%
Missouri
6.00%
6.25%
4.23%
Hosp ICF
ICF NH
NH No
No
Montana
6.90%
6.75%
0.00%
Hosp
ICF
NH
No
Nebraska
6.84%
7.81%
5.50%
ICF NH
NH Yes
No
Nevada
0.00%
0.00%
6.85%
Montana
6.90%
6.75%
0.00%
Hosp ICF
ICF NH
NH No
No
Nebraska
6.84%
7.81%
5.50%
Nevada
0.00%
0.00%
6.85%
NH
Yes
New
Hampshire
0.00%
8.50%
0.00%
8.50%
Hosp ICF NH
Yes
Nebraska
6.84%
7.81%
5.50%
NH
No
Nevada
0.00%
0.00%
6.85%
NH Yes
Yes
New
Hampshire
0.00%
8.50%
0.00%
8.50%
Hosp ICF NH
NH
New
Jersey
8.97%
9.00%
7.00%
Hosp
Nevada
0.00%
0.00%
6.85%
NH Yes
Yes
New
Hampshire
0.00%
8.50%
0.00%
8.50%
Hosp ICF NH
NH
Yes
New
Jersey
8.97%
9.00%
7.00%
Hosp
Yes
5.1
New Jersey
Hampshire
0.00%
8.50%
0.00%
8.50%
Hosp ICF NH
NH Yes
Yes
New
8.97%
9.00%
7.00%
Hosp
5.1
New
Mexico
4.90%
7.60%
5.13%
-8.7%
others
Yes
New
Jersey
8.97%
9.00%
7.00%
Hosp
ICF
NH
Yes
5.1
5.1-8.7%
New York
Mexico
4.90%
7.60%
5.13% -8.7%
others ICF NH Yes
Yes
New
8.82%
7.10%
4.00%
Hosp
5.1
New
Mexico
4.90%
7.60%
5.13%
-8.7%
others ICF NH Yes
Yes
New
York
8.82%
7.10%
4.00%
Hosp
North
Carolina
7.75%
6.90%
4.75%
Hosp
ICF NH No
New
4.90%
7.60%
5.13%
others
New Mexico
York
8.82%
7.10%
4.00% -8.7%
Hosp ICF
ICF NH
NH Yes
Yes
North
Carolina
7.75%
6.90%
4.75%
Hosp
No
North
Dakota
3.99%
5.15%
5.00%
ICF
Yes
New
York
8.82%
7.10%
4.00%
Hosp
ICF
NH
Yes
North
Carolina
7.75%
6.90%
4.75%
Hosp
ICF
NH
No
North Dakota
3.99%
5.15%
5.00%
ICF NH Yes
Yes
Ohio
5.93%
0.00%
5.50%
0.26%
Hosp
North
7.75%
6.90%
4.75%
Hosp ICF
ICF
No
North Carolina
Dakota
3.99%
5.15%
5.00%
ICF NH
Yes
Ohio
5.93%
0.00%
5.50%
0.26%
Hosp
ICF
NH
Yes
Oklahoma
5.25%
6.00%
4.50%
Hosp ICF NH No
North
3.99%
5.15%
5.00%
Ohio Dakota
5.93%
0.00%
5.50%
0.26%
Hosp ICF NH
NH Yes
Yes
Oklahoma
5.25%
6.00%
4.50%
Hosp
No
Oregon
9.90%
7.60%
0.00%
Hosp
Yes
Ohio
5.93%
0.00%
5.50%
0.26%
Hosp
ICF NH
NH
Yes
Oklahoma
5.25%
6.00%
4.50%
Hosp
NH
No
Oregon
9.90%
7.60%
0.00%
Hosp ICF NH
NH Yes
Yes
Pennsylvania
3.07%
9.99%
6.00%
Hosp
Oklahoma
5.25%
6.00%
4.50%
Hosp
Oregon
9.90%
7.60%
0.00%
Hosp ICF NH
NH No
Yes
Pennsylvania
3.07%
9.99%
6.00%
Hosp
NH
Yes
Rhode
Island
5.99%
9.00%
7.00%
Hosp
NH Yes
Oregon
9.90%
7.60%
0.00%
Hosp
Pennsylvania
3.07%
9.99%
6.00%
Hosp ICF NH
NH Yes
Yes
Rhode
Island
5.99%
9.00%
7.00%
Hosp
NH
Yes
South
Carolina
7.00%
5.00%
6.00%
Hosp
ICF
No
Pennsylvania
3.07%
9.99%
6.00%
Hosp
ICF
NH
RhodeCarolina
Island
