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Shelly Reese
Freelance writer
Cincinnati, Ohio

Disclosure: Shelly Reese has disclosed no relevant financial relationships.


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Best and Worst Places to Practice 2015

Shelly Reese  |  May 18, 2015

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Slide 1

Earning a living is about more than what you take home. It's about having choices about how and where you dispose of your disposable income—choices that can be severely curtailed by high taxes, malpractice costs, and the cost of living.

For all 50 states, we analyzed data on cost-of-living from the Missouri Economic Research and Information Center, malpractice payouts per capita from Diederich Healthcare, overall state and local tax burden from the Tax Foundation, and physician compensation from the 2015 Medscape Physician Compensation Survey and used this information to identify the 25 "best" states, where physicians can stretch their earnings the furthest and the five "worst" states, where they might have to pinch a few pennies.

We then asked Medscape readers for their recommendations, talked to recruiters about practice conditions in the various states, reviewed responses to the Physicians Foundation's 2014 survey of more than 20,000 US doctors, and interviewed practicing physicians to find out what makes their locations special.

After identifying the best states, we've suggested a town or city in each state that might interest you.

Slide 2

Tennessee has the second lowest cost of living in the United States and a tax burden of just 7.6%. Per capita malpractice payouts of $8.96 put Tennessee near the middle of the national pack, and the average physician compensation of $279,000 puts the state comfortably in the top 10.

But Tennessee earns lots of livability points that add to its economic appeal. Beyond the Memphis music scene, the theme parks of Gatlinburg and Pigeon Forge, and the majestic beauty of Great Smoky Mountains National Park, Tennessee offers a vast array of attractions for everyone from barbeque aficionados, bourbon lovers, and Civil War buffs to fly fisherman and white-water rafters.

City to consider: Nashville is saturated with doctors; nearby alternatives provide promising practice opportunities. Franklin and Murfreesboro, both located about a half-hour to the south, are economically progressive communities that offer excellent schools and good hospital systems, says John Hawkins, a vice president with the physician recruiting firm Merritt Hawkins. What's more, "doctors in those towns will make about $20,000 more than they would in Nashville," he says. Franklin placed number 42 on Money's 2014 Best Places to Live list.

Image from iStock

Slide 3

Mississippi ranks respectably in terms of compensation—physicians there earn an average of $275,000—and has relatively low taxes and malpractice payouts. In addition, the state's extremely low cost of living enables physicians there to live far more comfortably than many of their peers in the more expensive Northeastern states.

"Mississippi has low property taxes; the state recently enacted tort reform, and doctors are paid really well there," says Steve Marsh, managing partner for the Medicus Firm, an Atlanta-based physician recruiting firm.

City to consider: Oxford is home to Ole Miss and for a small city offers a variety of cultural activities, including a monthly arts crawl featuring free exhibitions, receptions, and shuttle service. The town's population increased by a hefty 10.5% between 2010 and 2013, and the January unemployment rate was 6.4%, significantly lower than the state average.

Image from University of Mississippi Brand Photography

Slide 4

Oklahoma boasts a low cost of living, and physicians responding to the Medscape survey also reported high incomes: an average of $304,000. At 8.5%, the average state and local tax burden is well below the national average of 9.8%.

Oklahoma doctors may have trouble finding adequate staff support. Oklahoma has just 746 nurses per 100,000 patients—about 15% lower than the national average, according to the Kaiser Family Foundation—and the percentage of nurse practitioners (NPs) in the state is about one half the national average. That may contribute to physician frustration: Nearly one quarter of Oklahoma physicians who recently responded to a Physicians Foundation survey say they are adopting, or plan to adopt, a concierge model in the next few years.

City to consider: "Tulsa is pretty much a hidden gem," says Merritt Hawkins' divisional vice president Tommy Bohannon. "It has one of the more active arts communities in the country, and you have terrific dining, shopping, and cultural opportunities." Tulsa is home to OSU–Tulsa and the University of Tulsa.

Image from iStock

Slide 5

Texas is a business-friendly state with no state income tax, lots of metropolitan areas, an abundance of high-profile health systems, and numerous teaching institutions. Given its size, the state can accommodate almost any geographic, climatic, or metropolitan preference. A Texas constitutional amendment passed in 2003 limiting medical malpractice lawsuits has significantly reduced payouts, which amounted to only $3.74 per capita last year. Owing to the state's corporate practice of medicine statute, hospitals in Texas cannot hire physicians directly, notes Bohannon.

