CALIFORNIA Health Care Almanac MARCH 2021 California Physicians: A Portrait of Practice Physicians Executive Summary Executive Summary Although the number of active physicians increased by 21% between 2006 and 2018, and exceeded the 10% population growth, many areas in California face substantial shortages of primary care providers and specialists. CONTENTS California Physicians: A Portrait of Practice presents detailed information about the supply, distribution, and Supply. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 demographic characteristics of the state's physicians and provides important context for understanding the challenges of caring for people during a public health emergency like COVID-19, as well as the complexity of Hours Worked. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 caring for an aging and increasingly racially/ethnically diverse population.* Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 KEY FINDINGS INCLUDE: • The supply of licensed physicians does not adequately reflect their availability to provide care. Less than Practice Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 half of California's physicians provided patient care 40 or more hours per week. Education and Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 • Physician supply varied by region. Out of nine regions in the state, only four regions (Greater Bay Area, Orange County, Sacramento Area, San Diego Area) had the recommended supply of primary care Income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 physicians (PCPs). The Inland Empire and San Joaquin Valley had the lowest supply of PCPs and specialists. Medical Groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 • Over one-third of California's physicians were over 60. Physicians over 50 work fewer hours per week on patient care than their younger counterparts. Quality of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 • The Latinx population is underrepresented among physicians. Latinx people represented 39% of California's population, but only 6% of the state's physicians and 8% of the state's medical school graduates. Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 • Physicians were less likely to accept uninsured patients than patients with any type of insurance, including Medi-Cal. • California ranked first in the nation in the percentages of both medical students and residents who remain in the state to practice. • Twenty-eight percent of physicians (39% of PCPs and 23% of specialists) attended an international medical school. *Data presented were collected prior to the onset of the COVID-19 pandemic. Some findings, most notably the amount of time spent providing care via telemedicine, may have changed since the pandemic began. CALIFORNIA HEALTH CARE FOUNDATION 2 Physicians Active Physicians Supply California, 2006 to 2018, Selected Years The number of active physicians NUMBER OF PHYSICIANS (IN THOUSANDS) (MDs) practicing in California has grown steadily, increasing 21% 105 97 101 from 2006 to 2018. During this 91 94 time, growth in the state's supply 87 89 of physicians exceeded population growth, which increased by 10% (not shown). 2006 2008 2010 2012 2014 2016 2018 Note: Data include MDs who indicated they worked 20 or more hours per week, except residents, fellows, and MDs who are retired, semiretired, working part-time, temporarily not in practice, or not active for other reasons. Sources: State Physician Workforce Data Report (2007, 2009, 2011, 2013, 2015, 2017, and 2019), Assn. of American Medical Colleges. CALIFORNIA HEALTH CARE FOUNDATION 3 Physicians Supply of Select Providers Supply California, 2016 and 2020 Supplies of physicians, physician MDs assistants, and three types of 112,929 advanced practice nurses in California 123,941 +10% Nurse Practitioners grew between 2016 and 2020, while 19,646 the supply of clinical nurse specialists 24,256 +23% decreased. Doctors of osteopathic Physician Assistants ■ 2016 9,752 ■ 2020 medicine (DOs) had the highest 12,033 +23% rate of growth while MDs had the DOs 6,408 largest increase in the number of 8,634 +35% professionals. Clinical Nurse Specialists 3,662 3,047 -17% Nurse Anesthetists 1,802 2,069 +15% Nurse Midwives 1,133 1,198 +6% Notes: DO is doctor of osteopathic medicine. Data include all providers with an active California license and a California address. The Agency for Healthcare Research and Quality (AHRQ) has estimated that 52% of nurse practitioners and 43% of physician assistants are primary care practitioners. See Primary Care Workforce Facts and Stats No.2: The Number of Nurse Practitioners and Physician Assistants Practicing Primary Care in the United States (PDF), AHRQ, October 2011. Sources: Survey of Licensees (private tabulation), California Dept. of Consumer Affairs (DCA), 2016; and DCA Annual Licensing Statistics, DCA, 2020. CALIFORNIA HEALTH CARE FOUNDATION 4 Physicians Health Care Providers, by Type and Region Supply California, 2020 Medical care can be obtained from ■ MDs ■ DOs ■ NPs ■ PAs physicians (MDs and DOs), nurse Central Coast (n = 8,869) 71% 6% 13% 9% practitioners, and physician assistants. Greater Bay Area In 2020, MDs and DOs composed (n = 43,966) 79% 13% 5% 3% 78% of these health care providers in Inland Empire (n = 13,832) 65% 9% 16% 10% California. In the Northern and Sierra Los Angeles County 75% 5% 13% 6% region, they composed 69% of health (n = 43,689) care providers. Northern and Sierra (n = 4,588) 62% 7% 19% 12% Orange County (n = 14,642) 70% 6% 15% 9% Sacramento Area (n = 10,794) 74% 5% 13% 7% San Diego Area (n = 16,962) 73% 5% 15% 7% San Joaquin Valley (n = 11,478) 67% 6% 18% 9% California (N = 168,864) 73% 5% 14% 7% Notes: DO is doctor of osteopathic medicine. NP is nurse practitioner. PA is physician assistant. Data include all providers with an active California license and a California address. The total number of MDs in California includes 44 physicians who could not be allocated to a region because a valid zip code was not provided. Segments