California Physician Supply and Distribution: Headed for a Drought? JUNE 2018 Contents Authors 3Summary Janet M. Coffman, MPP, PhD Margaret Fix, MPH 4Introduction Healthforce Center and Philip R. Lee 4Methodology Institute for Health Policy Studies University of California, San Francisco 4Findings Physician Supply and Activities Michelle Ko, MD, PhD Specialty Distribution Department of Public Health Sciences University of California, Davis Physician Demographics Practice Types Physician Participation in Medi-Cal About the Foundation The California Health Care Foundation is 12Conclusions dedicated to advancing meaningful, measur- Supply of Active Patient Care Physicians able improvements in the way the health care Distribution of Physician Specialties delivery system provides care to the people of Demographics of California Physicians California, particularly those with low incomes and those whose needs are not well served by Practice Types the status quo. We work to ensure that people Physician Participation in Medi-Cal have access to the care they need, when they Limitations need it, at a price they can afford. Recommendations CHCF informs policymakers and industry lead- 16Appendices ers, invests in ideas and innovations, and A.Methodology connects with changemakers to create a more B.California Medical Board Mandatory Survey Instrument responsive, patient-centered health care system. C.California Medical Board Supplemental Survey Instrument For more information, visit www.chcf.org. D.California Counties Included in Regions E. Physician Race/Ethnicity Categories F. Identifying and Categorizing Physician Specialty G. upply of Active Patient Care Physicians in 10 Major S Categories of Specialties, by Region, 2015 27Endnotes California Health Care Foundation 2 Summary T his report describes the number of licensed physi- The distribution of both primary and specialty care cians in California in 2015, including their practice physicians was uneven in the state. Ratios of active activities, demographic characteristics, and geo- patient care physicians per 100,000 people in the Inland graphic distribution. Data were derived from the Medical Empire and San Joaquin Valley regions were approxi- Board of California’s mandatory survey for relicensure mately half that of the Greater Bay Area for both primary and a voluntary supplemental survey conducted in 2015. care and specialty care physicians. Where data from 2013 were available, changes from 2013 to 2015 were included. The distribution of physicians across types of practice varied by physician age and specialty. Over 40% of physicians age 60 or older were in solo practice, whereas Key Findings 79% of those under 40 years old reported that they prac- Less than half of the 139,000 medical doctors licensed ticed in Kaiser Permanente or in another group practice. by the state of California (61,196) could be identi- Psychiatrists were more likely to be in solo practice or to fied as active patient care physicians (physicians who work in a community health center or public clinic than provided 20 or more hours per week of patient care physicians in other specialties. in California). Some physicians with California licenses did not practice in California. Others did not renew Physicians were more likely to accept patients with any their licenses within the two-year period required under type of health insurance than uninsured patients, but California law. Some were completing residency or fel- were less likely to accept Medi-Cal than other forms lowship training. of health insurance. In 2015, 62% of primary care physi- cians and 64% of specialists had any Medi-Cal patients. The total supply of active patient care physicians Fifty percent of primary care physicians and 57% of spe- declined slightly between 2013 and 2015. This trend cialists had any uninsured patients. appears to be driven by the aging of the physician work- force. Older physicians reported spending fewer hours per week on patient care, and were the most likely to Recommendations report providing no patient care at all. The percentage To address the challenges in California physician supply of active patient care physicians over age 60 declined by and distribution identified in this study, the authors offer eight percentage points between 2013 and 2015, while the following recommendations: the percentage of active patient care physicians in other $$ Increase funding to expand undergraduate medical age groups remained stable. education, particularly in underserved areas. Female and male physicians engaged in patient care $$ Increase funding to expand graduate medical edu- at similar rates. A slightly higher percentage of females cation, particularly in specialties with projected reported spending at least 20 hours per week on patient shortages. care (81% of females versus 78% of males). $$ Provide financial incentives for both primary care and specialty physicians to practice in underserved areas. Latinos and African Americans were substantially underrepresented in the physician workforce. Five $$ Support opportunities for international medical grad- percent of active patient care physicians reported Latino uates to practice in underserved areas of the state. ethnicity, versus 38% for the general population. Three $$ Increase investments in programs that address the percent of physicians were African American, versus 6% diversity of the physician workforce. of the general population. $$ Invest in technologies, such as telehealth and elec- Thirty-two percent of California’s active patient care tronic consultation and referral, that can maximize physicians were primary care physicians (defined as scarce physician resources, especially for rural areas. family physicians, general internists, general pediatri- $$ Provide training, support, and incentives for team- cians, and general practitioners). based care. California Physician Supply and Distribution: Headed for a Drought? 3 Introduction Major demographic trends are driving an increasing Analyses were limited to physicians with active licenses demand for health care in California. The state’s total who were located in the state (as determined by zip population is projected to increase by 6.4 million people code) and were no longer in training. To broadly com- between 2015 and 2035, and the population age 65 or pare primary care versus specialty care physician supply, older is projected to increase by 4.9 million.1 With an physicians in the following specialties were categorized aging population, patient health needs will likely increase as primary care physicians: family medicine (including in complexity and severity. To anticipate the state’s abil- general practice), general pediatrics, and general internal ity to respond to these demographic trends, California medicine (including geriatric medicine). The remainder policymakers need to understand the current supply of were classified as specialty care physicians. active physicians, the number providing patient care, and how they are distributed across the state. This report provides detail on the total number of active Findings licensed physicians (MDs) in California, across its regions and 58 counties. It also describes the number of hours Physician Supply and Activities licensed physicians spend on patient care and other According to the Medical Board of California’s records, activities. Findings regarding the specialty, age, gen- approximately 139,000 physicians had an active license der, and racial and ethnic distribution of active patient in California in 2015 (Table 1). However, fewer than half of care physicians and their practice settings are presented. all MDs licensed by the state of California (61,196) could When applicable, findings from 2013 are compared to be identified as active patient care physicians (physicians findings from 2015. who provided 20 or more hours per week of patient care in California). The differences were due to several factors. More than 25,000 physicians with California licenses did Methodology not practice in the state. Some physicians did not renew their licenses within the two-year period required under The study methodology is discussed briefly here. California law, while others were completing residency or For a more detailed description of methods, refer to fellowship training. Appendix A. Table 1. Active Licensed Physicians, 2015 Most of the data presented in this report are from the Medical Board of California’s mandatory survey, which NUMBER OF MDs contains information on physician demographics, spe- cialty, board certification, location, and practice activities, Active California license 139,222 including time spent on patient care. The survey is California zip code 113,034 administered to physicians