Is California Ready for Millions of Newly Insured?

by Mari Edlin, California Healthline Regional Correspondent

TOPIC ALERT:

Three million to four million Californians will become eligible for health insurance in 2014 thanks to the Affordable Care Act, but will the state's health care workforce be able to handle the new demand?

"Because persons who have health insurance tend to use more primary care than persons who are uninsured, there is concern that the current supply of primary care providers (physicians, nurse practitioners and physician assistants) may not be adequate to meet demand," said Janet Coffman at UC-San Francisco's Philip R. Lee Institute for Health Policy Studies.

California's health care workforce is expected to more than double over the next 10 years from today's total of about 840,900 workers to 1.8 million workers by 2022.

According to the Medical Board of California, the number of licensed physicians/surgeons in the state grew slowly for several years in the last decade and peaked at 127,436 in 2009. The most recent total is 124,398.

Workforce expansion to keep up with health system reform may not be enough in California.

In addition to the immediate need generated by the newly insured, California is expecting a 15% growth spurt over the next 20 years, putting added, sustained stress on the health care workforce. Not only will the state need more health care workers, it will need differently trained workers. Advances in health information technology and new models of care require different skills and specially trained personnel.

Those problems, according to the Center for the Health Professions at UC-San Francisco, are compounded by an increasingly diverse and aging population and by the growing burden of chronic illness.

Lack of Access, Diversity, Distribution at Heart of Problems

Catherine Dower, associate director of research for the Center for the Health Professions, acknowledged that while some shortages exist, the primary concern is distribution of those resources throughout the state.

She called the problem a "geographic mismatch," with some parts of California, including the Bay Area, having a greater supply of health care workers compared with areas such as the Inland Empire and the San Joaquin Valley. Urban and suburban areas along the coast get the better end of the deal.

Coffman agreed, saying, "Improving the geographic distribution of primary care providers and their ability to care for diverse populations is even more important than increasing the overall supply."

Dower also said there is a large disconnect between patients' cultural backgrounds and those of their providers. For example, only 5% of physicians and 8% of nurses in the state are Latino, compared with 37% of the population.

"With stepped-up demand, we need to get a handle on who these newly insured Californians are and their health status. While we need to maintain or improve safety and quality of care, the biggest, immediate challenge will be access to care," Dower said.

Recommendations for Long-Term Solutions

Although there is no quick fix to meet the needs of the newly insured, Dower shared some suggestions from a recent report she co-authored, "California's Health Care Workforce: Readiness for the ACA Era." The report recommends:

  • Promoting training and residency programs in primary care, especially in under-represented communities;
  • Investing in health information technology, including a data clearinghouse, a tool for tracking outcomes, electronic health records and telemedicine;
  • Enabling nurse practitioners and physician assistants to practice at the top of their competency levels;
  • Improving the education pipeline for medical students and residents; and
  • Developing financing models to narrow the large discrepancy between salaries for primary care providers and specialists.

Angela Minniefield, deputy director for California's Office of Statewide Health Planning and Development, Health Care Workforce Development Division, believes that health care workforce development efforts focused on different health care delivery models such as patient-centered medical homes, culturally competent care and technology are ways to expand access to care, particularly in underserved areas.

"We are cautiously optimistic about ensuring a sufficient health care workforce for California," Minniefield said. "Until more primary care physicians are trained, we will need to rely on interdisciplinary care teams," she added.

Despite the initiatives adopted by OSHPD and by other California organizations, Coffman said efforts to reboot the primary care provider supply have not yet reached their potential, due mostly to limited resources.

Federal funding for grants for training primary care providers and other health professionals was cut by 27% between 2011 and 2012, limiting monies for training, loan repayment programs and career development.

Coffman, however, is heartened by a couple specific federal and state efforts. The National Health Service Corps helps practices serving low-income populations recruit primary care, mental health and dental providers. In California, the University of California's PRIME -- "Programs in Medical Education" -- is aimed at enrolling and graduating medical students who will care for residents of underserved communities, including inner-city areas, rural communities, the Inland Empire and the Central Valley.

"In my opinion, these targeted efforts are more valuable than simply increasing enrollment in primary care provider education programs," Coffman said.

Burden on Medical Groups

In evaluating the health care workforce landscape, Tony Marzoni, executive vice president of the Palo Alto Medical Foundation, can't ignore the impact of decreased reimbursement -- especially under Medicare -- for all procedures. He also sees little relief under the new state insurance exchanges.

"We're lowering salaries while making our services more affordable," he said.

"Without more primary care providers, patients will go to the emergency room, the most expensive and least effective way to deliver care," Marzoni predicted.

Marzoni said that PAMF, a multidisciplinary group of 950 physicians, is the only provider group other than Kaiser still accepting new Medicare patients in California. He estimates that approximately 25% of the foundation's patients are enrolled in Medicare.

Electronic Health Records, Mid-Level Practitioners May Help

Marzoni holds out hope for technology. More than 80% of the medical group’s patients use an online application to access their electronic health records, make appointments, review test results, email providers and track outcomes -- all of which free up provider time to better care for more patients.

The federal government has added an incentive to promote the installation and meaningful use of electronic health records -- payments for physicians, dentists, physician assistants, nurse practitioners and nurse midwives in California, who serve a high percentage of Medi-Cal patients and adopt the technology. Medi-Cal is California's Medicaid program.

Marzoni anticipates that mid-level practitioners, such as physician assistants, nurse practitioners and others, will play a large role in helping the state meet its health care workforce needs.

PAMF uses more than 250 mid-level practitioners mostly in specialty care. The trend is to use mid-level practitioners more in primary care, Marzoni said.

"These practitioners offer huge opportunities if allowed to work up to their potential and require less training than physicians but can do a lot," he said. "They are also ideal for providing services in underserved communities."

Coffman is concerned, however, that California's regulations governing the practices of mid-level providers are more restrictive than those in other states -- perhaps making it more cost-effective to hire primary care physicians instead.

Health Reform Law Could Bolster Primary Care

Although health care reform will increase the number of patients seeking care from California's understaffed health care workforce, the law also opens doors that could improve primary care and help develop new workers and new jobs. The ACA initiatives include:

  • A 10% increase in reimbursement rates for certain services from Medicare Part B for qualifying primary care providers and general surgeons in health professional shortage areas, effective through Dec. 31, 2015;
  • Payment bonuses for primary care physicians treating Medicaid beneficiaries in 2013 and 2014, at least equal to reimbursement rates under Medicare Part B;
  • Federally supported health care workforce loan repayment programs;
  • Diversity training for health professionals; and
  • Medicare reimbursement for Federally Qualified Health Centers.

For more on the health care provider shortage in California, see Thursday's Capitol Desk post.

Rob Tookoian
The shortage of providers in the San Joaquin Valley is due in no small part to the low reimbursement rate by all payors, starting with Medicare, relative to the rest of the state. The San Joaquin Valley, known as area 99 when it comes to Medicare reimbursement, is among the lowest in the country, let alone California. It is extremely difficult to recruit providers into the Valley unless they already have a personal connection to the area. When you add that to the paltry reimbursement, you have a real uphill battle in improving the healthcare of the populous.

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