may not add to 100% due to rounding. See Appendix A for a list of counties within each region. Sources: Survey of Licensees (private tabulation), California Dept. of Consumer Affairs (DCA), 2016; and DCA Annual Licensing Statistics, DCA, 2020. CALIFORNIA HEALTH CARE FOUNDATION 5 Physicians Estimating the Number of Active Patient Care Physicians Supply California, 2020 Counting physicians in California is not All Active Practicing clear-cut. Many physicians with active MDs Out-of-State California licenses are not considered 152,123 28,182 "active patient care physicians" License Not Renewed Did Not in 2 Years Residents/ Answer Patient because they do not practice in Care Question California, did not renew their licenses 9,249 Fellows Non- 7,963 respondents No Patient Patient Care during the last biannual renewal 6,595 Care <20 Hours cycle, are residents or fellows, did 3,772 8,217 per Week Active Patient Care not respond to the medical board's 12,677 MDs mandatory survey, or do not provide 75,468 patient care. EXCLUDED Notes: The Medical Board of California surveys MDs when they obtain or renew their licenses. Nonrespondents include MDs who did not complete the survey and those who did not respond to questions about hours worked. Physicians who did not renew their licenses between February 2018 and January 2020 are excluded. Source: Survey of Licensees (private tabulation), Medical Board of California, January 2020. CALIFORNIA HEALTH CARE FOUNDATION 6 Physicians Primary Care Physicians and Specialists Supply California vs. United States, 2018 and 2020 Based on data collected by the NUMBER PER 100,000 POPULATION 160 Association of American Medical 155 7 150 12 145 ■ DOs Colleges in 2018 and by the Medical 140 135 147 150 ■ MDs 130 125 Board of California (MBC) in 2020, 120 115 110 105 131 California's supply of primary care 100 95 RECOMMENDED SPECIALIST SUPPLY physicians (PCPs) and specialists (85–105)* 90 85 80 6 met the minimum per capita ratios 75 8 RECOMMENDED recommended by the Council 70 81 PCP SUPPLY 65 (60–80)* 60 55 75 on Graduate Medical Education. 50 45 40 60 According to MBC data, the supply of 35 30 25 PCPs in California just barely met the 20 15 10 minimum recommended supply. 5 0 PCPs Specialists PCPs Specialists PCPs Specialists AAMC, US 2018 AAMC, CA 2018 MBC, 2020 *The Council on Graduate Medical Education (COGME), part of the US Department of Health and Human Services, studies physician workforce trends and needs. COGME ratios include DOs and are shown as ranges in the chart above. MBC data do not include DOs. Notes: PCP is primary care physician. The Assn. of American Medical Colleges (AAMC) data include those physicians who self-reported their type of practice as "direct patient care." For the AAMC data, the number of specialists per 100,000 was estimated by subtracting the ratio of active patient care primary care physicians per 100,000 population from the ratio of all active patient care physicians per 100,000 population. The Medical Board of California (MBC) data include MDs who renewed their license between February 2018 and January 2020, answered the question on MBC's survey regarding their specialty, had a California address, and provided patient care at least 20 hours per week, and exclude residents, fellows, and nonrespondents (i.e., those MDs who did not respond to the MBC survey or did not answer questions about specialty). Of the 75,468 active patient care physicians in California, 163 (0.2%) did not report their specialty or board certification. Sources: 2019 State Physician Workforce Data Report, Assn. of American Medical Colleges, November 2019, tables 1.2, 1.4; Survey of Licensees (private tabulation), Medical Board of California, January 2020; and Annual Estimates of the Resident Population by Sex, Age, Race, and Hispanic Origin for the United States: April 1, 2010 to July 1, 2019 (NC-EST2019-ASR6H), US Census Bureau, June 2020. CALIFORNIA HEALTH CARE FOUNDATION 7 Physicians Primary Care Physicians and Specialists, by Region Supply California, 2020 NUMBER PER 100,000 POPULATION Physician supply varied by region. RECOMMENDED RECOMMENDED PCP SUPPLY SPECIALIST (60–80)* SUPPLY Out of nine regions, five regions fell San Joaquin Valley 47 (85–105)* ■ PCPs 81 ■ Specialists short of the recommended supply of Inland Empire 41 PCPs, and two regions were below the 83 Northern and Sierra 48 recommended supply of specialists. 91 The Inland Empire and San Joaquin Central Coast 58 117 Valley regions had the lowest ratios Orange County 61 (number per 100,000 population) of 139 Los Angeles County 58 both PCPs and specialists of all regions 140 in the state. San Diego Area 61 144 Sacramento Area 66 144 Greater Bay Area 80 173 California 60 131 *The Council on Graduate Medical Education (COGME), part of the US Department of Health and Human Services, studies physician workforce trends and needs. COGME ratios include DOs and are shown as ranges in the chart above. Notes: PCP is primary care physician. Data include MDs who renewed their license between February 2018 and January 2020, answered the question on the Medical Board of California (MBC) survey regarding their specialty, had a California address, and provided patient care at least 20 hours per week, and exclude residents, fellows, and nonrespondents (i.e., those MDs who did not respond to the MBC survey or did not answer questions about specialty). Of the 75,468 active patient care physicians in California, 163 (0.2%) did not report their specialty or board certification. There were 19 physicians who did not provide geographic information. Sources: Survey of Licensees (private tabulation), Medical Board of California, January 2020; and Annual Estimates of the Resident Population by Sex, Age, Race, and Hispanic Origin for the United States: April 1, 2010 to July 1, 2019 (NC-EST2019-ASR6H), US Census Bureau, June 2020. CALIFORNIA HEALTH CARE FOUNDATION 8 Physicians Primary Care Physicians per 100,000 Population, by County Supply California, 2020 PCPs were