who are renewing licenses in Two-year cohort 93,023 the state (required every two years). Responses from MDs who renewed their licenses between August 1, 2013, and Not in training 87,111 July 31, 2015 were analyzed. Survey response 81,003 Information on practice settings was derived from a vol- Answered patient care question 77,847 untary supplemental survey administered to a sample Any patient care: 1+ hours per week 71,348 of physicians whose licenses were due for renewal from June through December 2015. Patient care: 20+ hours per week 61,196 Identified specialty and/or board certification 60,231 Source: Analysis of Medical Board of California data by the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. California Health Care Foundation 4 Patient care. Of 81,003 non-trainee physicians with prac- Figure 2. Percentage of Licensed Physicians Who Spent Time on Selected Activities, by Hours Per Week, tice locations in California who completed the survey, Primary Care vs. Specialty Care, 2015 the average number of hours spent per week on patient care was 34.6 (Figure 1). Primary care and specialty care HOURS SPENT PER WEEK physicians provided similar percentages of patient care ■ 0 ■ 1–9 ■ 10–19 ■ 20–29 ■ 30–39 ■ 40+ at 20+ hours per week, but the percentage of specialists that reported spending 40+ hours per week on patient Primary Care (n = 25,067) Patient Care care was somewhat higher (Figure 2). 7 7 7 13 23 44 Research Figure 1. Weekly Hours Spent on Selected Activities 84 11 211 by Licensed Physicians, 2015 Teaching <1 60 30 6 21 Administration 7.4 35 43 12 5 23 Telemedicine Administration 81 16 211 Other <1 34.6 82 13 311 4.5 3.5 Specialty Care (n = 55,195) Teaching Research Patient Care 8 6 7 11 19 49 2.6 1.8 Research Patient Care Other Telemedicine 64 24 6 3 22 Note: Physicians who did not answer the survey question about a particular Teaching professional activity were not included in the estimate of mean hours spent 44 42 10 311 on that activity per week. Administration 28 50 14 5 22 Other activities. While patient care was the primary Telemedicine activity of most physicians, they also reported hours 82 14 211 spent on other activities such as research, teaching, and Other <1 administration (Table 2). Over half reported spending 75 18 3112 time on administrative activities, with about 18% spend- Notes: Labels are %. Segments may not sum 100% due to rounding. ing 10 or more hours per week on them. Approximately Source (Figures 1 and 2): Analysis of Medical Board of California data by 22% reported spending one or more hours per week the Philip R. Lee Institute for Health Policy Studies, University of California, on research and nearly 40% spent one or more hours San Francisco. Table 2. Percentage of Licensed Physicians Who Spent Time on Selected Activities, by Hours Per Week, 2015 (N = 81,003) HOURS PER WEEK DID NOT 0 1–9 10–19 20–29 30–39 40+ ANSWER Patient care 8.0% 6.2% 6.3% 10.8% 19.4% 45.3% 3.9% Administration 24.3% 38.4% 10.8% 3.9% 1.3% 2.1% 19.1% Research 50.9% 14.7% 3.4% 1.6% 0.9% 1.2% 27.3% Teaching 37.9% 29.3% 6.5% 2.0% 0.5% 0.8% 23.0% Telemedicine 51.2% 8.9% 1.4% 0.5% 0.2% 0.6% 37.2% Other 46.1% 9.7% 1.9% 0.8% 0.3% 0.9% 40.3% Source: Analysis of Medical Board of California data by the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. California Physician Supply and Distribution: Headed for a Drought? 5 on teaching. Specialist physicians were more likely than Figure 3. Hours Per Week Spent on Patient Care primary care physicians to report spending at least one by Licensed Physicians, 2013 vs. 2015 hour per week on research, teaching, or administration (Figure 2). ■ 2013 ■ 2015 Change in activities from 2013 to 2015. From 2013 TOTAL RESPONDENTS to 2015, the number of active licensed California phy- 82,042 sicians who had completed training and answered the 81,003 mandatory survey decreased by 1.3% from 82,042 to 81,003, while the number who answered the patient care Answered Patient Care Hours hours question increased 1.2% from 76,906 to 77,847 76,906 (Figure 3). The number of physicians who reported prac- 77,847 ticing patient care for at least 20 hours per week declined 2.4% from 62,694 to 61,196. Over the same period, the 20+ hours number of physicians reporting no hours spent on patient 62,694 care doubled from 3,121 to 6,499 physicians. 61,196 0 hours Specialty Distribution 3,121 Supply of primary and specialty care MDs. Thirty- 6,499 two percent (19,497) of active patient care physicians reported practicing in a primary care specialty, defined as family medicine, general internal medicine, or pediatrics Figure 4. Supply of Physicians, by Specialty, 2015 (Figure 4). Another 32% practiced in medical specialties, surgical specialties, and general surgery. Nineteen per- cent practiced in facility-based specialties, which consist Other of emergency medicine physicians, anesthesiologists, 6% pathologists, and radiologists. In 2015, there were 50 primary care physicians and 104 specialists per 100,000 Surgical Specialties persons in the state. 12% Primary Care 32% Furthermore, the development of hospitalist practices and the number of hospital-based physicians has risen in Medical recent years.2 In the supplemental survey, approximately Specialties 2.3% of family physicians, 8.8% of general internal medi- 18% cine physicians, and 4.7% of pediatricians in California OB/GYN reported practicing in a hospital over 90% of the time. 5% This suggests that the total number of primary care phy- Facility-Based Specialties Psychiatry sicians based on specialty alone may be overestimated, 19% 6% particularly among general internists. 2% General Surgery Note: OB/GYN is obstetrics and gynecology. Source (Figures 3 and 4): Analysis of Medical Board of California data by the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. California Health Care Foundation 6 Primary and specialty care physicians by region. Figure 5. Physicians per 100,000 Residents, by Region The supply of physicians who spent at least 20 hours Primary Care vs. Specialty Care, 2015 per week on patient care varied across regions and by specialty (Figure  5; for detailed counts by region, see ■ Primary Care Appendix G). The Inland Empire and San Joaquin Valley ■ Specialty Care Central Coast regions had the lowest numbers of primary care and spe- 49.5 cialty physicians per 100,000 people. 92.9 The distribution of physicians varied by county. The Greater Bay Area supply of primary care physicians per 100,000 people 64.1 ranged from a low of 0 in Alpine County to a high of 138.2 113 in Napa County (see Figure 6). Similarly, the sup- Inland Empire ply of specialty physicians per 100,000 people ranged from a low of 0 in Alpine County and Sierra County to 34.5 a high of 234 in Napa County. Several counties had no 64.3 or few physicians in specific specialties, including geriat- Los Angeles County ric medicine, endocrinology, psychiatry, pulmonary care, 51.3 and rheumatology (see detailed data file on chcf.org 3 for 110.3 counts of all specialties by county). Not having any physi- cians in a specialty in a county poses a barrier to access, Northern and Sierra especially in California, where many counties cover large 46.9 geographic areas. 75.6 Orange County Figure 6. PCPs per 100,000 Residents, by County, 2015 52.0 Del 108.4 Norte Siskiyou Modoc Sacramento Area ◾ <34 53.7 Trinity Shasta Lassen ◾ 34– 49 Humboldt ◾ 50–59 113.3 Tehama Plumas ◾ >59 San Diego Area Mendocino Glenn Butte Sierra Nevada STATE AVERAGE 49.8 Lake Colusa Yuba Placer 49.8 112.3 Sutter Yolo El Dorado Sonoma Napa Sacra- Alpine 114 mento Amador 0 San Joaquin Valley Solano Calaveras Marin San Contra Joaquin Tuolumne Mono 39.4 CALIFORNIA Costa San Francisco Alameda Stanislaus Mariposa 65.0 104.1 / 49.8 San Mateo Santa Merced Clara Source (Figures 5 and 6): Analysis of Medical Board of California data by Santa Cruz Madera Fresno the Philip R. Lee Institute for Health Policy Studies, University of California, San Inyo San Francisco. Benito Tulare Monterey Kings San Luis Obispo Kern Santa Barbara San Bernardino Ventura Los Angeles Orange Riverside San Diego Imperial Note: PCPs is primary care physicians. California Physician Supply and Distribution: Headed for a Drought? 7 Figure 7. Age of Active Patient Care Physicians Physician Demographics by Region, 2015 Age. Physicians over age 60 accounted for 36% of the 77,847 nontrainee licensed physicians with practice loca- ■ <40 ■ 40–60 ■ >60 tions in California who provided information about hours Central Coast spent on patient care. Among active patient care physi- 12% 56% 32% cians, 27% were over age 60. In the Northern and Sierra Greater Bay Area region, older physicians accounted for 37% of active 19% 59% 22% patient care physicians (Figure 7). Inland Empire Change from 2013 to 2015. Over the two-year period, 18% 56% 26% the percentage of survey respondents practicing in Los Angeles County California over age 60 increased from 31% to 36%. 