City to consider: Many physicians are happy living in Tyler. "Moved here 12 years ago as a cardiologist," said one Medscape member responding to a poll. "Greatest combination of a mid-sized town/small city with the amenities of a much larger city. The medical community here is unbelievable. Two large hospital systems and about 1000 physicians overall, representing every specialty. A wonderful place for a family and to raise children. Less than an hour and a half from Dallas. Hardwood and pine forests as far as you can see. Truly the most beautiful part of the great state of Texas!"

Image from Wikimedia

Slide 6

Wyoming doesn't have a state income tax, and an abundance of highly compensated specialists in resort communities—Jackson Hole is a hotbed for orthopedic surgeons—tilts the state's compensation rate to a hefty $312,000. Because managed care doesn't have a presence in the state, providers can continue practicing under a fee-for-service model, says Merritt Hawkins' Ben Cowen, who says the state benefits from a strong payer mix and financially stable, largely community-owned, healthcare organizations.

But Wyoming isn't nirvana. There are only 1118 professionally active physicians in Wyoming, according the Kaiser Family Foundation, and a whopping 97% responding to the Physicians Foundation 2014 Survey of American Physicians say they are at capacity or overextended.

City to consider: Casper came in number 50 on Money's Best Places to Live in America 2014. Although it may be small—the city's population is just under 60,000—Casper has some urban amenities, such as a symphony and a planetarium, to augment Wyoming's natural beauty. Be forewarned: Casper's growth makes housing hard to come by, and a high male-to-female ratio may make it a tough place for a bachelor to find a date.

Image from iStock

Slide 7

Although the average compensation is a middling $276,000, a rock-bottom cost of living, moderate malpractice payouts, and an average tax burden enable Idaho physicians to maximize their earnings. In addition, Idaho offers unparalleled outdoor recreational activities for hikers, skiers, snowboarders, kayakers, and mountain bikers.

In many ways, Idaho is two states: the rural north and the Boise-dominated south, where competing health systems have gobbled up private practices at an extraordinary rate. A wave of physician retirements may hit soon: More than 1 in 5 Idaho doctors responding to the Physicians Foundation survey say they plan to retire in the next few years.

City to consider: For outdoor enthusiasts, you can't beat Boise. The city is ringed by miles of hiking and biking trails, and kayakers have easy access to the Boise River, which runs through the heart of the city. World-class ski slopes are a short drive away. Housing in Boise is less expensive than in most major metropolitan areas, and the city, home to Boise State, has plenty of nightlife. Boise has relatively mild seasons and a low crime rate to add to its appeal.

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Slide 8

In many ways, South Carolina flies under the radar. It isn't a leader in any one category, but it has above-average performance in all of them, making the Palmetto State an overall attractive destination.

Dr Patricia Wilson Witherspoon, assistant medical director at USC's Department of Family and Preventive Medicine, says South Carolina is a great place for family medicine because doctors can practice to the full scope of their training: "There aren't entrenched territorial lines, and you don't need a lot of additional certifications." As far as quality of life goes, South Carolina offers a warm climate and warmer people. "Although we are a mid-sized state, we have a small-town feel, and we have a festival for every vegetable and meat item."

City to consider: Columbia is the state capital and home to several museums and the state university. It has plenty of quaint neighborhoods, and is just a half-hour from sprawling Lake Murray and 2 hours from the beach. The University of South Carolina School of Medicine is home to an NIH Complementary and Alternative Medicine Center, one of only 11 nationwide.

Image from iStock

Slide 9

It's no secret that New England has a high concentration of physicians, high cost of living, and tough winters. But New Hampshire is a relative oasis in the high-cost Northeast. Taxes are low—the state taxes only dividends and interest, not wages—and physicians reported a robust average compensation of $300,000.

New Hampshire's physicians and its residents are quick to adjust to new developments in the healthcare marketplace. Nearly one half of the New Hampshire physicians responding to the Physicians Foundation survey say they participate in an accountable care organization (ACO), and the state has one of the highest enrollment rates in its federal-run insurance marketplace, according to the Kaiser Family Foundation. New Hampshire has a healthy population as well: United Health Foundation ranks the state number 7 in overall health.