concentrated in urban Del Norte Siskiyou Modoc PCPs per 100,000 counties along the California coast. ■ 0 to 36 ■ 37 to 49 Many rural and inland counties Shasta Lassen Trinity ■ 50 to 61 Humboldt ■ 62 to 101 had low ratios of PCPs per 100,000 Tehama Plumas Mendocino Glenn Butte population. Sierra Nevada Yuba Placer Lake Colusa Sutter Yolo El Dorado Sonoma Sacra- Amador Alpine Napa mento Solano Calaveras Marin San Tuolumne Contra Joaquin Mono San Francisco Costa Alameda Stanislaus Mariposa San Mateo Santa Merced Clara Santa Cruz Madera Fresno San Inyo Benito Tulare Monterey Kings San Luis Obispo Kern Santa Barbara San Bernardino Ventura Los Angeles Orange Riverside San Diego Imperial Notes: PCP is primary care physician. Data include PCPs who renewed their license between February 2018 and January 2020, answered the question on the Medical Board of California survey regarding their specialty, had a California address, and provided patient care at least 20 hours per week, and exclude residents, fellows, and nonrespondents (i.e., those MDs who did not respond to the survey or did not answer questions about specialty). Sources: Survey of Licensees (private tabulation), Medical Board of California, January 2020; and Annual Estimates of the Resident Population by Sex, Age, Race, and Hispanic Origin for the United States: April 1, 2010 to July 1, 2019 (NC-EST2019-ASR6H, SC-EST2019-ASR6H-06), US Census Bureau. CALIFORNIA HEALTH CARE FOUNDATION 9 Physicians Top Ten Specialties Supply California, 2020 The three largest specialties in NUMBER OF ACTIVE PATIENT CARE PHYSICIANS California were primary care Internal Medicine 9,663 specialties. Among physicians who reported their specialty, internal Family Medicine 6,912 medicine, family medicine, and Pediatrics 5,432 pediatrics together represented 29% Anesthesiology 4,971 of all active patient care physicians in the state. Psychiatry 4,660 Emergency Medicine 4,405 Obstetrics/Gynecology 3,598 Radiology 2,771 Cardiology 2,604 Orthopedic Surgery 2,324 Notes: Data include MDs who renewed their license between February 2018 and January 2020, answered the question on the Medical Board of California survey regarding their specialty, had a California address, and provided patient care at least 20 hours per week, and exclude residents, fellows, and nonrespondents (i.e., those MDs who did not respond to the survey or did not answer questions about specialty). Physician self-reported primary, secondary, and board certification specialties were used to determine the specialty. Physicians whose primary specialty was internal medicine and who listed a secondary specialty (e.g., cardiology) were assigned to the secondary specialty. Similarly, pediatricians with a subspecialty were assigned to the secondary specialty. Of the 75,468 active patient care physicians in California, 163 (0.2%) did not respond to the question on the survey regarding their specialty. Source: Survey of Licensees (private tabulation), Medical Board of California, January 2020. CALIFORNIA HEALTH CARE FOUNDATION 10 Physicians Patient Care Hours Worked Hours Worked California, 2020 The total number of physicians with AVERAGE WEEKLY HOURS active licenses does not accurately No Response (1%) reflect the availability of physicians No to provide care. Less than half of Hours California physicians devoted 40 hours 1 to 9 8% or more per week to patient care. 6% Eight percent of active physicians did 10 to 19 40 or not provide patient care. Physicians 7% more also spent time on other professional 44% activities, such as administration, 20 to 29 12% research, and teaching. 30 to 39 22% Notes: Data include MDs who renewed their license between February 2018 and January 2020, had a California address, and exclude residents, fellows, and nonrespondents (i.e., those MDs who did not respond to the the Medical Board of California survey). In 2020, 1% of physicians who responded to the survey did not answer the question about patient care hours. Segments may not total 100% due to rounding. Source: Survey of Licensees (private tabulation), Medical Board of California, January 2020. CALIFORNIA HEALTH CARE FOUNDATION 11 Physicians Physician Hours Worked, by Activity Hours Worked California, 2015 and 2020 The hours worked per week by AVERAGE WEEKLY HOURS 66 physicians has stayed constant over the past five years. The average 54.3 53.3 ■ Telehealth physician's workweek was 53 hours in - 1.8 - 2.2 ■ Administration/Other 2020. Of those hours, 34 were spent 9.9 9.7 ■ Research/Teaching ■ Patient Care on patient care. 8.0 7.4 34.6 34.0 0 2015 2020 Notes: Data include MDs who renewed their license between February 2018 and January 2020, had a California address, and exclude residents, fellows, and nonrespondents (i.e., those MDs who did not respond to the the Medical Board of California survey or did not answer questions about hours worked). Data were collected before the COVID-19 pandemic and therefore do not reflect the number of hours physicians devoted to telemedicine during the COVID-19 pandemic. Source: Survey of Licensees (private tabulation), Medical Board of California, 2015 and 2020. CALIFORNIA HEALTH CARE FOUNDATION 12 Physicians Physician Hours Worked, by Activity and Years Since Graduation Hours Worked California, 2020 Later in their careers, physicians work AVERAGE WEEKLY HOURS fewer hours per week and dedicate 59.1 58.8 57.6 ■ Telehealth less time to providing patient care. ■ Administration/Other 2.1 2.8 2.7 54.2 53.3 ■ Research/Teaching 7.8 9.4 2.0 10.8 2.2 ■ Patient Care 10.9 44.5 9.7 8.5 8.4 1.4 7.4 9.5 40.6 7.2 7.4 38.2 36.7 30.7 34.2 6.2 1.2 34.0 27.3 7.2 5.3 17.1 1-10 11-20 21-30 31-40 41-50 51+ Overall YEARS SINCE MEDICAL SCHOOL GRADUATION Notes: Data include MDs who renewed their license between February 2018 and January 2020 and had a California address, and exclude residents, fellows, and nonrespondents (i.e., those MDs who did not respond to the Medical Board of California survey or did not answer questions about hours worked). Data were