17% 52% 31% Among these physicians, the percentage engaged Northern and Sierra in active patient care decreased by eight percentage 9% 55% 37% points. The percentage of active patient care physicians in the younger age groups remained stable over the Orange County same period. 14% 58% 28% Sacramento Area Gender. In 2015, 33% of survey respondents were female. 17% 62% 21% The age distributions of male and female physicians were San Diego Area quite different; this is largely due to the growth in the number of women entering medical school since the 17% 60% 23% 1970s. Among nontrainee physicians in California who San Joaquin Valley provide patient care at least 20 hours per week, 34% of 14% 56% 30% male physicians were over age 60, versus only 14% of California female physicians (Figure 8). 17% 57% 27% A slightly higher percentage of females than males were Note: Segments may not sum 100% due to rounding. engaged in active patient care (81% vs. 78%). Figure 8. Age Distribution of Active Patient Care MDs Within each age group, male and female physicians by Gender, 2015 in California were engaged in active patient care (i.e., provided patient care 20 or more hours per week) at ■ Female ■ Male similar rates (Figure 9, page 9). The largest differential was among those age 40 to 60. In this age group, 90% 66% 62% of male physicians were engaged in active patient care, versus 83% of female physicians. For both genders, the 54% proportion of physicians who provided patient care 20 or more hours per week was substantially lower among phy- sicians over 60 than it was among younger physicians. 34% 34% 25% 14% 12% ALL AGES <40 40–60 >60 Source (Figures 7 and 8): Analysis of Medical Board of California data by the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. California Health Care Foundation 8 Figure 9. Percentage of Female and Male MDs Engaged in Active Patient Care, by Age, 2015 Race and ethnicity. The racial and ethnic breakdown of California’s physicians differed considerably from that of the overall population (Table 3). ■ Female ■ Male Compared to the state population, the physician popu- 91% 93% 90% lation was composed of a higher percentage of Asians 81% 83% 78% (28% of physicians and 14% of population). The percent- age of Latino physicians was 33 percentage points lower 60% 61% than that of the Latino state population (5% of physi- cians versus 38% of the population). African Americans accounted for 6% of the population but 3% of physicians. The California Office of Statewide Health Planning and Development defines the following Asian ethnic groups as “underrepresented” in medicine: Cambodian, Thai, Vietnamese, and Other Southeast Asian.4 The mandatory ALL AGES <40 40–60 >60 survey data indicated that 7% of California’s physicians Source: Analysis of Medical Board of California data by the Philip R. Lee were “underrepresented” Asian ethnicities, Pacific Institute for Health Policy Studies, University of California, San Francisco. Islanders, or Native Hawaiians. Table 3. Race/Ethnicity of Active Patient Care MDs and State Population, 2015 % STATE # OF MDs % OF MDs POPULATION American Indian / 72 0.1% 0.4% Alaska Native Asian 16,892 27.6% 13.6% African American 1,556 2.5% 5.9% Latino 3,097 5.1% 38.4% The racial and ethnic breakdown Middle Eastern 1,696 2.8% N/A Multiracial/ethnic 209 0.3% 2.8% of California’s physicians differed White 19,673 32.1% 38.7% considerably from that of the Other 1,658 2.7% 0.2% Decline to state* 8,779 14.3% N/A overall population Did not answer race/ 7,564 12.4% N/A ethnicity question* Total 61,196 100.0% *A substantial number of physicians are not accounted for among the listed groups because 14% declined to report their race/ethnicity and 12% did not answer the survey question about race/ethnicity. Note: The survey included an option to self-identify as Middle Eastern with unspecified nationality or ethnicity. The ACS does not have a corre- sponding Middle Eastern response option. For California’s population, multiracial/ethnic was derived from combining multiple single-item responses (whereas the physician survey allowed respondents to select all response options). Sources: Analysis of Medical Board of California data and American Community Survey (ACS) data by the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. California Physician Supply and Distribution: Headed for a Drought? 9 Figure 11. ractice Types of Active Patient Care Physicians P Practice Types by Major Specialty Category, 2015 (n = 5,082) In 2015, 5,117 physicians (approximately 8% of all active patient care physicians) completed the voluntary supple- ■ Group ■ Kaiser ■ CHC/Public ■ Solo ■ Other mental survey that included questions about practice Family Medicine type. Of those, 25% were in solo practice and 64% were 39% 12% 12% 33% 4% in a group practice or Kaiser Permanente. Practice type varied by physician age. Forty-two percent of physicians General Internal Medicine over 60 reported being in solo practice, whereas 61% of 40% 17% 6% 32% 6% those under 40 reported working in a group practice and Pediatrics 18% practiced in Kaiser Permanente (Figure 10). A higher 50% 12% 12% 21% 5% percentage of younger physicians worked in community Medical Specialty health centers and public clinics. A slightly higher per- 52% 12% 1% 32% 4% centage of older physicians practiced in other types of settings, which includes VA and military sites. Facility-Based Specialty 59% 14% 1% 16% 11% Practice types varied by specialty (Figure 11). Psychiatrists General Surgery were the most likely to be in solo practice or to practice in 36% 15% 2% 41% 6% a community health center or public clinic and least likely Surgical Specialty to be in a group practice compared to other specialties. Facility-based specialists, such as emergency medicine 52% 9% 1% 34% 4% physicians, were the most likely to be in group practice. Psychiatry 17% 7% 17% 47% 13% Obstetrics and Gynecology 46% 17% 4% 30% 3% Other 41% 6% 47% 6% Notes: CHC/Public is community health center or public clinic. The number of observations for Figure 11 is lower than the number of observations for Figure 10 because the specialty of 35 MDs could not be identified. Figure 10. Practice Types of Active Patient Care Physicians, by Age, 2015 (n = 5,117) ■ ALL AGES ■ <40 ■ 40–60 ■ >60 61% 49% 49% 42% 41% 25% 24% 18% 16% 14% 9% 6% 7% 6% 5% 4% 6% 5% 6% 7% Solo Practice Group Practice Kaiser Permanente CHC/Public Clinic VA/Military Other Source (Figures 10 and 11): Analysis of Medical Board of California data by the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. California Health Care Foundation 10 Figure 12. Physicians with Patients in Practice Physician Participation in Medi-Cal by Coverage Type, 2015 The voluntary supplemental survey also asked physi- cians questions about the types of health insurance they ■ ALL PHYSICIANS accept. Figure 12 presents information on the percent- ■ Primary Care ■ Specialty Care ages of physicians who had patients in their practices by Medi-Cal type of insurance coverage. Physicians were most likely 64% to have patients with private insurance coverage in their 62% practices, followed by patients with Medicare coverage. 64% Only 62% of primary care physicians and 64% of special- ists had any Medi-Cal beneficiaries in their practices. Medicare 74% In 2015, California physicians were less likely to accept 64% new Medi-Cal patients than patients with Medicare or 78% private health insurance (Figure 13). Only 55% of pri- Private Insurance mary care physicians and 62% of specialists accepted 87% new Medi-Cal patients. Conversely, physicians were 86% more likely to accept new Medi-Cal patients than new 87% uninsured patients. One in 3 primary care physicians and 4 in 10 specialists accepted new patients who were Uninsured uninsured. The extent to which physicians accept new 55% patients affects the ability of patients who are newly 50% insured, or who switch from one type of health insurance 57% to another, to find a physician who will care for them. Figure 13. Physicians Accepting New Patients by Payer, 2015 ■ ALL PHYSICIANS ■ Primary Care ■ Specialty Care Medi-Cal 60% In 2015, California physicians were 55% less likely to accept new Medi-Cal 62% patients than patients with Medicare Medicare 77% or private health insurance. Conversely, 62% physicians were more likely to accept 83% new Medi-Cal patients than new Private Insurance 85% uninsured patients. 79% 87% Uninsured 38% 32% 41% Source (Figures 12 and 13): Analysis of Medical Board of California data by the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. California Physician Supply and Distribution: Headed for a Drought? 