5.99%
9.00%
7.00%
Hosp ICF NH Yes
Yes
South
7.00%
5.00%
6.00%
Hosp
No
South
Dakota
0.00%
0.00%
4.00%
ICF NH No
Rhode
Island
5.99%
9.00%
7.00%
Hosp
Yes
South Dakota
Carolina
7.00%
5.00%
6.00%
Hosp ICF
ICF
No
South
0.00%
0.00%
4.00%
No
Tennessee
0.00%
6.50%
7.00%
Hosp
ICF
NH No
South
Carolina
7.00%
5.00%
6.00%
Hosp
ICF
No
South
Dakota
0.00%
0.00%
4.00%
ICF
No
Tennessee
0.00%
6.50%
7.00%
Hosp ICF
ICF NH No
No
Texas
0.00%
0.00%
6.25%
South
Dakota
0.00%
0.00%
4.00%
Tennessee
0.00%
6.50%
7.00%
Hosp ICF
ICF NH No
No
Texas
0.00%
0.00%
6.25%
ICF
No
Utah
5.00%
5.00%
4.70%
Hosp
ICF
NH
Undecided
Tennessee
0.00%
6.50%
7.00%
Hosp ICF
No
Texas
0.00%
0.00%
6.25%
ICF NH
No
Utah
5.00%
5.00%
4.70%
Hosp ICF
ICF
NH Yes
Undecided
Vermont
8.95%
8.50%
6.00%
Hosp
NH
Texas
0.00%
0.00%
6.25%
ICF
No
Utah
5.00%
5.00%
4.70%
Hosp
ICF
NH
Undecided
Vermont
8.95%
8.50%
6.00%
Hosp ICF
ICF NH No
Yes
Virginia
5.75%
6.00%
5.00%
Utah
5.00%
5.00%
4.70%
Hosp
Vermont
8.95%
8.50%
6.00%
Hosp ICF
ICF NH
NH Undecided
Yes
Virginia
5.75%
6.00%
5.00%
ICF
No
Washington
0.00%
0.00%
6.50%
1.50%
Hosp
ICF
NH
Yes
Vermont
8.95%
8.50%
6.00%
Hosp ICF
Yes
Virginia
5.75%
6.00%
5.00%
ICF NH
No
Washington
0.00%
0.00%
6.50%
1.50% 2%
Hosp ICF
NH Yes
Virginia
5.75%
6.00%
5.00%
ICF
No
Washington
0.00%
0.00%
6.50%
1.50%
Hosp
ICF
NH
Yes
2%
West Virginia
6.50%
7.00%
6.00%
gross
2%
gross Hosp ICF NH Yes
Washington
0.00%
0.00%
6.50%
1.50% 2%
Hosp
West Virginia
6.50%
7.00%
6.00%
gross
Hosp ICF
ICF NH
NH Yes
Yes
Wisconsin
7.75%
7.90%
5.00%
Hosp
ICF
NH
No
2%
West
Virginia
6.50%
7.00%
6.00%
gross
Hosp
ICF
NH
Yes
Wisconsin
7.75%
7.90%
5.00%
Hosp
ICF
NH
No
Wyoming
0.00%
0.00%
4.00%
Hosp ICF NH
NH Yes
No
West
Virginia
6.50%
7.00%
6.00%
gross
Hosp
Wisconsin
7.75%
7.90%
5.00%
Hosp
Wyoming
0.00%
0.00%
4.00%
Hosp ICF NH
NH No
No
Wisconsin
7.75%
7.90%
5.00%
Hosp
Wyoming
0.00%
0.00%
4.00%
Hosp ICF NH
NH No
No
[Providers
(hosp), intermediate
care facilities (ICF), and nursing
Wyoming include hospitals
0.00%
0.00%
4.00%
Hosp homes
NH(NH)].
No
State
State
[Providers include hospitals (hosp), intermediate care facilities (ICF), and nursing homes (NH)].
[Providers
include
hospitals
(hosp),
intermediate
care facilities
(ICF),
and homes
nursing
homes (NH)].
[Providers
include hospitals
(hosp),
intermediate
care facilities
(ICF), and
nursing
(NH).]