collected before the COVID-19 pandemic and therefore do not reflect the number of hours physicians devoted to telehealth during the COVID-19 pandemic. Source: Survey of Licensees (private tabulation), Medical Board of California, January 2020. CALIFORNIA HEALTH CARE FOUNDATION 13 Physicians Age of Physicians Demographics Select States vs. United States, 2018 Like many states, a large percentage PERCENTAGE OF TOTAL PHYSICIANS of California's physicians are over 60. ■ Under 40 ■ 40 to 60 ■ Over 60 One-third of physicians in California were in this age group in 2018. Florida 13% 51% 36% New York 18% 47% 35% California 16% 51% 34% Illinois 20% 50% 30% Texas 19% 53% 28% United States 17% 51% 32% 0.0000 16.6667 33.3334 50.0001 66.6668 83.3335 Note: Data include all active MDs and doctors of osteopathic medicine (DOs). Segments may not total 100% due to rounding. Source: 2019 State Physician Workforce Data Report, Assn. of American Medical Colleges, 2019, table 1.9. CALIFORNIA HEALTH CARE FOUNDATION 14 Physicians Gender of Medical School Graduates and Physicians Demographics California vs. United States, 2018 The proportion of males and females Medical School Graduates Active Physicians among California medical school graduates were equal in 2018. The share of female graduates has grown significantly, from 9% in 1966 (not 47% 36% US US shown) to 50% in 2018. Males still 53% 64% represented the majority of physicians Female in California and nationwide, largely 38% Female CA CA due to the gender gap in medical 50% school graduates in the past. Male 50% Male 62% Notes: Data include active MDs and doctors of osteopathic medicine (DOs). Segments may not add to 100% due to rounding. Sources: 2019 State Physician Workforce Data Report, Assn. of American Medical Colleges (AAMC), 2019, table 1.7; and B-2.2: Total Graduates by US Medical School, Sex, and Year, 2014-2015 Through 2018-2019, AAMC, October 16, 2019. CALIFORNIA HEALTH CARE FOUNDATION 15 Physicians Race/Ethnicity of Medical School Graduates, Physicians, Demographics and Population The racial/ethnic breakdown California, 2019 and 2020 of California physicians is not representative of the state's diverse California Medical School population. Latinx people represented Active Patient Care MDs, 2020 Total California Population, 2019 Graduates (MD), 2019 39% of the population but 6% of Native American (<1%) Native Native No Response Other American (<1%) Unknown (2%) American (<1%) Other active patient care physicians and 8% 4% 3% 5% Black 6% of medical school graduates. Studies Other Decline White 16% White Asian / White have found that minority patients to State 33% 33% Pacific Islander 37% Black 15% 18% N= N = 75,468 6% N = 1,172 39.5 million in race/ethnic concordant provider 3% Asian / relationships are more likely to use Latinx Pacific Islander Latinx Asian / Latinx Black Pacific Islander 6% 34% 8% 39% needed health services, are less likely 32% to postpone or delay seeking care, and report greater satisfaction and better patient-provider communication.* Notes: Data include all MDs who renewed their license between February 2018 and January 2020, had a California address, and provided patient care at least 20 hours per week, and exclude residents, fellows, and nonrespondents (i.e., those MDs who did not respond to the Medical Board of California survey). Other includes those of two or more races, and those of unknown race/ethnicity. The Association of American Medical Colleges uses American Indian and Alaska Native, Black or African American, and Hispanic, Latino, or of Spanish Origin. The Census Bureau uses Black or African American, American Indian and Alaska Native, and Hispanic. Segments may not add to 100% due to rounding. *Ana H. Traylor et al., "The Predictors of Patient-Physician Sources: Survey of Licensees (private tabulation), Medical Board of California, January 2020; B-6.1: Total Graduates by U.S. Medical School and Race/Ethnicity (Alone), 2018-2019, Assn. of Race and Ethnic Concordance: A Medical Facility Fixed- American Medical Colleges, October 16, 2019; and Annual Estimates of the Resident Population by Sex, Race, and Hispanic Origin for California: April 1, 2010 to July 1, 2019 (SC-EST2019- Effects Approach," Health Services Research 45, no. 3 (June SR11H-06), US Census Bureau, June 2020. 2010): 792–805, doi:10.1111/j.1475-6773.2010.01086.x. CALIFORNIA HEALTH CARE FOUNDATION 16 Physicians Latinx Physicians and Population, by Region Demographics California Latinx physicians were underrepresented in all regions of San Joaquin Valley 7% 53% California, particularly in regions Inland Empire 7% with the highest proportion of Latinx 52% 6% population: the Inland Empire, Los Los Angeles County 49% Angeles, and the San Joaquin Valley. Central Coast 7% 44% San Diego Area 7% 37% Orange County 5% 34% Latinx 4% Greater Bay Area 24% ■ Physicians, 2020 ■ Population, 2019 Sacramento Area 4% 22% Northern and Sierra 4% 19% CA AVERAGE (6%) CA AVERAGE (39%) Note: Data include all MDs who renewed their license between February 2018 and January 2020, had a California address, and provided patient care at least 20 hours per week, and exclude residents, fellows, and nonrespondents (i.e., those MDs who did not respond to the Medical Board of California survey). Sources: Survey of Licensees (private tabulation), Medical Board of California, January 2020; and Annual Estimates of the Resident Population by Sex, Race, and Hispanic Origin for California: April 1, 2010 to July 1, 2019 (SC-EST2019-SR11H-06), US Census Bureau, June 2020. CALIFORNIA HEALTH CARE FOUNDATION 17 Physicians Spanish-Speaking Physicians, by Region Demographics California, 2020 In six of the nine regions of California, Spanish-Speaking over 10% of the population primarily Population, 2019 spoke Spanish. In all nine regions, the Central Coast 28% 15% percentage of physicians who reported Los Angeles County 27% 17% that they speak Spanish exceeded the percentage of the population that San Diego Area 24% 11% primarily spoke