‘A tremendous gap’: Local doctors on the challenges they face in Los Alamos
Between 2017 and 2021, New Mexico lost 30% of its primary care providers, according to a 2023 report by the New Mexico Health Care Workforce Committee, a group of stakeholders within state agencies and health care organizations. New Mexico also experienced the second largest increase in malpractice premium costs in the nation from 2021 to 2022, according to a study by the American Medical Association.
While the Bureau of Health Workforce has not designated Los Alamos as a Health Professional Shortage Area, the number of medical providers in the county is declining. And as the population of Los Alamos continues to increase, wait times for appointments have increased as well, forcing many residents to look for providers in other counties or even in other states.
Many health care professionals believe this number of departures may have increased significantly following the passage of state laws that raised caps on medical malpractice damages. Prior to the legislation, first signed into law in 2021, medical malpractice damages were capped at $600,000, but in recent years, those caps have increased to as much as $5.5 million for hospitals and outpatient facilities. The amount is set to increase to $6 million next year. Critics of the legislation say this is a key reason many doctors have chosen to move to other states, such as neighboring Texas, where most malpractice damages are capped at $250,000.
Boomtown interviewed several local doctors and nurses for this story. While they love New Mexico and the patients they work with, the majority have also considered leaving the state due to problems with hospital management, state laws, or other national issues.
Leaving the Profession
Ann Gardner was a supervisor at the Medical Associates of Northern New Mexico for years, but as concerns about health care in the area mounted, she made the difficult decision to leave her job. Clashes with insurance companies were a factor that drove her out.
Most insurance companies are for-profit entities. To make a bigger profit, Gardner said that many insurance companies create new policies that require prior authorizations or limit the amount of time doctors can spend with a patient, which can lead to a lower standard of health care.
“Patients are the product,” Gardner said.
Los Alamos clinics also do not accept all kinds of insurance, adding another barrier to those seeking treatment and to the professionals trying to provide quality care.
“Doctors’ offices have a contract with the insurance company, and then they decide between the two of them what percentage [companies are] willing to pay,” Gardner said.
These contracts usually last two or three years, but if insurance companies will not pay what the clinic feels is enough to support their staffing, Gardner said clinics may stop taking insurance from that company altogether.
A decline in access to health care puts a strain on everyone, but it is also a concern for those in the medical field and can contribute to health care providers moving away from New Mexico.
Michael Lucia is a telehealth pulmonologist who works in Los Alamos and has lived in Santa Fe since 2018. He and his wife love living in New Mexico but he said that potentially losing access to good health care could cause them to consider moving elsewhere.
“We’ve been coming here for 25 years, and knew we always wanted to retire [in New Mexico],” he said. “We both discussed that one thing that would make us leave … would be [the lack of] access to health care.”
Lucia said Los Alamos has a good number of specialists compared to other more rural areas around the state; however, in recent years, the county has lost many primary care physicians, who patients generally need to see first in order to get a referral to see a specialist. And when people are not able to get an appointment with a doctor or are not able to get a referral for a specialist, their health problems often worsen, or they may have to seek inferior care.
“There’s a tremendous gap in the need versus the supply, especially in my particular field, where there’s only maybe a couple of dozen doctors in the entire state,” he said.
Another doctor who has practiced medicine in Los Alamos for two decades and who spoke to Boomtown on the condition of anonymity said the community also lacks family medicine options. One reason for this is that primary care physicians earn less than specialists, and that, coupled with the cost of living in and around Los Alamos, causes some primary care physicians to seek opportunities elsewhere.
With fewer primary care options available in Los Alamos, patients face long wait times for appointments, forcing many to seek treatment from an urgent care facility or even a hospital’s emergency room; however, this has caused wait times at those facilities to increase as well.
Additionally, when a family care doctor is unable to diagnose a condition or lacks the resources to offer treatment, patients must be referred to a specialist, and in many cases, this requires travel to another hospital in other parts of the state.
To help with these health care worker shortages, Los Alamos and other rural areas have begun relying in part on temporary, roving doctors known as locums, short for the Latin phrase locum tenens, which means “to stand in place of.”
Bill Moore worked as a locum in Los Alamos, filling the OB-GYN position at Los Alamos Medical Center until administrators found other doctors willing to relocate to town permanently.
LAMC hired Moore through CompHealth, one of the largest health care staffing companies in the country. Agencies like CompHealth offer a quick solution to hospital staffing shortages, particularly in locations like New Mexico with multiple open positions but not enough qualified candidates.
These struggles are not unique to New Mexico, though. Moore said it has always been difficult for small, rural communities to recruit medical professionals, and that even when he was in medical school in the late 1980s, recent graduates rarely wanted to move to rural areas. Part of the problem, he said, is that new doctors want to face challenges in order to become better doctors, and many don’t think they will gain that experience by practicing medicine in small towns like Los Alamos. Moore said that most rural doctors also tend to be several years older than doctors in larger cities, and when medical facilities find experienced doctors willing to relocate to Los Alamos, they tend to be older and often near retirement.
