The situation is looking a little bleak, according to Jeff Oxendine of the UC-Berkeley School of Public Health.
"We currently have work force shortages in primary care, clinical laboratory science workers, pharmacy and public health, those are already in shortage," Oxendine said recently at an informational panel discussion in the Capitol Building, put on by the California Health Policy Forum. "And it's about to get worse."
The health care provider shortage will be felt even more acutely, he said, because demand is about to boom.
"The aging of the state will increase demand dramatically," he said. In fact, the baby boomer population started to reach retirement age this year, and the number of seniors in California is expected to double by 2020. By 2030, one in five Californians will be older than age 65. Seniors use more health care resources, Oxendine said.
"On top of that demand, we expect to see roughly four million new enrollees in California with health care reform," Oxendine said. "Who will take care of all of those people?"
Health care providers are aging, too. "About 30% of physicians in California are over 60 years old," Oxendine said. "Not only is it an aging group there, but it's an aging group of leaders in health care, as well as just the number of aging professionals."
But wait. There's more. The physicians and other health care providers in California are concentrated in higher-income areas, which means the problem in rural and underserved areas -- where a good percentage of the impending boom in the newly insured will be -- is especially dire.
"Coverage doesn't equal access," Oxendine said. "Access is already a problem with Medi-Cal, and that will intensify."
So, to summarize: an inadequate supply of providers, distributed unevenly, about to contract because those providers are aging, serving a population that's growing exponentially and getting older and needier. Can it be any worse than that?
"Well, at the same time, educational capacity is being cut," Oxendine said.
The pipeline of new physicians, for instance, is actually in danger of shrinking, due to budget cuts. The planned expansion of the UC system to include a new medical school at UC-Riverside has been slowed, and legislators have warned that all UC schools stand to be severely cut back if tax extensions aren't passed and California lawmakers need to enact an all-cuts budget.
Few newly trained physicians plan to go into primary care. Of the ones who do, not many will work in rural or underserved areas.
It's enough to make you want to duck your head and hum, Oxendine said.
The Way Out
There are a few general commitments that must be made, according to Oxendine:
- Invest in training programs;
- Protect against cuts to higher education;
- Keep community colleges funded and implement more training programs there;
- Fix the primary care payment disparity; and
- Increase incentives for new physicians to work in underserved communities.
Some of those pursuits -- changing reimbursement levels, increasing the number of medical school graduates in California and training more allied health workers -- will take a lot of time. Because the senior crunch is happening now and the expected influx of insured patients resulting from health care reform is due in less than three years, California will need to look at other options, Oxendine said.
"Even if we do everything right, we still won't have enough providers in time," he said. "So we have to enhance the ones we have."
That means making sure that physicians, nurses and other providers are being used to the maximum extent of their training -- a concept called working to the top of your license, according to Catherine Dower, a UCSF researcher and co-director of the Health Workforce Tracking Collaborative, who also spoke at the Capitol Building forum.
"Nurses and other providers should practice to the full extent of their education and training, at top of their license, at the top of their competence," Dower said.
The idea is that physicians and nurses spend a lot of their time doing busy work. By arranging the workplace so that ancillary health care professionals can handle some of those tasks that don't take as much training, that frees doctors and nurses to do more, to care for more patients. Proponents say it also will provide better care for patients.
Among the obstacles to taking the top-of-license approach, Dower said, are the fragmented rules in California for what mid-level providers -- physician assistants and licensed nurse practitioners -- are allowed to do.
"Nurse practitioners, for instance, can order or furnish drugs," Dower said. "It looks like a prescription, but it's not." Because nurse practitioners work under supervision of a physician, the actual prescription has to be approved by that doctor. "And in California, there's a cap on the number of nurse practitioners each doctor can collaborate with," she said. Those NPs are critical to helping physicians work to the top of their license, Dower said.
"About one-fifth of the primary care work force in California is nurse practitioners," Dower said. "It doesn't cost as much to produce an NP as it does to produce an MD," she said. "You get increased access without compromising quality."
Top of License in Action
Mike Witte is medical director of the Coastal Health Alliance, a set of clinics in the western, rural part of Marin County.
"We use what we call Teamlettes," Witte said. "A group of people assigned to every patient. Administrative, clinical, psychiatric, all of us working at the top of our license, because there's a lot of stuff done in medicine that can be done at other levels."
The group of clinics cares for a large safety-net population, Witte said, about one-third Latino patients, most of them Spanish-only speaking.
"We take care of everyone who walks in the door," Witte said. "About 20% are commercially insured, 20% are Kaiser, another 25% Medi-Cal or Medicare, the rest uninsured. It's a bit of a paradigm for what happens across the state." Medi-Cal is California's Medicaid program.
The clinics use the health care home model, which includes behavioral and dental health care, and features a number of mid-level practitioners.
"One of the limitations [for us] is how we get paid. Right now, we get paid for someone who's sick or hurt, or for a checkup. But they're pretty perverse incentives, if you think about it. Some of that's appropriate and necessary, but there's so much care that can go outside the walls. Even acute care can be done distally, from far away."
The key to a smooth health care system is to take care of all the little things -- from phone calls before appointments to getting treatment from specialists such as a diabetes educator during a visit for some other health issue -- according to top-of-license proponents.
"Health care can happen locally. There are a lot of resources beyond what we now call medical care," Witte said. "We want to use all of the providers, the direct care workers, in-home supportive services -- and all of that stuff needs to get paid for, because if it doesn't, it creates more cost down the road."