California faces major physician shortage

California is facing a primary care physician shortage, and one of the only solutions to address it is sitting on the edge of a fiscal cliff.  The Teaching Health Center program, which places new resident physicians in underserved communities, will lose federal funding unless Congress acts to reauthorize it by Sept. 30.

A study released on Aug. 15 by the University of California at San Francisco projected that due to population and insurance coverage expansion, the state will need an additional 4,700 primary care clinicians and providers by 2025.

Some programs have already suffered. Several Teaching Health Centers outside of California didn’t recruit new resident classes this summer.

Low-income Californians are the most affected by this shortage, which is why Teaching Health Centers have become such an important solution. Research indicates that residents who graduate from these programs are more likely to work in safety-net communities than residents from traditional programs.

Teaching Health Centers started as part of the Affordable Care Act: Congress authorized five years of funding starting in 2011, and two years ago, the funding was reauthorized until Sept. 30 of this year. For the program to continue, Congress most vote on reauthorization bills in the House and the Senate before that deadline.

Some programs have already suffered. Several Teaching Health Centers outside of California didn’t recruit new resident classes this summer, knowing that their sole source of funding might dry up by October.

Congresswoman Cathy McMorris Rodgers, R-WA, who authored the House’s reauthorization bill, told Capitol Weekly that graduates of Teaching Health Center programs are 55 percent more likely to continue practicing in underserved communities.

Anecdotal evidence from the first Teaching Health Centers in California supports that estimate.

At Clinica Sierra Vista’s Teaching Health Center in Fresno, two of the first six graduates stayed on as clinicians, two went on to work as safety net providers, and two went into private practice, according to Clinica Sierra Vista CEO Stephen Schilling.

“By having these residency programs in these areas you’re likely to have 60 percent of those residents stay in these underserved areas.” — Troy Kurtz.

Tim Fraser, a spokesperson for the Family Health Centers of San Diego told Capitol Weekly of similar results: four of the first six graduates from their Teaching Health Center program stayed with the clinics.

Winston Liaw is Medical Director at the Robert Graham Center where he researches the medical workforce and the effects of Teaching Health Centers on physician shortages. According to Liaw, the centers are effective because they provide residents exposure to working with low-income and safety-net populations.

“[Medical students] are demanding educators have curricula on how to take care of diverse populations and how to work in resource-poor settings,” Liaw said. “They want to work with underserved populations because that’s just the ethos that they have.”

Teaching Health Centers, advocates and researchers say, help translate that ethos into numbers.

A study released by the Graham Center found that 33 percent of Teaching Health Center graduates went on to practice in underserved communities. By comparison, only 18 percent of the traditional residency graduates surveyed did the same.

According to Troy Kurz, a first-year resident at UC Riverside and a former visiting scholar at the Graham Center, most residents practice within 100 miles of their residency once they graduate.

“By having these residency programs in these areas you’re likely to have 60 percent of those residents stay in these underserved areas,” he said.

“[In Bakersfield] We have 50 percent less providers per capita than do the 13 coastal counties in California.” — Stephen Schilling

Schilling offered perhaps the most compelling evidence for Teaching Health Centers’ comparable success recruiting residents to underserved communities. In a 20-year affiliation with UC Irvine, Clinica Sierra Vista saw approximately 240 residents come to Kern County through recruitment programs and partnerships. Schilling said he was only able to successfully recruit one of those residents.

“I would not call that a program that works to change the dynamics of health manpower shortage in our underserved rural parts of California,” Schilling said of the exchange.

Compare that with the two-thirds of the clinic’s first Teaching Health Center graduating class who remained in underserved communities.

“[In Bakersfield] We have 50 percent less providers per capita than do the 13 coastal counties in California,” Schilling said. “They have gobs of physicians wanting to live in those communities versus living in these less-populated, more-rural, more-climate-extreme communities…that’s just a reality.”

Liaw agreed that geographic desirability was one factor responsible for the shortage of physicians in rural areas. A lack of exposure to underserved populations and lower reimbursement rates are likely at fault for the underserved populations in more urban settings.

“The provider shortage also disproportionately impacts, for example, Latino and African-American populations,” said Carmela Castellano-Garcia, President and CEO of the California Primary Care Association (CPCA). “We serve a very diverse population. Over 80 percent are people of color, over half are Latino, and there aren’t enough culturally competent clinicians to address the population.”

Because most primary care residencies are three years, it is difficult, if not impossible, for Teaching Health Centers to commit to funding new residents.

Castellano-Garcia says that Teaching Health Centers are not only the best way to draw clinicians to these underserved communities, but the best way to train them as well. Hands-on experience dealing with low-income populations is the best way to ensure that providers are well equipped to work in resource-poor settings, she said.

Right now, the bill to reauthorize these Teaching Health Centers is just a draft, but the language is identical in the House and the Senate and has bipartisan sponsorship. These are promising signs. Still, the uncertainty around federal funding has already affected some Teaching Health Center programs.

Kurz and Liaw published a report on the effect of unstable funding on Teaching Health Centers. Specifically, they looked at the effects of a $55,000 per resident decrease that occurred with the first reauthorization. The study found that after the reductions, Teaching Health Centers graduates went from comprising a third of new family practice physicians to just 7 percent.

That research on instability has been borne out by experience. Because most primary care residencies are three years, it is difficult, if not impossible, for Teaching Health Centers to commit to funding new residents if, for example, the federal funding is only authorized through the first year of their residency.

“Some Teaching Health Centers already have a gap in their programs, having foregone recruitment of new classes this summer due to the uncertainty of funding after September 30. Despite initial approval for just over 900 slots, programs only recruited for and filled 742 positions last year, according to Hope Wittenberg, Director of Government Relations for the Council of Academic Family Medicine.”

With a shortage in the thousands of providers on the horizon, the 95 current residents in California’s Teaching Health Centers will fall far short of what’s needed to address the

Other programs are more fortunate. Some states, including California, have supplementary funding from the state. This year’s budget allocated 5.7 million to support existing residency slots at existing Teaching Health Centers, a spokesperson for the Office of Statewide Health Planning and Development (OSHPD) told Capitol Weekly in an email.

Still, the state funding is hardly robust.

“The problem is the OSHPD stash is not nearly sufficient to cover the cost of an 18-person residency program and its faculty,” Schilling said. “It would keep a very small skeletal version of that program alive.”

And with a shortage in the thousands of providers on the horizon, the 95 current residents in California’s Teaching Health Centers will fall far short of what’s needed to address the problem.

“Six Teaching Health Centers with 100 residents being trained is, quite frankly, woefully inadequate to address the need,” Castellano-Garcia said. “It is the tip of the iceberg.”

Liaw pointed out that if the program was funded by a more permanent source like the Centers for Medicare and Medicaid Services, rather than from Department of Health and Human Services appropriations, it would be much more effective.

“We see that the program works, we just need to scale it,” he added. For now, however, the long game isn’t in sight: proponents just hope Teaching Health Centers will live past September 30.