Note to readers: Each week through November 2019, a selection of our 101 California Influencers answers a question that is critical to California’s future. Topics include education, healthcare, environment, housing and economic growth.
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California Influencers this week answered the following question: What can California communities do to attract doctors and other qualified medical practitioners? Below are the Influencers’ answers in their entirety.
“Our critical health workforce needs must also serve as a core theme”
Robert Ross - President and CEO of The California Endowment
Over a year ago our foundation (The California Endowment) partnered with like-minded health foundation colleagues – the California Health Care Foundation, the Blue Shield of California Foundation, the California Wellness Foundation, and the Gordon & Betty Moore Foundation – to catalyze the formation of the California Future Health Workforce Commission. This group of 25 public, private, corporate, research and academic experts crafted a comprehensive plan to address this question, and it was finalized in January of this year. The full report and its 30 recommendations for action is available here, but here are the prioritized highlights:
California has some great and effective pipeline programs to prepare students from low-income and underrepresented backgrounds for health careers, but they need to be scaled up. The role of community colleges is core and critical to this strategy.
More scholarships for qualified students from such backgrounds who intend to serve and practice in needy communities – especially in the Central Valley and rural communities.
Expand the recruitment and training of students from rural areas to practice in their home communities. We must reverse the “brain-drain” of talent leaving rural settings.
Strengthened focus and attention on the career pipelines for nurse practitioners, mental health practitioners, and community health workers – and with our aging population in mind.
Build on some of the fabulous California ideas for training physicians – such as the University of California’s PRIME program, and the brand new Kaiser Permanente medical school – who focus on physician training and financial support for those committed to serving the underserved.
Finally, our critical health workforce needs must also serve as a core theme of our state’s economic development and workforce strategy – it’s a two-for-one deal for California!
Financial support, physician empowerment key to attracting doctors
Carmela Coyle - President and CEO of the California Hospital Association
Let’s start by ensuring greater financial support for physician residency programs – especially those that serve rural and underserved areas, where there’s a shortage of doctors. We know that doctors tend to stay and work in communities where they are trained. Not only does this help prevent shortages of health professionals, it also is an investment in clinicians’ deeper understanding of a community’s specific health needs, health disparities and other public health concerns. It’s an investment that pays off for generations.
Physicians also need the ability to choose how they want to work – whether they want to be solo practitioners, join a medical group practice, or be directly employed, an increasingly preferred option among younger physicians. California is one of the few states that restricts this choice.
Ensuring the financial stability of hospitals – a key physician partner – also is important. Doctors need to be assured of the long-term sustainability of their partners as they work to innovate care delivery.
And of immediate concern: California’s high cost of living. Addressing this issue, especially when it comes to housing, will help our state accommodate more working medical professionals, especially those who are just beginning their careers.
It’s all about incentives: education, training and debt forgiveness
Le Ondra Clark Harvey - Director of Policy and Legislative Affairs for the California Council of Community Behavioral Health Agencies
We live in a day and age where there is unequal access to timely or affordable health care. There are many reasons that this happens; one such reason is a lack of trained health care workforce to meet the service demands. There are not enough educational programs, or residency and internship slots for physical and behavioral health practitioners. For those who graduate, the crippling student debt they must begin repaying makes it less appealing to work in underserved and rural communities.
Part of the answer is to find ways to incentivize careers in the health care workforce by creating opportunities to erase student debt. While there has been recent funding allocated to student loan repayment, much more is needed. Additionally, bolstering the health care career pathway by educating young people about the benefits of entering the field, increasing residency and internship slots — particularly in communities that have a low health care worker to patient ratios, and increasing the numbers of student loan and stipends is where we must focus first.