City to consider: The Manchester-Nashua metropolitan area is home to nearly one third of the population of New Hampshire. The cities, located just over an hour from Boston, have strong economic ties with their southern neighbor but are more affordable and have their own local characters. Residents of southeastern New Hampshire tend to be younger and more educated and have a higher per capita income than those in the northern part of the state.

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Slide 10

Nebraska has a cost of living well under the US average, low malpractice payouts (just $4.43 per capita last year), ample physician support (the ratio of registered nurses [RNs] to the population is nearly 19% higher than the national average), and a healthy population. United Health Foundation ranks the state in the top 10 in overall health, and life expectancy is nearly 1 year longer than the national average. Nebraska is also an extremely wealthy state. Shale and agriculture are major industries, and Lincoln and Omaha are telecommunications hubs.

Given the health of the state economy, "you have strong industry and infrastructure," says Merritt Hawkins' Bohannon. "You also have a lot of small communities where healthcare is pretty well funded and where you have amenities you wouldn't necessarily expect."

City to consider: Kiplinger's calls Omaha the "best city to raise your kids in," in part because of its rock-solid schools; low crime rate; abundance of playgrounds; and family-friendly amenities, such as a zoo, children's museum, and children's theater. With low unemployment and median income above the state average, Omaha is likewise ranked one of the best cities for savers by; just ask Warren Buffett.

Image from Dreamstime

Slide 11

Because most goods must be shipped in to the state, Alaska has a high cost of living. Fortunately for residents, the state is flush with petroleum revenues, so it doesn't charge an income tax. Physicians in Alaska enjoy top-notch compensation: Those who responded to Medscape's survey reported average compensation of $330,000—almost $50,000 above the national average.

But it isn't the money that draws many doctors to Alaska; it's the adventure, the lifestyle, and the landscape. Dr John Cullen, who practices family medicine in Valdez, says Alaska "is an incredibly fun place to practice medicine" because the practice opportunities are so vast. With the nearest tertiary care hospital 350 miles away, he has ample opportunity to practice procedural medicine, deliver babies, and attend trauma patients. But after 21 years in Valdez, what he enjoys most are his deep ties to the community. "I've watched the babies I delivered grow up, and I'm caring for a second generation of patients. It's pretty amazing."

City to consider: Dr Cullen says that "anywhere in Alaska is a great place to practice," but he is partial to Valdez. The tight-knit community has just over 4200 year-round residents, but the population swells to about 7000 in the summer. Surrounded by the Chugach Mountains, Valdez is a skier's paradise. "You can go cross-country skiing in the morning and back-country skiing in the afternoon, and sail in the evenings," he says. "To me, that's the perfect day."

Image from iStock

Slide 12

Alabama is like South Carolina in that it doesn't stand out in any one particular measure but has strong overall performance: The cost of living and tax burden are in the bottom quintile, the per capita malpractice payout is below the national average, and compensation is just shy of the national average. More than one half (53%) of the Alabama doctors responding to the Physicians Foundation survey say they'd recommend a career in medicine.

Alabama doctors take their autonomy seriously. To avoid the possibility that physicians in the state might one day have to demonstrate electronic health record proficiency as a condition for licensure, in September 2014 Alabama became the first state in the nation to pass legislation prohibiting consideration of "meaningful use" as a condition of medical licensure.

City to consider: Birmingham is popular with physicians, recruiters say. One quarter of the state's population lives in the metro area. Although founded on an industrial base, Birmingham has become one of the most important business centers in the Southeast and is a major banking center. The city is home to the University of Alabama's medical and dental schools. Birmingham's cultural fare includes ballet, opera, and a symphony orchestra.

Image from iStock

Slide 13

Kentucky has a low cost of living, above-average compensation ($277,000), and a wealth of outdoor and recreational opportunities. Although Kentucky is home to several small to mid-sized cities, including Louisville, Lexington, Paducah, Ashland, and Covington, the state is often overlooked as a practice location.

That's too bad, says Dr Ron Waldridge II, who practices family medicine in Shelbyville, a small community located about halfway between Louisville and Lexington. Although the state faces significant health challenges—Kentucky has the highest smoking rate in the nation, and 30% of the adult population is obese—Dr Waldridge says that public and private organizations are making progress in addressing health problems by designing programs that address broader socioeconomic issues.

City to consider: Nestled in the heart of horse country, "Lexington offers good balance," says the Medicus Firm's Marsh. "It's not too big and not too small. The traffic isn't bad. It's a nice mid-sized city that's known as a college town, but that's not its only identity."

