With a shortage of primary care physicians, lack of resources to educate new ones and low Medi-Cal reimbursement rates discouraging physicians from treating low-income patients, California's health care system is facing a scarcity of physicians on the eve of a major expansion.
Aging physicians are retiring and new ones are not being trained in sufficient numbers or quickly enough in many parts of the country, but the problem is particularly acute in the most populous state. Only one in four California counties has the recommended ratio of 60 to 80 primary care physicians for each 100,000 residents, according to the California Medical Association.
Things are about to get considerably worse. Roughly six million more Californians will be newly insured in 2014 because of the Affordable Care Act and about half of them will be eligible for Medi-Cal, California's Medicaid program. The three million or so with private insurance will have a hard enough time finding a physician, but Medi-Cal recipients may have an even harder time. Only 57% of California's physicians are willing to accept new Medi-Cal patients.
California has nine medical schools, with a 10th and 11th in the planning stages. A proposed medical school at UC-Riverside is caught in a predicament: The school did not receive preliminary accreditation partly because the national accreditation panel had concerns the school would not get state funding.
In planning stages for years, the school was scheduled to open next fall, carrying hopes of easing a severe physician shortage in the Inland Empire. Another medical school -- still early in the planning stages -- is proposed at UC-Merced. The fate of UC-Riverside's medical school could have a bearing on what happens in Merced.
One new medical school -- even two new schools -- would help, but they alone won't entirely solve the dearth of primary care doctors in California.
What will? We asked experts and stakeholders what California policymakers can do to encourage a healthy supply of family physicians.
We got responses from:
- Catherine Dower, Center for the Health Professions, UC-San Francisco
- G. Richard Olds, Dean, UC-Riverside School of Medicine
- Karen Shore, President and CEO, Center for Health Improvement
- Carol Havens, President, California Academy of Family Physicians
- Richard Rajaratnam, President, Riverside County Medical Association
Multiple Solutions to Primary Care Challenges
Center for the Health Professions, UC-San Francisco
If the problem is a shortage of family physicians, then a solution would be to train more of them. But the problem as currently understood is that California faces a chronic undersupply of primary care services in rural and underserved areas and increased burdens of a growing and aging population, plus millions more newly insured under the PPACA. The challenge is primary care and because primary care is delivered by clinicians from various professions in different settings, we have the opportunity to pursue multiple solutions.
The primary care work force consists of physicians (including osteopathic and medical doctors in family practice, internal medicine, general practice and pediatrics), physician assistants and nurse practitioners. Primary care sites include private offices, community health centers and hospital-based ambulatory care sites.
Given the layered aspects of the primary care challenge, we would be limiting ourselves if we focused only on medical schools, which will address part of the problem but may also produce unneeded specialists and primary care doctors practicing in well-supplied regions.
More nuanced solutions include increasing our trust in nurse practitioners and physician assistants; relying more on technology; expanding loan repayment programs for clinicians in underserved areas; and exploring new practice models.
Based on the evidence, California could expand the scope of practice for NPs and PAs without compromising safety or quality. And we could expand the production of NPs and PAs by building new programs or expanding existing ones at a fraction of the time and financial costs associated with medical schools.
While most primary care is delivered face-to-face, more diagnostic, preventive and care management services could be delivered remotely. California has led the world with its technological savvy that has yet to be applied fully to health care. Policy decisions could include payment guidelines that do not discriminate against telehealth; teaching practitioners to use telehealth; and supporting the development of hard- and software that connect people in their homes with clinicians at distant locations.
We also could rethink primary care and acknowledge that getting some care at retail clinics, school-based health centers, nurse-managed health centers, community clinics or automated kiosks may be -- depending on the situation -- as appropriate, safe and effective as care from a traditional practice model.
With ongoing challenges likely to be exacerbated by changes on the horizon, it is time to think creatively about the many promising options we have to deliver high-quality primary care.