“Workforce gluts and shortages are not just an urban/rural divide”
Bruce Chernof - President and CEO of The SCAN Foundation
California’s biggest workforce-related problem is a dramatic and perverse maldistribution of health care professionals. Workforce gluts and shortages are not just an urban/rural divide, but also driven by poverty and lack of insurance coverage – and it’s time for change. First, California needs to create recruitment and admissions strategies for state schools that more aggressively draw applicants from today’s underserved communities. This means identifying and building leadership from within underserved communities, which is critical to achieving access to high quality care for all. Yet, recruitment alone is not enough. Today’s medical professionals graduate with educational debt that’s generally the size of a modest home mortgage and that often means idealism and service are pitted against monthly bills. To address these challenges, California should create a much more robust debt forgiveness and loan repayment program for doctors and other care professionals willing to provide care in underserved communities – maybe a year of debt forgiveness for each year of medical school and residency? Finally California needs to develop strategies big and small that encourage mature physicians to continue to serve in communities of need. Solutions could include things as small as medical license fee forgiveness to large scale payment reform such as differential payments for healthcare services delivered.
How we attract the most qualified practitioners to our life-saving mission
Joe Alvarnas - Vice President of Government Affairs and Senior Medical Director for Employer Strategy for City of Hope
California is challenged by a growing physician shortage that risks compromising our ability to deliver effective cancer care to Californians. A 2016 American Society of Clinical Oncology report found that California had one of the lowest population ratios of oncologists in the nation. While our state is known for its diverse communities and endless natural beauty, high living costs often compel medical school graduates and physicians to look elsewhere for work.
To overcome these challenges, we need to acknowledge what drives practitioners and ensure our medical centers support these values. Fundamentally, physicians and other clinical staff are drawn to work in places where they are respected and where barriers to delivering high quality, compassionate care without compromise are eliminated. As a National Cancer Institute-designated Comprehensive Cancer Center, City of Hope cultivates an environment where employees are fully supported in their efforts to bring life-saving innovations to patients affected by cancer, diabetes, and other life-threatening disease. By partnering with physicians, clinical teams and health care systems to reduce unnecessary burdens and lessen economic disincentives to providing patients with optimal care, I believe that California’s leaders can foster an environment in which we can ensure that the best talent will come here and stay here.
Let’s be clear. There is, in fact, no ‘statewide’ nursing shortage
Bonnie Castillo - Executive Director of California Nurses Association/National Nurses United
UCSF’s Healthforce Center’s credible evaluation of the nursing workforce indicates there is a sufficient supply of nurses graduating from nursing programs, provided that current enrollment numbers are maintained. In some areas like San Francisco, Central Valley and the Central Coast regions, there may be shortages. The best thing that California can do to preserve a healthy supply of registered nurses is to recommit through legislation or the budget, an investment in nursing education: create more slots at the community college level and fund nurse faculty recruitment, especially in the shortage areas. Beware of hospital corporations that cry “nursing shortage” to avoid safe staffing ratios and private for-profit nursing schools that do the same in order to avoid state regulation of their programs.
“There isn’t one silver bullet to address the medical shortage in California”
Jeannine English - Former National President of AARP
There isn’t one silver bullet to address the medical shortage in California but an important and immediate first step would be to allow nurse practitioners to work independently of doctors thereby expanding their scope of practice. In 22 states and the district of Columbia, nurse practitioners can practice and prescribe without physician collaboration or supervision. So why not in California where the need is great? Because of a turf war between the California Medical Association and the Nurse Practitioners that has nothing to do with quality of care and seems to ignore the rigor of advanced education, testing and certification programs that are now fundamental for nurse practitioners. The result of this dispute is that many people do not receive adequate health care. Appallingly, half of Californians find themselves in communities without adequate access to care because only 16 of our 58 counties have enough primary care physicians. The California Legislature needs to quit pandering to the California Medical Association and their lobbyists and enact legislation to allow full practice authority for nurse practitioners.