Image from iStock

Slide 14

You can't beat Indiana for Midwest livability and stability. The cost of living is nearly 10% lower than the national average; the schools are strong; and you have plenty of pro and college sports teams, and such spectacles as the Indy 500.

From a physician's perspective, Indiana has a lot to offer. At $286,000, average compensation is almost 6% higher than the national average. The state was a pioneer of tort reform, notes Bohannon, and there are abundant practice opportunities for doctors who might want to practice in a community or academic hospital.

City to consider: A city of more than 800,000, Indianapolis offers lots of urban amenities, including professional and collegiate sports teams, museums, and a beautiful river walk while delivering small-city livability. The mean commute time is less than 23 minutes and the median home price is $118,000, a third less than the US average. For those interested in a career outside the clinical setting, pharmaceutical giant Eli Lilly and insurance powerhouse Anthem are both based in Indianapolis.

Image from iStock

Slide 15

Although physicians in the heart of the heartland earn about 4% less than the national average, according to the Medscape compensation survey, that's offset by a cost of living nearly 7% lower than the national average. Last year, malpractice claim payouts per capita in Missouri were about one half the national average.

Whereas metro areas such as St. Louis are bastions for healthcare, Missouri's underserved areas are desperate for doctors—so much so that last July, the state legislature passed a controversial law allowing recent medical school graduates to practice primary care in underserved areas without completing a residency in a teaching hospital. Although these areas have a hard time attracting doctors, Bohannon notes that empty-nesters who love to hunt and fish will love the southern part of the state.

City to consider: St. Louis has plenty to offer in terms of arts and culture: symphony, ballet, theater, and outstanding restaurants. "The Hill" has some of the best Italian food west of the Boot. Home to Washington University and St. Louis University, the city boasts premier teaching hospitals, including Barnes-Jewish Hospital and St. Louis Children's Hospital. In March 2014, iVantage Health Analytics named St. Louis one of the top 10 cities for healthcare.

Image from iStock

Slide 16

Iowa is an all-around healthy state. Life expectancy and high school graduation rates are above the national median, whereas smoking, adult obesity, and the percentage of adults reporting fair or poor health is below it. True, the state insurance marketplace has enrolled fewer participants than any other—only 20% of the eligible population—but that number is offset by the unusually high number of people who have signed up for individual health plans outside the exchange.

Iowa is also healthy from a physicians' point of view. At $285,000, average compensation is more than 5% above the national average, whereas the cost of living and the tax burden are 7.4% and 10.2% lower than the national average, respectively. One half of Iowa doctors reported positive morale, and more than one half say they'd recommend a career in medicine.

City to consider: Ames made Money's top 10 list of "best cities" this year. Median family income tops $77,000, and the median house price is just under $146,000. Home to Iowa State University, this town of 60,000 is investing in some noteworthy improvements, including a major expansion of the public library and a $55-million series of renovations to its elementary schools.

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Slide 17

Georgia has been a physician magnet in recent years, offering doctors affordable living, healthy compensation, and reasonable taxes. But Georgia also offers plenty of outdoor recreational activities, thanks to the Chattahoochee National Forest and the sunny coast. Doctors are in demand in Georgia because the state population is growing at a faster rate than the nation's as a whole. And Georgia's population is younger than the national average: Medicare beneficiaries constitute only 13% of the overall inhabitants.

The sprawling Atlanta metropolitan area, with an estimated population of 5.6 million, provides an economic, cultural, and transportation hub for the state and a healthcare nexus, and Georgia offers a wide range of practice opportunities beyond its urban core.

City to consider: Kiplinger's recently named Suwanee, a well-heeled northwestern suburb, one of the best places to raise kids, on the basis of its excellent schools and proximity to recreational activities. Likewise, Cumming and Johns Creek, located in the northeast, are popular destinations, says Merritt Hawkins vice president John Hawkins.

Image from Dreamstime

Slide 18

Although regional income disparities have decreased in recent years, physicians in the upper Midwest still do very well. Minnesota physicians reported a generous average compensation of $288,000 last year. The state's healthcare scene is progressive: More than 95% of Minnesota physicians responding to the Physicians Foundation survey say they use an electronic medical record, and 37% say they participate in an ACO. Nearly 55% report high morale—the second highest rate of any state.

But it's not just the clinical setting that makes Minnesota a great place to practice. The schools are strong; unemployment is low; and at 81.1 years, the average life expectancy is long. Minnesota has abundant outdoor recreational opportunities, but you need to embrace the cold and snowy winters.