11 Conclusions The Northern and Sierra, San Joaquin Valley, and Inland Empire regions had particularly low supplies of active The analysis of Medical Board of California mandatory patient care physicians across multiple specialties. Not survey data provides an overview of the supply of physi- surprisingly, people from these counties also reported cians in the state as well as detail on their distribution substantial difficulty in accessing care. In the Northern across active patient care, specialty care, and the regions and Sierra region, an estimated 10% and 20% of adults, where they practice. respectively, had difficulty finding primary and specialty care in 2015.6 In the Greater Bay Area, only 6% and 10% reported similar challenges. Prior analyses of the Medical Supply of Active Patient Care Board data have documented an ongoing low physician Physicians supply in rural areas in the state.7 Less than half of all physicians with California medi- cal licenses could be identified as providing patient care for 20 or more hours per week (i.e., active patient Demographics of care). Current totals of medical licenses overestimate California Physicians the supply of physicians who are available to provide Declining hours spent on patient care paralleled the patient care to the state’s population. Of physicians who aging of the physician workforce. The number of phy- had active California license in 2015, 26,000 were not sicians responding to the Medical Board’s mandatory located in California. Out-of-state physicians may retain survey who were age 60 or older increased from 24,567 California licenses for many reasons, and can include in 2013 to 29,082 in 2015. Consistent with ongoing state those who completed training in California but relo- and national trends, California physicians age 60 or older cated to practice elsewhere, military service members provided fewer hours of patient care than younger physi- stationed in other locales, and physicians who previously cians, and some discontinued all patient care activities. In practiced in the state who moved but wished to retain California, physicians over age 60 accounted for 90% of licensure. Among those located in California who were physicians who provided zero hours of patient care per not in training, most reported providing care at least one week. hour per week. Although the total number of physicians with California licenses increased from 2013 to 2015, the Gender parity in the physician workforce did not number engaged in active patient care declined from appear to drive the decline in the supply of active 62,694 to 61,196. patient care physicians. Contrary to past concerns that the increasing number of female physicians would The number of physicians who did not provide any substantially reduce the supply of physicians providing patient care increased between 2013 and 2015. The patient care,8 similar proportions of male and female phy- number of active licensed physicians who reported sicians in California met the definition of active patient spending no hours per week on patient care increased care. Compared to male physicians, female physicians 108% from 3,121 in 2013 to 6,499 in 2015. were less likely to report spending 40+ hours per week on patient care, but were more likely to report spend- ing 20 to 39 hours per week. Of physicians who did not Distribution of Physician Specialties provide any patient care, the majority were male, likely The distributions of primary and specialty care physi- because males constitute a much higher percentage of cians were highly uneven across regions. The Inland older physicians. Empire and San Joaquin Valley regions had 40% fewer primary care physicians per capita than the Greater Bay The proportion of active patient care physicians who Area, and less than half as many specialists per capita. were members of underrepresented minority groups Previous research has found that nurse practitioners (NPs) was substantially lower than the state’s population, and physician assistants (PAs) fill some of the gaps in pri- particularly Latinos and African Americans. Latino mary care physician supply, especially in regions that physicians comprised only 5% of the active patient have low ratios of primary care physicians to population. care physician supply, even though 38% of California In California, 52% of NPs and 26% of PAs provided pri- residents were Latino in 2015.9 Whereas 6% of state resi- mary care.5 dents reported being African American, only 3% of active California Health Care Foundation 12 patient care physicians did. Only 9% of Californians who patients with any type of health insurance. However, they entered medical school during the 2017–2018 academic were also less likely to accept new Medi-Cal patients year were Latino and only 4% were African American.10 than to accept new patients with Medicare or private Substantial underrepresentation among physicians is health insurance. Sixty percent of physicians accepted associated with ongoing challenges in access to care for new Medi-Cal patients. The corresponding percentages minorities, irrespective of insurance or socioeconomic for new Medicare patients and new patients with private status.11, 12 health insurance were 77% and 85%, respectively. Practice Types Limitations Younger physicians elected group practice settings This study has limitations related to the data and design. over solo practice. Nearly 80% of physicians under age First, the data were derived from physician self-reports. 40 practiced in a group practice or Kaiser Permanente, The actual amount of time spent providing patient care compared to less than half of physicians over 60. This and performing other professional activities may differ. is consistent with historical and national trends. Younger Furthermore, the mandatory survey only asks that respon- physicians have gravitated toward larger practices for sev- dents report hours spent on an activity; counts are not eral benefits, including reduced call schedules, increased equivalent to access. Second, due to revisions in the sur- flexibility in working hours, and improved information vey instrument across years, change over time could not technology.13 be assessed for several items, such as physician-reported specialty. Third, this study was limited to physicians with Practice type varied by specialty. Sixty percent of psy- doctorates of medicine. Doctors of osteopathic medicine chiatrists reported practicing in solo and “other” settings, were not included. The study also did not assess whether versus 25% of pediatricians. Among the major specialty physician capacity was extended by NPs or PAs, or categories, psychiatrists also had the lowest percentage broader multidisciplinary care teams that include regis- practicing in group practice settings (17%). Practice set- tered nurses, medical assistants, and/or other personnel. ting differences carry implications for access to care: In Fourth, the description of the racial/ethnic composition additional analyses from the supplemental survey, nearly of the physician workforce was incomplete because more three-quarters of psychiatrists in solo practice reported than 26% of physicians did not report their race/ethnic- that none of their patients were covered by Medi-Cal. ity. Fifth, generalizability of analysis of practice types and physician acceptance of Medi-Cal and uninsured patients was limited because the supplemental survey represents Physician Participation in Medi-Cal a small percentage (8%) of all patient care physicians. Physicians were more likely to accept patients with Although a quasi-random selection method was used, any type of health insurance than uninsured patients. response rates differed by age group, with response In 2015, only 50% of primary care physicians and only rates of 50.2% over age 60, 27.4% for ages 40 to 60, and 57% of specialists had any uninsured patients in their 14% under age 40. practices. Lastly, the Medical Board’s mandatory survey does not Physicians were less likely to have any Medi-Cal specify what constitutes “patient care.” In the survey, tele- patients in their practices than patients with Medicare health was listed as a separate item, although that would or private health insurance. Sixty-two percent of pri- likely fall under the broader category of patient care. A mary care physicians had any Medi-Cal patients in their recent study using electronic medical records found that practices, whereas 64% had Medicare patients, and physicians spend 50% of their time on office visits and 86% had privately insured patients. For specialists, the the remainder on electronic documentation and commu- corresponding percentages were 64%, 78%, and 87%, nication.14 Physicians may differ on their perceptions as to respectively. whether these latter activities constitute “patient care.” In addition, many physicians practice collaboratively with Patterns of acceptance of new patients were similar. nurse practitioners or physician assistants, which may Physicians were less likely to accept any new uninsured lead them to provide more “patient care” than physi- patients in their practices than they were to accept new cians who see only their panel of patients. California Physician Supply and Distribution: Headed for a Drought? 