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What’s up, Doc? Not the number of physicians serving rural California
Petris Center points to geographic disparities in doctor distribution

| 22 July 2004

Although the current supply of physicians in California is adequate, there are persistent shortages of doctors in low-income and rural counties, particularly those with high Hispanic populations, according to a UC Berkeley research report released in late June.

Moreover, there are troubling signs of a future statewide doctor shortage because many physicians are likely to retire over the next five to ten years, the report says.

Using data from the American Medical Association’s Masterfile, which tracks the physician workforce in the United States, researchers from Berkeley’s Nicholas C. Petris Center on Healthcare Markets and Consumer Welfare analyzed the supply of physicians in California over the past 25 years. Their resulting report, “Is There a Doctor in the House?” provides one of the most complete pictures to date of long-range trends in California’s physician workforce.

The researchers found that there were not enough physicians per capita in the state’s low-income and non-metropolitan regions despite growth in the number of doctors statewide. Since 1978, the ratio of California physicians to the population has jumped 25 percent, but the growth has not significantly benefited non-metropolitan areas, the report says.

Glenn, Modoc, and Yuba counties repeatedly ranked in the bottom 10 in the state for physician-to-population ratios. All three counties had fewer than 78 physicians per 100,000 residents and are considered Primary Care Health Professions Shortage Areas by the U.S. Department of Health and Human Services.

In contrast, the higher- income counties of Marin, Napa, San Francisco, San Mateo, and Santa Barbara consistently ranked in the top 10 for concentration of physicians, with more than 169 physicians per 100,000 persons.

“Our finding of geographic disparities comes as no surprise,” said Richard Scheffler, professor of health economics and public policy, director of the Petris Center, and co-author of the report. “Doctors are influenced by the same market forces as the rest of us, and will go to areas where people have the ability to pay for their services. Low-income regions tend to have fewer people with health insurance or other means of paying for their health care.”

Some of the physician shortfall is made up by a higher percentage of nurse practitioners and physician assistants in the small, rural counties. These professions, which have grown rapidly over the past decade, are well represented in small, rural counties such as Sierra, Humboldt and Inyo.

But while these clinicians provide an important resource in underserved areas, they do not negate the need to attract more physicians to those regions, the researchers said.

To increase the number of people who can pay for health care and thus attract more physicians to an underserved area, the researchers recommend expanding health-insurance programs such as Healthy Families and Medi-Cal. They also suggest developing financial incentives (such as scholarship or loan-forgiveness programs) for doctors willing to practice in the area, providing clinical education and encouraging persons from underserved areas to pursue careers in medicine.

“There is evidence that doctors who grew up in rural areas are more likely to practice in rural areas,” said Janet Coffman, research associate at the Petris Center, based at the School of Public Health, and lead author of the report. “It’s a matter of seeking out those health-care professionals who want to practice in those communities.”

Other ideas include the utilization of innovative developments in telemedicine that enable doctors in urban areas to reach out to rural patients. “There have been incredible advances in information technology that can improve access to care in underserved regions,” said Tim Brown, associate director of research at the Petris Center and a report co-author.

In addition to the findings of geographic disparities, the report revealed that the number of active patient-care physicians over age 65 more than tripled between 1978 and 2002, and the number aged 56 to 65 doubled. There was a modest growth of doctors aged 40 or younger since the late 1970s, but a closer look at the trend since the early 1990s shows a decrease in doctors in that age group. The state needs to reverse that trend if it is to offset the expected retirements, the authors say.

“Although we don’t find evidence of a statewide shortage now, we should not be complacent, because there are indications of a potential shortage in the future,” said Coffman.

The authors note that the average real income of California physicians has fallen behind the U.S. average, presenting a potential challenge in the recruitment of new doctors.

“As the incomes of doctors in California lag behind the rest of the country, it becomes less attractive to live here, particularly since the cost of living is so high,” said Scheffler. “Three-quarters of the doctors in California come from other states or countries. We are competing against other regions where physicians could be earning more money and paying less for food, gas and housing.”

Among the report’s other findings is that African-Americans, Hispanics, and Native Americans remain significantly underrepresented among physicians in California.

“We don’t have nearly enough diversity in our physician population, especially when you consider the racial and ethnic makeup of California’s population,” said Brown. “Previous research links increased diversity in the medical profession with reductions in racial and ethnic disparities in the use of health care. African-American and Hispanic physicians also provide a disproportionate amount of care to persons from their own racial and ethnic groups.”

Scheffler points out that it is particularly important to increase diversity among generalist physicians. “The primary- care physicians, in contrast to the specialists, stand at the frontline of patient health care and therefore develop more rapport with their patients,” he said. “More outreach and scholarship programs are needed to increase underrepresented minorities in the physician workforce. What is encouraging is that there is more diversity among younger physicians, but there is still a ways to go before the physician workforce can adequately mirror the state’s population.”

The researchers hope that the report’s analysis of long-range trends and current snapshot of California’s physician ranks will form the basis of sound policy decisions. They emphasize the need for state policymakers to monitor trends in physician supply closely to avert a future physician shortage statewide.

An electronic copy of the executive summary and full report is available by calling the Petris Center at 643-4100.