City to consider: Forbes ranks Minneapolis a top-20 town for careers and business, making it a great city for relocating physicians whose spouses may be looking for employment. Minneapolis is home to such companies as General Mills, Target, and Best Buy.

Image from Dreamstime

Slide 19

Kansas is a well-kept secret. Although the tax burden is nearly on par with the US average, the cost of living is a considerable 8% lower and malpractice payouts are about 30% lower. Most Kansas doctors say they'd still recommend medicine as a career, according to the Physicians Foundation survey.

Dr Diane Steere, a Wichita physician, says Kansas is a great place for family medicine. "The state has a very strong primary-care orientation," she says. "There is a lot of mutual respect with specialists." And although physicians are often concentrated in the metropolitan areas, the state's aggressive efforts to recruit primary care doctors to its more rural regions has actually created shortage of doctors in such cities as Wichita, she says. "There's still plenty of room left for more doctors."

City to consider: Wichita's cost of living makes it one of the most affordable cities in the United States, according to both and MSN Real Estate, and January unemployment was just 5.2%. Dr Steere says she appreciates the easy commutes, the quality of the schools, and a surprisingly vibrant cultural scene that supports a local opera and a symphony orchestra. "It's a great place to raise a family, and what would be a million-dollar home on the coasts costs less than one quarter of that in Wichita."

Image from iStock

Slide 20

"Louisiana is underserved, so they recruit aggressively and pay well," says Merritt Hawkins' Bohannon. "The state has large Medicaid and Medicare populations, so reimbursement may not be the highest, but it's reliable."

Traditional practice models still reign in Louisiana. More Louisiana doctors responding to the Physicians Foundation survey say they remain independent (52%) than in any other state, and few (11%) say they are aligned with an ACO.

City to consider: In 2013, Coldwell Banker Real Estate ranked Prairieville, located 30 minutes south of Baton Rouge, the second most "booming suburb" in the nation. With a population of 27,599, Prairieville has grown 60% since 2000, thanks to high-performing public schools, low crime, and moderate unemployment. The median household income in Ascension Parish is nearly $70,000.

Image from iStock

Slide 21

Statewide, both the cost of living and physician compensation in Montana hover very close to the national average, making economic conditions in the state fairly typical. But there's nothing typical about the scenery or the quality of life enjoyed by residents of Big Sky Country.

Those who enjoy outdoor activities, such as skiing, mountain biking, and fly fishing, will love Montana. What's more, all those outdoor activities help make Montana a healthy state. Statewide, residents experience better health outcomes—as measured by lower rates of premature death, poor physical health days, poor mental health days, low birthweight, and poor overall health—than the nation overall, according to the Robert Wood Johnson Foundation's (RWJF's) County Health Rankings & Roadmaps. In addition, they have lower rates of smoking, obesity, and physical inactivity.

City to consider: Some of Montana's beautiful towns come with serious price tags. The cost of living in college towns, such as Missoula and Bozeman, is well above the state and national averages, and real estate in both locations can be pricey. But it's hard to deny the appeal of Bozeman, with its easy access to the Bridger Bowl and Big Sky ski resorts as well as Yellowstone National Park.

Image from iStock

Slide 22

Lots of people want to live in Arizona, so the economics of practicing there aren't quite as desirable as that of some of the other states on the list, and doctors may find that there's a big financial incentive to practice in a rural underserved market vs one of the more sought-after urban areas. For doctors interested in rural medicine, there's plenty of need—the ratio of population to primary care physicians in Arizona's rural communities can be as high as 5959:1, according to RWJF's County Health Rankings & Roadmaps.

City to consider: Several Medscape readers suggested Scottsdale as a "best place." "I think Scottsdale is one of the best. Low state and property taxes, a high population of seniors who need healthcare, more sunshine than most places, low cost of living, and a perfect place to raise a family," wrote one cardiologist. "The snow is 2 hours away; the beach is 4 hours away." January unemployment in the Phoenix-Mesa-Scottsdale area was lower than in other metro areas.

Image from iStock

Slide 23

North Carolina is a beautiful state with something for everyone: mountains; ocean beaches; a moderate climate; professional sports; and major universities, including four medical schools. The cost of living is 3.5% below the US average. If the prospect of playing nearly year-round golf appeals to you, North Carolina may be your ideal destination.

