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STRATEGIES FOR INCREASING PHYSICIAN SUPPLY IN MEDICALLY UNDERSERVED COMMUNITIES IN CALIFORNIA

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Kevin Grumbach
Kevin Grumbach
Kevin Grumbach
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Janet Coffman
Janet Coffman
Janet Coffman
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Ruth Liu
Ruth Liu
Ruth Liu
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Elizabeth Mertz at University of California, San Francisco
Elizabeth Mertz
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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.
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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. ...
Mertz, E, Anderson, G, Grumbach, K and O'Neil, E. (2004) Evaluation of Strategies to Recruit Oral Health Care Providers to Underserved Areas of California. CPRC Brief. Vol 16. No 5. September.
Technical Report
Full-text available
  • Sep 2004
... @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. ...
Mertz E, Anderson G, Grumbach K, & O'Neill E. (2004). Evaluation of Strategies to Recruit Oral Health Care Providers to Underserved Areas of California. San Francisco, CA: Center for California Health Workforce Studies, UCSF Center for the Health Professions.
Technical Report
Full-text available
  • Jan 2004
... 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). ...
The Production of Physicians for Low-Income Communities in Panama: A Case Study
Article
  • Jan 2017
Gross inequality in access to health services is a common problem in developing countries like Panama. This study responds to the current shortage of physicians from economically depressed communities in Panama. By using qualitative research methods, I examined the personal, financial, curricular and environmental factors that shape low-income students’ commitment to become physicians; the forces that shape these medical students to practice medicine once they graduate; and how policies and institutional practices in medical schools in Panama influence rates at which low-income students become physicians. Specifically, data sources were used to explore how the nation’s educational policies, as well as recruitment, admissions, and student support practices in medical schools, influence rates at which low-income students become physicians. Documents were analyzed to determine statistical trends in medical school enrollment and completion for some of the selected medical schools; and the availability and effectiveness of various policy initiatives enacted to increase the production of physicians across the country. ^ Interviews were conducted with senior academic officers of medical schools (e.g., vice provost, deans and directors) and others who know much about the country’s current human resources challenges in medicine (e.g., a former minister of health, the deputy minister of education, and the health senior adviser to the president of Panama). Interviews with these stakeholders provided insights into the educational, political, and economic forces that shape whoever enrolls in and ultimately completes medical school. Additionally, recent graduates or students in their final year of medical school from four schools of medicine in the Republic of Panama participated in focus groups, to offer information into the personal, familiar and institutional factors that supported and undermined low-income students’ goals of becoming doctors. Some attention was paid to socioeconomic demographics of communities in which certified physicians ultimately choose to practice. ^ The findings of this study provide Panamanian policymakers with valuable information for defining better approaches to train physicians for underserved areas and may help Panama achieve compliance with the millennium objectives that were agreed to by member countries of the World Health Organization in 2000. Finally, implications for future research on the training of low-income students to become physicians in underserved communities are proposed.
... 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. ...
The Role of Medical Education in Reducing Health Care Disparities: The First Ten Years of the UCLA/Drew Medical Education Program
Article
Full-text available
The University of California, Los Angeles (UCLA)/Charles R. Drew University Medical Education Program was developed to train physicians for practice in underserved areas. The UCLA/Drew Medical Education Program students receive basic science instruction at UCLA and complete their required clinical rotations in South Los Angeles, an impoverished urban community. We have previously shown that, in comparison to their UCLA counterparts, students in the Drew program had greater odds of maintaining their commitment to medically disadvantaged populations over the course of medical education. To examine the independent association of graduation from the UCLA/Drew program with subsequent choice of physician practice location. We hypothesized that participation in the UCLA/Drew program predicts future practice in medically disadvantaged areas, controlling for student demographics such as race/ethnicity and gender, indicators of socioeconomic status, and specialty choice. Retrospective cohort study. Graduates (1,071) of the UCLA School of Medicine and the UCLA/Drew Medical Education Program from 1985-1995, practicing in California in 2003 based on the address listed in the American Medical Association (AMA) Physician Masterfile. Physician address was geocoded to a California Medical Service Study Area (MSSA). A medically disadvantaged community was defined as meeting any one of the following criteria: (a) federally designated HPSA or MUA; (b) rural area; (c) high minority area; or (d) high poverty area. Fifty-three percent of UCLA/Drew graduates are located in medically disadvantaged areas, in contrast to 26.1% of UCLA graduates. In multivariate analyses, underrepresented minority race/ethnicity (OR: 1.57; 95% CI: 1.10-2.25) and participation in the Drew program (OR: 2.47; 95% CI: 1.59-3.83) were independent predictors of future practice in disadvantaged areas. Physicians who graduated from the UCLA/Drew Medical Education Program have higher odds of practicing in underserved areas than those who completed the traditional UCLA curriculum, even after controlling for other factors such as race/ethnicity. The association between participation in the UCLA/Drew Medical Education Program and physician practice location suggests that medical education programs may reinforce student goals to practice in disadvantaged communities.