“We can build a pipeline of people eager and able to serve communities”
Mark Ghaly - Secretary of the California Health and Human Services Agency
I’ve recruited health professionals to work throughout California, often into designated Health Professional Shortage Areas, for nearly 15 years. I’ve come to recognize three essential strategies to creating optimal environments that attract people to the clinical settings that need them. First, we must address financial factors including through debt relief, and reducing barriers for trained individuals seeking a move to California. Second, we must create appealing jobs that can minimize the potential for burnout many full-time clinicians report. This includes allowing doctors an opportunity to lead integrated care teams with nurses, advanced practice providers, social workers, pharmacists, community health workers and behavioral health professionals. It also must include reducing paperwork so providers can focus on patient care and activities beyond the bedside such as community engagement work, research, and teaching. Third, we must be more strategic in training our own. We know that health professionals often work where they train. Given this, we should build training programs – schools, residencies and practicums – in regions where we want trainees to work (and live) and in specialties where we project shortages: behavioral health, primary care, geriatrics. If we want a workforce that looks like California, we must also create pathways for the full diversity of Californians to find appeal in health careers. Lastly, we must embrace California’s innovative spirit and evolve our education and training practices: in an era of tele-education, the road to licensure can be shortened so the cost of a healthcare education is more attainable. With these and other steps, we can build a pipeline of people eager and able to serve communities across California.
California’s Medi-Cal reimbursement rate needs to be raised to incentivize providers and increase access
Marie Waldron - California State Assemblywoman (R-Escondido)
Our state is suffering a shortage of doctors and medical practitioners and Californians are not receiving the medical care they need. With the state’s affordability crisis, there is hardly an incentive for medical students to study here or open a practice in California after receiving their degree. California’s housing crisis is getting worse and graduates are hurting from student loan debt. Doctors are struggling to keep their practices open because reimbursement rates for Medi-Cal patients are too low, especially in rural areas.
In an attempt to solve the shortage, the Legislature has pursued a number of bills to ease the burden of student loan debt for future medical practitioners and doctors. California also needs to increase Medi-Cal reimbursement rates so doctors are incentivized to work in rural and underserved areas. For years, I’ve worked with colleagues on both sides of the aisle to craft common-sense laws to ensure that doctors are paid fairly for the work they do. For example, my AB 1963 would have increased reimbursement rates for providers who are certified in treating opioid and heroin addiction.
We need to lower the cost of education, of taxes and of housing by reducing the excessive amount of regulations. If we want to solve the shortage of doctors, we must deal with our affordability crisis first.
“California’s communities need to be creative in how they can address this imbalance”
Zach Friend - Second District Supervisor for Santa Cruz County
High cost of living, significant medical school debt and a desire for an improved work/life balance are all impacting the availability of doctors and medical practitioners — especially in rural communities. In our county, we’ve experienced difficulties recruiting and retaining family physicians, mental health professionals and other specialists. California’s communities need to be creative in how they can address this imbalance. Some cost-effective solutions include loan repayment and forgiveness programs, transitional housing opportunities, expansion of telehealth options in rural communities and providing coverage schedules that are attractive for those seeking a better work/life balance. While ideally these programs, especially loan forgiveness programs, would have federal investment these are things the state (and even local counties) could prioritize. The cost of such a program is less than the cost of negative health outcomes associated with longer wait times to see specialists, wellness checks from family physicians or other forgone preventive opportunities. A little bit of creativity can help recruit, and retain, essential medical personnel and have positive health outcomes in our communities.
“Reform our health system to be more efficient and effective”
Anthony Wright - Executive Director of Health Access California
The California Future Health Workforce Commission states clearly: “California does not have enough of the right types of health workers in the right places to meet the needs of its growing, aging, and increasingly diverse population,” citing not just of shortages, but of “mismatches.” There’s no dearth of doctors in Beverly Hills, but there is in fast growing regions like the Central Valley and Inland Empire. And while 40% of Californians are Latino, just 7% of California physicians are.
Yes, we need to train and recruit more medical professionals, especially in primary care, and those who have the language and cultural competency to address the needs of all Californians.
We also have to reform our health system to be more efficient and effective with the workforce we have, so Californians get the right care at the right time, and are not subject to unnecessary care. Expanding coverage so every Californian is in the system will help as well — having too many uninsured in an area makes it harder for doctors to build a practice there. Ultimately, we need to fix our fragmented health care industry to be inclusive and integrated, so we have the tools to best address these issues.
