The best, worst parts about practicing orthopedics in 7 states


West Virginia was named the worst state to practice medicine in for 2024 by Medscape, while Wisconsin was named the best. 

Seven orthopedic and spine surgeons told Becker's what makes their state the best — and worst — place to practice medicine in 2024: 

Note: These responses have been lightly edited for length and clarity.

Michael Burdi, MD. Partner at Community Orthopedic Medical Group (Mission Viejo, Calif.): The best part of running a practice in Southern California is the weather and generally fitter and healthier than average patients. The worst part is abysmal reimbursement, high cost of living and workforce along with a plethora of competition (a surplus of specialist physicians), making any negotiating with payers challenging at best.

Hazem Eltahawy, MD, PhD. Neurosurgeon
at Detroit Medical Center: The worst part about running a private practice in my state of Michigan is that some insurances have come up with a rule that for urgent inpatient surgeries the surgeon has to submit a separate request for authorization of surgery either before or within a limited time period from the actual surgery date. It is illogical that a patient who is admitted to the hospital or arrives at the ER for an urgent neurological or musculoskeletal problem such as spinal cord compression with cauda equina syndrome or spinal cord injury due to spinal fracture would need some form of insurance authorization for the surgical services to get reimbursed. At those critical times, sensitive and urgent surgical decisions are made, and the last thing that a patient or their treating team need to worry about is their insurance and whether an authorization for services is needed. It has to be struck down.

Ramis Gheith, MD. Chief Medical Officer at DxTx Pain Spine (Kansas City, Mo.):  

Best aspects 

1. Low cost of living

Missouri has a relatively low cost of living compared to many other states, which can make it more affordable for both healthcare providers and patients.

2. Malpractice insurance costs

Missouri has lower medical malpractice insurance premiums compared to many other states, which can reduce overhead costs for medical practices.

3. Favorable regulatory environment

The state has a relatively favorable regulatory environment for medical practices, with less stringent regulations in some areas compared to other states.

4. Patient demand

With a growing population, particularly in urban areas like St. Louis and Kansas City, there is a steady demand for medical services.

5. Educational institutions

Missouri is home to several medical schools and teaching hospitals, providing a strong talent pool and opportunities for collaboration and continuing education.

6. Community support

Many communities in Missouri highly value their healthcare providers, often leading to strong patient loyalty and community support for local practices.

Worst aspects

1. Rural healthcare challenges

Rural areas in Missouri face significant healthcare challenges, including provider shortages, limited access to specialized care, and financial difficulties in maintaining rural hospitals and clinics.

2. Reimbursement rates

Medicaid reimbursement rates in Missouri are lower than the national average, which can impact the financial viability of practices that serve a large number of Medicaid patients.

3. Economic disparities

Economic disparities can lead to variability in patients' ability to pay for services, impacting the financial stability of practices, especially in economically disadvantaged areas.

4. Regulatory changes

Although the regulatory environment is generally favorable, changes at the state and federal levels can create uncertainty and require practices to adapt quickly to new rules and requirements.

5. Competition in urban areas

While urban areas offer a larger patient base, they also come with higher competition among healthcare providers, which can make it challenging to attract and retain patients.

6. Insurance market variability

The health insurance market can be unpredictable, with frequent changes in policies and coverage that affect both patients and providers.

7. Public health issues

Missouri faces significant public health challenges, including high rates of chronic diseases such as obesity, diabetes, and heart disease, which can place a high demand on medical services and affect patient outcomes.

8. Legislative environment

Missouri's legislative environment can sometimes pose challenges, with debates over healthcare policies, Medicaid expansion and other issues including unfavorable work compensation regulations (unfavorable to patients), imbalance in insurance regulation allowing carriers to dictate care for patients while disregarding provider input, can all impact how medical practices operate.

Maahir Haque, MD. Surgeon at Spine Group Orlando (Celebration, Fla.): The best part of practicing in Florida is that there is significant population growth. There is considerable volume to sustain practice growth. This said, the major hospital systems are simultaneously buying primary care practices, which has the potential to adversely affect clinical volumes for community orthopedic surgeons. The worst part about practicing in Florida — and specifically Central Florida — is the insurance environment. The major insurers really take advantage of private practice doctors, which has led to significant consolidation and increased cost of care as most orthopedic surgeons have become employed.  

Peter Passias, MD. Associate Chief, Co-chair and Medical Director of the Spine Research Program at Duke University (Durham, N.C.): The best part of my area is the excitement and the growth that is present in the research triangle, coupled with the focus on research, development and academics. Managing change in an expanding environment allows for opportunity but also requires constructing frameworks that have not previously been utilized.

Mark Testaiuti, MD. Surgeon at Coastal Spine (Mount Laurel, N.J.): Having worked in the state of New Jersey for my entire career, I would say that New Jersey is a very progressive state to work in from the standpoint of the excellent quality of healthcare provided throughout the major metropolitan areas. With that said, there are distinct differences in regional care in N.J. that one finds in any state. One particular area of amusement for me is the disparity in billing and reimbursement from the north to the south part of the state, even if the geographic distance is less than 100 miles with the southern part of the state, sometimes seeing 20 to 30% less reimbursement for the exact same procedure. A more controversial topic of significant impact over the last two decades is with New Jersey motor vehicle insurance and the substantial changes in coverage of vehicular personal injuries. In years past, there was a standard coverage policy that covered and reimbursed treatment of all injured and qualified insured drivers in the state of New Jersey. Similar to the way other states have developed tort options or mandates for personal health insurance as primary coverage of injuries with motor vehicles being secondary, N.J. has similarly adopted these strategies for cost containment. However, shortly after 2010 or 2011 and as a result of negotiations between hospitals and PIP insurance companies, spinal surgeries were completely disallowed from New Jersey ASCs and could only be done at a hospital. Again, N.J. spinal surgeons have adapted to these more significant changes or have moved out of state. To end on a positive note, the New Jersey workman's compensation system is rather robust with a very organized group of insurers, adjusters and nurse case managers that help to direct care to the most qualified and effective providers. Interestingly, they have come to realize the cost savings of ASCs versus hospitals and have been increasingly allowing spine surgeries to go to ASCs for care. This has benefited all involved with similar or improved outcomes (from an infection standpoint) and higher patient satisfaction. This has been quite gratifying personally in my practice as I have been doing the majority of the worker's compensation cases in my ASC since 2007. Additionally, in the state of New Jersey, we transfer our lumbar fusions or multi-level cervical procedures after postoperative recovery in the ASC to a local, acute care rehab facility, where they convalesce and receive identical, postoperative care, antibiotics, PCA, fever, work-ups, etc., with a more intense daily therapy program providing for earlier mobilization. This lasts anywhere from two to five days at a much improved price point versus the hospital with similar care and patient satisfaction.

Nolan Wessell, MD. Assistant Professor of Orthopedic Surgery at the University of Colorado School of Medicine (Aurora): While we've experienced an economic boom over the past decade, that has been coupled with increasing expenses for real estate, equipment, staffing, etc. When combined with declining reimbursements, the long-term sustainability of orthopedic and spine practice will hang in the balance. Just recently, we've seen an increase in the cap on medical malpractice lawsuits. Colorado is slowly moving up the list of states with higher medical malpractice claims. Additionally, we've seen state-led initiatives such as hospital discounted care nobly work to provide access to care for underserved populations, but oftentimes it provides little to no reimbursement to either providers or healthcare organizations. These changes feel like a multi-faceted threat to our viability that needs to be addressed at all levels if we hope to continue to provide high quality care that improves people's lives.

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