Table
4. Regulatory
Climate
Comparison
[Providers
include hospitals
intermediate care facilities (ICF), and nursing homes (NH)].
Table 4. Regulatory
Climate(hosp),
Comparison
Table 4.and
Regulatory
Climate
Journal of American Physicians
Surgeons Volume
19 Comparison
Number 4 Winter 2014
Table 4. RegulatoryCON
Climate Comparison
Surgery
Pilot
Licensure Liability CME
State
CON
Surgery
Pilot
Licensure Liability CME
Office Dispensing Restrictions
MOL
Board
State
119
GME
GME
[Providers include hospitals (hosp), intermediate care facilities (ICF), and nursing homes (NH)].
Table 4. Regulatory Climate Comparison
Table 4. Regulatory Climate Comparison
Liability20CMECME GME
GME
Licensure Liability
CON
Pilot
Licensure
Office Dispensing Surgery
Arizona
No
LicenseDispensing
($200)
Yes
4.12
20
Board
Office
Restrictions
MOL
Board
Arizona
No
License
($200)
Yes
4.12
20
Arkansas
Special Permit
None
2.95
20
1
Alabama
Yes
License
($100)
Accreditation
2.69
5.18
25
Arizona
No
License
($200)
Yes
4.12
20
Arkansas
Yes
Special Permit
None
2.95
20
California
No
Severe
2.86
25
/
50
Alaska
Yes
Free
Laser
only
4.69
25
2
Arizona
No
License
($200)
Yes
4.12
20
Arkansas
Yes
Special
Permit
None
2.95
California
No
Free
Severe
2.86
25 / 5020
Policy
1
Arizona
No
License
($200)
Yes
4.12
20
Arkansas
Yes
Special
None
2.95
California
No
Free Permit
Severe
2.86
25 / 5020
Policy
Colorado
No
Free
statement
Attempt
4.08
0
1
Arkansas
Yes
Special
Permit
None
2.95
California
No
Free
Severe
2.86
25 / 5020
Policy
Colorado
No
Free
statement
Attempt
4.08
0
Connecticut
Yes
CS
Lic
($10)
Accreditation
1.82
20.98
25
1
California
No
Free
Severe
2.86
25
25/ /5050
Policy
Colorado
No
Free
statement
Attempt
4.08
0
Connecticut
Yes
CS
Lic ($10)
Accreditation
1.82
20.98
25
Delaware
Yes
Free
None
5.32
20
Policy
1
Colorado
No
Free
statement
Attempt
4.08
0
Policy
Stmt.
Connecticut
Yes
CS
Lic ($10)
Accreditation
1.82
20.98
25
Delaware
Yes
Free
None
5.32
20
District
of
Colorado
No
Free
statement
Attempt
4.08
0
2
Connecticut
Yes
CS
Lic ($10)
Accreditation
1.82
20.98
25
Delaware
Yes
Free
None
5.32
20
District
of
Columbia
Yes
license
None
1.47
19.31
25
Connecticut
Yes
CS
Lic
($10)
Accreditation
1.82
20.98
25
1
Delaware
Yes
Free
None
5.32
20
District
of
Columbia
Yes
license
None
1.47
19.31
25
Florida
Yes
License
($100)
Severe
2.28
20
Delaware
Yes
Free
None
5.32
20
District
of
D.C.
