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STRATEGIES FOR INCREASING PHYSICIAN SUPPLY IN MEDICALLY UNDERSERVED COMMUNITIES IN CALIFORNIA

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Abstract

Although California has an ample supply of physicians overall, they are poorly distributed. More than 4 million Californians live in communities designated as Health Professional Shortage Areas, and the number who lack access to primary health care is probably far greater, particularly in low-income rural and inner-city communities. Concerns about the geographic maldistribution of California physicians led to the state legislature's passage of Senate Concurrent Resolution 23 (SCR 23, 1997), calling for analysis of policies to foster a more equitable distribution of physicians. This Brief summarizes the recommendations in a report prepared for the California Policy Research Center in response to SCR 23. Three types of interventions can be effective in improving physician supply in underserved areas, particularly when implemented collectively to form a continuum: • Practice-environment strategies attempt to make practice in shortage areas more attractive • Medical education strategies address the training experiences of physicians • Applicant pool strategies target the types of students who enter medical school Practice-environment interventions have the quickest "pay off" in improving physician distribution, because they target the point when physicians are ready to enter practice. Medical education and applicant-pool strategies are integral to a comprehensive plan but take longer to yield results. PRACTICE-ENVIRONMENT RECOMMENDATIONS Health service corps programs are a mainstay of efforts to place more primary care physicians in underserved communities. Under these programs, physicians agree to practice in medically underserved communities in exchange for scholarships or repayment of student loans. Other effective strategies include job matching programs and locum tenens (temporary placement) programs, which provide temporary relief for physicians to take family leave or pursue professional development opportunities. Implementation of the following recommendations would help provide more primary care physicians in the short term: • California should resurrect its Shortage Area Medical Matching Program, which matched graduating residents with practice opportunities in underserved areas.
STRATEGIES FOR INCREASING PHYSICIAN SUPPLY IN
MEDICALLY UNDERSERVED COMMUNITIES IN CALIFORNIA
Kevin Grumbach, Janet Coffman, Ruth Liu, and Elizabeth Mertz
Although California has an ample supply of physicians overall, they are poorly distributed. More than
4 million Californians live in communities designated as Health Professional Shortage Areas, and the
number who lack access to primary health care is probably far greater, particularly in low-income rural
and inner-city communities. Concerns about the geographic maldistribution of California physicians
led to the state legislature's passage of Senate Concurrent Resolution 23 (SCR 23, 1997), calling for
analysis of policies to foster a more equitable distribution of physicians. This Brief summarizes the
recommendations in a report prepared for the California Policy Research Center in response to SCR
23.
Three types of interventions can be effective in improving physician supply in underserved areas,
particularly when implemented collectively to form a continuum:
Practice-environment strategies attempt to make practice in shortage areas more attractive
Medical education strategies address the training experiences of physicians
Applicant pool strategies target the types of students who enter medical school
Practice-environment interventions have the quickest "pay off" in improving physician distribution,
because they target the point when physicians are ready to enter practice. Medical education and
applicant-pool strategies are integral to a comprehensive plan but take longer to yield results.
PRACTICE-ENVIRONMENT RECOMMENDATIONS
Health service corps programs are a mainstay of efforts to place more primary care physicians in
underserved communities. Under these programs, physicians agree to practice in medically
underserved communities in exchange for scholarships or repayment of student loans. Other effective
strategies include job matching programs and locum tenens (temporary placement) programs, which
provide temporary relief for physicians to take family leave or pursue professional development
opportunities. Implementation of the following recommendations would help provide more primary
care physicians in the short term:
California should resurrect its Shortage Area Medical Matching Program, which matched graduating
residents with practice opportunities in underserved areas.
California should match federal funding for the National Health Service Corps State Loan
Repayment Program.
The state should support pilot programs that encourage innovative public health-oriented prevention
activities for physicians participating in the above programs.
The state should support the Rural/Underserved Provider Opportunity Program's locum tenens
network in rural California.
Page 1 of 3Physician Supply in Underserved Communities
MEDICAL EDUCATION RECOMMENDATIONS
Over the long run, practice-environment strategies have limited effectiveness because they do not
expand the pool of persons predisposed to practice in undeserved areas. Medical education
strategies complement them by giving medical students and residents educational opportunities in
underserved communities. These practical experiences have been found to stimulate and reinforce
interest in caring for underserved populations. California has several existing structures for funding
and organizing medical education programs that can be expanded to prepare physicians for practice
in underserved areas.
The state should maintain the Song-Brown Family Physician Training Program and develop more
uniform standards for measuring the success of applicant organizations at placing graduates in
underserved communities.
The Song-Brown program should receive additional resources to fund family practice residency
programs that would recruit graduating medical students from underrepresented groups at medical
schools throughout the United States.
The state should match federal funding to support the Shortage Area Medical Education and
Training Program.
California should convene a special task force to develop a comprehensive, statewide plan for rural
medical education.
Medi-Cal Graduate Medical Education funds should include incentives for residency programs to
provide educational experiences that prepare residents to care for underserved populations.
