California's Physician Shortage Likely to Get Worse

Retiring doctors, low Medi-Cal reimbursement rates, and the federal health care reform law are exacerbating California's shortage of primary care physicians, Bay Area health care providers and medical associations say.

Already, only a quarter of California's counties meet the recommended ratio of 60 to 80 primary care doctors for every 100,000 residents, according to the California Medical Association. (In the Bay Area, there are 78 primary care physicians for every 100,000 residents.)

“We are very much worried about the shortage in general,” said Callie Langton, health care workforce policy expert at the California Academy of Family Physicians. “Twenty years ago, a lot more physicians were going into primary care, and the replacement rate is not high.”

Nearly a third of doctors are 60 or older and are close to retirement, but only 42 percent of medical students are going into primary care. According to the California Medical Association and the California Healthcare Foundation, the number of young doctors pursuing primary care decreased over the past decade because the it's one of the lowest paid medical specialties.

Family practitioners earn an average of $143,000, while anesthesiologists and surgeons can earn well over $200,000, according to the Bureau of Labor Statistics.

"Payment is a big concern," said Langton. "Primary care physicians have lot of debt. They earn a respectable salary, but coming out of medical school with as much debt as you’ll earn in a year, some students are encouraged to choose sub-specialties so they can pay off debt faster. So, we have a shortage of primary care physicians because of that."

Eighty percent of medical school graduates begin their careers in debt; on average, doctors graduating from public medicals school leave owing $150,000, while those graduating from private medical schools have, on average, $177,500 in debt, according to the Association of American Medical Colleges.

While the number of primary care doctors is shrinking, the demand for the care they provide is about to soar, thanks to the federal health care reform law.

Under the law, known as the Affordable Care Act, as many as 6 million more Californians will be able to obtain health insurance coverage, with nearly half eligible for coverage under Medi-Cal. Many of the newly insured will try to seek treatment from primary care physicians and family practice doctors, who provide the kind of cradle-to-grave, coordinated care that emphasizes preventive medicine, which can help reduce health care costs.

But fewer physicians than ever — just 57 percent — say they are now willing to accept new Medi-Cal patients, according to the California Healthcare Foundation. Many doctors say the reimbursement rate — that is, the amount of money the state pays them for treating patients — is too low. California sets the rate, which is the fourth lowest among all 50 states, according to the California Medical Association.

The majority of new Medi-Cal patients will be seen at community health centers, according to Dr. Ricky Y. Choi, head of pediatrics at Oakland's Asian Health Services Community Health Center, a nonprofit health care provider.

Choi said his center, which expects to see 4,000 new MediCal patients, doesn't mind the low reimbursement rates, because they are better than no fee or sliding-scale fees paid by the uninsured, whom the clinic is mandated to serve.

California isn't training enough doctors to work in such clinics — or to serve as family practice physicians. There are only 39 family practice residencies in the state, which together have 286 slots for the multi-year programs, says Langton, so at most "we're turning out 250 to 280 family physicians a year."

At the Contra Costa County Regional Medical Center in Martinez, a three-year residency program in family medicine enrolls 13 medical school graduates each year. It receives hundreds of applicants each year. 

The medical center is part of Contra Costa’s health system, which operates its own health care plan and includes 10 community health centers. Administrators anticipate that 900 more patients a month will be enrolling in the health plan starting on July 1, when Medi-Cal eligibility is expanded to include more low-income people.

Dr. William Walker, the county’s health services director, said the center is preparing by expanding space in the clinics and lobbying to keep as many of the family medicine residents as possible when they graduate. But demand for primary care doctors, including family doctors, is great now, and the center must compete with other health systems in the Bay Area.

“Some of the residents have career goals outside the county, but a fair number take jobs with us or in the community,” he said. “Kaiser is now the big recruiter. We can’t compete with Kaiser in salaries. We are putting together a package of incentives that includes teaching and work that is appealing — inpatient and outpatient work. That’s the best we can do.”

Walker said that many of his residents are attracted to the program because they have a “social commitment” and want to work at a safety-net facility — one that serves low-income people.

The number of residency slots in the state can't increase without approval from Congress. The number has been frozen since 1997 when Medicare, which funds residencies, capped it. Several California bills would address the uneven distribution of physicians in the state and encourage more primary care medicine, says Lisa Folberg, vice president for policy at the California Medical Association.

But there is no quick fix for a looming physician shortage. California has only nine medical schools and while a high percentage — nearly 70 percent of medical graduates and residents — decide to stay in the state to practice medicine, there still are not enough to meet demand, especially in many areas of the state. "The problem with the workforce,” Folberg said, “is the long pipeline for physician training."