13 Recommendations continues to be weighted toward specialty fellow- The supply of physicians in California may not be able to ships.20 Investment in residency programs should be keep pace with growth in the state’s demand for medi- targeted to primary care specialties, psychiatry, and cal care due to population growth and aging. As with other specialties in which shortages are projected.21, 22 the general population, the population of physicians is The state budget for 2017–18 and the governor’s aging, and older physicians will likely continue to scale budget proposal for 2018 –19 included $33 million back on patient care activities. Although the future of for primary care residency programs. The state will health insurance coverage remains unclear, coverage need to maintain funding for primary care residency does not confer access without a health care workforce to programs at this level to meet the state’s needs and provide care. Policymakers, providers, and plans should should explore options for obtaining funding from invest in strategies that both bolster the number of physi- other sources, such as Medi-Cal and Medicare. cians and extend their services in innovative ways. $$ Increase funding for financial incentives to encour- To address the challenges in the supply of physicians in age both primary care and specialty physicians to California, the authors recommend the following: practice in underserved areas. Scholarship and loan repayment programs have demonstrated success in $$ Increase funding to expand undergraduate medi- both recruitment and retention of primary care physi- cal education (i.e., medical school), particularly in cians in underserved areas, particularly rural areas.23 underserved areas. California has a higher ratio of medical school applicants to medical school admis- $$ Support opportunities for international medical sion slots than most other states.15 Increasing the graduates to practice in underserved areas of the number of medical students could help increase the state. Maintaining policies and mechanisms to sup- supply of physicians because over 60% of California port international medical graduates (IMGs) is critical medical students remain in the state.16 Several new for meeting the health care needs of California’s medical schools have opened in recent years and population. Nationwide, IMGs made up 18.5% of several more are planned. The combined efforts of generalist physicians in rural areas, and a higher per- these schools would help to boost the total supply centage practice in rural Health Professions Shortage of physicians. Increased funding should be targeted Areas.24 In California, IMGs constituted 21.8% of particularly for recruiting students who are interested primary care physicians in nonmetropolitan counties. in caring for underserved populations and who Program administrators have reported that recent are interested in practicing in specialties that are shifts in immigration policy have raised challenges in projected to experience shortages, such as family hiring, recruiting, and retaining IMGs for residency medicine, general internal medicine, general pediat- and fellowship positions.25 Policymakers should con- rics, and psychiatry.17, 18 tinue advocacy for visa programs that allow IMGs to train and remain in the state.26 $$ Increase funding to expand graduate medical edu- cation (i.e., residency and fellowship programs), $$ Increase investments in programs that particularly in specialties with projected shortages. address diversity of the physician workforce. Residency programs are another important source of Underrepresentation in medical schools is attrib- physicians; 70% of physicians who completed resi- uted to multiple factors, including inequities in K–12 dency in California remain in the state to practice.19 education, a lack of support and mentorship in col- However, in 2016, California ranked 31st among the leges, and inadequate prioritization and institutional 50 states with respect to the ratio of residents and commitment to diversity.27 Multiple programs across fellows per 100,000 population. Also, California the pipeline, from K–12 programming, community ranked 35th in the rate of growth of residents and colleges, undergraduate recruitment, post-baccalau- fellows between 2006 and 2016. Despite increases reate, and undergraduate medical education have in federal and state support for primary care train- been shown to increase both diversity and the num- ing, graduate medical education in California ber of physicians practicing in underserved areas.28 California Health Care Foundation 14 $$ Invest in technologies that can maximize scarce physician resources, especially for rural areas. Greater investment in training and technology to expand telehealth via electronic advice refer- rals, virtual consults, and care navigators / primary care liaisons would expand access to primary and specialty care.29 For specialty care in particular, reim- bursement for videoconferencing, mobile therapy technologies, and peer providers would alleviate a lack of specialists. $$ Provide training, support, and incentives for team-based care. Care teams that consist of several types of personnel — including nurse practitioners, physician assistants, and community-based sup- port staff such as care coordinators and community health workers — can expand the number of patients that primary care physicians can serve. Primary care physicians should receive training on both team management (leadership of other health care per- sonnel) and panel management (population health management). Reimbursement mechanisms should support care delivered by teams that include several types of members. To facilitate adoption of these models, community health centers and other pro- viders who have experience in team models could facilitate learning collaboratives with private provid- ers. These efforts can also be adapted for specialty care; for example, physician assistants can extend the practices of general surgeons by providing initial evaluations, assistance in the operating room, and follow-up care.30 California Physician Supply and Distribution: Headed for a Drought? 15 Appendix A. Methodology The Medical Board of California requires physicians State Physician Supply to reapply for MD licenses every two years. Physicians Assessing geographic distribution and supply. To undergoing relicensure are required to complete a man- assess geographic distribution, the study used respon- datory survey, which includes questions regarding their dent practice zip codes to count the number of physicians demographics, practice location, professional activities, in the state and in each California county. If no practice primary and secondary specialty, board certifications, zip code was available (3%), the zip code for the respon- and whether they have completed residency and/or dent’s primary mailing address on file at the Medical fellowship training (see Appendix B for the mandatory Board was used. Responses were aggregated by region survey instrument). (see Appendix D for California counties in regions). To calculate the supply of physicians per capita, the study In addition to the survey for all re-applicants, the Medical used estimates of the state and county populations in Board, in partnership with the University of California, 2015 from the US Census Bureau’s American Community San Francisco, also administered a voluntary supple- Survey. mental survey to a sample of physicians who were due for renewal in June and December 2015. Because the Physician Activities physicians were selected by birth month rather than any Describing physician activities. The survey asked physi- practice-related characteristics, the sample approximates cians to report the number of hours spent per week on a random sample. Physicians were eligible for inclusion in the following activities: patient care, research, teaching, analyses of responses to the supplemental survey if they administration, telemedicine, other. Hours devoted to had an active California license, practiced in California, each activity were categorized as zero and then increas- had completed training, and provided patient care