Convincing younger doctors to come to Los Alamos is made even more difficult by the cost of living in the area, a particular hardship for new doctors fresh out of medical school who are saddled with lots of student loan debt.
“It’s a very difficult process … in the sense that the housing prices are so high compared to just about any other small town,” he said.
Burnout and ‘Brain Drain’
As health care facilities struggle to recruit doctors and nurses to practice in town, many providers have left simply because of burnout, or what is known as “brain drain,” the mass migration of skilled health care professionals from low-income areas to higher-income ones.
Lucia said that brain drain has been a concern in New Mexico for many years, but that the issue was greatly exacerbated by the pandemic.
One local physician who spoke to Boomtown on the condition of anonymity said that health care facilities in Los Alamos are also competing with LANL for well-educated workers. She said she has seen several clinic staff members leave to work at the lab, including advanced practice providers and at least one physician.
The county’s population is also growing older, according to Susie Belle Peterson, the clinical manager at Los Alamos Visiting Nurse Service Inc. As community members age, more care will be needed, emphasizing the urgent need for more access to health care in the area. Additionally, as doctors and nurses age, it becomes more difficult for them to care for others.
“That can be really exhausting, especially when you spent 20 years in nursing, you’ve injured your back — which is a very common issue — or you are dealing with PTSD from working those Covid years,” she said. “What many people are finding, and I’m hearing over and over, is ‘I can’t do bedside any longer.’”
For doctors and nurses that remain in Los Alamos, their work often becomes harder. And because patients are made to see many different providers at many different hospitals, counties, and even states, their care is diminished. Furthermore, most insurance companies require a new medical record to be created each time a patient sees a new provider or is treated at a new hospital. Instead of this being an integrated system, these records are rarely shared with other doctors, making it more difficult for all the doctors involved to adequately understand and treat patients. For many doctors, one of the most challenging parts of their job is communicating a patient’s history to other physicians.
Morgan Johnson is a physician assistant at El Centro Family Health in Española. She said she rarely receives records or notes from other hospitals.
“It’s not any one hospital’s fault, but it’s just also probably the lack of staffing,” she said. “Our medical records department is always understaffed, so there’s usually one person doing the job of three.”
Compensation for most health care providers comes from private insurers, Medicare, Medicaid, and Affordable Care Act plans, and to receive reimbursement, providers must meet certain criteria and doctors must fill out lots of paperwork, documenting every patient interaction. If a patient does not come into a clinic for an appointment but instead talks to their provider over the phone or patient portal, doctors may not be paid for that time. This includes certain kinds of telehealth visits.
In addition to these criteria, insurance companies have grown to dictate the kind of treatment doctors can offer their patients, as well as how much these providers are paid.
Peterson with Los Alamos Visiting Nurses said that the difficulties patients experience with their insurance companies often cause delays in treatment as well.
“With insurance, people have to reach medical necessity for receiving services from us,” she said. “Sometimes they either have insurance that we don’t accept, or with insurance, we need to see them so often as well. Sometimes people have co-pays that are very expensive, and it can cost a lot of money out of pocket until they reach those certain co-pays.”
She said that, with this less-effective health care, patients might start looking for treatment elsewhere. Doctors, in turn, are trying to start alternative practices with models such as direct primary care, which do not depend on insurance.
Elena McAtee, a primary care provider in Los Alamos, started Sol Direct Primary Care after facing difficulties with insurance at MANNM. She said that Medicare reimbursement rates have dropped as well, perhaps setting a trend for insurance companies.
“This is a big issue,” she said. “Medicare reimbursement is basically the tone setter; what they reimburse, other insurance will typically follow.”
Even though most patients in Los Alamos use private insurance, lower Medicare payouts will still negatively affect health care for everyone. In addition, as reimbursement rates decrease and malpractice insurance rates increase, providers will have to increase their costs.
Another doctor interviewed for this story who spoke to Boomtown on the condition of anonymity said that, due to cuts to Medicare reimbursements and rising overhead costs, doctors in her clinic have not received raises since 2014.
Patrick Martin, a direct primary care physician who runs Satori Healing, said it is difficult for doctors to operate under insurance companies’ requirements, even if the coverage they provide is important for patients.
“If I was running a business that only took Medicaid patients, I wouldn’t be able to keep my doors open just because of the very, very low reimbursement rates,” he said.
Martin stopped taking insurance in January, after it became too challenging for his practice to get paid for the services they provided. Months later, he still receives messages from insurance companies about how they overpaid him for patients he saw more than a year ago.
“They’re the ones who are deciding what it is that they’re going to pay for the visit,” Martin said. “So it doesn’t matter what I charge for the visit. They come up with their own way or their own value of what it is, and if I have an argument and I say, ‘Well, look, you’re way under here for this,’ the arbitration board is run by the insurance company, so I’m kind of screwed either way.”