“Expansion has further strained a system that is being hit hard”
Dustin Corcoran - CEO of the California Medical Association
Under the Affordable Care Act, California has expanded access to care more than any other state. But that expansion has further strained a system that is being hit hard by increased demand from an aging patient population and physician retirements as Baby Boomers age out of the workforce and physician burnout increases. Two new programs funded by Proposition 56 tobacco tax revenues are working to stem that tide. The CalHealthCares loan repayment program offers up to $300,000 in debt relief for physicians who serve low-income patients. Prop. 56 revenues will also fund hundreds of physician residency slots – with an emphasis on low-income and underserved communities – to ensure we are training the physicians we need in the communities that often struggle to attract and retain physicians. This targeted approach has been effective in addressing physician shortages in critical areas and is one the state should continue and expand as we continue to work to expand access to affordable care for all Californians.
“We need to educate more of them right here at home in the Golden State”
Robin Swanson - Swanson Communications
In order to recruit more doctors in California, we need to educate more of them right here at home in the Golden State. We simply don’t have enough medical school students to keep pace with the growing demand of elderly and sick people here. California has 18.4 medical students per 100,000 people; far short of the national average of 30.3 per 100,000. Loan forgiveness programs for doctors are an important, but only temporary solution. If we aren’t investing in more world-class medical schools in California, the number of doctors who receive their education in other parts of the country, and end up building careers, lives and families in those same communities, will only continue to soar. It’s shocking that in the last 40 years, the only new public medical school to open in our state is at UC Riverside.
California communities should also look at recruitment from creative sources, like doctors who have served in our military. While recruitment for physicians who have just finished their schooling and training is at an all-time high, the Defense Department is actually planning significant cutbacks in military medical personnel. Providing these experienced service men and women incentives to come live and work in California should be a high priority in the quest to find qualified doctors and medical practitioners to serve our growing population.
“Overall, effective solutions will require a deep and honest look”
Chet Hewitt - President and CEO of the Sierra Health Foundation
Like many other issues facing our state, California’s health care professional shortage will have a heavier impact on Californian’s communities already experiencing disproportionate challenges in their access to quality health care. Therefore we must view creating and retaining qualified and dedicated medical practitioners as a commitment to health equity for all Californians.
To achieve the number and type of health care professionals our state will need, we have to ensure the full diversity of interested Californians are able to pursue their goal of becoming doctors or other health care practitioners. To create this varied pool of prospective health care professionals, we need to focus on the need for educational equity for students – particularly those from low-income neighborhoods both urban and rural – who are interested in pursuing health careers and who would benefit from educational and mentorship support.
Once we have expanded the pool of trained medical professionals, we must also work to ensure that they are able to practice in all of our state’s communities. Help in defraying the high cost of housing in many areas, as well as student debt relief, are two areas that communities and our state as a whole should explore. Those who follow their calling to help others through medicine should not be limited in their choices of where to practice resulting from a need to pay off loans.
Overall, effective solutions will require a deep and honest look at who we are, and who has been included and supported in our society. Failure to address the medical profession shortage will be a societal failure, and if we are unable to correct it we ultimately will put the health status of all communities in jeopardy.
Here is the future path for health care professionals
Lloyd Dean - CEO of CommonSpirit Health
First, the health of California and the health of our communities depends on health access for every person living in this state. And that means that we must ensure that trained and skilled health workers are available in both urban hubs and small towns. As the co-chair of the California Future Health Workforce Commission, I am working with leaders across the state to open and expand new pathways into professional health careers. We need not look for complicated solutions, but simple and practical approaches that anyone can set into motion now. First, we need to build our local workforce from within, supporting students from underserved areas – at all levels of their academic careers – with mentorship and scholarship opportunities. We also need to recruit students from rural areas to practice near their home town. But the big takeaway is this, we cannot continue to plan for the future, we must act now to create meaningful and sustainable change. I believe this holistic approach will create a lasting foundation to help all people in our communities live healthier and safer lives.