Primary care doctors growing scarce

by Drew Johnson, San Francisco Chronicle

Roughly 4 million additional Californians are expected to obtain health insurance by 2014 through the federal health law, an expansion that will likely exacerbate the state’s doctor shortage and could even squeeze primary care access in the Bay Area, experts say.

Even without the Affordable Care Act, a worsening doctor shortage had been forecast as the state’s and nation’s population ages and grows, and as a generation of older doctors retires. But by mandating that individuals have insurance and expanding Medicaid, the law will extend coverage to an additional 30 million Americans and place a greater strain on the physician workforce, especially for primary care.

"Now with the Affordable Care Act, we’re going to have an even greater need," said state Sen. Ed Hernandez, D-West Covina (Los Angeles County), chairman of the Senate Health Committee. The need for more primary care doctors is addressed in the federal health law through various financial incentives, and California’s medical schools and hospitals are putting a greater emphasis on primary care training and expanding residency programs. But the effects of such efforts may not be felt for years.

In an attempt at a more immediate fix, Hernandez said he plans to push for legislation to give pharmacists, nurse practitioners and physician assistants more authority in patient care.

"We have to use the current provider workforce we have much more efficiently," he said.

California’s doctors

The strength of California’s physician workforce falls in the middle when compared with other states. A 2011 report from the Association of American Medical Colleges found that California had a higher physician-to-resident ratio than most states and a higher primary care physician-to-resident ratio than the national average.

A new medical school at UC Riverside, set to open next fall, could help ease shortages in areas like the Inland Empire, but the AAMC report found that more than 30 percent of California’s doctors were 60 or older – the second highest rate of any state.

At the moment, the Bay Area, Sacramento and Orange County have enough primary care physicians and specialists, said researchers in a 2010 report from the California HealthCare Foundation, a grant-making nonprofit that works to improve health care in California.

But Maribeth Shannon, the director of the foundation’s market and policy monitor program, said the Bay Area could find itself in a primary care crunch as more people gain coverage.

"That will be tested," she said.

The report found that a number of regions – including San Diego and Los Angeles – had more than enough specialists but not enough primary care physicians, and that rural areas lacked a sufficient number of all kinds of doctors.

Progress being made

Through the health law, the federal government has increased funding for primary care programs. It is also boosting payments for primary care physicians who see Medicaid patients, although studies have found just over half of California’s primary care doctors were accepting new patients with Medi-Cal, the state’s Medicaid program.

Physicians say they are beginning to see progress.

Dr. Thomas Balsbaugh, director of the family and community medicine residency program at UC Davis, said more medical school graduates at the university are entering family care residencies in recent years. And the Davis residency program has grown by two spots in recent years, from 46 to 48 residents.

"People are recognizing that we’re in an unsustainable pattern," he said.

The family care residency program at UCSF has also expanded, from having spots for 13 first-year residents to 15, said Dr. Margo Vener, a professor of family and community medicine.

Vener said choosing primary care as one’s field is a difficult choice for medical students, in part because many graduate in debt and specialists pull much higher salaries.

A student’s story

Kendra Johnson, a fourth-year UCSF medical student, estimated she will be $160,000 in debt when she graduates and called the fact that specialists make more "the elephant in the room" for her and her classmates who hope to enter primary care residencies.

Johnson, who is from Wisconsin, said she was drawn to primary care because it involves keeping communities healthy.

"People are realizing how important (primary care) is in a way that’s kind of novel," Johnson said.

Both Vener and Johnson said the notion that the best and brightest should pursue specialties is starting to change with the emphasis on primary care, especially with the hope that it can reduce care costs.

"It’s increasingly clear that the cutting edge in medicine is primary care," Vener said.