HIV/AIDS Among Mexican Migrants and Recent Immigrants in California and Mexico
Article
This special issue contains original review articles by researchers from the University of California and the Secretariat of Health of Mexico. The articles on epidemiology prevention and health care services review available published data and selected unpublished data on Mexican migrants in California specifically and across the United States. These articles identify research and intervention needs and where available document effective methods of outreach and interventions with the Mexican migrant population. An article addressing the issue within Mexico outlines the emerging data on the vulnerability of Mexicans migrating to the United States with regard to HIV sexually transmitted diseases and associated behaviors. Lastly a concluding article presents an analysis of policies that serve as barriers or facilitators of prevention and care for Mexican migrants in California. All the articles offer compelling evidence for integrating tailored outreach prevention and health care services for the Mexican migrant population into the overall health care infrastructure of communities in California and Mexico. (excerpt)
Variation in Participation in Health Care Settings Associated with Race and Ethnicity
Article
Full-text available
  • Oct 2004
To use the ecology model of health care to contrast participation of black, non-Hispanics (blacks); white, non-Hispanics (whites); and Hispanics of any race (Hispanics) in 5 health care settings and determine whether disparities between those individuals exist among places where they receive care. 1996 Medical Expenditure Panel Survey data were used to estimate the number of black, white, and Hispanic people per 1,000 receiving health care in each setting. Physicians' offices, outpatient clinics, hospital emergency departments, hospitals, and people's homes. Number of people per 1,000 per month who had at least one contact in a health care setting. Fewer blacks and Hispanics than whites received care in physicians' offices (154 vs 155 vs 244 per 1,000 per month, respectively) and outpatient clinics (15 vs 12 vs 24 per 1,000 per month, respectively). There were no significant differences in proportions hospitalized or receiving care in emergency departments. Fewer Hispanics than blacks or whites received home health care services (7 vs 14 vs 14 per 1,000 per month, respectively). After controlling for 7 variables, blacks and Hispanics were less likely than whites to receive care in physicians' offices (odds ratio [OR], 0.65, 95% confidence interval [CI], 0.60 to 0.69 for blacks and OR, 0.79, 95% CI, 0.73 to 0.85 for Hispanics), outpatient clinics (OR, 0.73, 95% CI, 0.60 to 0.90 for blacks and OR, 0.71, 95% CI, 0.58 to 0.88 for Hispanics), and hospital emergency departments (OR, 0.80, 95% CI, 0.69 to 0.94 for blacks and OR, 0.80, 95% CI, 0.68 to 0.93 for Hispanics) in a typical month. The groups did not differ in the likelihood of receiving care in the hospital or at home. Fewer blacks and Hispanics than whites received health care in physicians' offices, outpatient clinics, and emergency departments in contrast to hospitals and home care. Research and programs aimed at reducing disparities in receipt of care specifically in the outpatient setting may have an important role in the quest to reduce racial and ethnic disparities in health.
Policy Perspectives on Public Health For Mexican Migrants in California
Article
This analysis focuses on public policies that affect primary HIV prevention and access to HIV care for Mexican migrants residing in California. Policy or structural level interventions, as opposed to behavioral or psychologic interventions, help to shape the environment in which people live. We use a conceptual model for policy analysis in public health to understand better the challenges faced by Mexican migrants. We assess potential policy level interventions that may serve as barriers to or facilitators of primary HIV prevention and care for Mexican migrants. Among potential barriers, we discuss restrictions on public health services based on legal immigration status, limits placed on affirmative action in education, and laws limiting travel and immigration. Under potential facilitators, we discuss community and migrant health centers, language access laws, and the use of community-based groups to provide prevention and treatment outreach. We also report on the limited research evaluating the implications of these public policies and ways to organize for more responsive public policies.
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