Hope and warnings to other states from California family physicians

A guest post from the California Academy of Family Physicians, exclusive to KevinMD.com.

Despite the slight upward tick in medical students opting for careers in family medicine over the last two years, efforts aimed at solving the primary care physician shortage are often thwarted by state and federal policy decisions.

There is reason for hope, however: The number of medical school applications in California is extraordinarily high. A higher proportion of U.S. medical school graduates have helped to fill all of the available 2011 family medicine slots here. And a successful new “teaching health centers” model of family medicine residency training has been funded by the U.S. Department of Health and Human Services (HHS) to train physicians for work in underserved areas, with one of the first 11 teaching health centers located right here in California.

Yet a new medical school opening is delayed because the state budget, passed in June, provides no funding. Federal funding for the new residency program model is threatened. And physician payment, the ultimate means for maintaining a strong physician workforce, is at risk as the State of California is trying to reduce physician fees in our Medicaid program by 10 percent.

Leaders at the California Academy of Family Physicians (CAFP) believe that a comprehensive, coherent, state- and nationwide effort is essential to successfully solve the primary care physician shortage.

The primary care physician shortage in California

HHS’s Council on Graduate Medical Education recommends 60 to 80 primary care physicians per 100,000 people to adequately serve a population. In fast-growing regions of our state, such as the Inland Empire (Riverside/San Bernardino and environs), we have just 40. In low-income rural communities that comprise the San Joaquin Valley, where care for 25 percent of patients is paid for by Med-Cal, we have just 45.

We also face an increased demand for primary care physicians as our aging population grows larger and millions more people gain health care coverage under federal health care reform. Yet California is not greatly increasing the number of primary care physicians trained, even though 30 percent of primary care physicians in our state are age 60 or older and nearing retirement – the highest percentage of any state.

The need for more medical school and family medicine residency slots

Virtually all of the 303 family medicine residency slots available in 2011 in California are filled – 99.7 percent of available slots, compared with just 94.4 percent nationally. Yet the state is cutting funding for higher education and primary care residency programs are severely underfunded. Without increased support to create additional education and training opportunities, students will be forced to choose non-primary care specialties or to train in medical schools and residency programs in other states.

California consistently ranks in the bottom half of all states in resident and medical student output, a significant indicator of future physician supply. In 2009, some 45,500 students applied for just 1,084 spots at public medical schools here. Yet the opening of a new medical school at the University of California, Riverside is being postponed because the state budget does not include funding.

In addition, since 2003, six family medicine residency programs in California have closed because of a lack of funding, and many more operate in the red. High quality primary care residency programs are necessary to fill vacancies left by retiring physicians and meet escalating needs. Current funding streams make this difficult, as funding flows through sub-specialist-friendly hospitals, often leaving community-based specialties such as family medicine underfunded. Direct allocation of federal Graduate Medical Education funds to each family medicine residency program would go a long way toward ensuring solvency.

Funding threats to successful family medicine residency program model

In rural Modesto, the community came together to create California’s first “teaching health center” in 2009, based on the Valley Family Medicine Residency Program. Doctors Medical Center, Memorial Medical Center and Stanislaus County Health Services, with its network of outpatient clinics, formed a nonprofit consortium with the mission “to train physicians through service to those in need.” The Valley Family Medicine Residency Program is part of this effort.

In January 2011, HHS Secretary Kathleen Sebelius announced the designation of 11 new teaching health centers nationwide.  In this model, primary care residents are training in community-based settings similar to those in which they want to work in the future, instead of in sub-specialty-oriented hospitals. Valley Consortium received $625,000 in first-year funding, more than twice as much as any of the other centers. (Last year, nine of the 10 residents trained there stayed in the area.) Yet in May, the House passed HR 1216, which would eliminate the program’s current five-year funding cycle and would require teaching health centers to reapply each year for additional funding. This funding uncertainty makes it difficult to attract family medicine residents as they require three years of funding to complete a residency program. The Senate must vote on the measure for it to be enacted.

Medicaid challenges

Medi-Cal, California’s Medicaid program, pays for health care for 7.7 million Californians who already face a severe shortage of physicians willing to see them because Medi-Cal payments are too low. Yet the California Legislature passed a budget in June that reduces Medi-Cal physician payments by 10 percent, among other reductions.   Rates in California are already 20 percent lower than the national Medicaid rate and among the lowest in the U.S.  At the same time, at the federal level, physicians face a 29.5 percent cut in payments in the Medicare program unless Congress provides a fix to the Sustainable Growth Rate formula.

Given that primary care specialties are undervalued and underpaid across the health care system, decreasing Medi-Cal payments by 10 percent could provide further incentive for students to choose specialties other than primary care.  Patient access to care also could be damaged if practicing physicians opt out of the Medi-Cal program because of the cuts.

CAFP has supported a lawsuit filed by the California Medical Association (CMA) and other health care organizations to prevent the 10 percent cut.  The lawsuit has been successful to date, but will be considered by the U.S. Supreme Court in the fall on a narrow issue of whether beneficiaries and providers can bring a lawsuit enforcing the federal Medicaid Act and asserting that a provision of the Act preempts state laws that reduce reimbursement rates.

Meanwhile, the State of California has filed a State Plan Amendment for the Medi-Cal program to implement the 10 percent rate cut and a waiver to federal Medicaid rules that would greatly increase out-of-pocket costs to Medi-Cal’s impoverished enrollees – more bad medicine for California.

If the Supreme Court sides with the state, only the Centers for Medicare and Medicaid Services (CMS) can prevent the 10 percent cut by rejecting the amendment request. Representatives of CAFP and other health care organizations in our state are scheduled to meet with CMS Administrator Donald Berwick and members of Congress in Washington, DC on August 4 to advocate against the amendment.

Coordinated effort is necessary to remedy shortage

California family physicians are working hard to strengthen the primary care physician workforce, but it seems that for every gain, we are battling a corresponding challenge. We call on our elected leaders, medical education leaders and others to join with us to create a broad, well-coordinated effort to remedy the shortage, using a variety of approaches. Too often it seems that the right hand does not know what the left hand is doing, and we have no more time to lose.

Carol S. Havens is President of the California Academy of Family Physicians

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