Spanish. Orange County 22% 11% San Joaquin Valley 20% 16% Inland Empire 19% 12% Greater Bay Area 18% 7% Northern and Sierra 17% 4% Sacramento Area 12% 5% 0 5 10 15 20 25 30 Notes: Data include MDs who renewed their license between February 2018 and January 2020, had a California address, and provided patient care at least 20 hours per week, and exclude residents, fellows, and nonrespondents (i.e., those MDs who did not respond to the Medical Board of California survey or did not answer questions about specialty). Spanish- speaking population includes all people 5 and older who are Spanish speakers and speak English "less than very well." Sources: Survey of Licensees (private tabulation), Medical Board of California, January 2020; and 2019 ACS 1-Year Estimates, US Census Bureau, n.d., table S1601. CALIFORNIA HEALTH CARE FOUNDATION 18 Physicians Physicians, by Practice Setting and Region Practice Organization California, 2015 Most California physicians practice in a ■ Solo ■ Small/Medium Group ■ Large Group ■ Kaiser ■ Other group setting. The Kaiser Permanente Central Coast 34% 41% 12% 12% 1% medical groups, the largest group Greater Bay Area 25% 27% 19% 19% 11% practices in the state, accounted for over 10% of physicians in four of the Inland Empire 29% 27% 19% 15% 10% nine regions. Solo practices were most Los Angeles County 36% 27% 15% 12% 10% prevalent in the Central Coast and in Orange and Los Angeles Counties. Northern and Sierra 26% 44% 6% 22% 2% Orange County 38% 37% 12% 8% 6% Sacramento Area 19% 23% 28% 22% 9% San Diego Area 22% 34% 20% 10% 15% San Joaquin Valley 25% 39% 10% 9% 18% California 29% 31% 16% 12% 11% Notes: Data include MDs with active California licenses, California addresses, and who provided at least 20 hours of patient care per week and are based on a supplemental survey that elicited responses from 8% (approximately 5,200) of the active patient care physicians whose licenses were due for renewal between March and December 2015. Percentages are of those physicians who reported a practice type. Small/medium group practice consists of practices with no more than 49 physicians, excluding Kaiser Permanente. Other includes community clinics, public clinics, rural clinics, military facilities, Department of Veterans Affairs medical centers, and other settings. One percent of respondents to the supplemental survey did not provide a practice setting. Segments may not total 100% due to rounding. Source: Voluntary Supplemental Survey (private tabulation), Medical Board of California, 2015. CALIFORNIA HEALTH CARE FOUNDATION 19 Physicians Physicians with Patients in Practice, by Coverage Type Practice Organization California, 2015 PCPs and specialists were less likely to have patients who were uninsured ■ Medi-Cal ■ Medicare ■ Private Insurance ■ Uninsured than patients with any type of health insurance. About 60% of PCPs and 87% 86% 87% specialists had Medi-Cal patients in 78% 2015. 74% 64% 62% 64% 64% 55% 57% 50% All Physicians PCPs Specialists Notes: PCP is primary care physician. Data are based on a supplemental survey that elicited responses from 8% of MDs with active California licenses, California addresses, and who provided at least 20 hours of patient care per week whose licenses were due for renewal between March and December 2015. Physicians who reported having any patients in a payer category were included in the reported percentage. All differences are statistically significant at p < .05 except for the difference between Medi-Cal and Medicare for primary care physicians. Source: Voluntary Supplemental Survey (private tabulation), Medical Board of California, 2015. CALIFORNIA HEALTH CARE FOUNDATION 20 Physicians Physicians Accepting New Patients, by Payer Practice Organization California, 2015 In 2015, physicians were less likely to accept patients without health ■ Medi-Cal ■ Medicare ■ Private Insurance ■ Uninsured insurance than patients with insurance. Physicians of all types 87% were less likely to accept Medi- 85% 83% 79% Cal compared with other types of 77% insurance. 60% 62% 62% 55% 41% 38% 32% All Physicians PCPs Specialists Notes: Data are based on a supplemental survey that elicited responses from 8% of MDs with active California licenses, California addresses, and who provided at least 20 hours of patient care per week whose licenses were due for renewal between March and December 2015. Physicians who reported accepting any new patients in a payer category were included in the reported percentage. All differences across insurance types are statistically significant at p < .05. Source: Voluntary Supplemental Survey (private tabulation), Medical Board of California, 2015. CALIFORNIA HEALTH CARE FOUNDATION 21 Physicians Physicians, by Medical School Location and Specialty Education and Training California, 2020 About one-quarter of California's physicians attended medical school ■ Outside the US 28% 39% 23% ■ Other State in the state. Nearly 40% of the state's ■ California primary care physicians graduated from a medical school outside the US. 53% 48% 38% 23% 22% 24% All Physicians PCPs Specialists Notes: Data include MDs who renewed their license between February 2018 and January 2020, had a California address, and provided patient care at least 20 hours per week, and exclude residents, fellows, and nonrespondents (i.e., those MDs who did not respond to the Medical Board of California survey or did not answer questions about specialty). Medical school location could not be determined for 58 physicians. Among physicians whose medical school location could be determined, 163 did not report their specialty. Segments may not total 100% due to rounding. Source: Survey of Licensees (private tabulation), Medical Board of California, January 2020. CALIFORNIA HEALTH CARE FOUNDATION 22 Physicians Medical School Graduates, by Degree Education and Training California, 2003 to 2018 The number of graduates from 1,571 1,564 1,557 California's MD-granting universities 1600 1,528 ■ DOs ■ MDs 450 430 465 grew by 4% between 2003 and 2018. 