With six research hospitals and 100 community hospitals, the state has ample practice opportunities for physicians, who report an average compensation of $269,000. Over the past two decades, the state's economic focus has shifted from tobacco, furniture, and textiles to a knowledge-based economy—a trend that has benefited urban areas.

City to consider: The Research Triangle, cornered by Raleigh, Durham, and Chapel Hill, is a beautiful and thriving area, but physician density in the area is extremely high. Would-be transplants might find better opportunities in the Piedmont Triad region to the west, which includes the cities of Greensboro, Winston-Salem, and High Point. The recession cost the Triad a lot of manufacturing jobs, but the education and health sectors have been growing steadily.

Image from iStock

Slide 24

Some insist that Michigan is a great place to be a general practitioner: The state offers the seventh best cost of living in the nation, and malpractice payouts are low. For those who love boating and water sports, Michigan is a giant playground. Whereas Detroit has suffered painfully in recent years, such cities as Ann Arbor and Grand Rapids are growing, and their unemployment rates are lower than the national average. The state is home to 20 Fortune 500 companies, including Whirlpool, Kellogg, and Dow Chemical.

"You've got tons of medical schools and universities in Michigan," says Bohannon, which is a draw for doctors who like to mentor and train new physicians. Michigan is likewise known for its smooth and hassle-free licensure process, he says.

City to consider: Kiplinger's rates Ann Arbor the second best city in the United States for singles. The bustling college town, which provides easy access to Detroit, has lots to offer in the way of sports, entertainment, and restaurants. If you're looking for a more family-oriented environment, you might prefer Grand Rapids, on the western side of the state.

Image from Wikimedia

Slide 25

Compensation in Colorado is very close to the national average, and state and local taxes and malpractice payouts are below the national average. Median household income is comfortably above the national average. The state's cost of living is slightly above the national average largely because housing is relatively expensive.

Recreation-wise, Colorado is an outdoor playground with some of the best skiing, hiking, and mountain biking in the country.

City to consider: Denver is growing at a heady pace. The metro population is nearly 2.7 million and January unemployment was below both state and national averages, thanks in part to a diversified economy fueled by the aerospace, telecommunications, and technology industries. The Denver Art Museum recently added a new wing, and the city is home to the nation's second largest performing arts center.

Image from iStock

Slide 26

Average physician compensation in Virginia isn't as high as any of the other states on our list. At just $251,000, it's below the national average and the lowest of any of the recommended states on our list. But that's offset by a reasonable cost of living—far below that of neighboring Delaware and Maryland—and low malpractice payouts per capita.

Virginia is steeped in colonial and Civil War history, and its landscape includes everything from beautiful ocean beaches to the majestic Blue Ridge Mountains. Virginia offers a four-season climate and easy access to the cultural attractions of Washington, DC.

City to consider: Richmond, which is growing at twice the rate of the United States as a whole, has an educated workforce and a strong business community that includes six Fortune 500 companies. The city has targeted health and life sciences as an area for growth. The Virginia BioTechnology Research Park, a 34-acre site located in downtown Richmond and adjacent to Virginia Commonwealth University Medical Center, is home to more than 60 companies, laboratories, and research centers with 2000 workers.

Image from iStock

Slide 27

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Slide 28

New York, New York, is unquestionably a wonderful town. But for all its cultural attractions, the Big Apple is a tough market for a physician. At $249,000, average physician compensation is more than $22,000 below the national average. New Yorkers know they pay a premium to live in the city, but they may not be aware of just how hefty it can be. A 2013 report by the Economic Policy Institute found that a family of four living in Manhattan would spend $93,500 on food, transport, housing, healthcare, child care, and taxes—nearly twice as much as the same family purchasing the same products and services in Holly Springs, Mississippi, less than an hour south of Memphis.

City to avoid: New York City and its nearby counties are a tough place to practice medicine. In a May 2014 op-ed column in the New York Post, Dr Andrew Kleinman, president of the state medical society, cited exorbitant medical liability costs as a major problem. "A neurosurgeon in Long Island," he writes. "faces a 1-year premium of $330,000. That's more than some doctors in the state earn in a year." Dr Kleinman further mentioned high taxes and government mandates as a condition of medical practice, such as requirements to check databases for certain prescription drugs and counseling for HIV and hepatitis C tests, as making practice "more costly and less attractive to physicians here."