ing 10-hour increments, up to 40 or more hours per for at least 20 hours per week. These inclusion criteria week. Hours spent on patient care by age and gender ensured that the analysis focused on physicians whose were examined to assess whether there were age or gen- primary professional activity was providing patient care der differences in hours spent on patient care. to Californians (see Appendix C for the supplemental survey instrument). Among physicians who met the eli- Enumerating active patient care physicians. The gibility criteria, the response rate for the supplemental American Medical Association’s criteria were used to survey was 63% in 2013 and 22% in 2015. identify “active patient care” physicians as those who reported spending 20 or more hours per week on patient The lower response rate in 2015 was likely due to a care. change in the mechanism by which the Medical Board administered the online version of the supplemental sur- Specialty Distribution vey. In 2013, the supplemental survey was embedded Determining physician specialty. The survey asked in the same software platform as the licensure renewal physicians to report primary and secondary specialties, form and the mandatory survey, making it easy for phy- as well as board certifications. Physician specialty was sicians to complete the supplemental survey with little determined by the primary specialty; if no primary was additional effort. In 2015, physicians had to first submit reported, then secondary specialties were used to deter- the online renewal applications and mandatory survey mine specialty. If no primary or secondary specialty was responses and then go to a different software platform reported, then reported board certifications were used and re-enter some identifying information before com- to identify specialty. Among active patient care physi- pleting the supplemental survey. cians, 0.4% were missing specialty information under this algorithm. California Health Care Foundation 16 Identifying primary care physicians. The following spe- Change Over Time cialties were categorized as primary care: family medicine Because the Medical Board of California administers the (including general practice), general pediatrics, and gen- mandatory survey every other year in conjunction with eral internal medicine (including geriatric medicine). licensure renewal, responses to the 2013 survey were analyzed and compared to 2015 responses for items that Categorizing physician specialty. The study also created remained consistent over time. For this study, hours spent a 10-category measure to describe primary care and spe- on the different activities in medicine and the total num- cialty distribution in greater depth. The 10 categories were ber of active patient care physicians were compared. In family medicine, general internal medicine, pediatrics, 2015, the survey instrument included additional medical medical specialty, facility-based care, surgical specialty, specialty items as well as board certifications, allowing psychiatry, obstetrics/gynecology, general surgery, and more physicians to identify themselves as practicing in other. Facility-based care included specialties generally particular medical specialties. The survey change pre- practiced by physicians employed in or by health care vented comparison of physician supply in primary care facilities, including emergency medicine, anesthesiology, versus medical specialties across years. Trends in phy- radiology, and pathology. (See Appendix F for lists of the sician race/ethnicity could not be assessed because specialties included in each category.) response options for the question about race/ethnicity changed. Demographic Characteristics The California Medical Board retains data on physician age and gender for all licensed physicians, indepen- dent of the mandatory survey. The mandatory survey asked respondents to identify their race and ethnic- ity. The self-reported responses were categorized as follows: White, African American, Latino, Middle Eastern, American Indian / Alaska Native, Asian Not Underrepresented, Asian Underrepresented / Hawaiian / Pacific Islander, Multiracial/Ethnic, and Other. Asian Not Underrepresented includes Asian subgroups in which the percentage of physicians meets or exceeds the popu- lation percentage. (See Appendix E for detailed race/ ethnicity response items.) Practice Type The supplemental survey included a question that asked physicians to report the organizational setting in which they practiced. Practice types were categorized as fol- lows: solo practice, small medical partnership (2 to 9 physicians), group practice (10 to 49 physicians), large group practice including academia (50 or more physi- cians), Kaiser Permanente, community health center / public clinic, VA or military, or other (see Appendix C for supplemental survey instrument). California Physician Supply and Distribution: Headed for a Drought? 17 Appendix B. California Medical Board Mandatory Survey Instrument Page 3 of 8; Physician's and Surgeon's Renewal, v.09.2014F C54792 I. Physician Survey Are you retired? O Yes O No 1. ACTIVITIES IN MEDICINE (Mandatory) 2. PRACTICE LOCATIONS (Mandatory) Fill in one circle on each line. If you have hours for Patient Care, enter the primary and secondary practice location(s). Primary practice location (U.S. Only) Secondary practice location (CA Only) Hours None 1-9 10-19 20-29 30-39 40+ Zip Code County Zip Code County Patient Care O O O O O O Telehealth O O O O O O Administration O O O O O O CODES (CA County / 01 Alameda 16 Kings 31 Placer 46 Sierra Out of State) Lake 02 Alpine 17 32 Plumas 47 Siskiyou Research O O O O O O 03 Amador 18 Lassen 33 Riverside 48 Solano 04 Butte 19 Los Angeles 34 Sacramento 49 Sonoma 05 Calaveras 20 Madera 35 San Benito 50 Stanislaus Teaching O O O O O O 06 Colusa 21 Marin 36 San Bernardino 51 Sutter 07 Contra Costa 22 Mariposa 37 San Diego 52 Tehama 08 Del Norte 23 Mendocino 38 San Francisco 53 Trinity 09 El Dorado 24 Merced 39 San Joaquin 54 Tulare Other O O O O O O 10 Fresno 25 Modoc 40 San Luis Obispo 55 Tuolumne 11 Glenn 26 Mono 41 San Mateo 56 Ventura 12 Humboldt 27 Monterey 42 Santa Barbara 57 Yolo 13 Imperial 28 Napa 43 Santa Clara 58 Yuba 14 Inyo 29 Nevada 44 Santa Cruz 15 Kern 30 Orange 45 Shasta 98 Out of State 3. CURRENT TRAINING STATUS (Mandatory) O Residency O Fellow O Not in Training 4a. AREAS OF PRACTICE (Mandatory) Please mark one primary (P) practice area and all secondary (S) practice areas. P S P S P S O O Aerospace Medicine O O Infectious Disease O O Physical Medicine and O O Allergy and Immunology O O Internal Medicine Rehabilitation O O Anesthesiology O O Medical Genetics O O Plastic Surgery O O Cardiology O O Neonatal-Perinatal Medicine O O Psychiatry O O Colon and Rectal Surgery O O Nephrology O O Psychosomatic Medicine O O Complementary & Alternative O O Neurodevelopmental Disabilities O O Public Health and General Medicine O O Neurological Surgery Preventive Medicine O O Cosmetic Surgery O O Neurology with Special O O Pulmonary O O Critical Care Qualification in Child Neurology O O Radiation Oncology O O Dermatology O O Neurology O O Radiologic Physics O O Emergency Medicine O O Nuclear Medicine O O Radiology O O Endocrinology O O Obstetrics and Gynecology O O Rheumatology O O Epilepsy O O Occupational Medicine O O Sleep Medicine O O Facial, Plastic & Reconstructive O O Oncology O O Spine Surgery Surgery O O Ophthamology O O Sports Medicine O O Family Medicine O O Orthopedic Surgery O O Surgical Oncology O O Gastroenterology O O Otolaryngology O O Thoracic Surgery O O General Practice O O Pain Medicine O O Urology O O General Surgery O O Pathology O O Vascular Surgery O O Geriatric Medicine O O Pediatrics O O Hematology O O Other – Not Listed 4b. BOARD CERTIFICATIONS (Mandatory) Please mark any Board Certifications that you may have. If you have no current certifications, mark here: O None American Board of Allergy and Immunology American Board of Anesthesiology O Pediatric Anesthesiology O Allergy and Immunology O Anesthesiology O Sleep Medicine O Critical Care Medicine O Hospice and Palliative Medicine O Pain Medicine (Continued on reverse side.) California Health Care Foundation 18 Page 4 of 8; Physician's and Surgeon's Renewal, v.09.2014F C54792 American Board of Colon and Rectal O Clinical Cytogenetics O Pediatrics Surgery O Clinical Genetics (MD) O Adolescent Medicine O Colon and Rectal Surgery O Clinical Molecular Genetics O Child Abuse Pediatrics O Medical Biochemical Genetics O Developmental-Behavioral American Board of Dermatology O Molecular Genetic Pathology Pediatrics O Dermatology O Hospice and Palliative Medicine O Clinical and Laboratory American Board of Neurological Surgery O Medical Toxicology Dermatological