1,418 1,430 448 1,382 1,381 1,388 1,407 1400 1,295 1,305 1,309 322 1,311 332 333 329 347 336 During the same time, doctor of 1,284 297 1,250 329 244 281 286 osteopathic medicine (DO) graduates 1200 261 1,121 1,134 increased by 91%. The number of 1,078 1,071 1,094 1,080 1,092 1,051 1,060 1,049 1,055 1000 1,024 1,012 989 998 982 medical school graduates will likely increase because three medical 800 schools have opened since 2018, two 600 of which grant the MD degree and one of which grants the DO degree. 400 200 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Note: Data include graduates of allopathic (MD) and osteopathic (DO) medical schools. Sources: Graduates by Osteopathic Medical College and Gender 2000-18, American Assn. of Colleges of Osteopathic Medicine, February 11, 2015; B-2.2: Total Graduates by U.S. Medical School, Sex, and Year, 2010-2011 Through 2014-2015, Assn. of American Medical Colleges (AAMC), accessed June 16, 2020; and B-2.2: Total Graduates by U.S. Medical School, Sex, and Year, 2014-2015 Through 2018-2019, AAMC, October 16, 2019. CALIFORNIA HEALTH CARE FOUNDATION 23 Physicians Retention of Medical Students and Residents Education and Training California vs. United States, 2018 California retains a relatively high PERCENTAGE OF PHYSICIANS PRACTICING IN SAME STATE WHERE EDUCATED proportion of physicians who 80 ■ California ■ United States completed medical school or 70 residency in the state. In 2018, 71% California ranked first in the nation 60 63% for the percentages of both medical 50 students and residents who remain in the state to practice. 40 47% 30 38% 20 10 0 Medical School Residency Note: Data include graduates of allopathic (MD) and osteopathic (DO) medical schools. Source: 2019 State Physician Workforce Data Report, Assn. of American Medical Colleges, 2019, tables 4.1, 4.3. CALIFORNIA HEALTH CARE FOUNDATION 24 Physicians Medical Student Education Debt Education and Training United States, 2019 Over 70% of all medical school graduates had education debt in Graduates Median Total Education Debt with Education Debt (in thousands) 2019. A higher proportion of public medical school graduates had debt $215 than private medical school graduates. 74% 73% $200 $200 However, the median educational 71% debt for graduates of private medical schools was $15,000 higher than for graduates of public medical schools. Public Private All Public Private All Note: Education debt include both premedical and medical education debt. Source: Medical Student Education: Debt, Costs, and Loan Repayment Fact Card (PDF), Assn. of American Medical Colleges, October 2019. CALIFORNIA HEALTH CARE FOUNDATION 25 Physicians Medical School Specialty Choices Compared to Available Slots Education and Training United States, 2020 Orthopedic surgery and obstetrics/ PERCENTAGE OF SENIORS RANKING THIS SPECIALTY ONLY OR FIRST COMPARED TO AVAILABLE SLOTS gynecology were the most popular Surgical Specialties specialties among US medical school Orthopedic Surgery 81% seniors ranking residency choices Obstetrics/Gynecology 75% in 2020. Seniors choosing internal Anesthesiology 68% medicine and family medicine as General Surgery 67% their first or only choice filled just Other Specialties 41% and 33% of the available slots, Radiology-Diagnostic 64% respectively. Medical Specialties Emergency Medicine 64% Psychiatry* 62% Physical Medicine and Rehabilitation 52% Primary Care Pediatrics 60% Internal Medicine 41% Family Medicine 33% *Includes family medicine / psychiatry, internal medicine / psychiatry, pediatrics/psychiatry/child, and psychiatry. Source: Results and Data: 2020 Main Residency Match, National Resident Matching Program, May 2020. CALIFORNIA HEALTH CARE FOUNDATION 26 Physicians Employed Physician Earnings, Selected Specialties Income California, 2015 to 2019, Selected Years Since 2015, average Incomes for physicians in most specialties have AVERAGE ANNUAL INCOME (REAL) % CHANGE 2015 2017 2019 2015 TO 2019 not kept pace with the increase in Primary Care the Consumer Price Index. Among Family and General Practitioners $ 198,380 $ 190,626 $ 188,801 -5% specialties listed, only obstetricians/ Internists, General $ 199,200 $ 193,483 $ 197,335 -1% gynecologists experienced an Pediatricians, General $ 197,800 $ 177,616 $ 185,969 -6% increase in real wages. Psychiatrists Specialists experienced the largest decrease Anesthesiologists $ 264,040 $ 275,824 N/A N/A (−12%). Obstetricians/Gynecologists $ 209,100 $ 214,860 $ 219,826 5% Psychiatrists $ 250,090 $ 252,222 $ 220,011 -12% Surgeons $ 238,440 $ 222,848 $ 230,384 -3% Consumer Price Index $ 100,000 $ 102,913 $ 107,690 8% (2015 = $100,000 base) Notes: Wages were adjusted for inflation using estimates of the change in the Consumer Price Index from May 2015 to May 2017 and from May 2015 to May 2019. Does not include self-employed or government-employed physicians. Does not include ancillary income from sources such as directorships or call coverage. The Bureau of Labor Statistics did not report an estimate of average income for anesthesiologists in California in 2019. Source: "Occupational Employment Statistics," US Bureau of Labor Statistics, accessed May 6, 2020. CALIFORNIA HEALTH CARE FOUNDATION 27 Physicians Employed Physician Earnings, Selected Specialties Income California, 2019 For the specialties shown, the average AVERAGE ANNUAL INCOME AS A PERCENTAGE OF NATIONAL AVERAGE income for California physicians was near the national average for their All Occupations 115% specialties in 2019, despite California's Pediatricians, 109% higher cost of living. General Psychiatrists 107% Internists, General 105% Physicians and Surgeons, 103% All Other Obstetricians/ Gynecologists 101% Surgeons 98% Family and General 95% Practitioners Anesthesiologists 0% 0 27 54 Note: The Bureau of Labor Statistics did not report an estimate of average income for anesthesiologists in California. 