APPLICANT-POOL RECOMMENDATIONS
Although policies that alter the composition of the classes entering medical school have the most
delayed effects on service in shortage areas, they are critical elements of a comprehensive plan for
addressing physician shortage because they increase the number of physicians predisposed to
practice in medically underserved communities. The characteristics that students bring to medical
school -- such as rural upbringing, racial and ethnic identity, or values of public service -- are probably
the greatest influences on their decision to practice in an underserved community. Minority physicians
are much more likely to practice in underserved communities, and physicians who grew up in rural
areas are much more likely to practice in rural communities.
The recent decrease in enrollment of underrepresented minorities in medical schools in California and
the U.S. presents new challenges for the state's ability to train and recruit physicians to serve its
neediest populations. Since 1992, the number of underrepresented minority enrollees at University of
California medical schools dropped by 34%, from 138 students in 1993 to 91 in 1997. Only 12% of
first-year medical students in UC schools in 1997 were from underrepresented groups, compared with
21% in 1992. Similar trends are evident at private medical schools.
Individuals from disadvantaged backgrounds should have the opportunity to develop career interests
in health care and to be competitive applicants for entry into professional schools. Although California
is increasing resources for science enrichment programs targeted toward K-12 students, this
commitment must be matched by renewed investment in college-level educational enrichment
programs that focus specifically on promoting interest and educational achievement in the health
professions among disadvantaged students.
Page 2 of 3Physician Supply in Underserved Communities
The state should ensure that every campus in the UC, CSU, and community college systems has a
comprehensive program modeled on the federal Health Careers Opportunity Program (HCOP).
California should create a fund to promote partnerships between these college-level HCOP-type
programs and both UC and private medical schools in the state.
The state should provide support for at least one additional postbaccalaureate program to help
prepare promising disadvantaged applicants who have not been accepted to medical schools.
Medical school admissions policies must be sufficiently flexible and individualized to take full
account of the variety of characteristics and life experiences that may predict an applicant's
successful career in medicine and future professional contribution to the health of the public.
Kevin Grumbach, MD, is an associate professor of family and community medicine and
p
rincipal investigator of the Center for California Health Workforce Studies, University of
California, San Francisco; Janet Coffman, MPP, is the center manager; Ruth Liu was a
graduate student intern; and Elizabeth Mertz, MPA, is a research associate. This research was
funded by CPRC's California Program on Access to Care and the U.S. Bureau of Health
Professions. Another component of this research, focusing on declining medical school
admissions among underrepresented minorities, was published separately by the
investigators at the Center for California Health Workforce Studies, who prepared this report.
That publication is available on the Center's website: http://futurehealth.ucsf.edu/cchws.html.
The complete CPRC report is free to California state government offices. Others may order it by
sending a check to CPRC for $10, payable to UC Regents.
Page 3 of 3Physician Supply in Underserved Communities
... @BULLET In what way could existing programs be improved or expanded upon so they better articulate with one another? Grumbach, Coffman et al. 1999). ...
... In addition, providers weigh personal factors such as the preferences of other family members, attractiveness of certain geographic areas, or the type of preexisting dental facilities and services available in an area. Programs and policies to encourage oral health care providers to practice in underserved areas fall into one of three categories (Grumbach, Coffman et al. 1999): Additionally, many schools offer opportunities for students to gain direct experience in providing dental care for underserved populations through rotations or residencies. ...
... @BULLET In what way could existing programs be improved or expanded upon so they better articulate with one another? Grumbach, Coffman et al. 1999). ...
... In addition, providers weigh personal factors such as the preferences of other family members, attractiveness of certain geographic areas, or the type of preexisting dental facilities and services available in an area. Programs and policies to encourage oral health care providers to practice in underserved areas fall into one of three categories (Grumbach, Coffman et al. 1999): Additionally, many schools offer opportunities for students to gain direct experience in providing dental care for underserved populations through rotations or residencies. ...
... In addition, proposed increases for primary care physician reimbursements, enactment of the national residency exchange (Cheng, 2012), as well as primary care extension services were established. In general, strategies to address physician shortages fell into three categories: inventory of applicants, medical education, and physicians practice environment (Grumbach, Coffman, Liu, & Mertz, 1999). Most of the efforts concentrated in adding educational experience in underserved contexts (Chan et al., 2005;Strasser & Neusy, 2010;Woloschuk & Tarrant, 2002). ...
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... Maldistribution of physicians persists throughout the United States, with an estimated 20% of the population living in federally designated Health Professional Shortage Areas (HPSAs). 1 Strategies to alleviate physician shortages usually fall into one of three categories: applicant pool, medical education, and practice environment. 2 Prior research has identified potentially favorable applicant characteristics, such underrepresented minority race/ethnicity, 3-5 growing up poor 6 or in an underserved area, 3,7 participation in the National Health Service Corps, 3 interest before medical school, 3 and older age. 8 However, it is not known whether the second strategy, medical education, can successfully translate this knowledge into changes in the physician workforce. ...
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