Licensing, Malpractice, and Taxation
Several states have formed compacts that allow medical providers’ licenses to be valid across all included states. This allows providers to travel across state lines and give patients access to better, more complete treatment without them having to go to other states or clinics.
New Mexico has joined the nursing compact but has not done the same with any other positions, like physicians or telehealth providers. The idea to expand into other compacts was brought to the New Mexico Legislature during the regular session earlier this year, but it did not make it out of committee.
Kristina Fisher, the associate director of Think New Mexico, said it was because of the Trial Lawyers Association’s presence in the government.
“What the trial lawyers didn’t like about the compact was that there’s a provision that says you can’t sue the commission that oversees the compact,” she said.
Each state that is part of a compact must send one member of their medical board to join the Interstate Medical Licensure Compact, which ensures that every state is complying with the rules of the compact. According to Fisher, lawyers would have little reason to sue the Interstate Commission. However, if they did, they could potentially earn more money in a malpractice case.
“There was just a real, on-principle objection to giving anyone immunity from a lawsuit ever,” she said. “So in our perspective, it was a very theoretical objection that blocked something that would be very positive.”
Lucia, the telehealth pulmonologist, said licensing in New Mexico could stand to be reformed too. He first obtained his license to practice in New Mexico in 2013, and at the time, it took about three months. Since the pandemic, that time has grown substantially, something he believes is related to staffing shortages within the New Mexico Medical Board.
“It takes six to nine months to get your license here now,” he said. “In other states, you can get a license in as little as three months.”
While some states allow for doctors to get temporary licenses while their permanent ones are being processed, New Mexico does not offer this.
“They do not make it easier for me, for doctors, to get a license here at all,” Lucia said.
Licensing is but one barrier to those seeking to practice medicine in New Mexico though. Many doctors interviewed for this story pointed to the high costs associated with medical malpractice insurance in the state as a contributing complication for access to health care.
State lawmakers first passed legislation increasing caps on medical malpractice damages during the 2020 session, and the Medical Malpractice Act became law in 2021. Since then, various bills aimed at amending caps for malpractice damages have been introduced, but none have made their way to the governor’s desk.
Martin with Satori Healing said the passage of the act felt like a “slap in the face,” especially because it happened during the pandemic when health care providers were already overextending themselves.
“The other thing that that particular legislation had in it was it essentially made anybody who was affiliated with the hospital responsible for paying an award if they were sued,” Martin said. “So what that did, unfortunately for me as a practicing hospitalist, was it made most specialists — who are otherwise willing to come in and help me see and manage patients — very reluctant to do so.”
Furthermore, Martin said that the medical group he originally worked for pulled out of New Mexico altogether after losing a malpractice case at a hospital in Las Cruces.
During this year’s legislative session, state lawmakers proposed several potential solutions to lower malpractice insurance costs in New Mexico, but only one bill, Senate Bill 176, made it to a committee. The bill sought to lower the cap for medical malpractice damages, but it failed in the Senate Health and Public Affairs Committee in a 5-4 vote.
In New Mexico, certain medical malpractice cases go before the New Mexico Medical Review Committee, a group of three medical providers and three lawyers, before being heard in court. This group determines whether harm occurred, or standards of care were met, but some doctors said they found lawyers pursuing malpractice claims regardless of the committee’s decisions.
Taxes are another barrier for care in the state, according to several physicians. It is more expensive to practice medicine in New Mexico because the state requires that they pay a medical service tax. Insurers often don’t cover this tax, so the burden falls on doctors. Only three other states have a similar requirement: Ohio, Michigan, and Hawaii.
Administrative Woes
Another element making it difficult to attract and retain physicians in Los Alamos is clashes with local hospital management.
Though now the head of Satori Healing, Martin previously worked as a hospitalist at LAMC. He said he found that hospital administrators tended to ask that more patients be seen faster, while doctors wanted to spend more time with each of their patients.
“Specifically here, I was not very happy with the administration at the hospital,” Martin said. “I think it’s difficult, though, all over the country, for administrators to run rural hospitals just because the reimbursement is so poor, and they’re always trying to look for creative solutions in order to make things work … I feel like they really are trying to do the best job that they can, but there’s also a lot of restraints on them as well.”
Tyler Taylor had a similar experience with the management at LAMC before he retired in 2017. He’d previously worked for decades in rural Virginia where he said he felt that doctors had a better relationship with each other and with the hospital administration, as well as the capacity to make more of their own decisions and to work more closely with patients.
“There’s a lot more politics (in Los Alamos),” Taylor said. “There was a lot more frustration with the hospital.”
Despite difficulties ranging from local issues to systemic national challenges, doctors and nurses who spoke to Boomtown said they truly value their work and their patients.
“There’s always a downside to every occupation,” Lucia said. “But if you’re passionate about what you do, then it makes it a lot easier to get past the painful parts, the tedium, electronic medical records, and the billing.
“I really feel that I’m bridging a gap,” Peterson said. “That really helps give me a sense of purpose, that I am making a difference.”