81 108 Source: "Occupational Employment Statistics," US Bureau of Labor Statistics, accessed April 22, 2020. CALIFORNIA HEALTH CARE FOUNDATION 28 Physicians Medicaid-Medicare Fee Index Income California vs. United States, 2019 Medi-Cal, California's Medicaid MEDICAID PHYSICIAN FEES RELATIVE TO MEDICARE ■ California ■ United States program, paid physicians substantially less than Medicare and less than 0.78 Medicaid programs in most other 0.76 0.80 0.73 states. Overall, Medi-Cal paid 0.73 0.72 physicians only 73% of what Medicare 0.67 0.61 R AN KED #20 RANKED paid them. It ranked 46th among all RANKED #37 #32 states in the ratio of Medicaid fees to R A NKED Medicare fees for obstetrical care. #46 Primary Care Obstetric Care Other Services All Services Notes: The Medicaid-to-Medicare fee index measures each state's physician fees relative to Medicare fees in each state. The Medicaid data are based on surveys sent by the Urban Institute to the 49 states and the District of Columbia that have a fee-for-service (FFS) component in their Medicaid programs (only Tennessee does not). These fees represent only those payments made under FFS Medicaid. Source: Stephen Zuckerman, Laura Skopec, and Joshua Aarons, "Medicaid Physician Fees Remained Substantially Below Fees Paid by Medicare in 2019," Health Affairs 40, no. 2 (Feb. 2021): 343–48, doi:10.1377/hlthaff.2020.00611. CALIFORNIA HEALTH CARE FOUNDATION 29 Physicians Medical Groups, by Type and HMO Enrollment Medical Groups California, 2019 In 2019, over 300 medical groups Prevalence of Group HMO Enrollment provided care to 21 million Californians enrolled in HMOs. University of CA University of CA While 43% of these medical groups and County and County were IPAs, they accounted for only 27% of enrollment. In contrast, 7% Group 7% Practice group practices, which include 13% Foundation/ the Permanente Medical Groups, Community represented only 13% of medical Clinic 16% Foundation/ N= Group groups but 50% of enrollment. Community N = 324 21.1 million Practice Clinic 50% 37% IPA 43% IPA 27% Notes: HMO is health maintenance organization. IPA is independent practice association. Data include medical groups with at least six primary care physicians (PCPs) that accept contracts directly from HMOs. Group practice includes Kaiser Permanente Medical Groups. Physicians frequently participate in more than one IPA. See Appendix B for definitions of medical groups. Segments may not add to 100% due to rounding. Source: #1 – The Active California Medical Group Market (as of Mar. 15, 2019), Cattaneo & Stroud, n.d. CALIFORNIA HEALTH CARE FOUNDATION 30 Physicians Physician Participation in HMO Medical Groups, by Region Medical Groups California, 2018 Among California physicians who ■ 1 Group ■ 2 Groups ■ 3 Groups ■ 4+ Groups contract with HMOs, physicians in Central Coast the Northern and Sierra region were (n = 2,541) 23% 28% 18% 31% less likely in 2018 to participate in Greater Bay Area (n = 15,396) 21% 18% 12% 49% multiple medical groups than those in Inland Empire 22% 17% 11% 50% other parts of the state. (n = 4,405) Los Angeles County (n = 13,988) 19% 23% 13% 45% Northern and Sierra (n = 137) 38% 17% 16% 29% Orange County (n = 5,068) 11% 16% 17% 57% Sacramento Area (n = 3,600) 12% 8% 34% 46% San Diego Area (n = 6,030) 14% 16% 21% 49% San Joaquin Valley (n = 4,220) 15% 19% 19% 47% California (n = 55,358) 18% 19% 16% 48% Notes: HMO is health maintenance organization. Data include physicians who reported California licenses and valid medical groups. Excludes physicians in the Permanente Medical Group and physicians who work for the Department of Veterans Affairs, correctional facilities, and other entities that do not contract with HMOs. Segments may not add to 100% due to rounding. See Appendix A for a list of counties within each region. Source: Public records request (private tabulation), Dept. of Managed Health Care, 2018. CALIFORNIA HEALTH CARE FOUNDATION 31 Physicians Medical Groups Meeting National Standards of Care, by Region Quality of Care California, 2018 Los Angeles County and Orange ■ Poor ■ Fair ■ Good ■ Very Good ■ Excellent County were the only regions in 2018 Central Coast with any medical groups whose (n = 15) 47% 20% 33% quality of care was rated excellent. The Greater Bay Area (n = 30) 10% 30% 60% quality of care provided by more than Inland Empire 49% 6% half of the medical groups in the San (n = 35) 46% Joaquin Valley was rated fair. Los Angeles County (n = 67) 43% 28% 21% 6% 1% Northern and Sierra (n = 4) 25% 75% Orange County (n = 34) 24% 50% 21% 6% Sacramento Area (n = 8) 13% 88% San Diego Area (n = 15) 33% 47% 20% San Joaquin Valley (n = 17) 53% 24% 24% Notes: Performance results are reported for physician organizations with commercial HMO health plan members. Each medical group's patient records are compared annually to a set of national standards for quality of care to ensure that medical groups are offering quality preventive care to members. Quality measures include immunizations for children, diabetes care, and cancer screening. Each group is awarded an aggregate quality score of excellent, very good, good, fair, or poor. Segments may not add to 100% due to rounding. Medical groups unwilling to report or who had too few patients to report were omitted from the analysis. See Appendix A for a list of counties within each region. Source: "Medical Group Report Card for Commercial HMO Plan Members," Office of the Patient Advocate, accessed May 15, 2020. CALIFORNIA HEALTH CARE FOUNDATION 32 Physicians ABOUT THIS SERIES The California Health Care Almanac is an online clearinghouse for data and analysis examining the state's health care system. It focuses on issues of quality, affordability, insurance coverage and the uninsured, and the financial health of the system with the goal of supporting thoughtful planning and effective decisionmaking. Learn more at www.chcf.org/almanac. AU T H O R S Janet M. Coffman, MPP, PhD Emmie Calimlim, MPH Margaret Fix, MPH Healthforce Center and Philip R. Lee Institute for Health Policy Studies University of California, San Francisco F O R M O R E I N F