Columbia
Yes
license ($100)
None
1.47
19.31
25
1
Florida
Yes
License
Severe
2.28
20
Georgia
Yes
Free
Accreditation
2.65
20
District
of
Columbia
Yes
license
None
1.47
19.31
25
Florida
Yes
License
($100)
Severe
2.28
20
1
Georgia
Yes
Free
Accreditation
2.65
20
Hawaii
Yes
Free
None
3.53
20
Columbia
license
1.47
19.31
25
Florida
Yes
License
($100)
Severe
2.28
20
Georgia
Yes
Free
Accreditation
2.65
20
1
Hawaii
Yes
Free
None
3.53
20
Idaho
No
License
($60)
None
2.43
20
Florida
Yes
($100)
Severe
2.28
Georgia
Yes
Free
Accreditation
2.65
20
Hawaii
Yes
Free
None
3.53
20
1
Idaho
No
License
($60)
None
2.43
20
Illinois
Yes
Free
Minor
3.45
15.64
50
Georgia
Accreditation
2.65
20
Hawaii
Yes
Free
None
3.53
20
Idaho
No
License
($60)
None
2.43
20
1
Illinois
Yes
Free
Minor
3.45
15.64
50
Indiana
No
license(20)
Accreditation
3.25
4.18
0
Hawaii
Yes
Free
None
3.53
20
Idaho
No
License
($60)
None
2.43
20
Illinois
Yes
Free
Minor
3.45
15.64
50
2
Indiana
No
license(20)
Accreditation
3.25
4.18
0
Iowa
Yes
license(50)
None
Blocked
3.6
20
Idaho
No
License
($60)
2.43
Illinois
Yes
Free
Minor
3.45
15.64
50
Indiana
No
license(20)
Accreditation
3.25
4.18
0
1
Iowa
Yes
license(50)
None
Blocked
3.6
20
Kansas
No
Free
Minor
2.93
50
Illinois
Yes
3.45
15.64
Indiana
No
license(20)
Accreditation
3.25
4.18
0
Iowa
Yes
license(50)
None
Blocked
3.6
20
1
Kansas
No
Free
Minor
2.93
50
Kentucky
Yes
Free
Severe
3.94
20
Indiana
No
license(20)
Accreditation
3.25
4.18
0
Iowa
Yes
license(50)
None
Blocked
3.6
20
Kansas
No
Free
Minor
2.93
50
1
Kentucky
Yes
Free
Severe
3.94
20
Louisiana
Yes
license(75)
Severe
5.58
20
Iowa
license(50)
None
Blocked
3.6
Kansas
No
Free
Minor
2.93
50
Kentucky
Yes
Free
Severe
3.94
20
2
Louisiana
Yes
license(75)
Severe
5.58
20
Maine
Yes
Free
None
3.05
50
Kansas
No
Minor
2.93
Kentucky
Yes
Free
Severe
3.94
20
Louisiana
Yes
license(75)
Severe
5.58
20
1
Maine
Yes
Free
None
3.05
50
Maryland
Yes
Special
Permit
None
2.91
19.27
25
Kentucky
Free
Severe
3.94
20
Louisiana
Yes
license(75)
Severe
5.58
20
Maine
Yes
Free
None
3.05
50
3
Maryland
Yes
Special
Permit
None
2.91
19.27
25
Policy
Louisiana
Yes
license(75)
Severe
5.58
20
Maine
Yes
Free
None
3.05
50
Maryland
Yes
Special Permit
None
2.91
19.27
25
1
Policy
Massachusetts
Yes
Prohibited
statement
Attempt
1.66
22.37
50
Maine
Yes
Free
None
3.05
50
Maryland
Yes
Special
Permit
None
2.91
19.27
25
Policy
2
Policy
Stmt.
Massachusetts
Yes
Prohibited
statement
Attempt
1.66
22.37
50
Michigan
Yes
License
($85)
None
Fighting
2.56
50
Maryland
Yes
Special
Permit
None
2.91
19.27
25
Policy
Massachusetts
Yes
Prohibited
statement
Attempt
1.66
22.37
50
Michigan
Yes
License
($85)
None
Fighting
2.56
50
2
Minnesota
No
Free
None
1.49
25
Policy
Massachusetts
Yes
Prohibited
statement
Attempt
1.66
22.37
50
Michigan
Yes
License
($85)
None
Fighting
2.56
50
Minnesota
No
Free
None
1.49
25
1