Immunology O Neurological Surgery O Neonatal-Perinatal Medicine O Dermatopathology O Neurodevelopmental Disabilities O Pediatric Dermatology American Board of Nuclear Medicine O Pediatric Cardiology O Nuclear Medicine O Pediatric Critical Care Medicine American Board of Emergency O Pediatric Emergency Medicine Medicine American Board of Obstetrics and Gynecology O Pediatric Endocrinology O Emergency Medicine O Obstetrics and Gynecology O Pediatric Gastroenterology O Critical Care Medicine O Critical Care Medicine O Pediatric Hematology-Oncology O Emergency Medical Services O Female Pelvic Medicine and O Pediatric Infectious Diseases O Hospice and Palliative Medicine Reconstructive Surgery O Pediatric Nephrology O Medical Toxicology O Gynecologic Oncology O Pediatric Pulmonology O Pediatric Emergency Medicine O Hospice and Palliative Medicine O Pediatric Rheumatology O Sports Medicine O Maternal and Fetal Medicine O Pediatric Transplant Hepatology O Undersea and Hyperbaric Medicine O Reproductive O Sleep Medicine Endocrinology/Infertility O Sports Medicine American Board of Facial Plastic & Reconstructive Surgery American Board of Ophthalmology American Board of Physical Medicine and O Facial Plastic & Reconstructive O Ophthalmology Rehabilitation Surgery O Physical Medicine and American Board of Family Medicine American Board of Orthopaedic Surgery Rehabilitation O Family Medicine O Orthopaedic Surgery O Brain Injury Medicine O Adolescent Medicine O Orthopaedic Sports Medicine O Hospice and Palliative Medicine O Geriatric Medicine O Surgery of the Hand O Neuromuscular Medicine O Hospice and Palliative Medicine O Pain Medicine O Sleep Medicine American Board of Otolaryngology O Pediatric Rehabilitation Medicine O Otolaryngology O Spinal Cord Injury Medicine O Sports Medicine O Neurotology O Sports Medicine American Board of Internal Medicine O Pediatric Otolaryngology O Internal Medicine O Plastic Surgery Within Head/Neck American Board of Plastic Surgery O Adolescent Medicine O Sleep Medicine O Plastic Surgery O Advanced Heart Failure and O Plastic Surgery Within Head/Neck Transplant Cardiology American Board of Pain Medicine O Surgery of the Hand O Pain Medicine O Cardiovascular Disease American Board of Preventive Medicine O Clinical Cardiac Electrophysiology American Board of Pathology O Aerospace Medicine O Critical Care Medicine O Pathology – Anatomic/Pathology- O Occupational Medicine O Endocrinology, Diabetes and Clinical O Public Health and General Metabolism O Pathology – Anatomic Preventive Medicine O Gastroenterology O Pathology – Clinical O Clinical Informatics O Geriatric Medicine O Blood Banking/Transfusion O Medical Toxicology O Hematology Medicine O Undersea and Hyperbaric Medicine O Hospice and Palliative Medicine O Clinical Informatics O Infectious Disease O Cytopathology American Board of Psychiatry and O Interventional Cardiology O Dermatopathology Neurology O Medical Oncology O Neuropathology O Psychiatry O Nephrology O Pathology – Chemical O Neurology O Pulmonary Disease O Pathology – Forensic O Neurology with Special O Rheumatology O Pathology – Hematology Qualification in Child Neurology O Sleep Medicine O Pathology – Medical Microbiology O Addiction Psychiatry O Sports Medicine O Pathology – Molecular Genetic O Brain Injury Medicine O Transplant Hepatology O Pathology – Pediatric O Child and Adolescent Psychiatry O Clinical Neurophysiology American Board of Medical Genetics American Board of Pediatrics O Epilepsy O Clinical Biochemical Genetics (Continued on Page 5.) California Physician Supply and Distribution: Headed for a Drought? 19 Page 5 of 8; Physician's and Surgeon's Renewal, v.09.2014F C54792 O Forensic Psychiatry O Nuclear Radiology O Hospice and Palliative Medicine O Geriatric Psychiatry O Pediatric Radiology O Pediatric Surgery O Hospice and Palliative Medicine O Vascular and Interventional O Surgery of the Hand O Neurodevelopmental Disabilities Radiology O Surgical Critical Care O Neuromuscular Medicine O Pain Medicine American Board of Sleep Medicine American Board of Thoracic Surgery O Psychosomatic Medicine O Sleep Medicine O Thoracic and Cardiac Surgery O Sleep Medicine O Congenital Cardiac Surgery American Board of Spine Surgery O Vascular Neurology O Spine Surgery American Board of Urology American Board of Radiology O Urology American Board of Surgery O Female Pelvic Medicine and O Diagnostic Radiology O Surgery Reconstructive Surgery O Radiation Oncology O Vascular Surgery O Pediatric Urology O Medical Physics O Complex General Surgical O Hospice and Palliative Medicine Oncology O Neuroradiology 5. POSTGRADUATE TRAINING Years completed. O 1 O 2 O 3 O 4 O 5 O 6 O 7 O 8 O 9+ 6. CULTURAL BACKGROUND Select one or more that best describe your cultural background. O African O Fijian O Mexican O South American O African American O Filipino O Middle Eastern O Taiwanese O Alaskan Native O Guamanian O Native American O Thai O American Indian O Hawaiian O Other Asian O Tongan O Black O Indian O Other Hispanic O Vietnamese O Cambodian O Indonesian O Other Pacific Islander O White O Central American O Japanese O Pakistani O Chinese O Korean O Puerto Rican O Other (not listed) O Cuban O Laotian/Hmong O Samoan O European O Malaysian O Singaporean O Decline to State 7. FOREIGN LANGUAGE PROFICIENCY In addition to English, indicate additional languages in which you are proficient. O African Languages O Hebrew O Panjabi (Punjabi) O Ukrainian O American Sign O Hindi O Persian (Farsi) O Urdu Language O Hmong O Polish O Vietnamese O Amharic O Hungarian O Portuguese O Xiang Chinese O Arabic O Ilocano O Russian O Yiddish O Armenian O Indonesian O Samoan O Yoruba O Cantonese O Italian O Scandinavian Languages O Croatian O Japanese O Serbian O Other Chinese O Fijian O Korean O Spanish O Other Non-English O Formosan (Amis) O Lao O Swahili O Other Sign Language O French O Mandarin O Tagalog O Other (not listed) O French Creole O Mien O Telugu O German O Mon-Khmer O Thai O Decline to state O Greek (Cambodian) O Tonga O None O Gujarati O Navajo O Turkish 8. WEB SITE PROFILE Do you want the following information included in your physician profile on the Medical Board’s Web site? Cultural Background O Yes O NO Foreign Language Proficiency O Yes O NO Gender O Yes O No 9. E-MAIL ADDRESS WILL NOT BE RELEASED TO THE PUBLIC. Please print e-mail address below. (Continue to Renewal Application on reverse side.) California Health Care Foundation 20 Appendix C. California Medical Board Supplemental Survey Instrument DearPhysician, TheUniversityofCalifornia,SanFrancisco(UCSF)anditsteamofexperiencedresearchers,withtheassistanceoftheMedicalBoardof California(MBC),isseekinginformationregardingphysicianpracticesinCalifornia.Yourresponsestothesequestionsarecriticalinforming publicpolicy.Yourparticipationinthisendeavorisvoluntaryandtheinformationwillbetreatedconfidentiallyandwillnotaffectthetimingor anyotheraspectofyourlicenserenewal.ThesuppliedinformationwillbeanalyzedbytheresearchteamatUCSFandthefindingswillbe presentedonlyinaggregate.Nopersonaloridentifyinginformationwillbesharedwithpayersorotherparties,andaspecifiedprotocolwillbe followedtosafeguardtheinformationyouprovide.TheUCSFresearchteammaycontactyourofficetoconfirmsomeoftheinformationyou supplied. Wewouldgreatlyappreciateyouransweringthefollowingquestionnaireandincludingyourresponses,alongwithyourotherlicense renewalinformation,intheenvelopeprovided.Alternatively,ifyouarecompletingyourrenewalonline,youmaysubmityourresponses throughtheWebsite.ThestudyquestionshavebeenreviewedandapprovedbytheMBCandUCSF’sCommitteeonHumanResearch. JanetCoffman,PhD,AssociateProfessor NatalieLowe UniversityofCalifornia,SanFrancisco MedicalBoardofCalifornia (415)476-2435 (916)263-2382 Pleaseanswereachquestionbycompletelyshadingtheappropriatecirclelikethis l 1.PRACTICETYPEWhatisyourprincipalpracticelocation?(checkonlyone) Solopractice ¡ KaiserPermanente ¡ Smallmedicalpartnership(2to9physicians) ¡ Communityhealthcenter/publicclinic ¡ Grouppractice(10to49physicians) ¡ VAormilitary ¡ Largegrouppracticeincludingacademia(50+physicians) ¡ Other(specify___________________________) ¡ 2.TIMESPENTINHOSPITALSETTINGSDoyouspend90%ormoreofyourtimeinhospitalsettings(inpatientoremergencydepartment)? Yes¡ No¡ 3.PATIENTAGESWhatpercentagesofyourpatientsareinthefollowingagegroups?(writeinpercentages,totalshouldsumto 100%.) Age0-17Years Age18-64Years Age65YearsorOlder Total _____________+ ______________+ _________________= 100% 4.PAYERSOfyourtotalnumberofpatients,whatpercentagecomesfromeachpayersource?Pleasemakethetotal approximatelyequalto100%(Forexample,50-59%private,30-39%Medicare,and10-19%Medi-Cal) Private, Other(e.g.,VA, commercial, Medicare Medi-Cal Uninsured CHAMPUS) otherinsurance 0% ¡ ¡ ¡ ¡ ¡ 1to9% ¡ ¡ ¡ ¡ ¡ 10to19% ¡ ¡ ¡ ¡ ¡ 20to29% ¡ ¡ ¡ ¡ ¡ 30to39% ¡ ¡ ¡ ¡ ¡ 40to49% ¡ ¡ ¡ ¡ ¡ 50to59% ¡ ¡ ¡ ¡ ¡ 60to69% ¡ ¡ ¡ ¡ ¡ 70to79% ¡ ¡ ¡ ¡ ¡ 80to89% ¡ ¡ ¡ ¡ ¡ 90to99% ¡ ¡ ¡ ¡ ¡ 100% ¡ ¡ ¡ ¡ ¡ 5.ACOIsyourpracticepartofanaccountablecareorganization(ACO)-agroupofphysiciansandhospitalsthatcollaborate withoneanotherandacceptcollectiveaccountabilityforthecostandqualityofcaredeliveredtoapopulationofpatients)? Yes¡ No¡ DoNotKnow¡ California Physician Supply and Distribution: Headed for a Drought? 