As the Inland Empire grapples with a shortage of primary care physicians, experts say the solution hinges on creating more medical residencies.
New state legislation could help. AB 1176 proposes to increase the number of primary care medical residencies in underserved regions, such as the Inland Empire. The new slots would be funded by levying a fee on insurers.
The bill, co-authored by Assembly members Paul Bocanegra (D-Pacoima) and Rob Bonta (D-Oakland), would encourage the creation of more family medicine residencies, an area of primary care for which there is a particular need statewide. The Inland Empire's 32 family medicine residencies listed in the National Resident Matching program aren't enough to keep the region supplied with family doctors, according to experts.
G. Richard Olds, dean of UC-Riverside's new medical school, said there are not enough residencies to meet current demand, which is expected to intensify when 500,000 uninsured residents become eligible for health coverage in 2014.
Statewide, the shortage of primary care physicians is the most severe in the Inland Empire, according to health care officials. The region has a population of four million and is one of the fastest-growing areas in the nation, but it has only half the recommended number of primary care doctors, according to a California HealthCare Foundation report. CHCF publishes California Healthline.
San Bernardino and Riverside counties have an existing shortage of 3,000 physicians and are projected to have a shortage of 5,000 physicians in the next 10 years, Olds said.
Studies have shown that many physicians end up practicing where they complete their residencies. In California, that trend is stronger than in the rest of the country. According to the American Association of Medical College's State Physician Workforce Data Book, 69% of graduates stay in California after completing residencies here, compared to the national average of 47%.
Daniel Giang, vice president of graduate medical education at Loma Linda University Medical Center, said 30% of the doctors practicing in San Bernardino County trained at Loma Linda.
The shortage of medical residencies is not just a regional or even statewide problem. Nationally, medical residencies have not kept pace as medical schools have increased enrollment.
Sequestration May Reduce Funding
One of the factors limiting the creation of new residency positions is money. Federal funding for medical residencies has been capped for a number of years and could be reduced further as a result of sequestration, experts said.
Meanwhile, the cost for teaching hospitals and other entities that offer residency programs is substantial.
The cost for educating each resident is about $100,000, Giang said. The residents' stipend, benefits, professional liability insurance, overhead for administering the program and accreditation costs all contribute to the overall price tag, he said. Providers can receive some reimbursement from Medicare to partially cover the cost of residencies. Because residents are often not as efficient as experienced doctors, the services they provide don't help fill the cost deficit, he said.
The problem is further compounded because once a hospital has invested three years in training a physician, more than half the trained residents end of working elsewhere, he said.
"Teaching hospitals lose a tremendous amount of money from providing graduate medical education," Giang said. "No teaching hospital in California is making money on its graduate medical teaching program."
Olds said despite the cost, there is an incentive for hospitals in regions with physician shortages to create residencies because if recruitment and retention are difficult, training doctors themselves may be the only source of new hires those hospitals have.
"Where are the future doctors going to come from?" he asked.
Competition Is Possible
With the launch of UC-Riverside's new medical school this fall, graduates who want to stay in the area will likely be competing with Loma Linda University students for residency slots. The new medical school is the first public medical school to open in the state in about 40 years.
Giang said there would be no direct competition between Loma Linda and UCR, and Loma Linda is helping UCR start some residency positions.
The fact remains, however, that if graduates from the two programs want to stay in the region, they will be applying for many of the same slots.
Olds said UCR is well on its way toward creating more residency slots than will be needed by graduates in the hopes of attracting additional residents from outside the region.
"Our desired outcome is high-quality physicians who practice in Southern California in the areas we need," he said.
A related bill (SB 21), by state Sen. Richard Roth (D-Riverside), would provide $15 million annually to the medical school. Olds said much of that money would be used to hire teaching faculty to start residencies. He also wants to increase the class size from 50 students to 80.
In addition, the school has designed a loan-to-scholarship program to entice graduates to complete their residencies and practice locally, Olds said. If a graduate ends up practicing in the region, he or she would not have to pay back the loan.
"One of the reasons doctors don't go into primary care is that they are heavily in debt, and they know they won't make as much money in primary care," Olds said.
Dylan Roby, a professor and researcher at the UCLA Center for Health Policy Research, said the presence of two medical schools in the region will likely be beneficial and help attract doctors. He does not expect the region to encounter some of the recruitment challenges faced by other areas of California that also have physician shortages, such as Bakersfield and Fresno, which don't have the same ability to pull together a network of academic medical centers, he said.
"I don't think Riverside is subject to those issues because I think they have some very forward-thinking doctors there," he said. "I think the infrastructure is there for a physician to be engaged in care and do interesting things."
ACA Could Help
The Affordable Care Act addresses the need for more primary care physicians and sets up some new mechanisms to encourage the training of more residents in that discipline. For example, the ACA allows some residency slots in specialty areas to be re-categorized into primary care and for some residency slots to be permanently reassigned to underserved areas if a hospital closes. The ACA also provides funding for residency programs at federally qualified health centers.
Residency slots will be created at the San Bernardino site of the expanded Social Action Community Health System-Norton clinic, which is an FQHC, Giang said.
Likewise, UCR's medical school is working with FQHCs in Riverside County to create residency slots there.
However, Olds said many FQHCs aren't in a position to start new residencies and that's why more new slots haven't been established.
"That's something that most of them haven't done, and that's a big thing to take on if you've never done that before," he said.
Meanwhile, the legislation to increase medical residencies, AB 1176, is moving closer toward a vote. The bill cleared the Assembly Health Committee in late April and was taken up by the appropriations committee this week.
Olds said that if nothing is done, the Inland Empire will only have one-third of the primary care doctors it needs in the next 10 years.
Both he and Giang stressed that any programs created to increase primary care doctors must be tied to the regions that need them the most.
"What we want to do ... is train residents to be good physicians who will stay in the area," Giang said. "Many medical students move away from the region to get a residency program. By funding residency programs, you can funnel people into primary care specialties."