Mississippi
Yes
Free
None
Attempt
3.56
4.15
20
Massachusetts
Prohibited
statement
1.66
22.37
50
Michigan
Yes
License
($85)
None
Fighting
2.56
50
Minnesota
No
Free
None
1.49
25
Mississippi
Yes
Free
None
Attempt
3.56
4.15
20
1
Missouri
Yes
license(90)
None
2.76
25
Michigan
License
($85)
Fighting
2.56
50
Minnesota
No
Free
None
1.49
25
Mississippi
Yes
Free
None
Attempt
3.56
4.15
20
Missouri
Yes
license(90)
None
2.76
25
1
Montana
Yes
Prohibited
None
2.63
0
Minnesota
No
Free
1.49
25
Mississippi
Yes
Free
None
Attempt
3.56
4.15
20
Missouri
Yes
license(90)
None
2.76
25
Montana
Yes
Prohibited
None
2.63
0
2
Nebraska
Yes
Free
None
4.7
25
Mississippi
Attempt
3.56
4.15
20
Missouri
Yes
license(90)
None
2.76
25
Montana
Yes
Prohibited
None
2.63
0
Nebraska
Yes
Free
None
4.7
25
1
Nevada
Yes
license($350+WC)
Accreditation
2.07
4.85 20 / 3525
Missouri
license(90)
None
2.76
Montana
Yes
Prohibited
None
2.63
0
Nebraska
Yes
Free
None
4.7
25
Nevada
Yes
license($350+WC)
Accreditation
2.07
4.85
20
/
35
20
/
35
3
New
Hampshire
Yes
Free
None
2.65
16.99
50
Montana
Prohibited
2.63
0
Nebraska
Yes
Free
None
4.7
Nevada
Yes
license($350+WC)
Accreditation
2.07
4.85 20 / 3525
New
Hampshire
Yes
Free
None
2.65
16.99
50
2
New
Jersey
Yes
Restrictions
Severe
2.26
23.24
Nebraska
Free
None
4.7
25
Nevada
Yes
license($350+WC)
Accreditation
2.07
4.85 20 / 3550
New
Hampshire
Yes
Free
None
2.65
16.99
50
New Mexico
Jersey
Yes
Restrictions
Severe
2.26
23.24
50
3
New
No
Restrictions
None
5.28
25
Nevada
Yes
license($350+WC)
Accreditation
2.07
4.85
20
/
35
New
Hampshire
Yes
Free
None
2.65
16.99
50
New
Jersey
Yes
Restrictions
Severe
2.26
23.24
50
New York
Mexico
No
Restrictions
None
5.28
25
2
New
Yes
Prohibited
Accreditation
Fighting
2.98
38.83
0
Hampshire
Free
None
2.65
16.99
50
New
Jersey
Yes
Restrictions
Severe
2.26
23.24
50
New
Mexico
No
Restrictions
None
5.28
25
New Jersey
York
Yes
Prohibited
Accreditation Fighting
Fighting
2.98
38.83
0
1
North
Carolina
Yes
Restrictions
Severe
3.56
4.51
50
New
2.26
23.24
New
No
Restrictions
None
5.28
25
New Mexico
York
Yes
Prohibited
Accreditation Fighting
Fighting
2.98
38.83
0
North
Carolina
Yes
Restrictions
Severe
3.56
4.51
50
1
North
Dakota
No
Free
None
3.75
2.96
20
New
Mexico
Restrictions
5.28
25
New
Yes
Prohibited
Accreditation
Fighting
2.98
38.83
0
NorthYork
Carolina
Yes
Restrictions
Severe
Fighting
3.56
4.51
50
North
Dakota
No
Free
None
3.75
2.96
20
1
Ohio
Yes
Free
Severe
Blocked
5.52
50
New
York
Prohibited
Accreditation
Fighting
2.98
38.83
0
North
Carolina
Yes
Restrictions
Severe
Fighting
3.56
4.51
50
North
Dakota
No
Free
None
3.75
2.96
20
Ohio Carolina
Yes
Free
Severe
Blocked
5.52
50
1
Policy
North
Yes
Restrictions
Severe
Fighting
3.56
4.51
50
North
Dakota
No
Free
None
3.75
2.96
20
Ohio
Yes
Free
Severe
Blocked
5.52
50
Policy
Oklahoma
Yes
Free
statement
Blocked
4.65
20
Policy
Stmt.
