California Medical Association Physicians dedicated to the health of Californians Darin Latimore, M.D. Assistant Dean, Office of Student and Resident Diversity UC Davis School of Medicine Physician Workforce 101

California Physician Supply Estimates There are about 119,000 physicians with an active California license However, MBC reports only 66,500 are active patient care physicians working more than 20 hours a week Of those not found to be active patient care physicians, 6,000 are still in training, 20,000 are practicing outside of California, and 19,000 are practicing fewer than 20 hours per week

California Physician Demographics Physician Age Nearly 30% of active CA physicians are over 60 years old, the largest percentage of any state In the last 20 years, the number of physicians over 65 has tripled while the number of physicians has doubled More physicians are retiring each year in CA than are entering the workforce. This trend is expected to continue until 2020

California Physician Demographics Physician Ethnic and Racial Diversity

California Physician Demographics Physician Education 74% of California’s active patient care physicians come from out-of- state or foreign medical schools International medical graduates represent 26% of all active patient care physicians and 31% of all primary care physicians in the state Approximately 2/3 of California’s “home-grown” physicians graduated from UC medical schools

California Physician Demographics Primary Care and Specialty Distribution 34% of active CA patient care physicians are PCPs and 66% are specialists California has an uneven distribution of physicians across counties ▫74% of CA’s 58 counties have an undersupply of PCPs ▫45% of counties have an oversupply of specialists ▫43% of counties have an undersupply of specialists Primary care residencies continue to draw lower levels of interest

California Physician Supply and Demand: Demographic Factors Educational Opportunity There are 17.2 medical students per 100,000 population in California (US average: 30.1) There are 25.1 medical residents per 100,000 population in California (US average: 35.7) California medical schools have room for 41.1% of medical students born in the state (US average: 61.9%)

California Physician Supply and Demand: Financial Factors Medical Student Debt The average medical student graduating in 2009 carried over $156,400 in debt 86% of medical students carry an outstanding loan when they graduate Public medical school tuition increased 11.1% annually from 2001 to 2006 and continues to grow If current trends continue, the average medical school debt will be $750,000 by 2033

California Physician Supply and Demand: Financial Factors Medical Student Debt (cont.) The cost of medical school is the #1 deterrent for Black, Hispanic and Native American students Since 2000, medical students are increasingly coming from higher- income families Students with high debt are less likely to pursue family practice and primary care

California Physician Supply and Demand: Political Factors Medi-Cal Rates CA has the 4 th lowest Medicaid (Medi-Cal) rates in the US, paying on average 56% of the Medicare fee schedule Only 57% of physicians were able to accept new Medi-Cal patients in 2008 There is considerable overlap between medically underserved regions and areas with a high proportion of Medi-Cal patients

California Physician Supply and Demand: Political Factors Federal Healthcare Reform Expands Medicaid to nearly all citizens with income at or below 133% of the Federal Poverty Level (FPL). This should make 1.7 million uninsured Californians newly eligible for Medi-Cal Establishes a state-run Health Insurance Exchange, and offers premium credits and federal subsidies for individuals with incomes between 133% and 400% of the FPL. 1.4 million currently uninsured Californians should be eligible for some level of assistance This represents a nearly 10% increase in California’s insured patient population

California Physician Supply and Demand: Political Factors Federal Healthcare Reform (cont.) Primary care and rural workforce reforms Diversity enhancement and cultural competency training Workforce analysis and development commissions

California Physician Pipeline: Medical School Population Growth In the last 15 years California’s population has grown by 20%, while the number of medical school graduates has remained stagnant at approximately 1,000 In 2009, there were over 45,500 applications submitted to California medical schools for 1,084 positions

California Physician Pipeline: Medical School In-State Matriculation Only 41% of medical students from California are able to attend an in-state medical school California is ranked 37 th in the nation in this category 90% of public medical school matriculants and 53% of private medical school matriculants are state residents

California Physician Pipeline: Medical School Retention California has the #1 retention rate for medical school graduates in the nation (62%) California has the #2 retention rate for residents/fellows in the nation (69%) However, only 26% of active patient care physicians in the state went to medical school in California

California Physician Pipeline: Graduate Medical Education Residency Positions In 2010, over 37,500 medical students applied for only 25,520 residency positions in the United States There is a particular shortage of residency slots in California, which hosts 12% of the nation’s population but only 8.3% of its residency positions California ranks 32 nd among states in its resident-to-population ratio, with 25.1 residents per 100,000 people (the national average is 35.7 residents per 100,000 people)

California Physician Pipeline: Graduate Medical Education Funding Medicare funds nearly 70% of GME ($8.4 billion in 2008) but has been frozen since 1997 Medicaid funds almost 30% of GME ($3.78 billion in 2008, $187.3 million in CA) but is skewed away from CA by the FMAP formula Unlike most states with Medicaid managed care, California does not fund GME through its capitation rates, but through fee-for-service programs only

California Physician Pipeline: Graduate Medical Education Process Concerns “The approval process…is time consuming at best and at worst frequently a major barrier that must be negotiated in order to expand the number of trainees in any accredited program.” -Council on Graduate Medical Education, 19 th report

Recommendations 1. Train more physicians in California Increase medical school enrollment and the number of medical schools in California. Direct logistic and financial support for two new medical schools currently being developed at UC Merced and UC Riverside. Expand the number of residency slots in California by aggressively pursuing private funding in the short term, while advocating for long term federal reforms in the areas of the Medicare funding freeze and the Medicaid FMAP formula. California should also encourage innovation in residency training to better reflect the ambulatory care models of the future.

Recommendations 2. Increase incentives for pursuing primary care Increase scholarships/grants for medical students to reduce medical education debt. Provide higher compensation for primary care services. Explore the possibility of a shortened primary care education track that does not compromise the quality of physician training or the breadth of clinical exposure

Recommendations 3. Increase incentives for working in underserved areas Expand existing state loan repayment programs for PCPs and specialists working in underserved areas Increase Medi-Cal reimbursements

Recommendations 4. Increase diversity of the physician workforce Support and expand post baccalaureate premedical programs that help to increase ethnic and socioeconomic diversity of medical students. Research indicates that graduating from these programs increases the likelihood going to medical school by over three-fold. Encourage and recruit more students from underserved communities, who will likely return to serve those areas after completing training, to go into medicine. This includes the support of premedical advising services and mentorship opportunities in a clinical setting for youths considering medical careers.

Recommendations 4. Increase diversity of the physician workforce (cont.) Reduce financial barriers to pursuing medicine by offering more scholarships and grants to students with ethnically and economically diverse backgrounds. Develop and support medical education programs and continuing medical education courses with specialized curricula that teach physicians the art of providing culturally competent care.

Questions?