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Train Physicians Where They Are Needed
G. Richard Olds
Dean, UC-Riverside School of Medicine
While California has an absolute shortage of primary care physicians, the real issue for California is the uneven distribution of those physicians.
According to the California HealthCare Foundation, more than two-thirds of California counties already have fewer than the minimum number of primary care physicians per capita considered adequate to meet demand. Predictably, those counties with the most severe shortages are either rural or in rapidly growing regions, such as Inland Southern California and the Central Valley.
Since the two principal determinants of where physicians practice are where they grew up and where they finished residency training, the most effective means of addressing California's primary care shortage is providing both medical education and post-graduate training in the areas of highest need.
The School of Medicine at UC-Riverside, the state's first public medical school in more than four decades, aims to do just that. Policymakers should find the will to help fund the start-up of this medical school as expeditiously as possible.
It takes a minimum of seven years to train a primary care physicianm, and the lack of sustained state funding for the UCR medical school already has pushed back the planned opening from 2012 to 2013. Inland Southern California's population will grow by an estimated 24% over the next decade, and many of the 44% of current physicians who are ages 55 and older will retire, further reducing health care access.
Policymakers also can support reforms in medical education that would encourage more students to pursue primary care medicine. These approaches include a greater emphasis upon clinical training in ambulatory settings, development of longitudinal patient experiences for medical students and innovative options for dealing with medical school debt on the front end of medical training.
The UCR School of Medicine will enact each of these reforms.
In both clinical rotations for medical students and residency training, we are developing affiliations with outpatient health care providers, including community clinics and federally qualified health centers, multi-specialty practice groups and HMOs. Medical schools traditionally have trained their students in tertiary care academic medical centers, which give trainees a skewed view of the medical profession. More training needs to occur in ambulatory settings where the vast majority of medical care is delivered.
Throughout the second and third years of medical school, UCR students will have continuity-based clinical experiences that enable students to establish more meaningful interactions with patients, thus inspiring more students to choose primary care specialties.
Additionally, we plan to establish an innovative loan-to-scholarship program where selected students who ultimately practice in primary care or high-shortage specialties have their loans converted to outright scholarships. If students can begin their medical education without the worry of accumulating debt, it will solidify their intended career goals to practice in primary care.
By supporting medical education approaches such as those we are developing at UC-Riverside, state policymakers can tangibly and positively affect the primary care physician work force in the high-need areas of California.
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Expand Scope of Providers, Manage Demand
President and CEO, Center for Health Improvement
Given the complexity of issues related to improving access to primary care in California, a number of solutions are required, focusing on both increasing the supply of health care providers and managing the demand for primary care services.
Policymakers need to invest in multiple approaches to increase the supply of primary care providers -- and not just of primary care physicians. Although increased primary care physician supply through the addition of medical schools, larger class sizes in existing medical schools and more residency training program slots clearly is an important component of improving access to primary care services, investments to increase the supply of professionals such as nurse practitioners, physician assistants, and social workers/therapists also are needed.
Many practices in California are embracing the concept of a patient care team, composed of multiple providers who practice at "the top of their license" -- i.e., provide care at the fullest extent of their training/competency. Another important consideration for policymakers relates to potentially expanding scopes of practice for non-physician clinicians because these are somewhat restrictive in California compared with other states. To achieve a culturally and linguistically diverse primary care work force that more accurately reflects the demographics of California's population, efforts should be made in middle and high schools to interest more students in primary care professions.
The other side of the equation relates to managing demand for primary care services. Health reform is expected to significantly increase the number of consumers with health insurance coverage. It also is expected that the newly insured will have pent-up demand for preventive and other primary care services. The newly covered -- particularly in certain parts of California -- will place further demands on a system that already struggles to provide needed primary care. Outreach and education efforts -- in a variety of languages and formats -- will be needed to let consumers know about their potential eligibility for various health insurance programs, and about what to expect when they are seeking care. They should be informed about different types of primary care providers, and how they work together to make up a care team that will be responsible for keeping individuals healthy, and caring for them when they are ill.