Physician density in the metropolitan area is another drawback. Of the state's 62 counties, Manhattan, Brooklyn, Nassau, Suffolk, and Bronx counties experienced the largest increases in the number of doctors between 2004 and 2012, according to an August report by the Center for Medical Consumers, a not-for-profit patient advocacy group. The report ranks New York second only to Massachusetts in physician density per capita, with 345 practicing doctors per 100,000 residents.

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Slide 29

Although Rhode Island physicians care for a lot of patients from adjacent Massachusetts, physician density in the state is extremely high. Rhode Island physicians responding to the 2015 Medscape Physician Compensation Survey reported lower pay than any other doctors in the country. At $217,000, average compensation is nearly 20% below the national average. Unfortunately for doctors in the area, that shortfall isn't offset by other economic factors: Rhode Island is among the 10 most expensive states in terms of both cost of living and overall tax burden.

Rhode Island also suffers from a languishing economy, stagnant population, and out-migration of talent, according to an October report by the New England Economic Partnership. Although the state's employment dropped from a peak of 11.9% in March 2010, it still ranks among the highest in the nation. Even growth sectors are operating "with the brakes on," the report concludes. From 2012 to 2017, employment in education and health services is expected to grow by only 0.6% per year in Rhode Island—less than one half of the 1.4% rate anticipated for the New England region as a whole.

City to avoid: Gallup ranked the Providence, Rhode Island/Warwick, Massachusetts, metro area one of the worst for job creation in 2014. Thumbtack, in partnership with the Ewing Marion Kauffman Foundation, gave Providence a failing grade in terms of its overall friendliness to small business, saying that the city is among the worst in the nation for employers seeking to start a new business and hire workers.

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Slide 30

Physicians practicing in Maryland, particularly in the suburbs surrounding Washington, DC, face the same uphill battle as those in other major metropolitan areas: a high cost of living and too many doctors. Although education and health services have been the strongest industry sector for the state, showing a 2.9% gain year over year in April, the state economy as a whole grew a lethargic 1.8% during the same period.

More than four decades ago, Maryland established an all-payer hospital rate-setting system, under which facilities in the state are paid the same amount by all government and private health insurers. In January 2014, Maryland and the Centers for Medicare & Medicaid Services announced an initiative to modernize the all-payer system by promoting value rather than volume. That may present issues for specialists whose work is procedure-based and whose affiliated institutions may not have a mechanism for gain-sharing.

City to avoid: Business Insider ranked Baltimore the 36th most violent city in the world last year, with 37.8 homicides per 100,000 residents—more than Juárez, Mexico. Baltimore's population is dwindling, and the city is known for its long commutes, which may explain why Sperling's Best Places has ranked Baltimore among the most difficult cities to navigate and the most irritation-prone cities.

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Slide 31

Massachusetts is a medical mecca, with world-class healthcare institutions and cultural amenities. But many readers saw the Boston glass as half empty, and looking through a strictly economic lens, they're right. Massachusetts has high taxes, a high cost of living, exorbitant housing costs, and average physician compensation that is $23,000 below the national average. As far as quality of life goes, the blizzard conditions Boston experienced this winter may have even the hardiest Northeasterner longing for a little sunshine.

Massachusetts physicians responding to the Physicians Foundation survey were the third most likely to say that they are working at capacity or feel overextended. Despite the challenges, more than one half the Massachusetts doctors responding to the Physicians Foundation survey reported positive morale and say they would recommend a career in medicine.

City to avoid: Chelsea, a diverse city located across the Mystic River from Boston, is struggling with many of the problems currently plaguing US cities, including a heroin epidemic and overtaxed schools. Spillover from Boston's development boom are driving up prices for multifamily units.

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Slide 32

Connecticut suffers from the same problems as the other states on our "worst" list: It costs a lot to live there, and doctors don't make a lot to compensate. The cost of living in Connecticut is more than 45% higher than the US average, and the cost of housing alone is more than twice the national average. Connecticut physicians responding to the Physicians Foundation survey reported the lowest morale of physicians in any of the Northeastern states.

But it's not just doctors who are upset. In a Gallup poll released in April 2014, nearly one half (49%) of Connecticut residents surveyed said they'd leave the state if they could—the second highest rate among the 50 states.

City to avoid: Hartford, the insurance capital of the world, has a high crime rate and low job creation. Connecticut is a wealthy state, but one third of Hartford's residents live below the poverty line.

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