21 6.NEWPATIENTS a.Areyoucurrentlyacceptingnewpatientsinyourpracticewithprivateinsurance? Yes¡ No¡ b.AreyoucurrentlyacceptingnewMedicarepatientsinyourpractice? Yes¡ No¡ c.Areyoucurrentlyacceptingnewfee-for-serviceMedi-Calpatientsinyourpractice? Yes¡ No¡ d.AreyoucurrentlyacceptingnewMedi-Calmanagedcare(HMO)patientsinyourpractice? Yes¡ No¡ e.Areyoucurrentlyacceptinganynewuninsuredpatientsinyourpracticewhoareunabletopay? Yes¡ No¡ rd f.Areyouacashonly(no3 partyinsurance)practice? Yes¡ No¡ 7.MEDI-CALPAYMENTRATESWhatimpact,didanincreaseinMedi-Calpaymentratesforprimarycarephysiciansin2014 haveonyourwillingnesstocareforMedi-Calpatients? a. IncreasedMedi-Calparticipation ¡ b. NochangeinMedi-Calparticipation ¡ c.DecreasedMedi-Calparticipation ¡ 8.REASONSFORLIMITINGMEDI-CALPATIENTSHowimportantiseachfactorbelowasareasonyoudonotacceptorlimitthe numberofMedi-Calpatientsinyourpractice? Very Moderately Alittlebit Not Acceptall REASONS Medi-Calpatients important important important important a.AdministrativehassleofMedi-Cal ¡ ¡ ¡ ¡ ¡ b.DelaysinMedi-Calpayment ¡ ¡ ¡ ¡ c.AmountofMedi-Calpayment ¡ ¡ ¡ ¡ d.Medi-Calpatientshavecomplexneeds ¡ ¡ ¡ ¡ e.Medi-Calpatientsaredisruptiveinthe waitingroom ¡ ¡ ¡ ¡ f.Practicealreadyhasenoughpatients ¡ ¡ ¡ ¡ 9.REFERRALS-PRIVATEINSURANCEDuringthelast12months,howoftendidyouhavedifficultyobtainingthefollowing servicesforyourpatientswithprivateinsurance? PRIVATEINSURANCE Hardlyever Occasionally Sometimes Frequently Almostalways a.Referralstospecialists ¡ ¡ ¡ ¡ ¡ b.Diagnosticimagingservices ¡ ¡ ¡ ¡ ¡ c.Referralsforoutpatient ¡ ¡ ¡ ¡ ¡ mentalhealthservices 10.REFERRALS-MEDI-CALDuringthelast12months,howoftendidyouhavedifficultyobtainingthefollowingservicesfor yourpatientsonMedi-Cal? MEDI-CAL Hardlyever Occasionally Sometimes Frequently Almostalways a.Referralstospecialists ¡ ¡ ¡ ¡ ¡ b.Diagnosticimagingservices ¡ ¡ ¡ ¡ ¡ c.Referralsforoutpatient ¡ ¡ ¡ ¡ ¡ mentalhealthservices California Health Care Foundation 22 Appendix D. California Counties Included in Regions NORTHERN AND SIERRA SACRAMENTO AREA GREATER BAY AREA NORTHERN AND SIERRA CENTRAL COAST SAN JOAQUIN VALLEY INLAND EMPIRE LOS ANGELES COUNTY ORANGE COUNTY SAN DIEGO AREA COUNTIES Central Coast Monterey, San Benito, San Luis Obispo, Santa Barbara, Santa Cruz, Ventura Greater Bay Area Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, Sonoma Inland Empire Riverside, San Bernardino Los Angeles County Los Angeles Northern and Sierra Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Inyo, Lake, Lassen, Mariposa, Mendocino, Modoc, Mono, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, Yuba Orange County Orange Sacramento Area El Dorado, Placer, Sacramento, Yolo San Diego Area Imperial, San Diego San Joaquin Valley Fresno, Kern, Kings, Madera, Merced, San Joaquin, Stanislaus, Tulare California Physician Supply and Distribution: Headed for a Drought? 23 Appendix E. Physician Race/Ethnicity Categories White Middle Eastern White European American Indian / Alaska Native American Indian African American Native American African Alaska Native African American Black Multiracial/Ethnic Latino Other Central American Cuban Mexican Puerto Rican South American Other Hispanic California Health Care Foundation 24 Appendix F. Identifying and Categorizing Physician Specialty Family Medicine Medical Specialties Family Medicine Allergy and Immunology General Practice Cardiology Critical Care General Internal Medicine Dermatology Internal Medicine Endocrinology Geriatrics Epilepsy Gastroenterology Pediatrics Hematology Hospice and Palliative Medicine Obstetrics and Gynecology Infectious Disease Medical Genetics Psychiatry Neonatal-Perinatal Medicine Psychiatry Nephrology Psychosomatic Medicine Neurology Occupational Medicine General Surgery Oncology Pulmonology Facility-Based Specialties Rheumatology Anesthesiology Sleep Medicine Emergency Medicine Pathology Surgical Specialties Radiology Colon and Rectal Surgery Cosmetic Surgery Other Specialties Facial/Plastic/Reconstructive Surgery Aerospace Medicine Neurological Surgery Complementary and Alternative Medicine Ophthalmology Pain Medicine Orthopedic Surgery Public Health and General Preventive Medicine Otolaryngology Other Specialty Pediatric Surgery Plastic Surgery Spine Surgery Sports Medicine Surgery of the Hand Surgical Critical Care Surgical Oncology Thoracic Surgery Urology Vascular Surgery California Physician Supply and Distribution: Headed for a Drought? 25 Appendix G. Supply of Active Patient Care Physicians in 10 Major Categories of Specialties by Region, 2015 Central Greater Inland Los Angeles Northern Orange Sacramento San Diego San Joaquin Unknown Coast Bay Area Empire County and Sierra County Area Area Valley Region California Primary Care Family Medicine 591 1,439 652 1,768 381 697 471 674 728 35 7,436 General Internal 367 2,287 602 2,050 194 600 486 698 579 32 7,895 Medicine Pediatrics 203 1,179 295 1,078 85 352 265 362 331 16 4,166 Specialty Care Obstetrics and 160 849 214 812 64 285 184 255 255 15 3,093 Gynecology Psychiatry 232 1,231 275 1,027 77 221 213 368 239 18 3,901 General Surgery 79 345 135 380 68 113 100 123 142 6 1,491 Facility-Based 603 2,090 792 2,953 394 934 820 1,141 740 57 11,343 Specialties Medical Specialties 567 2,709 747 3,179 211 948 642 1,001 697 48 10,749 Surgical Specialty 384 1,835 504 2,118 193 693 460 757 431 40 7,415 Other Specialty 151 700 220 750 57 241 157 263 196 7 2,742 Unknown Specialty 45 206 82 304 35 77 57 66 91 2 965 Physician Supply Total MDs 3,382 15,689 4,518 16,419 1,759 5,161 3,855 5,708 4,429 276 61,196 Region Population 2.3 7.7 4.5 10.2 1.4 3.2 2.3 3.5 4.2 39.1 (in millions) Total MDs/100K 144.3 205.1 100.6 161.4 125.0 162.8 169.5 164.0 106.6 156.3 $$ Primary Care 49.5 64.1 34.5 51.3 46.9 52.0 53.7 49.8 39.4 49.8 $$ Specialist 92.9 138.2 64.3 110.3 75.6 108.4 113.3 112.3 65.0 104.1 Source: Analysis of Medical Board of California data by the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. California Health Care Foundation 26 Endnotes 1.Total Estimated and Projected Population for California: July 1, 16.“2017 State Physician Workforce Data Book,” Association of 2010 to July 1, 2060 in 1-Year Increments, State of California American Medical Colleges, www.aamc.org. Department of Finance, www.dof.ca.gov. 17.Janet Coffman, Timothy Bates, Igor Geyn, and Joanne Spetz, 2.“Hospitalists: A Growing Part of the Primary Care Workforce,” California’s Current and Future Behavioral Health Workforce Association of American Medical Colleges, www.aamc.org. Needs, UCSF Healthforce Center, February 12, 2018, healthforce.ucsf.edu. 3.“California Maps: How Many Primary Care and Specialist Physicians Are in Your County?” California Health Care 18.Joanne Spetz, Janet Coffman, and Igor Geyn, California’s Foundation, August 2017, www.chcf.org. Primary Care Workforce: Forecasted Supply, Demand, and Pipeline of Trainees, 2016 – 2030, UCSF Healthforce Center, 4.“Target Participants” in The Mini Grants Program Grant Guide August 15, 2017, healthforce.ucsf.edu. for Fiscal Year 2017–18, Office of Statewide Health Planning and Development, 2018, www.oshpd.ca.gov (PDF). 19.“2017 State Physician Workforce Data Book,” Association of American Medical Colleges, www.aamc.org. 5.Janet Coffman, Igor Geyn, and Kristine Himmerick, California’s Primary Care Workforce: Current Supply, Characteristics, and 20.Anastasia J. Coutinho et al., “Changes in Primary Care Pipeline of Trainees, UCSF Healthforce Center, February 17, Graduate Medical Education Are Not Correlated with 2017, healthforce.ucsf.edu (PDF). Indicators of Need: Are States Missing an Opportunity to Strengthen Their Primary Care Workforce?,” Academic 6.“AskCHIS,” University of California, Los Angeles, accessed Medicine: Journal of the Association of American Medical March 2017, healthpolicy.ucla.edu. Colleges, 92, no. 9 (September 2017), doi:10.1097/ 7.Craig Paxton, California Physicians: Surplus or Scarcity? ACM.0000000000001539. California Health Care Foundation, March 2014, 21.Coffman et al., California’s Current and Future Behavorial www.chcf.org (PDF). Health Workforce Needs. 8.Lindsay Hedden et al, “The Implications of the Feminization 22.Spetz, Coffman, and Geyn, California’s Primary Care of the Primary Care Physician Workforce on Service Supply: A Workforce. 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