O R M AT I O N California Health Care Foundation 1438 Webster Street, Suite 400 Oakland, CA 94612 510.238.1040 www.chcf.org CALIFORNIA HEALTH CARE FOUNDATION 33 Appendix A: California Counties Included in Regions REGION COUNTIES Central Coast Monterey, San Benito, San Luis Obispo, Santa Barbara, Santa Cruz, Ventura NORTHERN Greater Bay Area Alameda, Contra Costa, Marin, Napa, San Francisco, AND SIERRA San Mateo, Santa Clara, Solano, Sonoma Inland Empire Riverside, San Bernardino Los Angeles County Los Angeles SACRAMENTO Northern and Sierra Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, AREA 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 GREATER BAY AREA San Diego Area Imperial, San Diego San Joaquin Valley Fresno, Kern, Kings, Madera, Merced, San Joaquin, NORTHERN Stanislaus, Tulare AND SIERRA CENTRAL COAST SAN JOAQUIN VALLEY INLAND EMPIRE LOS ANGELES COUNTY ORANGE COUNTY SAN DIEGO AREA CALIFORNIA HEALTH CARE FOUNDATION 34 Appendix B: Definitions Medical Groups Physicians Medical groups are organized and managed differently: Physician classifications can differ between organizations. This report relies on two • Community clinic. A clinic that operates under California Health and Safety organizations for physician counts: the American Medical Association (AMA) and the Medical Board of California (MBC). Code 1204(a), which requires that it provide care to low-income and underserved populations, and charge fees based on patients' ability to pay. A community clinic Active physicians are licensed physicians who are: is operated by a tax-exempt nonprofit corporation and is supported by either public • Not retired, semiretired, working part-time, temporarily not in practice, or not or private donations and contributions. active for other reasons and who work 20 or more hours per week (AMA) • County group. A county-formed group of physicians that typically provides services • Currently licensed (MBC) through the county health department. • Foundation. A type of group practice under California Health and Safety Code Active patient care physicians are active physicians who: 1206(l), which stipulates that a medical foundation must operate a nonprofit, tax- • Identify their major professional activity as direct patient care (AMA) exempt clinic, conducting research as well as providing patient care and health • Provide patient care at least 20 hours per week (MBC) education. The foundation must have at least 40 physicians, at least 10 of whom have to be board-certified, and at least two-thirds of all physicians must practice Primary care physicians (PCPs) are those physicians whose primary specialty is: on a full-time basis at the clinic. The physicians are independent contractors to the • Family medicine / general practice, internal medicine, or pediatrics, foundation, but the foundation owns the facilities, equipment, and supplies, and including the respective subspecialties (AMA) employs all nonphysician personnel. • Group practice. A corporation, foundation, partnership, or other type of organization • Family medicine, internal medicine, general pediatrics, or geriatrics and do not have a secondary specialty that suggests they may provide specialty care (MBC) formed for the purpose of providing patient care. Group practices are more regulated than IPAs. To be recognized by the Center for Medicare & Medicaid Services as a Specialists are those physicians whose primary specialty is not considered group practice, the organization must direct the majority of its physicians' bills primary care. (MBC) through the organization, pay for its own overhead, and follow other regulations specified under California Health and Safety Code 1206(l). • Independent practice association (IPA). An association that contracts with independent physician practices so that they may work together as one when contracting with HMOs and other payers. • University of California Medical Center. A medical group operated by the University of California as part of one of its medical schools. CALIFORNIA HEALTH CARE FOUNDATION 35 Appendix C: P hysicians per 100,000 Population, by County, California NON- NON- NON- PRIMARY PRIMARY UN- PRIMARY PRIMARY UN- PRIMARY PRIMARY UN- CARE CARE KNOWN TOTAL CARE CARE KNOWN TOTAL CARE CARE KNOWN TOTAL Alameda 2,396 1,301 6 3,703 Mariposa 4 3 0 7 Santa Barbara 611 260 2 873 Alpine 0 0 0 0 Mendocino 77 49 1 127 Santa Clara 3,665 1,601 10 5,276 Amador 32 30 0 62 Merced 114 74 0 188 Santa Cruz 293 199 3 495 Butte 285 107 0 392 Modoc 7 2 0 9 Shasta 212 104 2 318 Calaveras 15 13 0 28 Mono 28 6 0 34 Sierra 1 1 0 2 Colusa 8 3 0 11 Monterey 453 217 4 674 Siskiyou 34 20 0 54 Contra Costa 1,543 882 8 2,433 Napa 217 97 0 314 Solano 604 305 0 909 Del Norte 13 13 0 26 Nevada 107 55 0 162 Sonoma 671 367 2 1,040 El Dorado 144 80 1 225 Orange 4,408 1,928 13 6,349 Stanislaus 586 332 2 920 Fresno 980 521 3 1,504 Placer 694 361 2 1,057 Sutter 93 56 0 149 Glenn 2 5 0 7 Plumas 20 6 0 26 Tehama 19 27 0 46 Humboldt 139 67 0 206 Riverside 1,771 940 9 2,720 Trinity 2 1 1 4 Imperial 101 48 1 150 Sacramento 2,380 1,012 3 3,395 Tulare 267 181 0 448 Inyo 23 11 0 34 San Benito 32 12 0 44 Tuolumne 63 39 2 104 Kern 633 363 0 996 San Ventura 984 519 3 1,506 2,103 990 13 3,106 Bernardino Kings 69 53 1 123 Yolo 178 109 2 289 San Diego 4,954 2,083 12 7,049 Lake 43 24 0 67 Yuba 38 22 0 60 San Francisco 2,539 894 10 3,443 Lassen 21 13 0 34 Unknown 11 8 0 19 San Joaquin 619 419 3 1,041 Los Angeles 14,059 5,776 39 19,874 Total 51,693 23,612 163 75,468 San Luis 382 150 1 533 Madera 173 75 0 248 Obispo Marin 526 222 0 748 San Mateo 1,247 556 4 1,807 Notes: Data include MDs who renewed their license between February 2018 and January 2020, had a California address, provided patient care at least 20 hours per week and exclude residents, fellows, and nonrespondents (i.e., those MDs who did not respond to the Medical Board of California survey). Source: Survey of Licensees (private tabulation), Medical Board of California, January 2020. CALIFORNIA HEALTH CARE FOUNDATION 36