1
20/ /16
16
North
Dakota
No
Free
None
3.75
2.96
20
Ohio
Yes
Free
Severe
Blocked
5.52
Policy
Oklahoma
Yes
Free approval
statement
Blocked
4.65
20 / 1650
Oregon
Yes
OMB
Accreditation
Attempt
3.36
30
1
Ohio
Yes
Free
Severe
Blocked
5.52
Policy
Oklahoma
Yes
Free
statement
4.65
20 / 1650
Oregon
Yes
OMB approval
Accreditation Blocked
Attempt
3.36
30
Pennsylvania
No
Free
None
2.82
24.76
50
2
Policy
Oklahoma
Yes
Free
statement
Blocked
4.65
20 / 1630
Oregon
Yes
OMB
Accreditation
Attempt
3.36
Pennsylvania
No
Free approval
None
2.82
24.76
50
Rhode
Island
None
2.02
17.4
20
2
Oklahoma
Yes
Free
statement
Blocked
4.65
20
/
16
Oregon
Yes
OMB
approval
Accreditation
Attempt
3.36
30
Pennsylvania
No
Free
None
2.82
24.76
50
Rhode
Island
Yes
Free
None
2.02
17.4
20
South
Carolina
License
($100)
Severe
1.33
20
1
Oregon
Yes
OMB
approval
Accreditation
Attempt
3.36
30
Pennsylvania
No
Free
None
2.82
24.76
50
Tennessee
Severe
2.72
Rhode
Island
Yes
Free
None
2.02
17.4
20
South
Carolina
Yes
License
($100)
Severe
1.33
20
South
Dakota
license
2.71
4.88
0
3
Pennsylvania
No
Free
None
2.82
24.76
50
Tennessee
Yes
Free
Severe
2.72
20
Rhode
Island
None
2.02
17.4
Texas Carolina
No
Prohibited
Fighting
2.79
3.02
24
South
Yes
License
($100)
Severe
1.33
20
South
Dakota
No
license
None
2.71
4.88
0
Tennessee
Severe
2.72
1
Rhode
Island
Yes
Free
None
2.02
17.4
20
Texas
No
Prohibited
Severe
Fighting
2.79
3.02
24
South
Yes
License
($100)
1.33
20
Utah Carolina
Prohibited
2.44
South
Dakota
No
license
None
2.71
4.88
0
Texas
No
Prohibited
Fighting
2.79
3.02
24
South
Carolina
Yes
License
($100)
Severe
1.33
20
1
Utah Dakota
Prohibited
2.44
South
No
license
None
2.71
4.88 Bd Cr 20
/0
Utah
Prohibited
2.44
South
Dakota
No
license
None
2.71
4.88
2
Bd Cr 20
/0
Vermont
Yes
Free
2.78
4.36 15
Bd
Cr//15
Vermont
Yes
Free
None
2.78
4.36 Bd
15Cr
Bd
of Pharmacy
1
Vermont
Yes
Free
None
2.78
4.36 15 15
of Pharmacy
Bd
Pharm
license
Virginia
Yes
license
Yes
Attempt
3.11
1
Bd
of Pharmacy
Virginia
Yes
license
Yes
Attempt
3.11
15
Washington
Yes
Free
Accreditation
4.45
50
2
Virginia
Yes
license
Yes
3.11
15
Washington
Yes
Free ($35)
Accreditation Attempt
4.45
50
West
Virginia
Yes
License
None
4.32
25
25/ /1616
1
Washington
Yes
Free
Accreditation
4.45
50
West Virginia
Yes
License ($35)
None
4.32
Wisconsin
Yes
Free
None
Attempt
1.9
3.07 25 / 1615
1
West
Virginia
Yes
License
None
4.32
Wisconsin
Yes
Free ($35)
None
Attempt
1.9
3.07 25 / 1620
15
Wyoming
No
Free
None
6.79
2
Wisconsin
Yes
Free
None
Attempt
1.9
3.07
15
Wyoming
No
Free
None
6.79
20
Wyoming
No
Free
None
6.79
20
[WC:
additional workers’
compensation
requirements
/ restrictions apply to those
seeking a
[Policy
Stmt:
policy
statement.
An
agency
issues
recommended
measures,
but
there
is
no
dispositive
statutory
language.
[WC:
additional
workers’
compensation
requirements
/
restrictions
apply
to
those
seeking
a
license to dispense medications in the office.
WC: additional
workers’
compensation
requirements
/ restrictions
apply to those
a license
to dispense
[WC:
additional
workers’
compensation
requirements
/ restrictions
applyseeking
to those
seeking
a
license
to dispense
medications
in the
office.
medications
in the office.]
license
to dispense
medications in the office.
State
120
Conclusions
Journal of American Physicians and Surgeons Volume 19 Number 4 Conclusions
Conclusions
The climate in many states makes it difficult to practice independently or to maintain a
Winter 2014
Conclusions
The climate in many states makes it difficult to practice
independently or to maintain a financially viable practice at an
affordable cost to patients. Physicians should research the taxes
and regulations in a state before investing in a practice there.
Philip Eskew, D.O., J.D., M.B.A., is a third-year resident in family medicine
at Heart of Lancaster Regional Medical Center. He is also a member of the
Kentucky Bar Association. Contact: philsq@gmail.com.
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121