By simultaneously tackling this problem from both the supply and demand sides, California will be able to increase its primary care capacity and be more prepared to meet the needs of those seeking care.
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Action Needed on Several Fronts
President, California Academy of Family Physicians
Solving California's primary care physician shortage requires immediate coordinated action among state, federal, private and public stakeholders. The shortage will not improve unless significant changes are made in medical education, residency training, health care delivery and payment policies. Policymakers should act in the following areas.
Medical education: To encourage students interested in primary care to join the field, California policymakers should expand scholarship and loan repayment programs by creating medical school loan forgiveness programs.
Residency training: State policymakers should provide incentives to increase the proportion of residents trained in primary care. We encourage policymakers to reward creation of additional primary care training slots, as other states have done. The mere 303 family medicine positions available in California's programs already are filled for fall 2011, and that number is inadequate to meet California's future needs. Because physicians tend to practice in the same areas where they train, limited training opportunities only worsen our shortage. Since 2003, six California family medicine residency programs have closed because of a lack of funding; others operate in the red. Funding flows through subspecialist-friendly hospitals, leaving community-based specialties such as family medicine gravely underfunded. Direct allocation of federal graduate medical education funds to family medicine programs would help ensure solvency.
Health care delivery: Anchoring every patient's care in a patient-centered medical home will lead to better patient health, decreased health care costs and improved patient and provider satisfaction, as has been shown in numerous pilots throughout the country. The efficiencies created by the model also are a solution to the physician shortage, for in this model every member of the health care team works at the top of his or her license. Policymakers can do much to support adoption of the medical home model, including developing a statewide standard and participating in pilot projects and demonstrations rolled out as part of national health care reform.
Payment: California ranks among the lowest of all the states in Medi-Cal payments to physicians. The current overall payment system is skewed as well, with primary care services seriously undervalued by all payers. Rewarding physicians who provide primary and preventive care, including expert management of chronic conditions to keep patients as healthy as possible, is essential. In addition, supporting the role of physicians in patient-centered medical homes, who coordinate each patient's care throughout the health care system, is critical. Such changes would increase the number of medical school graduates who see primary care specialties as a viable economic path.
Solving the family physician shortage won't be easy, but with sufficient commitment, it can be done.
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Low Reimbursement Contributes to Physician Shortage
President, Riverside County Medical Association
California is facing a dwindling supply of family medicine doctors. This shortage has reached critical proportions in Riverside County. Currently, Riverside County ranks 57th out of California's 58 counties for state reimbursement of health care and emergency room services.
Riverside County is California's fourth most populous county but ranks near the bottom in funding to counties for health services because of an outdated and flawed formula that has never been adjusted to recognize California's changing demographics and massive population shifts to the inland areas of California.
Riverside County physicians get paid less for the same service provided by their colleagues in other parts of the state. For example, Riverside County has three times the indigent population of San Francisco County but receives one-fifth of the reimbursement for comparable emergency department treatment to its low-income residents. Doctors in Riverside County also are paid anywhere between 13% to 27% less for a 10-minute office exam under Medicare than physicians practicing in surrounding counties.
Because of low reimbursement, Riverside County has a hard time attracting and keeping doctors. Riverside County suffers from the most acute shortage of doctors in California, having just half the number of doctors recommended for adequate health care services. The benchmark for primary care physician to population ratio is 60 to 80 per 100,000 people. Riverside County currently has 34 primary care physicians to 100,000 people.
California policymakers need to recognize the need to adequately fund health care and to establish fair reimbursement rates that will attract and keep doctors in Riverside County. Policymakers also need to recognize the importance of opening the new UC-Riverside medical school to train new doctors and to support the increase in federal funding for more medical residency slots in Riverside County, as it is long recognized that doctors tend to stay in the area in which they complete their residency.
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